key: cord-337606-x7v26xrj authors: vernooij-dassen, myrra; verhey, frans; lapid, maria title: the risks of social distancing for older adults: a call to balance date: 2020-06-24 journal: international psychogeriatrics doi: 10.1017/s1041610220001350 sha: doc_id: 337606 cord_uid: x7v26xrj nan it is argued that the psychosocial implications of the covid-19 pandemic exacerbate and often supersede its direct medical impact (ayalon, 2020) . this might be due to social distancing as the key strategy to effectively fight the spread of the covid-19 infection. while social distancing can protect and save lives, its deleterious effects on older individuals need also to be recognized and minimized in order to preserve their quality of life to the extent possible. social distancing deprives older adults from direct interaction with their social environment and thereby disturbs the potential of social health to preserve their quality of life. the social capacities of older adults and the response of their social environment are powerful means to adapt to challenging situation such as a pandemic by social interactions stimulating mental health and cognitive functioning. however, being disconnected from loved ones and people giving pleasure and meaning to life constitutes an additional risk and makes older adults more vulnerable to loneliness and to deterioration of mental and cognitive functioning. in this commentary, we review the impact of social distancing on mental and social health and on cognitive functioning and describe practical strategies to counteract the adverse effects of social distancing on older individuals. social distancing or "physical distancing" is defined globally as maintaining at least 6 feet of distance from other people, avoiding crowds or large gatherings, and staying at home. social distancing is designed to reduce interaction between people in a broader community in which individuals may be infectious, but have not yet been identified, hence not yet isolated. social distancing may reduce transmission of respiratory droplets (wilder-smith and freedman, 2020). the most vulnerable persons in the covid-19 outbreak are older adults (>70 years of age). social distancing affects society and social life by changing cultural habits and increases risk for impairments in social and mental health and cognitive functioning. social distancing challenges social health. social health is a new paradigm bridging biomedical and social sciences by emphasizing the role of social interaction in managing health, formulated as the ability to adapt and self-manage. social health reflects the competencies of the individual to participate in social interaction and the influence of the social environment on the individual's balance of capacities and limitations (huber et al., 2011; vernooij-dassen et al., 2019) . social health ranges from a flourishing social life to loneliness. it is a dynamic process in which the individual is the conductor. conducting complex social processes seems to be supported by wisdom. wisdom might affect the quality of social relationships positively: loneliness has been found to be correlated strongly and inversely with wisdom (lee et al., 2019) . in contrast to public opinion, loneliness severity and age had a nonlinear relationship with increased loneliness in the late 20s, mid 50s, and late 80s (lee et al., 2019) . social distancing restricts individuals reaching out to their social environment and vice versa. it also deprives older adults from meetings that allow them to fulfill spiritual needs and meet family and friends. for instance, for many filipinos going to church on sunday followed by family gatherings is a tradition they look forward to, but now adds to a sense of sadness (buenaventura et al., 2020) . thus, social distancing deprives people of the many valuable assets of social health: faceto-face interactions characterized by sharing emotions such as pleasure as well as physical closeness. face-to-face interactions have been replaced by e-communications. technology is a great communication facilitator. but older adults need more than virtual contacts. when older adults are facing the challenges of social isolation, they are particularly vulnerable to rapid decline (steinman et al., 2020) . this is especially evident in long-term care facilities. in long-term care facilities, there is not only a high virus outbreak but also an outbreak of loneliness. dying alone, due to the social distancing measures, is major fear and the last thing we want. the tragedy is that the very measure designed to protect older adults (namely, social isolation) endangers their quality of life and even their quality of dying. social distancing in its extreme form by quarantine and social isolation during previous periods of severe coronavirus outbreaks has been found to be associated with mental health problems such as depression, anxiety, and stress (rohr et al., 2020) . more than 50% of chinese people participating in a covid-19 study (n = 1210) rated negative psychological impact of the outbreak, with 28.8% of the participants reporting moderate to severe anxiety (wang et al., 2020) . quarantine had negative associations with cognitive functioning (rohr et al., 2020) . these risks need more attention especially since social distancing may be mandatory for a longer period in some cases. there is a striking consistency between these results and those of dementia research. a lack of social interaction is associated with incident dementia (kuiper et al., 2015) . conversely, epidemiological data indicate that a socially integrated lifestyle had a favorable influence on cognitive functioning (bellou et al., 2017) and could postpone the onset of dementia (fratiglioni et al., 2004) . hypothetically, social interactions may trigger reactions which might require the use of preexisting cognitive processes or activating compensatory approaches (fratiglioni et al., 2004; vernooij-dassen et al., 2019) . how to explain this potential of the brain to improve cognitive functioning? it is in the plasticity of the brain. the plasticity of the brain allows activating preexisting cognitive processes or activating compensatory approaches: the cognitive reserve (fratiglioni et al., 2004) . this is a very promising angle in dementia research. but what is the working mechanism in relation to social health? we hypothesize that social health can act as the driver for accessing cognitive reserve through active utilization of social resources (vernooij-dassen et al., 2019) . it reflects hope on how to prevent dementia and to mitigate its consequences. social interactions for humans are like water for plants. social interactions during the covid-19 crisis are embedded within intergenerational solidarity. with an impressive intergenerational solidarity, the first outbreak wave has been managed. but intergenerational solidarity is shifting. younger generations want to resume normal life and suggestions are being made about excluding those aged 60 plus from societal activities in order to regain normality. ageism is playing a role. almost one quarter of analyzed tweets during the covid-19 outbreak had ageist content (jimenez-sotomayor et al., 2020) . political decision makers are confronted with these tendencies. in this new unlocking phase of the covid-19 crisis, it is crucial to reduce the negative consequences by limiting social distancing as much as possible. it is the balance between protection and its risks that counts. this is a call to translate this balance into policies that do not challenge intergenerational solidarity and lead to ageism. therefore, the needs of all generations should be considered without excluding the older generation. there are a number of strategies that geriatric providers, policy makers, community groups, and older individuals themselves can do to lessen the negative impact of social distancing on social and mental health and cognitive functioning of older individuals. • to optimize social health and ease social isolation despite social distancing measures: increase social contacts; engage with a person really close to you, especially when you are living alone; take personal responsibility for managing feelings of loneliness (kharicha et al., 2020) visit people with dementia as much as possible (www.alzheimer-europe.org); use all kinds of communication tools including telephone and video communication (www.interdem.org blog chattat); provide palliative care and use advance care planning to consider needs and wishes (tilburgs et al., 2019) . social distancing is meant to save the lives of vulnerable older adults, but it comes with high costs. the strategic response to the covid-19 crisis should not only aim to save lives, develop effective treatments, and revive the economy but also protect individuals and societies from the social, mental, and cognitive adverse effects of social distancing. there is nothing new under the sun: ageism and intergenerational tension in the age of the covid-19 outbreak systematic evaluation of the associations between environmental risk factors and dementia: an umbrella review of systematic reviews and meta-analyses covid-19 and mental health of older adults in the philippines: a perspective from a developing country an active and socially integrated lifestyle in late life might protect against dementia social relationships and mortality risk: a meta-analytic review how should we define health? coronavirus, ageism, and twitter: an evaluation of tweets about older adults and covid-19 managing loneliness: a qualitative study of older people's views. aging and mental health social relationships and risk of dementia: a systematic review and meta-analysis of longitudinal cohort studies high prevalence and adverse health effects of loneliness in community-dwelling adults across the lifespan: role of wisdom as a protective factor meeting the care needs of older adults isolated at home during the covid-19 pandemic educating dutch general practitioners in dementia advance care planning: a cluster randomized controlled trial bridging the divide between biomedical and psychosocial approaches in dementia research: the 2019 interdem manifesto immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china key: cord-328349-bg2zatzz authors: hwang, tzung-jeng; rabheru, kiran; peisah, carmelle; reichman, william; ikeda, manabu title: loneliness and social isolation during the covid-19 pandemic date: 2020-05-26 journal: international psychogeriatrics doi: 10.1017/s1041610220000988 sha: doc_id: 328349 cord_uid: bg2zatzz loneliness and social isolation are associated with adverse physical and psychological consequences which are particularly prevalent in older persons. during this unprecedented time of the covid-19 pandemic, we must follow social distancing guidelines to protect ourselves and to reduce the spread of coronavirus. at the same time, it is crucial to maintain social connections with each other, especially with older persons, to help cope and reduce the negative consequences of loneliness and social isolation. it is important to develop new strategies (e.g. virtual health care and new government policy) to address loneliness and social isolation among older adults for the post-pandemic era. the covid-19 pandemic has led to implementation of unprecedented "social distancing" strategies crucial to limiting the spread of the virus. in addition to quarantine and isolation procedures for those who have been exposed to or infected with covid-19, social distancing has been enforced amongst the general population to reduce the transmission of covid-19. the risk of covid-19 infection is greater for older adults over the age of 60 years who are at a heightened risk of severe illness, hospitalization, intensive care unit admission, and death (us cdc, 2020) . according to the centre for evidence-based medicine, the case fatality rate (cfr) is about 4% for patients over 60 years old, 8% for patients over age 70 years, and approximately 15% for patients over the age of 80 (oxford covid-19 evidence service, 2020) . this compares with cfr of 0.0026%-0.3% in those under age 45. however, there is a high cost associated with the essential quarantine and social distancing interventions for covid-19, especially in older adults, who have experienced an acute, severe sense of social isolation and loneliness with potentially serious mental and physical health consequences. the impact may be disproportionately amplified in those with pre-existing mental illness, who are often suffering from loneliness and social isolation prior to the enhanced distancing from others imposed by the covid-19 pandemic public health measures. older adults are also more vulnerable to social isolation and loneliness as they are functionally very dependent on family members or supports by community services. while robust social restrictions are necessary to prevent spread of covid-19, it is of critical importance to bear in mind that social distancing should not equate to social disconnection. the present position paper aims to describe the nature of loneliness and social isolation among older persons, its effect on their health, and ways to cope with loneliness and social isolation during the covid-19 pandemic. loneliness and social isolation frequently co-occur and are all too common in older adults. while the term loneliness refers to subjective feelings, social isolation is defined by the level and frequency of one's social interactions. as a generally accepted concept, loneliness is defined as the subjective feeling of being alone, while social isolation describes an objective state of individuals' social environments and interactional patterns. studies suggest that while loneliness and social isolation are not equal to each other, both can exert a detrimental effect on health through shared and different pathways. prior to the covid-19 pandemic, loneliness and social isolation were so prevalent across europe, the usa, and china (10-40%) (leigh-hunt et al., 2017; xia and li, 2018 ) that it was described as a "behavioral epidemic" (jeste et al., 2020) . the situation has only worsened with the restrictions imposed to contain viral spread. loneliness is associated with various physical and mental repercussions, including elevated systolic blood pressure and increased risk for heart disease. both loneliness and social isolation have been associated with an increased risk for coronary artery disease-associated death, even in middle-aged adults without a prior history of myocardial infarction (heffner et al., 2011; steptoe et al., 2013) . furthermore, research has shown that both loneliness and social isolation are independent risk factors for higher all-cause mortality (yu et al., 2020) . being lonely has several adverse impacts on mental health. reduced time in bed spent asleep (7% reduced sleep efficiency) and increased wake time after sleep onset have been related to loneliness (cacioppo et al., 2002; fässberg et al., 2012) . increased depressive symptomatology may also be caused by loneliness, along with poor self-rated health, impaired functional status, vision deficits, and a perceived negative change in the quality of one's life (lee et al., 2019) . a systematic review of suicide risk also found that loneliness is associated with both suicide attempts and completed suicide among older adults (fässberg et al., 2012) . loneliness, along with depressive symptoms, are related to worsening cognition over time. a systematic review concluded that loneliness and social isolation were significantly associated with incident dementia (kuiper et al., 2015) . the proposed mechanism for the adverse health impacts of loneliness focuses on the physiological stress response (such as increased cortisol) (xia and li, 2018) . abnormal stress responses lead to adverse health outcomes. for social isolation, the mechanism may be related to behavioral changes, including an unhealthy lifestyle (such as smoking, alcohol consumption, lower physical activity, poor dietary choices, and noncompliance with medical prescription) (kobayashi and steptoe, 2018; leigh-hunt et al., 2017) . a smaller social network with less medical support exacerbates these conditions. recognizing and developing a better understanding of these possible mechanisms should help us to design the most impactful interventions. there are established ways to maintain feelings of being connected to others despite having to maintain social distancing. by organizing our activities every single day, we can become more resistant to the onset of feelings of loneliness. for older adults, some tips are as follows. • spend more time with your family. utilize opportunities offered by the pandemic. before the pandemic, some family members may have been distracted by work and school commitments, but now they may have more time at home and a higher degree of freedom to connect with older loved ones. in the era of social distancing, quality interactions using physical distancing of at least two meters along with the use of personal protective equipment such as masks enable contact with family members. this is vitally helpful to defend against loneliness. • ensure basic needs are met. family and carers should ensure food, medication, and mask accessibility for older adults, especially those who live alone. • structure every single day. to stay confined at home for much of every day is a psychological challenge for many people. when most outdoor activities are not available, it is not easy to maintain a regular daily schedule. however, we can encourage and support engagement with activities deemed pleasurable by the older person with benefits for physical, mental, and spiritual well-being. regular scheduling is especially supportive for older people at risk of delirium, which is characterized by a disturbance of circadian rhythm. television and youtube channels adapted for older adults with proper physical and mental programs (e.g. exercise programs, mindfulness practice, and music programs) can also be very useful. • maintain physical and mental activities. exercise has benefits for physical and psychological health (specifically for mood and cognition). there is evidence that regular engagement in mentally challenging and new activities may reduce the risk of dementia. although we may not be able to exercise together as before, we should maintain physical activities at the individual level. besides, these personal physical activities can be performed at a group level by setting a common goal, sharing our progress, or creating a friendly competition via social media. • pursue outdoor activities while following the guidance of social distancing. brief outdoor activities are usually still possible and beneficial to health. one can feel much better as a result of sunlight exposure and the ability to see other people while still maintaining physical distancing. • manage cognition, emotion, and mood. loneliness is often associated with negative thoughts (cognitions). moreover, anxiety and depression may cause social withdrawal which will exacerbate the loneliness and isolation associated with social distancing. acquiring reliable information about the pandemic helps avoid unnecessary worry and negative rumination. conscious breathing, meditation, and other relaxation techniques are helpful for the mind and body and can decrease one's level of anxiety and depression. emotional support for family members and friends is especially important during this harsh pandemic period, but one should not hesitate to seek help as well. • pay attention to psychiatric symptoms. the pandemic is quite stressful for every individual, and the significant stress can precipitate the occurrence or recurrence of mental disorders in some people, especially vulnerable older people. depression, anxiety, and sleep disturbance are common, especially when one is under quarantine or self-isolation. other symptoms include anger, irritability, and compulsive behaviors, such as repeated washing and cleaning. furthermore, the experiences of social isolation and quarantine may bring back post-traumatic stress disorder symptoms for those previously exposed to other related events such as the severe acute respiratory syndrome and middle east respiratory syndrome epidemics (hawryluck et al., 2004) . online screening tools and rating scales can help us to understand the magnitude of the impact on our mental health. people with existing psychiatric disorders and their family members should pay special attention to their mental health and follow important tips to prevent worsening of symptoms. medical assistance should always be sought when necessary, particularly in response to the expression of suicidal ideation. those taking prescribed psychiatric medications should make sure that their supply is adequate, despite the limitations imposed by social distancing and the difficulty in visiting the pharmacy. government agencies, social service organizations, and healthcare providers should consider offering online psychological services (or at least phone services) to those psychogeriatric patients who need medical advice during the social isolation period. • take special care of older people with dementia and their family carers. the world and the way people live have significantly been disrupted in response to the covid-19 pandemic. changes are always stressful and require people to adapt. however, people with dementia have compromised adaptive function, and the pandemic may aggravate negative emotions and invoke behavioral and psychological symptoms. recognizing that people with dementia may find it difficult to understand and comply with social distancing, caregivers should try to give instructions on hand hygiene, social distancing, and other protective measures in a simple, straightforward, and understandable way. regular daily schedules and activities should be arranged and individually tailored to the dementia patient's interests. family carers might be under especially severe levels of stress and feel even more isolated and alone. more detailed information on the unique aspects of the pandemic's effects on dementia caregiving is available on the alzheimer's disease international website (alzheimer's disease international, 2020). the societal impact of the covid-19 pandemic has been broad and very challenging. no aspect of normal societal functioning has been spared. quarantine and social distancing are necessary measures to prevent the virus from spreading but also lead to elevated levels of loneliness and social isolation, which in turn produce physical-and mental-health related repercussions. adopting appropriate steps to keep social and familial connections, maintain healthy activities, and manage emotions and psychiatric symptoms can help relieve the adverse consequences of loneliness and isolation. the pandemic has illuminated the pre-existing threat to well-being that older adults frequently experience with social isolation and loneliness. perhaps we can use this moment to commit ourselves to addressing these unfortunate aspects of life for older adults in the post-pandemic period, for example, developing virtual health care, new technology, and government policy. on the may 23, 2020, in collaboration with interdem, ipa ran a webinar program addressing this very issue: "covid-19, social distancing and its impact on social and mental health of the elderly population." adi offers advice and support during covid-19 do lonely days invade the nights? potential social modulation of sleep efficiency a systematic review of social factors and suicidal behavior in older adulthood sars control and psychological effects of quarantine social isolation, c-reactive protein, and coronary heart disease mortality among community-dwelling adults battling the modern behavioral epidemic of loneliness: suggestions for research and interventions social isolation, loneliness, and health behaviors at older age: longitudinal cohort study social relationships and risk of dementia: a systematic review and metaanalysis of longitudinal cohort studies high prevalence and adverse health effects of loneliness in community-dwelling adults across the lifespan: role of wisdom as a protective factor an overview of systematic reviews on the public health consequences of social isolation and loneliness global covid-19 case fatality rates social isolation, loneliness, and all-cause mortality in older men and women severe outcomes among patients with coronavirus disease loneliness, social isolation, and cardiovascular health social isolation, loneliness, and all-cause mortality in patients with cardiovascular disease: a 10-year follow-up study none. t. j. hwang wrote the manuscript, k. rabheru, c. peisah, w. reichman and m. ikeda served as scientific advisors and participated in writing or technical editing of the manuscript. key: cord-302708-wt86pp4l authors: bonell, chris; michie, susan; reicher, stephen; west, robert; bear, laura; yardley, lucy; curtis, val; amlôt, richard; rubin, g james title: harnessing behavioural science in public health campaigns to maintain ‘social distancing’ in response to the covid-19 pandemic: key principles date: 2020-08-01 journal: j epidemiol community health doi: 10.1136/jech-2020-214290 sha: doc_id: 302708 cord_uid: wt86pp4l nan coronovirus disease 2019 (covid19) , like middle east respiratory syndrome (mers) and severe acute respiratory syndrome (sars), is an infection arising from a coronavirus. the covid-19 pandemic is unprecedented in recent times in terms of the global spread of infection and the resultant morbidity, mortality and burden on health systems. 1 2 in the absence of a vaccine, reducing transmission of the covid-19 virus requires rapid and extensive behaviour change to enact protective behaviours 3 and 'social distancing' across whole populations. although 'social distancing' is the current most used term, it actually refers to maintaining physical separation by reducing the number of times people come into close contact with each other across whole populations. 4 social distancing applies regardless of infection status and is thus distinctive from quarantine or the isolation of those with suspected or diagnosed infection, which is also an important element of infection control. 5 6 governments across the world are implementing a diverse range of interventions to promote adherence to social distancing measures, which include elements of education, persuasion, incentivisation, coercion, environmental restructuring, restriction and enablement. 7 8 interventions have been developed rapidly and could not be informed directly by evidence, given the novelty of the virus and rapid spread of the pandemic. 9 despite this lack of direct evidence, a body of behavioural science exists which can usefully inform the current interventions and promote adherence to these restrictive measures. this body of science has been developed through the study of other infections (including other coronaviruses such as mers and sars), other areas of health and other areas of behaviour. this body of science suggests a number of principles which could ensure that interventions are more likely to achieve their intended outcomes and less likely to generate unintended harmful consequences. as a group of behavioural and social scientists who have shared their advice with government through the uk's government office for science, we have collaborated to develop a series of principles to inform interventions to promote whole population adherence to social distancing measures. these were informed by members' expertise and knowledge of existing theory and evidence, rather than by any formal review of the literature. 1. clear and specific guidance: information will be necessary, but insufficient, for whole population behaviour change, which also requires motivation and the opportunity to implement change. 10 nonetheless, information is important and must provide clear and specific guidance for exactly what behaviour individuals should adopt to implement social distancing. 11 2. 'protect each other' messages are promising, particularly when building on messages promoting collective identity and supportive social norms (see point 3). messages promoting care for others are rooted in the psychology of social identity, 12 social influence 13 and moral behaviour, 14 with evidence of benefits in the covid-19 and other health contexts. 15 16 'protect each other' messages should stress how desired behaviours benefit the group and protect its most vulnerable members, including those we love. this will be enhanced by concrete examples, powerful images and the actual voices of those we need to protect (loved ones, the vulnerable, healthcare systems and workers) linked to clear, specific advice on how to implement social distancing. images and accounts of widespread population adherence (rather than examples of non-adherence) can persuade 'conditional co-operators' (those whose willingness to help others is conditional on being aware of others doing so) to over-ride individual selfinterest and to act in the collective interest. 17 18 in communicating such messages, it is important to recognise variation across population groups, for example by age, socio-economic status and ethnic group, in terms of what is given up when adhering to social distancing, 19 which might inform segmented communication and enablement strategies (see principle 8 below). in contrast, 'protect yourself ' messages will have limited overall impact among the general public because many consider themselves at low risk of severe consequences from covid-19 infection and are unlikely to be persuaded otherwise. 20 21 this may be different for those with specific vulnerabilities who are asked to 'shield' themselves for extended periods of time. 3. 'stand together' messages emphasise how our sense of self is rooted in our proud membership of groups such as families, neighbourhoods, communities and nation, linked to sense of duty, solidarity and inclusion. messages should come from voices representative of and trusted by the group rather than those perceived as partisan or self-interested. 22 messages may be tailored to appeal to specific sub-groups based on gender, age or regional, ethnic or cultural affiliations, 23 drawing on family and faith/interfaith voices particularly for some class and ethnic groups. 24 in doing so, it is critical to draw on voices that are appropriate to the group in question. for instance, young people are particularly influenced by the voices of peers and others of their age group including celebrities/influencers, which need to be harnessed to improve adherence. 25 26 it is also critical to avoid stereotypic or divisive messages. rather, by using inspiring concrete examples (such as community and healthcare volunteers) it should be stressed that diverse groups, for example, differing in ethnic or socioeconomic background, are working together, helping each other and are all integral parts of a common community. messaging will be undermined where policies are perceived as unequitable or socially divisive. 4. 'this is who we are' messages should draw upon the social norms (informal rules that govern behaviour) of groups. 27 messages should be presented as reflecting and affirming group culture (injunctive norms: 'this is who we really are'), and group behaviour (descriptive norms of evolving behaviours: 'this is what we are doing'). 28 messages which imply people are doing undesirable things ('don't panic buy'; 'don't cheat on adherence') may have unintended harmful consequences by undermining descriptive norms. 5. avoid messages based on fear or disgust in relation to other people: disgustbased messages may play a role in campaigns encouraging people to wash their own hands but must not be used in messages about others' hygiene or infection status. these would be counterproductive in the control of covid-19 because they would undermine collective identity and efficacy, and may lead to the stigmatisation of affected individuals or groups. 29 6. avoid authoritarian messages: messages based on coercion and authority can in some circumstances achieve large changes in the short term but can be hard to sustain in the longer term. evidence shows that individuals and populations differ markedly in their receptiveness to what may be seen as authoritarian moral messages and that sustained lock-downs can be associated with civil disorder, particularly where populations perceive inequities in how these are managed. 14 26 30 7. 'make a plan and review it regularly' messages can build on points 1-4, rooted in the psychology of reflective decisions to break emotion-or habitdriven behaviour. plans may help maintain behaviour change by helping people to anticipate possible barriers and enablers to adherence and address these in advance. 31 32 messages should give clear, specific and calm advice, helping households to plan together how to commit to social distancing while still accessing income, food, social networks and communication, and exercise. circumstances will evolve, so householders should be encouraged to review plans regularly. planning materials should be provided in paper copy or via online or smartphone app support. 8. 'make it possible' messages: reward, incentives and enablement tend to be more effective influences on this kind of behaviour than punishment, disincentives or castigation. 33 34 since behaviour is influenced by social context, 35 messaging will be more persuasive and effective if there is a clearly communicated offer of timely and generous support in terms of income, employment rights and food, online access to social networks, communication, entertainment, education, and parenting and mental health support, and opening up more green space to public access. such support needs to be long-term to support maintenance of behaviours and embrace progressive universalism-open to all but aiming to maximise benefits for the most disadvantaged. 36 reducing physical barriers to social distancing will increase adherence and reduce the distrust, distress and mental ill health arising from them. 26 campaigns should also consider the potential for unintended consequences using existing frameworks to minimise these possibilities. 37 11. co-design: interventions should be codesigned and piloted with relevant audience groups using a range of methods including online engagement and ethnography, and virtual focus groups. 9 17 38 they should be evaluated using pre-agreed indicators of delivery, reach and impact, and the evaluation should feed back into future communications. polling and quantitative and qualitative research data should be used to assess the impact of the overall communications programme on trends in, for example, a) sense of collective identity, b) sense of duty of care to others, c) motivation for social distancing, d) behaviour planning and e) behaviour change. we have drawn on our knowledge of behavioural and social science to outline key principles which can be used to inform the development of behavioural and social interventions for the response to the covid-19 pandemic, to maximise their potential and minimise the risk of unintended harms. these principles do not remove the need for empirical formative research with relevant communities to inform interventions or for interventions to be pre-tested prior to implementation and evaluated once implemented. however, we hope that they provide a helpful means of ensuring that such efforts focus on the best candidate interventions. with public health england (phe), in collaboration with the university of east anglia. the views expressed are those of the authors and not necessarily those of the nhs, the nihr, the department of health and social care or public health england. provenance and peer review not commissioned; externally peer reviewed. this article is made freely available for use in accordance with bmj's website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by bmj. you may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained. 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inequalities in england post-2010. london: the marmot review dark logic": theorising the harmful consequences of public health interventions ebola and public authority: saving loved ones in sierra leone acknowledgements ly is an nihr senior investigator and her research programme is partly supported by nihr applied research collaboration (arc)-west, nihr health protection research unit (hpru) for behavioural science and evaluation, and the nihr southampton biomedical research centre (brc). key: cord-324234-3l8n9mhf authors: brennan, john; reilly, patrice; cuskelly, kerry; donnelly, sarah title: social work, mental health, older people and covid-19 date: 2020-05-12 journal: international psychogeriatrics doi: 10.1017/s1041610220000873 sha: doc_id: 324234 cord_uid: 3l8n9mhf nan social work with older people in ireland: the pre-covid-19 context of practice legislation and service provision for older people in ireland have been given low priority until recent years which, it could be reasoned, is reflective of the systemic and legislative discrimination (donnelly and o'loughlin, 2015) . recently, however, there are indications that aging is beginning to be constructed in a more positive framework and older people are now almost universally perceived as a deserving group who are entitled to better quality and increased resourcing of services and support from the state (scharf et al., 2013) . in ireland, social workers have a key role in the care of older people. they work in general health and mental health and social care settings within the hospital, community, and residential and palliative care sectors. the largest number of such social workers are based in the acute general hospital setting. significantly, social workers in ireland and across europe regularly work with people, families, and/or groups who are in crisis. they work in the gray areas of confusion, uncertainty, and doubt (jordan, 2000) nouns that can aptly fit the covid-19 context very well. within the context of covid-19 in ireland, it should be noted that while social workers are employed in public residential care units, they are rarely employed in the nursing homes which are primarily run by the private sector. social workers engaging with the general population of older people work with people presenting with a range of issues including mental health needs. increasingly, social workers are likely to work with those older people who experience poverty, ill-health, depression, dementia, substance abuse, or those with unresolved traumas from previous years (phillips and ray, 2012) . issues of loss and grief are regularly to the fore in such situations. working with the whole system including families and informal carers is also a key aspect of the work. there are also a subset of social workers working in specific psychiatric settings. the types of mental health difficulties manifest in older people in ireland are similar to that found elsewhere in the world. older people with mental health difficulties can present with anxiety and depression, dementia-related behaviors, and problems arising from alcohol misuse; a smaller cohort of older people can present with late-onset psychosis or schizophrenic type conditions. the social workers in the specialist mental health subset are based in community mental health teams and in acute psychiatric hospital and residential care settings. a further subset comprises social workers working on psychiatry of later life teams. the precise mental health social work role on the older persons' mental health teams is significantly a family-focused role. a large part of the support/intervention is in relation to family support, especially concerning persons with cognitive impairment, such as dementia. interventions will vary depending on the underlying mental health difficulty. the covid-19 pandemic has exacerbated many issues for older people and their carers, while throwing up new difficulties, particularly an increase in mental health difficulties (galwa et al., 2020) . ageism, human rights, social justice, and ethical dilemmas form a backdrop to, for example, experiences of illness, death and dying, grief and loss, isolation, and safety concerns. additionally, there is a reduction in formal support from service providers during these unprecedented times. for older people generally, covid-19 has hugely challenged their opportunities to exercise self-determination in realizing their own well-being. for example, older people who are vulnerable because of a mental health problem may be further excluded from decision-making about their own care needs or plans. given the underlying levels of ageism in society in ireland and elsewhere, social justice was a key issue in pre covid-19 times at both the individual and policy levels. however, such concerns have been exacerbated even further by the present extraordinary circumstances resulting from covid-19. for older people in nursing/residential homes for older people in nursing homes, they are at an increased risk of contracting the covid-19 virus. at the time of writing, the virus is present in onethird of nursing homes in ireland with 50% of all covid-19-related deaths occurring in these settings (department of health, 2020b). when care homes have residents who have dementia, and who may be prone to wandering, risks of spreading the illness increase even more. a further concern is that such residents will be given antipsychotics to sedate them which in itself is a risk; such practices are also abusive and a denial of rights and a deprivation of liberty. risk of abuse is even greater when there are replacement or temporary staff and given the absence of visiting families who can act as an aid to monitoring their loved one's health and wellbeing. in addition, isolation has increased for all residents because visiting has largely stopped leading to increased loneliness as a result with a concomitant increase in depressive feelings and anxiety levels. the overstretched care staff themselves are at risk of severe burnout, precipitating perhaps a further threat of abusive care practices. this risk is further increased because many safeguarding and protection social workers in ireland have been redeployed to "contact and tracing" teams meaning that there are significantly fewer frontline social workers to investigate and monitor abusive situations. also, many homes are being managed by agency staff due to staff sick leave. such sick leave absences have left some nursing homes with difficulties getting replacement staff, thereby impacting on the general care of the residents. aside from the physical care that is potentially diminished, the human relationships formed between residents and regular staff are consequently broken in these circumstances. covid-19 restrictions also impact on the rights of residents including end-of-life wishes which may not be sought or be disregarded entirely. funeral rituals, traditions, and arrangements have been for the most part entirely disrupted. residents are often dying without the presence of close family members. family members therefore do not have the opportunity to say good-bye before losing their loved one unless a phone or video call can be facilitated. after death, coffins are now closed when covid-19 has been diagnosed so family members do not get to see their relative before burial or cremation; ambiguous or unresolved grief amongst some bereaved older people or relatives may be a by-product of such funeral practices. for older people living in the community many of the difficulties regarding staffing and visiting are similar and psychiatric and other day services are closed. the consequent problems of isolation, anxiety, and depression are similar too. increased suicidal ideation is now an issue. older people including those with mental health problems are at significant risk of abuse or neglect (donnelly and o'loughlin, 2015) . care planning for those with enduring mental health conditions have had to be reviewed to find ways to continue to offer support. as outlined earlier, older people aged over 70 have been "strongly advised" to do what is termed in ireland, to "cocoon." despite the good intentions, there are strong elements of ageism in this policy given that many people over age 70 are fit and well. as lynch suggests, "we need to remember the rather arbitrary nature of what old age is and how this 'chronological age' is a fairly loose benchmark : : : " (2014: 77). this policy has to be a risk to the mental health of otherwise healthy older people. for social workers carrying out their roles the mechanisms used to offer social work services and support have had to change dramatically during covid-19. in ireland, social work has been deemed an essential service, and therefore social workers continue to do their jobs. however, the face-to-face delivery of this service is now much reduced. in its place, online methods of communication beyond telephones are being sought and tested across the country. maintaining the professional relationships with the users of the social work services remains crucial. social workers have changed their work hours and changed work practices to achieve social distancing protocols with colleagues and many now work part-time from home during each week. some social workers have been temporarily redeployed to undertake new roles or tasks, for example, moving from working with community-based older people to a position as a family liaison worker for nursing homes in a local area. however, in some instances, as mentioned above, redeployment has meant a decrease in frontline social work. the near complete absence of social work services in nursing homes in ireland has been a problem even before the onset of covid-19. the use of internet platforms, such as zoom, has increased hugely to facilitate meetings, conference calls, and learning opportunities. such platforms are also being used to give opportunities to social workers to debrief, be supported or get advice from colleagues. social workers in residential, hospital, and community settings have sought new creative ways to advocate for and support older people to find ways to overcome social isolation, receive information, and access resources, including increased usage of assistive technology. social workers have attempted to keep face-to-face contact with older people by offering "walking appointments," that is, meeting the person at their home, but meeting outside and walking at a physically safe distance together which encourages physical activity, decreases social isolation, and allows the social worker to maintain direct contact. as referred to above, the issues that covid-19 has highlighted include dealing with grief and loss in circumstances, where the normal routines have been upset, or in the case of death, the usual rituals cannot be adhered to. examples of practices by social workers redeployed to nursing homes include facilitating residents to see and talk to family members via social media apps; asking families to purchase tablets for the residents to allow them to maintain regular contact, updating family members on daily basis, preparing family and residents for, and offering support during and after end of life and engaging with funeral undertakers around the particular requirements thrown up by covid-19, such as having to use cadaver pouches for the deceased. social workers in community settings have mobilized volunteers to deliver shopping, meals, medicines, and other necessary items. they are making telephone calls to prompt the taking of medications, to address concerns and maintain contact. aside from the work with families mentioned above, social work has continued to support family caregivers in their carer roles. information giving, linking with agencies and resources, advocacy, and emotional support are key tasks during this pandemic. many carers are fearful about what should happen if they become unwell and are no longer in a position to provide care for their loved one, so ongoing psychological support is critical. supporting carers is particularly important in situations where there are pre-existing concerns about safety, for example, in relation to a loved one with dementia. this concern is further heightened when a family member is resistant to intervention. given that home visiting has largely ceased, social workers are finding new and innovative ways to support carers who are under pressure from their caring role. at a more global level, the international federation of social workers has worked with national social work organizations and other international agencies to provide opportunities for professional learning and support via webinars and its website. this has reinforced the sense of a global community, that we are all in this together and that people above all else matter in the world. as mentioned above, social workers work regularly with individuals and families in crisis situations, so dealing with complex situations is part of daily professional life. this has stood them in good stead in this current crisis, even though it is unprecedented. social workers are in the frontline in ireland and across europe and further afield in supporting older people emotionally and practically to maintain their mental health. this pandemic gives us an opportunity to explore new ways of communicating and offering care to older people. one of the key issues learned is the need to refocus policy toward the provision of health and social protection services that are comprehensive, commentary 3 integrated, accessible to, and affordable for all. from a european perspective, a greater emphasis must be given to social priorities to balance what have been the dominant economic priorities in european union policies. this would help to protect the economic and social rights of older people generally and for those with enduring mental illness. the high incidence of and death rates from covid-19 in nursing homes should be the catalyst for an examination of how we can meaningfully address both societal ageism and the stigma associated with mental health problems. responses to the pandemic have shown the similarities between problems in different countries and that we can learn much from each other. in this regard, preparations for a future pandemic must be undertaken so that there is sufficient ppe for professionals to do their jobs safely. it should also be recognized too that staff can have the same anxieties as the people they are attempting to assist. social workers and other frontline staff must be supported and have opportunities to debrief through good self-care and organizational support strategies. it is clear that the covid-19 crisis has thrown up particular challenges in the care of older people with mental illness. it is important to remember that the term crisis refers to change and or opportunity, so change is an important aspect of crisis (loughran, 2011) . we hope therefore that as we transition to a new normal, that we take this unique opportunity to call for the setting up integrated, person-centered long-term care systems in each country (who, 2020) which promote human rights prioritize each person's needs and provide the necessary resources and support to enable all older people with mental illness to age well. john brennan is an independent social worker. he has a particular interest in social work with older people, having had extensive practice experience in hospital social work settings. he is the vice-president of the international federation of social workers europe and the vice-chair of the irish association of social workers. patrice reilly is a social work team leader in integrated care for older persons in the irish health service executive. patrice has extensive experience working in partnership with older persons and their families in community care and across statutory and voluntary sectors. patrice is currently working in a newly created covid-19 role offering family liaison and bereavement support in a number of public nursing homes. kerry cuskelly is a principal social worker in adult mental health services. she has extensive experience of working in partnership with individuals, families and communities in relation to mental health. in supporting the response to changes in service provision in the context of covid-19, kerry has led out on the development of initiatives in relation to the provision of tele-health and familyfocused supports in mental health. dr. sarah donnelly is an assistant professor of social work and co-director of the professional masters in social work at the school of social policy, social work and social justice, university college dublin. she has extensive practice experience as a senior medical social worker in a variety of clinical areas including neurology and age-related healthcare and is a co-convenor of the european network for gerontological social work. guidance on cocooning to protect people over 70 years and those extremely medically vulnerable from covid-19 growing old with dignity: challenges for practice in an ageing society the mental health consequences of covid-19 and physical distancing: the need for prevention and early intervention social work and the third way: tough love as social policy understanding crisis therapies: an integrative approach to crisis intervention and post traumatic stress social work with older people changing generations: findings on new research on intergenerational relations in ireland. social policy and ageing research centre (sparc), trinity college dublin, and the irish centre for social gerontology (icsg) statement -invest in the overlooked and unsung: build sustainable peoplecentred long-term care in the wake of covid-19 statement-invest-in-theoverlooked-and-unsung-build-sustainable-people-centredlong-term-care-in-the-wake-of-covid-19 key: cord-334574-1gd9sz4z authors: little, jessica s.; romee, rizwan title: tweeting from the bench: twitter and the physician-scientist benefits and challenges date: 2020-11-11 journal: curr hematol malig rep doi: 10.1007/s11899-020-00601-5 sha: doc_id: 334574 cord_uid: 1gd9sz4z purpose of review: social media platforms such as twitter are increasingly utilized to interact, collaborate, and exchange information within the academic medicine community. however, as twitter begins to become formally incorporated into professional meetings, educational activities, and even the consideration of academic promotion, it is critical to better understand both the benefits and challenges posed by this platform. recent findings: twitter use is rising amongst healthcare providers nationally and internationally, including in the field of hematology and oncology. participation on twitter at national conferences such as the annual meetings of american society of hematology (ash) and american society of clinical oncology (asco) has steadily increased over recent years. tweeting can be used advantageously to cultivate opportunities for networking or collaboration, promote one’s research and increase access to other’s research, and provide efficient means of learning and educating. however, given the novelty of this platform and little formal training on its use, concerns regarding patient privacy, professionalism, and equity must be considered. summary: these new technologies present unique opportunities for career development, networking, research advancement, and efficient learning. from “tweet ups” to twitter journal clubs, physician-scientists are quickly learning how to capitalize on the opportunities that this medium offers. yet caution must be exercised to ensure that the information exchanged is valid and true, that professionalism is maintained, that patient privacy is protected, and that this platform does not reinforce preexisting structural inequalities. social media is a rapidly evolving platform for communication that is increasingly being utilized across the academic medicine community. twitter, a free microblogging platform, enables users to read and post 280-character messages called "tweets" [1•, 2] . twitter provides novel opportunities for physician-scientists to interact and collaborate across institutions and diverse fields. it increases access to research and enables real-time discussion of new publications [3] . not only does it serve to disseminate information, it also may be utilized as a means to generate data [4, 5] . as this platform is increasingly integrated into the academic medical community, it is important to consider both the benefits and potential challenges posed by this technology. opportunity to connect and advance common interests. even trainees at an early stage are able to follow and engage with leading experts in a particular specialty with greater ease, thus advancing their understanding of key scholarship or topics of discussion at the forefront of the field [5, 6] . additionally, engagement on twitter prior to and during academic meetings can help build professional relationships and communities that may lead to future collaborations or opportunities for career advancement [1•, 2, 7] . in one recent analysis of tweets during the american society of clinical oncology annual meetings between 2011 and 2016, pemmaraju and colleagues found that both individual authors and overall number of tweets significantly increased over the 5year period [8] . meeting attendees may tweet responses and commentary to presented scholarship and even arrange "tweet ups" or face-to-face meetings for those who met virtually on twitter [5, 9] . and while in the past, missing a national or international conference may have led to loss of access to important new data, ideas, or opportunities for collaboration, now, as academic meetings are increasingly integrated with social media, physicians can watch presentations, participate in discussions, and network with other attendees remotely [1, 10, 11] . mentorship and academic sponsorship can also be practiced through the medium of twitter. mentors or academic sponsors advanced in their field who have increased influence or impact on twitter can promote the accomplishments of their mentees to increase their individual visibility. likewise individuals can promote their own accomplishments including research publications, academic promotions, or awards targeting a broader audience that may result in additional career opportunities [12, 13] . and as social media engagement continues to grow, academic institutions such as mayo clinic have even begun to consider ways to incorporate social media scholarship into metrics for academic promotion and tenure [14• ]. while there are considerable potential professional benefits to engaging in social media platforms such as twitter, there are also challenges. social media may blur the line between the professional and personal identity of a physician and missteps may harm the professional reputation of users [15, 16] . it is therefore critical to compose each "tweet" with the understanding that the post will be public and permanent [5] . in one 2010 study let by chretian et al., 5156 tweets from selfidentified physicians were analyzed over one month. of those, 144 tweets were categorized as unprofessional with 38 representing potential patient privacy violations, 33 containing profanity, 14 with sexually explicit material, and 4 with discriminatory statements. and amongst the 27 users responsible for privacy violations, 25 (92%) were identifiable by full listed name on profile, photo, or linked website [17, 18] . furthermore, physicians are not simply at risk of disapproval by colleagues and patients or punitive actions by employers. a survey of the directors of medical and osteopathic boards revealed 92% (44 out of 48 respondents) indicating at least one of several online professionalism violations had been reported to the board. in response 71% held disciplinary hearings and serious disciplinary outcomes including license restriction, suspension, or revocation occurred at 56% of the boards [18] . in response to these concerns, the american medical association created guidelines for social media use amongst physicians [19] . however, this guidance does not provide clear rules of conduct and should serve as simply the first step in the construction of formal policies and training across institutions for physicians on social media. another key issue that is introduced by the use of twitter is the potential amplification of implicit biases and structural inequality already problematic in academic medicine. while many maintain that twitter can increase equity by opening new channels of communication to diverse individuals across geographic, socioeconomic, and disciplinary barriers, others argue that social media may increase the impact of those who already have the most impact and exacerbate inequality [12] . gender inequalities have already been identified in many key areas across medicine, and gender bias in the way women are addressed and perceived may affect career advancement [20, 21] . how twitter reinforces these biases must be considered. one study by zhu et al. identified twitter users amongst speakers and coauthors presenting at academy health's 2018 annual research meeting and evaluated their most recent tweets. amongst more than 3000 health services researchers, women had less influence on twitter than men with half of the mean number of followers, and fewer mean likes and retweets per year. these differences were largest amongst full professors and similar across the distribution of number of tweets [22• ]. further investigation is needed into whether these inequities exist for other underrepresented minorities on twitter. finally, it is important to acknowledge that twitter may have detrimental effects on the productivity of participants. while there are small steps being taken towards acknowledging activity and scholarship on social media at certain institutions, there is still minimal formal recognition of physician use of twitter in a professional sense [6, 14] . it can be easy to sacrifice the slower more laborious work of designing studies, writing papers or book chapters, and keeping up with patient charting when faced with the potential positive feedback loop of a popular tweet. benefits social media and twitter in particular have radically transformed the landscape of information sharing, and this is especially relevant in relation to biomedical research. the platform presents opportunities for rapid review of new papers, easy access to multiple journals and expert opinions, increased potential for crowdsourcing, and enhanced postpublication peer review. physicians can follow respected journals, professional societies, and mentors or colleagues who may be sharing important advances in the field. in this way, physicians can stay up to date with minimal time expended. tweets and articles can be saved or "bookmarked" to review in more detail later [5] . similarly, researchers may increase the impact of their work by using twitter. one study analyzing 4208 tweets showed that highly tweeted articles were 100 times more likely to be highly cited than less-tweeted articles [23] . journals may also utilize social media such as twitter to increase the impact factor of their work. one group recently proposed instituting a tif or twitter impact factor for journals to measure the academic reach and impact of a journal on the social media platform [24] . twitter has also encouraged innovative forms of communicating research findings. another recent prospective case control crossover study looked at 44 research articles published in the same year in annals of surgery. each article was tweeted in two formats: as the title alone or as the title with a visual abstract. a strong correlation was found between the use of visual abstracts and increased dissemination on social media. additionally, the articles with a visual abstract tweeted received more site visits than the articles without visual abstracts. [25] one area that has expanded rapidly on twitter is postpublication peer review and twitter journal clubs. journal clubs have long served as important tools for propagating new research, practicing evidence-based medicine, and developing skills to evaluate research design and validity of the findings [26] [27] [28] . recently a diverse range of twitter journal clubs have arisen including id journal club, nephjc, jgim twitter journal club, and others [27, 28] . organizers will choose articles and indicate a date and time for the meeting. tweets are organized and referenced by hashtags and participants can follow along or interact by commenting on individual tweets. content experts or authors may be invited and physicians at all levels may join in to learn collectively. and while these meetings often cater to physicians and physicianscientists, journal clubs are typically open to any individual including patients, allowing improved public dissemination of new research advances. crowdsourcing and collaboration during peer review may lead to important findings of design or methodology errors, statistical inconsistencies, or other flaws in publications. in one case, twitter critics rapidly identified errors in methodology in an article in science titled "genetic signatures of exceptional longevity in humans". within a week, the authors released a statement acknowledging a technical error in the lab test used and the paper was eventually retracted [29] . as the speed and breadth of scientific publication increases, twitter remains an important resource to critically appraise the expanding literature. crowdsourcing and network utilization may also be used positively to impact public health efforts by disseminating educational information to communities, amplifying emergency notifications, and enhancing aid efforts when needed [2] . this has been a particularly useful tool during the covid-19 pandemic of 2020 as the cdc and local health departments have used twitter to circulate critical health information. while social media provides an immense opportunity for information uptake and dissemination, there are important caveats to this information exchange. misinformation is rampant, and developing the ability to discern true facts from misinformation is increasingly challenging as technology advances. new innovations such as the verified badge allow users to know if accounts are authentic, though this may not apply uniformly. as pershad et al. noted, while a celebrity may be verified due to his/her role in the public eye, that individual's views on healthcare topics such as vaccination may not be valid health information [2] . additionally, twitter engagement may be purchased unbeknownst to viewers. in one analysis of the asco 2016 annual meeting, the second largest number of retweets was from fake engagement or purchased retweets by a third party [8] . in another study by desai et al., tweets contained in the official twitter hashtags of thirteen medical conferences from 2011 to 2013 were analyzed. the twitter influence of third-party commercial entities was found to be similar to that of healthcare providers [30] . it is critical to curb this fake engagement at professional medical meetings moving forward to reduce bias and promote transparency. even if physician accounts and engagement are authentic, financial conflicts of interest are frequently not revealed on social media. this may also lead to bias in transmission of information, particularly if populations with less medical expertise such as patients are involved. in one study in jama, 504 out of 634 hematologist-oncologists in the usa who use twitter were found to have some financial conflicts of interest [31] . however, no clear regulations regarding disclosure exist in regard to physician social media and this should be duly considered when evaluating information sources. another example of the potential challenges of twitter was demonstrated with the rapid increase in preprints over recent years and notably during the covid-19 pandemic. while preprints are beneficial in making novel findings rapidly available, these manuscripts often have not undergone the full peer review process. inexperience from the media and lay public in distinguishing peer-reviewed from non-peer-reviewed publications can lead to magnification of findings that are erroneous [32, 33] . twitter not only creates unique opportunities for learning about new research findings, it can also provide rich clinical educational content [34] . "tweetorials" or threaded tweets are used frequently to present lessons on clinical topics and engage learners at all levels [35] . teaching podcasts such as "the curbsiders" and "clinical problem solvers" have also utilized twitter to widen their audience and condense important lessons into easily digestible tweets. one systematic review examined 29 studies that assessed the effect of social media platforms on graduate medical education. these modalities were used to share clinical teaching, points, disseminate evidence-based medicine, and circulate conference materials. given the fast-paced nature of medical residency, social media provides a logical space for on-the-go learning and review. one notable finding was that most studies offered mixed results and provided little guidance on how best to incorporate social media platforms formally into graduate medical education [36] . not only does twitter provide opportunities for trainee and continuing medical educations, it also may be used as a critical tool for patient education [37] . in one survey-based study, a breast cancer social media twitter support community was created. respondents reported increased knowledge about their breast cancer in a variety of areas and participation led 31.2% to seek a second opinion or bring additional information to the attention of their treatment team [38] . on twitter, communities can be created for and by patients using diseasespecific hashtags [39] . for rare diseases in particular, these communities can facilitate new avenues for connection, education, and collaboration between patients and physicians working in highly specialized areas [40] . these networks can even be used as modes to propagate information about available clinical trials to diverse populations [41] . important limitations to learning via twitter remain. patient privacy issues can arise, particularly as photos, radiology, and case descriptions are more widely shared [2, 5, 42] . twitter can serve as an echo chamber, where ideas are magnified by like-minded individuals in close networks, reducing the sharing of outside perspectives [6] . finally, the volume of information can overwhelm users, making it difficult to distinguish valuable knowledge from irrelevant comments. there are significant benefits to the effective utilization of social media platforms such as twitter. physicians and scientists may grow their networks, gain career opportunities, expand the impact of their research, connect with patients, stay up to date on novel discoveries, and much more. however, clear frameworks for professional use of this technology are still being developed. it is vital to better understand the risks to patients and providers in order to safely and deliberately integrate this valuable tool into our institutions and practices. conflict of interest the authors declare that there is no conflict of interest. human and animal rights and informed consent this article does not contain any studies 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social media in graduate medical education cancer patients on twitter: a novel patient community on social media twitter social media is an effective tool for breast cancer patient education and support: patient-reported outcomes by survey disease-specific hashtags for online communication about cancer care rare cancers and social media: analysis of twitter metrics in the first 2 years of a rare-disease community for myeloproliferative neoplasms on social media-#mpnsm cancer communication in the social media age pathology image-sharing on social media: recommendations for protecting privacy while motivating education publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-338654-ma9ayu80 authors: eaton, lisa a.; kalichman, seth c. title: social and behavioral health responses to covid-19: lessons learned from four decades of an hiv pandemic date: 2020-04-25 journal: j behav med doi: 10.1007/s10865-020-00157-y sha: doc_id: 338654 cord_uid: ma9ayu80 our public health approaches to addressing covid-19 are heavily dependent on social and behavioral change strategies to halt transmissions. to date, biomedical forms of curative and preventative treatments for covid-19 are at best limited. four decades into the hiv epidemic we have learned a considerable amount of information regarding social and behavioral approaches to addressing disease transmission. here we outline broad, scoping lessons learned from the hiv literature tailored to the nature of what we currently know about covid-19. we focus on multiple levels of intervention including intrapersonal, interpersonal, community, and social factors, each of which provide a reference point for understanding and elaborating on social/behavioral lessons learned from hiv prevention and treatment research. the investments in hiv prevention and treatment research far outweigh any infectious disease in the history of public health, that is, until now with the emergence of covid-19. which public health response must rely on behavioral and social factors for disease prevention varies greatly depending on disease transmission factors (e.g., mode of disease transmission, rapid travel and trade patterns, economic and health care infrastructure stability). unfortunately, covid-19, has presented itself as a formidable agent posing multiple unique challenges. as a novel virus with no residual immunity from prior exposure, herd immunity can't be relied upon to halt social networks of disease transmission. covid-19 is highly contagious, with multiple transmissions occurring per one contagious person (reproduction rate) during the early stage of outbreak-a relatively elevated rate compared with many other infectious diseases . infections initially present with symptoms that are mostly indistinguishable from other viral diseases, stalling early detection. furthermore, with no curative option, treatment is focused on symptom management. the current state of covid-19 disease transmission has left our public health approaches to be heavily dependent on social and behavioral change strategies to halt transmissions. although different from the social and behavioral dynamics of transmission and pathogenesis, hiv infection offers lessons learned for those who are embarking on this area of research for preventing the spread of covid-19. almost 40 years after the first cases of aids were identified in the us, and with still no effective vaccine, we have learned a considerable amount about the reliance on social and behavioral approaches to slowing infectious disease. the investments in hiv prevention and treatment research far outweigh any infectious disease in the history of public health, that is, until now with the emergence of covid-19. here we outline broad, scoping lessons learned from the hiv epidemic tailored to the nature of what we currently know about covid-19. as a unifying framework, we posit that the social ecological model of health (hanson et al., abstract our public health approaches to addressing covid-19 are heavily dependent on social and behavioral change strategies to halt transmissions. to date, biomedical forms of curative and preventative treatments for covid-19 are at best limited. four decades into the hiv epidemic we have learned a considerable amount of information regarding social and behavioral approaches to addressing disease transmission. here we outline broad, scoping lessons learned from the hiv literature tailored to the nature of what we currently know about covid-19. we focus on multiple levels of intervention including intrapersonal, interpersonal, community, and social factors, each of which provide a reference point for understanding and elaborating on social/behavioral lessons learned from hiv prevention and treatment research. the investments in hiv prevention and treatment research far outweigh any infectious disease in the history of public health, that is, until now with the emergence of covid-19. with our existing healthcare infrastructure we are currently unable to clinically manage the onslaught of coronavirus disease 2019 . existing vaccine development platforms have rendered an 18-month optimistic timeframe for broad-reaching biomedical approaches to prevention (coreil, 2013) . avenues for prevention and treatment outside of an effective vaccine will, therefore, invariably rely on changing social/behavioral patterns (e.g., physical distancing and selfisolation) for containing the spread of disease. the extent to 2005) may prove useful as it attends to levels of intervention that may serve to frame responses to covid-19. the model has multiple foci, including intrapersonal, interpersonal, community, and social factors, each of which provide a reference point for understanding and elaborating on social/behavioral lessons learned from hiv prevention and treatment research. sustained, individual-level, behavioral change is challenging to achieve. interventions targeting individual-level behavior change have remained a cornerstone of hiv prevention (herbst et al., 2005; crepaz et al., 2007; johnson et al., 2006) . there exist critical threads of similarity in our current covid-19 prevention strategies to efforts aimed at stemming hiv transmission. interventions to alter the behavioral patterns of individuals can have important and substantive impact on risk reduction and disease outcomes, but are likely not sufficient for disease eradication. further, it has long been known in hiv prevention and treatment research that intervention effects to alter behavioral patterns can vary greatly across populations and that sub-populations in greatest need of support for changing behavioral patterns are also most likely to experience barriers to accessing support (faugier & sargeant, 1997) . covid-19 prevention efforts are currently largely dependent on individual-level behavior change, including self-isolation and physical distancing, to an unprecedented scale. we know from hiv prevention and treatment research that information, motivation, and behavioral skills are key to initiating behavior change, but are unlikely sufficient for sustained change if only individual components are addressed (fisher et al., 2006) . changes in behavioral patterns are challenging to maintain overtime and, similar to many vaccines, may rely on booster sessions to support (eaton et al., 2013) . limitations to maintaining altered behavioral patterns are observed across a broad spectrum of health behavior change and rely on multi-level intervention approaches (see below) (summers & curtis, 2020; wiltink et al., 2007) . medical mistrust and conspiracy beliefs undermine datadriven public health interventions. uptake of effective hiv treatment advances has long been stymied by underlying mistrust of health care and conspiracy beliefs regarding the origin of hiv, the existence and characteristics of the virus itself, and the purpose and impact of antiretroviral medications (kalichman, 2009; bogart & bird, 2003; eaton et al., 2017) . mistrust of governmental initiatives to implement public health interventions are largely based on a history of abuse of vulnerable populations (e.g., tuskegee syphilis experiment) (bogart & thorburn, 2005) and racial/ethnic discrimination documented within health care infrastructure (obermeyer et al., 2019) . however, new social influences, primarily driven by more general anti-science and antigovernment forces, are impacting covid-19 containment efforts (dyer, 2020) . social media is used to distribute messages warning that covid-19 does not exist, that it is harmless, that is manmade, that a cure exists and is being withheld by the government, that it is being used to justify an imminent 'police state', etc. (butler, 2020) . these conspiracy-driven messages are all well-documented lines of thought in hiv social science research, and critically, result in harmful outcomes (nattrass, 2012; kalichman, 2017) . we have observed in hiv research that conspiracy beliefs tend to be driven by a rejection of authority (i.e., as a political ideology) or as a psychological state of paranoia (kalichman, 2009 ). most critically, we know that poor political leadership results in highly fertile social foundations for developing conspiracy theories towards public health initiatives (nattrass, 2012) . there is likely no better example of the destructive power of conspiracy thinking on public health than the history of the hiv epidemic in south africa during the presidency of thabo mbeki. it is estimated that 330,000 individuals died due to lack of hiv treatment and 35,000 infants were born with hiv as a result of conspiracy driven public health programing (chigwedere et al., 2008) . the need to combat anti-science rhetoric and conspiracy thinking in the era of covid-19 has been apparent since its first days in right-wing media and anti-vaccine activists' propaganda (depoux et al., 2020; garfin et al., 2020; li et al., 2020; llewellyn, 2020) , and failure to squelch the seeds of mistrust will be paid in the cost of human life. social stigma of hiv is grounded in racism, homophobia, and sexism, and the stigmatization of covid-19 has already occurred. social stigma is complex and omnipresent, and acts as a driver of social hierarchy. the extent to which social stigma has weakened efforts to slow hiv transmission is challenging to quantify, however, it is acknowledged as one of the most formidable social factors working against hiv prevention and treatment (brent, 2016) . stigma in hiv social science literature is viewed as a process where individuals living with hiv experience status loss as a result of their hiv positive status (goffman, 1963) . those who experience stigma are devalued, ostracized, and ignored (goffman, 1963; link & phelan, 2001) . in the case of covid-19, elements of social stigma and social hierarchy are currently unfolding. elderly and individuals with compromised immune systems have elevated morbidity and mortality related to covid-19 relative to other groups. political discussion is rife regarding the social tipping point of protecting populations viewed as most vulnerable (e.g., advocacy for the need to protect all human life (mckinley & goldmacher, 2020) vs advocacy for weighing the value of human life (rodriguez, 2020) ). these actions effectively create an in-group vs out-group mentality, or social hierarchy, and have detrimental impacts on public health measures (nyblade et al., 2009 ). the establishment of in-groups versus out-groups perpetuates the devaluing of out-group members, bolsters disproportionate power and influence of in-group members, and is used as a justification for the mistreatment and disregard of out-group members (link & phelan, 2001) . for example, the use of the phrase "chinese virus" (rogers et al., 2020) for covid-19 serves to establish social dominance, blame, and social delineation, all justifications for acts of discrimination, in this case, against people of asian heritage (person et al., 2004) . approaches to addressing stigma in the context of promoting well-being and disease prevention exist and likely provide relevant tools applicable to addressing covid-19. interventions to address stigma have been developed that target individuals, health care workers, communities, and social figures, which will likely find new purpose in covid-19 (andersson et al., 2020; rao et al., 2019; stangl et al., 2013) . research on the hiv pandemic has long established that hiv co-occurs with multiple intersecting epidemics, creating what singer termed a syndemic (singer & clair, 2003) . individuals experiencing mental health and substance abuse problems, food insecurity, housing instability, and overall social marginalization are the most vulnerable to hiv, and hiv infection perpetuates these co-occurring conditions (robinson et al., 2016; walters et al., 2020; turpin et al., 2020; . while the transmission of covid-19 is, of course, markedly different from hiv, there needs to be heightened concern for communities most afflicted by poverty, high population density, barriers to physical distancing, and limited access to health care and other resources-these factors will amplify vulnerability to covid-19. in turn, we should expect covid-19 to exacerbate mental health problems and substance abuse by cutting off social support, increasing stress, further reducing access to services, and impeding healthcare among individuals living in poverty and possessing limited personal agency and social capital (stein, 2020) . multi-level community interventions yield more robust and sustainable outcomes than single-level efforts to prevent hiv transmission. initial social/behavioral interventions to slow hiv transmission largely prioritized the changing of individual level behavior (johnson et al., 2009 ). the field evolved, however, to acknowledge that individual behavior is heavily influenced by the broader social and structural systems wherein behavior occurs (iom, 1995) , and the need to develop multi-level interventions capable of addressing multiple systems that influence behavior (e.g., health care providers, employment, personal safety, health care access) was prioritized (blankenship et al., 2006; des jarlais, 2000) . in the context of covid-19, the most pressing social/behavioral component to containment appears to be physical distancing and hygiene strategies. social influence models of behavior change have proven effective in changing and sustaining changes in behavior by shifting social norms and reinforcing risk reduction efforts (kelly et al., 1997 (kelly et al., , 2006 latkin et al., 2009) . while these models have relied on face-to-face interactions as the vehicle of change, they have been translated to online platforms that are immediately implementable for sustaining measures to contain and mitigate covid-19 (green et al., 2015; marhefka et al., 2012 marhefka et al., , 2013 marhefka et al., , 2014 young et al., 2014; rice et al., 2012; chiu & young, 2015) . examples of multi-level interventions to impact these practices include messaging to promote social distancing and good hygiene behaviors (individuallevel behavior change, delivered at the community-level), the closing of schools and non-essential business services (structural-level), and the increased availability of sanitizing products (e.g., hand sanitizer, disinfectant wipes) in public spaces (structural-and social-level). multi-level interventions pose multiple assessment and implementation related challenges, but have the potential for high efficacy in altering the course of disease (auerbach, 2009 ). community mobilization for disease prevention. engaging multiple societal sectors to address health, social, or environmental issues is the cornerstone of community or social mobilization (unaids, 1997). as outlined by lippman et al. (2013) critical components of community mobilization include: a defined or shared concern, critical consciousness regarding the concern, organizational structure with links to groups/networks, individual or institutional leadership, collective/shared activities and actions, and social cohesion. across the history of hiv in the us there exist multiple instances of community mobilization efforts beneficially impacting the lives of people affected by hiv. similar to what we are currently observing with covid-19, community mobilization efforts to address hiv have typically focused on changing federal level responses. particularly in the earliest days of the hiv epidemic in the us, community mobilization efforts were ultimately highly effective at challenging and changing the response to hiv at the federal level (unaids, 1997) . but efforts were sustained and hard fought. we are observing similar patterns with covid-19 where communities most affected (e.g. high population density cities and communities initially impacted) are appealing to the broader community for a national level response. hiv emerged as a global threat to public health more than 40 years prior to covid-19, and while the lack of public health preparedness for the current pandemic is well recognized (carinci, 2020) , social and behavioral scientists aiming to contribute to the containment and mitigation of covid-19 will be well-served by the lessons we have learned in hiv prevention and treatment research. preventing the worst care scenarios of covid-19 morbidity and mortality can be achieved through intrapersonal, interpersonal, community, and societal levels of data-driven and well-coordinated interventions. hiv prevention and treatment sciences has not always achieved these goals, but the lessons we have learned should be evaluated for use in the case of covid-19 and for future pandemics. stigma reduction interventions in people living with hiv to improve health-related quality of life transforming 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syndemic framework texas' lieutenant governor suggests grandparents are willing to die for us economy trump defends using 'chinese virus' label, ignoring growing criticism. the new york times syndemics and public health: reconceptualizing disease in bio-social context a systematic review of interventions to reduce hivrelated stigma and discrimination from 2002 to 2013: how far have we come covid-19 and rationally layered social distancing novel digital architecture of a "low carb program" for initiating and maintaining long-term sustainable health-promoting behavior change in patients with type 2 diabetes the syndemic threat of food insecurity and hiv testing a syndemic index of psychosocial and structural factors associated with hiv testing among black men community mobilization and aids a syndemic model of exchange sex among hiv-positive men who have sex with men long-term weight loss maintenance after inpatient psychotherapy of severely obese patients based on a randomized study: predictors and maintaining factors of health behavior project hope: online social network changes in an hiv prevention randomized controlled trial for african american and latino men who have sex with men estimation of the reproductive number of novel coronavirus (covid-19) and the probable outbreak size on the diamond princess cruise ship: a data-driven analysis key: cord-349231-9ibv0730 authors: zsido, andras n.; arato, nikolett; lang, andras; labadi, beatrix; stecina, diana; bandi, szabolcs a. title: the connection and background mechanisms of social fears and problematic social networking site use: a structural equation modeling analysis date: 2020-07-24 journal: psychiatry res doi: 10.1016/j.psychres.2020.113323 sha: doc_id: 349231 cord_uid: 9ibv0730 previous research warned that internet and social media use could have a negative effect on the social lives of excessive users. based on the social compensation hypothesis, however, factors related to social fears could lead to problematic social networking site (sns) use because individuals try to compensate for their offline popularity. it was shown that individuals with higher levels of social fears tend to prefer computer-mediated (cmc) instead of face to face (ftf) communication. here, we aimed to create a model that shows the direct and indirect effects of social anxiety and self-esteem on problematic sns use. a total of 215 participants filled out our survey including measures of social anxiety, self-esteem, fear of negative evaluation, social media and internet addiction. using structural equation modeling we tested the indirect and direct effects between the variables. our results indicated that social anxiety and lower self-esteem could lead to favoring cmc over ftf communication, which may result in problematic internet (piu) and sns use as a compensatory behavior to cope with fear of negative evaluation. the indirect pathways might highlight relevant differences behind the motivation of piu – anonymity – and problematic sns use – control. theoretical as well as practical implications are discussed. concern arose that the internet could negatively affect the social lives of excessive users (ahn, 2011). social relationships not only have a crucial role in development but the skills we learn or do not learn affect our later lives as well (dishion and patterson, 2015) . although interaction through the internet, e.g. using social networking sites (sns), can have positive effects such as forming communities and fostering social support (allen et al., 2014; bonetti et al., 2010; yen et al., 2012) , computer-mediated communication (cmc) also comes with a serious pitfall of lacking many social cues (postmes et al., 1998) . the two major features of cmc is anonymity and the control it offers over managing social situations (caplan, 2002; hancock and dunham, 2001) . according to the social compensation hypothesis, i.e. individuals turn to online communication due to their difficulty in forming friendships offline (bonetti et al., 2010; weidman et al., 2012) , these features might be the reason why socially anxious individuals -who feel uncomfortable communicating face-toface (ftf) -prefer cmc instead (pierce, 2009; weidman et al., 2012; yen et al., 2012) . similarly, the compensatory internet use theory (ciut) (kardefelt-winther, 2014) proposes that different forms of problematic internet use (piu) serve as a compensatory behavior to cope with existing problems (wolniewicz et al., 2018) such as shyness (chak and leung, 2004) , loneliness (caplan, 2007) , and fear of missing out (wolniewicz et al., 2018) . thus, in the present study, we investigated whether individuals with higher levels of social anxiety are more likely to prefer cmc over ftf communication due to either the anonymity or the control offered by the internet, and snss in particular, over social interactions. according to the ciut, we used increased piu and problematic sns use as indicators of favoring cmc over ftf communication. our results may help to find effective preventive methods of problematic sns use and to aid individuals with higher levels of social anxiety. 5 a defining characteristic of social anxiety is fear of social or performance situations in which the person is exposed to possible scrutiny by others (american psychiatric association, 2013; bögels et al., 2010; stein and stein, 2008) . that is, people with social anxiety fear that this scrutiny could be embarrassing or humiliating and that others will judge them in a negative way. indeed, it was shown (winton et al., 1995) that people with higher levels of social anxiety have a bias towards identifying others' emotional expressions as negative. fear of negative evaluation in social situations (winton et al., 1995) and distorted negative selfbeliefs (goldin et al., 2009 ) could indicate a vulnerability to social anxiety; possibly because such individuals show a reduced tendency to self-favoring compared to others (de jong, 2002) . further, low self-esteem could increase the possibility of developing problematic sns use (baturay and toker, 2017) . indeed, the anticipation of negative evaluation by others in individuals who have lower self-esteem can result in anxiety in social situations (kocovski and endler, 2000) . low self-esteem (you et al., 2019) plays an important role in the development of social anxiety. the anonymity and control of the internet and cmc could set such individuals free from references to prior negative experiences related to social situations (young and lo, 2012) . thus, individuals with low self-esteem could also favor cmc over ftf communication. previous studies (pierce, 2009; prizant-passal et al., 2016; yen et al., 2012) showed that social anxiety was lower in highly socially anxious individuals when using cmc, resulting in feelings of relative comfort at online platforms. social anxiety is a shared precursor of the development of piu (yen et al., 2012) . it was also shown that low self-esteem was positively related to piu (kahraman and demirci, 2018; kim and davis, 2009) . while it has been proposed that psychological benefits could be derived from cmc (allen et al., 2014; bonetti et al., 2010; yen et al., 2012) , long-term effects of problematic sns use could include cyberbullying behavior and depression (kircaburun et 6 al., 2018) , higher alienation from peers (assunção and matos, 2017), victimization (martínez-ferrer et al., 2018) and loneliness (moody, 2001) . therefore, it is vital to map possible points of intervention to help socially anxious people avoid piu and problematic sns use. nonetheless, results are still mixed which could be due to the fact that the majority of the aforementioned studies are still only correlational in nature. there is a strong call (prizant-passal et al., 2016) to establish causal relationships between social anxiety and internet use. in the present study we sought to test a possible model on the connection and background mechanisms of social anxiety and problematic sns use (see figure 1 ). in this model, we hypothesized that social anxiety and self-esteem (level 1) will facilitate fear of negative evaluation in face-to-face social situations (level 2). in turn, negative evaluation would lead to heightened piu and problematic sns use (i.e. seeking online anonymity and control by favoring cmc communication, level 3). we recruited 215 caucasian participants (132 females), aged 18-60 years (m=33.81, sd=14.59) through the internet by posting invitations on various forums and mailing lists to obtain a heterogeneous sample. the data were collected in 2019, before the covid-19 pandemic. the participants filled out the questionnaires online, using google forms, on a voluntary basis. none of them reported having a psychiatric disorder. additionally, we deleted three invalid entries (one duplication and two fakes), thus they were not analyzed. the research was approved by the hungarian united ethical review committee for research in psychology and was carried out in accordance with the code of ethics of the world medical association (declaration of helsinki). informed consent was obtained from all participants. the rses contained 10 items (urbán et al., 2014 ) rated on a 4-point likert-type scale. higher scores indicate more positive self-esteem. the cronbach's alpha was .89. we used the 8-item brief version of the fne questionnaire (perczel-forintos and kresznerits, 2017; weeks et al., 2005) . all items are rated on a 5-point likert-type scale with higher scores implying higher fear of negative evaluation by others. the cronbach's alpha was .93. we used the 6-item version of the sps (peters et al., 2012) the questionnaire consists of 18 items and three subscales: obsession, neglect, and control disorder. all items are answered on a 5-point likert-type scale. the three subscales add up to the total score, where a higher score signifies a higher level of problematic internet use (demetrovics et al., 2008) . the cronbach's alpha was .88. problematic sns use was measured with the bergen social media addiction scale (bsmas). the bsmas contains six items reflecting core addiction elements regarding sns use (andreassen et al., 2016; bányai et al., 2017) . items are rated on a 5-point likert-type scale. higher scores imply higher levels of problematic social media use. the cronbach's alpha was .87. we performed a structural equation modelling using the jasp statistical software version 0.11.1 for windows (jasp team, 2019) utilizing the lavaan (v. 0.6-1) package for r (rosseel, 2012) to assess fit measures for our proposed models. we used the diagonally weighted least squares (dwls) estimator (bandalos, 2014) . to evaluate model fit, we used the chisquare, the comparative fit index (cfi), the tucker-lewis index (tli), and the root mean square error of approximation (rmsea) the cutoffs for good model fit were nonsignificant chi-square (kline, 1998) , cfi and tli values of .95 or greater (hu and bentler, 1998) , rmsea value of .08 or lower (browne and cudeck, 1992) . for the indirect pathways, we also calculated the percentage of indirect effects. .052, 90%ci = [.00 -.14], srmr = .032). in line with our hypothesis sps (β = .55, p < .001) and rses (β = -.38, p < .001) scores predicted bfne (r 2 = .66). further, bfne predicted both piuq scores (β = .49, p < .001, r 2 = 0.24) and bsmas (β = .44, p < .001, r 2 = 0.19). we did not find a direct effect from rses or sps to either piuq (β = .07, p = .296 and β = .02, p = .787, respectively) or bsmas (β = -.01, p = .891 and β = .11, p = .081, respectively). regarding the indirect pathways, we found that sps through bfne predicted both piuq (β = .27, p < .001, 93.4%) and bsmas (β = .24, p < .001, 65.9%) scores. similarly, rses predicted both piuq (β = -.19, p < .001, 74.5%) and bsmas (β = -.17, p < .001, 95.5%) scores through bfne. regarding covariances, sps and rses (β = -.50, p < .001), and piuq and bsmas (β = .65, p < .001) scores showed strong covariances as expected. see figure 1 for the model and table 1 the goal of our study was to test a model on the connection and background mechanisms of social anxiety and problematic sns use. we proposed that that higher levels of social anxiety and lower self-esteem will facilitate fear of negative evaluation. through fear of negative evaluation, these would lead to problematic internet use and problematic sns use, probably due to favoring cmc over ftf communication. our results are in line with that of previous studies (pierce, 2009; stein et al., 2001; stein and stein, 2008; weidman et al., 2012; yen et al., 2012) showing that highly socially anxious individuals prefer using cmc over ftf because it reduced their anxiety. the novelty of the present study is that we showed that heightened social anxiety as well as low self-esteem could result in the overuse of the internet and snss and that this happens due to fear of negative evaluation of others. our findings may lend further support to the social compensation hypothesis (bonetti et al., 2010; weidman et al., 2012) and the ciut (kardefelt-winther, 2014) such that social anxiety and lower self-esteem could lead to favoring cmc -indicated by higher scores on problematic internet and sns use measures -as a compensatory behavior to cope with fear of negative evaluation. the overview of the hierarchical organization of the model provides several important implications. social anxiety had a significant role in piu and problematic sns use through the mediating effect of fear of negative evaluation. according to our results, fear of negative evaluation seems to be the maladaptive social evaluating mechanism that socially anxious individuals compensate for through piu and problematic sns use. features such as the anonymity, feeling of control and cmc might be more appealing for individuals who suffer in ftf situations because of their fears of others' negative opinions. the role of the appearance of evaluation-based factors could be helpful for possible interventions such as cognitivebehavior therapy approaches focusing on averting the accretion of distorted cognitions potentially leading to social phobia (dogaheh et al., 2011; shirotsuki and noda, 2019) . in fact, higher levels of self-esteem could also have a protective role based on its effects on the fear of negative evaluation in our model. this is consonant with previous empirical results (cheng et al., 2015; perczel-forintos and kresznerits, 2017) and also in line with previous research highlighting the role of self-esteem and fear of negative evaluation in social anxiety (kocovski and endler, 2000; you et al., 2019) . our model supports the social compensation hypothesis (bonetti et al., 2010; weidman et al., 2012) such that individuals who fear negative evaluation by others or having higher levels of social anxiety will favor cmc over ftf due to the reduction in social cues and the control afforded by the internet because they will feel more comfortable while communicating with others (allen et al., 2014; valkenburg and peter, 2009 ). the indirect pathways might also highlight relevant differences behind the motivation of piu and problematic sns use. that is, social anxiety through fear of negative evaluation leads to higher levels of sns use which, as an epiphenomenon, also means higher scores on piu. the key here could be that socially anxious individuals will rely on the control over social interactions offered by social media sites. in contrast, negative self-esteem and fear of negative evaluation could also lead to the heightened use of snss, but presumably, the ones that offer anonymity to the user (e.g. forums), i.e. "hiding" behind cmc but meanwhile maintaining the seeking for social interactions. the described mechanisms contribute to the preference of cmc above ftf, which was found to be a possible vulnerable aspect of social functioning (postmes et al., 1998; ruppel et al., 2017; van der meijden and veenman, 2005) . although the high correlation between piu and problematic sns use might also be a limitation, the shared variance (approx. 50%) showed that while these problematic behaviors share a common root, they also have unique features (bányai et al, 2017) , which might be a proof for the different motivation we discussed. to sum up, our findings imply that personality-based constructs such as self-esteem and social anxiety could affect behavioral processes, e.g., piu and problematic sns use, yet the role of the mediating components is also important. our model provides an opportunity to better understand the complex interaction of clinically relevant constructs and identify potential aspects for intervention. the dispute over the relevance of ftf and cmc forms of social interactions is proved to be an ideal explanatory-framework for a better understanding of these processes. further longitudinal research is needed to clearly and directly understand their exact role in the appearance and prevalence of internet-and social-media related behavioral addiction. limitations of our study include a theoretical assumption of our model placing selfesteem and social anxiety at the same level and therefore allowing a covariance between them. this technical construction does not allow us to identify a causal relationship in the case of the two root-variable, further investigations are needed to clarify the nature of the association. another important aspect could be, in future studies, the question of probable gender differences. in the case of social anxiety, the female dominance is fairly described (asher et al., 2017) , similarly, previous review articles indicate that females can be described with a relatively lower level of self-esteem compared to males (bleidorn et al., 2016) . the role of these imbalances and their possible effects on the further levels of our model is still unclear. although the main goal of the present study was to show whether social anxiety, self-esteem, and fear of negative evaluation can have a role in the development of problematic internet and sns use, the amount of explained variance by the model indicated that there might be other key factors at play. future research should aim to explore other major factors that could facilitate problematic sns use and, thus, help preventive work. these limitations notwithstanding, we showed that personality-based self-reflective psychological constructs could effectively influence the behavioral level of our everyday functioning. in this process, the most important aspect is the role of the mediating variables. identifying them and clearly define their role could provide potential and promising opportunities for working out preventive psychological options to avoid the emergence of maladaptive behaviors. our results may also have implications on the current shift from offline to online communication due to the covid-19 pandemic. 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style, social support and emotional intelligence key: cord-352122-u9pv2x2j authors: yang, xiao; yang, xiufang; kumar, poornima; cao, bingrong; ma, xiaohong; li, tao title: social support and clinical improvement in covid-19 positive patients in china date: 2020-08-24 journal: nurs outlook doi: 10.1016/j.outlook.2020.08.008 sha: doc_id: 352122 cord_uid: u9pv2x2j objectives: to explore the relationship between psychosocial support related factors and the mental health of covid-19 positive patients. methods: this exploratory study of thirty-five covid-19 positive patients were enrolled between february 1(st) to march 1(st), 2020. sleep quality, depression, anxiety, and social support were measured and social support related data of participants were collected. psychological intervention was administered and patients were followed two weeks post intervention. linear regression was performed to explore the relationship between psychosocial risk factors and improvement of psychological symptoms. results: thirty-two individuals exhibited sleep, depressive and anxiety symptoms which improved post support intervention. at baseline, symptoms were associated with gender, severity of pneumonia, social support. better social support at follow-up and improvement from covid-19 predicted improvement in their psychological symptoms. conclusions: this initial evidence from china may stress the importance of administering psychosocial intervention during the treatment of covid-19 for better patient outcomes in other countries. the coronavirus disease 2019 was declared a global pandemic march 11, 2020 by the world health organization (ducharme, 2020) . covid-19 appears more efficiently transmitted and more virulent than the severe acute respiratory syndrome (sars) and the middle east respiratory syndrome (mers) coronaviruses (wang, horby, hayden, & gao, 2020) . the rapid rise in the number of confirmed cases and deaths along with the unknown epidemiology of this novel pathogen reportedly causes psychological problems in many people, among which stress, fear, anxiety, and depression are the most common (lai et al., 2020) . previous studies found that some patients with sars experienced anxiety and depression which can potentially make their treatment more challenging and less effective (cheng & wong, 2005; yunping yang, ma, & wang, 2003) . one practitioner's report found that the provision of psychological intervention to those who were suffering from sars or other comparable infectious diseases led to significant clinical implications such as maintaining psychological wellbeing and help fight against emerging infectious diseases (sim & chua, 2004) . with regard to this current pandemic, early psychological intervention (ma, du, & guo, 2004) or timely mental health care (xiang et al., 2020) were addressed. however, more evidence-based outcomes of psychosocial interventions for covid-19 need to be evaluated (cheng & wong, 2005) . psychosocial support usually refers to the care or support that a person feel they get from others or the feeling of belonging to a social network that provides mutual assistance (bluestone, 1998) . adequate and positive psychosocial support has been reported to help relieve the level of stress, anxiety (n. yang et al., 2018) , depressive symptoms (y. yang, 2006) , and have a positive effect on sleep quality (kent de grey, uchino, trettevik, cronan, & hogan, 2018; prati & pietrantoni, 2010) . by releasing cytokines, better sleep may also indirectly help patients maintain optimal immune function and thus help them fight against the infection (irwin, 2002; lange, dimitrov, & born, 2010) . psychosocial intervention studies on sufferers with sars found that psychological distress emerging in the acute stage were ameliorated with social support including certain types of behavioral and verbal responses of health workers (cheng & wong, 2005) . a recent research during the covid-19 pandemic also confirmed the effects of social support on the improvement of psychological problems (xiao, zhang, kong, li, & yang, 2020) . it is possible that early psychological intervention and social support can play a critical role in both the physical and mental health status of covid-19 positive patients. as anxiety and depression problems are common negative emotion experienced by patients during epidemics of such an infectious disease (yunping yang et al., 2003) , social support may help reduce the level of stress and anxiety (n. yang et al., 2018) . also, sleep quality is an important indicator of health status. the positive effect of social network factors (particularly the relationships with relatives / friends) for sleep quality may help people maintain optimal immune function (irwin, 2002; lange et al., 2010) , which indirectly help them fight the virus. nevertheless, studies on sleep, anxiety, and depressive symptoms of covid-19 positive patients and those on the psychological intervention for them are still limited. the exploratory research on the factors associated with the symptoms and the remission of those symptoms after intervention is almost none. moreover, psychological impact of those infectious diseases may persist or evolve over time. longitudinal studies are warranted to assess the important determinant factors of psychosocial distress and the protective factors of some coping strategies, with potential application in early identification of cases experiencing psychological problems. therefore, based on both physical and psychological intervention in the isolated intensive care unit in the east district of wuhan people's hospital, the aim was to achieve three objectives with this study. first, to explore the sleep quality, psychosocial status of confirmed positive covid-19 patients using psychological scales. second, to explore the change of their psychological status after the clinical treatment and psychological intervention during the hospitalization. third, to identify the social support related risk factors of mental health and their improvement. thirty-five confirmed positive covid-19 patients in the isolated intensive care unit (icu) in the east district of wuhan people's hospital were enrolled february 1, 2020 to march 1, 2020. the diagnosis of covid-19 was confirmed for each patient according to the novel coronavirus infection pneumonia diagnosis and treatment standards (shen et al., 2020) . this study was conducted in accordance with the declaration of helsinki and was approved by the ethics committee of our hospital. verbal informed consent was provided by every subject and participants were allowed to terminate the survey at any time they desired. the survey was anonymous, and confidential. a descriptive exploratory design was employed. demographic and social support related data were collected including age, gender, education, marital status, number of family members infected, psychiatric history, psychiatric family history, any close relatives or friends who died in the pandemic, the number of children, and their living status. information on the severity of pneumonia (highest mode of oxygenation: nasal catheter for oxygen, high flow oxygen, endotracheal intubation) and the results of serology test for covid-19 (positive or negative) were also collected to provide the information of the severity and improvement of covid-19. sleep quality, depression, anxiety, and social support were assessed using the chinese version of pittsburgh sleep quality index (psqi) (carpenter & andrykowski, 1998) , patient health questionnaire (phq-9) (kroenke, spitzer, & williams, 2001) , generalized anxiety disorder assessment (gad-7) (spitzer, kroenke, williams, & lowe, 2006) and the social support rate scale (ssrs) (w. dai et al., 2016) , respectively at two stages: stage 1: the day when they were hospitalized, and stage 2: two weeks after they were hospitalized. the questionnaire of psqi was used to measure sleep quality (carpenter & andrykowski, 1998) . according to the suggested criteria, a total score of 0-5 points means having a very good night's sleep; 6-10 points means the sleep quality is not bad; 11-15 points means the sleep quality is fairly bad; and 16-21 points means the sleep quality is very bad. the total score ranged from 0 to 2l. higher the score, worse is the sleep quality. the cronbach's alpha for internal consistency of the psqi was 0.811. phq-9 is a reliable, valid, and widely used measurement of depression severity (kroenke et al., 2001) . a total score of <4 indicates minimal depression; 5-9 indicates mild depression; 10-14 indicates moderate depression; 15-19 refers to moderately severe depression; and 20-27 indicates severe depression. the cronbach's alpha for internal consistency was 0.81. gad-7 is a valid, efficient and widely used tool for screening for generalized anxiety disorder and assessing the severity in clinical practice and research (spitzer et al., 2006) . a total score of 5, 10, and, 15 are interpreted as the cut-off points for mild, moderate, and severe levels of anxiety, respectively. this is also similar to levels of depression on the phq-9. the cronbach's alpha for internal consistency was 0.92. ssrs was used to measure the level of social support received by individuals. it consists of 10 questions (graded 1-4) with a total ssrs score ranges from 12 to 66 points. higher scores mean a higher and satisfactory social support. the ssrs has good reliability and validity, with a cronbach's alpha for internal consistency ranging between 0.89 and 0.94. all participants were assessed by a trained psychotherapist and nurse who voluntarily travelled to work in the icu, east district of wuhan people's hospital. according to basic principles and timely mental health care for emergency psychological crisis interventions for the covid-19 (china; xiang et al., 2020) , she provided mental health care for those hospitalized patients during that time. psychological intervention mainly included the following steps. first, an in-person interview was conducted to collect a systemic perspective. in order to evaluate the psychosocial impact of such an infectious disease on patients and their family members and close friends. this will help us make a plan for a more comprehensive efforts to alleviate their psychosocial burden for current or in the future. next, face-to-face intervention and online consulting was given, including listening, positive attention, supportive psychotherapy, empathy, muscle and breath relaxation, and cognitive behavioral therapy. we instructed them do the training of body detection and control, muscle and respiratory relaxation. cognitive behavioral therapy was applied based on an ever-evolving formulation of patients' problems and the individual conceptualization. for example, we helped a person who always felt chest tightness to notice those uncomfortable experience, the trigger factors and distinguish the physical and psychological uncomfortable. then helped them build the rational cognitive processing of those symptoms. all treatments were conducted depending on the physical and mental situation of each patient, ranging from 15-30 minutes each time, usually three times a week. data in this study were analyzed using the statistical package for the social sciences (spss 24.0 for mac). the anova and chi-squared (χ2) tests were used to analyze clinical information of patients at baseline. linear regression was used to determine the relationship between the measured social support-related factors and baseline sleep, anxiety, and depression symptoms and the improvement of these measures. for stage 1, three linear regression models for three variables (psqi, phq9, gad7), separately. social support related factors for linear regression included age, gender, marital status, education level, number of family members infected, any close relatives or friends who died in the pandemic, severity of pneumonia, and score of social support rating scale (ssrs). the method for linear regression was stepwise. a p value < 0.05 was considered to be statistically significant. for stage 2, three linear regression models for the reduction of three variables (psqi, phq9, gad7), were used separately. social support related factors for linear regression included age, gender, marital status, education level, number of family members infected, any close relatives or friends who died in the pandemic, severity of pneumonia, nucleic acid test at stage 2, and score of social support rating scale (ssrs) at stage 2. reductions of score were calculated for patients with psqi ≥ 6, phq9 ≥ 5, and gad7 ≥ 5, separately. three patients with score of psqi less than 6, 3 patients with score of phq9 less than 5, and 4 patients with score of gad7 less than 5 were excluded in each model. the method for linear regression was stepwise. a p value < 0.05 was considered to be statistically significant. thirty-five patients (21 men and 14 women) were included in this study (age 57±13.5 years). nine of them had negative test results at stage 2. besides the social support measured by ssrs, other social support related factors of patients are presented in table 1 . this study found that sleep quality measured by psqi of covid-19 positive patients were positively associated with gender and severity of pneumonia (β 1 = 6.275, p 1 = 0.000; β 2 = 3.774, p 2 = 0.013). other factors included in the model were not found to be significantly related to sleep symptoms. depression symptoms were positively associated with severity of pneumonia, gender, and lower social support at stage 1 (β 1 = 5.913, p 1 = 0.000; β 2 = 2.941, p 2 = 0.005; β 3 = -0.229, p 3 = 0.040). other factors of interest in the model were not found to be significantly related to depression symptoms. anxiety symptoms were associated with number of family members infected (β = 2.057, p = 0.001). other factors of interest in the model were not found to be significantly related to anxiety symptoms. after 2 weeks of treatment, an assessment of ssrs, psqi, phq9, and gad7 was performed for every participant. after intervention, ssrs was significantly higher (p =0.000) and the scores of psqi, phq9, and gad7 were significantly lower (p = 0.000, p = 0.000, p = 0.000) than those at baseline (fig. 1) . this study also found that improvement of sleep quality for patients were positively associated with the improvement from covid-19 and better social support at stage 2 (β 1 = -38.122, p 1 = 0.000; β 2 = 2.867, p 2 = 0.046). other factors of interest were not found significantly related to the change. improvement of depression was positively associated with higher education level (β = 13.965, p = 0.026). other factors were not found significantly related to the change. improvement of anxiety was not significantly associated with any factors of interest. overall this study found that most covid-19 positive patients had sleep, depressive, and anxiety symptoms. many factors could have accounted for this high proportion of patients having psychological problems during this global pandemic. for instance: factors including person-to-person virulent virus, uncertainty, misinformation, over-information, shortage of health care, isolation and separation from loved ones, loss of lives etc. could have contributed to their mental health symptoms. in addition, the relatively older age (mean = 57 years) and more critical condition of (all recruited from the icu) the participants may partially explain the high ratio of psychosocial problems. specifically, older people were more likely to be anxious, depressive, and suffer from sleep disturbance, even more than those in need of physical and mental health care (y. dai et al., 2016) . from the linear regression analysis between the clinical symptoms at stage 1 and social support related factors of covid-19 positive patients, revealed that psychosocial symptoms had a significantly positive association with several social support related factors. specifically, sleep and depression were associated with both gender and severity of pneumonia. in addition, poor social support at stage 1 was observed to be associated with depression. in contrast, anxiety was associated with number of infected family members. gender differences in depression have been widely reported in prior studies with twice the number of women diagnosed with depression than men (seedat et al., 2009) . interestingly, previous findings have also shown that women with depression suffered more sleep disturbance (x. yang et al., 2017) . association between clinical symptoms and severity of pneumonia is not entirely surprising, as it is commonly believed that poor physical situation are usually associated with psychological problems and worse outcomes (henderson & moran, 1983 ). positive social support may help relieve the level of stress, anxiety. and elderly individuals may tend to be more sensitive to social support and afraid of being neglected (lamont, nelis, quinn, & clare, 2017) . this may have contributed to depressive symptoms of participants in this study. those who having family members infected is anxiety provoking, especially when the individual themselves got infected. this was confirmed in this study when anxiety was uniquely related to family members infected. the study found that patients' psychological symptoms improved after intervention. this was positively associated with the improvement from covid-19, better social support at stage 2 and higher education level. the improvement of physical situation reflects effective physical support which may help relieve their stress and maintain good psychosocial status. moreover, a higher education level is recognized to be an important social determinant of health (shankar et al., 2013) . it can afford people better economic, social, and personal resources needed for better physical and mental health as well as increase people's capacity for better decision making regarding their health (kim, choi, kim, & pop-eleches, 2018; shankar et al., 2013) . indeed, physical and psychological wellbeing and sleep are affected by many socio-cultural factors (yao, yu, cheng, & chen, 2008) . social support was reported to be strongly associated with mental status as well as the significant predictors of psychological symptoms at follow-up (george, blazer, hughes, & fowler, 1989) . a study about the covid-19 pandemic confirmed the effects of social support for improvement of psychological problems (xiao et al., 2020) . our current study also found that the psychosocial status improved after treatment (anderson & ozakinci, 2018) and better social support (relationship with family, close friends, colleagues, health care worker, mental health care worker etc.) can help patients improve sleep quality and ameliorate their psychological distress, thus helping reduce their negative emotion levels during the pandemic (cheng & wong, 2005) . despite the findings, this research study had three major limitations. first, the absence of a control group made the comparison of psychological intervention between groups impossible. such an absence was unavoidable though because we provided mental health care for anyone who needed it according to the ethical principle and requirements. second, more details about the severity of the covid-19 and the exact quantized measures of improvement for those patients hospitalized at icu. the highest mode of oxygenation and the results of covid-19 to provide some information about the situation and the change of the disease since there were no objective and quantified measures to be used. finally, a long-term follow-up may be helpful even after the patients were discharged because mental health is as important as physical health. the current research found that a large proportion of covid-19 positive patients in intensive care unit suffered from psychosocial problems. physical and psychological well-being and sleep are affected by many social support related factors. adequate social support and early intervention may help these patients achieve better clinical prognosis during such pandemic of infectious disease. the findings from this study of chinese covid-19 positive patients may stress the importance of administering psychological intervention during the treatment of covid-19 for better outcomes in other countries. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. none. the data that support the findings of this study will be available from the corresponding author on reasonable request. phq9≥5, gad7≥5 separately. 3 patients with score of psqi less than 6, 3 patients with score of phq9 less than 5 and 4 patients with score of gad7 less than 5 were excluded in each model. follow-up (stage 2). effectiveness of psychological interventions to improve quality of life in people with 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disorders and psychological intervention in patients with severe acute respiratory syndrome chinese journal of psychiatry relationships between personal, depression and social network factors and sleep quality in community-dwelling older adults we thank all health-care workers involved in the diagnosis and treatment of patients in the east district of wuhan people's hospital. key: cord-300541-5wea9w32 authors: abdoul-azize, hamidou taffa; el gamil, rehab title: social protection as a key tool in crisis management: learnt lessons from the covid-19 pandemic date: 2020-09-01 journal: glob soc welf doi: 10.1007/s40609-020-00190-4 sha: doc_id: 300541 cord_uid: 5wea9w32 worldwide, the social protection programs have become a key tool for policymakers. these programs are executed to achieve multiple objectives such as fighting poverty and hunger, and increasing the resilience of the poor and vulnerable groups towards various shocks. recently, with the rapid spread of the covid-19 pandemic, many countries started to implement social protection programs to eliminate the negative impacts of the covid-19 pandemic crisis and enhance community resilience. this study aims to explore the current implementation of social protection programs during the covid-19 pandemic in the most affected countries as well as to provide learned lessons from countries that had not previously considered implementing social protection programs up until the covid-19 crisis. this review was carried out by searching through wos, google scholar, ilo, world bank reports, and aljazeera television. the search was conducted over literature and systematic reviews on the implementation of social protection programs during previous pandemic crises and especially in the current covid-19 pandemic. the findings revealed that social protection programs become a flexible and strategic tool to respond to the covid-19 pandemic. furthermore, the study highlighted a lack of comprehensive strategy amongst the countries in executing the social protection programs to respond to covid-19. finally, the study concluded with some learned lessons and implications for the practitioners and policymakers in managing future pandemics. early at the beginning of 2020, the who declared the new epidemic namely "the novel coronavirus disease 2019" as a worldwide public health emergency (wu et al. 2020 ). on february 11, 2020, china accounted for about 42,708 infected cases and by 27 july 2020, the covid-19 pandemic spread over about 216 territories with a total of confirmed cases estimated at 16,114,449 and with about 646,641deaths. the most affected countries are the usa, brazil, india, russian, peru, chile, uk, mexico, spain, iran, pakistan, and italy (who 2020). according to the increasing spread of the covid-19 pandemic, many countries applied different measures such as closing the airports, implementing bans for some commodities and medical products, reducing work time, home quarantine, and curfews. these measures affect the country's economic sectors and risk to increase social inequality and poverty. hence, many countries start to implement various spp to cope with the negative socioeconomic impacts of the covid-19 pandemic. initially, social protection programs (spp) have been executed by many countries to fight hunger and poverty. therefore, andrews et al. (2018) and hidrobo et al. (2018) highlighted that the spp play key roles in supporting the poor to get out of poverty and hunger. previously, many authors indicated that the spp address chronic poverty, reduce social inequality, and enhance the livelihood of the poor (alderman and yemtsov 2012) . accordingly, spp spread rapidly in africa where the number of spp beneficiaries tripled in the last 15 years (beegle et al. 2018) . for instance, handa et al. (2018) emphasized that the delivery of cash transfers has multiplier effects on the economy of low-income countries. moreover, atinc and walton (1998) noted that during the asian financial crisis, countries such as south korea, indonesia, thailand, and malaysia executed spp to thwart and alleviate severe economic failure and deprivation. in this context, ilo (2020) and hallegatte and hammer (2020) mentioned that the spp are executed new social protection schemes to support the poor and vulnerable groups during the covid-19 pandemic. these spp consisted of elders and health care assistance, unemployment protection, social security, and in-kind and cash transfers. the current study will focus on the spp which are implemented by the governments to assist the poor, vulnerable groups, and economic sectors to mitigate the consequences of the covid-19 pandemic. derived from the above consideration, the spp include all public policy initiatives to combat hunger, reduce poverty and social inequality, and stabilize the economy. consequently, the study aims to explore the current implementation of spp in covid-19, particularly in the most affected countries. it also provides learned lessons for countries that had not previously considered implementing spp up until the covid-19 crisis. early by the 1990s, the spp have been executed by many countries to cope with the economic crisis. recently, the european consensus included the spp in the 2030 agenda for sustainable development due to their vital role in combating hunger, reducing poverty, and social inequality (un 2015) . despite the global increase of spp, there is no specific definition of what social protection stands for but the international labor organization (ilo) mentioned in 102 conventions that social protection is considered as "social security". besides, guhan (1994) highlighted that ilo definition of social protection can only be accepted for the case of developing countries. consequently, brand (2001) mentioned that in ldcs, social security is a component of integrated antipoverty policies. these policies include providing productive resources, and ensuring employment, minimum wage, and food security to the poor and vulnerable groups. the spp refer to providing income through medical care assistance, sickness benefits, unemployment, family, and maternity assistances. this means that spp consist of both private and public measures targeting to assist the poor and vulnerable groups and therefore to reduce their exposure to economic and social vulnerability (brand 2001; devereux and sabates-wheeler 2004) . accordingly, niño-zarazúa et al. (2012) and fiszbein et al. (2013) clarified that spp are performed to tackle the causes of poverty and its indicators, especially in developing countries. furthermore, niño-zarazúa et al. (2012) and fiszbein et al. (2014) noted that the social protection has three main functions: protecting the basic levels of consumption, facilitating human investment, and assisting the poor to overcome some difficulties. in this context, fiszbein et al. (2014) emphasized that the key role of social protection in the agenda post-2015 is "an instrument for the goals of reducing poverty, reducing inequality, reducing risk and vulnerability". therefore, the social protection includes three main components: social insurance, labor market intervention, and social assistance programs. the world bank atlas of social protection indicator of resilience and equity (aspire) is the most acknowledged classification of social protection and consisted of social insurance, labor market, social assistance, and private transfers (table 1) . worldwide, the spp have rapidly increased; lowder et al. (2017) noted that during the two past decades, about 2.1 billion people are beneficiaries of the spp in developing countries. in addition, fiszbein et al. (2014) emphasized that over the world, about 24% of the extremely poor are beneficiaries of the social assistance programs, 3% of the population benefit from social insurance, and 3% of the population are the recipient of the labor market. the types and the coverage of spp vary from one region to another. in this context, devereux (2002) and dev et al. (2007) mentioned that the schemes of social protection, the spp funding, the targeting approaches, the monitoring systems, and the size of the programs depend on the political objectives. according to the world bank (2020), worldwide, about 74.3% of the population in high-income countries, 64.2% of the population in upper-middle-income countries, 31.1% of the population in lower-middle-income countries, and 19.1% of the population in low-income countries are covered by spp. however, about 80.9% of the population in lowincome countries are not covered by spp (fig. 1 ). recently, many countries challenged various crises either natural disasters or human-made crises. in fact, crisis and crisis management become key concepts and many authors highlight the essential of these concepts in critical decisions. accordingly, santana (2004) mentioned that the term "crisis" is so complicated to define due to several reasons; its construct, it is overlapping with other terms such as catastrophe and disaster, and its different application and use. for faulkner (2001) and prideaux et al. (2003) , the crisis refers to an unpredictable and self-made situation due to various causes that commonly lead to catastrophic changes difficult to handle. for instance, previously, sönmez et al. (1999) mentioned that the crises include political instability, terrorism, conflicts, wars, natural disasters, public health threats, and so on. tamer (2004) stated that due to the rising occurrence of various disasters, crisis management becomes a significant topic for policymakers in many countries. indeed, there are several approaches to manage crises. moe and pathranarakul (2006) highlighted that proactive approach is widely applied by policymakers in managing the crises. this approach includes mitigations, preparedness, and warnings and aims at reducing social disorders during the crises. additionally, solt (2018) emphasized that mitigation strategies are executed by the governments, organizations, and institutions and they include the implementation of new legal regulations, creating new programs, initiatives, or committees to reduce the adverse impacts of the crisis. compared with previous pandemic crises such as ebola, aids, and sars that occurred in sierra leone, liberia, south africa, and malawi, the covid-19 pandemic is a global threat. accordingly, worldwide, the pandemic affects diversely the countries and led to various negative impacts such as macroeconomic crises, bankruptcies, the increase of social inequality, and poverty (furman 2020; odendahl and springford 2020; gali 2020) . this risks to affect the countries' economy and worsen the living conditions. mcinnes (2016) and tandon and hasan (2005) asserted that the pandemics mostly affected the poor and vulnerable groups with limited resources which cannot allow them to overcome the adverse consequences of the crisis. in this context, many countries focused on implementing various crisis management strategies and measures to cope with the negative impact of covid-19. according to fink (1986) , crisis management refers to a comprehensive process, which includes strategies reducing the occurrence and the impacts of the crises. furthermore, tamer (2004) highlighted that crisis management involves all private and/ public interventions. it is an important topic for policymakers regarding the increasing occurrence of various disasters. many authors stated that pandemics are a great challenge for policymakers. crisis management strategies and policies are one of the most key tools to deal with the negative socioeconomic impacts. in this context, the social protection becomes a vital policy which contains various types of programs targeting to prevent, mitigate, and cope with the impacts of the crisis (holzmann and jørgensen 2001; hooghe and marks 2003; rutkowski and bousquet 2019) . previously, spp have been implemented during pandemic crises (see table 2 ). in fact, the first cases of ebola were registered in sierra leone by september 30, 2014. then, the accordingly, many ngos and some international organizations supported the governments to breakout the ebola pandemic. for instance, unicef implemented infant feeding programs which targeted to improve the quality of primary health care, building units to isolate infected people, delivering medical supplies, and increasing communities' awareness (acosta et al. 2011; who 2015; hewlett and hewlett 2007; shiwaku et al. 2007; hick et al. 2010; shin et al. 2018) . likewise, in malawi and south africa, spp especially cash transfer programs have been realized to deal with hiv prevalence. these programs were delivered under conditional assistance to girls aged between 15 and 24 years old to enhance their school attendance and increase their awareness about sexual culture (baird et al. 2012; pettifor et al. 2016) . for instance, in malawi, cash transfers were provided for 18 months to support families to mitigate with deprivation and poverty risks. this cash transfer has been implemented through collaborations between various actors such government, non-governmental organization, civil society, and international organizations (baird et al. 2012; pfeiffer 2003; barrientos 2016) . table 2 shows that spp have been executed during some previous pandemic crises such as ebola, aids, and hiv. these pandemics occurred in low-income countries and most of the executed spp focused mainly on in-kind and cash transfers. additionally, these programs are targeted to the poor and vulnerable groups (ebola survivors, pregnant or lactating women, malnourished children) to support them to overcome the impacts of the crises. it can be noticed that the abovementioned pandemic crises occurred in low-income countries where most of people live under poverty line. on the other hand, covid-19 is the current pandemic crisis. it differs from the previous ones according to its worldwide spreading and its negative impacts on the economy. in addition, the covid-19 pandemic affected mostly the highincome countries and upper-middle income countries. consequently, many countries executed several measures to breakout the covid-19 pandemic. one of the most important measures is the implementation of spp. gentilini et al. (2020c) highlighted that over the world, around 195 countries implemented various spp such as safety net, finance, social insurance, and labor market to respond to the covid-19 pandemic. as a result, 131 countries implemented about 271 cash transfers programs by june 2020, 125 countries executed about 63 social insurance programs, and 85 countries implemented approximately 140 labor market programs. in this study, the systematic review has been used. it consists of summarizing and assessing the state of knowledge related to a given research question structured to existing knowledge. (2017) according to ford and pearce, (2010) systematic review differs from the traditional literature review. firstly, it focuses on clear questions; secondly, the approach specifies systematic, clear reformulation, and criteria to select relevant research. therefore, it includes the full reporting of search terms and the criteria for inclusion and exclusion of articles. the current study is based on data collected from english peer-reviewed scientific literature documenting the spp concept, implementation and types of spp in the covid-19 pandemic in the most affected countries. relevant articles published and current information related to the covid-19 pandemic from wos, google scholar databases, ilo, world bank reports and aljazeera television have been selected according to well-defined inclusion and exclusion criteria as shown in table 3 . to access to the primary literature related to spp executed in managing the covid-19 pandemic, search terms (social protection, social protection programs, covid-19 pandemic, social assistance, pandemic crises, social insurance, cash & inkind transfers, vulnerable groups, mitigation, pandemic crisis, covid-19 breakout/coping strategy, crisis management, middle and high-income countries) have been used through wos, google scholar, ilo, world bank, and who web sites. a total of 250 relevant publications were selected from the initial screen but after importing into endnote 180, articles were retained. a visual check of the titles was conducted to remove 80 articles. the abstract of 100 articles have been read according to the inclusion criteria from which 80 was retained for full review. finally, a total of 62 relevant papers (articles, official reports) have been retained for the full review. according to the main components of spp (types of programs, targeting beneficiaries, and delivered social grants), the authors designed table 4 to give an overview about the implementation of these programs in the most affected countries. table 4 shows that many countries implemented spp to provide financial support to the poor, vulnerable groups, and economic sectors, which are impacted directly/indirectly by the covid-19 pandemic. these programs include employment protection measures, cash and in-kind transfers, social insurance to the poor, vulnerable groups, firms, and companies to enhance their resilience to cope with the challenges posed by the covid-19 pandemic. from table 4 , it can be noticed that most of the countries executed assistance programs, especially in-kind and cash transfers. this could be due to the easy implementation of these types of spp and their ability to enhance people's resilience to cope with the direct consequences of covid-19. these programs could also increase the livelihoods of the targeted beneficiaries and reinforce their ability to respect the restricted measures such as lockdown and curfews implemented by the countries during the covid-19 pandemic. similarly, braun and ikeda (2020) mentioned that the cash transfer programs are implemented to alleviate consumption inequality, deliver assets, and enhance the capacity of the poor and vulnerable groups. on the other hand, in this study, almost the high-income countries implemented labor market programs such as grants to support the firms and businesses. this could help them to overcome the increasing unemployment rate due to the covid-19 pandemic. hence, these programs are implemented to support the small-and middle-size enterprises and informal employees who can be easily affected by the pandemic. these results are consistent with ilo (2009), and asenjo and pignatti (2019) who reported that unemployment protection programs are temporary policies which target to decrease the unemployment rate during the crisis. in addition, fort et al. (2013) clarified that limited financial and managerial resources make smes and informal employees more vulnerable to exogenous shocks. with regard to the type of beneficiaries, both high-income and upper middle-income countries executed social insurance programs targeting to elderly, people with severe disabilities, employees staying at home without any remote work, people infected by covid-19, workers without social insurance, and migrants. these programs could help those beneficiaries to overcome the impacts of the covid-19 pandemic. likewise, sumberg and sabates-wheeler (2011) highlighted that spp prevent and protect vulnerable groups against various shocks. • employees who lost their work due to covid-19 • financial support to the unemployment insurance fund and all health expenditures social assistance the study showed that public spp become key tools in managing the covid-19 pandemic. accordingly, high-income, middle-income, and low-middle income countries implemented spp as an economic stimulus to respond to short-, middle-, and long-term negative consequences of the crisis. this study explores the current implementation of spp in covid-19, particularly in the most affected countries. it source: provided by authors from gentilini et al. (2020a, b, c) , ilo (2020) and mayberry et al. (2020) showed that social protection becomes a key policy tool, especially in high-income countries where spp are executed for multi-purposes. therefore, spp are flexible and adoptable tools that the policymakers could use to enhance community resilience for various future shocks such as pandemic crises. accordingly, the findings of this study are essential to inform the policymakers in the countries with lack of proper spp to include such programs in their social protection schemes for better management of various crises in the future. then, in low-income countries, the policymakers could, for instance, formalize the spp applied by ngos or include them in the public social protection scheme. this could help the countries to assist efficiently the vulnerable groups during various future crises. it can be seen that within some economic and political organizations such as the european union and the african union, there is a lack of comprehensive strategies in implementing the spp to overcome the impacts of the covid-19 pandemic. therefore, there is an urgent need for these organizations to plan common social protection policy for better management of crises in the future. conflict of interest the authors declare that they have no conflict of interest. ethical approval this article does not contain any studies with human participants and animals performed by any of the authors. the nongovernmental sector in disaster resilience: conference recommendations for a policy agenda productive role of safety nets: background paper for the world bank 2012-2022 social protection and labor strategy social safety nets promote poverty reduction, increase resilience, and expand opportunities unemployment insurance schemes around the world evidence and policy options (no. 995045193402676). international labour organization social consequences of the east asian financial crisis effect of a cash transfer programme for schooling on prevalence of hiv and herpes simplex type 2 in 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of firm age and firm size protecting people now, helping the economy rebound later. mitigating the covid economic crisis: act fast and do whatever the effects of a money-financed fiscal stimulus social protection and jobs responses to covid-19: a real-time review of country measures social protection and jobs responses to covid-19: a real-time review of country measures social protection and jobs responses to covid-19 social security options for developing countries thinking ahead: for a sustainable recovery from covid-19 can unconditional cash transfers raise long-term living standards? evidence from zambia ebola, culture and politics: the anthropology of an emerging disease surge capacity and infrastructure considerations for mass critical care social protection, food security, and asset formation social risk management: a new conceptual framework for social protection, and beyond unraveling the central state, but how? types of multi-level governance protecting people, promoting jobs: a survey of country employment and social protection policy responses to the global economic crisis, report to the g20 leaders' summit social protection responses to the covid-19 crisis country responses in asia and the pacific poverty, social protection and agriculture: levels and trends in data global coronavirus cases exceed two million: live updates crisis! what crisis? global health and the 2014-15 west african ebola outbreak estimating the future number of cases in the ebola epidemic-liberia and sierra leone an integrated approach to natural disaster management. disaster prevention and management social protection in sub-saharan africa: getting the politics right bold policies needed to counter the coronavirus recession. mitigating the covid economic crisis: act fast and do whatever it takes the effect of a conditional cash transfer on hiv incidence in young women in rural south africa (hptn 068): a phase 3, randomised controlled trial international ngos and primary health care in mozambique: the need for a new model of collaboration events in indonesia: exploring the limits to formal tourism trends forecasting methods in complex crisis situations the symbolic violence of 'outbreak': a mixed-methods, quasi-experimental impact evaluation of social protection on ebola survivor wellbeing available at https://blogs. worldbank.org/dev4peace/social-protection-protecting-poor-andvulnerable-during-crises measuring vulnerability among orphans and vulnerable children in rural malawi: validation study of the child status index tool crisis management and tourism: beyond the rhetoric the effectiveness of international non-governmental organizations' response operations during public health emergency: lessons learned from the 2014 ebola outbreak in sierra leone future perspective of school disaster education in nepal. disaster prevention and management managing international financial crises: responses, lessons and prevention tourism in crisis: managing the effects of terrorism linking agricultural development to school feeding in sub-saharan africa: theoretical perspectives türkiye'de ve polis teşkilatında kriz yönetimi yapısının terör açısından değerlendirilmesi highlighting poverty as vulnerability: the 2005 earthquake in pakistan transforming our world: the 2030 agenda for sustainable development aspire: the atlas of social protection: indicators of resilience and equity world bank who: ebola situation report 16 nowcasting and forecasting the potential domestic and international spread of the 2019-ncov outbreak originating in wuhan, china: a modelling study publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-346194-l8svzjp2 authors: nazir, mehrab; hussain, iftikhar; tian, jian; akram, sabahat; mangenda tshiaba, sidney; mushtaq, shahrukh; shad, muhammad afzal title: a multidimensional model of public health approaches against covid-19 date: 2020-05-26 journal: int j environ res public health doi: 10.3390/ijerph17113780 sha: doc_id: 346194 cord_uid: l8svzjp2 covid-19 is appearing as one of the most fetal disease of the world’s history and has caused a global health emergency. therefore, this study was designed with the aim to address the issue of public response against covid-19. the literature lacks studies on social aspects of covid-19. therefore, the current study is an attempt to investigate its social aspects and suggest a theoretical structural equation model to examine the associations between social media exposure, awareness, and information exchange and preventive behavior and to determine the indirect as well as direct impact of social media exposure on preventive behavior from the viewpoints of awareness and information exchange. the current empirical investigation was held in pakistan, and the collected survey data from 500 respondents through social media tools were utilized to examine the associations between studied variables as stated in the anticipated study model. the findings of the study indicate that social media exposure has no significant and direct effect on preventive behavior. social media exposure influences preventive behavior indirectly through awareness and information exchange. in addition, awareness and information exchange have significant and direct effects on preventive behavior. findings are valuable for health administrators, governments, policymakers, and social scientists, specifically for individuals whose situations are like those in pakistan. this research validates how social media exposure indirectly effects preventive behavior concerning covid-19 and explains the paths of effect through awareness or information exchange. to the best of our knowledge, there is no work at present that covers this gap, for this reason the authors propose a new model. the conceptual model offers valuable information for policymakers and practitioners to enhance preventive behavior through the adoption of appropriate awareness strategies and information exchange and social media strategies. several patients with symptoms of pneumonia of unknown facts were reported in mid of december, 2019 in wuhan, hubei province, china [1] . after an investigation by world health organization (who), it was identified as a new virus called covid-19, and with time, it spread rapidly throughout china and other countries [2] . according to who, it has been reported that there are 2.6 million confirmed cases, 0.184 million deaths, and 0.722 million recoveries from 2019-ncov worldwide. as evidence of this spread, one such case was reported on january the 24th, 2020 when a person reportedly from china came to pakistan on 21st of january 2020 via dubai. on the 24th he was examined and was found to be positive for covid19 . it was then that pakistan for the first time was exposed to the virus and became part of the affected countries globally. according to the government of pakistan's reports, today the number of confirmed cases in pakistan is 27,474 and the number of confirmed deaths is 618. punjab and sindh are the two mainly affected provinces. moreover, due to the lack of medical resources in developing nations, pakistan also faces challenges in preventing the spread of re-emerging and new infectious diseases. thus, during the outbreak of infectious disease, these countries focus on alternatives to medical facilities to overcome its spread. awareness and accurate information bring the behavioral changes among the people; they can be perceived as half treatment without any expense. social media has become an important source to broadcast awareness and information regarding control of infectious disease [3] . according to [4] , social media consists of different applications, including social networking sites, and blogs, that are founded on the scientific and ideological foundation of web 2.0 (for example, facebook, youtube, and twitter) that allow users to make, share content, and participate in different activities. social media itself is a catch-all expression for sites that may consist of various social actions. social media is designed of an electronic-mediated platform relying upon web-based innovations that permit users to make a profile and share ideas, imagines/clips, and information in the virtual networks system. even though many cases which were initially reported exposed the seafood market in wuhan, according to the current epidemiologic information, this virus is spreading from one individual to another at a very high rate of transfer [5] . with time, 2019-ncov has infected almost all countries on the planet. iafusco, ingenito [6] argued that in these critical circumstances, it has been very difficult for developing nations to communicate with uninfected individuals along with infected persons because this virus can spread quietly from one person to another. it has become complicated for the governments and doctors to communicate with their citizens during an infectious disease outbreak, therefore, social networking sites are playing a critical role in enabling the populations to connect virtually. some years ago, several disease outbreaks of the same nature, for example, ebola, zika flu, and dengue fever, around the globe revealed insights into the significant power of communication strategies concerning such diseases [7] . researchers said that social networking sites (sns) are a scoping evaluation of the utilization of search queries in disease surveillance [8] . first reported in 2006, the viewed literature highlighted accuracy, speed, and cost performance that was comparable to existing disease surveillance systems and recommended the use of social media programs to handle all circumstances of infectious disease systems. now, due to the advanced innovation of web 2.0, sns have appeared to play an essential role for public health specialists to control the spread of such infectious disease. it has been observed that social networks perform an excellent evaluation of real-time data reporting which keeps the state and people posted for the possible solutions of public health safety during epidemics [9] . with this recognizable increase in infectious outbreak in pakistan, public health centers are facing severe problems and challenges at work to act for the prevention of disease at various levels. due to a lack of time and resources, it has become complicated for the nations to address these issues and challenges in a short time. a fear of physical spread hinders health sector workers to interact with patients and suspects in person. therefore, the response time of governments and health departments to tackle the sign and symptoms which lead to the detection of both infectious and noninfectious diseases and their preventions, respectively, is affected by the updates and real-time reporting of social media. in this study, the researchers determined the outcome of social media on the preventive behavior among people about covid-19, how individuals gain information and awareness knowledge through social media to control covid-19. the study also analyzed the direct effect of social determinants on the preventive behavior of such conditions. the study was structured into five sections. after the introduction, the researches present thorough and critical analysis of current and most relevant literature along with hypotheses development. the third section contains material and methods used in this study to achieve the stated study objectives. the next section is about the main results of the study and discussions related to these results. the final section is about the main conclusions, findings, and the future research options. undeniably, online communication is used as an outlet for individuals to freely make and post data that is dispersed and extended worldwide after the advanced foundation of web 2.0. news media, conventional scientific outlets, and online networking sites create a platform for minority perspectives and individuals who are sometime, not being captured by other sources. individuals seek information from an assortment of sources and continually update it from the health sector. conventional news media has become recognizable as a comprehensive source of health information to prevent infectious disease in the public health sector. they provide information and awareness widely through social networking sites for reducing infectious diseases [10] . a few years ago, people did not have any communicational access to exchange their information directly with the government and health sectors, at that time, traditional media, such as newspaper, television, and so forth, played a critical role as a source of information exchange to the public [11, 12] . traditional media provided information about the disease to the public regarding public health issues [13] . therefore, citizens relied on traditional media as a foundation of knowledge which helped them to understand the critical condition of risk and receive precautions about the issues. however, after the advanced foundation of web 2.0, there became a rapid change in the use of media technology, and people have increased their social media usage by registering in almost all the social network accounts, for example, facebook, twitter, and youtube. this can also be seen from the increasing number of registered subscribers on all social web services to exchange their health information during any infectious disease outbreak [14] . unlike traditional media, which just engaged users to a limited amount of used and obtained information, in social media people make their profile and share health-related information to others, also making comments on health-related posts, and these sites also give the users the opportunity to join any public health-related groups [15] . for example, at the time of the h1n1 flu virus outbreak, people used social networking sites as an information exchange medium and gave opinions related to health [16, 17] . however, with the fast use of social networking sites, information access has changed, now people do not rely exclusively on the traditional or government news media, instead they trust sns to get essential information from the public health sector. for example, twitter was primarily utilized by the public for the exchange of experience, opinion, and knowledge among individuals during infectious disease [11] . specifically, sns have become a common source for general society to interchange their information when conventional news media offer very restricted information about an infectious disease outbreak due to some official pressure and limitations [18] . as per media policies, the public's reliance on media will, in general, escalate at the time of significant emergencies. when information is not promptly accessible from traditional news media, people, as information makers and disseminators themselves, assemble electronic methods such as social media for information exchange [19] . digital observation is an internet-based observation system that provides a current situation of public health problems by evaluating data stored digitally [20] . there are now numerous infectious disease observations in an epidemiological practice by which the predominance, outbreak, and extent of infectious disease are checked to build up patterns of active actions and advancements for management and control systems. the fundamental role of infectious disease observation is to observe, forecast, and reduce the harm caused by outbreak and epidemics situation as well as enhance the information system for specialists and the population concerning factors which could possibly be used in such conditions [21] . revealing occurrences of outbreaks has been shifted from manual record-keeping systems to worldwide online communication networks through sns [22] . therefore, we can draw our first hypothesis as the following: there is a significant relationship between social media and preventive behavior among people about covid-19. it is critical for public health sectors and government agencies to take any effective initiatives for the control of diseases, however, it is very difficult for developing countries to detect the infectious disease outbreak. observational capacity for detection of infectious diseases could be very costly and the developing countries lack resources to measure the outbreak of infectious disease at the time of exposure. hence, some social networking websites provide solutions to handle some of these challenges during an outbreak. online networking sites provide a source of information to detect infectious outbreaks earlier with very cheap cost and provide a way to increase their reporting clearly [23] . the exchange of health information on social networking sites has been seen as an opportunity for health sectors to increase public health observation [24] and to predict and control infectious diseases [25] . due to insufficient medical services in developing nations like pakistan, the authorities face severe complications to contain and eradicate the chances of spread of such infectious diseases. consequently, in case of an emergency, such communities start practicing alternatives to medical facilities to control the spread. therefore, we can safely propose the following: there is a significant relationship between social media exposure and information exchange about covid-19 among people. information exchange mediates the relationship between social media exposure and preventive behavior among people about covid-19. awareness regarding control of the infectious disease can overcome the financial burden for precautions. earlier knowledge about the outbreak of disease can overcome the level of its spread [26] . several methods can be used, like social media, internet access, tv, and so forth, by the nations to spread awareness about the precautions of disease. at present, mostly social networking platforms are being used as an important source to spread awareness of emergency to control an epidemic [27] . in the past, some researches have been conducted to evaluate the effect of social media to minimize the spread of infectious disease through preventive behavior. the results prove that social media is playing an essential role in overcoming the prevalence through prevention and reducing infection spread by awareness [28] . awareness brings behavioral changes among communities. as the phrase states, "prevention is better than cure". such awareness may be considered as half treatment without any expense. therefore, the researcher draws their next hypotheses as the following: there is a significant relationship between social media exposure and awareness knowledge. awareness knowledge mediates the relationship between social media exposure and preventive behavior among people about covid-19. many researchers have proved that during the infectious outbreak, socio-economic factors profoundly influence the prevention behavior towards diseases. the individuals with high income and education level have shown to be connected more with social media for the preventive measures [29] [30] [31] . furthermore, numerous studies argued that aged people followed better precautions by wearing a mask, using sanitizer, and keeping healthy respiratory hygiene [32, 33] . likewise, the relationships between the social determinants and prevention behaviors have presented that females [34] , individuals with high literacy [29] , and aged people [35] preferred to stay at home instead of visiting public places during an infectious period. however, according to the research conducted in the uk during a swine flu outbreak, individuals who have a low literacy rate/income level or are unemployed have avoided using public transport and visiting crowded places, in comparison with those individuals who have a high level of social determinants [33] . so, we can formulate following hypotheses. there is no significant relationship between high-income individuals and preventive behaviors among people about covid-19. there is no significant relationship between aged individuals and preventive behaviors among people about covid-19. there is no significant relationship between gender of individuals and preventive behaviors among people about covid-19. there is no significant relationship between high-educational individuals and preventive behavior among people about covid-19. research methodology, the principles and techniques used for gathering and analyzing data, plays an essential role in achieving the objectives of the study. this section presents the overall data sampling, research design, and data collection method used to find the objectives of the current study. an online survey was conducted by researchers in march 2020 during the covid-19 outbreak using social media tools like facebook, twitter, whatsapp, and email. a link was developed, and the structured survey was shared with participants on this link through different social media tools like facebook, twitter, whatsapp, and email. the intention behind the selection of online data collection using social media tools was maintaining the social distancing principle. this research is based on individuals from different geographical areas of punjab and azad jammu and kashmir, pakistan. the study was conducted on social media during 5 march 2020 to 25 march 2020. the sample size of 500 respondents was used through a random sampling method and examined with spss amos. the main reason for choosing this sampling method was that the researcher placed the questionnaire online. the researcher used a likert scale of 5 points. the hypotheses were measured using a scale by [36] . social determinants are considered very important in social science research and these were measured to check the significant direct effect of these control variables on preventive behavior among people about covid-19. the essential statistical components are age, gender, education, and income. these demographic components were necessary for the assessment of our objectives. the details of these variables are given in table 1 . the proposed model and variables investigated in this study are demonstrated in figure 1 . the proposed model and variables investigated in this study are demonstrated in figure 1 . sem technique was performed to examine the hypotheses discussed above. tables 2-4 show the key consequences for the hypotheses. researchers used path models to check the impact of social media on mediating variables, that is, information exchange and awareness knowledge regarding preventive behavior among people about covid-19 as a dependent variable and checked the direct effect of control variables on preventive behavior among people about covid-19. additionally, path analysis and maximum likelihood method were used to verify the mediated impact of health communication (awareness knowledge and information exchange) among social media and sem technique was performed to examine the hypotheses discussed above. tables 2-4 show the key consequences for the hypotheses. researchers used path models to check the impact of social media on mediating variables, that is, information exchange and awareness knowledge regarding preventive behavior among people about covid-19 as a dependent variable and checked the direct effect of control variables on preventive behavior among people about covid-19. additionally, path analysis and maximum likelihood method were used to verify the mediated impact of health communication (awareness knowledge and information exchange) among social media and preventive behavior. amos version 24 was used to check the statistical relationship between variables. initially, we tested the model fit index with comparative fit index (cfi) and root mean square error of approximation (rmsea); a cfi ≥0.97 and rmsea ≤0.055 mean the fit was acceptable (hu and bentler, 1999). the indirect effect of social media on behaviors was calculated using the same statistical tool through 2000 bootstrap samples. critical factor analysis (cfa) was used to test the discriminant and convergent validity of every construct of the measurement model. we also checked the factor score of each item, and all items exceeded the threshold of 0.6 (p < 0.001). the value of ave ranged from 0.55 to 0.79 (all values are exceeding the threshold 0.5), and cr ranged from 0.82 to 0.92 (all exceeding the threshold of 0.7). according to the parameter estimation results of table 4 , the direct impact of social media exposure on preventive behaviors concerning h1 (β = −0.097 p < 0.001) showed an insignificant direct relationship between independent variable and dependent variable. therefore, h1 was not supported. according to the results of h4 (β = 0.389, p < 0.01) and h2 (β = 0.377, p < 0.01), both showed significant direct effect of social media on awareness knowledge and information exchange. so, we accepted these two hypotheses. therefore, we can say that social networking sites have been used as an important strategy to spread awareness and information at the time of emergency to control the covid-19 outbreak. health communications via social media were positively significantly influenced by awareness and information exchange and indirectly influenced the adoption of preventive healthcare behavior. h6, h7, h8, and h9 tested whether age, gender, income, and education would be insignificantly associated with preventive behaviors. the parameter estimates showed that h9 education (β = 0.106, p < 0.01), h7 age (β = −0.052, p < 0.01), h8 gender (β = 0.041, p < 0.01), and h6 income (β = 0.023, p < 0.01) have negatively insignificant relationships with preventive behaviors. all these control variables were supported according to our theory. it is not necessarily individuals with high literacy/income and aged people who avoid using public transport and crowded places. the effects of high social components were directly insignificant on preventive behavior to control the epidemic disease of covid-19. according to the study findings, every type of individual can acquire an advantage through social media campaigns regarding the preventive behavior against covid-19. h5 and h3 tested whether awareness knowledge and information exchange directly influenced preventive behavior during an infectious disease outbreak like covid-19. estimated parameters in table 2 illustrated that awareness knowledge (β = 0.454, p < 0.001) and information exchange (β = 0.199, p < 0.001) have a positive significant direct relation with preventive behavior and have a full mediating effect between the social media and preventive behavior, as illustrated in tables 2 and 3 and figure 2 . social media provides the possibility for individuals to be aware of private or public awareness campaigns. eke [37] supported this theory that public awareness affects an individual behavior during an infectious disease outbreak to control its spread. our study showed that public or private awareness through social media could overcome the spread of infectious disease. the connectivity between the constructed hypotheses of our theory test is shown in table 4 , table 5 and figure 2 . according to the results of direct relation, no direct relationship exists between social media exposure and preventive behavior, however, awareness knowledge and information exchange create a mediating effect between the social media exposure and preventive behavior, so there exists a strong relationship between social media exposure and preventive behavior with the full mediation of awareness knowledge and information exchange. in conclusion, the covid-19 outbreak in china significantly damaged the human population across the globe. this included widespread distrust, a high number of deaths, high public stress, and economic damage. this study analyzed the effect of social media on preventive behavior during the covid-19 outbreak in pakistan. firstly, it should be counted that social media has become an increasingly popular source of awareness and information for health communications, especially the connectivity between the constructed hypotheses of our theory test is shown in table 4, table 5 and figure 2 . according to the results of direct relation, no direct relationship exists between social media exposure and preventive behavior, however, awareness knowledge and information exchange create a mediating effect between the social media exposure and preventive behavior, so there exists a strong relationship between social media exposure and preventive behavior with the full mediation of awareness knowledge and information exchange. in conclusion, the covid-19 outbreak in china significantly damaged the human population across the globe. this included widespread distrust, a high number of deaths, high public stress, and economic damage. this study analyzed the effect of social media on preventive behavior during the covid-19 outbreak in pakistan. firstly, it should be counted that social media has become an increasingly popular source of awareness and information for health communications, especially during an outbreak. the data have been collected and analyzed as the outbreak started in pakistan in 2020. this study examined how social media plays an essential role in formulating preventive behavior during the covid-19 outbreak in pakistan. the results of this research revealed that social media exposure is associated with two relevant variables, awareness knowledge and information exchange, and these variables mediate the relationship between social media exposure and preventive behavior among people regarding covid-19. social media reinforces and enhances health-related communication by raising awareness campaigns and disseminating reliable information to the users in an emergency regarding preventive behaviors. social media has become a source of rapid information and can be updated promptly. if the utilization of social media becomes more accurate or scientific then the social media can provide a very efficient and user-friendly way of monitoring the facts and figures of epidemic both locally and at an international level. the use of social media as a communicating tool during the infectious disease outbreak is a new method of observation, but provides a potential source of an accurate and quick assessment of progression of the current condition of disease within communities. social media has also become the most accessible and valuable tool, particularly in a social-economic and climatic context [36] . mostly, developing nations like pakistan do not have any excess to maintain and control the surveillance system in a timely manner during an infectious disease outbreak. therefore, due to lack of resources, most developing nations use social media networks for health communication tools to prevent and control the spread of infectious disease in a community [37] . thus, social media can afford a fast method of surveillance that forecasts the real-time burden of infectious disease and hence also can guide preventive strategies to control the epidemic. the study has some limitations as only data from pakistan were collected. therefore, the results may not be easily generalized to other developing countries, but are useful for politicians, health administrators, governments, policymakers, and social scientists, especially for those whose circumstances are like those in pakistan. the conceptual structural equation model provides useful information for policymakers and practitioners to enhance preventive behavior through the adoption of appropriate awareness strategies and information exchange and social media policies. the study demonstrates how social media exposure indirectly impacts preventive behavior and illustrates the paths of influence through either awareness or information exchange. to the best of our knowledge, the study is probably the first in the concerned area. the study investigated how only some social variables can help prevent covid-19. future researchers can investigate other variables lying under the category of social sciences and their role in dealing with covid-19 and its impacts. the future studies can also specify the sectors, like health workers, education, police, and other security agencies. the authors declare no conflict of interest. the effect of control strategies to reduce social mixing on outcomes of the covid-19 epidemic in wuhan, china: a modelling study a novel covid-19 from patients with pneumonia in china modeling the role of information and limited optimal treatment on disease prevalence users of the world, unite! the challenges and opportunities of social media the continuing 2019-ncov epidemic threat of novel covid-19es to global health-the latest 2019 novel covid-19 outbreak in wuhan, china the chatline as a 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cord-314779-f5nvspcg authors: roth, steffen; valentinov, vladislav title: east of nature. accounting for the environments of social sciences date: 2020-06-07 journal: ecol econ doi: 10.1016/j.ecolecon.2020.106734 sha: doc_id: 314779 cord_uid: f5nvspcg at the core of ecological economics is the image of the economy as an open system embedded in the natural environment whose carrying capacity is limited. the present paper revisits this image by drawing upon the constructivist implications of luhmann's social systems theory. to luhmann, the modern society consists of a multitude of social systems each bringing forth and observing their own environments. if the luhmannian vision is accepted, then ecological economics can be said to privilege the observational perspective of natural sciences. the unfortunate consequence of this privileging is the underestimation of a broad range of multidimensional sustainability risks which are foregrounded by the numerous alternative observational perspectives which are just as legitimate. it is argued that, rather than relativizing the sustainability concerns of the modern ecological economics, the luhmannian perspective generalizes and radicalizes them. in doing so, the latter perspective opens new possibilities not only for navigating these risks but also for envisioning new resources and solutions. the understanding of the present-day sustainability challenges, as well as the practice of sustainability accounting, rest on specific assumptions about the relationship of the economy to its outer environment. for many ecological economists, these assumptions are centred around the idea that the economy is an open system embedded in the environment which is usefully classified into societal and natural. karl william kapp (1985, p. 152) , an early contributor to the ecological economics literature, seminally attributed the phenomenon of social costs not only to the corporate decision-making under capitalism, but also to "the open-system character of the economy". this open system character of the economy has many implications, such as materiality and the relevance of multiple time-space scales, each calling for a multidisciplinary approach (luzzati, 2009; luzzati, 2010a luzzati, , 2010b . most importantly for the present purposes, the open systems character that makes the economy susceptible to the limits of the environmental carrying capacity. the vision of the economy as an open system embedded in a finite environment seems to also underlie, e.g., elkington (1997) triple bottom line concept. as elkington explained, "sustainable development involves the simultaneous pursuit of economic prosperity, environmental quality, and social equity. companies aiming for sustainability need to perform not against a single, financial bottom line but against the triple bottom line" (ibid, p. 397) . the logic of the environmental embeddedness of the economy seems straightforward and impeccable. if the environmental carrying capacity is limited, and if systems populating this environment overstrain this carrying capacity, it is logical that they are in trouble (luzzati et al., 2014, p. 100 ). this trouble, or sustainability risks, can be given an alternative formulation suggested by niklas luhmann's theory of social systems. while ecological economics was admittedly not a central concern to luhmann, he devoted a 1989 book to the ongoing ecological crisis, which he took to be a specific illustration of the more general theme of the precariousness of the relations of social systems, of all types, to their outer environments. to luhmann, system-environment relations are precarious because of the fact that the main function of social systems is to reduce, externalize, or blind out the complexity of their environment. while the complexity-reducing function is highly valuable for boundedly rational individuals, it exposes social systems themselves to sustainability risks. thus, luhmann (1989, p. 62) came to the conclusion that "the key to the ecological problems, as far as the economy is concerned, resides in the language of prices… the economy cannot react to disturbances that are not expressed in this language". this argument strikes a chord with much of the ecological economics literature (valentinov, 2014a (valentinov, , 2014b , despite this literature's systems-theoretic focus on open systems (e.g., kapp, 1985; luzzati, 2009 luzzati, , 2010a rather than on the operational closure which is a mainstay of luhmann's thought. yet, what may turn out to be problematic for ecological economics is luhmann's social systems theory. he believed social systems to construct their own environments in the course of their functioning. this means that, apart from this functioning, and apart from the ways systems observe reality, the nature of the environments in which the systems are embedded cannot be specified. against this backdrop, the key research question of the present paper pertains to the clarification of the nature of sustainability risks from the point of view of his social systems theory. luhmann designates the modern society as polycontextural, or, as roth et al. (2019) explain, "constructed by alternative and contingent observational perspectives that may be mutually conflicting and discrepant". from this perspective, a polycontextural society does not have any single, fixed, and definitely known environment. instead, there is a multitude of social systems each bringing forth their own environments. contrast this implication with those of elkington's (1997) triple bottom line concept. elkington rightly assumed that the practice of the traditional bottom line rested on problematic assumptions about the nature of the relations of the economy with its outer environment, both societal and natural. elkington has questioned these assumptions and replaced them by his own, thus substituting one type of certainty for another. the essential luhmannian insight, however, is that in a polycontextural society, such certainty does not exist at all. instead, there is a multitude of social systems each bringing forth their own environments. consequently, if the focus on any type of the environment happens to be dominant or privileged, the role of the other possible and equally legitimate types of environments, and the sustainability risks associated therewith, most likely will be underestimated. insofar as ecological economists can be said to privilege a certain observational perspective on the natural and societal environment, their professional knowledge, profound as it is, may yet turn out to be dangerously one-sided. the positive way of formulating the above contention is that the polycontextural regime of the modern society provides a space for a radical amplification and multiplication of sustainability concerns as the primary area of interest of many ecological economists. to make that case, the following sections reconsider the concept of nature underlying the ecological economics scholarship, contrast the notions of the environments embraced by the natural and social sciences, and on that basis, reconceptualize the triple bottom line approach in the emerging multienvironmental context. this reconceptualization opens new possibilities and envisions new resources for navigating sustainability risks. the paper concludes with a discussion of how these new possibilities and resources can be harnessed by strategic management tools. as a transdisciplinary field of study, "ecological economics addresses the relationships between ecosystems and economic systems in the broadest sense." (costanza, 1989, p . 1) while the latter focus has early been complemented by or extended to a social systems perspective, the primary goal of ecological economics (ee) has always remained the "sustainable wellbeing of both humans and the rest of nature" (costanza, 2020, p. 1) ; and in the pursuit of this worthy goal, the transdiscipline has consequently developed a high level of facility in incorporating and combining insights from economics, further social sciences, and the natural sciences. yet, the implication that economics is a social science may also be contested for an economics that accentuates the word ecological and aims to "recast economics as a life science" (røpke, 2004, p. 300; van passel, 2007, p. 31; costanza, 2020, p. 1) . there is hence a considerable tension between this organic view of economics and the increasingly popular demands for an advancement of its social sciences stream (spash, 2011 (spash, , 2012 , as it seems hard to impossible to reconciliate those who "remain wary (…) that the basis of human social relations can be reduced to, and essentialized within, the natural world" (hird, 2010, p. 738) with those convinced that "(d) etermining what is necessary for safeguarding environmental functions for future generations is a matter for the natural sciences." (hueting and reijnders, 2004, p. 255) . in fact, the contradiction could hardly be more blatant: on the one hand, proponents of the natural sciences camp suggest (ruth, 2006) and are criticised (van hecken et al., 2015) for building economic laws, social institutions, and ethical standards on natural scientific insights. on the other hand, the social sciences camp is accused of culturally turning its back on precisely these insights (hird, 2010) while holding that both money and nature, and hence the cornerstones of entire field, are social constructions (fourcade, 2011) . the fact of social construction may be derogatively registered by those who hold religious or metaphysical beliefs in the sanctity of nature as something primordial and antecedent to human activity (cf. blancke et al., 2015) . yet, the understandings of naturalness can be often themselves unmasked as social constructions framed by the prevailing institutional structure (cf. valentinov et al., 2019a valentinov et al., , 2019b . these and further severe contradictions notwithstanding, however, both streams of ecological economics agree on the general adequacy and utility of the attempted "integration and synthesis of economics and ecologynot the disciplines as they existed at the time, which were seen as too narrow in their conceptions of the issuesbut of the study of economic and social systems embedded in and interdependent with their ecological life support systems" (costanza, 2020, p. 2) . hence, the "recognition that the economy is embedded within society, which is embedded within the rest of nature" (ibid.) is widespread; and even if some reservation might apply to the implication that economy and society belong to the realm of nature, the convention to define sustainability along an economic, social, and ecological or environmental dimension (basiago, 1995; european commission, 2001 ) is well-established and has gained particular prominence under the "triple bottom line" label (elkington, 1994 (elkington, , 1998 mauerhofer, 2008; ahi et al., 2018; vatn, 2020 ) (see fig. 1 ). 1 as impactful, integrative, and intuitive this idea may be, it remains grounded in the assumption that the environment of society in general and the economy in particular is adequately referred to as nature. in the subsequent sections of this article, we shall contest this basic assumption, reclaim a social scientific approach to the concepts of environment and ecology, reconceptualises nature as the environmental view of the social subsystem called natural sciences, and extend this regional nature-perspective to a broader concept of environment. starting from its roots in the 1960s (e.g., boulding, 1966; daly, 1968 ) and likely extending well into the anticipated future of the discipline (costanza, 2020) , ecological economics has always been open to systems thinking. terms and ideas such as economic system, social system, system of life, ecosystem, or nature as system consequently belong to the basic conceptual equipment of the transdiscipline. yet, the dominant systems-theoretical paradigm of the transdiscipline seems to be anchored in the open systems theory going back to the groundbreaking work of the biologist ludwig von bertalanffy (cf. von bertalanffy, 1968). interestingly, the discipline of biology has brought forth an alternative and in a sense opposite systems-theoretical paradigm, the theory of operationally closed, "autopoietic" systems. in this context, autopoiesis means that "everything that is used as a unit by the system is produced as a unit by the system itself" (luhmann, 1990, p. 1 more differentiated models distinguish between larger numbers of nested systems, e.g., from the outside in, physical environment, society, institutionalpolitical system, and economy (luzzati, 2010b, p. 53) . 3). the latter paradigm, while anticipated by von bertalanffy himself, mainly originates from the work of natural scientists maturana and varela, 1992 who were searching for an encompassing biological definition of life. maturana and varela (ibid) came to understand the essence of life in terms of the interrelated phenomena of autopoiesis and operational closure, both of which have been later appropriated by luhmann. as autopoietic systems, living organisms "produce not only their structures, but also the elements of which they consist, within the network of these very elements" (luhmann, 2012, p. 76f) . as a result, autopoietic systems can be said to operate "only in the context of [their] own operations" (luhmann, 2018, p. 33) . if life is understood in terms of its autopoietic organization, it would follow that "(t)he structure of living systems and their actual (material) components are complementary yet distinct aspects of any biological explanation: they complement each other reciprocally but cannot be reduced to one another" (varela and maturana, 1972, p. 382) . we may read these lines as a reminder not to confuse our object of research with its footprint. life is not what it takes to live. as organisms, we are neither what we eat nor the air we breathe, and we are not our excrements and other ecological footprint either. and it is precisely this condition that explains why we do, and indeed can, crave for nutrition, water, oxygen, and all other environmental factors that we critically depend on. just as varela and maturana insisted on the dividing line between matter and life, niklas luhmann (1995 luhmann ( , 2013 drew and defended the distinction between the behaviour of autopoietic biological systems and the communicative autopoiesis of social systems, the latter of which he said to be reliant, yet not reducible to the level of individual behaviour. it is ironic that luhmann established this borderline between biological and social systems by drawing on a concept that was originally invented by biologists, and that this move exposed him to criticism from both natural and social scientists alike (see cadenas and arnold, 2015; king, 2001; mingers, 2002) , including humberto maturana: "i have had relatively long discussions with maturana on this point. he always told me that1 if one speaks of the autopoiesis of communication/ one has to show it. that is to say, one has to show that the concept really works in the domain of communication so that it is possible to state that an individual communicative act can come about only in the network of communication. it cannot be conceived as a one-time event. and it also cannot be conceived as produced externally, in a communication-free context, as it were-say, as a chemical artifact that then has a communicative effect. on the contrary, it must always be produced by and through communication. i believe that this claim does not create much difficulty. it is relatively easy to see-especially if one considers the linguistic tradition of saussure, for instance and all that came of it-that communication occurs via its own differences and has nothing to do with chemical or physical phenomena." (luhmann, 2013, p. 79) . the same intrinsic logic that draws the dividing line between biological and social systems as different forms of systems then also applies to the differentiation between different forms of social systems. thus, as much as biological and social systems constitute environments for each other, and as much as there is hence no overlap but only mutual influences or "irritation" between these two forms of systems, so too is there no overlap between different subsystems of the comprehensive social system we commonly refer to as society. if we now insist "that the economy is embedded within society" (costanza, 2020, p. 2) , then this claim is perfectly compatible with luhmannian social systems theory, in which the economy is a subsystem of society and thus a social system itself. a social systems-theoretical perspective also allows for the observation that the economic system is now confronted with two different forms of environment, namely one intra-societal and one extra-societal environment. there are, however, two major differences. first, a social systems-theoretical variant of the triple-bottom-line model depicted in fig. 1 , there would be no need for a border around the extra-social environment unless we intend to observe it as a(n eco)system and thus distinguish it from yet another environment (see fig. 2 ). the second big difference between an ecological economics and social systems-theoretical perspective is that the latter does not content itself with an ultimately cancelled negative definition of society as the complement of its economic subsystem. if we challenge the idea that society is properly defined as "economy and the rest of society", then we shift our focus from the economy to its intra-societal environment. in looking at this social ecology of the economy, however, we quickly realise that the economy is certainly not the only subsystem of society as politics, science, religion, art, or law clearly are social subsystems, too. as there is no system without environment, this discovery implies that all other systems are not only located in the intra-societal environment of the economy, but also locate the economy as much as all other in their respective intra-societal environments. in other words, the social ecology of the economy is made of numerous social systems, each of which has a different environment and thus a different view of the overall ecology of social systems. as each of these systems has a different view of the social ecology, they necessarily have a different view of the extra-societal environment, too. true, natural science defines this environment as nature; yet, from a religious point of view, this environment may be populated by spirits or gods, and most commonly referred to as one of these god's creation. for yet other subsystems, this environment might appear as an indefinite learning space or an equally gigantic though potentially shrinking stock of non-social resources. a truly social science that accounts for this multienvironmental condition would therefore need to refrain from over-identifying the extra-social environment with the environmental concepts and terminologies of the natural sciences. this is true because, first, it is hard to impossible to prove scientifically that one of the above-mentioned subsystems is essentially more important than the other(s). second, even if a scientific bias to science seems logical or at least comprehensible, it would still remain unclear why social sciences should favour an environmental concept of the natural sciences over a socialscientific one. in the subsequent section of this article, we shall therefore outline a social-scientific concept of environment, in the context of with the natural-scientific concept of nature is positioned as one environmental concept among others. regardless of whether we define ecological economics as a natural or a social science, it remains true that the economy is neither a natural nor a social science. as economy and science are two distinct though certainly interacting subsystems of society, the current situation, in which a transdisciplinary field attempts at almost coercing one social subsystem to adopt the environmental perspective of one branch of another subsystem, seems far from being natural. in looking at fig. 3 , the reductionist nature of this enterprise is even more evident: fig. 3 depicts a challenge and extension of the classical "3-d sustainability" (mauerhofer, 2008 ) models such as the triple-bottom-line and cognate frameworks. the basic feature of these models is that they locate the economy (the right-hand triangle) within society (the social environment of the economy triangle). society is then again embedded within an extra-social environment, which is commonly referred to as nature, ecosystem, or ecological environment. in order to observe ecosystems or nature, however, we need science in general and natural sciences in particular (luzzati et al., 2014, p. 100) . science, however, does not appear in its own models, which is as ironic as consequential as these models are used to argue that a sustainable economy must confuse its environment with the environment of the natural sciences. in fig. 3 , this condition is depicted as a prohibition to use an economic radar and obligation to use a natural scientific radar for environmental screening. as indicated earlier, in its more radical forms, this concurrent prohibition and obligation explicitly includes or is extended to the social environment, e.g., when ruth (2006, p. 339) suggests to establishing "the economic, legal, institutional and ethical basis" of sustainable human behaviour "on fundamental insights from the natural sciences". in revisiting fig. 3 , however, it becomes obvious that even this already enhanced version of the triple-bottom-line remains incomplete as economy and science are certainly not the only subsystems of society. moreover, it is just as sensible that these subsystems constantly influence each other. for instance, "(t)he political system depends upon informational and conceptual inputs and contributions from the other societal systems in the governance process-for example, the social and the natural sciences" (luks and siebenhüner, 2007, p. 418) , and the same is true vice versa. last not least, it is critical to realise that function systems constitute parts of the social environment for each other and that they are only one type of social systems that constitute the overall social environment, with other types being, for example, families or organizations. in figs. 3 and 4, the label "societal environment" is therefore written across the border between the "inner circle" from a social-scientific perspective, we therefore observe an entire ecology of interacting social subsystems and their corresponding environments. in the luhmannian terminology, what we observe is polycontexturality: a multitude of interdependent, yet mutually incommensurable and operationally closed systems bringing forth their unique definitions of both the societal and extra-societal environment. as important as the actually quite provincial natural environmental perspective might seem today against the backdrop of the urgent threats to its environment, so too is the perceived urgency no scientific argument to ignore, devalue, or even prohibit the environmental perspective of other subsystems of society in general and other subsystems of science in particular. however, from a social-scientific perspective, there is no need to ignore, devalue, or even prohibit the environmental perspective of the natural sciences either. rather, what is needed is a multifunctional perspective similar to the one depicted in fig. 4 . fig. 4 presents a social-scientific perspective on society and its internal and external environments. this perspective does not ignore, devalue, or even prohibit; to the contrary, it encourages the natural sciences to make universal claims about the nature of both the societal and the extra-societal environment of the economy or any other social system. yet, fig. 4 is also a reminder that universality must not be confused with exclusivity (luhmann, 1995, p. xlviii) . this means that each type of environment can harbour unique sustainability risks, many of which would remain unnoticed even by the modern sustainability concepts such as the triple bottom line concept. the relationship between the luhmannian systems theory and ecological economics is marked by a deep ambivalence, which, is not unique to the present paper. take the case of kenneth boulding, who was not only the author of the seminal "spaceship earth" metaphor but also an engaged systems theorist. whereas the spaceship metaphor evidently rested on boulding's firm belief in the certainty of the exhaustible and destructible nature of the environment of the economy, his systems-theoretical views were more open-ended. in his systemstheoretical treatise ecodynamics (boulding, 1978) , he titles one of the sections "the myth of the environment". in the section, he explains that "there is no such thing as an 'environment', if by this we mean a surrounding system that is independent of what goes on inside it. (…) it makes sense to divide the totality of the universe into parts that have some degree of independent dynamic pattern, but none of these parts is really independent of others: all interact. (…) everything is the environment of everything else" (ibid, p. 31). the luhmannian systems-theoretical perspective affirms the view that "there is no such thing as the environment", but for somewhat different reasons. if we agree that there is 1) no system without environment, 2) no ecology without a plurality of systems, and thus 3) no ecosystem without a plurality of environments, then we cannot assume the environment as a singular entity to be given with ontological certainty. it is rather the case that different social subsystems have different views of their environment, and that nature-the environment of the natural sciences-is nothing more or less than the environment of a subsystem of the scientific subsystem of society. does that mean that the luhmannian perspective relativizes the fundamental sustainability concerns of ecological economics? a sympathetic look at fig. 4 would suggest that these concerns are generalized and radicalized rather than relativized. while sustainability risks addressed by ecological economists are serious, they are observationally contingent. employing other observational perspectives may lead to the discovery of new dimensions of risks which are no less serious. on a more positive note, these risks may likewise engender entrepreneurial opportunities. just as the triple bottom line concept has provided inspiration for the development of sustainable business models (cf. joyce and paquin, 2016) , the polycontextural environment indicated in fig. 4 invites the use of strategic management tools for the purposes of the multienvironmental screening and accounting of the diverse logics and observational perspectives . these tools would open radically new possibilities for navigating multidimensional sustainability risks, particularly for those types of social systems (such as corporations) that are known to systematically blind out specific segments of environmental complexity or stakeholder interests valentinov et al., 2019a valentinov et al., , 2019b . take classical environmental scanning tools such as pest or its derivates pestle, steeple, steepled (see roth et al., 2017, p. 200f ), many of which give additional weight to ethics and the natural environment. while the individual letters p (politics), e (economy), s (society) and t (technology) have been continually supplemented or reshuffled, it is clear that critical aspects of the societal environment have escaped the attention of these and many other environmental scanning tools. health is one such factor, as the system does not seem to deserve a dedicated letter or specific attention and is typically lumped together with often both "political" and "social" issues. yet, the coronavirus crisis has shown in the most dramatic ways that such neglect may come at a cost. the same events have furthermore demonstrated the inescapable incommensurability of the individual spheres (kapp, 1977, p. 538; luzzati, 2009, p. 315) or subsystems of society (luhmann, 2002, p. 52; roth, 2019, p. 508) as emerging dilemmas or trade-offs between health on the one side and money or liberty on the other side clearly indicate that we are confronted here with some of "those questions that are in principle undecidable" (von foerster, 1992, p. 14) . in discussing the example of managerialized public health care, roth et al. (2019, p.8) argue that the "proliferation of this type of health care can be observed from multiple and equally legitimate points of view associated with the function systems, each of which potentially generates a distinct moral evaluation of this trend. business-like public health care may be politically endorsed (i.e. good) and economically efficient (i.e. good) while being inconsistent with medical professionalism and unchristian. it may at the same time present a setback for risk sport participants and probably even a scandal in the mass media system, while making no difference from an artistic or legal point of view. this diverse constellation of moral judgments shows the rise of business-like public health care to be simultaneously good, bad, and morally irrelevant. this example makes clear that functional differentiation precludes the automatic identification of economic, political, legal or scientific operations as inherently good or bad." in showing how quickly conventional judgments on the relative importance of the individual function systems may change, the 2020 coronavirus crisis, therefore, make a strong case that a better (mutual) understanding of how differently different function systems conceive of both their societal and extra-societal environment is essential. the basis of this understanding would be a strategic management tool that accounts for the, in principle, equal importance of all functions systems that could be acronymized "rhesamples" (roth et al., 2017, p. 201 ), a derivation from the initial letters of each of the 10 function systems: religion, health, economy, science, art, mass media, politics, law, education, and sport. as another implication for further research, a multiplication of sustainability concerns achievable by the proposed multienvironmental scanning would be capable of yielding information on the possible environmental shocks that might be suffered by specific social systems. that way, the introduction of multienvironmental scanning holds the potential to improve the resilience of the systems in question, a property which is often understood as the systemic capacity "to absorb change and disturbance and still maintain the same relationships" (holling, 1973, p. 14) . in the last decades, the concept of resilience rose to prominence in the context of the literature on the socio-ecological systems (ibid) and was applied to numerous other contexts. it was acknowledged that ensuring the resilience of the socio-ecological systems requires adaptive governance which must be conceptualized as multilevel and polycentric (van assche et al., 2019) . it is evident that the proposed multienvironmental scanning radically expands the observational capacity required for anticipating the possible shocks. while this may be a valuable contribution to the literature on the socio-ecological systems, the understanding of these systems may itself be transformed by the multiplication of observational perspectives suggested by a consistent application of the luhmannian insights. furthermore, the luhmannian systems theory may itself benefit from appreciating the way in which the polycontextural diversity of the modern society converges on the twofold understanding of the boundary between the social and the natural. as van assche et al. (2019) , p. 313) explain, "the ecological is the environment of the social in a double sense: internally and externally". the same understanding of the boundary is evidently applicable to the distinction between human organisms and what luhmann took to be psychic systems. there is room to argue that much of this complexity can be illuminated by the proposed multienvironmental scanning, especially given that the coevolution of organisms and psychic systems may itself be a reflection of the much more encompassing process of co-evolution of systems and environments constituting the regime of polycontexturality. finally, the diverse observational perspectives generate further insights going beyond risks and entrepreneurial opportunities. paradoxically as it sounds, these insights bring to the fore new solutions and new resources that have been invisible from the traditional or dominant perspectives. if contemporary societies are responsible for what we commonly refer to as ecological problems, then the solutions to these problems might require not ever-bigger natural-scientific efforts (shah, 2020) , but rather a shift of perspective to the environments of social sciences and a corresponding multienvironmental scanning that dislodges the problems while foregrounding the above opportunities that have not been clear before. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. a quantitative approach for assessing sustainability performance of corporations methods of defining 'sustainability fatal attraction: the intuitive appeal of gmo opposition the economics of the coming spaceship earth ecodynamics: a new theory of societal evolution the autopoiesis of social systems and its criticisms what is ecological economics? ecological economics in 2049: getting beyond the argument culture to the world we all want on economics as a life science towards the 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explanation institutions for sustainability-towards an expanded research program for ecological economics ethics and second-order cybernetics from nonprofit diversity to organizational multifunctionality: a systems-theoretical proposal he holds a habilitation in economic and environmental sociology awarded by the italian ministry of education, university, and research; a phd in sociology from the university of geneva; and a phd in management from the chemnitz university of technology. he is the field editor for social systems theory of systems research and behavioral science. the journals his research has been published in include germany, and senior researcher at the leibniz institute of agricultural development in transition economies in halle, germany. he has served on the editorial boards of several journals, such as the journal of economic issues, voluntas, and kybernetes. his research has been published in journals such as nonprofit and voluntary sector quarterly the authors are grateful to the editor and the anonymous reviewers for their close reading of our manuscript and their very helpful comments. key: cord-299065-wopsfrqg authors: mukhtar, sonia title: psychological impact of covid-19 on older adults date: 2020-07-22 journal: curr med res pract doi: 10.1016/j.cmrp.2020.07.016 sha: doc_id: 299065 cord_uid: wopsfrqg nan insufficient and inadequate attention has been paid to the mental health of older age group in terms of timely and quality psychological crisis intervention. social isolation, social distancing, social disconnectedness, and loneliness were found to be mediated with depression and anxiety in a similar study. 3 self-perceived social disconnectedness and perceived isolation predicted higher depressive and anxiety symptoms. 2 brief evidence-based psychological preventive public health interventions could be established and implemented within residential environment, healthcare facilities, nursing centers, religious and cultural organizations, social and community centers for older adults. 4 action-based psychological preventive public health strategies could cultivate social connection and promote healthy relationships with own-self and others. cognitive skills and social support networks could help older adults to foster meaningful connection and sense of belongingness during isolation period. cognitive, behavioral, social, positive and brief therapies delivered online or inperson could enhance mental wellbeing, improve social affiliation and support while simultaneously diminishing perceived loneliness. 2, 4 social isolation and social disconnection -a documented bidirectional and complex relationship between mental health issues and social disconnectedness -itself poses a serious public health concern among older adults especially due to the psychosocial reasons and physiological health problems such as mental health problems, cardiovascular, autoimmune, neurocognitive, neurobiological, and other at-risk health problems. pakistan's government should take concrete instructions for elderly people socially isolated at home or quarantined at healthcare facilities (hospital, clinic, isolation unit, daycare, community center, and place of worship) to have prescribed diet and medications and communicate about the meaning of social in-contact to mitigate their physical and mental health consequences. 2, 3 however, adherence to social isolation strategies could be weakened with time and such well-timed reinforced implementing preventive measures would efficiently prevent the aggravated morbidity of covid-19 related to affective mental health problems in older adults. no funding received. the authors declare no conflict of interest. effects of covid-19 pandemic in daily life s mukhtar mental health and emotional impact of covid-19: applying health belief model for medical staff to general public of pakistan brain behav immun s mukhtar mental health of medical workers in pakistan during the pandemic covid-19 s mukhtar mental health and psychosocial aspects of coronavirus outbreak in pakistan: psychological intervention for public mental health my gratitude goes to my elderly friends for sharing information about their current situations. the author declares no conflicts of interest. key: cord-342360-d7qc20i4 authors: mohamad, siti mazidah title: creative production of ‘covid‐19 social distancing’ narratives on social media date: 2020-06-03 journal: tijdschr econ soc geogr doi: 10.1111/tesg.12430 sha: doc_id: 342360 cord_uid: d7qc20i4 this paper offers an insight into the role of young people in shifting risk perception of the current global pandemic, covid‐19, via social distancing narratives on social media. young people are creatively and affectively supporting the social distancing initiatives in brunei darussalam through the use of social media platforms such as instagram, twitter, and tik tok. using qualitative content analysis (qca) data of social media content by bruneian youth, this paper reveals the localised and contextualised creative production of five ‘social distancing’ narratives as a response to the national and global concerns in times of a global pandemic: narrative of fear; narrative of responsibility; narrative of annoyance; narrative of fun; and narrative of resistance. this paper reflects on three key socio‐cultural reconfigurations that have broader implications beyond the covid‐19 crisis: new youth spatialities and social engagements; youth leadership in development; and consideration of social participation and reach in risk communication. this paper is motivated by the socio-cultural implications and reconfiguration of everyday life amidst and beyond the covid-19 pandemic in the period of intense social media use. the introduction of social media to the public in the mid-2000s and its development in recent years have created new youth spatialities and socio-spatial engagements that have significantly altered the way audiences consume information, participate in the content creation, and engage with the content circulated on the social media platforms. with a social mediascape that is characterised by participatory and networked culture and user-generated content (jenkins et al. 2013) , the creation, circulation, and consumption of information and contents are increasingly contextualised, and socio-culturally, and politically shaped. the ontological nature of our communication culture (the intense and expected users' self-disclosure) and the current social media practices, in the context of risk communication, are not making it easier for relevant stakeholders, especially public health practitioners to disseminate health risk information and to understand the communicative health practices and risk perception of the population. social media can be effectively utilised to communicate information on the covid-19 for public health awareness and interventions, while at the same time poses risk due to the confusion and uncertainties among the public from the misinformation, disinformation, and malinformation, apparent in the growing infodemic that accompanies a contemporary epidemic or a pandemic (cinelli et al. 2020; zarocostas 2020) . for instance, the upsurge of false information (or myths) circulated on social media related to covid-19 (commonly seen myth -eating garlic help prevent infection with the new coronavirus). world health organisation (who) and relevant government agencies (brunei's ministry of health included) took action by posting on their official instagram to highlight and debunk false information. equally important in this risk communication is risk perception of the population. risk perception cannot be generalised to the whole population as it is known to be based on a 'diverse array of information that (individuals) have processed on risk factors … and technologies, as well as on their benefits and contexts' (who 2002 ). an individual assesses risk according to own knowledge, experience, and socio-cultural environment. hence, the need to look into context and localities in this study. unlike during the time of the sars outbreak in 2003 when social media was uncommon, digital technology and new social media are now ubiquitously used by who and government bodies to spread awareness of the health risk, to share latest information, and to influence risk perception of the public on the severity of this pandemic. the intense internet and social media penetration create digital landscapes where information is widely available; from information, data, advice on the one hand to misinformation, speculation and even conspiracy theories on the other. to add to this, the audience of a few of the recent social media sites such as instagram, snap chat, and tik tok are predominantly younger people (ortiz-ospina 2019). this makes it imperative to study young people's responses to the pandemic in today's social media time. in brunei, young people are observed to be using social media in playing their part as community members in their own locality and as global citizens. in the context of covid-19 pandemic, considering that there is still not much knowledge on how risk is communicated, understood, and acted upon (smith 2006) including risk communication on social media platforms (kass-hout & alhinnawi 2013), this paper aims to reflect on how young people as active audience on social mediascapes are playing a key role in communicating risk to a fellow (young) audience and changing risk perception of a global pandemic, covid-19, via social media. of equal importance here are the potential socio-cultural transformations these young people's social media engagements could create beyond this current crisis, which are revealed in this paper. in the following section, a description of the qualitative content analysis (qca) of social distancing initiatives on social media is offered. this followed by a section that demonstrates young people's localised and contextualised creative responses to covid-19 through the five social distancing narratives: the narrative of fear; the narrative of responsibility; the narrative of annoyance; the narrative of fun; and the narrative of resistance. one particular action worth highlighting is their effort in making social distancing contents accessible and readable by other users such as by translating official documents to everyday social media language. the penultimate section, reveals three key socio-cultural implications and configurations (new youth spatialities and social engagements, youth leadership in development, and consideration of social participation and reach in risk communication) that have broader implications beyond covid-19. this paper draws from the researcher's preliminary study for an ongoing research project 'social media, risk perception, and risk communication of covid-19 in brunei darussalam', a research collaboration between universiti brunei darussalam and health promotion centre, ministry of health, brunei darussalam. as there is not much information known on audience's social media consumption in risk communication and their individualised, as well as contextualised risk perception, a preliminary research on how the audience deliver and circulate covid-19 related content on social media was conducted, leading to this preliminary finding on the active involvement of young people in highlighting the significance of social distancing in flattening the curve in the country. according to kemp (2020) , social media penetration in brunei was 94 per cent (410,000 population) by january 2020. the growth in the size of the digitally connected group consuming social media content in the nation justifies this interest in looking into social media use in risk communication in brunei darussalam. given the intensive digital transaction through the social media, this research examined the affective consumption and transaction of social media content on covid-19 among public in brunei darussalam and the impact of their social media transaction on their risk perception of covid-19. it seeks to investigate: one, the official social media content on covid-19 circulated by health practitioners and health organisations; two, the social media content on covid-19 consumed by the public in brunei; three, their risk perception and understanding of the covid-19 based on the social media contents transacted and consumed; four, their own appropriation, framing, and circulation of covid-19 on their social media platforms; and five, their health and behavioural practices as a response to their risk perception of covid-19. this research using qualitative content analysis (qca) on social media content between early march to the end of april 2020 is part of the fourth objective, which is to investigate audience appropriation, framing, and circulation of social distancing initiatives using the multimodal features of the sites, such as captions, images, videos, and hashtags. prior to finalising the research objectives, the author conducted a pilot discussion with her undergraduate students to seek their views of covid-19. at that time in point, the students were not really concern about this crisis. the general consensus was that this new coronavirus is only risky for those with underlying health conditions and older people. one student said that 'if i get covid, i'm going to recover', while another student claimed that the crisis was 'sensationalised' by the media. interestingly, a number of the students pointed out that the covid-19 memes (mostly humorous contents) circulated on social media help in changing the perception of covid-19 from high risk to low risk. their views, although not representative of the young people in the country, point to this group's low risk perception. it is safe to say that, this could also be the reason for the lack of discussion among the social media users on covid-19 in the country prior to the announcement of the first case on 9 march 2020. however, the social media landscape changed drastically right after, justifying the qca conducted on bruneians' social media from march 2020 onwards. to achieve the objective set and taking the above findings and observation into consideration, two data collection strategies were employed. one, the researcher followed covid-19 latest cases and issues in the country via the daily press conferences hosted by the ministry of health since 9th march 2020. social distancing related cases highlighted by the minister of health and invited ministers, the issues the public brought to front via media personnel through the question and answer session at the press conference, and issues mentioned by the audience of the press conference via the instagram live (comment section) of the invited media personnel were used to guide the second data collection strategy. this first strategy was employed to obtain the key concerns and issues that are considered important to bruneians in the context of covid-19 and social distancing measures. two, qca was conducted on random and selected (young people in the author's social media network who share social distancing contents on their social media) young bruneians' instagram and twitter contents based on the information obtained from the first data collection strategy. this step by step approach in the data collection allowed the author to follow the issues and the young people's individual social media sharing on social distancing issues. in total, over 30 individual profiles from instagram and twitter combined were observed for social distancing contents. specific social distancing contents observed include social distancing initiatives conducted by individuals, groups, and companies; key incidents happening in the country related to social distancing; the discussion on covid-19 statistics on number of infected, recovered and death to obtain the public's thoughts on the effectiveness of social distancing initiatives in the country; the growing social distancing creative contents on instagram for instance those that are accessible via #artcovidbn hashtag; and related viral cases in the country. contents on other sites such as youtube and tik tok are checked when they appear on the young people's instagram and twitter posts. the cross-platform integration functionality of social media allows for the same media contents to be shared simultaneously (bossetta 2018 ) and the spreadability of social media enables content on youtube to be retweeted on twitter via url sharing. the young people randomly and selectively chosen are between the ages of 18 and 36. a number of them are known in the country as pro-active youth who are keen to support the country's development. they are also currently volunteering as front liners to support the ministry of health. a few of these young people are not youth leaders and not directly involved in supporting the country's effort in curbing the crisis. there is a mixture of students, employed, and currently unemployed young people in the group. these young people's identity as bruneians were cross-checked with the details provided on their biography, their mutual followers, and their contents that are specific to brunei. the findings point to the role of young people in pushing the idea and practice of social distancing apparent via the social distancing narratives (narratives of fear, social responsibility, annoyance, and fun) affectively created, reproduced and circulated online. the findings did suggest that social distancing initiatives are supported more by the pro-active youth. the contents shared on the pro-active youth's social media include their volunteering activities as front liners. there are only limited findings that point to the existence of resistance among the young people. these young people's active engagements on social media sites in the context of social distancing initiatives reveal two interrelated factors that not only could lead us to reconsider how risk are contextually, spatially, and individually perceived, practised, and communicated by the audience, as both the producers and consumers of digital content. equally significant and at a more macro-scale level, it reveals the issue of access and power to social media and digital contents in this era of connectivity and media spreadability. when the first covid-19 case was confirmed in the nation on 9 march 2020, brunei government was quick to take actions. social distancing initiatives were disseminated to the public a few days after the first case was announced at the nation's first covid-19 press conference. a school holiday that was previously set on 16 march 2020, started three days earlier. within the two weeks since the first case, restaurants and gyms were closed, travel restrictions into and out of the country were imposed, a few supermarkets started to implement physical gap at counters and limiting number of customers entering their premises, places of worships are closed temporarily, working from home (wfh), and digital learning were quickly introduced. physical mobilities have not been restricted due to the relatively small number of infected cases (139 cases as of 6 may 2020) and low rate of infection in the country, unlike our neighbouring countries with their lockdown measures, singapore's circuit breaker and malaysia's movement control order. while physical movements are allowed, the public has been consistently advised to maintain social distancing, including the physical distancing of at least 1 metre. despite the nationwide social distancing initiatives, confining the public to their home and to maintain social distancing were not easy tasks, as experienced globally. mass gathering were still seen in some parts of the country despite the government's effort in halting the virus transmission suggesting a low risk perception among the members of the public. one critical incident that sparked the public outrage was the irresponsible act of a large group of locals visiting a night market in temburong district on the day of the opening of the temburong bridge, which connects brunei-muara with temburong district after 130 years of physical separation. the next day, brunei government restricted the opening time of the bridge and closed the night market to prevent potential community transmission of covid-19. social media sites were swiftly flooded by users reprimanding the public for going to the market in mass, disregarding the government's social distancing initiatives. apart from the government's circulation of social distancing reminders on their official channel (mass and new media) after this incident, social distancing efforts were affectively circulated, exchanged, and reproduced by the public on social media. from these localised and contextualised creatively and affectively produced and circulated content on covid-19, a combination of five narratives of social distancing initiatives are apparent: narrative of fear, narrative of responsibility, narrative of annoyance, narrative of fun, and narrative of resistance. the narrative of fear is visible in contents that stress danger and risk to older people and loved ones. detachment from family members due to isolation and quarantine for undetermined duration feed into the narrative of fear. the narrative of responsibility is visible in contents that call for the community to play their role as responsible citizen and community members to flatten the curve. this responsibility includes stressing the unselfish act of medical health professionals in looking after public in the isolation and quarantine centres. general public singing the praises for other front liners including youth volunteers who dedicated their energy and time to support the ministry of health in handling the pandemic. this narrative of responsibility is further instilled via the circulation of a video created by the ministry of health, a video of a medical health professional captioned hargai pergorbanan mereka (english translation -appreciate their sacrifices), warmly (with teary eyes) requesting members of the public to stay at home and together be responsible in preventing local transmission. via a personal communication with a public health officer from the ministry of health, she confirmed that the ministry wanted the public to hear the voices of the health care workers; being apart from their family members while caring for the infected patients and their gratefulness towards the community for their support. the video emphasises the need for the community to be equally responsible and supporting the front liners in their effort to curb the spread of the disease and to treat infected individuals was reposted and affectively appropriated on sites such as whatsapp, instagram, and twitter. through this affective content, it was hoped that the audience would be able to empathise with the front liners and adjust their views, actions, and habits (pedwell 2017) . living in a country with a small population (under 440,000 population as of may 2020) and in a collectivist society, bruneians imagined themselves related to each other either by blood or marriage. such an emotive video that emphasised communal responsibility would be more effective in evoking the emotion of the general public and to create and sustain the sense of shared responsibility, and sense of community and togetherness in time of a crisis and physical separation. a local hip hop duo, guardian of rhythm, created a video music titled 'don't push it' dedicated to the front liners, a title they took from minister of health's famous statement 'don't push it' that reminds public to be vigilant and responsible and to not push the country's limit in health provision during this pandemic (figure 1 ). this music video uploaded on youtube is one of the many creative contents appropriating minister of health's advice at the daily press conference to put pressure on social distancing. stickers, gif, songs, and appropriated hashtags such as #dontpushit #teranahsajadirumah (english translation -stay at home) are produced and circulated. to reach certain pockets of the population that might not be familiar with english language, one user took an initiative to translate the social distancing poster circulated via social media and mass media into colloquial malay language ( figure 2) . the narrative of annoyance is apparent in the deliberate sharing of one's frustration towards members of the public who insisted on leaving home, travelling overseas and possibly contracting covid-19 due to their international travel. there were also a few contents on social media highlighting cases of the public undergoing mandatory self-isolation and self-quarantine leaving home. the rising number of cases in the country was used strategically by the audience to highlight the severity (and potential risk) of covid-19. the creation and use of new terms such as 'covaval' (derived from the word covid and babal, a local term for unrepentant individuals particularly those who went to temburong and those insisted on travelling amid covid-19) to stress their annoyance and to push public to be more responsible (figure 3) . the narrative of fun by the young people were evident in the growing number of videos to show their coping strategies while on mandatory self-isolation and 'stay at home' are uploaded on tik tok and reshared on twitter, instagram and whatsapp. one example is a tik tok video made by bruneian international students who were isolated in their homes and a few hotels turned isolation centres for 14 days upon their return to the country as part of the country's precautionary measures to avoid potential community transmission. these students created individual videos of themselves dancing from one end of their room to the other end. when combined, this video is creatively demonstrating 'mobilities' while in isolation. this is one of the isolation/quarantine videos such as pass the brush and don't rush challenge seen on tik tok globally during this period exemplifying the spreadability of social media content and the upsurge in the use of one particular social media site, tik tok, (emarketer 2018; crowley 2020; johnston 2020; leslie 2020) as a coping mechanism and a mode to socially and creatively connect with others. interestingly, the narrative of resistance is less prominent in brunei's context. as previously mentioned, pro-social distancing narratives are more apparent on the local social media contents than those demonstrating anti-social distancing, which could be due to the less restrictions imposed on physical mobilities in the country. perhaps, there are contents demonstrating resistance to the social distancing initiatives in the country but have not surfaced or made known to the public for a number of possible reasons such as the author's limited access to contents of this group of social media users. to the best of the author's knowledge, there are only two contents (in video format) known to the public that fit the narrative of annoyance and/or resistance to social distancing. one video directly addressed the 'stay at home' instruction and was created and uploaded by a 22-year-old male on his instagram urging those who fear death to stay at home, while criticising the public for fearing the coronavirus, a human-made virus. he was charged for causing a breach of peace under the section 19 of the minor offences act, chapter 30 (faisal 2020) . after this event, the public is consistently reminded that any act that involves the publishing, forwarding or creating fake news and misinformation about covid-19 may be regarded as offences. another video made and shared on social media by a male in his 30s did not directly address social distancing initiatives but the after effect of the 'stay at home' on parents with schoolkids. in his video, he expressed his dissatisfaction with the current e-learning arrangements where the role of educators is transferred to parents. his video was uploaded on local reddit community page (r/brunei) and received backlash from the r/brunei community. other narrative of annoyance demonstrated by the young people are not specifically on staying at home rather was focused on the slow internet connection in the country that affected their ability to continue their studies online and the impact social distancing brought to their livelihoods. these narratives emerging from the creative production of social media contents demonstrate local youth responses to current situation by contextualising social distancing practice in the country. this is supported and made possible by the growing digital creative youth via their (digital) affective practices (wetherell 2012 ) that went beyond the content sharing to transmitting and recreating a discourse -it was civic engagement. both creatives and non-creatives take part in the social distancing initiatives as an active youth citizen who are involved in the community to strive for changes (adler & goggins 2005) . there are also presence of annoyance and resistance to social distancing as demonstrated above. social media sites act as new youth spatialities highlight the spreadability of digital content made possible affective production and consumption of the social distancing narratives (the narratives of fear and responsibility in particular) and abetted in initiating and sustaining the call for a change in social practices and mobilising youth's actions. this initiative needs 'mobile' and active youth taking the helm in creating and pushing new subjectivities and taking collective actions to improve and change the society, albeit temporarily due to this pandemic. three key socio-cultural implications and reconfigurations could be observed in the country and may become common practices after covid-19 crisis: one, new youth spatialities and social engagements; two, youth leadership in development; and three, consideration of social participation and reach in risk communication. these reconfigurations of everyday life due to the crisis could open up new avenues and research focus in geography intersecting between the geographies of young people and the geographies of digital media and communication and beyond geography, those relevant to risk communication strategies and public health. new youth spatialities and social engagements -as previously mentioned, the use of social media by young people is not new, this group of users has been known to dominate the online spaces, particularly social media sites. we could observe new online platforms offering youth with spaces for negotiating their current immobilities; stay at home/ social distancing measures. new sociotechnological adoptions in the country, possibly becoming the new normal in the community post crisis, are observed such as poetry club activities, open mic, and youth mentorship sessions conducted online by young people in the country pointing to the creation of creative spaces online and new ways for conducting social activities. such technological adaptation and creation of new social spaces are not limited to the young demographics but have also been adopted by the older generation, for instance the group recital of the al-quran via zoom exemplifying the rising digitalisation in the country. as a matter of fact, digital infrastructures (applications, websites, and internet of things to name a few) were already in place in the country prior to the crisis but was slow to be taken up by relevant agencies and individuals due to a number of reasons including lack of access due to financial constraints, low knowledge of technology, lack of motivation, and possibly fear of technology. the current pandemic that reconfigured our day to day operations and social practice, however, left these agencies and individuals with no option but to adopt new digital technologies. digital technologies and platforms have transformed the relationship between media and the geographies of everyday life (ash 2019) and young people as the main users of social media play a key role in this transformation as illustrated in this paper via the young people's creative contents creation on social media. these intense socio-spatial engagements of young people on social media amidst covid-19 demonstrate the interplay between media and the young people in reconfiguring the micro-geographies of young people. notwithstanding the growing literature on young people and social media use within the geography disciyouth leadership in development -in the context of brunei, a young developing country, youth engagements with the country's progress and development is relatively low. the country has only recently seen its young people's active involvement in addressing key issues and concerns in the country. government agencies in the country have been providing the young people with offline platforms for engagements, in particular, the ministry of culture, youth, and sports (mcys), the key supporter of young people's progress. in this time of crisis, mcys plays a huge role in expanding and intensifying youth communal engagement as can be seen in the establishment of covid-19 youth volunteer group to support the ministry of health. other youth involvement includes key youth leaders actively involved in creating and distributing personal protective equipment (ppe) to the medical health workers. moreover, the availability of social media platforms offers these young people with spaces to engage leading to the growing number of active and creative youth supporting and sustaining progress and development in the country. social media sites as seen in the previous section are affectively used by the young people to promote and support social distancing initiatives. such active engagement by the young people during this time of crisis signals the already existing youth leadership in the country. online and offline spaces are effectively utilised in pushing forward their agenda and concerns and for personal development, the expansion of individual agencies on social media. young people's engagement with the media (contents) and through the media (platforms) has potential implications on development planning and execution and could help in creating better futures (cupples 2015) . the growing social media content on social distancing via the cocreation of narratives highlights community engagement and collaboration based on the collective concerns of young people and their interests in keeping the community safe and healthy. at this point, despite this active participation and the youth's role in the context of social distancing initiatives, we need to question the reach and success of these narratives and its implication on risk perception of the population. the first question considers the issue of digital divide and access. who are these young people reaching out to and what about those who are not part of this social media community? despite high social media penetration in the country, public health information and risk communication on social media remain exclusive and are not reaching the socially 'disconnected' population. these narratives and initiatives by the young people only reach the social media users with access to their content. the asynchronicity of content delivery and consumption somewhat limit the access of the information. for example, instagram story posts that are only visible for twenty-four hours are only reaching the audience who are able to access the story within the time allowed. second, social distancing effort relies on the individual's perception of the risk of covid-19 to their individual health and family members. connected to the first point, risk communication that does not reach the population could have led to low risk perception rendering the initiative impossible or difficult to achieve. notwithstanding the efforts made by the young people on creating and adapting to this new social distancing practice, if information reach is limited, risk perception of the population will remain low. the audience (young people) and relevant government and non-government agencies have worked collectively and informally to create contents that are affective and impactful. however, such efforts would not reach majority of the population if access is limited. closely tied to this access to contents is the language use in communicating risk. using words such as 'social distancing' and 'social responsibility' may not work well with some segments of the population. those without access to social media where the social distancing term and practices are commonly demonstrated via caption, images, and videos, would not be able to fully understand what are meant by 'social distancing'. official information in the country is commonly disseminated in the official language, malay language, and in a second language, english. evidently, there are people in the country who are not well-versed in these two languages and would need the information to be translated to their colloquial language or dialects. one noteworthy context appropriation action in ensuring the social distancing measures reaching other segments of the population is the translation of the official document to lay people's everyday language in the forms of caption and hashtag (such as #teranahsajadirumah) by social media users. perhaps, this is one of the best times for the country to rethink and restructure its risk communication strategy by learning from the current socio-spatial practices and the loopholes in our (risk) communication system and strategy. beyond covid-19 crisis, considering media convergence (media accessible through various platforms), spreadability of social media, differential access, and language preferences of the population in communication would improve not only public health communication but has broader developmental implications. to conclude, this paper offers preliminary findings on the localised and contextualised creative productions of social distancing narratives in brunei and the role of young people in emphasising the importance of social distancing in this crisis via social media platforms such as instagram, twitter, and tik tok. using qca on young people's instagram and twitter contents, five narratives of local responses to social distancing practices were apparent: the narrative of fear, the narrative of responsibility, the narrative of annoyance, the narrative of fun, and the narrative of resistance. fascinatingly, the research data demonstrated more pro-social distancing narratives than it did for the narrative around resistance. technological affordances such as the participatory culture and spreadability of social media content supported the creative production of social distancing initiatives, which could bring community and civic impact. through individuals' collective actions on social media, they accentuate the role and social responsibility of each member of the public. this is not a single person's tasks; everyone plays an equal role in keeping the community safe and healthy. in times of a crisis, young people in the country played a huge role in supporting the social distancing measures through their everyday creative self-disclosure on social media and as such has brought three key socio-cultural reconfigurations to everyday life that have broader academic and developmental implications. the creation of new youth spatialities and intense social engagements were observed, which are of importance to geographers in understanding youth social realities and could open up academic discussions relevant to the geographies of young people and the geographies of media and communication. the expansion of already existing youth leadership in the country offers a reconsideration of the significance of youth's active social media engagements in the context of development. social participation and reach in risk communication brought our attention to the issue of access to information, differential use of communication platforms, and language preference for the betterment of public health communication. specific to risk communication during this pandemic, what are shared in this paper offer a rethinking of risk communication strategy that includes consideration of socio-culturally and politically appropriate and relevant approaches, and a strategy that is inclusive to all segments of the population. as observed globally, the covid-19 pandemic has forced us to alter our socio-cultural practices and adapt to our drastically reconfigured everyday life creating the new normal in our everyday practices. what is clear at this point in time is our dependencies on digital interconnectivity. with the uncertainties surrounding covid-19, we foresee other significant socio-cultural implications of covid-19, which could either favourably or unfavourably impact communities in their respective localities. what do we mean by 'civic engagement physical and virtual public spaces for youth: the importance of claiming spaces in media and popular culture digital geographies new spaces, blurred boundaries, and embodied performances on facebook the digital architectures of social media: comparing political campaigning on facebook, twitter, instagram, and snapchat in the 2016 u.s. election. journalism & mass communication quarterly 95 the covid-19 social media infodemic. available at <https:// arxiv.org/abs/2003.05004>. accessed on 4 development communication, popular pleasure and media convergence available at <https://www. newsw eek.com/tikto k-users -soar-viral -video s-coron aviru s-covid -19-1494229> accessed on 29 teens aren't using facebook as much as millennials and gen xers -here's the social platform each generation uses the most available at <https://borne obull etin.com.bn/ youth -charg ed-for-posti ng-video -breac hing rooted muslim cosmopolitanism: an ethnographic study of malay malaysian students' cultivation and performance of cosmopolitanism on facebook the performance of religiosity on spreadable media: creating value and meaning in a networked culture the rise of tiktok during covid-19. tinuiti, 21 april social media in public health available at <https://datar eport al.com/repor ts/digit al-2020-brune i-darus salam> available at<https://ourwo rldin data.org/rise-of-socia l-me-dia> social distancing via tiktok: using humor and facts to educate during covid-19. medscape, 16 april everyday lived islam: malaysian muslim women's performance of religiosity online mediated habits: images, networked affect and social change establishing geographies of children and young people responding to global infectious disease outbreaks: lessons from sars on the role of risk perception, communication and management affect and emotion: a new social science understanding simple saja permintaan yang berhormat dato, social responsibilities, teranah saja di rumah kalau nada keperluan penting untuk bejalan-jalan. &#129318;&#127995;♂️ #covid19 #socialdistancing #brunei #flattenthecurve #ter-anahdirumah the contents of this page will be used as part of the graphical abstract of html only.it will not be published as part of main article.in times of a global crisis, young people play a huge role in supporting the covid-19 social distancing measures through their everyday creative self-disclosure on social media. this paper demonstrates young people's collaborative, participatory, creative, and affective curation of 5 social distancing narratives on instagram and twitter: narratives of fear; responsibility; annoyance; fun; and resistance. via these narratives, they are shifting risk perception of covid-19 amongst their followers. beyond these micro-scale activities, the intense social media engagements and extensive digital connectivity during this covid-19 pandemic brought socio-cultural implications that reconfigure everyday practices and led to the creation of new youth spatialities and social engagement, the enhancement of youth leadership in development, and the rethinking of social participation and reach in risk communication. key: cord-313591-hb3gqksg authors: pek, kalene; chew, justin; lim, jun pei; yew, suzanne; tan, cai ning; yeo, audrey; ding, yew yoong; lim, wee shiong title: social frailty is independently associated with mood, nutrition, physical performance, and physical activity: insights from a theory-guided approach date: 2020-06-14 journal: int j environ res public health doi: 10.3390/ijerph17124239 sha: doc_id: 313591 cord_uid: hb3gqksg notwithstanding the increasing body of evidence that links social determinants to health outcomes, social frailty is arguably the least explored among the various dimensions of frailty. using available items from previous studies to derive a social frailty scale as guided by the bunt social frailty theoretical framework, we aimed to examine the association of social frailty, independently of physical frailty, with salient outcomes of mood, nutrition, physical performance, physical activity, and life–space mobility. we studied 229 community-dwelling older adults (mean age 67.22 years; 72.6% females) who were non-frail (defined by the frail criteria). using exploratory factor analysis, the resultant 8-item social frailty scale (sfs-8) yielded a three-factor structure comprising social resources, social activities and financial resource, and social need fulfilment (score range: 0–8 points). social non-frailty (snf), social pre-frailty (spf), and social frailty (sf) were defined based on optimal cutoffs, with corresponding prevalence of 63.8%, 28.8%, and 7.4%, respectively. in logistic regression adjusted for significant covariates and physical frailty (modified fried criteria), there is an association of spf with poor physical performance and low physical activity (odds ratio, or range: 3.10 to 6.22), and sf with depressive symptoms, malnutrition risk, poor physical performance, and low physical activity (or range: 3.58 to 13.97) compared to snf. there was no significant association of spf or sf with life–space mobility. in summary, through a theory-guided approach, our study demonstrates the independent association of social frailty with a comprehensive range of intermediary health outcomes in more robust older adults. a holistic preventative approach to frailty should include upstream interventions that target social frailty to address social gradient and inequalities. frailty is characterized by a loss of physiological reserves, leading to increased vulnerability of the older adult with stressor events [1] . frailty is widely regarded as a multidimensional construct with physical, cognitive, psychological, and social components. among these dimensions, social frailty is arguably the least explored. given the complex interplay between the dimensions of frailty and increasing appreciation of the contribution of social factors to health outcomes [2] , it is not surprising that social frailty has been gaining recognition and traction in recent years. however, the study of social frailty has been far from straightforward, being often intertwined with contextual, societal, and cultural considerations. the field has been hampered by the lack of theoretical frameworks to guide the conceptualization of social frailty. using the theory of social production function (spf) [3, 4] , bunt et al. recently proposed a conceptual framework whereby social frailty is defined as a continuum of being at risk of losing, or having lost, social resources, general resources, and social activities or abilities that are important for fulfilling one or more basic social needs during the life span ( figure 1 ) [5] . subsequent to this, a systematic review studying the operationalization of the social component of frailty revealed only three exclusive social frailty tools out of 27 frailty instruments, and a weight of 5-43% for the social dimension in the other instruments [6] . although the concepts of social isolation, loneliness, social network, social support, and social participation were identified through this effort, the review did not propose an overarching theoretical framework of social frailty. subjective well-being ("positive affect" as a higher-level outcome of social need fulfilment) fulfilment of basic social needs such as sense of belonging, social cohesion, social loneliness*, social support*, emotional support, experience of warm, trusted relationships [5] . this figure, adapted from bunt's social frailty concept, shows the categories of 'general resources', 'social resources', and 'social behavior/activities' that lead to the 'fulfilment of basic social needs', which in turn lends a positive impact to subjective well-being when needs are met. examples of elements in the categories are included, some of which are included in this study. * denotes elements included in our analysis. within asia, where many societies are aging rapidly, social frailty is especially germane due to challenges such as changing structures and attitudes towards older members of the familial unit [7] , social participation, and environments. prior asian studies examining the impact of social frailty have done so using brief questionnaires of 5-7 items which are primarily modeled after the 5-item [5] . this figure, adapted from bunt's social frailty concept, shows the categories of 'general resources', 'social resources', and 'social behavior/activities' that lead to the 'fulfilment of basic social needs', which in turn lends a positive impact to subjective well-being when needs are met. examples of elements in the categories are included, some of which are included in this study. * denotes elements included in our analysis. within asia, where many societies are aging rapidly, social frailty is especially germane due to challenges such as changing structures and attitudes towards older members of the familial unit [7] , social participation, and environments. prior asian studies examining the impact of social frailty have done so using brief questionnaires of 5-7 items which are primarily modeled after the 5-item fried's frailty phenotype score. for instance, using a 5-item social frailty questionnaire, studies in japan and korea reported that social frailty increased the risk of disability and depressed mood, and was associated with cognitive and physical deficits in older adults [8] [9] [10] . similarly, social frailty measured using a 5-item scale was associated with subjective memory decline, cognitive impairment, depression, and physical functioning, and predicted mortality in china [11] . a singapore study utilized a 7-item index to demonstrate that social frailty increased the prevalence and incidence of functional disability, independently and when combined with physical frailty [12] . though these studies revealed significant associations with the measured outcomes, they were not premised on a conceptual framework of social frailty. the construct validity of the social frailty brief scales was also not delineated through empirical statistical techniques such as factor analysis. furthermore, these studies mainly comprised less robust community-dwelling older adults, such that the relationship between social and physical aspects of frailty may potentially be confounded. in addition, other salient outcomes such as nutrition, physical performance, physical activity, and life-space mobility were not studied. lastly, in asian societies where traditional family values are cherished, commensality (the act of eating together) is generally considered a form of social engagement during mealtimes, with family or friends. however, earlier asian studies did not include any item that pertained to 'eating alone' when examining the association of social frailty with adverse outcomes [13] . we therefore conducted this study to examine the independent association of social frailty with a comprehensive range of intermediary outcomes in a representative cohort of non-frail community-dwelling asian older adults. there are two parts to our study. firstly, using validated items identified from prior asian studies, we performed exploratory factor analysis (efa) to derive a social frailty scale grounded in bunt's proposed conceptual framework. next, using the empirically developed social frailty scale, we studied the association of social pre-frailty and social frailty, independently of physical frailty, with outcomes of mood, nutrition, physical performance, physical activity and life-space mobility. through this, we aim to anchor understanding of the impact of social frailty on pertinent outcomes in an asian setting from a theory-based framework. the "longitudinal assessment of biomarkers for characterization of early sarcopenia and osteosarcopenic obesity in predicting frailty and functional decline in community-dwelling asian older adults study" (gerilabs 2) is a prospective cohort study involving cognitively intact and functionally independent adults aged 50 years and older residing within the community. we recruited 230 participants from december 2017 to march 2019. in this cross-sectional analysis, one participant was excluded due to missing values in the data. the final sample comprised 229 participants who completed all baseline clinical assessments. participants were included if they were (i) aged 50 to 99 years at study enrolment, (ii) community-dwelling, (iii) independent in both activities of daily living (adls) and instrumental adls, and (iv) non-frail as defined by the frail criteria [14] . we excluded participants with a known history of dementia or evidence of cognitive impairment (modified chinese version of mini-mental state examination (cmmse) score ≤21) [15] ; who are unable to walk 8-m independently; and living in a sheltered or nursing home. all participants provided written informed consent for inclusion before they participated in the study. the study was conducted in accordance with the declaration of helsinki, and the protocol was approved by the domain specific review board of the national healthcare group (dsrb ref: 2017/00850). we collected demographic data and comorbid vascular risk factors. anthropometric measurements including standing height and body weight were measured to calculate body mass index, in addition to waist, mid-arm, and calf circumferences. cognitive performance was assessed using the modified chinese version of mini-mental state examination (cmmse). functional status was evaluated using barthel's basic activities of daily living (badl) index [16] and lawton and brody's instrumental adl (iadl) index [17] . physical frailty was assessed using the modified fried phenotypic criteria [18] . the modified fried criteria were operationalized as follows [19] : (1) body mass index less than 18.5; (2) handgrip strength <26 kg for men and <18 kg for women measured using a hydraulic hand dynamometer (north coast exacta™ hydraulic hand dynamometer; north coast medical, inc., morgan hill, ca, usa) [20] ; (3) usual gait speed <0.8 m/s on the 3-m walk test; (4) low physical activity defined using the pentile cutoff of ≤29 on the frenchay activities index [21] ; and (5) fatigue endorsed on either of two questions from the center for epidemiologic studies-depression scale (ces-d) modified to assess fatigue. the five items were added to yield a total score (range 0-5), which corresponded respectively to a status of robust (0), pre-frail (1-2), and frail (3-5). we performed a literature search on social frailty in asia for studies with social frailty scales published before november 2017, supplemented by a reference search of retrieved articles and recommendations from experts in the field. the items identified from these published asian studies were used in our analysis. altogether, nine items were identified, comprising five items from makizako et al. [8] and tsutsumimoto et al. [9] ; two items from tanaka et al. [13] ; and two items from teo et al. [12] . the combined 9-item social frailty questionnaire was administered, with equal weightage of one point assigned to each item: (1) "do you live alone?"; (2) "do you go out less frequently compared with last year?"; (3) "do you sometimes visit your friends?"; (4) "do you feel you are helpful to friends or family?"; (5) "do you talk with someone every day?"; (6) "do you turn to family or friends for advice?"; (7) "do you eat with someone at least one time in a day?"; (8) "do you have someone to confide in?"; and (9) "are you limited by your financial resources to pay for needed medical service?". from teo et al., questions demonstrating duplication such as infrequent contact and social activities were removed. similarly, demographic questions on education and housing type were removed and captured under clinical assessment. mood was assessed using the 15-item geriatric depression scale (gds), with a locally validated cutoff score of ≥4 to distinguish presence of depressive symptoms [22] . nutrition was measured with the mini nutritional assessment (mna), with a cutoff score of <24 indicating malnutrition risk [23] . other nutritional parameters assessed included the simplified nutritional appetite questionnaire (snaq) [24] , as well as vitamin d and albumin levels. physical performance was measured using the short physical performance battery (sppb), which comprised balance, gait speed, and chair stand tests; a cutoff of <10 denoted poor physical performance [25] . physical activity was derived from the international physical activity questionnaire (ipaq) [26] after converting responses to metabolic equivalent task (met) minutes per week. life-space mobility was measured using the life-space assessment (lsa) [27] comprising spatial areas, frequency, and level of independence required. there are five life-space levels, which represented activities outside the bedroom, home, neighborhood, town, and beyond respectively. to ascertain the factor structure of the combined 9-item social frailty questionnaire, we conducted exploratory factor analysis (efa) using the kaiser-meyer-olkin (kmo) statistic as a measure of sampling adequacy and the bartlett test of sphericity to ascertain necessity to perform a factor analysis. we performed principal component analysis with varimax rotation to ascertain the underlying factor structure. the number of factors to be retained was determined by parallel analysis, a more robust and accurate method of factor retention that was less likely to overestimate the number of factors [28] . we eliminated items with loadings <0.4. the retained factors were interpreted using bunt's conceptual framework. using the resultant factors and items in the social frailty questionnaire, we derive optimal cutoffs to categorize participants into three subgroups: social non-frailty, social pre-frailty, and social frailty. the cutoffs were empirically determined based on distribution to match the trend seen in earlier asian studies. we performed univariate analyses to compare baseline demographics, cognitive performance, functional and frailty status, and outcome measures of mood, nutrition, physical performance, physical activity, and life-space mobility across the three subgroups. we used a one-way analysis of variance with bonferroni correction for post-hoc comparison and kruskal-wallis test respectively for parametric and non-parametric continuous variables, and a chi-square test for categorical variables. to determine the independent association of social pre-frailty and social frailty to our pre-specified outcomes, we performed hierarchical logistic regression, adjusting for age, gender, variables which were significant on univariate analysis, and physical frailty (modified fried phenotypic criteria). due to low numbers in the frail category by fried scoring, we used the total score instead in the logistic regression model. cutoffs for gds, mna, and sppb were defined using validated cutoffs as described, while low physical activity and low life-space mobility were defined using the cohort quintile cutoffs of ipaq < 2826 mets and lsa < 76 respectively. in model 1, we adjusted for age, gender, and other significant variables. in model 2, we adjusted for physical frailty in addition to the variables in model 1. for comparison, we performed logistic regression with physical frailty as the independent variable adjusting for age, gender and significant variables ( figure 2 ). using the resultant factors and items in the social frailty questionnaire, we derive optimal cutoffs to categorize participants into three subgroups: social non-frailty, social pre-frailty, and social frailty. the cutoffs were empirically determined based on distribution to match the trend seen in earlier asian studies. we performed univariate analyses to compare baseline demographics, cognitive performance, functional and frailty status, and outcome measures of mood, nutrition, physical performance, physical activity, and life-space mobility across the three subgroups. we used a one-way analysis of variance with bonferroni correction for post-hoc comparison and kruskal-wallis test respectively for parametric and non-parametric continuous variables, and a chi-square test for categorical variables. to determine the independent association of social pre-frailty and social frailty to our prespecified outcomes, we performed hierarchical logistic regression, adjusting for age, gender, variables which were significant on univariate analysis, and physical frailty (modified fried phenotypic criteria). due to low numbers in the frail category by fried scoring, we used the total score instead in the logistic regression model. cutoffs for gds, mna, and sppb were defined using validated cutoffs as described, while low physical activity and low life-space mobility were defined using the cohort quintile cutoffs of ipaq < 2826 mets and lsa < 76 respectively. in model 1, we adjusted for age, gender, and other significant variables. in model 2, we adjusted for physical frailty in addition to the variables in model 1. for comparison, we performed logistic regression with physical frailty as the independent variable adjusting for age, gender and significant variables ( figure 2 ). statistical analyses were performed using ibm spss statistics version 23.0 (ibm corporation, armonk, ny, usa). all statistical tests were two-tailed, with p < 0.05 considered statistically significant. statistical analyses were performed using ibm spss statistics version 23.0 (ibm corporation, armonk, ny, usa). all statistical tests were two-tailed, with p < 0.05 considered statistically significant. we studied 229 participants with a mean age of 67.22 ± 7.43 years, of which 167 (72.6%) were females (table 1) . participants received a mean 10.73 ± 4.36 years of education, with the majority (71.2%) residing in public housing apartments. comorbidities include hypertension (35.8%), hyperlipidemia (56.8%), and type ii diabetes mellitus (14.4%). the high cognitive score (cmmse, mean ± sd: 26.12 ± 1.73) and functional status (badl and iadl had respective median scores of 100 and 23, corresponding to the maximum score) attested to the relatively robust health of the participants. there were 196 (85.6%) robust and 33 (14.4%) pre-frail participants identified using the frail criteria. based on the modified fried criteria, only two (0.9%) participants were physically frail, with 95 (41.5%) physically pre-frail and 132 (57.6%) robust. factor analysis was appropriate as the kmo statistic was 0.586, and the bartlett test of sphericity was 186 (p < 0.0001). we chose a three-factor solution, as per the optimal number recommended by parallel analysis, which accounted for 50.5% of total variance ( table 2 ). taking reference from bunt's conceptual framework, the first factor (22.4% of variance) had three items which represented social resources; the second factor (15.5% of variance) had three items corresponding to social activities and financial resource; and the third factor (12.6% of variance) with two items denoted social need fulfilment. the question "do you feel you are helpful to friends or family?" was eliminated due to its low loading of 0.490 and non-discriminatory nature of having only six (2.6%) participants endorsing this item. thus, there were eight items in the final version of the social frailty scale (sfs-8). the items were summed to yield a total score which was used to categorize participants into three subgroups of social non-frailty (snf; 0-1 point), social pre-frailty (spf; 2-3 points) and social frailty (sf; 4-8 points). using these cutoffs to categorize the subgroups, 146 (63.8%) of participants were classified as snf, 66 (28.8%) as spf, and 17 (7.4%) as sf, which is consistent with the distribution trend seen in previous asian studies [8, 9] . table 2 . exploratory factor analysis (efa; varimax rotation, three-factor extraction, loadings >0.400). mean ± sd 1 2 3 comparing baseline characteristics across the three subgroups (table 1) , age increased and was significantly higher in sf subgroup compared with snf. educational level decreased and was significantly lower in spf compared with snf. there was no significant difference in gender, housing type, and anthropometric measurements. among comorbidities, only hypertension was significantly different across the three subgroups. badl was significant lower in the sf subgroup but there was no significant difference in cmmse and iadl. modified fried score was also significantly higher in sf and spf subgroups compared with snf, corresponding to the higher proportion of physical pre-frailty and frailty observed in these two subgroups. for the 8-item social frailty scale (sfs-8), total score increased significantly across the three subgroups (p < 0.001), with the post-hoc analysis indicating significantly higher scores in sf subgroup compared with spf and snf, and spf compared with snf (table 3) . likewise, all factor scores were significantly different across the three subgroups (all p < 0.001), with significant post-hoc differences when comparing sf with both spf and snf, and spf compared with snf. across the three subgroups (table 4) , gds score was significantly higher comparing sf with both spf and snf, and spf with snf (snf 0 (interquartile range, iqr: 0-1.00) vs. spf 1.00 (iqr: 0-2.00) vs. sf 2.00 (iqr: 1.00-3.00), p < 0.001). for nutrition, mna, snaq, and albumin level were significant (all p < 0.05), with post-hoc analyses indicating significant differences between spf and snf for mna and albumin level. for physical performance, sppb, gait speed, 5-time repeated chair stand, and handgrip strength were all significant across the three subgroups (all p < 0.05). post-hoc comparisons showed the sf and spf groups performing significantly worse than snf in sppb and 5-time repeated chair stand. gait speed was significantly slower in sf compared to snf, while handgrip strength was significantly lower in spf when compared to snf. in terms of physical activity and life-space, ipaq was significantly different across the three subgroups (p = 0.001), with post-hoc comparisons revealing significantly lower activity in sf and spf compared to snf. life-space mobility was significantly lower for life-space levels 2 and 5, corresponding to being in areas outside one's home and places outside one's town (p = 0.026 and p = 0.006, respectively), with significant difference between spf and snf in post-hoc analyses. we performed logistic regression analyses to examine the independent association of social frailty with outcome measures (table 5 ). in model 1, adjusting for age, gender, education, hypertension and albumin, spf was significantly associated with poor physical performance measured by sppb (odds ratio, or = 7.66, 95% confidence interval, ci = 1.43-41.14) and low physical activity (or = 3.66, 95% ci = 1.67-8.02), whereas sf was significantly associated with low mood (or = 6.88, 95% ci = 1.23-38.66); malnutrition risk (or = 11.13, 95% ci = 1.91-64.97); poor physical performance (or = 17.51, 95% ci = 2.63-116.58); and low physical activity (or = 4.46, 95% ci = 1.37-14.54). there was no significant association with life-space. when additionally adjusted for physical frailty in model 2, the significant association with poor physical performance and low physical activity remained for spf (or range: 3.10 to 6.22), and with low mood, malnutrition risk, poor physical performance, and low physical activity for sf (or range: 3.58 to 13.97). we repeated logistic regression analyses to examine the association of physical frailty with outcome measures. physical frailty was significantly associated with malnutrition risk (or = 3.47, 95% ci = 1.33-9.05), low physical activity (or = 1.78, 95% ci = 1.04-3.07), and decreased life-space (or = 2.19, 95% ci = 1.26-3.81), but not with low mood or poor physical performance. in the present study, using a theory-guided social frailty scale that is grounded in the bunt conceptual framework, we build upon growing body of evidence about the paramount importance of social frailty by demonstrating the independent associations of spf and sf with mood, nutrition, physical performance, and physical activity in non-frail community-dwelling older adults. even after adjusting for physical frailty, both spf and sf were associated with poor physical performance and low physical activity, with sf also associated with low mood and malnutrition. this increase in odds from snf to sf attests to a dose-response relationship for these outcomes, lending credence to the validity of our findings. with the significant prevalence of spf and sf at 28.8% and 7.4%, respectively, in our cohort of non-frail older adults, the independent associations of social frailty with intermediary outcomes which precede the onset of frailty and disability corroborate the contributory role of social components towards increased vulnerability in older adults [6] and emphasize the importance of evaluating social dimensions as part of a comprehensive geriatric assessment. the theoretical framework and definition of social frailty proposed by bunt et al. [5] reinforced our approach in understanding this complex construct. from the initial 9-item questionnaire, we excluded the item "do you feel you are helpful to friends or family?" despite it being an element under bunt's 'general resources' category. the non-discriminatory response with this item may either represent under-reporting due to desirability bias or the lack of relevance of feeling helpful to friends or family in the overall construct of social frailty. the resultant sfs-8 items cohered to our three factors of 'social resources', 'social activities and financial resource', and 'social need fulfilment', which addressed the various components when mapped onto bunt's social frailty concept. interestingly, the items grouped under factor 2 ( table 2 ) may suggest a relationship between constraints on financial resources for medical services with social activities of going out and eating with someone. alluding further to bunt's 'general resources' category, the trends observed in baseline characteristics, such as education, housing, badl performance and cognitive performance moving from snf to sf subgroups, also support the known-group validity of the sfs-8 cutoffs used to define subgroups. while a recent study considered the bunt's social frailty conceptual model when using a 4-item social frailty assessment tool to evaluate the impact on incident disability and mortality [29] , it only had one item per bunt category and did not comprehensively delineate the components that underpin social frailty [5] . notwithstanding differences in countries and cultures, our study provides a starting point for a theory-driven approach with reference to asian evidence, in examining the impact of social frailty on salient outcomes in older adults. as far as we are aware, this is the first study to examine the association between social frailty and nutrition in older adults, illuminating the magnitude of its impact on malnutrition risk. previous studies examining the relationship between frailty and nutrition [30, 31] placed heavy emphasis only on the physical aspect of frailty. in addition, our results showing the association between social frailty and depressive symptoms paralleled similar findings from a previous study [11] . indeed, insights from these findings can explicate the potential protective role of commensality against social frailty. besides leading to depressive mood and enhancing feeling of loneliness [32] , eating alone among older adults can also result in lower food diversity [30] and poorer nutritional status [33] , due to the lack of social companionship during mealtimes [34] . in the communal dining culture of asia, commensality thus serves as an important avenue for socialization where older adults enjoy interactions and gain valuable opportunities for companionship [35, 36] . in our study, although the majority (88.6%) of participants lived with others, it is disconcerting that 24.5% constantly ate alone and 28.4% did not talk to others daily. the reasons for these findings are unclear and warrant further studies to ascertain if the prevalence of eating alone and decreased social interaction is even higher amongst less robust populations of community-dwelling older adults. as an antecedent to functional decline and/or disability, physical activity is considered an important interventional target in the prevention of frailty in older adults [37, 38] . building upon emerging evidence that social frailty is an important risk factor of physical deficits [9] and disability [12] that may lead to the subsequent development of physical frailty in non-frail older adults [39] , our results showing significant associations of both spf and sf with physical performance and physical activity mirrored this trend. although physical performance and physical activity have been reported to be independently associated with life-space mobility in older adults [40, 41] , we did not find a similar association of social frailty with life-space mobility. interestingly, in our non-frail cohort (defined by frail score), social frailty was associated with adverse outcomes even after adjustment for physical frailty (modified fried), and conferred increased odds for gds, mna, sppb, and ipaq. taken together, our results suggest the preeminence of social frailty in assessing the risk profile of adverse health outcomes in robust populations of older adults. notably, three of the outcomes (gds, mna, and sppb) associated with social frailty are components of the novel construct of intrinsic capacity, which emphasizes on the more positive attributes of reserves and residual capacities, as opposed to deficits and limitations accumulated with aging in frailty [42, 43] . thus, consistent with a life-course approach towards healthy aging, our results suggest the possible role of upstream community-based interventions to target the deleterious impact of social frailty in non-frail older adults, such as programs that promote social interaction, engagement in physical activities, and sharing of nutritious meals to build social capital and intrinsic reserves through social networking and community participation [44, 45] . future studies should further delineate the longitudinal relationship between social frailty and intrinsic capacity and whether social frailty may be the forme fruste of an underlying age-related or even pathological process. in addition, although social determinants of health are often the main driver of health inequalities within and between countries [46] , better recognition of these conditions together with frailty has been mooted [47] . indeed, studies have shown that not only objective measures of socioeconomic status such as education, employment, and income impacted on frailty trajectories [48] , lower subjective social status was also associated with a higher incidence of frailty in men [49] . the specific relationship with social frailty in these studies, however, remains unclear. the increased odds of adverse outcomes associated with social frailty as illuminated in our findings, coupled with many socioeconomic elements contributing towards social frailty as outlined in bunt's framework [5] , become especially pertinent during the current covid-19 climate. the pandemic has galvanized the world into unprecedented efforts of instituting physical distancing, such that social frailty can be amplified due to the secondary effects of social isolation in many older adults [50] . other examples of how pandemic control measures may exacerbate inequalities include the withdrawal of 'non-essential' services that provide support for older adults living alone or with cognitive impairment, or the inequitable access to digital tools to mitigate social isolation amongst older adults from lower socioeconomic background who may have lower digital literacy. further studies are therefore warranted to better understand and address the social gradient and inequalities that may aggravate the impact of social frailty. this study has several limitations. firstly, the cross-sectional analysis precludes definitive conclusions about causality as reverse causation cannot be excluded. a causal relationship should be elucidated in well-conducted prospective studies to examine the longitudinal impact of social frailty on salient outcomes. secondly, our study comprised predominantly chinese older adult participants who were robust and higher functioning. thus, our findings may not be generalizable to non-chinese asian settings with more frail older adults. thirdly, we recognize that bunt's social frailty model supported a further understanding into self-management abilities by which one gains or maintains resources which are necessary for social need fulfilment and its higher-level outcome of subjective wellbeing, both of which were not examined in this study. finally, we utilized questionnaire items from previous asian studies to operationalize social frailty. nonetheless, it remains a complex construct which will require qualitative and mixed method approaches to explore in greater depth. in conclusion, our study supports the incorporation of a theory-grounded conceptual model of social frailty. the factors in our social frailty scale cohere with social resources, general resources, social behavior/activities, and fulfilment of basic social needs. we demonstrated the association of social frailty, independently of physical frailty, with important outcomes of mood, nutrition, physical performance and physical activity in healthy community-dwelling older adults. our findings highlight the need for further studies to consider the social dimension of frailty, design upstream interventions to target the impact of social frailty and address social gradient and inequalities. frailty in elderly people addressing social determinants of health which social needs are important for subjective well-being? what happens to them with aging? subjective 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determinants of health frailty, inequality and resilience impact of socioeconomic position on frailty trajectories in 10 european countries: evidence from the survey of health, ageing and retirement in europe socioeconomic inequalities in frailty in hong kong, china: a 14-year longitudinal cohort study meeting the care needs of older adults isolated at home during the covid-19 pandemic we would like to thank all participants who contributed to this study. the authors declare no conflict of interest. the funder had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. key: cord-328992-gkzfqmfv authors: chang, lennon y. c.; mukherjee, souvik; coppel, nicholas title: we are all victims: questionable content and collective victimisation in the digital age date: 2020-10-06 journal: asian j criminol doi: 10.1007/s11417-020-09331-2 sha: doc_id: 328992 cord_uid: gkzfqmfv traditionally, the idea of being a victim is associated with a crime, accident, trickery or being duped. with the advent of globalisation and rapid growth in the information technology sector, the world has opened itself to numerous vulnerabilities. these vulnerabilities range from individual-centric privacy issues to collective interests in the form of a nation’s political and economic interests. while we have victims who can identify themselves as victims, there are also victims who can barely identify themselves as victims, and there are those who do not realise that they have become victims. misinformation, disinformation, fake news and other methods of spreading questionable content can be regarded as a new and increasingly widespread type of collective victimisation. this paper, drawing on recent examples from india, examines and analyses the rationale and modus operandi—both methods and types—that lead us to regard questionable content as a new form of collective victimisation. web 2.0 is a participatory platform whereby information and the dissemination of information are no longer in the hands of a few. this indiscriminate liberty regarding dissemination of information has led to the circulation of a plethora of content which is authentic, but has also opened the door to 'questionable content' such as fake news, misinformation and disinformation. over the past few years, there has been a significant rise in the circulation of misinformation, disinformation, fake news and other problematic content through the meteoric rise in social media platforms. web 2.0 not only saw the rise of social media, but also of blogs, online news portals and media sharing applications, and it coincided with the widespread availability of cheap sim cards and low-cost smartphones. this led to a paradigm shift in an individual's role in information dissemination. individuals, who traditionally primarily played a passive role as consumers of information and not as active producers or circulators of content, can now also play an active role creating and circulating information. with the paradigm shift, the risk of abuse increased many fold. the indiscriminate access and power brought a significant rise in misinformation, disinformation, propaganda and other problematic content. the compact oxford english dictionary defines misinformation as false or inaccurate information given by someone. disinformation is defined as "information intended to mislead". propaganda is defined as "information that is often biased or misleading, used to promote a political cause or point of view", while satire is defined as "use of humour, irony, or exaggeration as a form of mockery or criticism". in this article, all the above-mentioned kinds of information are clubbed together under the umbrella term 'questionable information' or 'questionable content'. the abuse of technology to create and disseminate questionable information is producing a new form of "collective violence" and "collective victimisation." the world health organisation has defined collective violence as "the instrumental use of violence by people who identify themselves as members of a group-whether this group is transitory or has a more permanent identity-against another group or set of individuals, in order to achieve political, economic or social objectives" (zwi et al. 2002, p. 215 ) and the group suffering from the collective violence are collective victims (vollhardt 2012) . current research on collective violence/victimisation is concerned with the experience, denial/recognition of victimisation, victim identity, collective memories and includes violence caused by war, terrorism, state-perpetrated violence and organised violent crime (e.g. bagci et al. 2018; littman and paluck 2015; vollhardt 2020) . while research has shown that people see fake news as a bigger threat than violent crime, illegal immigration and even terrorism (mitchell et al. 2019) , there is still no research that discusses how the abuse of technology in the form of questionable information is causing a new form of collective victimisation. although questionable information might seem relatively harmless at the individual level, it can play a significant role in shaping the thought process of a large segment of society and influence decision making. when it comes to political content or sensitive issues, it could cause serious harm to society and then everyone becomes a victim. this article will focus on the significance of information in a democratic system and the scope and nature of questionable content. this paper proposes that to address successfully questionable information and collective victimisation, we need to consider its rationale and modus operandi (both the methods and types). this paper will also describe approaches undertaken by countries to meet the challenge of questionable information and their efficacy from the perspective of collective victimisation. not only ensures that the people are aware of their democratic rights but also are correctly informed about the obligations and duties which democracy entails (kuklinski et al. 2000) . only when individuals have the tool of information, can they judiciously and appropriately exercise their democratic rights including but not limited to voting rights. in the nineteenth century and into the twentieth century, citizens consumed political news primarily through newspapers. politicians and other political actors relied on newspapers to be their medium to propagate their ideologies or defend their actions. with the development of electronic media in the form of radio and television, political news found a faster and more attractive medium to reach most members of society (lazer et al. 2018) . while society was grappling with the challenges televised journalism was posing, the internet age dawned upon us and this was further enhanced by the introduction of the web 2.0 platform upon which social media thrived. online news consumption is reaching new heights due to the analytics and algorithms of social media to the extent that this form of media is well on track to eventually replace television in general (nguyen and western 2006) . social media is playing a significant role in the personal, social, economic and political transformation of individuals and can influence the mental health and decision-making capacity of people. in the recent past, several existing forms of crime have been facilitated through social media, and new forms of crime have been created which are dependent upon technology such as tampering with computer source documents, identity theft, phishing, online lottery scams, illegal access, data interference and child pornography. many of these crimes are a technological extension of existing crimes such as stealing computer resources, cheating by impersonation, terrorism and sexual crimes (broadhurst and chang 2013; chang 2017) . the theory of victimisation which was developed to address the concerns and issues of victims of crimes has remained static in terms of its scope as it limited itself to individuals and dominantly victims of conventional crimes. questionable content appearing on web-based platforms differs from content in traditional media in two primary ways: (a) traceability of the source of information and (b) the limit and extension of circulation. for instance, a news piece which is incorrect and falsified, when circulated through traditional media such as a newspaper or telecast, is easily traced and suitable action can be taken directly against the perpetrators. but in the case of similar misinformation on social media, who is the original source of the story often remains unknown. this added protection shields perpetrators and creates a more favourable environment for those wishing to circulate questionable content. secondly, the reach of content distributed on social media is less certain than the reach of content distributed through traditional media where tv ratings and print circulation are approximately known. content on social media has the potential to "go viral" and reach many more people than traditional media. thus, even though the consumption of questionable content on social media is predominantly individualistic, the ultimate impact is on society as a whole and can cause collective victimisation. questionable content in this context can be crystallised as content that is politically or ideologically motivated online disinformation, fake news, hate speech, online misinformation and foreign encroachment in the domestic affairs of the state, misreporting and misconstrued satire (shin et al. 2018; tenove et al. 2018) . such content has the potential to impact individuals and the population collectively by changing the attitude of consumers, creating scepticism towards the electoral process, blocking educated political decision-making, causing political unrest, communal riots, and violence, sabotaging free and fair electoral processes, altering the political landscape, marginalising certain classes or communities and damaging the economy (brown 2018) . the threats to the collective are not theoretical, as the world has already witnessed events such as the pizzagate incident (persily 2017) , russian interference with the 2016 u.s. presidential election (marvel 2019 ) and a wave of disinformation originating in china fed onto taiwanese internet domains, seeking to interfere in local and national elections (wong and wen 2020) . india, although a country with relatively limited internet penetration, has a significant number of people using social media and the spread of misinformation is extensive. the dissemination of questionable content has caused communal violence, lynching and innumerable incidents of violence against particular groups of people in india, as well as influencing the 2019 election (arun 2019; roozenbeek and van der linden 2019). fake news, online misinformation and disinformation regarding covid-19 (see below) occurred to such an extent that it moved the issue from being just a health pandemic to also being about communal tensions and religious conflict (ellis-petersen and rahman 2020). some of the questionable content was, on the face of it, absurd and yet many people believed it (sengupta 2020) . the nature of the platform makes it extremely difficult to curb. these forms of victimisation viewed through the prism of standard principles, embodied in constitutional law, human rights law, criminal law, the basic tenets of democracy, the un charter and international law, constitute a violation of india's domestic law as well as international law. in the space of a few months in early 2020 in india, there were a number of cases of questionable content regarding covid-19, targeting different political parties and religions and which had an impact over the collective even though they were accessed individually 1 : (a) an audio clip claimed that a vendor with a certain religious background was spreading covid-19. the perpetrator produced a 6 min and 42 s audio clip, within which he suggested that a vendor was selling vegetables at a low price with the ulterior objective of spreading covid-19. the audio clip was examined by the fact-checking organisation 'boom' and was found to be fake (alphonso 2020). it is apparent the perpetrator intended to use the audio clip to create communal hatred in the time of the pandemic. individuals received the message in their personal space, but the insecurity it created within the victims potentially could have given birth to a collective distrust in vendors based on their religious background and even violence if not tackled in time. many would not be aware of the follow-up fact-checking and would continue to live with the misinformation and the prejudice it fuelled. (b) during the time of covid-19, a photo of switzerland's matterhorn mountain lit with the indian flag was tweeted, claiming that it was lit in the name of hope after the leader of the government supplied hydroxychloroquine tablets (hcq-a drug for the treatment of rheumatoid arthritis and believed by some scientists to lessen the symptoms of covid-19). the tweet went viral and was shared widely via twitter and facebook. a factchecking organisation in india, altnews.in, found that, although the image of the indian national flag had been projected on the matterhorn, the claim shared along with the image that this happened after india supplied hcq tablets to the country was false. the projection on that day was to express solidarity with indians in the fight against covid-19 and was one of a series of flag projections intended to be a sign of hope as the world battled the novel corona virus (kinjal 2020a, b) . while the tweet in itself seems harmless, it had the intended effect of encouraging indians to feel an 'exclusive' and positive emotion about the nation and the performance of the political party in government. (c) over twitter, a picture demonstrating social distance practice during covid-19 at mizoram, a state in northeastern india, received many likes. however, boom (india) & boom myanmar ran verification of the picture, and it was found that the picture was not of mizoram but of kalaw, a hill town in myanmar's shan state (nabodita 2020) . while some would argue that by encouraging social distancing, its accuracy was unimportant as it had a positive influence over people. however, it was fake news and it might have had the perverse effect of causing additional covid-19 cases due to a false sense of security based on a belief that safe practices were protecting the community. (d) the impact of questionable content is strongly felt when popular individuals, political personalities or individuals circulate and share the information. for example, a video from bijnor, a district in the indian state of uttar pradesh, depicted an elderly fruit seller belonging to a minority faith, accused of sprinkling urine over bananas to be sold. eminent political figures and media personnel fuelled the circulation by circulating the video. it did not take much longer for the video to get viral. it was later found, and verified by bijnor police, that the elderly fruit seller had only washed his hands with water from the bottle and did not sprinkle urine as claimed in the video (jha 2020). the above incidents are illustrative of the power of questionable content and the damage it can cause to individuals and societal harmony. this damage can be brought on very quickly by the participation of entertainment or sport celebrities and political leaders as potential 'super spreaders'. the rationale for targeting such individuals is simple, as their re-posting is understood by their supporters as an endorsement and this will give a significant boost to the circulated content, even if it is questionable content. gossip and rumours have undoubtedly existed since the invention of languages; however, the invention of the gutenberg printing press in 1440 enabled precise and rapid reproduction of books, dramatically reducing their cost and increasing their availability, and thereby also increasing the scope for the circulation of misinformation and disinformation (posetti and matthews 2018) . the advent of the participatory web interface with its indiscriminate access to information has again significantly increased the opportunity for misinformation and disinformation and the speed at which it circulates. to access social media, all that an individual needs is a workable network and a device supporting the social media applications or website and then the individual is good to go. this indiscriminate access has been far more widespread than the understanding amongst the population about the nature of the technology. with no qualification necessary to use and access social media, the perpetrators and victims of questionable content are separated by no more than a click (chang 2012) . the industry of misinformation and ancillary activities we argue can be regarded as a new type of collective violence and is generating a new form of collective victimisation where individuals are not even aware that they are victimised. we consider here the rationale and motivation behind questionable content, and then the characteristics of questionable content. while any individual with a device which supports social media platforms potentially can be a perpetrator, perpetrators tend to be certain entities with particular objectives such as political entities, extra-political entities, extremists (ben-david and matamoros fernández 2016) and individuals or a group of individuals with nefarious motives. there are websites and portals which are entirely dedicated to the production of fabricated and manipulated information that operate under a name which is deceptively similar to that of a legitimate news organisation (allcott and gentzkow 2017). india is periodically a victim of such websites, as was evidenced by the website "viralinindia", which was shut down on account of abusing information prior to the 2019 general election. however, such entities are hard to shut down permanently as it is easy to re-emerge in some other form (usha 2019) . while perpetrators capitalise on the insecurities, prejudices and limited education of the victims and on the channel algorithms, the victims are unaware of and are not alert to the motives of the perpetrators. unwittingly, they aid and assist the perpetrators to (i) polarise the population for or against a particular cause, (ii) evoke emotions among the population and cloud independent and rational judgement, (iii) spread conspiracy theories and infuse distrust in the existing knowledge base, (iv) troll and infuse an existential crisis in an individual or even a group, (v) deflect blame and target another, create a parallel narrative and (vi) impersonate (roozenbeek and van der linden 2019). the perpetrators engage in all the above-mentioned strategies either for a pecuniary benefit or ideological validation (allcott and gentzkow 2017; silverman and singer-vine 2016). most media attention has focused on the use of these strategies by foreign agencies interested in domestic politics. during the 2020 taiwanese presidential election, questionable content was put into circulation. the questionable content did not stop with fake news and sought to manipulate public opinion by spreading misinformation (kuo 2019; lee and blanchard 2019). having regard to china's claim that taiwan is a part of china, the interference by an international entity must be viewed as potentially threatening taiwan's security and the coveted principle of self-determination. the modus operandi along with the content of questionable content helps us to determine and identify the actor, the rationale and also the intended target. various forms of questionable content are crafted to attain different objectives and impact individual behaviours or attitudes differently. collectively, they are often termed as a semantic attack, as the questionable content tends to adversely impact the semantics of information (kumar and geethakumari 2014) . the factors which differentiate between legitimate information and questionable information are certainty, accurateness, comprehensiveness and deceptiveness. a semantic attack is directed towards individual users of social media and is crafted in such manner which awakens the insecurities of individuals or reaffirms their existing belief (allcott and gentzkow 2017). in a nation with a heterogeneous and diverse population, the impact of miscommunication and like events could be tremendous. a nation-state with diverse religious practices, cultural heritage, socio-economic standards and educational disparity, and with the substantial reach of social network-enabled devices in the hands of such a diverse population, is prone to be a victim of insecurities. social media is a platform which provides an insight into the lives of others and individuals who previously had limited knowledge about the lives or thoughts of others can now access them with the click of a button. social media has led to a significant detrimental effect in the psychological condition due to comparison of self over social media with other participants (vogel et al. 2014) . the comparisons which stem out of insecurities are not limited to lifestyle comparisons but also intellectual comparisons. people engage to influence others by showcasing their intellectual abilities and ideological bent, which often is guided by intolerance and rigidity to accept a diverse outlook leading to extremism and polarisation (jost et al. 2018) . the propagation of questionable content is further aided by the speed of its circulation and uncertain geographical location of the source. styling and the text of questionable content are crafted in a particular manner depending on the type of questionable content such as satire, fake news, disinformation, propaganda and misinformation and on its audience. the style of questionable content differs from real news on several counts. fake news is often crafted with a longer and striking title, or heading, which attracts immediate attention, the vocabulary used is simpler, with limited use of technical words so that even a reader with limited education or intellectual abilities is not discouraged from reading it. furthermore, the presentation of the content is colourful, capitalised and dramatised to grab the attention of the potential target (horne and adali 2017) . when it comes to content, articles are shorter in length compared with real news and there are fewer punctuation marks and quotes which lowers the possibility of tracing the content back to an authoritative figure. there is greater use of adverbs, pronouns and redundancies. the content also prefers using self-referential terms such as 'i', 'we', 'you' and 'us' (horne and adali 2017). such self-referential terminology behaves as if the content directly speaks to the reader or on behalf of the reader; consequently, the reader feels connected with the message and messenger. satirical websites are producing content some of which can cause similar damage as fake news and misinformation when its reception is without a context. the wide range of actors also includes websites engaging in the production of a mixed format of news, with a certain portion being true and other portion fabricated thereby creating a cloud in the judgement of people at large (allcott and gentzkow 2017). india has been a victim of delivery of content from a website which engages in the dissemination of satire from eminent political figures leading to a grant of authenticity to the satire, at least in the mind of some. for example, a leading politician resorted to quoting from "fakingnews", a portal which declares itself as a satire and humour website, and he was subsequently re-tweeted by the official political handle of the political party forming government. (chaudhuri 2020) . the device of questionable content is equally exploited by the opposition in the indian parliament as they use this mechanism to question the credibility of the governing political party. opposition parties in the indian parliament have often attempted to malign the image of the prime minister by questioning his lifestyle and using visuals which are either wrongly dated or wrongly contextualised (kinjal 2020a, b) . questionable content in india frequently has elements such as religious intolerance, people with a certain political affiliation violating the law, photos and news related to celebrities, outrageous claims regarding the performance of government and international accolades received by india. most of the content is supported with photographs from unconnected events (see examples from boomlive, https://www.boomlive.in/fake-news). the questionable content capitalises on the strong religious sentiments of the majority, or political sentiment, which itself is connected to religious affinity, or with a little description and an image, which aids people with limited education to interpret or celebrities, who are often revered as a god by a large section of india's population. it is not that every individual who is accessing social media is bound to fall in the trap laid by questionable content. the most vulnerable are individuals with limited education or awareness about the medium and scope of the medium, those who lack an objective outlook or have had experiences which have had an impact on their psychological condition making them either insecure or prone to seeking validation of existing prejudiced ideology (allcott and gentzkow 2017; silverman and singer-vine 2016). having an education does not guarantee protection from questionable content. however, it can be argued that a limited education (including digital literacy) plays a significant role in the victimisation of individuals as it enables them to access social media but does not enable them to discern or make rationale choices in favour of real information. a lack of awareness and skills to identify fake news from real news enhances the circulation of questionable material. the insecurities upon which the questionable content capitalises were also in evidence in taiwan during the elections in 2018 and 2020, as well as during the covid-19 pandemic. to socialise, individuals do not need to leave their homes anymore, they can reach out to anyone and everyone through the algorithms of social networking. an individual sitting in the comfort of their home can spend hours over a social network, reading, watching, writing, contributing content. however, the significant change is that they now also are engaged in sharing the content they consume. while the individual presumes that they are acting on their own in their private domain and are not involving others, the moment their activities involve sharing, the impact goes beyond them individually. with the act of sharing, an individual actively enters the realm of algorithms of the social network, and the shared content has the potential to have an impact beyond the individual, extending to the individual's social network and then beyond to the social networks of the individual's social network growing exponentially until it eventually impacts society collectively, or at least a certain portion of it. when the information circulating is real and genuine, the impact is not necessarily adverse; however, unchecked questionable content undoubtedly has an adverse impact on people collectively. except for the perpetrators, who introduced the questionable material, all the other individuals who consumed it and actively shared it without verification could be considered collective victims of questionable content. often, when questionable content comes from someone in their contact list or from friends and family, the propensity is to believe in the content and it is often misconstrued as authentic and genuine as opposed to content received from an unknown person. recipients of questionable content often do not undertake a fact-finding exercise or analyse the information from an objective standpoint to ascertain its reliability; they are prone to trust their friends and family over social media unless there exists an ideological difference with the actor. with this trust reposed upon the contact and network, the recipient turns into actor and feels the need to share and inform others in their contact group thus becoming a victim as the recipient and also inflicting injury to others. the individual sharing questionable content has an impact on the collective by virtue of changing the attitude of consumers towards a particular issue or by creating general indifference towards an election by generating a certain amount of scepticism and distrust (persily 2017) . irrespective of the end goal-pecuniary benefit or ideological reach-questionable content creates a "blanket of fog" which conceals and cloaks authentic information and creates confusion over what to believe or to fall prey to the content circulated. the idea of "educated political decision" is subsequently lost leading to a situation where voters have been exposed to incorrect information influencing how they cast their votes or whether they vote at all. when this results in the election of individuals who would not otherwise have been elected, it can be regarded as collective victimisation as it engulfs the majority of the population (persily 2017) . the experience of the usa in 2016 suggests that social media can play a vital but not decisive role in communicating electoral news and that the average american voter did not just believe any fake news; however, they were likely to believe stories that favoured their preferred candidate (allcott and gentzkow 2017). india, the world's largest democracy, has also fallen victim to questionable content circulated over web-based social media platforms. oxford internet institute (2019) suggested that "the proportion of polarizing political news and information in circulation over social media in india is worse than all of the other country case studies we have analysed, except the us presidential election in 2016". and according to oxford internet institute (2019), a data collected in february to april 2019, 2 months right before the 2019 general election, showed that both bharatiya janta party (bjp) and indian national congress (ins) shared a substantial amount of news on facebook that they classified as "divisive and conspirational content", i.e., junk news and information. the potential of the questionable content impacting a collective is not only limited to political events as was seen during the covid-19 pandemic. crimes and forms of crimes have been ever-evolving and the internet age has created both new opportunities for crime and new crimes. the big question that lies before the government of each state is how to regulate information systems, and specifically questionable content. government-imposed regulations can be a double-edged sword as regulations can eliminate or restrict the flow of questionable content, while at the same time can potentially act as a legally sanctioned mechanism to gag real news and ultimately violate media independence, freedom of information and the right to free speech. it is a difficult issue to balance as india saw when the indian government was about to enforce a rigorous law suspending the accreditation of journalists propagating questionable content but soon froze it owing to protests from the media. in india, questionable material (rumours) circulated deliberately over whatsapp, a popular platform for text and media exchange over a smartphone, has resulted in several incidents of lynching (arun 2019) . the indian government felt that the onus was on whatsapp to stop the acts of lynching. through notices to whatsapp, the government put pressure on the company to address the problem by preventing the messages from spreading. whatsapp responded by installing a "forwarded" label to tell the reader that the individual sharing the content did not create it. while web-based platforms such as whatsapp are undoubtedly being used to amplify and target hate speech, if the aim is to limit the incitement to violence, then other factors that contribute to the production and promotion of questionable content such as the context, and the roles of leaders and local police, need to be addressed (arun 2019) . a holistic approach is needed for regulation including the identification and application of penal laws against the perpetrators. equally, those vulnerable to spreading questionable content need to be made cyber security aware to protect themselves from the content and from spreading the content (chang and coppel 2020) . in april 2019, the us law library of congress published a report on initiatives taken by a few countries from different regions to counter the menace of fake news. the uniform issue in the study was the role and impact of questionable content in the fair and free election process (the law library of congress 2019). a similar study was done by www.poynter.org, with selected countries representing various regions (see https://www.poynter.org/ifcn/antimisinformation-actions/). both studies reveal that countries have undertaken three approaches: (a) steps by government to monitor, assess and assist in the reduction of questionable material over social networking sites; (b) steps closely resembling the sanctions and strict measures against questionable content and (c) steps involving elements of awareness to control collective victimisation. however, there is not a uniform approach by the nation states. countries are attempting to address the growing challenge of questionable content through different measures including monitoring, imposing a sanction, conducting awareness programs and demanding accountability. however, regulation is not a simple answer as was seen in malaysia where legislation in 2018 faced heavy criticism for its broad definition of 'fake news' and was also examined for potentially being oppressive and regressive (the law library of congress 2019). a similar stance was taken in israel where there has been growing apprehension within the political opposition about excessive governmental control over information systems that could lead to violations of the essential right to information and freedom of speech (the law library of congress 2019). in both india and myanmar, the internet in parts of the country was shut down to stop the dissemination of information, ostensibly for security reasons but also to limit awareness of the situation on the ground. this can be seen as the gagging of the right to speech and an excessive imposition that violates not only human rights but also adversely impacts the economy (aung and moon 2020; kiran 2020). in 2018, the indian government proposed to penalise journalists for publishing and propagating fake news; however, the proposal was withdrawn amid protest and claims of interference by the prime minister's office (dutta 2018; khalid 2018) . rather than impose a repressive regulatory approach, the taiwanese government has adopted a "humour over rumour" strategy to counter questionable content. in order to provide timely and correct information, the government uses humourous memes to provide information. by mocking government officials themselves (e.g. the meme with the premier showing his rear saying "we only have one butt" (see image 1) to encourage people not to panic buy toilet paper during the covid-19 pandemic) or using a "spokesdog" (rather than a spokesperson) to communicate its public messages (see image 2). these messages successfully attract people's attention in a timely manner and effectively cut back the dissemination of questionable content. in another alternative to government regulation, fact checking organisations, such as altnews.in (india). boomlive.in (india) and mygopen.com (taiwan), investigate and identify questionable content. however, they are not always perceived as being independent. furthermore, social media platforms and applications that curb questionable content not only assist governments but also run the risk of becoming-or appearing to be-unaccountable agents of the government in determining what is acceptable content. in addition to the abovementioned, certain other innovative measures have been developed by the participants of the dotcom world (chang and grabosky 2017) . one such innovation involves an online game which enables the individual players to play the role of questionable content producer, and through this role-playing, the player gets psychological training to identify techniques used to produce such content (roozenbeek and van der linden 2019). regulation will never be enough to protect the population from questionable content and there needs to be a focus also on "hardening" the target. cybersecurity awareness training programs equip an individual with the ability to discriminate between real news and questionable content form part of the armoury. one example of such effort is cyberbaykin (see https://www. facebook.com/cyberbaykin/), which was created to raise awareness about cyber safety and risk in myanmar (chang and coppel 2020) . it is evident that questionable content over social media in the form of fake news, misinformation, disinformation, propaganda and misconstrued satire have become a menace to reckon with. it is also acknowledged that human rights relating to freedom of speech and the right to information are threatened. effective regulation of the world of questionable content will not be possible unless all measures such as monitoring and sanction are aided by awareness and accountability measures. one of the key barriers in need of resolution to successfully regulate questionable content in the information system is the lack of an acknowledgment that questionable content is collectively victimising the nation's population. the primary challenge to such an acknowledgement is due to the limited construct of the identification of 'victim'. traditionally, the subject of a criminal offence is considered to be the victim, and barring a few circumstances like war, genocide and similar acts, it is an 'individual' who forms the subject matter of victimisation. often, psychological damage is not considered as victimisation as evidencing the criminal act is difficult. the challenge of extending the idea of victimisation to a collective is a notch higher, in terms of difficulty. a question may arise, even after acknowledging that questionable content is playing an adverse role in the electoral process, why this is not categorised as collective victimisation of the nation's population? the answer might lie in the lack of scope to provide compensatory privilege to a collective, which is the essence in the study of victimology. besides, there exists another significant rationale for not categorising a nation's population as a collective victim: the authority or the political force shouldering the responsibility of regulating and addressing the collective victimisation may have taken advantage of the menace of questionable content. however, that remains a subject for later study. nonetheless, to make progress, we as a community need to appreciate and accept at the outset the concept of collective victimisation of a nation's population resulting from questionable content, before we try to make inroads to resolve and address the problem. viral audio clip claiming muslim vendors in surat are spreading coronavirus is false on whatsapp, rumours, and lynchings myanmar reimposes internet shutdown in conflict-torn rakhine, chin states: telco operator collective victimhood beliefs among majority and minority groups: links to ingroup and outgroup attitudes and attribution of responsibility for conflict hate speech and covert discrimination on social media: monitoring the facebook pages of extreme-right political parties in spain cybercrime in asia: trends and challenges propaganda, misinformation, and the epistemic value of democracy cybercrime in the greater china region: regulatory responses and crime prevention across the taiwan strait cybercrime and cyber security in asean building cyber security awareness in a developing country: lessons from myanmar the governance of cyberspace pm modi quotes 'faking news' in parliament to target former j&k cm omar abdullah govt to crack down on fake news, cancel accreditation of journalists publishing it. the print. retrieved 15 coronavirus conspiracy theories targeting muslims spread in india. the guardian. retrieved 15 this just in: fake news packs a lot in title, uses simpler, repetitive content in text body video from bijnor viral with false allegation that elderly muslim vendor sprinkled urine on fruits how social media facilitates political protest: information, motivation, and social networks modi government withdraws controversial order on fake news was switzerland's matterhorn mountain lit up in tricolour after india supplied hcq tablets? congress leaders falsely share photo of luxurious aircraft as pm modi's boeing 777 plane internet shutdown: india suffers $1.3 billion economic loss misinformation and the currency of democratic citizenship detecting misinformation in online social networks using cognitive psychology taiwan's citizens battle pro-china fake news campaigns as election nears. the guardian the science of fake news chinese 'rumors' and 'cyber armies' -taiwan fights election 'fake news'. reuters. retrieved 05 the cycle of violence: understanding individual participation in collective violence protecting the states from electoral invasions. the william and mary bill of many americans say made up news is a critical problem that needs to be fixed image of myanmar market's social distancing shared as mizoram the complementary relationship between the internet and traditional mass media: the case of online news and information junk news and misinformation prevalent in indian election campaign can democracy survive the internet a short guide to the history of 'fake news' and disinformation fake news game confers psychological resistance against online misinformation is government spraying coronavirus vaccine using airplanes? no, it's fake news the diffusion of misinformation on social media: temporal pattern, message, and source most americans who see fake news believe it, new survey says digital threats to democratic elections: how foreign actors use digital techniques to undermine democracy initiatives to counter fake news the rise and fall of fake news site 'viral in india': an interview with founder abhishek mishra social comparison, social media, and self-esteem collective victimization the social psychology of collective victimhood taiwan turns to facebook and viral memes to counter china's disinformation collective violence key: cord-351401-mloml4z3 authors: steinert, steffen title: corona and value change. the role of social media and emotional contagion date: 2020-07-21 journal: ethics inf technol doi: 10.1007/s10676-020-09545-z sha: doc_id: 351401 cord_uid: mloml4z3 people share their emotions on social media and evidence suggests that in times of crisis people are especially motivated to post emotional content. the current coronavirus pandemic is such a crisis. the online sharing of emotional content during the coronavirus crisis may contribute to societal value change. emotion sharing via social media could lead to emotional contagion which in turn could facilitate an emotional climate in a society. in turn, the emotional climate of a society can influence society’s value structure. the emotions that spread in the current coronavirus crisis are predominantly negative, which could result in a negative emotional climate. based on the dynamic relations of values to each other and the way that emotions relate to values, a negative emotional climate can contribute to societal value change towards values related to security preservation and threat avoidance. as a consequence, a negative emotional climate and the shift in values could lead to a change in political attitudes that has implications for rights, freedom, privacy and moral progress. considering the impact of social media in terms of emotional contagion and a longer-lasting value change is an important perspective in thinking about the ethical long-term impact of social media technology. the current coronavirus pandemic is an emotionally taxing time and people have a tendency to express and share their emotions, especially on social media platforms. evidence seems to suggest that it is primarily negative emotions, like fear and anxiety, that are shared in times of crisis. the idea pursued in this paper is that emotions and their spread on social media play a big role for a potential value shift in the wake of the recent coronavirus pandemic. (the coronavirus, or sars-cov-2, is the virus that causes the disease . the expression of negative emotions and feelings via social media, thereby reaching a lot of other people, could lead to an emotional contagion creating a negative emotional climate. this development is exacerbated by the fact that social media rewards emotionally charged messages. studies in psychology and sociology show that people adapt their values to circumstances. furthermore, values are internally structured so that when certain values increase in importance, the values that express opposite goals decrease in importance. when people are in a threatening situation or perceive a situation to be threatening, their values shift towards values emphasizing the security and conformity. a pervasive negative emotional climate facilitates the perception of threat and could thus contribute to a change in personal value towards values that emphasize security and stability of society. because personal and political values are related, threat-based change in personal value will likely foster a change in political values. in turn, the changed political values will lead to preferences of policies that focus on security, stability, and conformity. this political change could come to the potential detriment of rights and civil liberties because in times of perceived threat, people are more willing to give up said civil liberties. the account presented here of how emotional climate relates to value change also has normative implications for how we approach decision-making about the introduction of technologies that are supposed to remedy some of the consequences of the crisis. again, because people want social stability, health, and economic welfare to be secured, they could be willing to accept technologies that promise that. some of these technologies carry ethical risks, and we should make sure that ethically risky technology is not hastily introduced out of an emotional climate. although focused on the coronavirus pandemic, the paper makes a larger contribution. understanding the link between emotions, value change, and information technology can help to better grasp the role of technology in potentially socially disruptive long-term changes. emotions are based on values and concerns, that is, the things people care about (roeser and todd 2014; todd 2014) . according to the appraisal theory of emotion, emotions are responses that reflect a person's assessment of how significant something in the environment is for their wellbeing (moors et al. 2013) . similarly, the philosopher robert roberts has argued that emotions are concern-based construals (roberts 2003) . concerns are the things in life that people care about, including their needs and their attachments to things or other people. amongst other aspects, people have a concern for their well-being and their bodily integrity. furthermore, people are also concerned about and attached to other people. based on these attachments and interests (aka concerns), emotions signal that something in the situation affects something a person is concerned about. for instance, because a parent cares for their child, fear is usually the response when the well-being of the child is threatened. people usually care deeply about their health and the health of the people close to them. people also care about job security and personal freedom. many people perceive the current coronavirus pandemic as a threat to all of these things. with social distancing and quarantine as legal requirements in many countries, freedom is limited, likely leading people who are less afraid of health consequences to experience other negative emotions like anger or frustration. another important feature of emotions, besides appraisal, is that they have particular action-tendencies (frijda 1986 ). when we care about something, we are motivated to pursue courses of action that support or avoid harm to what we care about. thus, current fear for their lives, health, and livelihood will likely motivate some people to take protective actions. what is important here is that people perceive there to be a threat, whether or not the threat exists. a perceived threat is enough to motivate people. as will become clear later, the spread of negative emotions via social media can foster the perception that the threat is greater than it is. people tend to share emotions with others and are especially prone to sharing intense emotions (rimé 2009 ). in crises or traumatic situations, like natural disasters, accidents, or terrorist attacks, people experience a range of intense emotions. in trying times, social media is a popular medium for many people to share their thoughts and emotions. for example, immediately after the 2004 terrorist attack in spain, there was a steep increase in communication about the event, including the sharing of emotions (rimé et al. 2010) . because people share their feelings on social media, scientists use it to gauge the emotions of people related to situations of crisis. they found that negative emotions, like fear, anger, sadness, and a feeling of insecurity, prevail in these situations. for instance, in the two weeks after the terrorist attacks in new york city in 2001, people expressed more negative emotions in online diaries (cohn et al. 2004 ). anger was a leading emotion in the public's expression on twitter regarding the disappearance of flight mh307 (yeo et al. 2020) . in an analysis of tweets during hurricane sandy in 2012, a huge number of tweets belonged to the anger and fear category (brynielsson et al. 2013) . finally, in a study including over 60.000 twitter users after the terrorist attack in 2015 in paris, garcia and rimé (2019) found collective expressions of sadness and anger (but also long-term increase in expressions of solidarity). expressing emotions online does not mean that these emotions are inauthentic or do not represent what people really feel. although some people could misrepresent their emotions online, there is no evidence that misrepresentation is pervasive. in the current coronavirus pandemic, people experience that a lot of the things that they value are threatened. subsequently, people experience a lot of emotions, especially negative emotions. in a not yet peer-reviewed preprint including a dataset about the worries and emotions of uk residents collected in early april 2020, where participants had to write a short text about how they feel about the pandemic, researchers found that the prevalent emotions were anxiety, fear, and sadness (kleinberg et al. 2020 ). perhaps it is not surprising then, that on social media people express predominantly negative emotions, like fear and anxiety. here is some of the early available evidence for the emotions that people encounter and express on social media during the corona outbreak. (please note that some studies are pre-prints of yet to be published papers). looking at the link between social media exposure and mental health problems during the corona outbreak in china, researchers found that high social media exposure is associated with a high prevalence of depression and anxiety (gao et al. 2020) . examining data from the social media platform weibo, other researchers found an increase in negative emotions, like anxiety, after the announcement of the disease covid-19 (li et al., 2020) . the data also seems to indicate that people worry about their jobs and the economic situation in general. analyzing all corona-related twitter activity from mid-to end-january 2020, that is the early stages of the outbreak, researchers found that almost half of the tweets expressed fear (medford et al. 2020 ). finally, one study conducted in march 2020 found that instances of fear, sadness, and disgust were prevalent worldwide with the us, the netherlands, france, and switzerland showing especially high levels of expressed distrust and anger (dubey 2020) . in the following, i make the case that the sharing of negative emotions on social media could contribute to the development of a negative emotional climate in a society. this emotional climate could contribute to a change in personal values and this value change can have political ramifications. specifically, there is a link between personal values and political preferences. when people perceive their values to be threatened, they prefer policies that protect these values and are more inclined to accept measures that limit their civic freedom. people may also be quicker to accept proposed technological remedies to the crisis, without proper deliberation of the ethical risks. to understand how such a value change facilitated by online emotion expression and contagion can occur, i will first introduce emotion sharing and emotional contagion. in the last section i presented evidence that in traumatic situations and crises, people use social media to share their emotions. on social media emotions, much like in the offline world, emotions can spread from one person to another. this spread is known as emotional contagion. people are affected by the emotions of others and emotions can spread from one person to another. emotion contagion refers to the phenomenon that people's emotions become similar to other people's emotions because they were exposed to the emotions of these other people. some authors have likened emotions to infectious diseases that spread in social networks over an extended period (hill et al. 2010) . people are usually not aware of emotional contagion. furthermore, emotional contagion has consequences that extend beyond how people feel because emotions influence how people think and act (barsade et al. 2018) . the sharing of emotions can lead to emotion sharing feedback loops (garcia and rimé 2019) . that is, people talk or write about an event in reaction to how other people talk or write about the event. the emotional feedback loop and emotional contagion are accelerated by digital technology and social media (hill et al. 2010) . social media makes it easy to express and communicate emotions to people beyond the immediate social circle. this also increases the receivers of emotional contagion. furthermore, in times of coronavirus pandemic and social distancing requirements, many people spend more time in front of a screen, likely increasing emotion sharing and emotional contagion online. in the remainder of the text, i will use the terms digital emotions and online emotions to refer to emotions that are expressed online or experienced about the content posted on the internet, especially social media. that means that digital emotion or online emotion is not a new kind of emotion. importantly, in contrast to emotions that spread via face-to-face communication, digital emotions are technologically mediated emotions. that means the way that technology contributes to the way that emotions are shared and distributed. compared to offline emotion contagion, digital emotion contagion describes the phenomenon that the receivers' emotions become more like the emotions of the people that posted emotional messages (goldenberg and gross 2020) . again, emotional contagion explains how the transmitted emotions of individuals can grow into digital group emotions. social media platforms contribute to the spread of emotions online and subsequent emotional contagion. this has also to do with the business model of digital media companies and how they design their social media platforms. for instance, it makes sense for digital companies to try to promote emotion expression because emotions keep people engaged on the platforms and engagement means more opportunities to present ads and gather data. the way that emotion captures attention is an important part of the explanation of why emotional content goes viral on social media (brady et al. 2020) . indeed, on social media emotional information spreads more quickly than information that is not related to emotions. for instance, twitter messages about cancer that included joy, sadness, and hope are liked more than others, and tweets that contain joy and anger are retweeted more than others (wang and wei 2020) . furthermore, the presence of emotional-moral words in social media messages increase their spreading substantially (brady et al. 2017) , and digital media platforms seem to exacerbate content that induces outrage (crockett 2017) . the way that social media platforms operate may even intensify the negative aspects of outrage, like harassment or potentially anger, instead of turning outrage into a force of social progress (brady and crockett 2019) . the interest of digital media companies in people's emotions is also highlighted by the now infamous emotion manipulation study by facebook in 2014 , where users' emotions where manipulated through the emotional content of their news-feed to gauge emotion contagion through the social network. although there is some evidence that on social media platforms people usually share positive emotions more often than negative emotions. however, anger seems to be the exception (goldenberg and gross 2020) and some studies indicate that social media posts expressing anger are more likely to spread among users than posts expressing joy or sadness (fan et al. 2014 ). people's prevalent expression of negative emotions, like anger, fear, sadness, or disgust, during the current corona crisis may lead to an accelerated spread of negative emotions via emotional contagion. consequently, the emotional contagion mediated by social media may contribute to a longlasting change in how people emotionally relate to the world. the idea of an emotional climate is helpful here to think about the change in how individuals emotionally relate to the world and other people. joseph de rivera (1992) proposes that an emotional climate can be distinguished from emotional culture and emotional atmosphere. an emotional culture comprises the cultural codes and symbolic inventory by which emotions are expressed and regulated. for instance, emotion rules, emotion norms, and emotion narratives are part of the emotional culture. emotional atmospheres can occur when people jointly relate emotionally to a short-term event. for instance, the event of a political speech can have a particular emotional atmosphere. in contrast to an emotional atmosphere, an emotional climate is a longer-lasting way that people of a social community or society emotionally relate to the world and one another. in contrast to an emotional atmosphere, which is more transient and event-related, an emotional climate depends on pervasive socio-political and socio-economic conditions. examples for these conditions that affect many people are social inequality, repressive leadership, poverty but also natural disasters and widespread disease. there are positive and negative emotional climates. a positive emotional climate may occur in the aftermath of political revolution and in times of economic growth. for example, de rivera (1992) describes a shift from the emotional climate of fear to the emotional climate of hope in chile at the end of the military dictatorship. in the following sections, i show how a change towards a negative emotional climate may contribute to a change in personal values, which in turn has political ramifications. to understand how emotions may contribute to a change in people's values, it is important to understand how values relate to each other and how value change can occur. values are conceptions of "the desirable" that guide social actors, like people and groups, in their selection of actions and that influence the evaluation of actions and state of affairs (kluckhohn 1951, p. 395; rokeach 1973; schwartz 1999, p. 24) . we know from psychology and sociology that values are not static but can change. value change can occur on the individual as well as the collective or social level. for instance, lasting individual value changes have been observed concerning major life transitions like migration to a new country (bardi et al. 2014) . education may also contribute to long-lasting value change. for instance, completing an mba program can lead to an increase in self-oriented values and a decrease in other-oriented values (krishnan 2008) . to understand value change, it is helpful to consider how values are internally related. according to the influential schwartz theory of basic values (schwartz et al. 2012) , there are ten broad personal values. these values can be distinguished by their principal goal or motivation. for instance, the value of security has as its defining goal the safety and stability of society, relationships, and the self. the defining goal of the value of hedonism is pleasure and sensuous gratification for oneself. the internal structure of all values, that is how they relate to each other, is determined by how compatible the values are to each other. being motivated to pursue one value can conflict with another value. you cannot pursue conflicting values in one single act. for instance, the value of hedonism and the values of conformity or tradition do not share broad motivational goals. the first emphasizes pleasure for oneself and the second emphasizes self-restraint so as not to violate social norms and expectations. other values, however, emphasize similar goals and are motivationally compatible. for instance, the values of conformity and security are compatible because they both share similar goals that require the subordination of the self to social expectations. so, values are related to one another based on their motivational compatibility and incompatibility. due to this structure of how values relate to one another, when one value increases in importance, the opposite values decrease in importance. for instance, when people perceive a threat, the importance of self-protection values, like security and tradition, increases. what decreases is the importance of oppositional values that can be called self-transcendence values (schwartz et al. 2012) . self-transcendence values, like universalism and benevolence, emphasize the concern for the welfare and interest of other people. that oppositional values decrease/ increase in their importance could be observed in finish students after the terrorist attacks of september 11, 2001 (verkasalo et al. 2006) . the change of values is likely based on adaptive processes that adjust values to social, economic, and political circumstances (schwartz and bardi 1997) . for example, looking at the value orientation of turkish youth from 1989 to 1995, çileli (2000) found that people adapt their value orientation to the socio-economic changes in the turkish society: with economic improvements, young people changed to a more individualistic and competitive value orientation. values seem particularly sensitive to the threat to individual wellbeing, such as economic insecurity, and some authors have argued that people's values are shaped by how secure their survival is (inglehart 2018) . when existential survival is secure, as in times of a growing economy and job security, values prevail that are related to openness to change, diversity, and novel ideas. in contrast, in times of increased economic inequality and threatened livelihood, people concentrate on themselves, and values related to economic security become more important. for example, in a cross-national and comparative study of the change in value priorities of young europeans after the global financial crisis, sortheix et al. (2019) found a shift from values emphasizing growth and self-expansion, like hedonism, towards values related to self-protection, like security and tradition. in the current corona crisis, the health, well-being, and livelihood of a lot of people are in jeopardy and we have yet to witness all the negative economic consequences of the pandemic. putting together the adaptive feature of values, how they dynamically relate to one another, and the connection between value change and existential threats, one could expect that a certain value change is likely to occur concerning the current crisis. that is because a lot of people perceive the coronavirus pandemic as a threat (which is not to deny that it is a real threat). emotions and their spread on social media likely play a big role in such a value shift. emotions are a factor in the stability of values because affective support sustains collectively shared values (maio and olson 1998) . however, unbeknownst to many people that share their emotions during the coronavirus pandemic online, an emotional climate may develop that facilitates a change in value. the emergence of online emotion norms is one factor that could contribute to emotional contagion and subsequent development of an emotional climate. that is because emotion norms can facilitate emotional contagion. enabled by a recurrent confrontation with certain emotions, particularly negative emotions like fear, on social media during the corona crisis, an emotion norm to express such emotions may arise. emotion norms are a subset of social norms. social norms are expectations about how people, including oneself, act in certain situations (empirical expectation), and expectations of how people should act (normative expectation) (bicchieri 2005) . like other social norms, emotion norms involve expectations about what emotions people, and oneself, should experience and expectations about what they experience. emotion norms govern which emotions people are supposed to experience or express in a particular situation. these norms have also been called feeling rules (hochschild 1979) or display rules (ekman and friesen 1975) . like offline social life, social media is governed by emotion norms. for instance, in the case of digital mourning, norms guide the content and form of emotional display and what type of reactions are appropriate (wagner 2018 (waterloo et al. 2018) . being confronted with ubiquitous displays of particular emotions online could create the expectation that others experience a particular emotion and that you should also experience this emotion in a particular context and express it online. emotion norms and emotional contagion mutually enforce each other: emotion norms may emerge from and further facilitate emotional contagion. in turn, emotional contagion strengthens emotion norms. the interplay of emotional contagion and emotion norms, facilitated by the way social media platforms encourage emotional content, may lead to a long-lasting change in the emotional climate of a society. recall that an emotional climate is the mutable but usually long-lasting way that people of a social community or society emotionally relate to the world and one another. also recall that emotional climates are related to political and economic factors but emotional climates can also emerge in the wake of massive collective events, like natural disasters or a pandemic. evidence from previous catastrophes and preliminary empirical findings for the coronavirus pandemic suggest that predominantly negative emotions, like fear and anger, are expressed online. fostered by digital emotional contagion and emerging emotion norms, this could lead to a negative emotional climate. this emotional climate could extend beyond particular communities and nations. social media may even "magnify the intensity of global emotional synchrony" (coviello et al. 2014 ) because it allows communication and sharing of information and emotions without direct contact and across national borders. as a consequence of the corona crisis, a change towards a more negative emotional climate, which is a climate where emotions like fear and anxiety are prevalent, may contribute to a shift in values. part of the explanation is the link between attention and emotion. you may recall that emotions are based on concerns. emotions put the focus of our attention on a particular thing or an aspect of a situation that is relevant to our concerns. as michael brady puts it, "emotions capture and consume attention" (brady 2013, chapter 3) . fear, for instance, directs our attention to potential danger. however, people are not forced to accept the evaluative construal of an emotion. for example, i do not have to accept that the animal is dangerous only because i experience fear. nevertheless, an emotion bestows on us an inclination to assent to the view of the situation that the emotion presents. the fact that emotions are essentially linked to attention also explains why emotional content is more engaging on social media. emotional content just captures our attention. the so-called broaden-and-build theory of emotions can help explain how positive and negative emotions contribute differently to value change. according to the broaden-andbuild theory of emotions (fredrickson 2004; fredrickson and branigan 2005) , positive emotions, like joy and happiness, broaden the scope of attention and expand the thoughtaction repertoire. for example, joy triggers the urge to play, and curiosity triggers exploration. due to positive emotions, the cognition of people widens and people tend to notice a wider range of possible actions and creative ideas. in contrast, negative emotions, like fear, narrow the mindset and the thought-action repertoire, and put the focus of attention on the perceived threat and means of avoidance and survival. undoubtedly, the coronavirus pandemic is a threat to a lot of things people value. negative emotions capture attention and focus it both on the perceived threat and on the means to avoid it. the negative emotional climate, facilitated by the spread of emotionally charged messages on social media, could lead to the experience that certain values are under constant threat. this, in turn, could lead to a longerlasting change in personal values. the abovementioned internal dynamic relation of values explains how this may come about. as noted, values are dynamically related. the rise of importance of one value means a decline in importance of another opposite value. for example, according to this account, which has been validated multiple times, the values of security and freedom are motivationally opposed; when the importance of one increases, the importance of the other decreases. similarly, the rise of importance of security (e.g. safety and social stability) is accompanied by a decline of the importance of values related to openness to change and tolerance. recall that motivationally compatible values can reinforce each other's importance. for instance, values emphasizing security and tradition are compatible with each other because they have the same underlying motivational goals. now, a negative emotional climate, which focuses attention on a potential threat, could increase the importance of values emphasizing security, safety, and other motivationally compatible values. thereby downgrading the importance of oppositional values. research seems to corroborate the idea that emotions influence a change in values in such a systematic way. the fear of a (perceived) threat of terrorism has led to a change in the cosmopolitan values of tourists towards values of security (veréb et al. 2018) . also, perception of threat, linked to the political and economic conditions in a country, has been shown to lead to diminished tolerance (gibson 2002) . aristotle argued that political attitudes can be influenced by evoking emotions and the influence of emotions on political attitudes is well-documented by scientists. negative emotions seem to be particularly powerful. for instance, mediated by negative emotions like anger and anxiety, an external threat like war can improve people's evaluation of presidential performance. the anger and anxiety after the 9/11 attacks shifted public attitude regarding the conservative president bush in a positive direction (lambert et al. 2010) . anger is positively related to support for aggressive policies towards out-groups (halperin et al. 2013 ). the effect of emotions seems so powerful that even if the cause of anxiety has nothing to do with politics, it can carry over to the political domain and have an influence on political beliefs (renshon et al. 2014) . applying the account that links emotional climate to value change and political preferences to the current corona crisis: people's expression of negative emotions like fear or anger on social media may lead to a more negative emotional climate facilitated by emotional contagion processes. such a negative emotional climate characterized by people's fear for their health and the health of others may increase the importance of values like security. this, in turn, decreases the importance of values like tolerance or caring for people outside of their immediate circles. besides, the livelihood and economic standard of many people are in jeopardy. fear for their livelihood motivates people to protect it, which conceivably increases the importance of values related to this protection, like the value of security or conformity. this potential value change has political ramifications because personal values are related to political preferences. recall the value dimension of self-transcendence. self-transcendence values include the value of universalism, which emphasizes understanding, tolerance, and the protection of the welfare of other people. benevolence is another selftranscendence value. basic personal values structure and anchor political values like equality, patriotism, and civil liberties (schwartz et al. 2010) . researchers consistently show that people who strongly value universalism favor policies aimed at equality, social justice, and social welfare, whereas people who strongly value security favor political measures aimed at safety, stability, and social order (caprara et al. 2006) . the political value of law and order is motivationally grounded in fear of uncertainty and the (perceived) threat of a disruption of social order. an anxiety-induced broad shift in personal values and political values may lead to a broad acceptance of policy decisions that limit civil liberties and reduce social justice for the sake of stability and avoidance of threat. there is some indication that a threat to personal security prompts people to give up their rights and freedoms for greater security (davis and silver 2004) . a negative emotional climate and the accompanying shift in values also have normative implications for how we should go about decision-making regarding the introduction of technologies that purportedly remedy some of the adversarial effects of the crisis. to secure the values of stability and security, people may be more inclined to accept surveillance of their health by digital tracking and tracing apps despite the risks for data security and loss of privacy. in the urge to fight the pandemic, leaders should not neglect the effects of a negative emotional climate on decision making and hurriedly introduce ethically risky technologies. some leaders, particularly business leaders, may even take advantage of such a climate to push questionable technology for economic gains. besides using an ethical framework for the development of digital interventions to fight the coronavirus pandemic (morley et al. 2020) , people should be put in a position to effectively evaluate the ethical benefits and drawbacks of technologies heralded as counter-measures for the pandemic. a negative emotional climate can influence this evaluation, which is why even more care is needed here. although a fast-moving pandemic requires quick decisions, there should be a public debate and public deliberation about the technological measures that are going to be implemented is inevitable. to make political decisions more democratic and procedurally fair, the public should be involved in the process of decision making of risky technologies. emotions should be integrated into political decision making about potentially risky technology (roeser and pesch 2016) . extending this idea, public debate and responsible innovation should acknowledge both the importance and potential negative impact of emotions (steinert and roeser 2020) and reflect on the potential impact of emotional climates on policy decisions. another thing to consider is that a broad societal change in values from values emphasizing tolerance and openness towards values emphasizes security and stability could strengthen people's preference for political measures that roll back advancements in moral progress. these political measures and accompanying social changes could be hard to reverse after the crisis is over. one aspect of moral progress is the move towards a more inclusivist morality (buchanan and powell 2018) . moral inclusiveness means expanding the range of entities that are candidates for moral consideration. in contrast, an exclusivist morality only considers the in-group worthy of moral consideration. there have been various moves in history towards expanding the moral circle in this sense. for instance, full moral consideration of women and minorities, and the moral acknowledgement of at least some nonhuman animals. most normative theories take moral progress seriously and most normative theories would consider the expansion of our moral concerns as an improvement of morality. advancement of inclusivist tendencies seems to be bound to particular socio-economic conditions, like high economic productivity and high physical security. that is why an inclusivist morality could be called a "luxury good" (buchanan and powell 2018, p. 210) . because inclusive morality depends on favorable conditions, the possibility of regressing back to exclusivist moral responses looms, and under less favorable conditions exclusivist tendencies will likely (re)occur. for example, fear of economic security can intensify negative outgroup attitudes and lead to aggressive responses towards out-groups to preserve economic security (riek et al. 2006) . the epistemic context plays a crucial role here. conditions do not have to be dire, what is important is how people perceive the conditions. leaders for instance can exploit that by either misrepresenting the economic situation, by making people believe that there is a threat from an outgroup or that social cohesion is in jeopardy. social media can affect the epistemic context. because negative emotions influence how people perceive the corona pandemic and its consequences, a negative emotional climate could lead to a pervasive negative perception of the situation that makes a regress to exclusivist moral tendencies possible. if we care about morality, we should care about moral progress and an inclusivist morality. that also means that we should care about the possibility of a moral regress facilitated by the emotional climate and the role that technology plays for it. to briefly recap. emotions matter, especially in times of crisis. here, i have made the case for how, during the ongoing coronavirus pandemic, the sharing of emotional content on social media platforms can contribute to value change. emotion sharing could lead to digital emotional contagion which could facilitate an emotional climate. we have reason to believe this emotional climate influences the value structure. the emotions that spread in this crisis are predominantly negative (although positive emotions do occur and should not be neglected), which could result in an emotional climate that will have a negative character. based on the dynamic relations of values to each other and the way that emotions relate to values, the negative emotional climate could result in a societal value change towards values emphasizing security and tradition and this could have particular implications for political attitudes. the corona crisis puts a spotlight on social, political, and economic issues that were already present before the outbreak, like health and income inequality. similarly, looking at the link between the corona pandemic, emotions, and social media puts into sharp relief, once again, how social media is designed to engage us and how it rewards attention-grabbing emotional content. technology companies are already the big winners of the pandemic because social distancing drives people online. the combination of emotional contagion and social media could lead to a change in values. ironically, the companies that provide the platforms that contribute to emotional contagion and a potential change in value are also the ones that will benefit the most from a potential value change. in the face of a lethal pandemic, privacy may decrease in priority whereas the longing for health and security increases. as a consequence, tracking and monitoring technology in the name of health may look more attractive to people, despite potential ethical risks for privacy. if negative emotions, like fear, prevail, and people are more eager to give up privacy in the name of health and security, technology companies will reap even more benefits. so maybe on top of social distancing what is needed during a pandemic of a highly contagious disease is a little bit of 'social media distancing' (carmichael 2020) . thinking about the impact of social media in terms of emotional contagion and a longer-lasting value change is an important perspective in considering both the hard to notice long-term ethical impacts that social media can have and social media's potential contribution moral regress. acknowledgements i would like to extend my gratitude to two anonymous referees for their really helpful comments. many thanks to tanja hentschel for crucial suggestions and her support in preparing the manuscript. this publication is part of the project value change that has received funding from the european research council (erc) under the european union's horizon 2020 research and innovation programme under grant agreement no. 788321. funding this work was supported by h2020 european research council (grant no. 788321) . open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in 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covid‐19 is personal date: 2020-05-17 journal: acad emerg med doi: 10.1111/acem.14016 sha: doc_id: 302431 cord_uid: 13hperkz we are colleagues and friends working together in busy emergency departments in washington dc. as black physicians working in urban america, we do not find the recent deluge of news reports chronicling the disproportionate effect that the coronavirus disease (covid‐19) pandemic is having on the disenfranchised and minority populations in our country shocking. we have long been witness to and are in a constant state of alarm over the legal, medical, educational, social and economic inequities faced by the most vulnerable residents of this country. the authors have no conflicts of interest to report. this article is protected by copyright. all rights reserved dr. janice blanchard (orcid id : 0000-0001-7230-2583) dr. tenagne haile-mariam (orcid id : 0000-0003-1226-476x) article type : commentary -unsolicited we are colleagues and friends working together in busy emergency departments in washington dc. as black physicians working in urban america, we do not find the recent deluge of news reports chronicling the disproportionate effect that the coronavirus disease pandemic is having on the disenfranchised and minority populations in our country shocking. we have long been witness to and are in a constant state of alarm over the legal, medical, educational, social and economic inequities faced by the most vulnerable residents of this country. 1 as this epidemic is showing all of us, the disease may vary, the particular population might be different, the name of the city or town can change but the outcome is almost uniformly predictable. covid-19 has highlighted racial and ethnic inequities. 2, 3 we can all see them in the daily, undeniable numbers that flash at us from our phones and television screens. we are grateful to the press for illustrating the statistics with poignant, often personal stories that highlight the acuity and indecency of these inequalities. 2 like all emergency physicians, not only do we worry about the patients we treat on a daily basis with covid-19, we also worry about our families at home. yet further, for us this pandemic takes on a deeper meaning. our hometowns are the cities that are facing some of the largest tolls in covid-19 cases among people of color. when a black, latinx or native american "person under investigation" for covid-19 comes into the emergency department, we not only see our patient, but we also see our mother, father, aunt, and uncle. we realize that we are among the this article is protected by copyright. all rights reserved lucky ones. we have regular jobs in the medical sectors with some stability during this pandemic. we also have a place to call home, a regular means of transportation and the ability to practice effective social distancing. many of our black and brown patients are too sick to be discharged, showing signs of severe illness upon arrival to the emergency department and rapidly decompensating over a few hours to several days despite our best efforts to provide critical care. as the media has highlighted, the alarmingly high rates of covid-19 deaths among communities of color could be due to chronic diseases such as hypertension, diabetes and coronary artery disease. many of these illnesses that predict poorer outcomes for covid-19 may cause providers to deem care futile. as noted by chomilio et al, resources that rely solely on clinical guidelines can place patients of color, who have higher rates of chronic disease, at a disadvantage. this can be further complicated by the implicit bias that may impact provider decisions about allocation of the receipt of critical care. 4 we also know that crucial social determinants of health, such as ready access to nutritious foods, outdoor spaces to exercise, secure housing and regular income are disproportionately lacking in many predominately ethnically minority communities. it is most ironic that members of these communities are also disproportionately represented in the service industries that have continued to extensively support our nation as white collar workers shelter in place. 5 to decrease these inequities, we need more than just additional data, increased testing and expanded access to medical equipment. if we concentrate solely on building a system that better prepares us to detect and control future pandemics or if we only use our resources to build a huge national stockpile with which to combat future scourges, we stand the risk of failing our most disadvantaged populations over and over again. we cannot ignore the urgent need to address the social determinants of health that are reflected in the lack of resources present in certain communities and are associated with increased morbidity and mortality. we must design healthcare solutions that are nuanced enough that we are able to address health disparities while improving health outcomes for all patients. for example, appropriate as they are, social distancing mandates and increased testing for covid-19 will not yield the expected outcomes if we do not make tangible efforts to address the clear patterns in racial disparities that have emerged. this article is protected by copyright. all rights reserved the robert wood johnson foundation has noted that in order to improve health for all communities, we must build a "culture of health." 6 this means thinking broadly about approaches that address health and well-being across all social domains. in addition to supporting strong access to care, we must create safe spaces for individuals to live and exercise as well as provide healthy food options, equitable transportation, a clean environment, and address the racial wealth divide. 6 it is hard to socially distance if your city does not have an adequate transportation structure in place to get to work. it is hard to socially distance if your job has limited workspace and you fear the consequences of calling out sick. if there are no grocery stores in your area, trying to stand 6 feet apart in a convenience store is not realistic. and if you are homeless and get covid-19, you can't stay in your apartment waiting to get better from the illness. if you do have a home but live in a multigenerational household, as do approximately a quarter of all black, latinx and asian american residents do, it is difficult to go home without infecting your family. 7 public health recommendations do not fully address the realities that people of color are experiencing. 8 covid-19 has highlighted many of the social disparities that exist for communities of color. as dr. anthony fauci has stated this pandemic 'ultimately [shines] a very bright light on some of the real weaknesses and foibles in our society". 9 it is time that we address the social issues that lead to the alarming rates of covid-19 in our communities. we hope that in doing so, we can also improve the social infrastructure that are at the root of some of the disparities we are seeing today. let's not just shake our heads and say how awful things are without initiating change. let's use this opportunity to design long-term solutions. communities in action: pathways to health equity the coronavirus is infecting and killing black americans at an alarmingly high rate covid racial data tracker the harm of a colorblind allocation of scarce resources labor force statistics from the current population survey pew charitable trust. the return of the multigenerational household covid-19 and african americans accepted article key: cord-349546-60nsap32 authors: bland, a. r.; .roiser, j. p; mehta, m. a.; sahakian, b. j.; robbins, t. w.; elliott, r. title: covid-19 induced social isolation; implications for understanding social cognition in mental health date: 2020-10-08 journal: psychological medicine doi: 10.1017/s0033291720004006 sha: doc_id: 349546 cord_uid: 60nsap32 nan social distancing measures to combat the spread of the severe acute respiratory syndromecoronavirus 2 (sars-cov2) infections are likely to have unintended consequences on mental health and emotional wellbeing. social isolation, loneliness and uncertainty are key risk factors for developing mental health problems and pose a significant concern for the long-term consequences of social distancing (vatansever, wang, & sahakian, 2020) . nevertheless, this pandemic has illuminated the struggle of many people with mental health disorders, who live socially disconnected and isolated lives every day, long before the emergence of coronavirus 2019 (covid-19) and societal 'lockdown'. social integration has been found to be robustly linked to social cognitive ability; the mental operations needed to perceive, interpret and process information for adaptive social interactions (green, horan, & lee, 2019) . without the ability to interpret emotional facial expressions in others and understand subtle social cues, social integration and maintaining social support networks is problematic. a fundamental question remains as to whether social cognition deficits are inherent vulnerability markers of mental health problems, whereby people with impaired social cognitive skills have difficulty with forming normal social support networks resulting in withdrawal and loneliness, or whether they are a secondary consequence of prolonged periods of isolation and poor social connections resulting from mental health symptoms. social distancing measures have presented a unique opportunity to examine the effects of social isolation on people without prior mental health disorders in order to ascertain whether social isolation has a detrimental impact on social cognitive ability. this will inform the extent to which social cognitive deficits are attributable to reduced social contact. this has important implications for how we interpret social cognitive deficits in mental health disorders and inform the development of appropriate interventions. indeed, if social isolation causes direct impairments to a particular aspect of social cognition, this suggests that preventing or reducing perceived isolation, enhancing social support and reducing loneliness may prevent the development of social cognitive deficits associated with mental health problems. this has critical implications for outcomes such as maintaining interpersonal relationships and face-to-face employment. alternatively, if social isolation does not produce impairments in aspects of social cognition in the absence of mental health problems, it may be the case that social cognitive disruption is inherent to the pathology of mental health disorders. in this case, treatments should target symptom-specific impairments in order to improve social cognition and linked functional outcomes. this not only has important implications for understanding the effects of social isolation due to covid-19 pandemic, but also has wider implications for understanding the interactions between social isolation, social cognition and mental health. we examined social cognitive ability during the most stringent period of uk government enforced 'lockdown' (21 april to 10 may) in 107 adult participants who had not previously experienced mental health problems. following ethical approval and with informed consent, we distributed online neuropsychological tasks assessing emotion recognition, emotional attention and cooperative behaviour to examine social cognitive ability in comparison to normative performance data obtained pre-covid-19. for emotional facial recognition specifically, which is thought to be a robust marker of mental health disruption, we observed significantly reduced positive biases [f (1306) = 13.46, p < 0.001, η p 2 = 0.09]. this was driven by significantly reduced accuracy in recognising happy faces [f (1306) = 6.01, p = 0.003, η p 2 = 0.04] and significantly increased accuracy in recognising sad faces [f (1306) = 9.92, p < 0.001, η p 2 = 0.07]. interestingly, we found that affective biases during covid-19 were related to how connected people were during lockdown with people who experienced greater disruption to their usual social network, showing the greatest decline in positive bias in emotional recognition. our results point towards the significant impact of social distancing measures on social cognitive ability. however, it remains unclear whether the impact of social isolation is transient and returns to typical levels upon normal social connectivity resuming or whether the impact continues longer-term. understanding these cognitive mechanisms by which enforced social isolation impacts mental health is vital. this will inform development of treatment and preventative interventions that target specific aspects of social cognition to improve functional outcomes and help inform specific targets for effective change and intervention for people at risk of debilitating mental health disorders. nonsocial and social cognition in schizophrenia: current evidence and future directions covid-19 and promising solutions to combat symptoms of stress, anxiety and depression financial support. this research received no specific grant from any funding agency, commercial or not-for-profit sectors. key: cord-328461-3r5vycnr authors: chire saire, j. e. title: infoveillance based on social sensors to analyze the impact of covid19 in south american population date: 2020-04-11 journal: nan doi: 10.1101/2020.04.06.20055749 sha: doc_id: 328461 cord_uid: 3r5vycnr infoveillance is an application from infodemiology field with the aim to monitor public health and create public policies. social sensor is the people providing thought, ideas through electronic communication channels(i.e. internet). the actual scenario is related to tackle the covid19 impact over the world, many countries have the infrastructure, scientists to help the growth and countries took actions to decrease the impact. south american countries have a different context about economy, health and research, so infoveillance can be a useful tool to monitor and improve the decisions and be more strategical. the motivation of this work is analyze the capital of spanish speakers countries in south america using a text mining approach with twitter as data source. the preliminary results helps to understand what happens two weeks ago and opens the analysis from different perspectives i.e. economics, social. infodemiology 1 is a new research field, with the objective of monitoring public health 2 and support public policies based on electronic sources, i.e. internet. usually this data is open, textual and with no structure and comes from blogs, social networks and websites, all this data is analysed in real time. and infoveillance is related to applications for surveillance proposals, i.e. monitor h1n1 pandemic with data source from twitter 3 , monitor dengue in brazil 4 , monitor covid19 symptoms in bogota, colombia 5 . besides, social sensors is related to observe what people is doing to monitor the environment of citizens living in one city, state or country. and the connection to internet, the access to social networks is open and with low control, people can share false information(fake news) 6 . a disease caused by a kind coronavirus, named coronavirus disease 2019 (covid19) started in wuhan, china at the end of 2019 year. this virus had a fast growth of infections in china, italu and many countries in asia, europe during january and february. countries in america(central, north, south) started with infections at the middle of february or beginning of march. this disease was declared a global concern at the end of january by world health organization(who) 7 . south america has different context about economics, politics and social issues than the rest of the world and share a common language: spanish. the decisions made for each government were over the time, with different dates and actions: i.e. social isolation, close limits by air, land. but, there is no tool to monitor in real time what is happening in all the country, how the people is reacting and what action is more effective and what problems are growing. for the previous context, the motivation of this work is analyze the capitals of countries with spanish as language official to analyze, understand and support during this big challenge that we are facing everyday. this paper follows the next organization: section 2 explains the methodology for the experiments, section 3 presents results and analysis. section 4 states the conclusions and section 5 introduces recommendations for studies related. the present analysis is inspired on cross industry standard process for data mining(crisp-dm) 8 steps, the phases are very frequent on data mining tasks. so, the steps for this analysis are the next: • select the scope of the analysis and the social network • find the relevant terms to search on twitter • build the query for twitter and collect data • cleaning data to eliminate words with no relevance(stopwords) • visualization to understand the countries . cc-by-nc 4.0 international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/10.1101/2020.04.06.20055749 doi: medrxiv preprint considering the countries where spanish is the official language, there are 9 countries in south america: argentina, bolivia, chile, colombia, ecuador, paraguay, perú, uruguay, venezuela and every nation has a different territory size as the table tab. 1 shows. therefore, analyze the whole countries could take a great effort about time then the scope of this paper considers the capital1 of each country because the highest population is found there. at the same time, there are many social networks with like facebook, linkedin, twitter, etc. with different kind of objective: entertainment, job search and so on. during the last years, data privacy is an important concern and there is update on their politics, so considering the previous restriction twitter is chosen because of the open access through twitter api, the api will help us to collect the data for the present study. although, the free access has a limitation of seven days, the collecting process is performed every week. actually, there is hundreds of news around the world and dozens of papers about the coronavirus so to perform the queries is necessary to select the specific terms and consider the popular names over the population. the selected terms are: ideally, people only uses the previous terms but, citizens does not write following this official names then special characters are found like @, #, -, _. for this reason, variations of coronavirus and covid19 are created, i.e. { '@coronavirus', #covid-19', '@covid_19' } the extraction of tweets is through twitter api, using the next parameters: • date: 08-03-2020 to 21-03-2020, the last two weeks . cc-by-nc 4.0 international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/10.1101/2020.04.06.20055749 doi: medrxiv preprint • change format of date to year-month-day • eliminate alphanumeric symbols • uppercase to lowercase • eliminate words with size less or equal than 3 • add some exceptions to eliminate, i.e. 'https', 'rt' this step will help to answer some question to analyze what happens in every country. • how is the frequency of posts everyday? • can we trust on all the posts? • the date of user account creation • tweets per day to analyze the increasing number of posts • cloud of words to analyze the most frequent terms involved per day the next graphics presents the results of the experiments and answer many questions to understand the phenomenon over the population. at beginning, a fast preview about the frequency of post per country will support us to understand how many active users are in every capital. four things are important to highlight from fig. 2: (1) venezuela is a smaller country but the number of posts are pretty similar to argentina, (2) paraguay is almost a third from peru territory and the number of publications are very similar, chile is one small country but the number of publication are higher than peru and (4) uruguay is the smallest one with more tweets than bolivia and colombia even ecuador has more. by other hand, considering data from table 1 , there is a strong relationship between internet, social media and mobile connections in argentina, venezuela with the number of tweets and but a different context for colombia, this insight show us the level of using in bogota and says how the internet users are spread in other cities on colombia. so, a similar behavior explained previously is present over this data. . cc-by-nc 4.0 international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/10.1101/2020.04.06.20055749 doi: medrxiv preprint considering the image fig.2 , the number of post for each country, the total number of tweets is up to five millions(5 627 710), close to half of million(401 979) per day. so, the question about veracity is important to filter and analyze what people is thinking, because the noise could be a limitation to understand what truly happens. by consequence, it is necessary to consider some criterion to filter this data. first, argentina has the highest number of publications in last two weeks. for example, the firt dozen of the top users in buenos aires are: 'portal diario', '.', 'clarín', 'radio dogo', 'camila','el intransigente', 'agustina', 'pablo', 'frentedetodos', 'ale','lucas', 'diario crónica' later, a search about the users, one natural finding is: they are related to newspapers, radio or television(mass media). but there is people with many hundreds of tweets and regular people. the next image fig. 3 has the names of users and quantity of posts. #bolivia siete covid @pagina gobierno salud @larazon cruz ministro medidas cuarentena caso #coronavirusbo santa @rtp pais #esultimo emergencia personas @erboldigital anibal paciente confirma pide #lapaz informa confirmados nuevo oruro presidenta hospital primer @jeanineanez #elalto #urgente pacientes #deahora prevencion presidente ciudad evitar anuncia informo @sumaj warmi nacional nuevos dice sospechosos #loultimo alto prevenir centro medicos atencion china italia declara cuba tres horas #deultimo poblacion #santacruz ministerio propagacion video mundo hospitales enfrentar autoridades tras @yerkogarafulic #coronavirusmundo luis @luchoxbolivia #anibalcruz jeanine medico debido #mundo #ultimo virus gobernacion #videonoticias pandemia municipal estan primera manos policia reporta suspension #oruro @radiolider97 frente helping the visualisation from monday to sunday during the last two weeks, a cloud of words is presented in fig. 6 showing the first thirty terms per country. it is important to remember every country promote different actions on different dates. . cc-by-nc 4.0 international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/10.1101/2020.04.06.20055749 doi: medrxiv preprint infodemiology and infoveillance: tracking online health information and cyberbehavior for public health social web mining and exploitation for serious applications: technosocial predictive analytics and related technologies for public health, environmental and national security surveillance pandemics in the age of twitter: content analysis of tweets during the 2009 h1n1 outbreak building intelligent indicators to detect dengue epidemics in brazil using social networks what is the people posting about symptoms related to coronavirus in bogota, colombia? early epidemiological analysis of the coronavirus disease 2019 outbreak based on crowdsourced data: a population-level observational study who. who statement regarding cluster of pneumonia cases in wuhan, china. beijing: who 9 the crisp-dm model: the new blueprint for data mining infoveillance based on social sensors with data coming from twitter can help to understand the trends on the population of the capitals. besides, it is necessary to filter the posts for processing the text and get insights about frequency, top users, most important terms. this data is useful to analyse the population from different approaches. key: cord-295786-cpuz08vl authors: castillo-sánchez, gema; marques, gonçalo; dorronzoro, enrique; rivera-romero, octavio; franco-martín, manuel; de la torre-díez, isabel title: suicide risk assessment using machine learning and social networks: a scoping review date: 2020-11-09 journal: j med syst doi: 10.1007/s10916-020-01669-5 sha: doc_id: 295786 cord_uid: cpuz08vl according to the world health organization (who) report in 2016, around 800,000 of individuals have committed suicide. moreover, suicide is the second cause of unnatural death in people between 15 and 29 years. this paper reviews state of the art on the literature concerning the use of machine learning methods for suicide detection on social networks. consequently, the objectives, data collection techniques, development process and the validation metrics used for suicide detection on social networks are analyzed. the authors conducted a scoping review using the methodology proposed by arksey and o’malley et al. and the prisma protocol was adopted to select the relevant studies. this scoping review aims to identify the machine learning techniques used to predict suicide risk based on information posted on social networks. the databases used are pubmed, science direct, ieee xplore and web of science. in total, 50% of the included studies (8/16) report explicitly the use of data mining techniques for feature extraction, feature detection or entity identification. the most commonly reported method was the linguistic inquiry and word count (4/8, 50%), followed by latent dirichlet analysis, latent semantic analysis, and word2vec (2/8, 25%). non-negative matrix factorization and principal component analysis were used only in one of the included studies (12.5%). in total, 3 out of 8 research papers (37.5%) combined more than one of those techniques. supported vector machine was implemented in 10 out of the 16 included studies (62.5%). finally, 75% of the analyzed studies implement machine learning-based models using python. supplementary information: the online version contains supplementary material available at 10.1007/s10916-020-01669-5. according to the world health organization (who) report in 2016, nearly 800,000 people have committed suicide [1] . suicide is a tragic situation that affects families, neighbours, leaving significant effects on those who survive. it is considered the second cause of unnatural death in people between 15 and 29 years old [2] . the report on "death statistic according to cause of death in spain" published by the national statistics institute, in 2017, the last year for which data is available, states a total of 3679 suicides. moreover, 140 fewer suicides than the previous year have been reported in 2018 (3539) [3] . the multiple scenarios that families and individuals face in their daily routine can lead to this tragic situation. consequently, committing suicide is a critical public health challenge that numerous countries address in different manners [4] . suicidal behaviours are a complex phenomenon that is influenced by multiple factors such as biological, clinical, psychological, and social considerations [5] . on the one hand, suicide is preceded by milder manifestations, such as thoughts of death or suicidal ideation [6] . on the other hand, suicide is closely related to the model of society in which an individual lives [7] . moreover, it is directly related to the experience of high-stress circumstances and lifestyle changes [8] . currently, the effects of covid-19 and isolation will cause a significant emotional impact worldwide [9] . in particular, people who have suffered from mental health diseases are in an even more fragile situation [10] . therefore, an increase in anxiety and depression disorders, drugs use, loneliness, domestic violence and even suicide are expected to occur in these individuals [11] . consequently, the risk of suicide attempts has increased among the population [9] . multiple novel factors contribute to an increase in suicide risk [12] . in particular, the measures for prevention of covid-19 that includes social distancing plans are strictly related to suicide risk [9] . the reduction in physical contact can lead to loss of protection against suicide [9] . these factors will be even more relevant among people who have previous mental health problems [13] . social distancing is necessary to control the covid-19 pandemic and decrease the propagation of the virus [14] . however, a global perspective on indirect mortality is also essential [15] . social distancing is connected to an increased risk of suicidal behavior [16] . therefore, social distancing must be addressed through a global intervention plan that implements new models to combat physical distancing using social networks [17] . in this context, several new technologies have been identified as a crucial resource to detect people in suicide risk [18] . furthermore, young people who constitute a vulnerable group commonly use social networks [19] . social networks are a popular method of communication between people [20] . consequently, social networks are an appropriate method to recognize the behaviour of the person according to the content of their posts [21] . the analysis of the user's posts on social media is a complex problem [22] . the complexity is even higher if the objective is to estimate the suicide risk [23] . also, if the analysis is carried manually by experts, discrepancies usually occur due to the peculiarities of the language used in social networks [24] . therefore, automatic architectures that use machine learning (ml) methods should be developed. nevertheless, numerous of these automated systems require the availability of datasets that allow the training of predictive models which is a critical limitation [25] . on the one hand, these datasets currently do not exist, or they have limited specifications. on the other hand, unsupervised models do not require training. however, these models need datasets for validation [26] . currently, the use of ml techniques to analyze health-related data is a trending topic. moreover, the use of different systems based on ml in different areas, such as disease diagnosis and bioinformatics presents promising results [27] [28] [29] [30] [31] [32] [33] . in particular, for mental health, various models and tools for suicide risk prevention have been proposed in the literature [34] . this scoping review aims to identify the current ml techniques used to predict suicide risk based on information posted on social networks. this paper reviews the state of the art on this topic focusing on the ml methods, the objectives, the data collection techniques, the development process and the validation metrics used. the main contribution of this study is to summarize the state of the art and to provide a description of the common outcomes and limitations of current research to support future investigations. the remaining of this paper is organized as follows. section 2 presents the methodology concerning the search strategy, study selection criteria, screening process, and data extraction. the included studies are analyzed in section 3 and are discussed in section 4. finally, the most relevant findings and the limitations of the study are summarized in section 5. the prisma extension for conducting scoping reviews, the technical details of the machine learning techniques, internal validation strategies and main outcomes of the selected studies are included as supplementary material. this study summarize the requirements and methods for enhanced suicide risk assessment using social networks. consequently, the authors conducted a scoping review using the methodology proposed by arksey and o'malley et al. [35] . furthermore, the authors have followed the prisma-scr proposed by tricco et al. [36] . the overall procedure is annexed as supplementary material (appendix i). on the one hand, arksey and o'malley et al. [35] framework is widely used on scoping reviews concerning the health domain. this framework presents relevant recommendations to summarize findings and identify research gaps in the existing literature. on the other hand, the prisma extension for scoping reviews built by tricco et al. [36] defines a checklist of the significant items to be reported when a scoping review is conducted. the authors have performed a systematic review to identify relevant papers that use suicide risk assessment models in social networks. the search has been conducted during march 11-13 of 2020. the databases used are pubmed, science direct, ieee xplore and web of science since they are the most relevant sources and include the most significant scientific work. the authors have defined the search terms, and the selection of the studies focus on literature written in the english language. the search string used in the databases was: ["suicide" and ("social networks" or "social network") and "algorithm"]. to select the relevant studies on this topic, the authors defined the following inclusion criteria: & the studies include algorithms or models to estimate suicide risk using the social network. the research papers were excluded if they were not written in the english language, do not include a specific suicide intervention or do not report information regarding technical aspects of the model/algorithm used to detect suicide risk on social networks. the screening process of the papers obtained through the search strategy was performed by two authors independently (gc and gm). the process was divided into two phases. firstly, the authors have reviewed the title and abstract. secondly, the authors have analyzed all the manuscript. the conflicts were resolved by common consensus. the extraction of the data from the selected studies was performed by four authors (gc, gm, or and ed). the authors examined the completed form for consistency and accuracy. the extracted data is split into two sets, such as general and technical information. general information refers to the title, year, authors, objectives and methods included in the study. the technical information set is based on luo et al.'s guidelines [37] and contains the following categories: & objectives: refers to the main goals of the proposed ml models. a taxonomy was defined to describe those goals: ○ text classification: models that aim to classify post into several categories, including a binary classification, based on post content. ○ entity recognition: models that aim to identify several public entities in the text. ○ emotion recognition: models that aim to identify emotions expressed in the post content. ○ feature extraction: models that aim to collect information regarding characteristics of the post content such as lexical, semantic or sentiment features (word polarity). ○ topics identification: models that aim to analyze themes being addressed in the dataset or the posts. ○ features selection: models that aim to select automatically features, including optimization and feature reduction, to be included as predictor parameters in the predictive model. ○ score estimation: models that aim to estimate a quantitative suicide risk value. ○ data sources: refers to where the data set for the study is collected. we have followed the taxonomy used by gonzalez-hernandez et al. [38] : ▪ generic social network (gsn): social network containing information about a range of topics (e.g. twitter, facebook and instagram). ▪ online health community (ohc): domain-specific networks that are dedicated exclusively for discussions associated with health. ○ inclusion and exclusion criteria: information regarding what method was followed to include the data in the data set. the authors define the following possible categories: ▪ keywords: this category includes all studies that defined a set of keywords, hashtags, or phrases to be used as queries or filters. ▪ direct selection: a set of participants is selected, and then, data from their social networks are included. ○ dataset annotation: the labelling process followed for dataset annotation. the authors defined the following possible methods: ▪ manual annotation: the annotation process involved the participation of humans that assessed post contents and assigned one of the possible classes defined. ▪ corpus: authors used an existing annotated corpus to train and test the proposed predictive models. ▪ previous scores: an assessment using a standard scale or other quantitative instrument was previously conducted. then, posts were labelled according to the user's score. ○ ml techniques: general ml techniques used in the study. ○ platform: platform or language programming used to develop the ml models proposed in the study. ○ strategy: how datasets were split into training and testing data. ○ performance metrics: refers to the metrics used to evaluate the performance of the models ○ outcomes: refers to the predictive performance of the final model. the authors retrieved 426 articles in the search conducted in research databases. after removing duplicates, 424 items were selected for screening. the title and abstract review stage resulted in the exclusion of 344 articles since most of the studies do not cumulative focus on suicide risk, social networks and ml methods. after the application of the inclusion and exclusion criteria, 19 papers are included in this work. three articles were excluded in the full-review stage. one study was excluded since it is based on suicidal behaviour without including a social media analysis [39] . another study was excluded because it proposes an approach to analyze social media posts for suicide detection, but the authors did not develop any model [40] . finally, the last exclusion in this stage was conducted since the study proposed by [41] does not include ml techniques. from the full-text review, 16 articles were then selected for inclusion [26, [42] [43] [44] [45] [46] [47] [48] [49] [50] [51] [52] [53] [54] [55] [56] . the flow diagram representing the search process is shown in fig. 1 . furthermore, the detailed information is presented as supplementary material (appendix i). the results of the application of artificial intelligence algorithms or models for suicide risk identification using data collected from social networks have been analyzed in this study. furthermore, this paper presents a summary and comparison of the state-of-the-art methods and technical details that address this critical public health challenge. this section introduces a brief description of the articles included in this scoping review. ambalavan et al. 2019 [42] developed several methods based on nlp and ml to study the suicidal behaviour of individuals who attempted suicide. the authors built a set of linguistic, lexical, and semantic features that improved the classification of suicidal thoughts, experiences, and suicide methods, obtaining the best performance using a support vector machine (svm) model. birjali et al. 2017 [43] presented a method based on ml classification for the social network twitter to identify tweets with risk of suicide. the authors used svm, where smo (sequential minimal optimization) is implemented as the best model in terms of precision (89,5%), recall (89,11%) and fscore (89,3%) for suspected tweets with a risk of suicide. burnap et al. 2017 [44] developed a set of ml models (using lexical, structural, emotive and psychological features) to classify texts relating to communications around suicide on twitter. this study presents an improved baseline of the classifier using the random forest (rf) algorithm and maximum probability voting classification decision method. furthermore, the proposed method achieves an f-score of 72.8% overall and 69% for the suicidal ideation class. chiroma et al. 2018 [45] measured the performance of five ml algorithms such as prism, decision tree (dt), naïve bayes (nb), rf and svm, in classifying suicide-related text from twitter. the results showed that the prism algorithm had outperformed the other ml algorithms with an f-score of 84% for the target classes (suicide and flippant). desmet et al. 2018 [46] have implemented a system for automatic emotion detection based in binary svm classifiers. the researchers used lexical and semantic features to represent the data, as emotions seemed to be lexicalized consistently. the classification performance varied between emotions, with scores up to 68.86% f-score. nevertheless, f-scores above 40% was achieved for six of the seven most frequent emotions such as thankfulness, guilt, love, information, hopelessness and instructions. du et al. 2018 [47] have investigated several techniques for recognizing suicide-related psychiatric stressors from twitter using deep learning-based methods and transfer learning strategies. the results show that these techniques offer better results than ml methods. using a convolutional neural network (cnn), they have improved the performance of identifying suicide-related tweets with a precision of 78% and an f-1 score of 83%, outperforming svm, extra trees (et), and other ml algorithms. the recurrent neural network (rnn) based psychiatric stressors recognition presented the best f-1 score of 53.25% by exact match and 67.94% by inexact match, outperforming conditional random fields (crf). fodeh et al. 2018 [48] proposed a suicidal ideation detection framework that requires a minimum human effort in annotating data by incorporating unsupervised discovery algorithms. this study includes lsa, lda, and nmf to identify topics. the authors conducted two analysis with k-means clustering and dt algorithms. dt showed better precision (84.4%), sensitivity (91.2%) and specificity (82.9%). grant et al. 2018 [49] automatically extracted informal latent recurring topics of suicidal ideation found in social media posts using word2vec. the proposed method uses descriptive analysis and can identify similar issues to the expert's risk factors. jung et al. 2018 [50] have implemented an ontology and terminology method to provide a semantic foundation for analyzing social media data on adolescent depression. they evaluated the ontology obtaining the best values of precision (76.1%) and accuracy (75%) using dt algorithms. liu et al. 2019 [51] performed a study to evaluate the feasibility and acceptability of proactive suicide prevention online (pspo). pspo is a new approach based on social media that combines proactive identification of suicideprone individuals with specialized crisis management. they evaluated different ml models in terms of accuracy, precision, recall and f-measure to get the best performance. the svm model showed the best performance overall, indicating that pspo is feasible for identifying populations at risk of suicide and providing effective crisis management. o'dea et al. 2015 [52] studied whether the level of concern for a suicide-related post on twitter could be determined based solely on the content of the post, as judged by human coders and then replicated by ml. they evaluated ml models and decided that the best performing algorithm was the svm with term frequency weighted by inverse document frequency (tfidf). the results show a prediction accuracy of 76%. parraga-alava et al. 2019 [26] present an approach to categorize potential suicide messages in social media, which is based on unsupervised learning using traditional clustering algorithms. the computational results showed that hierarchical clustering algorithm (hca) was the best model for binary clustering achieving average rates of 79% and 87% of f1-score for english and spanish. sawnhey et al. 2019 [53] investigate feature selection using the firefly algorithm to build an efficient and robust supervised approach for suicide risk detection using tweets. after applying different ml techniques, rf + bfa and cnn-lstm obtained the best results in accuracy, precision, recall and f1-scores in specific datasets. shahreen et al. 2018 [54] used svm and neural networks (nn) for text classification on twitter. the researchers used three types of weight optimizers, namely limited-memory bfgs, stochastic gradient descent and an extension of stochastic gradient descent which is adam to obtain maximum accuracy. the results show an accuracy of 95.2% using svm and 97.6% using neural networks. they have used 10-fold cross-validation for model performance evaluation. sun et al. 2019 [55] have proposed a hybrid model that combines the convolutional neural network long short-term memory (cnn-lstm) with a markov chain monte carlo (mcmc) method to identify user's emotions, sample user's emotional transition and detect anomalies according to the transition tensor. the results show that emotions can be well sampled to conform to the user's characteristics, and anomaly can be detected using this model. zhang et al. 2014 [56] have used npl methods and ml models to estimate suicide probability based on linguistic features. the experiments performed by the researchers indicate that the lda method finds topics that are related to suicide probability and improve the performance of prediction. they obtained the best root mean square error (rmse) value of 11 with a linear regression at 1-32 scale. this paper presents a detailed analysis of the results in the following sections: study objectives, data collection, model development process and this section show data pre-processing, data preparation, sentiment analysis, dataset annotation, ml techniques, platforms and internal validation. the distribution of the included studies according to the year of publication are presented in fig. 2 . most of the included studies propose models to classify collected text into suicide-related categories. text classification is the most common objective in the included studies (12/16, 75%) [26, [42] [43] [44] [45] [46] [47] [48] [51] [52] [53] [54] . a score estimation of suicidal probability based on post content was proposed in one of the included studies (1/16, 6,25%) [56] . feature extraction and feature selection were identified as main objectives in four different studies (4/16, 25%) [48, 50, 53, 56] . the remaining categories (entity recognition, theme identification and emotion recognition) were identified only in a study (1/16, 6.25%) [47, 49, 55] . in total, 4 of 16 studies (25%) can be grouped in two categories, involving text classification (3/4) [47, 48, 53] or score estimation (1/4) [56] . different data sources were selected to perform data collection for training and testing of the proposed models. in total, 13 out of the 16 included studies (81.25%) used general social networks (gsns) for data collection [26, 43-48, 50, 52-56] . the most popular gsn used as the data source in the included studies was twitter (10/16, 62.5%), followed by forums or microblogs (3/16, 18.75%). other gsns used were weibo (2/16, 12.5%), facebook, instagram, tumblr, and reddit (1/16, 6.25%). three studies used ohcs (18.75%), two of them used suicide-related subreddit [42, 49] , and the other one used a sina microblog [51] . three studies have collected data from ohcs used all posts/comments without defining inclusion/exclusion criteria. most of the remaining studies defined suicide-related keywords or phrases to filter posts out (10/13, 76.92%) [43-48, 50, 52-54] . zhang et al. [56] , recruited potential participants, and then, the selected participants' posts in weibo have even used. finally, two studies that used gsns did not define inclusion/exclusion criteria (2/13, 15.38%) [26, 55] . the data collection time spam must be reported in mlbased studies as it is defined by the luo et al.'s guidelines [37] . however, seven of the included studies did not report the time spam when data collection was performed (43.75%) [42, 43, 45, 46, [54] [55] [56] . one of the included studies did not report the dataset size (1/16, 6.25%) [54] . the dataset sizes were between 102 posts (minimum) and 1,100,000 posts (maximum). four out of the remaining 15 studies have used sample sizes between 100 and 999 posts (26.67%) [26, [42] [43] [44] . three of them used sample sizes with more than 800 posts. five studies reported dataset sizes between 1000 and 5000 posts (33.33%) [45, 47, 50, 52, 53] . finally, six studies used large dataset, including more than 10,000 posts (40%). the number of users/participants represented in those datasets was only reported in three studies (18.75%). one of those three studies recruited 697 participants and then collected data from their weibo accounts [56] . the other two studies analyzed the user's data collected to report the number of unique users involved in the study (n = 3873; n = 63,252) [48, 49] . although using basic statistics to describe dataset is defined as a relevant factor regarding the reliability of mlbased studies in the health domain, as suggested by luo et al.'s guidelines [37] . however, three of the included studies did not report any dataset description (3/14, 21.43%) [42, 54, 55] . moreover, only three studies included information regarding ethical issues to collect and manage social media data (3/16, 18.75%). two of those studies obtained the ethical approval from ethics committee: liu et al. [51] from the institutional review board of the institute of psychology, chinese academy of science, and o'dea et al. [52] from the university of new south wales human research ethics committee and the csiro ethics committee. the remaining study, conducted by ambalavan et al. [42] , adhered to the guidelines defined by kraut et al. 2004 [57] . it is highlighted that zhang et al. [56] assessed participants' suicide probability using a standard scale and have collected personal data. however, the information regarding ethical approval was not reported in the article. table 1 presents the summary of the results found in terms of the objectives of the study, data sources, ethical aspects, inclusion and exclusion criteria, time span, number of posts, part number and the description of the data of the papers included in this work. data pre-processing data pre-processing is a typical stage in the development process of ml-based models. this stage includes several techniques such as data cleaning, words removal (stop word and punctuation), data transformation, and addressing challenges of outlier or missing values. the reported information regarding data pre-processing is critical for study reproducibility. most of the included studies reported information regarding the pre-processing stage (14/16, 87 .5%) [26, 42, [44] [45] [46] [47] [48] [49] [50] [52] [53] [54] [55] [56] . several of these studies only reported vague information and did not include details on the specific techniques and tools used. however, the inclusion of a (sub) section describing data preprocessing is not mandatory. in total, 4 studies included a section/subsection reporting information regarding preprocessing. the remaining studies reported this information in the text. moreover, some studies presented this information in a different part of the article. the data mining techniques for feature extraction, feature detection, or entity recognition used in the included studies are summarized in table 2 . in total, 50% of the included studies (8/16) report the use of data mining techniques for feature extraction, feature detection or entity identification [26, 44, 46, 48, 49, 51, 53, 56] . the most common reported technique was liwc (4/8, 50%), followed by lda, lsa, and word2vec (2/8, 25%). moreover, nmf and pca were used only in one of the included studies (12.5%). in total, 3 out of 8 studies (37.5%) combined more than one of those techniques. seven out of the 16 included studies include sentiment analysis (43.75%). a sentiment ratio or polarity value was assigned to words or features in these studies. two of these studies used sentiwordnet to obtain the sentiment value [43, 44] . also, two studies used the categories defined in liwc as a basis of sentiment value estimation [44, 56] . furthermore, two studies used previously published lexicons to calculate it [46, 53] . finally, two studies calculated those values [50, 55] , automatically. supervised learning techniques require labelled, coded, or annotated datasets to train and test the models. in total, 15 out of the 16 included studies required annotated datasets. one of those studies did not report how annotations were performed (6.67%) [54] . most of the studies followed a manual process to annotate the training and test datasets, involving experts in the codification process (10/15, 66.67%) [42] [43] [44] [45] [46] [47] [50] [51] [52] [53] . some of these studies reported detailly how the annotation process was performed. two studies used existing annotated corpus (13.33%) [26, 55] . in one study (6.67%), the authors designed an algorithm to generate the labels automatically [48] . finally, a study recruited participants and assessed the participant's suicide probability using a standard scale, the suicide probability scale, and the model results were compared to those obtained using the scale (6.67%) [56] . analysis (hca), and association rules (ar). table 3 shows the distribution of these techniques in the included studies. svm was the most used technique being implemented in 10 out of the 16 included studies (62.5%) [42] [43] [44] [45] [46] [47] [51] [52] [53] [54] . the second most used technique was dt (7/16, 43.75%) [43-45, 47, 48, 50, 51] , followed by lr (5/16, 31.25%) [42, [50] [51] [52] [53] and rf (4/16, 25%) [45, 47, 51, 53] . dl, nb and km were used in 3 out of the 16 included models (18.75%). in total, 2 models based on nn were proposed (12.5%) [42, 50] . finally, 7 of those 15 techniques were used only in a study (lir, knn, gbm, rof, pam, hca, and ar). in total, 25% of the included articles used only a technique to implement the proposed model [46, 49, 55, 56] . the remaining studies developed the proposed models using 2 different techniques (3/16, 18.75%) [48, 52, 54] , 3 techniques (3/16, 18.75%) [26, 42, 50] , 4 techniques (5/16, 31.25%) [43-45, 47, 51] , or 5 techniques (1/16, 6.25%) [53] . the platform or software tool used to implement the mlbased models is identified by half of the included studies. python was the most used tool (6/8, 75%) [26, 42, 46, 49, 52, 54] . one of these studies combines python and r [26] . two out of the 8 studies used weka software to develop the proposed models [43, 44] . one of the included studies focus on topic identification, and authors followed a manual analysis of topics proposed using the models to estimate their validation [49] . five of the remaining included studies did not report information regarding internal validation strategy followed to assess the validity of the proposed models (33.33%) [26, 43, 48, 50, 55] . the 10-fold cross-validation was the most implemented strategy in the included studies (8/10, 80%) [44-46, 51-54, 56] . one study followed a 70-30 proportion rule to split the dataset in training and test datasets (10%) [42] . however, the technique used to split the data is not reported. other study followed a 7-1-2 proportion to split the dataset for classifier model validation and a manual selection for classifier validation (10%) [47] . all studies reported the performance parameters used in the validation process. precision, recall and f-score are the most used performance parameters (12/15, 80%) . in total, 66,67% (10/15) of the studies have used accuracy as a performance value. fodeh et al. [48] used specificity, sensitivity and area under the receiver operating characteristic (roc) curve (6.67%). zhang et al. [56] used rmse value to validate their estimation model. social networks are an effective method to detect some behaviours. moreover, they are particularly relevant to identify subjects at suicide risk. the extensive use of social networks leads the authors to investigate the current scenario concerning suicide prevention. this is the primary motivation of the presented research. this study verifies the trends and results of applying ml algorithms and the methods used by various researchers to address this critical situation. indeed, considering the covid-19 pandemic, social networks are one of the most used methods of communication. therefore, it is relevant to survey the main techniques, algorithms and models applied to social networks to detect suicidal risk behaviours. in total, 43,75% (7/16) of the studies does not provide the time spam information concerning the experiments conducted. this is a relevant limitation, as proposed by luo et al.'s guidelines [37] . moreover, 81,25% (13/16) does not specify the number of participants involved. the anonymization of the participant information should be justified. however, it is possible to characterize the participants involved in the studies and maintain their privacy at the same time. this information allows us to conclude that the quality of the reports of suicide risk prediction models must be increased. the authors must report relevant items to ensure reliability. furthermore, the details of the datasets used are not presented in 18,75% (3/16) of the analyzed literature. although the use of basic statistics to describe dataset is defined as a relevant factor regarding the reliability of ml-based studies in the health domain as proposed by luo et al.'s guidelines [37] . the dataset description is of utmost importance since the efficiency of the specified results, and their future improvements are closely connected with the sample size. furthermore, three studies did not report any dataset description (3/14, 21.43%) [42, 54, 55] . consequently, it is critical to question what reasons can justify the inexistence of the dataset description. indeed, this can be related to confidential concerns. however, it is essential to mention that without the complete dataset information is not possible to ensure the absence of bias or deficiencies in the information used. moreover, it is not possible to ensure the reproduction of the experiments. in total, 76.92% (10/13) of the studies defined suiciderelated keywords or phrases for text analysis. furthermore, text classification is the objective of 75% of the analyzed studies. consequently, this denotes a significant limitation concerning the multiple forms of visual communication items such as emoticons that are currently used. however, the reason why most of the authors does not consider the visual components in sentences is not clear. this can be related to technical limitations of the used software tools. consequently, it is necessary to promote new research activities to solve this critical limitation. the pre-processing data stage is required to develop or replicate the ml-based model. therefore, most of the included studies indicated information about the pre-processing stage (14/16, 87.5%) [26, 42, [44] [45] [46] [47] [48] [49] [50] [52] [53] [54] [55] [56] . moreover, it should be noted the majority of the studies only present vague information regarding pre-processing data methods and validation strategy. pre-processing is an essential aspect of detecting suicide risk using ml. however, according to the results achieved, there is a significant limitation related to the unstandardized information of each analyzed research. additionally, the authors note that most of the reviewed papers do not present the data processing methods in detail. consequently, there is a significant limitation concerning the real reason for this scenario. this can be related to methodological or practical difficulties. however, the question about what motivates this trend still exists. furthermore, there is no justification for this scenario in the before-mentioned studies. therefore, future research on the subject should ensure the detailed information about the pre-processing methods. a specific annotated dataset for suicide risk on social media is also a critical limitation. in total, 10 of the 15 papers (75%) have performed manual annotation. however, it should be noted that the peculiarities of the multiple languages used in social networks can be a relevant limitation for data labelling [38, 58] . the sentiment analysis has been performed in most cases assigning the polarity to the words [59] . however, these polarities could vary according to specific domains such as suicide and considering the terminology used in social networks. therefore, it is relevant to perform sentiment analysis that encompass the linguistic entities as phrases [60] . stakeholders have reported several ethical issues as critical factors in the use of social media as a participatory health tool [61] . in this sense, those relevant issues must also be addressed appropriately in ml research applied to the health domain. despite this relevance, ethics is not appropriately discussed by authors in their reports. there is a lack of information regarding ethical issues in the included studies. only three studies included information regarding ethical issues to collect and treat social media data (3/16, 18.75%). however, the doubt regarding the reasons that justify the inexistent ethical agreements of the majority of the works still exist. consequently, a critical limitation is found regarding the ethical concerns involved in the collection and analysis of this sensitive type of data. two of those studies obtained an ethical approval from the ethics committee ( [42, 52] ). however, ethical and privacy concerns associated with the data gathering method are a controversial practice. to justify its use, formal prospective studies analyzing if and how physician access to a patient's social media influences care should be performed [62] . this paper has presented a scoping review on the main techniques, algorithms and models applied to social networks to detect suicidal risk. in total, 75% of the included studies propose models to classify collected text into suicide-related categories. text classification is the main objective of 75% of the included studies. furthermore, 50% of the included studies (8/16) report explicitly the use of data mining techniques for feature extraction, feature detection or entity identification. the most commonly reported method was liwc (4/8, 50%), followed by lda, lsa, and word2vec (2/8, 25%). nmf and pca were used only in one of the included studies (12.5%). in total, 3 out of 8 research papers (37.5%) combined more than one of those techniques. one the one hand, svm was the most used technique being implemented in 10 out of the 16 included studies (62.5%). on the other hand, the second most used technique was dt (7/16, 43.75%), followed by lr (5/16, 31.25%) and rf (4/16, 25%). the most used platform to implement the ml-based models is python (6/8, 75%). furthermore, all studies reported the performance parameters used in the validation process. precision, recall and fscore were the most used performance parameters (12/15, 80%) . in total, 10 out of 15 studies used accuracy as a performance evaluation metric (66.67%). in summary, ml methods for suicide risk detection and prevention are adjusted to each region, supporting the current pandemic scenario towards enhanced public health and well-being. nevertheless, this scoping review has some limitations related to its primary objective. this paper only reviews studies that focus on suicide risks. the papers have been selected using a scoping review methodology in four research databases and written in english. however, other research studies can be available in different languages and databases. moreover, the authors are aware that are multiple algorithms available bases on statistical assessment. still, this review only surveys articles that include ml methods to detect suicide risk on social networks. as future work, several activities can be conducted, such as creating an annotated corpus for various languages, developing new ml models, especially in other languages than english. these activities aim to classify posts, estimate suicide risk, analyze potential predictive parameters, optimize predictive parameters, and analyze topics considering the temporal component of user posts and specific tools to analyze sentiment. world health organization: who | suicide data a systematic literature review of technologies for suicidal behavior prevention instituto nacional de estadistica: españa en cifras suicide and suicide risk psychosocial and psychiatric risk factors for suicide: case-control psychological autopsy study the suicidal process; prospective comparison between early and later stages beyond risk 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participatory health and social media working group ethical considerations for participatory health through social media: healthcare workforce and policy maker perspectives: contribution of the imia participatory health and social media working group social media and suicide: a review of technology-based epidemiology and risk assessment publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements this research has been partially supported by european commission and the ministry of industry, energy and tourism under the project aal-20125036 named bwetake care: ictbased solution for (self-) management of daily living.thanks to the research grants from senacyt, panama. ed receives funding and is supported by the v plan propio de investigación de la universidad de sevilla, spain. conflict of interest the authors declare that they have no conflict of interest.ethical approval this article does not contain any studies with human participants or animals performed by any of the authors. key: cord-334178-3u7tyszd authors: wang, chun-yuan; guo, jinyun; kuo, ming-feng title: the building of social resilience in sichuan after the wenchuan earthquake: a perspective of the socio-government interactions date: 2020-06-30 journal: safety science doi: 10.1016/j.ssci.2020.104662 sha: doc_id: 334178 cord_uid: 3u7tyszd abstract in november 2007, china implemented its emergency response law to ensure national unified leadership and collaboration when responding to emergencies. in recent years, china’s main focuses for enhancing disaster management have included emergency preparation, emergency management, and legal system mechanisms. however, its well-designed management system faced a great challenge during the wenchuan earthquake in 2008. by examining the literature on the development of disaster management, we realized that enhancing self-organization in communities can effectively resolve problems caused by collective actions and strengthen resilience to disasters. in the decade since the wenchuan earthquake, the literature has focused more on empowering communities during disaster management in china. however, literature on the compatibility of social resilience and the government-dominant model in china is still scant. this study investigates china’s current disaster management system design; specifically, it identifies ways and methods for counteracting any conflicts between disaster management under social synergies and china’s emergency management system. it further explores what factors facilitate the balance between social synergies and the emergency management system if the two concepts were fused together. using case studies, in-depth interviews, and a focus group in the field of public administration, this study collected qualitative data to understand the changes in china’s disaster management system since the wenchuan earthquake as well as provide recommendations for future reform. in the past 20 years, disaster prevention and rescue operation systems have become an important issue discussed in related fields (buck, trainor and aguirre, 2006; hsiung et al. (2010) ; stumpf, 1999; yang, 2009) . in order to deal with an increasing number of disasters, the chinese government initiated research on mitigation-related programs. for example, in april 1998, the state council promulgated and implemented the disaster reduction plan of the people's republic of china (1998 china ( -2010 ; in august 2007, the government promulgated the national comprehensive disaster reduction eleventh five-year plan. such efforts aimed to further emphasize the role and function of social participation. also in 2007, the national people's congress officially adopted the emergency response law of the people's republic of china, which went into effect on november 1. articles 6 and 48 of this act regulate, respectively, the "establishment of an effective social mobilization mechanism by the nation" and "the people's government … immediately organize relevant departments to mobilize emergency rescue teams and social forces." related to preventing, reducing, and relieving disasters; capacity building; community involvement; and international cooperation related to the resulting analysis (ministry of civil affairs, 2016, accessed on 2017/12/10). in 2018, the national people's congress approved the establishment of a new agency, the ministry of emergency management, to further strengthen the overall management of emergencies and non-emergency events as well as improve the overall levels of emergency management in order to integrate various emergency rescue forces. such developments show that the non-governmental organizations' (ngos) and the government's cooperation mechanisms and responses to the public crisis have gradually gained importance in china in recent years (wang, 2009 ). however, as disagreements or contradictions occur when different units or departments cooperate in disaster management, there is an urgent need to establish a system between the public and private sectors through collaborative relationships to facilitate cooperative reciprocity (chen, 2008, p. 40) . in other words, it is important to consider how to interact with and coordinate disaster-relief ngos with inter-governmental, inter-departmental, and/or civil organizations to construct disaster resilience and implement post-disaster recovery measurements (benson et al., 2001; mushkatel and weschler, 1985; rubin and barbee, 1985) . this article explores the compatibility of western literature on disaster management and social resilience with china's governance structure. although the chinese government wants to be more open to public participation under the traditional administratively oriented system, the level of openness is still deeply influenced by the government system. on one hand, the government wants to open authorization to allow decentralization; however, because of institutional problems, there are still limitations. on the other hand, society also wants to contribute to or expects to expand autonomous governance. however, barriers such as a lack of resources and space have kept them from entering the disaster management network (wang, 2009; wang and chang, 2011) . the main research question of this study is: how has social resilience been built since the wenchuan earthquake? this paper adopts the viewpoint of the dynamic interaction of multiple actors to emphasize how social organizations and communities play a role in sociogovernment interactions and strengthen the resilience of the government and social organizations during disasters. the article first reviews the relevant literature on the interaction between chinese society and the government as well as disaster management, and it examines the current situation and major challenges of disaster prevention and rescue-related mechanisms in china. this study collects qualitative data through in-depth interviews and analyzes the development of disaster resilience construction in the 10 years since the wenchuan earthquake in sichuan in 2008. it also analyzes feasible strategies for future disaster self-organization from different perspectives. the development of disaster management in china has been highly valued in the past decade. scholars have examined the literature on disasters in china from 1999 to 2007, which included 1023 records, as well as between 2008 and 2017, which included 9285 records. there are 3461 articles on the wenchuan earthquake alone (wang et al., 2019) . since the 1950s, china has endured several major natural disasters, such as the tangshan earthquake and yangtze river floods. knowing how to deal with natural disasters has gradually attracted the government's attention. the united nations proposed the international decade for natural disaster reduction in 1990, which facilitated china's establishment of the national committee for disaster reduction to improve cooperation among different departments and agencies at the state level. thus, china's first generation of disaster management paid more attention to natural disasters and the role of the government at the state level (zhang, 2012) . in 2003, facing the challenges of severe acute respiratory syndrome (sars) outbreaks, the chinese government reviewed its disaster management system and initiated reforms for a second generation of development (wang et al., 2016) . the disaster management system of this period generally focused on different types of disasters as well as coordination among various agencies and departments (lu and han, 2018; zhang, 2012) . the emergency response law of the people's republic of china, issued in 2007, adopted the government-led model. article 4 of this law decrees that "the state shall establish an emergency response system mainly featuring the unified leadership, comprehensive coordination, categorized management, graded responsibility and territorial management." meanwhile, article 6 decrees that "the state shall establish an effective social mobilization mechanism to strengthen the awareness of public safety and risk prevention and control of all citizens and improve the ability of risk avoidance and rescue in the whole society." the seemingly well-designed system encountered severe challenges, particularly after the 2008 wenchuan earthquake. in zhong (2007) , zhong pointed out that "the ineffective system and political sensitivity of crisis management means that china is likely to become more vulnerable to disasters, disturbances, and other critical contingencies" (p. 92). under china's one-party political system, the mobilization of various areas to persuade or even force members of political groups or other members of society to identify, obey, cooperate, and support lacks sustainability (wang, 2009; zhang, 2012) . the literature has highlighted the importance of ngos' and civil society's participation in disaster management systems (lu and xu, 2015; lukaszczyk and williamson, 2010; meier, 1995) . ten years after the wenchuan earthquake, systematically examining the interaction between government and ngos in the disaster management system and constructing an effective and sound resilience system have become critical and urgent issues. the one-party political system with an authoritarian regime in china has three main characteristics: it is led by the communist party of china (cpc) party, it has a high level of hierarchy, and it has a strong and robust ability to gather resources at higher levels of government (zhang, 2012) . in recent years, this system has been challenged in terms of its disaster response performance and effectiveness in large-scale disasters. although some scholars have pointed out the advantages of control and command systems and have considered the system a force for improving the efficiency and effectiveness of disaster response (gao, 2008; shan and chen, 2007) , others have asserted that china's organizational structure and response model should be more flexible to improve disaster management performance (guo and kapucu, 2015; liu and xiang, 2005) . comfort (1994) argued that disaster management networks can be understood as self-organizing systems, which is an important corrective action for the assumptions of central planning. with its non-linear and dynamic nature, society can produce a self-organizing process sufficient to reallocate resources and actions so that the crisis is reduced, and society thus continues to operate stably. in other words, self-organization provides a more simple and effective way to deal with complex work than the traditional mechanical view of the organization (wheatley and kellner-rogers, 1996) . wheatley and kellner-rogers (1996) described organizations as being adaptable, flexible, self-renewing, and self-leaning while also having clever features. these characteristics only exist in a living system. modern organizations have increasingly emphasized complex adaptive systems. a complex environment includes five characteristics: they are composed of many agents who act and interact in unpredictable ways; they are sensitive to changes in the initial state; they adapt their behavior to the environment in an unpredictable way; they swing between stability and instability; and when an imbalance is encountered, they make emergency moves, meaning the complex system is dynamic and non-linear. the concept of emergency self-organization is a complex theory of "anchor phenomenon" (plowman et al., 2007) . comfort (1994) pointed out that, in a rapidly changing environment, in order to assess the existence of self-organization and its performance in the social system, the concept of self-organization needs to be redefined and explained. first, self-organization is a process in a social context through continuous interaction in a scenario. through verbal, written, or electronic forms of communication involving two or more participants, these behaviors become the most common ones within the system or between the system and the environment. these actions may also include different forms of communication, such as non-verbal communication or the use of symbols. it indirectly delivers powerful information through examples and actions. communication behavior includes direct and indirect forms, and these behaviors are the foundation in the process of self-organization. the three elements of self-organization include identity, information, and relationships. additional characteristics include that the intrinsic driving force in this process of communication is the creative self-expression desire or "autopoiesis"; self-organization, along with selections, creates the system's capacity to adapt to environmental conditions; self-organization recognizes that some units exert influence and control over other units in an interdependent system; and self-organizing systems are massively parallel operational systems (comfort, 1994; wheatley and kellner-rogers, 1996) . according to the logic of collective action (olson, 1965) , unless there are very few members in a group or there are mandatory special designs, neither a rational nor self-interested individual will take action for public interest. in a risk-prone society, individuals will take actions and pay attention to their own interests to reduce any individual potential crises (such as the quality of buildings in which they live and the re-planning of illegally constructed areas). however, when it comes to improving collective actions to strengthen the resilience of the community, there are only a few actions, and the discussions on self-organization are effective actions to solve collective problems (jan 2004) . the significance and importance of self-organization in disaster management has gradually emerged from the previously discussed literature. however, when examining the system in china, it is necessary to understand that the government still plays a critical role in disaster management. in other words, ensuring good interactions between the government and society during disaster management is a key direction that any post-wenchuan earthquake reforms of the disaster management system should follow. the concept of resilience appeared earlier in the field of engineering, ecosystems, and socio-ecological studies (brand and jax, 2007; folke, 2006) . in social sciences, resilience can be defined as "capacity for collective action in the face of unexpected extreme events that shatter infrastructure and disrupt normal operating conditions" (comfort et al., 2010, p. 33) . in terms of crisis and disaster management, boin, comfort, and demchak (2010, pp. 2-5) pointed out that, for non-routine emergencies, the so-called low-chance, high impact incident has made it difficult for the government to respond using the four stages of traditional disaster management (mitigation/prevention, preparation, response, and recovery). resilience depends on this social system, the learning of past disasters to achieve better protection in the future, and the degree of self-organization of risk reduction measurements (jan 2013) . in recent years, the literature has gradually developed a resilience system model from a cooperative perspective, demonstrating that a community's capabilities are important for improving disaster resilience. for example, norris et al. (2008) considered community resilience as a set of networked adaptive capacities. this network includes four major elements: economic development, social capital, information communication, and community capabilities. ronan and johnston (2010) proposed the strengthening systems 4r prevention model, in which system resilience means the communities affected by disaster are able to cooperate and communicate with various organizations, experts, and community groups to face disasters and crises. in the past, different levels of government units have often played the role of command and coordination in a major disaster whereas civil rescue teams from different organizations were the first responders at the front lines. however, in some cases, the government is unable to effectively control and deploy sufficient rescue organizations and related resources, resulting in overlapping resources or faults and, thus, weakened disaster relief (liu et al., 2003) . the interaction between government and non-government actors has become a trend in future disaster prevention and rescue, making it important to understand how to properly use ngos' resources for disaster management (huang et al., 2012; lin, 2013) . in the face of large-scale disasters, the government's disaster prevention capability is far from the threat posed by the disaster itself. therefore, determining ngos' role in the traditional government-based disaster management system has become an important issue for public governance. ngos can play at least eight roles in disaster prevention and rescue: organizers, coordinators, resource integrators, information communicators, supporters, counselors and educators, consultants, and advocates (zhou and wang, 2010) . however, observations of the relationship between state and society in china make it evident that the development of the country's nonprofit organizations (npos) and the search for a model for the development of chinese civil society are topics that concern many scholars. there are also some important issues worthy of discussion, such as the duality of government and the people and the dual nature of the chinese society (kang, 1999; sun, 1994) ; the three pathways-namely, from the bottom up, top down, and cooperation (jia, 2003) ; and the administrative absorption of society (kang et al., 2010) . liu (2007) identified three features of china's current npo legal system: dual control over management systems, permitting and laissez-faire approach in management processes, and restrictions on competition and inhibited development in management strategies. the interpretation of these models highlights the fact that the government still plays the dominant role when interacting with society. the government's interactions with civil society organizations, voluntary organizations, and ngos during the 2008 wenchuan earthquake have received extensive attention. wang (2009, p. 31) pointed out that "the government's drawbacks and deficiencies in public crisis management are mainly because it is difficult to sustain." under the propaganda and encouragement of political entities, mainly political parties, the entire political system plays the role of persuading and even forcing members of political groups or other members of the society to accept, obey, cooperate, and support the capacity of the entire political system. however, such mobilization lacks sustainability. tong and zhang (2012) demonstrated that, due to china's long-term policy restrictions, the development of chinese civil organizations still has a long way to go. although more than 300 civil society organizations were mobilized for disaster relief following the earthquake, with more than 3 million volunteers participating in the action (optimists even consider 2008 as china's first year of civil society), a year later, the number of ngos still within the disaster-stricken area had likely fallen below 50, with fewer than 50,000 total volunteers. therefore, through training and management development, ngos' involvement during emergency and social mobilization mechanisms can be conventionalized. the pre-zero draft of the post-2015 framework for disaster risk reduction of the third un world conference on disaster risk reduction (wcdrr) stated that such efforts: [need] to be reinforced further by the post-2015 framework for disaster risk reduction with a much stronger focus on anticipating long-term risk scenarios and concrete measures to prevent the creation of new risk, reduce the existing risk and strengthen economic and social resilience of countries and people, by addressing both people and assets' exposure and vulnerability. (unisdr, 2014, p. 3) the social resilience perspective emphasizes the social motivation and collective action ability of the people during disasters (manyena, 2006) . the scope includes the influence of individuals or communities on collective behavior, collective decision, and collective actions with various informal institutions. important focuses of such efforts are how local informal institutions can help overcome the difficulties of collective action and form the interaction between local organizations and the state as well as contribute to society (li and lin, 2014) . social resilience involves social entities-whether individuals, organizations, or communities-and their ability to tolerate, absorb, respond to, and adapt to various environmental and social threats (keck and sakdapolrak, 2013) . maguire and hagan (2007, pp. 16-17) pointed out that social resilience is the capacity of a social entity (e.g., a group or community) to "bounce back" or respond positively to adversity which is understood as having three properties comprising aspects of how people respond to disasters: resistance, recovery, and creativity. the literature has suggested that an array of factors may impact social resilience, including trust (e.g., enemark, 2006) , social cohesion and a sense of community (e.g., poynting, 2006) , and communication and information (e.g., ink, 2006) . zolli and healy (2013) pointed out two ways to enhance resilience: enhance its ability to fend off and overcome the limitation during these major damages (even when permanent damage is caused) and maintain (or even expand) survival ability in the ever-changing environment in order to adapt to the new environment healthily, even when pushed to the limits. from economics to ecology, almost all resilience systems have a rigorous feedback mechanism to detect upcoming mutations or critical limitations. for example, in an ecosystem such as the coral reefs, some organisms may change their behavior due to environmental degradation. the same behavior also applies to human society, except that we rely heavily on various tools and techniques to strengthen our alertness to the environment. when sensing information that the system is about to cross its limitation, a system with true resilience uses dynamically reorganized efforts to ensure that the mission is continued, and the scale of operations is maintained. many systems have built-in counteracting mechanisms that start working once the crisis occurs; the counter-measure mechanism attacks like the human immune system, restoring the system to a normal state. aldrich (2012) pointed out the importance of social capital for building social resilience in post-disaster recovery, and the cultivation of trust is the key factor in accumulating social capital (newton, 2001) . on may 12, 2008, sichuan province in mainland china experienced a magnitude 8.0 earthquake (also known as the wenchuan earthquake) that killed almost 70,000 people, injured more than 370,000, and left almost 18,000 missing. in addition, nearly 4 million buildings collapsed or were damaged. more than 15 million people needed emergency resettlement, and the estimated economic losses were roughly 845 billion rmb, making it the most severe disaster since the tangshan earthquake in 1976 (china news, 2008/9/25). from a social perspective, the relevant functions of emergency management in the past are distributed in multiple departments and at different levels of government. the function is unclear, and there is a lack of institutional mechanisms for emergency management as well as a lack of efforts by the public, the media, volunteers, and ngos. when it comes to the exchange and cooperation of external resources, there is a widespread phenomenon of mobilization and light coordination, and social organizations are slow to develop their ability to participate in disaster relief (xue and tao, 2013; zhang et al., 2011; zhang and zhang, 2016) . in march 2018, china established the emergency management department, which had an important impact on the entire disaster management system. in order to understand and analyze how the government worked together with civil organizations, volunteer organizations, and community organizations in order to enhance social resilience after the wenchuan earthquake, this study collected qualitative data through in-depth interviews and focus group discussions from 2016 to 2018. the main purpose of the in-depth interviews was to explore, realize, and understand the life experiences of others and the meanings they have given. as the core of interview research is an interest in other people's stories (seidman, 2006) , the research methods related to participation, observation, and narrative helped better understand the evolution of social resilience in china (especially in sichuan) after the wenchuan earthquake in 2008. over the past two years, the research team, which consists of crossstrait scholars, has taken advantage of exchange visits and arranged for meetings and field studies in the earthquake-affected area. qualitative data were collected through a snowballing approach. after being introduced to an officer in the department of emergency management in chengdu city, sichuan province, and based on the recommendation of scholars in the university, the research team contacted participants involved in the relief or recovery efforts following the wenchuan earthquake as well as scholars in the field of disaster management. participants in the focus group discussion and in-depth interview respondents included two main targets: practitioners, who are the main persons or directors of social organizations, and scholars and researchers from universities in the public administration and disaster management fields. in order to analyze issues from different angles and include more perspectives from respondents outside of sichuan province, this study also conducted interviews in beijing and shanghai. these meetings were recorded, with the participants' permission. although no government officials agreed to participate in interviews due to the sensitive nature of socio-government interactions, with their help, the research team was able to participate in and observe the district government emergency management working forum organized by the municipal government. table 1 presents the information about focus groups and in-depth interviews. article 3 of the law of the people's republic of china on incident responses defines "emergency events" as natural disasters, major accidents, public health incidents, and social security incidents that occur suddenly, cause or may seriously endanger society, and require emergency measures to deal with the situation. in addition to the classification of the severity of disasters and the hierarchy of vertical systems, the law authorizes horizontal response departments to deal with different types of disasters. the law and administrative regulations stipulate that the relevant departments of the state council are responsible for responding to emergencies. different interviewees pointed out that the horizontal design of this disaster-based approach caused challenges in terms of communication and coordination. the literature also pointed out that the mechanical disaster prevention and the design of the focus exclusively on the efficiency of the system members to complete the work create a drawback in this design, making it difficult to respond quickly to environmental or sudden changes (chang, 2016; hatch, 1997; jan, 2004) . from the academic point of view, it may be better to establish a more comprehensive system instead of the single-hazard system, which may result in some problems, such as a lack of information sharing and communication between the different governmental agencies. if something happens today, maybe they do not know how to communicate effectively. (interviewee c) another explained: there is always a coordination problem between the departments and departments within the government, and then there is also coordination problems among the government, enterprises, and the ngos in emergency management. (interviewee h) the ministry of emergency management was established to coordinate emergency management and comprehensive disaster management, standardize and integrate social rescue forces, facilitate the connection between social organizations and the government, and enhance the synergy between government and social organizations (gao and liu, 2018; wang, 2018) . these functions can be examined in three aspects. first, the ministry accelerates the construction of social forces to participate in the disaster relief platform. for example, in march 2019, the social emergency force participated in the online application system for disaster relief. it was officially put into operation to realize the functions of online registration and reviews of social emergency forces, disaster information releases, rescue applications, and rescue management. second, the ministry coordinates some policy issues that plague social emergency forces and prevents them from effectively participating in emergency response. for example, in january 2019, the ministry of transport and the ministry of emergency management jointly issued the "notice on doing a good job in social traffic vehicles for inter-provincial disaster relief and highway traffic protection" 《关于做好社会力量车辆跨省抢险救灾公路通行服务保障工作的通知》 to establish a nationwide unified emergency rescue road for free passage and related service guarantee. third, the ministry improves social organizations' ability to participate in disaster relief. for example, in june 2018, the ministry of emergency management held the first professional training of social forces that participate in disaster relief work; six months later, in december, it launched the first national social emergency strength skill competition. in addition to the integration of government departments, it is important to know how to implement emergency management into community governance-a task facing china's emergency management system reforms in the past decade. one interviewee stated: now we have a community grid management system in each district-that is, we are divided into this unit grid in this urban area. if some problem occurs in this unit grid, it will be systematic and immediately mobilize specific forces to the rescue. (interviewee h) the research team also participated in the district government emergency management working forum organized by the chengdu emergency management office, during which it acquired a better understanding of the emergency work from the perspectives of government and community safety and the setting up and operation of the community micro fire station. furthermore, the data indicate that the current chinese emergency management system has focused more on the importance of community risk awareness and capacity building. after the wenchuan earthquake, the number of social organizations involved in disaster emergency rescue and the amount of disaster relief funds invested in china continued to grow, and the rescue areas and rescue methods involved showed diversified development. meanwhile, the legal system's emergency mode relied on the emergency response law as the main body and emergency response plan system at all levels. yet disaster coordination governance continued to face challenges from the government, the light society, the inefficient operations of resource integration and emergency management, the insufficient cultivation of specialized teams, and inadequate support measures for social forces and participation (jin, 2004; zhou and liu, 2015) . to this end, the chinese government has focused on improving the laws and regulations, policy planning, and behavioral norms of social forces participating in disaster relief. its main content involves the role of market and social forces in disaster prevention, mitigation, and relief. these environmental traits can easily impact the routine operation procedures and decision-making processes of government agencies. in the past, administrative organizations emphasized the development of stability, rationality, and linearity. however, under the advent of the risk society, the concepts of chaos and non-linearity continually impact the thoughts of the traditional public sector. the factors that impact social resilience include trust and social cohesion as well as a sense of community (enemark, 2006; poynting, 2006) . the interviewees pointed out how these factors affected efforts during the wenchuan earthquake and subsequent recovery phases. one interviewee provided a vivid example: a few years ago, i went to several communities and started promoting the idea. some local representatives said, "we want to do disaster prevention and reduction…to save your time, we can have a simple plan, and everyone just follow the guidelines of this plan." i came up with a question that took him a while to figure out the answer. i asked him, "if a real disaster hit the area, do you think people around the area would still follow the plan easily?" (interviewee a) other interviewees mentioned cases about accumulating trust between government and social organizations and between social organizations and community citizens: for example, we need to report to the school and the education bureau whom we invite to participate in the program. in other words, social organizations must first form a trusting relationship with the government. (interviewee g) for ourselves, we need to grasp the characteristics, principles, and norms of being social organizations. we are partners of the government. you will find that the government needs some time and space to slowly feel and understand social organizations for a better collaboration. (interviewee e) we started to do post-disaster services after the rescue phase. we build relationships with the villagers through a large number of activities, and we need to promote residents' autonomy and some things within the community (community awareness) and discover community leaders and community cadres. (interviewee f) in addition to trust, the interviewee from academia mentioned that the sense of community and cohesion also play important roles: the community in western society usually has some grassroots or civil organizations self-organized by the community residents. however, the community in china i observed was very different from the west in substance and structure… in china, currently the idea of "community" cannot be treated as a unit alone because the public's awareness of the community is still very weak. (interviewee j) in other words, social resilience involves a common reaction of all social entities, so it is important for the government to increase its trust in ngos and strengthen community awareness. as kooiman (1993) pointed out, there is no single actor in the policy implementation process that can have enough knowledge to deal with the increasingly complex issues. therefore, governing future disasters requires the cooperation of the public and private sectors to form different networks, share responsibilities, and engage in mutual granting power and capacity in order to achieve the best policy results. as one interviewee stated: especially after the ya-an earthquake, similar disasters were very stimulating to social organizations, and social organizations were becoming more and more professional. their professional courses were approved by the government. once the government's trust in social organizations is raised, they find that this mutual cooperation will benefit all social organizations, governments, and the general public. in order to form common goals, accumulate and exert more energy in disaster management, and effectively reduce the casualties caused by disasters, the self-organization mode in community and social organizations warrants more attention in the future. an emergency regulatory system refers to a mechanism built on methods and measures of the emergency management process. in some of china's government documents, the word regulatory is replaced by mechanism (wang et al., 2016) , suggesting that the trend of emergency management system design among authorities is to pursue collaboration. according to the interviewee from beijing: in fact, the government's role is constantly being revised. with the development of society, this is inevitable… after 2008, non-governmental organizations were eager to grow because of the wenchuan earthquake. within six months, these civil organizations were fully recognized. the government acknowledged that civil organizations can help solve many problems with high efficiency and good quality. since then, the importance of the rescue organization has been known, and various support policies have gradually emerged. (interviewee l) the relationship between ngos and the government varies in different situations (coston, 1998; najam, 2000; young, 1999 young, , 2000 . interviewee a pointed out that relationships with the government are also very subtle: in fact, the death rate of social organizations in china is very high because they can neither be separated from the government nor is it legal to leave the government. however, being too close to the government means that civil organizations must adapt to the government style of management, which limits civil organizations' openness-that is to say, they cannot find their position and may become temporary workers for the government. in recent years, a mechanism has gradually emerged during interactions between the government and social organizations that clearly stipulates the participation forms and legal guarantees of relevant units during disaster responses and establishes social public safety knowledge and participation in emergency drills. for example, in october 2015, the ministry of civil affairs issued the "guiding opinions on supporting and guiding social forces to participate in disaster relief work" 《关于支持引导社会力量参与救灾工作的指导意见》. this publication marked the first time that various social forces, including civil emergency relief organizations, were involved in disaster relief work within the government's normative system. on march 16, 2016, the national people's congress passed the charity law, and the voluntary service regulations were promulgated on august 22, 2017, which clearly stipulate that: when emergency incidents such as major natural disasters, accident disasters and public health events occur, it is necessary to promptly carry out rescue assistance, [and] the government should establish a coordination mechanism, provide the necessary information, and guide fundraising and rescue activities in a timely and orderly manner. the "opinions of the cpc central committee and the state council on promoting the reform of disaster prevention and mitigation and relief system" 《中共中央国务院关于推进防灾减灾救灾体制机制改革的意见》, issued on december 19, 2016, concluded that a sound social force participation mechanism is an important part of reforms of the mechanism for disaster prevention, mitigation, and relief and should encourage the full participation of social forces. the work of normal disaster reduction, emergency rescue, transitional resettlement, and restoration and reconstruction, among other efforts, requires multi-participatory social disaster prevention, mitigation, and relief patterns. the national comprehensive disaster prevention and mitigation plan (2016-2020) also clearly defined social emergency forces, such as volunteer emergency rescue teams. in the current development of communities in mainland china, individual community committees play an important role in mobilizing and integrating various types of community resources as part of their self-governance, which is a process of reducing conflicts, promoting cooperation, and enhancing the power and reputation of their own communities (liu, 2015) . as a traditional administrative organization, the community committee replaced the unit system and has become an important link for the country and society. during the diversified and rapid development of modern cities, especially as traditional mobilization organizations and administrative control methods are losing their legitimacy, re-mobilizing and absorbing the people to return to the ruling network of the ccp system have become urgent goals of the current reforms of mainland china (chen, 2011) . the interviewee from the volunteer organization emphasized the role of being a "supporter" of the government: there are specialists in every community, and their working experience may not be as much as our civil society. so we have to help them. when the government organizes large events, we, the civil organizations, will and should participate and provide the necessary assistance. (interviewee k) finally, community committees have also become more closely linked with the political party and the government; this link is rooted in the work of the cpc's party-building efforts. therefore, the interviewees perceived community committees as not having purely civil roles in disaster prevention and relief. on the other hand, non-governmental social organizations and communities are more oriented toward network-based development in disaster prevention and rescue issues. during the focus group discussion, social organizations' party-building work also attracted the authors' attention. interviewees pointed out that such work facilitated a closer relationship, thereby helping the party and the social organizations work together. under the chinese political system, research in recent years has focused on how to ensure that the government and society engage in better interactions and enjoy more effective cooperation. such developments in the decade following the wenchuan earthquake have attracted more discussion from scholars and experts in the field of emergency management. the relationship between the chinese government and its society has consistently maintained the conditions of big government/small society or strong government/weak society. "under such circumstances, it is difficult to carry out emergency social mobilization in an all-round manner, and the all-powerful government will not be able to react flexibly to events due to its rigid branches extended within its organization" (wang, 2010, pp. 24, 133) . therefore, the literature on disaster management has increasingly emphasized the development of community self-organization and social resilience in recent years. in addition to the community's ability to understand its own needs and effectively prevent and respond to disasters through collective actions, it is necessary to enhance community acceptance and community relationships to form closer relationships within the community. in china's political system, the authorization of power from the government to the communities, the cultivation of disaster prevention capabilities, and the level of autonomous decisionmaking are all important issues to examine in the future. from the discussion and analysis presented in this paper, we first find that the role and relationship among government, community, and civil society organizations in disaster management in china have indeed changed in the decade since the wenchuan earthquake. strengthening social resilience, trust, and the sense of community can facilitate efforts to bring all the social entities to work together. during large-scale disasters, the functions that the government fulfills are limited. the large role the chinese government has traditionally played is bound to need adjustment. second, although the chinese government has recognized the important role and function of social organizations in the development of social resilience in emergency management, the development of trust between the government and social organizations has still been a slow process under the current chinese government system. the accumulation of social capital remains weak, which is detrimental to the construction and development of social resilience. in other words, more interaction, communication, understanding, and dialogue between the government and the social groups are necessary in the future. finally, in recent years, relevant laws and regulations to promote the synergy mechanism have also been promulgated; the impact of such efforts on social resilience is a subject worthy of further observation. yet the elements of social resilience involve creativity in addition to resistance and recovery. the main source of this creativity is the selforganization of the community, which the authors believe is currently missing in china's disaster management system. in other words, it would be helpful if the chinese government could give moderately more space for civil society participation, making it more likely to include creative approaches in disaster management. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. building 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(104-2410-h-015-005-my2). key: cord-332432-q7u943k6 authors: hofkirchner, wolfgang title: a paradigm shift for the great bifurcation date: 2020-06-30 journal: biosystems doi: 10.1016/j.biosystems.2020.104193 sha: doc_id: 332432 cord_uid: q7u943k6 this paper is an attempt to achieve an understanding of the situation the evolution of humanity is confronted with in the age of global challenges. since global challenges are problems of unprecedented complexity, it is argued that a secular paradigm shift is required away from the overemphasis on allegedly neutral standpoints, on a mechanistic picture of the world and on deductive logics towards accounts of emergence, of systemicity, informationality and conviviality, building upon each other and providing together a transdisciplinary edifice of the sciences, in the end, for, and by the inclusion of, citizens. viewed from such a combined perspective, the current social evolution is punctuated by a great bifurcation similar to bifurcations other emergent systems have been facing. on the one hand, humankind is on the brink of extinction. it is the world occurrence of the enclosure of commons that is detrimental to sharing the systemic synergy effects and thus to the cohesion of social systems. on the other hand, humanity is on the threshold of a planetary society. another leap in integration would be the appropriate response to the complexity confronted with. humans and their social systems are informational agents and, as such, they are able to generate requisite information and use it to catch up with the complex challenges. they can establish convivial rules of living together in that they disclose the commons world-wide. by doing so, they would accomplish another evolutionary step in anthroposociogenesis. the concept of the global sustainable information society describes the framework of necessary conditions of conviviality under the new circumstances. the seemingly disruptive advent of the covid-19 pandemic outshone the climate change that has been gaining obvious momentum since the last fifty years to an extent that it threatens with a much more decisive rupture if science, technology and society are not unwilling to learn from the pandemic that there is nonlinear growth with complex challenges be they small or large and that human actors are not completely doomed to helplessness though. for such a lesson to learn, a secular shift in thinking and acting throughout sciences and everyday life is required because human actors need to be capacitated to cope with complex challenges such as the global problems. a shift is already underway though not yet hegemonic. this shift has to overcome three prejudices of conventional science: • the outdated ideology of value-free scientific research. the absence of values would make science distinct from biased everyday thought. but that's not the distinction. any research is driven by societal interests even if mediated by personal curiosity. any research implies particular values, reflected or not if not even camouflaged. of course, these values must not divert the findings of research, quite the contrary, they shall stimulate evidence-based research -and that's the distinction from biased opinion of everyday. science can critique opinions. in the last two decades, several labels have become aspirational for scientists: research shall be responsible, university research shall be aware of its third mission, namely, to serve the common good, applied research shall be replaced by use-inspired basic research, research shall become practically transdisciplinary in that it transcends science towards, and include in science, the values of everyday people that are affected by the results of research, best by letting them participate in research. these are attempts in the right direction: the acceptance that there is a limited controllability of what can be done. as everyday-thinking and -acting, science has limited controllability over its impact on society but within that certain limit it is capable of controlling and thus it must aim at doing so in a precautious way. neither phantasies of omnipotence nor of impotence are called for but a deliberate activism is (hofkirchner, 2013a, 62-71) . not everything that might be feasible is also desirable and not everything that might be desirable is also feasible. the feasible and the desirable need to be made compatible with each other. • the outdated mechanistic picture of the world. cause-effect relationships are fancied as if pertaining to a machine constructed by humans. cause and effect would obey laws of strict determinacy such that the effect would follow necessarily from the cause. but that is true only for a small subdivision of effective causality -causes can have different effects and effects can be brought about by different causes -, let alone final, material and formal causality (hofkirchner, 2013a, 86-95) . laws of nature and other parts of the world are not given for eternity. the late karl raimund popper called those laws propensities -an asymmetrical, contingent behaviour of the universe (1990) . this shows the right direction. strict determinism as well as indeterminism are false alternatives. less-than-strict determinism avoids both fallacies. • the outdated preponderance of methodologies that are based on deductive logics. deductivism is an attempt to deduce that which shall be explained or predicted from premises such that the phenomenon can be subsumed under a proposition of the form of a universal implication that covers the phenomenon. the premises suffice by definition for the conclusion, the phenomenon is thus reduced to a sufficient condition. but, in fact, those conditions are rarely sufficient. there is the search for alternative logics such as the hype for abduction or claims for a trans-classical logic (günther, 1990) . and there is the logic in reality of joseph brenner (2008) who grounds logic in reality, that is, he gives primacy to how reality works in principle when postulating logical principles. anyway, it needs to be accepted that explanation and prediction are incomplete and that they should focus on the adjacent necessary instead, that is, a necessary condition that might rarely be sufficient but should form a basis of understanding as close as possible to the phenomenon that shall be explained or predicted (hofkirchner, 2013a, 131-139; 1998) . neither deductivism nor irrationalism -for which anything would go -can convince but a reflexive rationalism that accepts incomplete deducibility with an ascendance from the abstract to the concrete where by each step a new assumption is introduced without deduction. the build-up of such a specification hierarchy is important for the transdisciplinarity in its theoretical sense -the consideration of as many facets of the phenomena as possible in order to achieve a unified understanding. the removal of those impediments for the progress of science are the milestones that the paradigm shift has to master. only if they will have been achieved, humanity will be ready to confront the global challenges in a way that safeguards mankind against man-made extinction. the next sections substantiate how, on the three pillars of deliberate activism, less-than-strict determinism and reflexive rationalism, a new understanding of the current situation of world society can be erected and how it can make the disciplines of the whole edifice of science responsive to that task. the sections will proceed from a systemic level to an informational level to a convivialist level. 1 emergentist systemism 'emergentist systemism' is a term introduced by poe yu-ze wan (2011) in the context of social theory, after it had been used in the field of social work in switzerland (e.g., obrecht, 2005) to characterise the approach of philosopher of science, mario bunge. bunge himself was rather used to terms such as 'emergentist materialism' to signify, e.g., his position in the field of the mind-body problem. however, he defined systemism in a broader sense, namely as 'ontology: everything is either a system or a component of some system. epistemology: every piece of knowledge is or ought to become a member of a conceptual system, such as a theory. axiology: every value is or ought to become a component of a system of interrelated values ' (2012, 189) . and he defined emergence as '[…] advent of qualitative novelty. a property of systems ' (2012, 185) . thus, emergentism is 'a world view or an approach' that focuses on emergence (2003, 38) . 'systemism, or emergentism', as he said (2003, 38-39) , 'is seem to subsume four general but one-sided approaches: 1. each of these four views holds a grain of truth. in putting them together, systemism (or emergentism) helps avoid four common fallacies.' this is by and large the sense in which emergentist systemism is understood here (hofkirchner, 2017a ) -as weltanschauung, that is, a world view that is not value-free (a german term by which mark davidson 1983 summed up ludwig von bertalanffy's general system theory and which will be subsumed here under the term praxiology), as conception of the world (ontology) and as way of thinking to generate knowledge about the world (epistemology). in a nutshell, emergent systemism means that, practically, humans intervene as a rule for the betterment of social life in real-world systems they conceive of by patterns they have already identified and that these systems are emergent from the co-operation of other systems that become or are their elements. this is called selforganisation. since the idea of emergent systems implies a kind of evolution, these systems are also known by the term evolutionary systems. evolutionary systems theory -a term coined by ervin laszlo (1987) , vilmos csanyi (1989) and susantha goonatilake (1991) but extended here to cover the meaning it received after the seminar held at the konrad lorenz institute for evolution and cognition research in vienna 1995 (van de vijver et al., 1998) -is the proper theory of self-organisation, a merger of systems theory and evolutionary theory by which the first was enabled to include more than ideas of maintaining systems only and the latter could emancipate from mechanistic interpretations of the darwinian model. self-organisation is characterised by evolvability and systemicity. that means that matter, nature, real-world events or entities evolve such that systems materialise as organisation of components (hofkirchner, 2013a, 58-59) . applying emergentist systemism to the edifice of science(s) brings a profound change (hofkirchner, 2017a) . how is the old paradigm's view of that edifice? let's start with philosophy, composed of epistemology, ontology and praxiology (ethics, aesthetics and else) as the most abstract enterprise and put it in the background. before that background, you have the three categories of formal sciences, real world sciences and applied sciences in juxtaposition. the formal sciences include logics and mathematics as disciplines. the real-world sciences comprise disciplines that investigate nature, on the one hand, and were called typically physics, chemistry, biology and else, and disciplines that investigate the social world, on the other, nowadays summarised under the term social and human sciences including sociology, cultural, political, and economic sciences and else. applied sciences assemble engineering, management, arts and else. every discipline is divided by sub-disciplines and sub-sub-disciplines besides all having their own legitimation as basic research, formal sciences are known for providing instruments for gaining knowledge in the real-world sciences, real-world sciences are needed for the provision of evidence for developing technologies, organisation, pieces of art. however, what makes the co-operation of sciences difficult is that they are siloed against each other by impermeable boundaries. connection between those mono-disciplines can be attempted only by heaping some of them together in a multi-disciplinary approach, which is no connection at all, or by peripheral exchanges in an interdisciplinary approach, which does not admit internal changes and keeps the disciplines as alien to each other as they have been before. driven by the confrontation with complex problems, things have begun to change already in the direction of semi-permeability of disciplinary boundaries, which, in the long run, paves the way for the establishment of new stable relations between them. emergentist systemism is not another discipline that just adds to the picture of the old disciplines. it causes rather a paradigm shift that has the potential to transform the whole edifice of science(s). philosophy that was deprived of fruitful relations to the disciplines of science in what had become normal science turns into systems philosophy now; formal sciences turn into formal as well as non-formal systems methodology; realworld sciences turn into sciences of real-world systems, that is, material, living or social systems; and, finally, applied sciences turn into a science that makes artefacts by designing systems and, in doing so, integrates them with social systems. so, at one blow, connectedness is unveiled between all inhabitants of the edifice. transgressions from one scientific endeavour to another can be mediated via jumping forth and back over shared levels of scientific knowledge. those levels form now a specification hierarchy. jumping from one specific level to a more general level allows comparison and adjustment of both levels. it allows the initial level to instigate knowledge adaptations on the target level or adoption of knowledge on re-entry from the target level. in addition, a more general level works as bridge for jumping up the ladder to even higher levels or down to different lower levels so as to help understand that their knowledge is just another specification of the knowledge they share at a higher level. this makes the sciences of evolutionary systems a transdiscipline and its inherent emergentist systemism makes the edifice of disciplines a transdisciplinary, common endeavour of all science. semi-permeability does not lift the boundaries. relative autonomy of disciplines is maintained in the overall transdisciplinary network. paraphrasing bunge, informationism is a term used here to denote a praxiological perspective on, an ontological conception of, and an epistemological way of thinking about, information, which takes centre stage in this tenet. for the sake of consistence, information is set to be based upon, and concretise further, systems, in particular, emergent information shall easily relate to emergent systems. this can be achieved through the assumption of informational agents -agents being emergent systems. thus, the generation of information is enshrined in the self-organisation of systems. any time a system self-organises, its agency brings forth information. an evolutionary system can be defined as 'a collection of (1) elements e that interact such that (2) relations r emerge that -because of providing synergistic effects -dominate their interaction in (3) a dynamics d. this yields a distinction between micro-level (e) and macro-level (r) and a process (d) that links both levels in a feedback loop' (hofkirchner, 2013a, 105) . with reference to, but in modification of, a triadic semiotics after charles sanders peirce (2000) , laying emphasis on the intrinsic connection of self-organisation with negentropy after edgar morin (1992, 350 and 368) and by usage of the term 'perturbation' introduced by humberto maturana and francesco varela (1980), information can be defined as 'relation such that (1) the order o built up spontaneously (signans; the sign) (2) reflects some perturbation p (signandum/signatum; (to-be-)signified) (3) in the negentropic perspective of an evolutionary system s e (signator; the signmaker' (hofkirchner, 2013a, 171) . 'information is generated if self-organising systems relate to some external perturbation by the spontaneous build-up of order they execute when exposed to this perturbation. in the terms of triadic semiotics, the self-organising systems, by doing so, assign a signification to the order and make it a sign which stands for the so signified perturbation' (hofkirchner, 2013a, 172) . this is the approach of a unified theory of information (hofkirchner, 2013) . it is worth noting that those assumptions attribute information generability to emergent systems according to the evolutionary type they represent. not only social systems and their inhabitants are qualified as informational agents (this would import the acceptance of umberto eco's threshold of semiosis applicable to the realm of human culture exclusively), not only biotic systems (this is the threshold of biosemiotics) but also physical systems in so far as they are able to self-organise are qualified to generate information in shades -as far as the respective evolutionary stages allow. emergent systems of any kind produce emergent information. as to the new scientific edifice, informationism is mounting systemism. systems philosophy becomes a systemic philosophy of information; systems methodology becomes a systemic information methodology; the sciences of real-world systems become sciences of information of real-world systems, that is, of material information, living information and social information; and the science of designing artificial systems becomes the science of designing information in artificial systems. all that information is emergent information. convivialism is a term denoting a social perspective (praxiology), a conception of the social world (ontology) and a social-scientific way of thinking (epistemology) for which conviviality is key. conviviality as term was introduced by the austrian-american writer, ivan illich, who published a book with the title tools for conviviality (1973) . it contained a philosophy of technology according to which technology should be socially controlled so as to reclaim personal freedom that is restricted by uncontrolled technological development. conviviality -illich was familiar with the spanish term convivialidad -has latin origins and means the quality of living together in the manner of dining together (convivor) of hosts (convivator) and guests (conviva) at common feasts (convivium). in the last decade, that term gained new attention when mainly about fourty french intellectuals -among them serge latouche, edgar morin or chantal mouffe -opened the discussion on a political manifesto for the redesign of social relations. the first manifesto was followed by a second, up-dated one in 2020 (internationale convivialiste). according to the latter, convivialism 'is the name given to everything that in doctrines and wisdom, existing or past, secular or religious, contributes to the search for principles that allow human beings to compete without massacring each other in order to cooperate better, and to advance us as human beings in a full awareness of the finiteness of natural resources and in a shared concern for the care of the world. philosophy of the art of living together, it is not a new doctrine that would replace others by claiming to cancel them or radically overcome them. it is the movement of their mutual questioning based on a sense of extreme urgency in the face of multiple threats to the future of humanity. it intends to retain the most precious principles enshrined in the doctrines and wisdom which were handed down to us.' convivialism is emergentist if seen in the context of emergent systems and emergent information. social systems are here considered as evolutionary systems, which is in stark contrast to how german sociologist niklas luhmann (1995) considered them (wan, 2011). though luhmann originally claimed to start with general system theory when elaborating his theory of social systems, a revisiting of bertalanffy would lead to different conclusions . such an approach has been pursued not only by bunge but also by members of ervin laszlo's general evolution research group, among them robert artigiani (1991) , by representatives of critical realism, in particular margaret s. archer (1995; 2010; and her project group on social morphogenesis at the centre for social ontology, and workers departing from us sociologist walter f. buckley (1967) , including the economist tony lawson (2013) and the relational sociologist pierpaolo donati (donati, 2011; donati and archer, 2015) . of course, many other sociologists are worth mentioning; even if they do not explicitly share a systems approach, they have nevertheless contributed with important insights to such a framework (giddens, 1984; alexander, 1995; mouzelis, 1995; reckwitz 1997) . social systems are the evolutionary product of living systems but contain living systems that get a social shape. the elements of social systems as conceived here are social agents -humans called actors -and their organisational relations are social relations -called structure. actors inhabit the micro-level of social systems, while the macro-level is where the structure is located. the structure is produced by the actors and it exerts a downward causation on the actors and their agency (hofkirchner, 2013b, 136; lawson, 2013 ). thus, social systems self-organise as living and material systems do, but they differ from living and material systems as to their mode of self-organisation. 'social self-organisation goes beyond biotic self-organisation, which, in turn, goes beyond physicochemical self-organisation' (hofkirchner, 2014, 120) . social self-organisation does so in that it transcends, re-invents, creates the social systems through the action, interaction and co-action of their actors, who -as informational agents -cognise, communicate and co-operate mindfully when reproducing and transforming their social systems, which, in turn, can be considered as higher-level informational agents. social self-organisation is not conceivable without the generation of specific social information. the triple-c model postulates a hierarchy of information processes such that cognition is the necessary condition for the functioning of communication and communication the necessary condition for the functioning of co-operative information, in short, co-operation (hofkirchner, 2013) . psychic functions such as thought and others, the ability to speak and the ability to devise and manufacture artefacts, in particular, tools, are characteristic of humans. all of them are knit together in social information: 'human thought is part of human cognition […]; human language is part of communication […] ; human tools are part of work that belongs to human co-operation' (hofkirchner, 2016, 286) . starting with work at the top (which refers to the structure on the system's macro-level), it is about constituting common goals and instituting common goals. work is consensual. co-operation involves finding and building consensus. what is needed here, are common intentions. common intentionality provides the perspective of the whole we, the perspective of the social system. consensualisation, in turn, presupposes a certain collaboration that designs specific tasks for reaching the shared goals and assigns these tasks to certain actors. that is done on the social information level below, on the level of language (which refers to the network of interactions the actors form on the system's micro-level). communication functions as the means to realise that kind of collaboration that is needed for the upper level. that is, taking the perspective of the other facilitates collaboration. however, taking the perspective of the other is promoted by taking the perspective of the whole in which one's own and the others' roles are included. what is required here, is readiness for a dialogue with sense for consilience. collaboration, in turn, presupposes a certain co-ordination that devises certain operations for fulfilling the tasks and supervises certain actors in performing the operations. that is worked out on the lowermost level, on the level of thought (which refers to the actions of the individual actors who are also located on the system's micro-level). cognition allows the actors to understand what kind of co-ordination is needed by the upper level. it enables the actors to reflect upon the relationship between operations, tasks and goals. what is necessitated here, is reflexivity, the capacity to reflect the social context in which the cognising actor is embedded (archer, 2010) , and conceptuality, the capacity to use concepts, all of which are influenced by verbal language (logan, 2007; . the rationale of every complex system is synergy (corning, 1983; . agents produce synergetic effects when co-operating systemically -effects they could not produce when in isolation. in social systems, synergy 'takes on the form of some social good. actors contribute together to the good and are common beneficiaries of that good -the good is a common good, it is a commons' (hofkirchner, 2014, 121) . the social relations are commoning relations. conviviality then, as a feature of emergent social systems with emergent social information, can be determined as the historical-concrete shape of the commoning relations. it is a social value that is highly esteemed, it is a theoretical conceptualisation of a social practice, and it is a measurand the value of which can be estimated by empirical studies -it is all of them in one because it is an expression of the quality of the commoning relations. it expresses how just those relations are constructed, how equitable, free and solidary, and to which degree they enclose or disclose the commons. conviviality is visionary and longs for actualisation. its actualisation would 'make the social systems inclusive through the disclosing of the enclosed commons and, by doing so, […] warrant eudaimonia, a good life in a good society, the flourishing of happy individuals in convivial social relations' (hofkirchner, 2017b, 286) . having defined the commons as social synergy and conviviality as measure of the actualisation of envisioned commoning relations, the critical theory perspective becomes apparent (hofkirchner, 2015, 97-99) -the perspective of a critical social systems theory as part of the social systems sciences in the new edifice of disciplines. conviviality is emergent. it develops over time and changes its forms in a contingent way. referring to michael tomasello's shared intentionality hypothesis and his interdependence hypothesis (tomasello et al., 2012; tomasello, 2014; , there have been two key steps in anthroposociogenesis (the becoming of humans and society) so far and, following the new systemic, informational and convivialist paradigm, a possible third one is imminent. the next subsections discuss those steps. leaps in quality emerge in systems as novel organisation due to a change in the organisational relations. thus, changes on the top-most levels of information generation and usage are decisive. all of them are shifts in co-operation. if work, language and thought build the human/social hierarchical levels of information from a synchronic point of view, then, from the diachronic point of view, it may well be assumed 'that it is conditions of co-operation that made the difference in evolution. evolutionary pressure unfolded a ratchet effect that yielded ever higher complex co-operation' (hofkirchner, 2016, 287) . the state of co-operation in the ancestors of humans is the origin of anthroposociogenesis. self-reinforcing processes came about. changes in the state of co-operation proliferated down to provoke changes on the level of communication -the development of human language -in order to propel co-operation and changes in the state of communication proliferated down to provoke changes on the cognition level -the development of thinking -in order to propel communication. in the beginning, so tomasello, there was a shift from individual to joint intentionality. individual intentionality of common ancestors of chimpanzees and humans was the point of departure about six million years ago. as living together was driven by self-interest of animal monads, there was no need for taking in consideration common goals, no need for thinking on a level beyond the actual egocentric perspective (tomasello, 2014, 4, 30) . early humans began to speciate only when they took advantage of going beyond individual intentionality and adopted 'more complex forms of cooperative sociality' (31). a first step occurred 'in the context of collaborative foraging' (33), that is, the hunting of large game and gathering of plant foods, around 2 million years ago. this step culminated about 400.000 years ago, when joint intentionality emerged. hunters and gatherers developed dyadic cooperations driven by a 'second-person morality ' (2016, 6) . hence a need for acknowledging a common goal, that is, an understanding that the partner shares the goal and both are committed to act according to its achievement. multiple and vanishing dyadic relationships formed in which early humans shared a joint goal. in order to support the negotiation of joint goals and the coordination of collaboration, human communication originated with 'a commitment to informing others of things honestly and accurately, that is, truthfully ' (2014, 51) . cognitively, 'when early humans began engaging in obligate collaborative foraging, they schematized a cognitive model of the dual-level collaborative structure comprising a joint goal with individual roles and joint attention with individual perspectives' (69). this was a premature state of conviviality. dyadic co-operation guaranteed the common good for the included actors. the shift from individual to joint intentionality was followed by a shift from joint to collective intentionality. collective intentionality emerged with early humans about 150.000 to 100.000 years ago. this shift occurred with the advent of culture, that is, of separate and distinct cultural groups, the interdependence that caused co-operation reigned 'not just at the level of the collaborating dyad, and not just in the domain of foraging, but at the level of the entire cultural group, and in all domains of life' (tomasello, 2016, 85) . this step created objective morality (6). co-operation became triadic. since then a need for group-thinking has become characteristic of humanity, that is, knowing that any person belonging to the same group culture can be expected to share the same values and norms -by constructing a meta-level such that any group member can imagine the whole of the group, the roles taken, her own as well as others' replaceability. in line with that, communication was to start with discourses about 'objective' facts in need of compelling arguments and cognition had to turn into fullblown human reasoning; 'the individual no longer contrasted her own perspective with that of a specific other […]; rather, she contrasted her own perspective with some kind of generic perspective of anyone and everyone about things that were objectively real, true and right from any perspective whatsoever ' (2014, 122) . cognition involved a new feature of generalisation capacity. this was the next step of conviviality. the third of the triad is relations of society that relate individuals to each other with respect to the common good -even if the concrete content of the common good became a matter of disputation and conflict. and today, a third step of anthroposociogenesis can be hypothesised. there might be a shift from collective intentionality to one that is shared universally, that is, on a planetary scale. that would be the transition to another convivial regime -an extension of the triad to the whole of humanity, an omniad. this extension would be necessary because the conflict over the commons has reached an extension that endangers conviviality at all and the curbing of the extension of the conflict over the commons by extending the triad to an omniad can be considered possible, which is discussed in the sub-subsections to follow. another step is necessary, given that it is agreed that there shall be a human future, which is tantamount with a humane future (hofkirchner 2017b ). in the course of evolution, complex systems move on trajectories on which bifurcations occur. they occur if and when the provision of synergy effects becomes problematic. bifurcations force the systems to change their trajectory. the old one cannot be continued any more. it bifurcates into a variety of possible future trajectories. there are two of them that span the whole variety in the possibility space between two extremes: systems might be able to achieve a leap from the previous level of evolution on which they could enjoy a steady state onto a higher level which forms part of a successful mega-evolution (haefner, 1992, 314; oeser, 1992 , 103-104) -a breakthrough to a path that transforms the systems into what is called meta-system (the metasystem transition) or supra-system -or they might even not be in the position to avert devolution -a path that leads to the breakdown of the systems. amplified fluctuations of parameters indicate the crossroads that demand taking one path or another. the nonlinear dynamics of complex systems make the crossroads appear in one as windows of opportunity to spiral upwards and as tipping points that let the systems spiral downwards into oblivion (laszlo 2001; 2006) . complex systems that can be observed today are those that could manage so far to harness synergy. the evolution of social systems is no exception. 'today, enclosures of the commons have been aggravated to such a degree that all of them morphed into global challenges. global challenges drive an accumulation of crises that mark a decisive bifurcation' (hofkirchner, 2017a, 10) . not only do global challenges cause a multi-crisis in the tension between, and among, social systems from the granularity of today's nation states down to the granularity of the smallest units made up by individualised actors, cutting across all social areas such as the cultural, the political, the economic, the ecological (eco-social) and the technological (techno-social) area and affect so humanity as a whole, but they also threaten, for the first time in human evolution, with the ultimate impact for humanity -with extinction. thus, that decisive bifurcation, in which a branch is much sought after to lead out of a dead-end branch, is called here the great bifurcation. that term resembles karl polanyi's term of the great transformation (1944) in that it embeds the conflict of market capitalism with democracy -the point that was of utmost importance to polanyi -in the complex systems context of anthroposociogenesis. 'either the social systems that together constitute mankind undergo a metasystem transition onto a higher level of organisation that allows the continuation of social evolution on earth or they, eventually, fall apart and discontinue anthropogenesis; either they succeed in rising their complexity such that they break through to a new step in the mega-evolution of humanity or there is a decline in complexity, a breakdown and devolution; either their differences can be integrated or they disintegrate themselves' (hofkirchner, 2020a, 1) . another step is not only necessary for a surviving and flourishing humankind. it is also possible and the reason for that is not only that such a step is grounded objectively in the possibility space given by the bifurcation. moreover, humans can be conceded the subjective potency to find the right way out of the crossroads, in particular, since the problems they come across are of anthropogenic origin and can be solved by a proper re-organisation of the social systems. they can view the evolution of humanity from the inside, explore and anticipate the way out and, finally, intervene accordingly (laszlo, 1987; 2001; 2006) . they belong to the first species on earth that can overcome self-made problems in the sharing of synergy. any emergent system can boost emergent information to catch up with the complexity of the challenges. 'if there is a mismatch between the complexity of a system and the complexity of the problems faced by the system, that system can catch up. […] intelligence is the capability of selforganising systems to generate that information which contributes in the best way to solving problems. the better their collective intelligence, that is, the better their problem-solving capacity and the better their capability to generate information, the better their handling of the crisis and the order they can reach. higher complexity not only signifies a higher degree of differentiation. at least as importantly, it signifies a new quality of integration. only a new level of integration can deal with an intensification of differentiation' (hofkirchner, 2017a, 10) . this can be called the law of requisite information (hofkirchner, 2020a, 3) that is elaborated on the basis of w. ross ashby's law of requisite variety (ashby, 1956) . according to the latter, a system is said to be able to steer another system, if the variety it disposes of corresponds, if not surpasses, the variety of the system to be steered. by departing from the narrow cyberneticist view through connecting variety with complexity and complexity with information and extending the reach of that which is to be steered from the outside to the inside, it can be concluded: 'requisite information is that appropriate information a system has about the complexity of the exterior and interior environment. requisite information safeguards the functioning of the system' (hofkirchner, 2020a, 3) . humanity entered the great bifurcation because 'the social relations of any partition of humanity are based on the principle of othering of partitions that are considered outside of them, thus not doing justice to legitimate self-interests of the rest of the partitions. frictions […] are caused by the lack of relations that would be valid for all partitions from a bird's eye view, that is, from a meta-level perspective. the establishment of such relations would mean the abolition of those frictions by a new supra-system in which all existing systems take part and shape according to the new relations on a higher level, following the application of the subsidiary principle as a basis for the preservation of diversity and autonomous agency" (hofkirchner et al., 2019, 455) . despite some literature based on biases due to biologism unable to imagine a transgression of the conceptual framework of the nationstate we, transnational relations have been taking shape. there is empirical evidence of co-operation between culturally homogeneous groups several tens of thousands of years ago, between cities around five thousand years ago, and between modern states since the seventeenth century (messner and weinlich, 2016; neumann, 2016; grimalda, 2016) . 'this co-operation between collective actors like groups, cities and states has already been paving the way for co-operation among the whole of humankind in the same way that dyadic, interpersonal co-operation between individual actors opened up the space of possibilities for triadic, societal co-operation' (hofkirchner et al., 2019, 455) . the term information society is gaining a new meaning. it does not mean a society that is only informatised, that is, penetrated by information technology as a report to france's president originally insinuated (nora and minc, 1978) . it means an informatised society only if that society uses its informatisation for becoming informational in a non-technical sense. becoming informational entails becoming sustainable and becoming sustainable entails, in turn, becoming global. such is information society on the point of obtaining another meaning in the context of critical social systems theory, which crystallises as critical information society theory. it points towards the global sustainable information society as a framework (hofkirchner, 2017c) : • informationality of the global sustainable information society means 'the envisioned state of informedness of informational actors and systems in which they will catch up with the complexity they are challenged by the great bifurcation to such an extent that […] they will dispose of the capacity to recognise the causes of the global challenges in order to accordingly re-organise human life on earth to master those challenges' (hofkirchner, 2020a, 2) . informationalisation signifies the provision of social information for the installation of safeguards against the deprivation of commons world-wide and thus a new step in the evolution of conviviality. • the provision of such safeguards, in turn, is the process of executing sustainability. sustainability in the framework of the global sustainable information society does so receive a new meaning too. it means 'the envisioned state of the world system that will be shaped and shaping the social relationships between all parts, and throughout any part, of humanity pursuant to the commoning relations on the higher level' such that 'dysfunctions in the working of the organisation of the social system are kept below a threshold the transgression of which would discontinue social evolution' (hofkirchner, 2020a , 2). • the higher level on which the commons shall be provided, is 'the envisioned state of world society as an integrated meta-and supra-system in which social relationships will connect all parts of humanity in all fields of human life', which, eventually, conveys a new meaning to globality in the context of the global sustainable information society. 'these commoning relations need to be lifted onto the planetary level, and the emerging superordinate system will nest all actors and systems according to the new expanded commoning relations. by that, global governance is carried out' (hofkirchner, 2020a, 2) . globalisation signifies the provision of the commons worldwide. the notion of the global sustainable information society is far from a blueprint of the future society but describes which necessary conditions need to be met if the great bifurcation shall be successfully passed. there are three imperatives of social information that must be obeyed so as to enable actors to take that next step in the evolution of convivial humanity. on the co-operative level, normative, valueladen information must become hyper-commonist, that is, it must orient the consciousness and conscience of the actors towards the reclaiming of the commons in a universal manner; on the communicative level, dialogical information must become all-inclusive, that is, it must not exclude any actor in a universal conversation about the common good; on the cognitive level, reflexive information must become meta-reflexive, that is, it must be concerned about changes of the meta-level that is a universe for all actors (hofkirchner, 2017c) . in order to accomplish that third step in conviviality, those imperatives, investigated by social sciences and humanities, need to be provided to civil society by translational sciences, all of them integrated and implemented by the new paradigm shift as transdisciplinary basis. scientific thinking as well as everyday thinking need to support each other in the comprehension and tackling of the next step. thus, emergentist systemism, informationism and convivialism, shifting research to a remedy for the global challenges, to a reconciliation of determinacy and indeterminacy, and to a logic of emergence, are no academic exercise of no avail. also, common sense is, in principle, capable of understanding those issues of the paradigm shift as well as becoming activist on that premises. the step will be an unprecedented revolutionary one. revolutionary thinking 'needs to focus on future social relations that are not yet actualised. it needs to anticipate them ideationally on a new meta-level, it needs to anticipate the meta-/suprasystem transition of the social systems.' and, taking up an idea of ernst bloch (1967), it 'does not only need to anticipate what is desirable but needs to explore which desirable is also possible in the here and now. only what is potential can be actualised. thus, it looks in the space of possibilities now for the foreshadowing of something that might become a future third' (hofkirchner, 2020b, 4) . the conclusion is that the current state of human evolution has been reached as emergent response to requirements of co-operation through two steps in anthroposociogenesis, namely, from the living together of individual monads towards a joint interaction in dyads and from that to a collective working together that was mediated by social relations -which are the social system's relations of the organisation of the commons -such that a triad has taken over the co-action of humans: a meta-level was constructed as a third that relates the interaction of the group members as a second and any action of a member as a first. now that global conditions require global co-operation, the third needs to be extended to another level ushering in a new phase. current discourses on whether or not our time shall be called anthropocene or whether or not we can stop the climate change or prevent pandemics like the covid-19 one, are dominated by pejorative connotations and negative imaginaries of the future. they lack a focus on the real potentialities of humanity that is just on the point of going through a possible next step of social evolution. extermination is the risk of the crisis. meta-reflexive global citizens, engaging in a global dialogue can kick off the emergence of global governance and thus solve the crisis. fin de siecle social theory -relativism, reduction, and the problem of reason realist social theory -the morphogenetic approach structure, agency and the internal conversation making our way through the world -human reflexivity and social mobility the reflexive imperative in late modernity social evolution: a nonequilibrium systems model an introduction to cybernetics sociology and modern systems theory the synergism hypothesis -a theory of progressive evolution nature's magic -synergy in evolution and the fate of humankind evolutionary systems and society -a general theory of life, mind and culture uncommon sense. tarcher relational sociology -a new paradigm for the social sciences the possibilities of global we-identities die tradition der logik und das konzept einer transklassischen rationalität emergence and the logic of explanation emergent information -a unified theory of information framework self-organisation as the mechanism of development and evolution on the validity of describing 'morphogenic society' as a system and justifyability of thinking about it as a social formation generative mechanisms transforming the social order ethics from systems -origin, development and current state of normativity transdisciplinarity needs systemism. systems 5, 15 creating common good -the global sustainable information society as the good society information for a global sustainable information society social relations -building on ludwig von bertalanffy intelligence, artificial intelligence and wisdom in the global sustainable information society taking the perspective of the third -a contribution to the origins of systems thinking icts connecting global citizens, global dialogue and global governance -a call for needful designs seconde manifeste convivialiste -pour une monde post-néolibéral macroshift -navigating the transformation to a sustainable world emergence and morphogenesis -causal reduction and downward causation the extended mind. the origin of language and culture what is information? propagating organisation in the biosphere, symbolosphere, technosphere and econosphere social systems the evolution of human cooperation the nature of nature sociological theory: what went wrong? routledge global cooperation and the human factor in international relations l'informatisation de la société mega-evolution of information processing systems semiotische schriften, 3 vols the great transformation -the political and economic origins of our time struktur -zur sozialwissenschaftlichen analyse von regeln und regelmäßigkeiten the direction of evolution -the rise of cooperative organization the metasystem transition a natural history of human thinking two key steps in the evolution of human cooperation -the interdependence hypothesis evolutionary systems -biological and epistemological perspectives on selection and self-organization such an account can be reached by a paradigm shift towards emergentist systemism, on the basis of which emergentist informationism is elaborated, on the basis of which, in turn, emergentist convivialism is elaborated. from that perspective, the great bifurcation can be regarded as a problem of coming-of-age of humanity. by accomplishing that evolutionary step, the rise of co-operative organisation would enable 'the emergence of a coordinated and integrated global entity' (stewart, 2014, 35) not seen before. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. key: cord-324185-zt88o3co authors: sovacool, benjamin k.; furszyfer del rio, dylan; griffiths, steve title: contextualizing the covid-19 pandemic for a carbon-constrained world: insights for sustainability transitions, energy justice, and research methodology date: 2020-10-31 journal: energy research & social science doi: 10.1016/j.erss.2020.101701 sha: doc_id: 324185 cord_uid: zt88o3co abstract the global covid-19 pandemic has rapidly overwhelmed our societies, shocked the global economy and overburdened struggling health care systems and other social institutions around the world. while such impacts of covid-19 are becoming clearer, the implications of the disease for energy and climate policy are more prosaic. this special section seeks to offer more clarity on the emerging connections between covid-19 and energy supply and demand, energy governance, future low-carbon transitions, social justice, and even the practice of research methodology. it features articles that ask, and answer: what are the known and anticipated impacts of covid-19 on energy demand and climate change? how has the disease shaped institutional responses and varying energy policy frameworks, especially in africa? how will the disease impact ongoing social practices, innovations and sustainability transitions, including not only renewable energy but also mobility? how might the disease, and social responses to it, exacerbate underlying patterns of energy poverty, energy vulnerability, and energy injustice? lastly, what challenges and insights does the pandemic offer for the practice of research, and for future research methodology? we find that without careful guidance and consideration, the brave new age wrought by covid-19 could very well collapse in on itself with bloated stimulus packages that counter sustainability goals, misaligned incentives that exacerbate climate change, the entrenchment of unsustainable practices, and acute and troubling consequences for vulnerable groups. the global covid-19, or coronavirus disease, pandemic has overwhelmed our societies, shocked the global economy, thrown energy markets into disarray and overburdened struggling health care systems and other social institutions around the world. unlike earlier modern disease outbreaks such as severe acute respiratory syndrome (sars), swine flu (h1n1), or ebola, the covid-19 virus is very easily transmitted by person-to-person contact. further, it has no known preexisting immunities, it is spread by people that do not appear to be sick, and the ratio between infections and fatalities is very high, particularly for older people and people with preexisting medical conditions. in medical terminology, society is undergoing a global pandemic with an immunologically naïve population. when addressing a group of sustainable development and medical professionals in april 2020, columbia university professor jeffrey sachs estimated that the virus that causes covid-19 (i.e. sars-cov-2) could infect half the world's population within the next few years [1] . although the global response to covid-19 may not be fully commensurate to the severity of the challenge, it has nevertheless disrupted longstanding notions of human resilience, disease preparedness, and even global health governance [2] . national and subnational responses to the disease have often been far-reaching and at times transformative, including not only mandatory lockdowns, quarantines and restrictions on travel but key interventions such as evacuations, the distribution of hygiene and sanitation kits, and the suspension of all public visitors. some countries have utilized mass surveillance (as well as tracking and contact tracing apps) to monitor symptoms within their populations, funded community participation in the development and distribution of personal protective equipment, or participated in the design of intersectoral and transnational cooperation and aid packages. more than $11 trillion in fiscal support measures had been announced by governments globally as of june 2020 to mitigate the economic impact from the pandemic, particularly impacts from the lockdown measures implemented to prevent spread of the disease [3] . these relief packages amount to nearly 15% or more of gdp in germany, japan and the united states, with the united states alone signing a massive $2 trillion covid-19 emergency bill and stimulus package in march 2020 [4] . the european union set up a €37 billion coronavirus response investment initiative to provide liquidity to small businesses and the health care sector [5] . the united kingdom also has invested heavily, launching a furlough program where the government paid the wages of 9.1 million affected workers (one quarter of the workforce) at a cost of more than £20 billion with an additional £38 billion in loans to businesses [6] . initial assessments of the economic consequences of the pandemic are sobering, with estimations of a global gdp contraction of 4.9% in 2020 [3] , global trade shrinking by 32% [7] and as many as 300 million people losing their jobs [8] . although the impacts of covid-19 on health systems and national economies are heavily covered in the media, and oft debated in the public, the implications of the disease for energy and climate policy are more prosaic. this special section of energy research & social science seeks to offer more clarity on the emerging connections between covid-19 and topics such as energy supply and demand, energy governance, future low-carbon transitions, social justice, and even the practice of research methodology. it features articles that ask, and answer: what are the known and anticipated impacts of covid-19 on energy demand and climate change? how has the disease shaped institutional responses and energy policy frameworks, especially in places such as africa where covid-19 is negatively affecting ongoing efforts to achieve access to modern energy? how will the disease impact ongoing patterns of innovation, social practices and future transitions, including not only adoption of renewable energy but also the electrification of mobility and mobility-as-a-service? how might the disease, and social responses to it, exacerbate underlying patterns of energy poverty, energy vulnerability, and energy injustice? lastly, what challenges and insights does the pandemic offer for the practice of research, and for research methodology? although ostensibly never intended as measures to reduce energy consumption, air pollution, or climate change directly, responses to the virus have had substantial connections with energy demand and greenhouse gas emissions. the most prominent drivers of these have been mandatory lockdowns or quarantines for households (people are only permitted to leave for essential reasons) and the related severe restrictions on travel. in late april 2020, more than half of the entire global population (54%) was under some form of a coronavirus lockdown, with their movement actively restricted and controlled by their respective governments. the share of energy use that was exposed to containment measures reached 50% [9] . as the top panel of fig. 1 indicates, the largest lockdowns were in india, china, and the united states. one article calculated that more people were in lockdown due to covid-19 than were alive during world war ii [10] . as the other panels of fig. 1 indicate, more than 100 countires had travel restrictions in place due to coronavirus in late march 2020 and the number of commerical flights has plummeted dramatically. abu-rayash and dincer (this volume [11] ) add that road transport is also down significanty given the large number people forced to stay at home. they further show that in canada not only did civil aviation activities drop by 71% compared to business-as-usual in late 2019, but also military aviatation activities were down by a significant 27% in 2020. they also projected that for 2021, greenhouse gas emissions for the canadian transport sector will be nearly 25% lower than than in 2019. covid-19 has not only affected travel and the energy involved in providing it, but also global energy supply chains and the viability of energy firms. writing in this volume [12] , hosseini argues that the most affected renewable energy sector has been solar energy and remarks that indeed, "the covid-19 pandemic has struck the renewable energy manufacturing facilities, supply chains, and companies and slowed down the transition to the sustainable energy world". the causes behind such shifts are manifold: governments have understandably redistributed public funding to combat the disease in a way that leaves less available for renewable energy incentives and tax credits. various renewable energy technology suppliers have placed staff on furlough and also adopted austerity measures and reduced operating capacity. projected installations are down significantly over earlier forecasts; one investment bank in the united states predicted residential-solar installations to fall by 48% year-over-year in the second quarter of 2020 and by 17% in the fourth quarter of 2020. this reinforces the projections provided by irena that total new solar pv capacity additions in 2020 will be roughly on par 2019, but this is as much as 20% below earlier expectations stated by several industry organizations [13] . the off-grid renewable energy sector could face even more dire circumstances, with the world bank noting that the pandemic has seriously disrupted electrifications efforts, meaning that sdg 7 (that encompasses universal energy access by 2030) is now unlikely to be met [14] . it is in this context that mark mccarthy akrofi and colleagues (this volume [15] ) caution that the pandemic could "reverse the enormous progress that off-grid energy companies have made to bring power to some 470 million people in the last decade." solar pv alone is responsible for employing about 4% of the entire african workforce but solar firms and enterprises are already being forced to cut jobs, lay off staff, and confront declining liquidity. due to a strong dependence on imported solar pv technology from china, where manufacturing has declined due to the pandemic, dramatic reductions on future installed solar capacity are also projected for countries such as india [16] . covid-19 is affecting global fossil fuel markets as well. hosseini (this volume [12] ) adds that the coronavirus has disrupted global oil markets far more than any geopolitical event has (such as an embargo from opec), weakening the ability of oil suppliers to control markets and driving down natural gas spot prices into the $2/mmbtu (million british thermal units) range. although geopolitical tensions between saudi arabia and russia played an early role in the 2020 oil price collapse [17] , demand destruction due to covid-19 has indeed been the driving force. jefferson (this volume) [18] writes "in the run-up to the collapse of crude oil prices in early 2020 it was primarily a division between russia and saudi arabia within opec which appeared to be the main force at work, but then the covid-19 pandemic took over, followed by us oil prices turning negative in april 2020, as may contracts expired and traders had to offload stocks with ongoing storage becoming extremely limited." he further states that despite the stimulus and recovery packages being offered by many nations, "there will be many oil sectors incurring losses, from us shale oil and canadian tar sands producers, to many standard crude oil exporters incurring problems with production equipment access and costs, or experiencing lack of competitiveness in key markets." recent data from the international energy agency confirms this point, noting severe reductions in global demand for oil and natural gas (see fig. 2 ). although not representative of all countries and regions, the special section does feature some deep and nuanced assessments of the particular impacts the pandemic is having on national energy supply or demand. nima norouzi and colleagues (this volume) [19] intimately trace the impacts of the virus where it first emerged in wuhan, china, looking at how it impacted not only national energy demand, but also precipitated steep declines (and future uncertainty) in patterns of electricity consumption and oil consumption, industrial productivity and energy markets. they specifically propose a methodology for analyzing such patterns during periods in which historical data becomes inaccurate because of a crisis event such as covid-19. azzam abu-rayash and colleagues (this volume) [20] closely analyze the impacts of the pandemic on electricity demand in ontario, canada, where they calculate declines in electricity consumption during april of about 14% or 1,267 gw and note distinct changes in demand patterns due to quarantine and travel restrictions. this corresponds with some positive externalities as well, including greenhouse gas emission reductions of 40,000 tons of co2 equivalent attributed to covid-19 with a monetary value of $131,844 for the month of april 2020. fig. 3 shows a similar trend in europe, with significant (and positive) reductions in air pollution noted across france, italy, and spain, largely from the curtailment of road transport. abouzar estebsari and colleagues (this volume [21] ) offer a well-reasoned explanation for why related reductions in electricity demand occurred, having analyzed patterns of electricity demand in spain, italy, belgium and the united kingdom (countries with more severe covid-19 movement restrictions) as well as the netherlands and sweden (countries with less restrictive measures). they found that during the second week of april 2020 only in sweden demand remained more or less the same (actually rising slightly) relative to a reference week in 2019. significant reductions were experienced in spain (25%), italy (17.7%), belgium (15.6%), the uk (14.2%) and even the netherlands (11.6%) due to covid-19. the ramifications of covid-19 extend well beyond the avoided energy consumption and emissions associated with travel and household lockdowns; they are also drastically shaping the strength (or erosion) of some energy institutions and policy frameworks. for instance, the pandemic is having a particularly pronounced effect on institutions and policy frameworks in africa, even though it is not (at the time of this writing) a major center of infections or death. mulualem gebreslassie (this volume) [22] writes that the closure of energy intensive businesses and industries in africa has meant a positive shift in that states can now provide scarce energy services to homes or national health care systems. as they conclude, the pandemic "may even convince the african continent to rethink and clear the way for investing more in clean and reliable energy resources and make business processes easy for those who are interested to enter the renewable energy sector." mark mccarthy akrofi and colleagues (this volume [15] ) add that african states are already rushing to intervene and stimulate recovery but do not specifically address how stimulus packages will influence the clean energy transition. further research therefore needs to examine how government stimulus can strengthen the renewable energy sector via various aid packages, economic incentives, and monetary and fiscal incentives-efforts müller et al. note are all broadly consistent with many national policy frameworks across the continent [23] . as already stated, the pandemic has significantly disrupted lives, businesses, and economies. furthermore, it could culminate in lasting effects on social norms and practices. to contextualize this claim, consider that the global response to covid-19 has necessitated unprecedented levels of coordination and information sharing with the intent of ultimately curtailing outbreaks and minimizing harm [24] . this has occurred at multiple levels of society at once across many different types of institutions-making it what the nobel laureate elinor ostrom would have called "organizational multiplicity" and a "polycentric" phenomenon [25, 26] . fig. 4 displays the variety of messages received about covid-19 merely by the lead author, including those from the mass media (covid-19 dominated headlines in the uk for weeks), companies and travel providers, national government, grocery stores, universities, restaurants, social groups and charities, and even churches. this phenomenon parallels what scholar eve kosofsky sedgwick terms the "christmas effect" [27] to describe the way that major parts of western society come together and speak "with one voice" for the christmas holiday. for it is annually during the christmas season that churches build nativity scenes and hold a greater number of masses; state and federal governments establish school and national holidays; the media run major advertising campaigns; and social events and domestic activities align. whenever society combines institutional inertia in this manner, it can exert profound and lasting influence over patterns of behavior, transcending individual firms and people. although certainly not festive, the "coronavirus effect" may be just as effective as the "christmas effect." such messages and strategies of communication underscore an immense amount of coordination across diverse and heterogeneous actors and organizations. the resulting messages were persistent, coming repeatedly and daily. they were prominent, in many times coming from sources people trust. they were multifaceted, coming from many sectors beyond health care including not only those in fig. 4 , but also the mayor of london sadiq khan, banks, libraries, political groups, airlines, friends, and family. one of the authors even had his "smart printer" send an automated email about ink delivery during the pandemic, as well as six emails from his dentist about dental hygiene during the pandemic. and the messages were personal, often prescribing very specific actions or recommendations (about washing, essential travel, social distancing, self-quarantining, and mask wearing) connected to personal health and calling for immediate changes in behavior and practice. given the coronavirus' ability to achieve this "christmas effect," hundreds of millions of people immediately adopted the new behavior of "social distancing," with fig. 5 showing its adoption in india, the united states, the united kingdom and singapore. when making the predictions mentioned in the introduction, jeffrey sachs even remarked that "we should expect to change our behaviors not just during this pandemic but perhaps forever." indeed, wisdom kanda and colleagues (this volume [28] ) argue that in the context of sustainability transitions, the pandemic is causing "disruptive" change not only by potentially accelerating transformations in incumbent socio-technical systems, but also by also affecting emergent innovations and niches. in the mobility sector, they discuss how in finland and sweden the virus has weakened the push for mobility-as-a-service efforts (given they involve sharing rides, not ideal in an environment of social distancing) but had less impact on the push for electric vehicles (given they permit individualized, private transport). they therefore suggest that the impacts of covid-19 on mobility practices and transitions are important research streams moving forward. caroline kuzemko and colleagues (this volume [29] ) take an even broader and more holistic view of the ways the pandemic can place pressure on sustainability transitions in the near-term and the longterm. they argue that covid-19 can alter the scope and pace of energy systems change with declining electricity demand and prices, the disruption of supply chains, and possible rebounds associated with recovery and stimulus packages. it could also shift financial investment flows away from incumbent industries and carbon intensive fuels. the pandemic is changing multi-scalar policy and politics by calling into question longstanding conventions about globalization and interconnectivity, as well as freedom of movement and geopolitical tensions between groups such as the united states and china or the united states and the world health organization. the pandemic is lastly transforming social and political practices, especially those related to telework/working from home as well a preferred modes of travel given the near-term focus on social distancing. here they warn that the lasting imprint of the pandemic is uncertain, with the potential that it entrenches unsustainable practices (such as driving a car) perhaps as great as its ability to introduce more sustainable practices (such as walking). they raise the critical question of whether there will be an acceleration of pre-pandemic drivers for sustainability across the dimensions they consider or whether momentum for sustainability will be lost as pandemic recovery plans are rolled out. kester et al. recently refer to this as the "dialectic" nature of future sustainability transitions, given they can reinforce dominant practices as much as they can reform existing ones [30] . even electric mobility, an innovation kanda and colleagues noted may ultimately be less affected by the pandemic, has unclear and highly differentiated impacts on sustainability as noted in table 1 . this means the adoption of electric vehicles is neither good nor bad in sustainability terms, it instead depends on how such innovations are governed and managed across areas such as vehicle use, daily life, social identity and systemwide environmental effects. the covid-19 pandemic has equally compelling linkages with energy crises, energy poverty, energy vulnerability and energy injustice. kathleen brosemer and colleagues (this volume [31] ) write that the pandemic will only "illuminate and compound existing crises in energy sovereignty." it is worsening already terrible inequalities in health care access among the navajo nation in the united states, where hospitals were overburdened before covid-19 outbreaks with caring for indigenous peoples harmed from coal mining and extraction as well as increases in kidney disease and cancer that resulted from many years of living next to abandoned uranium mines. the pandemic is compounding environmental injustices as covid-19 most affects those with preexisting medical conditions, and yet decades of poor environmental and air quality leave minority groups at heightened risk of having those conditions. it is undermining the ability of energy firms to guarantee the provision of energy access and modern energy services in times of austerity and uncertainty. it is lastly serving as a mechanism for powerful incumbent interests to usurp various regulatory processes that back their own narrow interests at the expense of the public good. one particular example is enbridge "taking advantage of divided public attention and a fraught financial situation during the covid-19 crisis to push forward permit applications" for a major change in the routes of one of their pipelines. such attempts at regulatory manipulation are not limited to north america; kalyani writes how vested interests in india were using the pandemic as an excuse to increase employment in the coal and gas sectors, even though these sectors operate contrary to india's stated climate policies [16] . paolo mastropietro and colleagues (this volume [32] ) add that "the covid-19 pandemic and the consequent lockdown exacerbated energy poverty and insecurity worldwide." however, they also note that the collective response from policymakers has been to attempt to safeguard vulnerable citizens by an array of protection measures including: • disconnection bans; • energy bill deferral and payment extension plans; • enhancement of energy assistance programs; • energy bill reductions or cancellations; • support measures for commercial and small industrial activities; • creation of funds and other support measures to suppliers. after reviewing the global prevalence of these measures, they conclude that two are "best" at minimizing vulnerability: direct energy assistance programs and bans on disconnections, the latter being the most widespread measure introduced by governments during the pandemic. matthew henry and colleagues (this volume [33] ) take an equally useful global analytical lens, reinforcing the recent call for a "just transition." this debate about a "just transition" is ongoing across many countries and provinces, with at least 14 national commissions, policies, or task forces in place across canada, china, czech republic, germany, ghana, indonesia, new zealand, scotland, south africa, spain, the united states and vietnam. as table 2 indicates, a "just transition" is backed by powerful coalitions and groups around the world. as henry and colleagues note, a just transition intends to ensure that as global society decarbonizes, it does not leave anyone behind. efforts must be made to offer income support for workers during the full duration of transition, to tailor local economic development tools for affected communities, and to offer realistic training or retraining programs that lead to decent work. they worry, however, that both the covid-19 pandemic and the global fall in oil prices could complicate ongoing attempts to realize a just transition-especially since the pandemic has resulted in the loss of more than 500,000 clean energy jobs and halted momentum in the push for solar energy and wind energy. they conclude however that the covid-19 crisis represents "a unique opportunity to adopt just transition principles into community and economic recovery efforts." the insights offered by this special section are not just topical or thematic. they also relate to the very art and craft of undertaking research, with some interesting insights for research design and research methodology. both jefferson (this volume [18] ) and kanda and colleagues (this volume [28] ) note how scholars, especially those designing energy programs (such as the global energy assessment) or utilizing table 1 the differentiated impacts of electric mobility and electric vehicles on sustainability. strengthens sustainability weakens sustainability vehicle uptake evs substitute for conventional cars and motorcycle. evs increase car-based mobility by drawing people away from active and public modes of transport. evs used more in intermodal (active and public transport) systems and in combination with measures to discourage car use. evs encourage excessive driving and are bought as second or third (luxury) cars. evs increase the use of car sharing/ride sharing schemes. evs increase the preference for private, single-occupancy driving practices. evs are a wakeup call to address private vehicle use if alternatives are available -public transport, shared services etc. evs, through their cheaper variable costs, enable longer distances, thus supporting urban sprawl. they also compete with public transport and shared services. evs allow for more family time as commutes are part of office hours. evs allow office hours to be extended to include commuting time. expression of gender evs and ev marketing break with gender distinctions through alternative design, comfort and ease of operations. evs and ev marketing reinforce stereotypical car images of masculinity (large, sporty, pickup trucks) or femininity (small, quiet, early generation evs). evs and ev marketing point to new stereotypes around responsible and sustainable car use. evs and ev marketing reinforce stereotypical car discourses of joy and notions of freedom. evs break with class distinctions, as low variable costs enable more mobility for all. evs reinforce class/wealth distinctions as high capital costs imply that only rich can afford them and their benefits. evs, through their broad deployment, signal a need for more efficient low-carbon propellants, alternative modes of transport, less mobility and spur pro-environmental behavior in other sectors evs have lower emissions, which lead to rebound effects: more miles travelled, heavier vehicles, more private vehicles. this is especially relevant if the ecosystem around evs fails to materialize, e.g. no battery recycling, only dump charging, nonrenewable electricity, etc. oil independence evs minimize and signal lower oil/gas consumption, which reduces dependency among households and non-oil producers on oil companies and oil producing countries. evs cause a reduction in demand for oil, which reduces the oil price and makes fueling conventional vehicles cheaper. lower oil prices also reduce oil sector investments and thereby limit production to a smaller group of oil producing countries (those with low variable costs) and counterintuitively increasing oil dependence on a smaller group of countries. evs are designed and promoted by sustainably oriented firms with a focus on innovation and entrepreneurship. evs are co-opted and marginalized by transnational conglomerates with little desire for social change. source: authors modification from kester et al [30] . selected organisations and movements supporting a "just transition" in 2019. conceptual frameworks (such as the multi-level perspective) need to better account for epidemics and pandemics as landscape shocks. the persistence, prominence, multifaceted and personal nature of effective messaging about the virus (discussed in section 3) also remind us about the importance of recognizing culture [34, 35] whenever researchers engage in communication or outreach. fig. 6 even shows the adapting to local culture of messages about social distancing and wearing masks. for instance, images about the virus in the western state of colorado (in the united states) feature skis and cowboys-symbols well embedded in local culture. lucha libre in mexico has played a relevant role in its culture since the late 1950s, mainly due to its masked wrestlers, who have incorporated their own family traditions, beliefs and fears into the design of their masks [36] . the louvre abu dhabi similarly adapted their messages about the pandemic to feature culturally appropriate attire for women, e.g. abayas on images of women performing social distancing. michael fell and colleagues (this volume [37] ) suggest that the pandemic represents not only an existential threat to society, but also a threat to the practice of research, given that it calls into question the internal and external validity of our findings in the academy. this includes both the validly of research done before the pandemic (given that society may never be the same after) and the future robustness of any research conducted during the pandemic (a situation of extreme anxiety and stress far removed from "normal" life, potentially making findings less stable over time). they argue that covid-19 changes the context for research as it creates an environment that may be unprecedented and highly unusual compared to future years. they note the pandemic is reconfiguring demographics in rapid and unforeseen ways, with advanced morbidity and mortality and differentiated effects across age, gender, or ethnicity. they argue (much as we have in section 3) that the pandemic is altering behaviors and daily routines; changing perceived personal and cognitive constraints and feelings; putting pressure on exiting social norms and identities; and materially changing homes and workplaces. taken together, these features of covid-19 may demand that we rethink in meaningful ways the design of future studies, how we determine demographically representative samples, how we collect data, how we interpret findings, and how we translate those findings into recommendations. such considerations are timely and relevant given the explosion of covid-19 publications that have appeared since the start of the pandemic. nearly 7,000 papers on the pandemic were published between february and may 2020 alone, and 3,000 of these were released through the preprint servers biorxiv, medrxiv and arxiv [38] . chen and colleagues (this volume [39] ) further these themes in their work on acceptance of and willingness to pay (wtp) for home energy management systems (hems) during the covid-19 pandemic in new york, usa. they note that the pandemic is having a distinct effect on survey participants with social-psychological variables, such as attitude toward hems and social norms, arising as important factors for explaining technology adoption intention. they also affirm some of the points raised by fell et al. about the unique situation survey respondents have found themselves in. many reported feeling "anxious" and others suggested that they felt they had a high chance of getting infected by coronavirus themselves-a salient message considering that the survey was conducted in new york, one of the global epicenters of the disease. the authors indicate that they hope that their survey results offer a "foundation for researchers to conduct larger-scale energy studies by considering the opportunities to build transdisciplinary collaborations through integrated methods and matching datasets." this might include future work on cultural differences in social distancing, how energy burdens are framed and distributed, what constitutes healthy built-home environments, and other social-psychological factors including perceived fairness or social networking. marius schwarz and colleagues (this volume [40] ) offer additional insights regarding the impacts of the pandemic on research methodology that are perhaps obvious but nonetheless highlight important and perhaps persistent trends. they argue that covid-19 is opening up new ways of doing research, of being an academic, of collecting data and attending conferences. they argue "the pace with which researchers adopted digital formats for conferences, lectures, and meetings showed that currently available tools can substitute many of the physical interactions at work. it also showed that academics are willing to use digital tools for scientific exchange." the pandemic has showcased that academics and those in higher education can quickly and creatively change how they deliver lectures and are accessible to students; how they give guest seminars and discuss findings; even how they may interview for jobs, do research interviews, and host online workshops. they hope that "going digital" in many of these formats and contexts will continue, given the generally positive nature of the energy or carbon savings involved [41] . they further suggest that such digital modes of interaction could come to substitute for physical modes in how academics work in groups, hold team meetings, and socially network. situated at the nexus of the covid-19 pandemic, energy systems, and climate change, this special section has revealed the complex, and often shifting, contours of how the disease is shaping global patterns of energy consumption, policymaking, and governance. it is altering the desirability of some emerging innovations and sustainability transitions, and heightening concerns over energy vulnerabilities and injustices. it is even challenging in fundamental ways how future energy and climate researchers go about their work. as table 3 reveals, these intersections can be weighty and protean, but they are also perilous and precarious. for every noted positive intersection with some aspect of stainability or doing research, or benefit, we see an almost equally salient negative intersection, or risk. take one of these examples: lowering demand for, and prices of, fossil fuels. is this a blessing-foretelling that fossil fuels are becoming unviable-or a curse-cementing fossil fuels as cheap and abundant sources of energy to be utilized for many years to come? potently, it is the aspect of energy justice and vulnerability that particularly has more negative intersections (risks) than positive ones (benefits). covid-19, as various authors presented in this special section, represents a strategic opportunity to work in parallel on designing and implementing economic and social recovery programs and advancing the global climate agenda towards a just transition. what is also evident from the special section is the multi-scalar and multifaceted nature of social responses to the pandemic, which have created a "christmas effect" or "coronavirus effect" of: • instructing people how to immediately alter and change their routines and practices in response to a crisis (e.g., social distancing, wearing masks, quarantining, and handwashing); • bolstering the strength and resilience of infrastructure and institutions (e.g., of hospitals and medical research institutions); • building capacity to monitor and manage emergency measures (e.g., trace infections, test people); • properly financing social responses in ways commensurate to a grand challenge (e.g., donations to national health services or the world health organization); • restoring economic activity gradually and via approaches that are backed by science (e.g., mandatory lockdowns and partial reopening, deployment of government rescue and stimulus funds); • harnessing innovation and rapidly developing critical new technologies (e.g., new therapeutics and vaccines); • utilizing a variety of trusted institutions and individuals to convey information and messages (e.g., the cdc, major news outlets, doctors and medical professionals); • while undertaking these steps, protecting the vulnerable (e.g., those with preexisting conditions, the unemployed and/or the indigent). although the impacts from the pandemic have so far been far from equitable or welcomed by the majority of people, this list of actions does offer a possible recipe for how future energy and climate planning could proceed as well, if policymakers and planners see the opportunity to transform social practices and institutions as much as the pandemic has. this could help achieve a "christmas" or "coronavirus" effect for energy and climate policy that encompasses: table 3 the dialectic or dualistic impacts the covid-19 pandemic can have on energy and climate sustainability and research. energy and climate impacts of the virus -sharp reductions in travel related energy consumption and carbon emissions -immediate reductions in electricity consumption -depression of fossil fuel markets (particularly coal, oil and gas) -immediate reductions in global air pollution -redistribution of scarce energy resources in african nations to homes or national health care system -acceleration of african stimulus packages for low-carbon transitions -disruption of clean energy jobs -disruption of clean energy supply chains -risk of real and substantial rebounds in consumption accelerated by stimulus and recovery packages -disruption of off-grid energy markets and eroded progress on energy access programs -potentially bolstered trends in the electrification of private transport -shifted financial and investment flows away from carbon intensive assets -transformed social and professional practices in ways that are less energy intensive (e.g., working from home, walking, cycling) -undercutting of demand-side innovations such as ridesharing or mobility-as-a-service -dis-incentivizing mass-transit and public transport due to social distancing norms -calling into question the increasing interconnectivity and globalization of socio-technical systems -accelerating a geopolitical divide between the united states and other actors (e.g. china, world health organization) connections with energy justice an vulnerability -implementation of a variety of emergency protective measures including bans on disconnection and targeted assistance packages -increased attention to the principles of a "just transition" and the need for stimulus packages to be low-carbon and equitable • instructing people how to immediately reduce their carbon footprints (e.g. using energy efficient technologies in their homes, eating less meat, avoiding air travel [42] ); • bolstering infrastructure, institutions and industrial strategy (e.g.. incentives for clean energy manufacturing and deployment including wind turbines, solar panels, electric vehicles [43] ); • building capacity to mitigate, monitor and manage emergency measures (e.g., tracking plans for universal energy access and sdg7, deployment of micro grids, bans on disconnection [44] ); • properly financing social responses in ways commensurate to the challenge (e.g., substantially increase funding for national and multinational climate and development organizations or green investment banks, investment for deployment of low-carbon technologies and infrastructure [45, 46] ); • restoring economic activity gradually and via approaches that are backed by science (e.g., development pathways synchronized to the ndcs of the paris accord or the findings of the ipcc, investment of economic stimulus funds in low-carbon technologies, green new deals [47] [48] [49] ); • harnessing innovation and the development of new technologies (e.g., the next generation of transport fuels, energy storage, smart grids or hydrogen fuel cells) [50] [51] [52] ; • utilizing trusted institutions and individuals to convey persistent and repeated information, messages and narratives in ways that resonate with audiences (e.g., major news outlets, the ipcc, governments, major corporations, churches, restaurants and celebrities sent persistently through various media channels) [53] [54] [55] [56] ; • while undertaking these steps, protecting the vulnerable (e.g., households in energy or mobility poverty, marginalized groups or indigenous peoples) [57] [58] [59] [60] . if such actions were taken in concert, progress on energy and climate would likely outpace all previous targets and milestones, rather than remaining chronically underfunded, underperforming and continually lagging behind expectations. both of these core findings-that covid-19 matches its promise of change with precariousness about the direction it goes, and that covid-19 responses offer a possible template for future energy and climate action-remind us that we remain at a critical but fragile crossroads. as much as we see great progress in efforts toward ameliorating the covid-19 crisis, we also see the same types of hindrances that have plagued progressive energy policy and climate action. specifically, lack of attention to warnings about a potential crisis, delayed responses to building evidence of crisis onset, nationalism at the expense of the global good, politics overshadowing social welfare, marginalized populations (e.g., people of low socio-economic status, or people in low and middle income countries) experiencing adverse consequences at higher rates, conspiracy theories and fatigue of mitigation measures. as fig. 7 both comically and tragically seeks to depict, climate change is akin to a perpetual pandemic, but one that multiplies threats in steeper and more severe ways than covid-19 or its economic consequences. markard and rosenbloom have the right of it when they write that unlike the pandemic, "climate change, in particular, threatens the very basis for continued human prosperity and requires an equal, if not greater, societal mobilization" [61] . hence, the opportunities emerging from the pandemic for energy systems and climate policy can be secured or squandered. without careful guidance, governance and consideration, the brave new age wrought by covid-19 could very well collapse in on itself with bloated stimulus packages, misaligned incentives, the embedding of unsustainable practices, and acute and troubling consequences for vulnerable groups. ssdn: epidemiology and economics of covid19 covid-19 gives the lie to global health expertise world economic outlook: the great lockdown trump signs $2 trillion coronavirus stimulus bill jobs and economy during the coronavirus pandemic uk furlough scheme spending exceeds 20 billion pounds trade set to plunge as covid-19 pandemic upends global economy more people are now in 'lockdown' than were alive during world war ii analysis of 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australia the misallocation of climate research funding the green new deal in the united states: what it is and how to pay for it canada's green new deal: forging the socio-political foundations of climate resilient infrastructure? a post mortem of the green deal: austerity, energy efficiency, and failure in british energy policy critical perspectives on disruptive innovation and energy transformation innovating innovation-disruptive innovation in china and the lowcarbon transition of capitalism are low-carbon innovations appealing? a typology of functional, symbolic, private and public attributes credibility, communication, and climate change: how lifestyle inconsistency and do-gooder derogation impact decarbonization advocacy climate change strategic narratives in the united kingdom: emergency, extinction,effectiveness using stories, narratives, and storytelling in energy and climate change research greenberg energy policy and research: the underappreciation of trust advancing an energy justice perspective of fuel poverty: household vulnerability and domestic retrofit policy in the united kingdom mobility justice in low carbon energy transitions justice, social exclusion and indigenous opposition: a case study of wind energy development on the isthmus of tehuantepec energy justice discourses in citizen deliberations on systems flexibility in the united kingdom: vulnerability, compensation and empowerment a tale of two crises: covid-19 and climate the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. key: cord-349256-ky3h37o6 authors: abrams, elissa m.; greenhawt, matthew title: special article: mitigating misinformation and changing the social narrative date: 2020-08-18 journal: j allergy clin immunol pract doi: 10.1016/j.jaip.2020.08.007 sha: doc_id: 349256 cord_uid: ky3h37o6 nan conflicts of interest: elissa abrams is a collaborator with the institute for health metrics and 23 evaluation, is on the national advisory board for food allergy canada, and is on the national 24 food allergy action plan action steering team for food allergy canada. matthew greenhawt is 25 supported by grant #5k08hs024599-02 from the agency for healthcare research and quality; is 26 an expert panel and coordinating committee member of the niaid-sponsored guidelines for 27 peanut allergy prevention; has served as a consultant for the canadian transportation agency, 28 thermo fisher, intrommune, and aimmune therapeutics; is a member of physician/medical 29 advisory boards for aimmune therapeutics, dbv technologies, sanofi/genzyme, genentech, 30 nutricia, kaleo pharmaceutical, nestle, acquestive, allergy therapeutics, allergenis, aravax, and 31 monsanto; is a member of the scientific advisory council for the national peanut board; has 32 received honorarium for lectures from thermo fisher, aimmune therapeutics, dbv 33 technologies, before brands, multiple state allergy societies, the american college of allergy 34 asthma and immunology, the european academy of allergy and clinical immunology; is an 35 associate editor for the annals of allergy, asthma, and immunology; and is a member of the 36 joint taskforce on allergy practice parameters 37 38 39 mitigating misinformation and changing the social narrative 40 41 the sars-cov-2 covid19 pandemic has exposed a defining issue of our in recent years, there has been increasing reliance upon cable news cycles and news 57 reporting from social media, often occurring in real time. during public health crises, such as 58 the recent h1n1 epidemic, with heightened risk perception, the public has become more 59 heavily reliant upon social media to inform their understanding of health information. this has 60 become particularly evident during covid-19. this information is available for public 61 consumption, often unvetted for accuracy, and at times politicized. however, even prior to the 62 pandemic, there was a shifting to the internet and forms of social media (such as facebook and 63 twitter) for basic medical information, easily accessible by patients for consumption and 64 professionals for dissemination. with this has come the tendency for misinformation to be 65 disseminated within many aspects of medicine. allergy as a specialty has not been immune to 66 this. over 50% of all patients may search online information sources before allergy 67 appointments. if online information is incorrect, as noted in an article about "dr google", 'this 68 can not only damage the patient-provider relationship, risk polarizing health beliefs and set up 69 discourse between clinician and patient, but also lead patients to seek non-evidence-based 70 promises of miracle cures, costly treatments, or unnecessary testing.' 4 worse, it may deter 71 actual medical progress being made to address treatment of their allergic disease. 72 take as one example igg4 testing as a marker of food allergy or sensitization, a test that 73 has been uniformly denounced by multiple allergy organizations including the canadian society 74 of allergy and clinical immunology. however, this is heavily marketed, often directly to 75 consumers or by non-allergists, as a valid and reliable test. igg4 testing has potential harms 76 including leading to unnecessary elimination diets (impacting growth/nutrition) ,heightened 77 anxiety about food choices, increased healthcare costs/service utilization, and the potential to 78 increase the risk of ige-mediated food allergy in young children due to misguided advice for 79 specific food avoidances. 5 however, despite the consistent disapproval of using these tests by 80 the medical community, igg4 testing is increasing in popularity among certain segments of the 81 population, is helping to foster labels such as 'non-celiac gluten allergic' within popular culture, 82 and may be driving consumer demand for such tests (some of which can be obtained without 83 j o u r n a l p r e -p r o o f clinician involvement). in fact, in canada, allergy testing was the most common test advertised 84 by naturopathic clinic's websites, and 'allergies' was the most common treatment ailment 85 advertised. 6 the centers for disease control found that in 2016 americans spent $30.2 billion 86 out-of-pocket on complementary health approaches. 7 87 another example, consider influenza vaccination in children with asthma. while the 88 influenza vaccine is broadly and universally recommended in the united states population, 89 children with asthma are noted to be higher risk for influenza-related respiratory complications, 90 and influenza vaccination is uniformly recommended among children 6 months and older. 91 asthma is the most common co-morbid medical condition among children who require 92 hospitalization due to influenza infection. 8 however, influenza vaccine uptake among children 93 with asthma in the united states can be as low as 48%. 9 for years, there was question of the 94 safety of this vaccine in asthmatics, build largely on expert theory and thin on evidence. 95 ultimately, after years of equivocation, this myth has been debunked, but doubt still lingers, 96 years later. studies have noted significant misinformation contributing to vaccine hesitancy 97 including concern that the vaccine might cause significant harm, low perceived safety and 98 efficacy of vaccines, low perceived susceptibility to complications from influenza, and 99 significant misconceptions about the influenza vaccine (such as that influenza vaccination can 100 cause symptomatic flu). 10 101 so why is such misinformation so pervasive? misinformation dominates our social culture, 102 and yet, 'advocates and affected individuals dominate discussions' while researchers and health 103 professionals are busy diagnosing/researching. 11 while medical policy and research is 104 important, it may not be reaching our patients, as the public becomes more reliant on the 105 media and social relationships to inform their level of risk perception, and to become their 106 more trusted source of healthcare information. who society views as a trusted healthcare 107 expert has shifted, in particular when there is ample access to a litany of information for 108 patients to research and influence their health beliefs. 109 with increasing health social movements, there is now extended overlap between scientific 110 knowledge, popular culture and a more complex 'public shaping of science' which physicians 111 have to engage, and not dismiss. 12 the media has significant leverage on the framing of public 112 health perception, and is instrumental in changing this narrative. 11 engagement of the media 113 through interviews, blogs, and press releases, and distilling of this message through social 114 media sources, would be impactful and is required to reach our patients. as noted in a recent 115 infoveillance study of tweets during the covid19 pandemic, 'there is…a need for a more 116 proactive and agile…health presence on social media to combat the spread of fake news.' 13 117 social media could also be used to monitor and track misinformation, and therefore be an 118 instrument to help respond to it. one such avenues is a public twitter dataset, as was recently 119 established for covid19. 14 this dataset is available to the research community and has 120 republished over 123 million tweets as well as statistics related to those tweets such as 121 reactions to covid-19 related events. the interesting aspect of this data set is that it 122 aggregates in real time, and can capture trends in how misinformation may segment among 123 viewers. this type of social media dataset is anticipated to have a role moving forward in 124 tracking misinformation as well as contextualizing the covid19 on-the-ground response. 125 physicians can sign up for alerts on major search engines, join listserves to receive updates, and 126 use the available information to better arm ourselves to counter misinformation. 127 j o u r n a l p r e -p r o o f however, in shifting the narrative to target misinformation we need to recognize that social 128 media is only one part of the larger problem. the ecological model, often used in health 129 promotion, provides a broader way of contextualizing misinformation in terms of individual 130 influences, relationships, community and society. 15 as noted in a recent book, 'ecological 131 models of health behavior emphasize the environmental and policy contexts of behavior, while 132 incorporating social and psychological influences. ecological models lead to the explicit 133 consideration of multiple levels of influence, thereby guiding the development of more 134 comprehensive interventions.' 15 135 as one example, consider influenza vaccine hesitancy. while social media may influence an 136 individual's health behavior, there is also a distinct role for interpersonal influences such as 137 interest among social circles in alternatives to traditional medications, and both familial and 138 peer group vaccine hesitancy. there are also broader community and societal factors 139 contributing to vaccination rates and attitudes including access to primary care, cost, and lack 140 of compulsory vaccination policies in the united states. to truly change the social narrative, 141 whether it be covid19 response, alternative health beliefs, or vaccination, we need to view an 142 individuals' opinions, even if largely shaped by social media, within their broader social and 143 societal context. 144 the covid-19 pandemic is shifting our world in ways beyond our imagination but has also 145 uncovered ways in which our system has to change. one of those ways is an increasing 146 recognition and response by physicians to the pervasive and dangerous misinformation that 147 abounds, in all areas of medicine. as physicians, we need to learn how to contribute to the 148 discussion and better inform our patients and change our mindset to engage in less traditional 149 avenues of knowledge dissemination. 150 united nations covid19 response health utility, and health beliefs among the us population during the shelter-in 161 place phase of the response to the sars-cov-2 pandemic how dr google is impacting parental medical decision making csaci position statement on the testing of food-165 specific igg supported by science?: what canadian naturopaths advertise to the 167 public factors associated 177 with refusal of childhood vaccines among parents of school-aged children: a case-control 178 study frames, claims and audiences: construction of food 180 allergies in the canadian media medical modernization, scientific research fields and the epistemic politics of 182 health social movements top concerns of tweeters 184 during the covid-19 pandemic: infoveillance study tracking social media discourse about the covid-19 186 pandemic: development of a public coronavirus twitter data set health behavior and health education theory, research, and practice 189 chapter 20 -ecological models of health behavior key: cord-286705-biundkbv authors: shek, daniel t. l. title: protests in hong kong (2019–2020): a perspective based on quality of life and well-being date: 2020-03-13 journal: appl res qual life doi: 10.1007/s11482-020-09825-2 sha: doc_id: 286705 cord_uid: biundkbv triggered by the fugitive offenders and mutual legal assistance in criminal matters legislation (amendment) bill 2019 in hong kong (extradition bill), many protests have taken place in hong kong in 2019–2020. using a perspective based on quality of life and well-being in different ecological systems, it is argued that the process of introducing the bill is the “heat” which has ignited the “fuels” represented by 12 pre-existing and new issues in quality of life and well-being. these issues included distrust in the central government, lack of national identity, political dissatisfaction, economic strains, mental health threats, drop in family quality of life, lack of life skills education, lack of evidence-based national education in the formal curriculum, slow response of the government, and alleged excessive use of force by the police. the fire has been intensified by “four strong winds”, including disinformation and misinformation, anonymity of the protesters, public support for the students, and support given by parties outside hong kong. possible solutions in terms of promotion of quality of life and well-being with reference to the fire triangle are discussed. are well-designed training and operation manuals for protests and strikes which can be easily downloaded from the internet. fifth, vandalism has been extensive in the social event. these included damage of 740 sets of traffic lights, 52.8 km of railings along the road, and 21,800 square meters of paving blocks (yau 2020) which require some hk$65 million to repair. besides, there was damage of 85 mass transit railway stations and 68 light railway stations, assault and doxing people holding contrary political views, and damage of shops owned by those who did not support the social movement (rthk radio 1 2020). perhaps the most striking examples are the damage of the legislative council building on july 1, 2019 and the occupation of the chinese university of hong kong and the hong kong polytechnic university in november 2019. besides, the use of foul language and physical violence to informally "settle" interpersonal conflicts was not uncommon in the movement. sixth, despite the great extent of violence and vandalism, public condemnation of such behavior was not strong. some people even show support for the use of violence in the social movement. for example, a survey showed that roughly 20% of the respondents supported the use of violence as a tactic and more than half of the pro-democracy respondents endorsed the use of laser pointers against the police (sum 2019) . finally, the social event is highly political in nature. although its origin was to protest against the extradition bill, it has gradually evolved into a movement with the slogan of "five demands, not one less". these five demands include "full withdrawal of the extradition bill", "retracting the classification of protesters as 'rioters'", "amnesty for arrested protesters", "an independent commission of inquiry into alleged police brutality", and "dual universal suffrage, meaning for both the legislative council and the chief executive" (wong 2019b) . besides, the slogan of "liberate hong kong, revolution of our time" emerged as the social event moved on. during the social movement, protesters have placed advertisements in foreign newspapers and waved us and uk flags during the protests, appealing for support from foreign governments. obviously, quality of life has been much hampered in the social movement. first, the economy has slowed down because of the social unrest. for example, the number of tourists has dropped by 56% (cheng 2019) and the unemployment rate has been climbing in the past few months. second, protests have created much disturbance to the ordinary lives of people. for example, during the occupation of the chinese university of hong kong, the east railway system service was much disturbed and the main highway joining the eastern part of the new territories was blocked. the cross-harbor tunnel was also out of service during the occupation of the hong kong polytechnic university by the protesters. as a result, workers had to take leave involuntarily or spent much longer traveling time. third, the social movement has been divisive and polarized for people with different political views. for those who support the protesters and five demands, they are called "yellow ribbons". on the other hand, those who do not support the protesters, they are called "blue ribbons". in many families, social groups, and work settings, people have become alienated and have conflicts with each other (chow 2019) . finally, the social movement has created well-being problems in people of hong kong. based on a large community sample, ni et al. (2020) reported that the prevalence of probable depression was 11.2% in 2019 which was much higher than that during 2009-14 (1.9%) and 6.5% after the occupy central movement in 2017. besides, the estimated ptsd prevalence rate was 12.8%. mogul (2019) also pointed out that ptsd symptoms were common in the protesters. ng (2020) used the term "mental health tsunami" to describe the situation which was brought forth by the repeated and direct involvement in violent conflicts between protesters and police, exposure to violence, disintegration of families and friends, and the declining economic conditions. why the fire broke out? quality of life and well-being issues as fuels we can use "fire" to represent the social event which has lasted for roughly 8 months. obviously, the fundamental question is why the fire broke out. in view of the highly political nature of the social movement, there are views suggesting that the event was initiated and orchestrated by forces outside hong kong. such views are primarily driven by the notion of "color revolution" which has occurred in places like tunisia and ukraine. in addition to western influences, taiwan has been suspected to play a strong role in the social movement. the reasoning is that by highlighting the message that the "one country, two systems" arrangement does not work, the president of taiwan (tsai ing wen) would get more support in the presidential election in 2020. although these conspiracy conjectures make sense on the surface, we need empirical evidence that cannot be easily substantiated. also, conspiracy theories alone do not give full attention to the psychology of the protesters and they cannot explain the perpetual involvement of young people as well as the determination of some of them to die for the sake of producing political changes in hong kong. unfortunately, not many systematic investigations have been conducted to explore the genesis of the social movement. a pioneer paper on the protests in hong kong in 2019 was written by purbrick (2019) who argued that in addition to errors in police operations, housing, poverty, and governance are three key factors underlying the social event. in this paper, we attempt to understand the social movement from the perspective of quality of life and well-being. the main thesis is that the social unrest exists because there are threats to and issues in quality of life and well-being in hong kong. from an individual perspective, quality of life is a multi-dimensional construct. according to felce and perry (1995) , overall quality of life is a function of three factors, including objective life conditions, including physical well-being (e.g., personal safety), material wellbeing (e.g., security), social well-being (e.g., acceptance and support), emotional well-being (e.g., respect) and development and activity (e.g., choice and control), subjective feelings of the objective life conditions and personal values and aspirations. obviously, threats to quality of life in these domains would arouse fear and distress for an individual. from a societal perspective, organization for economic co-operation and development (oecd 2011) proposed the following indicators of human well-being: health status, work and life balance, education and skills, social connections, civic engagement and governance, environmental quality, personal security, and subjective well-being. again, threats in well-being in these domains, particularly in the areas of governance and personal security, would lead to strong reactions from people in the society. according to the ecological perspective, there are different ecological systems governing human development where individuals experience well-being (or ill-being) in different systems. these include the personal system (e.g., threat to freedom and finding life meaning through involvement in a "revolution"), interpersonal system (e.g., peer influence and bonding amongst peer protesters), family system (e.g., lack of family warmth), social system (e.g., sensational social media influence), and political system (e.g., lack of trust in the government and support for protesters from bodies outside hong kong). by examining the quality of life and well-being in different systems, we can get some clues on the related deficiencies and threats in quality of life which have shaped the development of the social event in hong kong in 2019-2020. the fire triangle: fuels, heat, and oxygen according to the fire triangle, there are three basic elements of fire -fuels, heat, and oxygen. in this paper, we treat the quality of life and well-being issues as "fuels", the extradition bill as "heat", and some contextual influences (such as support from the general public for young people's involvement in protests) as "oxygen". there are ten pre-existing fuels and two new fuels for the "fire" as follows: pre-existing fuel no. 1: distrust in the central government hong kong had been a british colony from 1841 to june 30, 1997. although hong kong physically returned to china on july 1, 1997, it has been difficult for hong kong people to develop a high level of trust in the beijing government for two reasons. first, people tend to fixate on the unfortunate history of the cultural revolution and june 4th incident of 1989. second, as corruption in mainland china has been a thorny problem since the opening of china in the late 1970s, governance in china has been seen in a negative light by hong kong people. empirically, studies showed that the level of trust in the beijing government has been fluctuating with roughly 47.7% of the respondents having no trust in the first 6 months of 2019 (public opinion poll, the university of hong kong 2019b). lack of trust in the central government clearly suggests political uncertainty which constitutes a threat to the political well-being of hong kong people. studies have shown that 75% of the young respondents regarded themselves as "hongkonger" rather than "chinese" (public opinion poll, the university of hong kong 2019a). the weak national identity can be attributed to the vast differences in cultural and social background between hong kong and mainland china, such as views on individual freedom and governance. the negative stereotypes formed for mainland chinese people (e.g., poor hygiene and snobbishness) also constitute blocks to identify with the chinese national identity. as national identity is an important aspect of self-identity, a blurred national identity is a threat to personal well-being, which suggests a sense of rootlessness. under the british colonial rule, the governor was not elected but appointed by the british government (i.e., hong kong people had no say). until the last decade before the handover, the colonial government began to introduce some political reform initiatives. the basic law also stipulates that there would be a progressive change in the election systems of the chief executive and legislative council members. although the political system can be regarded as more "open" after 1997, hong kong people (particularly the youngsters) are not satisfied for two reasons. first, the current political system gives heavier weight to the businessmen who have been blamed to create economic and social inequalities in hong kong. second, as the government of the sar has not been working effectively after the handover, people generally want to have more say in important decisions for hong kong. obviously, dissatisfaction with the political system is a threat to political well-being (oecd 2011). one related factor that should be considered is the ideals of young people. in the good old days, the formula for youth development is to motivate young people to succeed in academic study (entrance to a government-funded university and study in a professional programme), get a job with a handsome salary and establish a happy family. however, for the generation z (i.e., commonly refers to young people born in the late 1990s and early 2000s), they are more autonomous, technology-oriented and more concerned about social issues (dolot 2018; gaidhani et al. 2019) . in other words, putting the material good life as the "carrot" does not really work for students of generation z because material possession may not be their primary concern. pre-existing fuel no. 4: economic strains (poverty, high housing price and high cost of living) although hong kong enjoyed almost full employment as well as high gpd per capita in early 2019, wealth distribution has been a persistent problem: roughly one in four adolescents grow up in poor families; the gini coefficient is disturbingly high (oxfam 2018); there were around 1.4 million poor people with 612,900 poor households in 2018 (government of the hong kong sar 2019). assuming 1% of the poor people were dissatisfied young people, it means around 14,000 young people were on the street protesting against the government. research has showed that poverty is a risk factor affecting the quality of family life and individual well-being, which would in turn undermine the healthy development of adolescents and cause problems such as the development of externalizing behavior. it also impairs the quality of life of the hong kong society. historically speaking, housing has been a thorny problem in hong kong. unfortunately, the problem has been much aggravated after the handover back to china. according to some surveys, the housing price in hong kong and the cost of living were the highest in the world (arcibal 2020) . there are three consequences of this situation. first, young people would find it difficult to get married, hence creating much frustration in youngsters. for some of the married young couples, they may be forced to stay in sub-divided flats that have security and hygiene problems. second, parents are expected to help children (as reflected in the saying of "the success of young people depends on the hard work of the father") which creates much intergenerational conflict in the family. finally, the rocket high housing price creates a sense of hopelessness in young people because it would be a heavy burden even for young professionals to buy a decent flat. the high housing price obviously triggers much negative emotions in young people. with the extradition bill, it is a good opportunity for them to air out their anger and hopelessness as well as a desire for "mutual destruction" (i.e., let us have nothing together). the high housing price is an obvious threat to physical well-being (shelter), psychological well-being (hopelessness), family well-being (conflict and tension within the family), social well-being (rich-poor divide), and political wellbeing (hatred for the government for its ineffective housing policies). although there was almost full employment in 2018, youth employment has been an issue of concern for many years (government of the hong kong sar 2019). with the introduction of more self-financed sub-degree and degree programs, many graduates are not able to move up the social ladder because the real income for university graduates has been quite stagnant since the handover (new century forum and new youth forum 2015). again, lack of upward social mobility triggers negative emotions in young people which eventually promotes a sense of hopelessness in young people (shek and siu 2019b) . this also explains why young people have psychological resistance to return to china because their lives have not improved much after the handover. it is also why some young people waved the british flag during demonstrations which are clearly a sign of remembering the "good old days" for university students under the british rule. obviously, the lack of opportunity for hong kong young people to have upward mobility is a serious threat to individual well-being and societal quality of life. nevertheless, young people are commonly not aware of the fact that the lack of social mobility also exists in many developed countries in the world and there was also much inequality under the british rule. under the influence of the chinese culture, hong kong emphasizes strongly on academic excellence and achievement, with success commonly defined in terms of good grades in public examinations and earning a lot of money. such social mentalities have three consequences. first, striving for academic excellence can be very stressful for young people which impairs their personal well-being. one consequence is that young people are prone to develop internalizing behavior such as depression and suicide. in fact, the appeal for "mutual destruction" can be regarded as a manifestation of mass internalizing behavior. second, the exam-oriented system naturally creates "losers" in young people. as only 18% of high school graduates can get governmentfunded university places, the number of "losers" created every year is quite substantial. third, it would be difficult for students to find authentic life meaning in study except "getting good grades". most of the time, young people in hong kong have "foreclosure" identity according to the psychosocial theory of erik erikson (i.e., commitment without crisis). hence, when young people face the slogan of "liberate hong kong, revolution of the time", the social movement gives them a noble and romantic life meaning which can be easily incorporated in their identity. in short, the morbid emphasis on academic excellence undermines the academic and personal well-being of students which can be easily filled by some heroic and grand ideals such as revolutionize hong kong to make the tomorrow better. young people in hong kong face many psychosocial stresses, including academic stress, low income, high property price, long working hours, and a small living environment. shek and siu (2019b) argued that the developmental context for hong kong adolescents is "unhappy", including unhealthy values, de-emphasis of holistic youth development, rise in hopelessness but drop in life satisfaction, emphasis on academic excellence but de-emphasis on academic quality of life, poverty, parenting issues, and drop in family well-being. obviously, stresses and risk factors in adolescent development can easily be translated into poor mental health amongst young people. there are research findings showing that adolescent hopelessness rises but life satisfaction drops in adolescent years (shek and liang 2018) . at the same time, their academic stress increases but their perceived support from school decreases (shek and chai 2019) . in other words, the well-being of adolescents in hong kong is at risk. in the special issue edited by shek and siu (2019b) , the papers show that mental health is a growing concern in young people in hong kong. there are also findings suggesting that mental health problems in university students are prevalent (lo et al. 2018 . in other words, young people with poor well-being are emotionally charged time bombs waiting to be detonated. finally, students with special educational needs may be a factor that should not be overlooked. when we examine the slogans of the protesters, it is not uncommon to see that there are many incorrectly written chinese characters. there are two possible explanationseither the protesters are poorly educated or they are dyslexic who are commonly having difficulties in writing chinese characters. it is noteworthy that students with special education needs (e.g., those with autistic features or dyslexic) are stubborn in their views. there are several disturbing developments of families in hong kong, including rising divorce and remarriage rates, rising cross-border marriages, worrying child abuse rates, growing number of parents who are not hong kong residents, growing cross-border workers, long working hours, and aging population. these problems negatively affect young people who experience family alienation and conflicts arising from unfavorable family circumstances. obviously, the social event constitutes an excellent opportunity for them to feel the warmth amongst the "comrades" and have deep sharing and mutual concerns amongst the participants who may not have such warm experience before. in other words, low family quality of life is a strong precursor for active and romantic participation in the social movement. nevertheless, there are also reports saying that some parents actually encourage their kids to actively participate in the movement, including engaging in violent behavior. although young people face many psychosocial stresses and challenges, there is weak systematic life skills education for adolescents. in many countries, social-emotional learning, soft skills and psychosocial competence, including the promotion of selfunderstanding, social understanding, interpersonal competence, responsible decision making, and self-management skills are strongly promoted. although critical thinking is emphasized in liberal studies under the new high school curriculum in hong kong, it is argued that students actually learn "criticism mentality" instead of "critical thinking". in a series of cross-sectional and longitudinal studies, showed that while different stakeholders endorsed the importance of life skills education in the formal curriculum, they perceived that life skills education in the formal curriculum was insufficient and life skills development in adolescents was incomplete. without such systematic education, the personal well-being of young people in hong kong cannot be adequately protected (shek and siu 2019a) . the neglect of soft skills education for young people in hong kong means that they do not possess adequate social competence skills to negotiate with other people or resolve conflicts, which are much needed. as intense anger and hatred are involved in the social event, learning how to empathize (look at things from others' perspective), manage one's and others' emotion (emotional quotient), forgive (write off emotional feelings and debts), and re-conciliate (re-build new relationships and move on) are important tasks for adolescents. these life skills are very important because there are studies showing that hong kong adolescents showed narcissistic behavior (leung 2013 ) and positive youth development attributes negatively predicted the use of foul language in adolescents (shek and lin 2017). although there is an area on moral, civic and national education in the formal curriculum, the policy and scope of the national education curriculum are unsystematic and uncoordinated. in a study comparing related moral, character and citizenship education in chinese societies (hong kong, mainland china, and taiwan) and non-chinese societies (singapore, uk, and usa), shek and leung (2018) identified several problems in this area, including absence of comprehensive planning and policy development, blurred concepts and lack of focus on holistic student development, lack of emphasis of moral and character education, problem of "penetrative" approach, absence of formal curriculum materials, problematic operational strategies, and lack of evaluation. besides, while national education is undertaken by the education bureau (formal school curriculum), the home affairs bureau (committee on the promotion of civic education), and the labor and welfare bureau (youth section in the social welfare department), there is little coordinated effort amongst the different bureaus. the lack of related education suggests that the personal well-being of young people in terms of moral competence cannot develop in a healthy manner. obviously, there are two difficulties in implementing moral education in hong kong. the first one is "what" should be covered. if the coverage covers chinese history in the past century, students can learn more about what happened in china, particularly the exploitation under western imperialism. however, as history is multifaceted, how to interpret historical facts is a thorny issue. the second issue is "how" to assess the outcomes. while an increase in knowledge is easy to demonstrate, positive change in attitude and behavior may not be easy to assess objectively. in view of the sensitive nature of chinese history, some schools simply cut the subject under the new education reform. under these circumstances, it is not surprising to note that many young people are not familiar with modern chinese history and geography of china. the responses of the government to the protests since june 2019 have been regarded to be slow and ineffective. besides condemning violence and vandalism, the government has relied primarily on the police to deal with the protests. the attempt to have dialogues with the public also does not appear to be very successful. most important of all, although the bill has triggered such a huge social event, no senior government official steps down. this is very interesting because in similar situations in other countries, some senior government officials would have stepped down to take political responsibility. again, this reflects the threat of political well-being in governance which intensifies public worry, anger, and frustration. of course, in understanding the responses of the government, two points must be noted. first, in view of the unprecedented nature and the extent of the protests, it is not easy to handle. as pointed out by the prime minister of singapore (lee hsien loong), singapore would be "finished" if similar protests happened in singapore (sim 2019) . second, dissatisfaction with the government has been a common theme in protests which intensifies the protests. for example, the commission of inquiry (1967) concluded that "a recent tendencynot only in hong kongto ascribe all the failings of the community to errors by the administration and to make greater demands upon it tends not only to enhance discontent but to exaggerate their extent" (p.129). there are numerous and serious allegations that the police used excessive force, such as in the protests held on june 12, july 14 and august 31, 2019 (purbrick 2019 ). on the other hand, the police was criticized as doing nothing when people in yuen long were attacked by those who did not support the protesters on july 21, 2019. obviously, such allegations are great threats to the personal well-being of the protesters and the social well-being of hong kong. on the one hand, some videos in the news reports and the internet strongly suggest that excessive force might have been used by the police. while some of the related complaints are still under the investigation of the independent police complaints council (ipcc), the mechanism does not earn the trust of hong kong people for two reasons. first, some ipcc members were appointed by the government, which means that their independence is doubtful. second, many protesters experiencing excessive force by the police do not complain because they have the fear that they will be prosecuted for involvement in riots. on the other hand, it should be noted that "innocence before proven guilty" is the cornerstone of the common law and the establishment of police violence and brutality requires evidence beyond reasonable doubt. besides, objectivity of some videos uploaded to the internet is not clear. in addition, it would not be objective if we ignore the fact that public perceptions of the police had been very good before the social event and the hong kong police ranked very high in terms of professional service in international surveys. for example, in the human freedom index (vásquez and porčnik 2019) , hong kong police ranked sixth (6th) under the indicator of "reliability of police". in the legatum prosperity index (2019), hong kong police ranked fourth (4th) out of 167 countries and regions under the indicator of "safety and security". similarly, hong kong police ranked fourth (4th) under "order and security" in the world justice project (2019). of course, having an excellent record does not necessarily mean that the alleged police issues do not exist. however, we also need expert views based on credible professionals (e.g., those who have expertise in police operations) using credible evidence from credible sources to make objective and fair judgments. there are several arrangements that create anxiety and threats for hong kong people. first, it extends the scope of extradition to cover mainland china. with the proposed changes, hong kong people who have committed certain crimes in china could be transferred to mainland china. second, there were several rounds of revisions in the process, thus giving people a sense that the whole package has not been well-conceived, and the changes were made to address the concerns of the businesspeople only. third, the proposed safeguards are considered not adequate by the public. finally, the consultation period was too short. some people queried that the consultation was too short for an issue which had not been resolved within 22 years after the handover. at the same time, the buy-in work was not enough, and consultation was not extensive. in particular, no specific strategies were used to address the concerns of young people, particularly via social media. besides, the publicity work of the government was neither creative nor innovative. finally, the government's non-sensitivity about the public reaction to the bill greatly intensified the fear. since the proposal was published, there had been numerous reservations voiced by different sectors of the society, including businessmen, lawyers, and barristers. however, the government did not feel the pulse of the community. also, despite the fact that many people joined the protest held on june 9, the government still decided to move to the second reading debate on june 12, 2019. such insensitivity to public reaction eventually triggered the fire. for the political fire on the extradition bill to take place, besides fuels (quality and life and well-being issues) and heat (worries that the bill had created and the public sentiment it had aroused), oxygen is a very important concern. in the social movement, several sources of wind have provided much "oxygen" for the social event. while misinformation refers to inaccurate information, disinformation refers to the deliberate dissemination of false information. in the social movement, there are numerous instances of misinformation. for example, for the number of protesters, it was claimed that there were 1 million and 2 million people joining the demonstrations in june 2019. however, while it cannot be denied that many hong kong people joined the protests, the figures quoted by the organizer were doubted by cnn (mezzofiore 2019) . concerning the occupation of the legislative council building on july 1, 2019, the police issued a warning at around 10:20 pm condemning the action of the protesters and giving the final warning for them to disperse. however, the watch of the chief superintendent had been altered to 5 pm (wong 2019a) in the video which suggests that the police had set a trap for the protesters. another example is the news reported by da kung pao on the assault on a legislative councilor (ho kwan yiu). while the news was released at noon on november 6, 2019, the time of release was amended to be 19:54 on november 5, 2019 (global times 2019). based on the amended news, it was claimed that the assault was self-directed by ho. in the initial stage of the protests, many protesters wore surgical masks. in the late stage of the protesters, some protesters wore gas masks and covered their whole face. while it is understandable that gas masks protect the protesters from tear gas, keeping one's identity anonymous actually intensified the scale of violence and vandalism because the fear of being identified would be minimized. besides, communication in social media on protests is also anonymous, hence facilitating the planning and implementation of the protests and vandalism. as it is well-documented in social psychology that people with anonymous identity would be more likely to engage in violent behavior (zimbardo 1969) , anonymity has supplied much "oxygen" to the intensity and duration of the social event. many people have shown support for the protesters (particularly the students) for several reasons. first, it is commonly believed that the public should give more allowance to students who are just "kids". second, some adults have the fear that the bill would break the "firewall" between hong kong and china. third, some people believe that the students are doing what they have not done, such as a fight for democracy for hong kong. fourth, many people are angry at the slow and nonresponsive responses of the government. fifth, many people support the prevailing but toxic beliefs that "disobey the law to get justice is acceptable" and "violence is sometimes necessary under certain circumstances". finally, many people believe that violence of the protesters is justified because police have used excessive force and there is police brutality. there is also public support in terms of finance. for example, around hk$70 million (us$9 million) related to the sparkle alliance was frozen by the police (mok et al. 2019) . the public's support for the protesters (including many professional associations) and not "cutting the mattress" with the violent protesters is definitely a strong reinforcement for the protesters. in the social event, many foreign political leaders have shown support for the protesters. unfortunately, very few of them touch upon the issues of violence and vandalism. such supportive gestures have created the false impression that the movement (including violence and vandalism) is reasonable, sacred and just. material support from taiwan in the form of gas masks was also reported (sui 2019) . it is apparent that there are many deep-seated quality of life issues behind the social movement. as such, the solution lies in properly addressing these quality of life threats and issues. primarily, it is important to cut or eliminate the pre-existing fuels as follows: 1. trust in the beijing government: it is important to build up trust in the beijing central government. in social psychological literature, the contact hypothesis suggests that contact is very important to reduce prejudice (pettigrew and tropp 2005) . hence, increased contact to understand mainland china will be helpful. looking at the bright and dark sides of china (as these two aspects exist in all countries) and appreciating the progress of china in the past four decades such as poverty alleviation for around 850 million people according to the world bank (he 2019) and acknowledgment of social problems (such as corruption) would be important. 2. nurturance of chinese national identity: it takes time to nurture because one has to "fall in love" and take pride in being chinese. systematic education at the community, family, and school contexts are indispensable so that young people can develop a sense of shared identity which further strengthens their positive identity. 3. political well-being: this is tough because the change in the political system will not take place overnight. in addition, as hong kong is an international financial center, it is not easy to reduce the influence of business corporations and related interest groups. however, given the recent overwhelming victory of the pan-democratic camp in the district council election in november 2019, young people who wish to change can still play an active role in the future legislative council and the chief executive elections. in any case, everybody has to learn that in an open and civilized society, we have to respect the views of the majority. 4. poverty alleviation and solving the housing problem: it is a high time to re-visit the issue of poverty in hong kong which also exists in many countries in the world. besides the work of the commission on poverty, every sector has to rethink about their role. in addition to financial capital, building human capital, family capital and social capital is also important to strengthen the developmental assets of poor adolescents, which can help them escape from the trap of intergenerational poverty. as housing implies physical security which shapes hope, this is the top priority issue to be addressed. 5. upward mobility: this is not easy to solve this issue because it is a global issue that is not specific to hong kong. however, as many young people do not want to join the manual labor force which can give a reasonable salary, there is a need to change the community culture to one that treasures different talents (i.e., not just scholastic skills) and there are different career paths for young people with different aspirations, interests, and skills. 6. education reform: there is a need to deeply reflect on the purpose and nature of education so that young people can study for their interests (i.e., not just for the "rice bowl") and multiple intelligences are emphasized. the challenge is not just for the government, but also for parents and the hong kong society. 7. promotion of adolescent well-being: relevant and adequate services should be provided for young people who need mental health services. a public health approach focusing on universal, selective and indicated prevention should be used. in particular, services for students with special education needs should be stepped up. besides, finding ways to promote hope and life satisfaction is also a priority task. in addition to changing the macro-environmental factors leading to hopelessness, evidence-based programs to cultivate resilience and hope in young people, such as the project p.a.t.h.s. (shek and sun 2013; ma et al. 2019 ) are indispensable. 8. promotion of family well-being: problem families are the ideal breeding grounds for adolescent externalizing behavior. hence, there is a need to promote family resilience in a high-risk environment and to strengthen parenting, communication as well as conflict resolution skills in the family. it is noteworthy that evidencebased programs on promotion of family resilience are almost non-existent in hong kong. 9. promotion of life skills education: in the absence of systematic life skills, socialemotional learning skills, and psychosocial competencies training in the formal education curriculum in hong kong, this gap should be urgently addressed (shek and siu 2019a) . young people should learn that: a) "an eye for an eye makes the whole world blind"; b) the essence of democracy is respecting the views of everyone, including those who do not hold the same views; c) it is morally wrong to blackmail the government by kidnapping the innocent public; d) besides rights and social justice, there are other virtues, including love, acceptance, and forgiveness, that are equally important; and e) while one can "criticize" the government, one should also look at things from different perspectives in a "critical" manner. 10. development and implementation of systematic moral and national education: one unfortunate observation of the social movement is that there is much hatred and deep erosion of the spirit of rule of law (such as widespread use of "doxing" and even physical violence in dealing with those who hold different views). as conflict resolution and mutual respect are not adequately covered in the current moral and national education curriculum, there is an urgent need to review and step up the related policies in hong kong. when implemented, policymakers should be aware of the related fears, such as the worry of brainwashing the young people. as such, practices in other countries can serve as the reference point because "international standards" will be used. regarding the "heat", there are many learning points for the government to reflect, particularly on its efficiency and responses in the whole social movement. for example, sufficient consultation time should be given to sensitive issues like the extradition bill. concerning the influence of social media, there is no way to stop it unless we follow what the spanish government did to deal with the occupation of the airport. however, the public can learn how to critically differentiate correct information, misinformation, and disinformation, particularly information disseminated and acquired through the social media. for anonymity, while it is a protection for not being arrested, people wearing masks should understand that anonymity would unleash the dark side of human nature. concerning public endorsement of violence, several questions should be considered by the public: a) what is the "civilized" and "mature" form of public demonstration? b) assuming the police has used excessive force, is vandalism the best response (i.e., "an eye for an eye")? c) how can we promote peaceful co-existence within diversity in political views? these are obvious quality of life issues awaiting answers. regarding alleged police violence brutality, there is a social consensus on setting up an independent panel of inquiry. however, to be fair to the police and protesters, if an independent panel of inquiry is established, it should examine violence and excessive use of force in both the protesters and police. finally, a critical understanding of the comments made by foreign governments and parties should be realizedwhether they are genuine concerns about hong kong or disguised manifestations of political and/or national interest. in conclusion, pre-existing and new quality of life and well-being threats and issues have shaped the development of the social event in the past 8 months in hong kong. without understanding quality of life issues in different ecological systems (such as fear about losing freedom, lack of political well-being, growing up in a poor environment, always being a loser, living without hope, inability to forgive and re-build), it would not be possible to find workable and meaningful solutions. once again, the case of hong kong demonstrates that economic development alone is not enough to promote human well-being in a society. in the report of the commission of inquiry (1967) reviewing the 1966 riots, it was concluded that "we do not believe that political, economic and social frustrations were the direct cause of the 1966 riots but within the economic and social fields there are factors, to which we have drawn attention and that need to be watched, lest they provide inflammable material which would erupt into disturbance should opportunity arise in the future" (p.148). after some 53 years, it is interesting to note that some of the deep-seated quality of life and well-being issues, such as inadequate housing, over-crowding, and limited chances in life come into the scene again. the only major difference is that many educated young people are involved in the social event in 2019-2020, in contrast to the predominance of poorly educated young people in the 1966 riots. hong kong tops global list of most expensive housing market again as protests make little dent tourist arrivals take sharpest plunge in november since protests began in hong kong hong kong's protesters are trying to break free from the "old seafood" generation a perspective based on quality kowloon disturbances 1966: report of commission of inquiry the characteristic of generation z. e-mentors quality of life: its definition and measurement understanding the attitude of generation z towards workplace government of the hong kong sar china's subsidies lifting rural villages out of poverty, but is xi jinping's plan sustainable? the legatum prosperity index: a tool for transformation hong kong kids more narcissistic than 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health professionals in hong kong depression and post-traumatic stress during major social unrest in hong kong: a 10-year prospective cohort study oecd better life initiative: compendium of oecd well-being indicators hong kong inequality report allport's intergroup contact hypothesis: its history and influence ethnic identity -chinese (per poll people's trust in the beijing central government (7-12/ 1997-1-6 a report of the 2019 hong kong protests commissioner of the hk police the impact of positive youth development attributes and life satisfaction on academic well-being: a longitudinal mediation study a study on the development of chinese students (character psychosocial factors influencing individual well-being in chinese adolescents in hong kong: a six-year longitudinal study use of foul language among chinese adolescents: developmental change and relations with psychosocial competences adolescent mental health policy and services in hong kong: seven unresolved problems waiting for solutions unhappy" environment for adolescent development in hong kong [special issue development and evaluation of positive adolescent training through holistic social programs perceptions of adolescents, teachers and parents of life skills education and life skills in high school students in hong kong singapore's lee hsien loong a social media hero in china for hong kong protest comments hong kong protests: the taiwanese sending 2,000 gas masks nearly a fifth of hong kong voters say they support violent actions by protesters, such as attacking opponents or hurling petrol bombs and bricks fugitive offenders and mutual legal assistance in criminal matters legislation (amendment) bill legal service division report on fugitive offenders and mutual legal assistance in criminal matters legislation (amendment) bill united nations development programme the human freedom index 2019 hong kong extradition bill: police deny rumours of pre-recording july 1 condemnation video and issue clarification hong kong protests: what are the "five demands"? what do protesters want? youngpost hk$65 million bill for repairs on public facilities vandalised by antigovernment protesters the human choice: individuation, reason, and order versus deindividuation, impulse, and chaos publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements the preparation for this editorial is financially supported by wofoo foundation and tin ka ping foundation. address all correspondence to daniel t.l. shek, department of applied social sciences, the hong kong polytechnic university (daniel.shek@polyu.edu.hk).open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. key: cord-325396-ot7pvexv authors: lönnroth, knut; tessier, lou; hensing, gunnel; behrendt, christina title: income security in times of ill health: the next frontier for the sdgs date: 2020-06-15 journal: bmj glob health doi: 10.1136/bmjgh-2020-002493 sha: doc_id: 325396 cord_uid: ot7pvexv nan ► universal health coverage (uhc) is at the forefront of the discussions on how to achieve the health-related sustainable development goals (sdg). ► a prominent part of the uhc agenda is to ensure that people are not impoverished due to high healthcare expenditures. while this is crucial, it is not sufficient to protect people from hardship in times of ill health, as illustrated in the ongoing covid-19 pandemic where lack of income security creates barriers for people to adhere to infection control measures. ► social protection systems ensuring income security when unable to work due to sickness are as important as schemes designed to reduce out-of-pocket healthcare expenditure. yet, this is not part of the uhc framework and not sufficiently visible in the sdg target on social protection. ► this contrasts sharply with the high prioritisation of income security in times of ill health when universal social protection systems were built in the last century in many of today's high-income countries. poor health can trap individuals, families and communities in a vicious disease-poverty cycle. while ensuring universal access to affordable healthcare in times of need is essential to break this cycle, income security in time of sickness or injury for all is equally important. recent evidence indicates that people who cannot work or are not allowed to work due to illness face high indirect costs linked to income loss, which can be compounded by the opportunity cost of time spent seeking and staying in care. for example, the ongoing covid-19 pandemic illustrates that lack of income security leads to economic hardship for individuals and creates barriers for adhering to infection control measures, 1 2 and similar challenges have previously been well-documented concerning tuberculosis. 3 both access to healthcare services and income security in case of illness are enshrined in the human rights to health and social security and in international standards on social protection. 4 5 income security acts on both the social determinants and the adverse consequences of ill health. the provision of sickness benefits is the primary responsibility of the state, usually implemented by social protection institutions under the joint stewardship of the health, social and labour sectors. yet, while access to healthcare services is at the forefront of the 2030 agenda through a dedicated target on universal health coverage (uhc), income security in case of ill health has limited visibility within the sustainable development goals (sdgs) and is underresearched, especially in low-income and middle-income countries (lmics). 6 unpacking sdg targets and indicators the sdgs constitute an unprecedented opportunity to accelerate synergistic actions on health and social protection. achieving the health targets under goal 3 will contribute to social well-being. moreover, the uhc target (3.8) has a specific indicator for financial protection (3.8.2), which measures occurrence of catastrophic out-of-pocket healthcare expenses. the focus is on direct medical costs while income security in times of ill health is not included. this was a conscious choice as the indicator measures what uhc intends to achieve: access to needed healthcare without financial hardship from paying for these services. 7 sdg target 1.3 on social protection aims to implement nationally appropriate social protection systems and measures for all, including floors. in principle, this scope includes income security in case of ill health. still, this dimension is currently missing in the related monitoring indicator 1.3.1 ('percentage of the population covered by social protection floors/systems') which reports social protection coverage for children, unemployment, old age, disability and work injury benefits, but not for sickness benefits. 8 this exclusion directly correlates to a shortage of comparable data across countries. indicators cannot capture all that is important of course, but they are an opportunity to set an accountability framework fostering the collection and publication of more and better data. in this respect, progress needs to be made. in line with the nine branches of social security defined under the international labour organization (ilo) convention no. 102, the world social protection database provides information on whether the legal framework includes entitlements to income support in case of sickness and collects national-level data on effective coverage for this contingency. yet, more reporting is necessary to allow for the elaboration of global estimates. 9 these challenges relate to the setup of such guarantees. indeed, many countries chose to cover this contingency through an employer's liability (ie, there is no social protection scheme as such, each employer is responsible to continue to pay the worker's salary during sick leave). this model has two effects. first, this form of protection is often limited to those covered under national labour legislation while those in informal employment remain unprotected. second, it can create a disincentive for employers to hire and retain workers from groups prone to sickness, as the full cost of sick leave falls on them. this is a concern for small and medium enterprises where resources can be limited. 10 the labour force in lmics is still largely informal. more efforts are necessary to extend social protection coverage, including income security in case of sickness, to those in informal employment and facilitate their transition to the formal economy, which also contributes to fostering decent work under goal 8 and the broader sdg agenda. income security in times of ill health has been part of social protection systems in many high-income countries (hic) for over half a century, often longer than universal access to healthcare. after a long period of heterogeneous and small-scale union-based or guild-based mutual funds, the first national legislations on social insurance came into force around the turn from the 18th to the 19th century in countries that are today classified as hic, but at the time had fiscal space that was no larger than today's poor countries. the 20th century saw scale-up in fits and starts towards universalism through periods of devastating wars and economic depression. 11 12 the bismarck and beveridge models did not only concern health coverage as defined today under the uhc framework. they were models for comprehensive social health protection, including both access to healthcare without hardship and income security in times of sickness. 13 one underpinning argument was that income security coupled with rehabilitation would help prevent permanent incapacity to work due to chronic conditions and hence reduce the burden on disability pension and poverty relief schemes. another was that income security would facilitate implementation of infectious disease control measures. none of the early schemes had only healthcare benefits. in many countries, including germany, uk and sweden, sickness benefits came first, followed by gradual introduction of healthcare benefits. lord beveridge stated upfront in his 1942 report that uk had by then already made progress on social insurance, and argued that it was now time to include also healthcare coverage since 'a plan for social security assumes a concerted social policy in many fields'. 14 the human rights framework and international labour standards followed this approach, considering income security in case of sickness an integral part of social health protection. 5 as early as 1927, the ilo adopted the first convention on sickness benefits, which was subsequently included in the social security (minimum standards) convention, 1952 (no. 102), the medical care and sickness benefits convention, 1969 (no. 130) and recommendation, 1969 (no. 134) . those instruments call on member states to set up systems ensuring protection in case of 'incapacity for work resulting from a morbid condition and involving suspension of earnings'. however, their global implementation was hampered by various factors, and the available data suggests effective coverage remains very low. 15 in spite of the inclusion of income security during sickness in the social protection floors recommendation, 2012 (no. 202), the recent united nations resolutions do not elaborate on it 16 and more needs to be done to better reflect it in the sdg framework. despite the universal declaration of human rights including 'the right to security in the event of sickness' and who's definition of health as including 'social wellbeing', attention to income security in times of sickness remains limited in the global health field. a reason is perhaps that uhc and scientific advances are expected to solve the problem through swift cures for most conditions. medical and allied science have advanced tremendously. healthcare services can cure more diseases and reduce risk of long-term disability. still, uhc will not eliminate the risk of income insecurity in case of sickness. the global tuberculosis and hiv/aids strategies are ahead of the game. 17 18 they include policy commitments on social protection and monitoring tools. heavily subsidised healthcare services have been scaled up globally for those diseases, which is probably why the limitations of affordable healthcare alone to prevent poverty effects of diseases have become obvious. evidence indicates that patients who pay little out of pocket for quality healthcare still face high indirect costs. 19 the national tuberculosis patients cost surveys coordinated by who show that patients experience variable levels of direct medical costs depending on the country context, but also high direct non-medical costs (mostly transport and nutrition) bmj global health and income loss, creating additional incentives to forgo care. 3 19 there is good reason to believe that income security is an equally important global challenge for people with both communicable and non-communicable diseases, including diabetes, cancer, cardiovascular diseases and mental health problems. the long-term solution should not be disease-specific social protection schemes but universal systems that provide better ways to extend income security protection in case of sickness for all. let's not wait until 2030 to put this issue firmly on the global health agenda and in the discussions on the future of social protection. 20 acknowledgements all authors are members of the health and social protection action research & knowledge sharing network (sparks), an international interdisciplinary research network. sparks' multi-sectoral team characterizes and evaluates the direct and indirect effects of social protection strategies on health, economic, and wider outcomes. contributors all authors conceptualised the paper, wrote it jointly and approved the final version. funding funding was received from the swedish research council (2018-05174). competing interests none declared. patient consent for publication not required. provenance and peer review not commissioned; externally peer reviewed. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ 4. 0/. orcid id knut lönnroth http:// orcid. org/ 0000-0001-6944-0256 income security during public health emergencies: the novel coronavirus (covid-19) poverty trap in vietnam social protection response to the covid-19 crisis who. global tuberculosis report general comment no. 19: the right to social security towards universal health coverage: social health protection principles. social protection spotlight brief income security during periods of ill-health: a scoping review of policies and practice in low-and middle-income countries tracking universal health coverage: 2017 global monitoring report jsessionid= ed79 2936 448a 1e92 bc6a 1e01 f4a7c3eb? sequence=1 [accessed 11 metadata for sustainable development goal 1 universal social protection to achieve the sustainable development goals can productivity in smes be increased by investing in workers' health? the emerging welfare state -swedish social insurance 1884-1955. lund, arkiv förlag gesundheitspolitik in der nachkriegszeit: grossbritannien und die bundesrepublik deutschland im vergleich universal health coverage" as a goal of international health politics, 1925-1952 health insurance: the influence of the beveridge report paid sick leave: incidence, patterns and expenditure in times of crises transforming our world: the 2030 agenda for sustainable development, resolution adopted by the general assembly on 25 global strategy and targets for tuberculosis prevention, care and control after 2015 unaids. unaids strategy 2016-2021 -on the fast-track to end aids beyond uhc: monitoring health and social protection coverage in the context of tuberculosis care and prevention centenary declaration for the future of work key: cord-346136-sqc09x9c authors: hamilton, kyra; smith, stephanie r.; keech, jacob j.; moyers, susette a.; hagger, martin s. title: application of the health action process approach to social distancing behavior during covid‐19 date: 2020-10-02 journal: appl psychol health well being doi: 10.1111/aphw.12231 sha: doc_id: 346136 cord_uid: sqc09x9c background: this study examined the social cognition determinants of social distancing behavior during the covid‐19 pandemic in samples from australia and the us guided by the health action process approach (hapa). methods: participants (australia: n = 495, 50.1% women; us: n = 701, 48.9% women) completed hapa social cognition constructs at an initial time‐point (t1), and one week later (t2) self‐reported their social distancing behavior. results: single‐indicator structural equation models that excluded and included past behavior exhibited adequate fit with the data. intention and action control were significant predictors of social distancing behavior in both samples, and intention predicted action and coping planning in the us sample. self‐efficacy and action control were significant predictors of intention in both samples, with attitudes predicting intention in the australia sample and risk perceptions predicting intention in the us sample. significant indirect effects of social cognition constructs through intentions were observed. inclusion of past behavior attenuated model effects. multigroup analysis revealed no differences in model fit across samples, suggesting that observed variations in the parameter estimates were relatively trivial. conclusion: results indicate that social distancing is a function of motivational and volitional processes. this knowledge can be used to inform messaging regarding social distancing during covid‐19 and in future pandemics. the covid-19 pandemic has had unprecedented global effects on mortality, way of life, national economies, and physical and mental health not previously experienced in modern times. it has presented governments, healthcare services, and education facilities with wide-scale and complex logistical challenges on how to manage the rapid spread of the disease and minimise the projected human and economic costs. given that, to date, there is no vaccine to protect against covid-19, non-pharmacological intervention is the only currently available means to reduce the spread of sars-cov-2, the virus that causes covid-19, and "flatten the curve" of infection rates. in response, national and statewide governmental measures aimed at minimising transmission of the virus including "stay at home" orders, closure of businesses and places of congregation, and travel restrictions have had a substantive impact on mortality rates (worldometer, 2020) . as rates of infection dissipate in some countries, particularly in countries like australia that have relatively low rates of daily infections, governments are now beginning to ease restrictions. however, preventive behaviors aimed at reducing infection rates remain highly pertinent given concerns over the potential for infection rates to rise again and fears of a "second wave". furthermore, some countries who are easing lockdown measures, such as some states in the us, still have high localised rates of infection, highlighting the imperative of ongoing performance of preventive behaviors to manage infection transmission. based on world health organization (who) recommendations (world health organization, 2020) and previous research on behaviors known to reduce virus transmission (jefferson et al., 2011; rabie & curtis, 2006; smith et al., 2015) , two key sets of covid-19-related behaviors that may apply to the population as a whole have been proposed . the first set is "personal protective behaviors" that are aimed at the individual in order to protect themselves or others (e.g. washing hands frequently, practicing respiratory hygiene). the second set involves behaviors aimed at ensuring physical distance between people (e.g. social distancing, stay at home orders). despite knowledge of these key behaviors in the prevention of virus transmission (e.g. islam et al., 2020) , there is a relative dearth of information on the determinants and mechanisms of action that underpin these preventive behaviors and how to strengthen individuals' capacity to adopt them. in the absence of direct evidence, knowledge to inform practice guidelines that governments and organisations can use to mobilise individuals into performing covid-19 preventive behaviors has been gleaned from applying general principles from behavioral science and the models of behavior that underpin them (lunn et al., 2020; michie et al., 2020; british psychological society, 2020; west et al., 2020) as well as findings of previous empirical investigations in the psychological literature on similar health and risk behaviors (e.g. face mask use, handwashing, distancing; chu et al., 2020; reyes fern andez et al., 2016; zhang, chung, et al., 2019; zhang et al., 2020) . although this approach is potentially useful in structuring thinking and recommendations in urgent times, there is a pressing need for direct evidence that identifies the key determinants of these covid-19 preventive behaviors and the processes involved. this knowledge can then be used to inform development of effective interventions to promote uptake and adherence to these behaviors. this is especially important given that individuals' beliefs may affect their adoption of non-pharmacological measures to prevent virus transmission (teasdale et al., 2014) . prominent among social cognition theories are dual-phase models which aim to provide a comprehensive theoretical account of health behavior uptake and participation, and the processes involved (hagger, cameron, hamilton, hankonen, & lintunen, 2020; hagger, smith, keech, moyers, & hamilton, 2020) . one such dual-phase theory that has been frequently applied to predict multiple health behaviors is the health action process approach (hapa; schwarzer, 2008; schwarzer & hamilton, 2020) . the hapa is an integrated model that combines features of stage, continuum, and dual-phase social cognition models. a key feature of the model is the distinction made between motivational (where an individual is in a deliberative mindset while setting a goal/forming an intention) and volitional (where an individual is in an implementation mindset while pursuing their goal) phases involved in behavioral enactment. in the motivational phase, intentions are conceptualised as the most important determinant of behavior. intentions are proposed to be a function of three sets of belief-based constructs: outcome expectancies (beliefs that the target behavior will lead to outcomes that have utility for the individual, conceptually identical to an individual's attitudes toward the behavior), self-efficacy (beliefs in personal capacity to successfully perform the target behavior and overcome challenges and barriers to its performance), and risk perceptions (beliefs in the severity of a health condition that may arise from not performing the target behavior and personal vulnerability toward it). in the volitional phase of the hapa, planning and action control strategies are important self-regulatory strategies that determine subsequent enactment of the target behavior (schwarzer, 2008; schwarzer & hamilton, 2020) . two forms of planning are proposed: action planning, a task-facilitating strategy that relates to how individuals prepare themselves in performing a behavior, and coping planning, a distraction-inhibiting strategy that relates to how individuals prepare themselves in avoiding foreseen barriers and obstacles that may arise when performing a specific behavior, and potentially competing behaviors that may derail the behavior. in addition, action control, a self-regulatory strategy for promoting behavioral maintenance through the monitoring and evaluation of a behavior against a desired behavioral standard, is also an important direct determinant of behavior (hamilton et al., 2018; reyes fern andez et al., 2016) . behavioral intention operates as a "bridge" between the motivational and volitional phases, while planning serves to link intentions with behavior. previous research has provided support for the hapa constructs in predicting health preventive behaviors, with prominent roles for outcome expectancies, forms of selfefficacy, planning and action control, with risk perceptions only relevant in certain contexts (see schwarzer & hamilton, 2020; . furthermore, the model has been used as a basis for effective behavior change interventions aimed at promoting increased participation in health-related behaviors (schwarzer & hamilton, 2020) . given that social distancing is a key evidence-based behavior that will minimise transmission of sars-cov-2 if performed consistently at the population level, the aim of the present study was to apply the hapa to identify the social cognition and self-regulatory determinants of this preventive behavior in samples of adults from two countries, australia and the us. these two countries provided an opportunity to examine the determinants of social distancing because they experienced rapid increases in covid-19 cases at relatively similar times during the pandemic and introduced public health advice as well as "lockdown" measures and "shelter-in-place" orders to minimise transmission, including social distancing. specifically, the current research aimed to identify potentially modifiable determinants that are reliably related to social distancing intentions and behavior, which may form targets of behavioral interventions to reduce covid-19 infection rates, and, going forward, other communicable diseases transmitted through person-to-person contact. the value of applying the hapa is that it provides information on phase-relevant constructs in determining this important behavior. proposed predictions among model constructs are summarised diagrammatically in figures 1 and 2 . figure 1 presents the hapa predictions excluding effects of past social distancing behavior. intention to perform social distancing was expected to be predicted by attitude (as a proxy for outcome expectancies), self-efficacy, and risk perceptions, and social distancing behavior was expected to be predicted by self-efficacy, intentions, action planning, coping planning, and action control. intention was proposed to mediate effects of attitude, self-efficacy, and risk perceptions on behavior. in addition, intention was expected to predict action planning and coping planning such that the planning constructs mediate the intention-behavior relationship. action control was proposed to predict behavior directly. although it is strictly a self-regulation technique aimed at facilitating better behavioral enactment, as proposed by the original hapa (e.g. schwarzer, 2008) , individuals who are effective at action control (i.e. self-monitoring) may also more likely form strong intentions. action control implies not only the recall of behavior but also the recall of intentions. self-monitoring of the concurrent behavior, therefore, may make the individual aware of their intention as well as their behavior, focusing on possible discrepancies between the two. it is plausible, then, that action control can be specified as a predictor of both intention and behavior. the coexistence of intention and action control within the same dataset allows this key question to be tested; which of the two factors may be more proximal to the behavioral outcome? action control might not be a time-specific variable, and individuals may self-monitor their behaviors at any point in time (see zhou et al., 2015) , even before goal setting. actions can be monitored before making intentions, while doing so, or afterwards. thus, examining the indirect (via intention) and direct effects of action control on behavior is intuitively meaningful, although not supported by the original hapa, and tested in the present study. figure 2 outlines the inclusion of past behavior in the model to test its sufficiency. although model effects were expected to hold with the inclusion of past behavior, it was expected to attenuate the size of the proposed effects consistent with previous studies (brown et al., 2020; hagger et al., 2018) . this was expected to be the case in the current study due to the relatively brief one-week follow up. the attenuation effect was proposed to model past decision making and effects of other unmeasured constructs on behavior. a sample of australian (n = 495, 50.1% women) and us (n = 701, 48.9% women) residents were recruited via an online research panel company. to be eligible for inclusion, participants needed to be aged 18 years or older and were required to not be subject to formal quarantine for covid-19. in addition to the inclusion criteria, participants were screened on the demographic characteristics of age, gender, and geographical region and quotas were imposed to ensure that the sample comprised similar proportions of these characteristics to the national population of each country. sample characteristics are presented in table s1 . data were collected in april and may 2020 during which time residents throughout australia and all states in the us were subject to "stay at home" orders to reduce transmission of the coronavirus. the study adopted a prospective correlational design with self-report measures of hapa constructs (attitudes, self-efficacy, risk perceptions, intentions, action planning, coping planning, and action control) and past engagement in social distancing behavior administered at an initial time-point (t1) in a survey administered using the qualtrics tm online survey tool. participants were informed that they were participating in a survey on their social distancing behavior and were provided with an information sheet outlining study requirements. they were also provided with a consent form to which they had to affirm before proceeding with the survey. participants were also provided with an information sheet providing instructions on how to complete the study measures. in addition, they were provided with a definition of the target behavior: "the following survey will ask about your beliefs and attitudes about 'social distancing'. what do we mean by social distancing? social distancing (also known as 'physical distancing') is deliberately increasing the physical space between people to avoid spreading illness. the world health organization and other world leading health authorities suggest that you should maintain at least a 1-2 m (3-6 feet) distance from other people to lessen the chances of getting infected with covid-19. when answering the questions in this survey, think about your social distancing behavior (i.e. maintaining at least a 1-2 m (3-6 feet) distance from other people)." one week later (t2), participants were contacted a second time by the panel company and were asked to self-report their social distancing behavior over the previous week using the same behavioral measure administered at t1. participants received a fixed sum of money for their participation based on expected completion time consistent with the panel company's published rates. approval for study procedures was granted prior to data collection from the griffith university human research ethics committee. study measures were carried out on multi-item psychometric instruments developed using published guidelines and adapted for use with the target behavior in the current study (schwarzer, 2008) . participants provided their responses on scales with 7-point response options. complete study measures are provided in table s2 . social cognition constructs. measures of attitudes, self-efficacy, risk perceptions, intentions, action planning, coping planning, and action control from the hapa were developed according to guidelines (schwarzer, 2007) . attitude was measured using three semantic differential items in response to a common stem: "my maintaining social distancing in the next week would be...", followed by a series of bi-polar adjectives (e.g. (1) worthless -(7) valuable). self-efficacy was measured using four items (e.g. "i am confident that i could maintain social distancing", scored (1) strongly disagree to (7) strongly agree). risk perception was measured using two items (e.g. "it would be risky for me to not maintain social distancing", scored (1) strongly disagree to (7) strongly agree). intention was measured using three items (e.g. "i intend to maintain social distancing", scored (1) strongly disagree to (7) strongly agree). action planning was measured using four items. participants were required to respond to the stem: "in the next week, i have made a plan regarding...", followed by the four items of the scale (e.g. ". . .when to maintain social distancing") on likert scales ranging from strongly disagree (1) to strongly agree (7). coping planning was measured using four items. participants were required to respond to the stem: "to keep my intention to maintain social distancing in the next week in difficult situations, i have made a plan...", followed by the four items of the scale (e.g. ". . .what to do if something interferes with my goal of maintaining social distancing") on likert scales ranging from strongly disagree (1) to strongly agree (7). action control was measured using three items (e.g. "i have consistently monitored when, how often, and how to maintain social distancing"), scored (1) strongly disagree to (7) strongly agree). past behavior and behavior.participants self-reported their participation in the target behavior maintaining social distancing in relation to others to minimise transmission of the coronavirus that causes covid-19. the measure comprised two items prompting participants to report their frequency of social distancing behavior in the previous week: "in the past week, how often did you maintain social distancing?", scored (1) never to (7) always and "in the past week, i maintained social distancing", scored (1) false to (7) true. demographic variables. participants self-reported their age in years, gender, employment status (currently unemployed/full time caregiver, currently full-time employed, part-time employed, on leave without pay/furloughed), marital status (married, widowed, separated/divorced, never married, in a de facto relationship), annual household income stratified by 11 income levels based on australia and us national averages, and highest level of formal education (completed junior/lower/primary school, completed senior/high/secondary school, postschool vocational qualification/diploma, further education diploma, undergraduate university degree, postgraduate university degree). binary income (low income versus middle/high income), 1 highest education level (completed school education only versus completed post-school education), and ethnicity (white/ caucasian versus non-white) variables were computed for use in subsequent analyses. hypothesised relations among hapa constructs in the proposed model were tested in the australia and us sample separately using single-indicator structural equation models implemented in the lavaan package in r (r core team, 2020; rosseel, 2012) . we opted for single-indicator models over a full latent variable structural equation model due to the complexity of the model and the large number of parameters. the single-indicator approach utilises scale reliabilities to 1 our cut-off for low vs. medium-to-high income was based on national income data for citizens on low incomes in the us (for a family of four, the low income threshold is us$25,465 per year; semega et al., 2020) and australia (for a family of four, the low-income average is $562 per week; aihw 2020). participants reporting incomes of $400-$599 per week ($20,800-$31,199 per year) or below were classified as low income. provide an estimate of the measurement error of each variable in the model. specifically, each variable in the model was indicated by its averaged composite with the error variance fixed at a value based on the reliability estimates using the formula: 1-reliability*scale variance. simulation studies have demonstrated that parameter estimates and model fit of single-indicator models compare very favorably with full latent variable structural equation models, particularly when sample sizes are small (savalei, 2019) . we freed parameters between the single-indicator latent variables according to our proposed model. two models were estimated, one excluding effects of past social distancing behavior (model 1, figure 1 ) and one which controlled for past behavior (model 2, figure 2 ) by freeing parameter estimates from past behavior on each construct in the model. we also controlled for effects of the following demographic variables in each model by freeing paths from each variable to all other model variables: gender, age, ethnicity, income, and education level. missing data were handled using the full information maximum likelihood (fiml) method. the fiml approach is a preferred approach to handling missing data as simulation studies indicate that it leads to unbiased parameter estimates in structural equation modeling (enders & bandalos, 2001; wothke, 1998) . model comparisons across the australia and us samples were conducted using multigroup analyses. an initial configural multisample model for the model excluding past behavior was estimated (model 3), which provided evidence for the tenability of the model in accounting for the data across both samples. this was followed by a restricted model in which the parameter estimates representing proposed relations among the hapa constructs and behavior were constrained to equality across the two samples (model 4). the fit of the constrained model did not differ significantly from the configural model across the two samples, which provided evidence that model parameters did not differ substantially. this was established using a formal likelihood ratio test of the goodness-of-fit chi-square for the configural and constrained models (byrne et al., 1989) . we also examined differences in the cfi; differences of less than .01 between values for the configural and constrained models have also been proposed as indicative of invariance of parameters (cheung & rensvold, 2002) . the configural (model 5) and constrained (model 6) multisample analyses were repeated for the model including past behavior. models were implemented using the maximum likelihood estimator with bootstrapped standard errors with 1,000 bootstrap replications. goodness of fit of the models with the data was evaluated using multiple criteria comparing the proposed model with the baseline model including the goodness-of-fit chi-square (v 2 ), the comparative fit index (cfi), the standardised root mean-squared of the residuals (srmr), and the root mean square error of approximation (rmsea) and its 90% confidence interval (90% ci). since the chi-square value is often statistically significant in complex models and has been shown to lead to the rejection of adequate models, we focused on the incremental fit indices. specifically, values for the cfi should exceed 0.95, values for the srmr should be less than or equal to 0.08, and values for the rmsea should be below 0.05 with a narrow 90% confidence interval (hu & bentler, 1999) . data files, analysis scripts, and output are available online: https://osf.io/mrzex/ attrition across the two data collection occasions resulted in final sample sizes of 365 (m age = 49.78, sd = 16.89; 50.1% women; attrition rate 26.27%) and 440 (m age = 51.77, sd = 16.26; 46.6% women; attrition rate = 37.23%) participants retained at follow-up in the australia and us samples, respectively. there were no missing data for the social cognition and behavior variables as participants could not advance through the survey without providing a response. there were a few instances of missing data for the demographic variables ranging from 0.5 per cent to 8.8 per cent in the australia sample, and 0.9 per cent to 6.4 per cent in the us sample as participants could opt not to respond to these items as they represented personal data. missing data are reported in table s3 . sample characteristics at follow-up are presented in table s4 , and comparisons on study variables between those retained in the study at follow-up and those lost to attrition are presented in table s3 . attrition analyses in the australia sample revealed that participants lost to attrition were younger and were more likely to be non-white. however, there were no differences in proportion of gender, income, and education level. a manova with the social cognition constructs and past behavior as dependent variables and attrition status (lost to attrition vs. included at follow-up) revealed no differences (wilks' lambda = 0.973, f(8) = 1.60, p = .115, partial g 2 = 0.026). attrition analyses in the us sample also indicated that participants lost to attrition were younger, and more likely to be men, non-white, and lower educated, and have low income, than those remaining in the study at follow-up. the manova testing for differences on social cognition and past behavior variables among participants lost to attrition and those included at follow-up revealed statistically significant differences (wilks' lambda = 0.957, f(8) = 3.90, p < .001, partial g 2 = 0.043). follow-up tests revealed that mean values for past behavior, attitudes, intentions, and self-monitoring with respect to social distancing were significantly lower among participants lost to attrition compared to those retained at follow-up. however, effect sizes for these differences were small (ds < 0.23). the total effect is computed as the sum of the indirect effects of the independent variable on the dependent variable through all model variables plus the direct effect. descriptive statistics for study variables are presented in table s4 . participants reported high levels of intention (australia sample, m = 6.54, sd = 0.66; us sample, m = 6.39, sd = 0.85) and behavior (australia sample, m = 6.10, sd = 0.67; us sample, m = 6.40, sd = 0.97) with respect to social distancing. internal consistency of the social cognition constructs was estimated using revelle's (2018) omega and internal consistency of the behavior variables and risk perception was estimated using the spearman-brown as they comprised two items each. results are presented in table s4 . all constructs in both samples exhibited acceptable internal consistency, and these data were used to estimate measurement error in subsequent single-item structural equation models. scale variance, descriptive statistics, and computed error variance terms used in structural equation models are also presented in table s4 . correlations among the model constructs and behavior and socio-demographic variables are presented in table s5 . the single-indicator structural equation models that excluded (model 1) and included (model 2) past behavior exhibited adequate model fit with the data for both the australia and us samples (see table s6 ). standardised parameter estimates and distribution statistics for each model in the australia and us samples are presented in tables 1 and 2, 2 respectively. focusing first on the models excluding past behavior, intention and action control were statistically significant predictors of social distancing behavior in both samples, with no significant effects for self-efficacy, action planning, and coping planning. there were also no significant effects of intention on action planning or coping planning in the australia sample, while intention predicted both planning constructs in the us sample. self-efficacy and action control were significant predictors of intention in both samples, with attitudes predicting intention in the australia sample only and risk perceptions predicting intention in the us sample, although the effect in the australia sample fell short of statistical significance by a trivial margin (p = .077). there were significant indirect effects of self-efficacy on behavior mediated by intention in both samples, and significant indirect effects of risk perceptions and action control on behavior mediated by intentions in the us sample only. intention and action control had significant total effects on behavior in both samples, with a further total effect of self-efficacy in the us sample. inclusion of past behavior led to an attenuation of model effects, consistent with previous research (brown et al., 2020; hagger et al., 2018) . notably, effects 2 full parameter estimates for the models in the australia and us samples are provided in tables s7 and s8, respectively. of all hapa constructs on behavior were reduced to a trivial size and were not statistically significant. effects of constructs on intentions remained with the same pattern as those in the model excluding past behavior for both samples, albeit with smaller effect sizes. the only exception was the action control-intention effect, which was reduced to a trivial size and non-significance in the us sample. past behavior predicted all model constructs with medium-to-large effect sizes in both samples. 3 comparisons of model fit across the australia and us samples revealed adequate fit of the configural models excluding (model 3) and including (model 5) past behavior, lending support for the tenability of the proposed pattern of model effects across the samples (table s6 ). constraining regression coefficients to be invariant for the models including (model 4) and excluding (model 6) past behavior resulted in no significant change in model fit according to the goodness-of-fit chi-square and the cfi with differences in the cfi across models less than .01 (table s6 ). these findings suggested that any observed differences in the parameter estimates of the models across the australia and us samples were relatively trivial. this is consistent with the highly consistent pattern of effects in the models in each sample with relatively minor sample-specific variation. the empirical literature has highlighted the imperative of non-pharmacological interventions in reducing the transmission of communicable viruses and preventing infection (jefferson et al., 2011; rabie & curtis, 2006; smith et al., 2015) . in the context of the covid-19 pandemic, participation in behaviors that prevent virus transmission is essential given the absence of a vaccine or clinically proven pharmacological therapy. sustained, population-level participation in such behaviors is not only important to reduce infections in the current pandemic phase, but also in the phases of easing restrictions to avoid a potential "second wave" of infections. there is a pressing need for evidence of potentially modifiable determinants of covid-19 preventive behaviors, such as social distancing, 3 the social distancing behavior and past behavior variables were associated with large skewness and kurtosis values. we checked to see whether the skewness and kurtosis values affected findings. so, we re-estimated our structural equation models using a square root transformation of these variables. the reanalysis revealed virtually identical coefficients and the exact pattern of effects found for the analysis using the untransformed behavior variables. analysis scripts and output for this auxiliary analysis are available online: https://osf.io/mrzex/?view_only=3ae43e6fa81c48c6880e65d 068f5435b on which to base interventions promoting population level participation in these behaviors. the current study aimed to address this need by identifying the theory based social cognition determinants of social distancing behavior, and the processes involved, in samples from australia and the us. the study adopted a correlational prospective survey design guided by the hapa. consistent with hapa predictions, intention and action control were identified as significant direct predictors of social distancing behavior in both samples, while intention predicted action planning and coping planning in the us sample. further, self-efficacy and action control were identified as significant predictors of intention in both samples. attitudes and risk perceptions were additional predictors in the australia and us samples, respectively. significant indirect effects were also observed; self-efficacy predicted behavior mediated by intention in both samples, and risk perceptions and action control were found to predict behavior mediated by intentions in the us sample only. despite these limited differences, it should be noted that comparisons of the models across the australia and us samples suggested that observed differences in parameter estimates across the samples were relatively trivial. findings are consistent with the auxiliary assumption promulgated in the hapa, and social cognition theories more generally, that the effects of the belief-based constructs reflect generalised processes that have a consistent pattern of effects across contexts, populations, and behaviors. in sum, the current findings indicate that individuals' social distancing behavior is a function of both motivational and volitional processes, and this provides formative data on potential targets for behavioral interventions aimed at promoting participation in this preventive behavior. results of this study provide qualified support for the application of the hapa, with its focus on constructs that represent dual phases of action. findings demonstrate a prominent role for self-efficacy as the key determinant of intentions, and intentions as the key determinant of behavior across both samples. these findings are in line with applications of the hapa in multiple health behavioral contexts , as well as research on social cognition constructs more broadly (hamilton, van dongen, & hagger, 2020; mceachan et al., 2011) . confidence in engaging in health behaviors and capacity to overcome setbacks and barriers have been consistently linked with future behavioral performance (warner & french, 2020) . the pervasive effect of intention on behavior is also aligned with a substantive literature on social cognition theories demonstrating intentions as the pre-eminent determinant of behavior (hamilton, van dongen, et al., 2020; mceachan et al., 2011) . overall, these effects suggest that social distancing behavior should be conceptualised as a reasoned action. however, the current study also demonstrated a prominent role for constructs representing volitional processes in the enactment of behavior. in particular, action control, a construct reflecting individuals' application of key self-regulatory skills to enact behavior, was a consistent predictor of both intentions and behavior across the samples. individuals possessing these skills are not only more likely to form intentions to perform social distancing behaviors, but are also more likely to engage in the behavior through, for example, an automatic process. specifically, the direct effect not mediated by intentions suggests that individuals with good action control might be more effective in structuring their environment or forming habits that promote enactment of social distancing without the need for extensive deliberation or weighing up of options. over time, these individuals are likely to form habits, that is, performance of behaviors that are activated through cues and contexts independent of the goals and intentions that originally gave rise to them (aarts et al., 1998; hagger, 2019; verplanken & orbell, 2003; wood, 2017) . research has suggested that individuals possessing these skills are effective in controlling their actions more broadly, but also that such skills can be acquired or learned (gardner, 2015; gardner et al., 2020) , which provides a potential avenue for intervention: training people to be more effective in regulating their own actions. interestingly, current research shows that risk perceptions have small effects on intentions and subsequent behavior. risk perceptions had small but significant effects in the us sample, and a small effect which fell short of statistical significance in the australia sample. this pattern of effects is consistent with applications of the hapa and other social cognition models like protection motivation theory, which found relatively modest or null effects of risk perceptions on intentions and behavior (zhang, chung, et al., 2019) . in the context of covid-19 prevention and social distancing behavior, it is common knowledge that the infection will not have serious consequences for the majority of the population, and is likely only to be serious for those with underlying conditions or impaired immunity, or the elderly. as a consequence, perceived risk may not be a major influence on decisions to act. instead, it seems that self-efficacy and action control are more pervasive and consistent determinants of behavior, and these may be more pertinent targets for intervention. action and coping planning were expected to mediate intention-behavior effects in the current model, such that planning is an important part of the process of intention enactment for social distancing. however, findings indicated that neither form of planning mediated intention effects on behavior, contrary to hapa predictions. these findings are not, however, unique, and previous research has demonstrated considerable variability in the role of planning in intention enactment, and effect sizes are often small (rhodes et al., 2020; . taken together, it seems that volitional processes such as action control are far more pervasive in promoting social distancing intentions and behavior. introduction of past behavior in the current model had marked influences on the size of model effects, rendering effects of almost all model constructs on intentions and behavior trivial and not statistically significant. one interpretation of these findings is that the current model is not sufficient in accounting for social distancing over time. however, it was not unexpected that past behavior would have pervasive effects on subsequent behavior over such short range prediction and, given the high stability of social distancing behavior, it is unsurprising that it accounts for model effects over time. it must also be stressed that past behavior alone is not a construct and does not, therefore, offer any information other than on the stability of social distancing behavior (ouellette & wood, 1998) . some have proposed that past behavior is indicative of habitual influences on behavior, but research examining habit as a construct suggests that it is more than performing a behavior frequently, and that the quality of the behavioral experience, such as experiencing it as automatic or without explicit thought, better characterises habitual processes (aarts et al., 1998; hagger, 2019; verplanken & orbell, 2003) . nevertheless, the residual effect of past behavior may provide some indication of unmeasured constructs on subsequent behavior, particularly those that bypass effects of intentions and are more likely rooted in non-conscious processes that lead to behavior, such as implicit attitudes or motives. research applying social cognition models like the hapa provides useful guidance for the development of future behavioral interventions aimed at promoting social distancing behaviors. although participants' intentions toward, and actual participation in, social distancing behavior were relatively high, scores and variability estimates suggested that some participants were reporting lapses in their social distancing behavior. such lapses present considerable risks to coronavirus transmission, particularly in areas of high prevalence where the likelihood of contact with infected persons is substantially elevated. our research provides some indication of the constructs that should be targeted for change and also the types of behavior change techniques that make up the content of interventions (hagger, cameron, et al, 2020; hagger, smith, et al., 2020; kok et al., 2016) . based on current findings, strategies to promote self-efficacy should be foremost in potential targets of interventions to promote intentions and behavior. interventions that have manipulated mastery experience (i.e. practicing a behavior) and vicarious experience (i.e. observing a model performing the behavior) have been shown to be successful in strengthening self-efficacy, as have interventions that provide feedback on past or others' performance (warner & french, 2020) . tailoring of these strategies could also be considered and targeted at uptake of the behavior for those that have not already adopted the behavior (e.g. demonstration of appropriate social distance when in line to purchase goods) or at maintenance of the behavior (e.g. developing a rule of thumb on keeping an appropriate social distance every time when in line to purchase goods). action control was another key determinant of intentions and behavior. this suggests that it is important that individuals acquire monitoring and self-regulatory strategies with respect to their social distancing behavior. for example, action control involves consistent monitoring as to whether an individual follows through on their intentions for the target behavior (schwarzer & hamilton, 2020) . monitoring helps identify discrepancies in behavior (e.g. not being at an appropriate social distance when in line to purchase goods), and noting a discrepancy can trigger taking additional action to ensure goals are achieved (e.g. adjusting the distance) or for disengaging from the goal (e.g. abandoning the goods and leaving the shop) (webb & de bruin, 2020) . in order to promote better action control, interventions may prompt self-monitoring (e.g. through selfobservation of social distancing behavior) or be monitored by others (e.g. shop attendant prompts an individual to increase their social distance). given that constructs such as attitudes and risk perceptions were not strong, consistent determinants of social distancing behavior, strategies targeting change in these constructs may not be at the forefront of behavioral interventions to promote social distancing. however, context-specific interventions that target change in attitudes for individuals in australia and risk perceptions, particularly for individuals in the us, may assist in promoting stronger intentions. strategies aimed at promoting attitude change and increased risk perceptions usually involve information provision (e.g. providing information about health consequences, highlighting the pros over the cons of social distancing) and communication-persuasion (e.g. using credible sources to deliver messages, using framing/reframing methods) about the importance of maintaining social distancing (hamilton & johnson, 2020) . however, reviews suggest that such strategies relate more to short-term change rather than sustained, longer-term impact on behavior (jepson et al., 2010) . another approach could be the use of fear appeals which seek to arouse negative emotional reactions in order to promote self-protective motivation and action (kok et al., 2016) . however, caution is needed when using fear appeals to attempt to change behavior as excessively heightened fear may be counter-productive in motivating individuals to engage in preventive behaviors (kok et al., 2018; lin, 2020) , and may even be counter-productive because they are responses aimed at mitigating fear, such as avoidance or denial, neither of which may manage the risk itself (hagger et al., 2017; leventhal et al., 1998) . there is evidence that messages that highlight risk but also provide coping information to increase self-efficacy (kok et al., 2018) and that use positive prosocial language (heffner et al., 2020) may be effective because they are more readily accepted and prevent defensive and avoidant reactions. however, current evidence suggests that interventions targeting change in attitudes and risk perception are unlikely to be enough to promote social distancing. the present research has a number of strengths including focus on social distancing, a key preventive behavior aimed at reducing transmission of sars-cov-2 to prevent covid-19 infections; adoption of a fit-for-purpose theoretical model, the hapa, that provides a set of a priori predictions on the motivational and volitional determinants of the target behavior; recruitment of samples from two countries, australia and the us, with key demographic characteristics that closely match those of the population; and the use of prospective study design and structural equation modelling techniques. a number of limitations to the current data should also be noted. that there was substantive attrition at follow-up in both samples is an important limitation. non-trivial attrition could result in selection bias. for example, participants who are more motivated or engaged may be overrepresented in the sample. in the current study, participants were provided with multiple reminders to complete measures at follow-up, but more intensive recruitment and incentivisation of non-responders may have further minimised attrition rates. it should be noted that participant drop-out affected the demographic profile of the samples, particularly among underrepresented groups. this is particularly relevant to the current context given data indicating that covid-19 infection and mortality rates are higher in underrepresented minority and socioeconomic groups (cdc, 2020) . a potential solution would be to oversample in underrepresented groups in which attrition rates are likely to be high and should be considered in future research. furthermore, our recruitment strategy was focused on producing samples with characteristics that corresponded with those of the national population on gender and state. however, the samples were not stratified by salient demographic or socioeconomic variables. the current samples cannot be characterised as representative of the australian or us population. taking these biases into account, the current findings should not be considered directly generalisable to the broader population. in addition, the current study adopted a prospective design, which provided a basis for the temporal ordering of constructs in the model. however, the correlational design of the current study means that inferences of causality are based on theory rather than the data. furthermore, the current design did not permit modeling of the stability or change in model constructs over time. the latter represents an important caveat when utilising current data as a basis for intervention. future research should aim to adopt cross-lagged panel designs that model change in constructs over time, and utilise intervention or experimental designs that target change in model constructs and observe their effects on behavior. also, the study was conducted over a one-week period. although this is a relatively brief follow-up period, it was considered appropriate given the high speed of virus transmission and the need for prompt adoption of social distancing in the population to prevent widespread infection. the current results, however, do not confirm the extent to which model constructs predict social distancing over a longer period, and long-term follow-up would be necessary to support the application of the hapa in accounting for maintenance of social distancing, which is especially important as lockdown restrictions ease in order to prevent a "second wave" of infection. the present study also relied exclusively on self-report measures which may introduce additional error variance through recall bias and socially desirable responding. future studies may consider verification of behavioral data with non-self-report data such as the use of gps mapping of mobile phones or using observation to verify rates of social distancing behavior in particular contexts (e.g. workplaces, grocery stores). it might also be useful for future studies to investigate the role of social factors, as suggested in the hapa, on social distancing behavior. this is particularly important given the considerable potential for "social" influences to affect individuals' behavior in minimising person-to-person contact with others outside the individual's immediate household. precedence for these effects comes from previous research which has found that pressure from important others and moral obligation toward others predicts adherence to covid-19 preventive behaviors, including social distancing (hagger, cameron, et al, 2020; hagger, smith, et al., 2020; lin et al., 2020) . finally, this research was conducted during a period when it is likely that participants were already engaging in social distancing and, thus, already had substantive experience with the behavior, indicated by the high scale mean scores for past behavior (m = 6.5 on a 7-point scale) in both samples. this likely explains the substantive effect of past behavior in attenuating model effects and the need for longitudinal designs or using methods such as ecological momentary assessment that capture moment-by-moment changes over time in behavior. given the urgent need for populations to adopt covid-19 preventive behaviors, such as social distancing, the present study applied the hapa to predict key motivational and volitional determinants of social distancing behavior in samples across two different countries, australia and the us. overall, the current findings provide qualified support for some of the core proposed effects among the motivational and volitional factors in the model, as well as their effects on individuals' social distancing behavior. the current study fills a knowledge gap in the literature on the social psychological processes that guide social distancing behavior in an unprecedented context of a pandemic and suggests that the motivational and volitional constructs of self-efficacy, intention, and action control, in particular, may have utility in explaining this important covid-19 preventive behavior. despite the correlational design, the current findings suggest multiple potential routes to behavioral performance that can serve as a basis for the development of intervention and enable further testing of effects of the techniques on both behavior change and the targeted theory constructs. additional supporting information may be found online in the supporting information section at the end of the article. 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behavior predicts future behavior r: a language and environment for statistical computing handwashing and risk of respiratory infections: a quantitative systematic review psych: procedures for psychological social-cognitive antecedents of hand washing: action control bridges the planning-behaviour gap planning and implementation intention interventions lavaan: an r package for structural equation modeling a comparison of several approaches for controlling measurement error in small samples the health action process approach (hapa): assessment tools modeling health behavior change: how to predict and modify the adoption and maintenance of health behaviors changing behaviour using the health action process approach income and poverty in the united states use of non-pharmaceutical interventions to reduce the transmission of influenza in adults: a systematic review public perceptions of non-pharmaceutical interventions for reducing transmission of respiratory infection: systematic review and synthesis of qualitative studies behavioural science and disease prevention: psychological guidance reflections on past behavior: a self-report index of habit strength confidence and self-efficacy interventions monitoring interventions applying principles of behaviour change to reduce sars-cov-2 transmission habit in personality and social psychology coronavirus disease (covid-19) advice for the public worldometer covid-19 coronavirus pandemic modeling longitudinal and multiple group data: practical issues, applied approaches and specific examples health beliefs of wearing facemasks for influenza a/h1n1 prevention: a qualitative investigation of hong kong older adults predicting hand washing and sleep hygiene behaviors among college students: test of an integrated social-cognition model a meta-analysis of the health action process approach the role of action control and action planning on fruit and vegetable consumption martin s. hagger's contribution was supported by a finland distinguished professor (fidipro) award (dnro 1801/31/2105) from business finland. data files and analysis scripts are available online from the open science framework project for this study: https://osf.io/mrzex/?view_only=3ae43e6fa81c48c 6880e65d068f5435b key: cord-291596-lp5di10v authors: singh, shweta; dixit, ayushi; joshi, gunjan title: “is compulsive social media use amid covid-19 pandemic addictive behavior or coping mechanism? date: 2020-07-07 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102290 sha: doc_id: 291596 cord_uid: lp5di10v nan "is compulsive social media use amid covid-19 pandemic addictive behavior or coping mechanism? 1 dr. shweta singh, 2 ayushi dixit, 3 owing to easy accessibility of internet, globally there are more than 3 billion social media users accounting for 49% of the world's population. in india, the number of social media users stands more than 376 million with a population of more than 1.36 billion (statista, 2020) . the mental health impact of covid-19 is not limited to affected persons, their families and the healthcare force but embraces society's response at large (tondon, 2020). amid the pandemic and subsequent nationwide lockdown, there has been a surge in social media usage which is also reflective of a social response worldwide. for instance, in india 87% people reported increase in its usage with 75% spending increasing amount of time on facebook, twitter and whatsapp (business today, march 30, 2020) . given the backdrop of this alarming data, it is pertinent to debate two questions i.e. (a) "does the current pattern of social media usage suggest a trend towards addictive behavior or has it become a coping mechanism to deal with current global crisis?" and (b) "what are the current and future implications of this trend on addictive behavior and mental health of people?". considering its widespread use across ages, social media is known to be a source of social reinforcement and validation. this platform provide people with an opportunity to share ideas, interact socially, form relationships, draw attention of others and create social image (kietzmann et al., 2011) . during the current global crises when 'social distancing' has become a norm, over-engagement in social media has become a 'psychological necessity' thereby helping people to address their needs of human j o u r n a l p r e -p r o o f interaction and coping with the pandemic. therefore, despite the precautionary guidelines of social distancing, it provides people a platform to remain socially connected and universalize distress caused by the current crisis. apart from socialization, social media is also being used for academic and workrelated purposes like conducting online lectures, webinars, meetings and ensuring work from home. one of the major advantages of social media is that it facilitates awareness and provides mental health support by making resources available to those facing distress caused by lockdown and to those who are isolated as a result of being quarantined. with the help of this platform, data scientists and healthcare professionals have recently surfaced as social media influencers with the aim to mobilize people for taking proactive steps to deal with the crisis (the economic times, 2020). in the ongoing scenario, social media has become one of the major sources for updating information on covid-19 for people. however, it's irresponsible use poses the challenge of 'infodemics' i.e. a situation when 'misinformation' spreads rapidly thereby affecting thinking and subsequent behavior of people. recently who had cautioned people against social media rumors which lead to panic, stigma and irrational behavior (who, 2020). given the rise in usage of this media, it becomes necessary to address its association with mental health. the relationship between social media disorder and mental disorders becomes controversial which is attributable to diagnostic complications (pantic, 2014) . research in the past has shown that compulsive usage of social media impacts physical and mental health including cardio-metabolic health, sleep, affect, self-esteem, well-being and functioning, especially in adolescents (turel et al., 2016 , cheng et al., 2014 van rooij and schoenmakers, 2013) . in light of the present pandemic, mental health conditions are found to be associated with the amount of social media exposure. for instance, a study during covid-19 outbreak in wuhan china, found the prevalence of depression, anxiety and a combination of depression and anxiety (cda) to be 48%, 23% and 19% respectively. moreover 82% participants who were frequently exposed to social media reported high odds of anxiety as well as cda (gao et al,2020) . it is well known to us and also resonated by research that 'internet addiction' is predominantly linked to increased social media or gaming activities schoenmakers, 2013, van rooij and prause, 2014) . while dsm-5 (apa, 2013) and the stable version of icd-11 (who, 2018) have identified 'internet gaming disorder' (igd) as a provisional disorder, social media disorder is still not acknowledged. increasing research is advocating that social media disorder should be considered an addictive disorder just like igd (pantic, 2014; ryan et al., 2014) . according to the dsm-5, a person is diagnosed as having igd if there is fulfillment of 5 (or more) of the 9 criteria (preoccupation, tolerance, withdrawal, persistence, escape, problems, deception, displacement, and conflict) during a period of 12 months. since social-media disorder and igd both relate to internet use, researches refer to nine igd j o u r n a l p r e -p r o o f criterion of dsm-5 for constructing diagnostic tools and establishing internet / social media addiction (regina et al, 2016; van den eijnden, 2016) . since covid-19 outbreak began from end of 2019 and crossed international borders from the beginning of 2020, undeniably '12 months dsm 5 criterion' is not applicable. but it is difficult to say if five or more igd dsm-5 criteria are fulfilled by the excessive social media users. it comes with a word of caution that excessive social media usage is known to be highly addictive due to its psychological, social and neurobiological basis. during current pandemic, like many other uncertainties, it is unclear whether this compulsive use of social media is just a 'phase' and a coping mechanism or an indication of addictive behavior having mental health implications. hence, in terms of current research implications and management, it is imperative to keep the contextual issue of global pandemic in mind and differentiate between addictive and extremely involved behavior. it can be explored whether (apart from the criterion of 12 month duration) people fulfill at least 5 out of 9 igd criterion of dsm-5. here it would be worthwhile to add that because of unique sociocultural context, experience of various asian countries during covid -19 pandemic needs to be studied and shared with the world (tondon, 2020). moreover, any research conducted on addictive behaviors in the current time should consider longitudinally the pre-present-post lockdown social media usage pattern and its mental health implications among individuals across all age groups. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. diagnostic and statistical manual of mental disorders, fifth edition internet addiction prevalence and quality of (real) life: a metaanalysis of 31 nations across seven world regions mental health problems and social media exposure during covid-19 social media? get serious! understanding the functional building blocks of social media online social networking and mental health the social media disorder scalecompute rs in human behaviour the uses and abuses of facebook: a review of facebook addiction the covid-19 pandemic, personal reflections on editorial responsibility health outcomes of information system use lifestyles among adolescents: videogame addiction, sleep curtailment and cardio-metabolic deficiencies the social media disorder scale a critical review of "internet addiction" criteria with suggestions for the future het (mobiele) gebruik van sociele media en games door jongeren covid-19 pheic global research and innovation forum: towards a research roadmap the new indian express). covid pandemic,social media and digital distancing-the new indian express url how covid-19 has made data experts the new-age social media influencers -the economic times 87% people reported increase in its usage with 75% spending increasing amount of time on facebook (statista) 2020. number of social media users worldwide mental health professionals serving selflessly during current global pandemic. key: cord-320147-29a7njqi authors: mendes, luís title: how can we quarantine without a home? responses of activism and urban social movements in times of covid‐19 pandemic crisis in lisbon date: 2020-06-23 journal: tijdschr econ soc geogr doi: 10.1111/tesg.12450 sha: doc_id: 320147 cord_uid: 29a7njqi in lisbon, during the covid‐19 pandemic period, new spaces for contestation and the action of urban social movements intensified, capitalising on the visibility for the right to housing, as a basic human right and an unconditional public health imperative, to fulfil the duties of lockdown and social isolation, imposed by the state of exception. its narrative and strategies reinforces the counter‐hegemonic movement that denounces the logics of commodification and financialisation in the housing sector, placing hope in a post‐capitalist transition in the post‐covid horizon. we conclude that the actors in this urban struggle have limited power over the changes they initiate, or make an effort to inflict, if they are not involved in a concerted and politically integrated action, not least because the achievements they obtain are temporary and exceptional, like the state of emergency imposed by covid‐19. a global emergency situation due to the outbreak of the covid-19 pandemic obliges governments to mobilise resources to enable the response of health authorities and implement economic recovery plans that protect the most fragile citizens from the impacts of the crisis caused by the pandemic. the situation of an authentic state of exception (agamben 2010 (agamben , 2020 ) that exists in portugal due to the expansion of the covid-19 pandemic and the triggering of the state of emergency 1 with the mandatory social isolation and lockdown, as well as limitations on freedom of movement, resistance and economic activities, intensified the discussion around the right to housing in portugal. it demonstrated how poor access to the right to housing, in the midst of a pandemic crisis, not only turns out to be a condition of worsening socio-territorial inequalities and residential segregation of the pre-covid, but also an obstacle to full compliance with sanitary standards. now, the collectives and associations that defend this right were able to capitalise on it as a human right, focusing on the difficulty of access to housing in conditions of decent habitability that allow the isolation required by the political health authorities, catapulting this issue to the top of the social and political agenda. digital protests, campaigns, petitions, open letters and memoranda addressed to political authorities with responsibility in the matter have multiplied. after all, how can we quarantine without a home? (accornero et al. 2020; mendes 2020) . the period of covid-19 has exposed the contradictions of the portuguese urban economic recovery model of the last decade in the post capitalist crisis 2008-2009, based on the pillars of the dynamics of real estate and the touristification of the territory, generating rapid growth, but with little environmental, social and economic sustainability (seixas et al. 2015; barata salgueiro et al. 2017) . the economic recovery was based on a rentist, extractivist and predatory model of austerity urbanism that generated numerous phenomena of accumulation by dispossession taking advantage of the capital gains produced by an overheated housing market, especially in the inner city of lisbon (harvey 2012; peck 2012; sevilla-buitrago 2015; mendes 2017) . the urban restructuring of the main portuguese cities, especially lisbon, produced phenomena of strong socio-spatial injustice, massive evictions never seen in portuguese urban history, based on transnational gentrification, real estate speculation and financialisation of housing (aalbers 2012 (aalbers , 2016 mendes 2018a; sequera & nofre 2019) . the dynamics of social protest, demands and pre-covid urban struggles are now essential in order to capitalise on collective learning, the social capital of the networks created and the impact they have had on placing the issue of the right to housing on the public and political agenda, in the last years (mayer 2010; colomb & novy 2016; sequera & nofre 2018) . how are the urban social movements that formed in lisbon in the pre-covid responding to the growing and aggravated inequalities in the housing market during the current pandemic? even though we know that the covid-19 pandemic crisis is recent, and that the problem of the right to housing is as old in portugal, as in the world, this paper aims to contribute to fill the knowledge gaps that exist in the national and international literature on this matter. did the reorganisation of the strategies of these activisms during covid-19 allow the response of the government, the party system and representative democracy, which were made with a sense of urgency, by immediately suspending evictions and moving forward with temporary and extraordinary measures to guarantee the basic right to housing or shelter, that allowed isolation in lockdown period? in order to answer these questions, and in addition to a review of the national and international literature on urban social movements and some recent interventions and papers on covid-19, the methodological line is composed of qualitative methods and techniques (semi-structured interviews to activists 2 and critical content analysis of social media and other propaganda) that allow a macro analysis of the various laws that produced quarantine urbanism during this period of state of emergency, crossed with a micro analysis of ethnographic fieldwork of the performance of those various associations and movements, taking into account the research-action work developed by the author as activist in the last three years. the paper is organised in three main parts. the first part very briefly frames the debates on activism and urban social movements on the right to housing in general, its principles and recent developments. the second part addresses the new spaces of contestation created by anti-evictions urban social movements in pre-covid period in lisbon, namely, their characteristics and organisational forms, assessing the political potential for reversing the current situation of housing crisis. the third part explores the recent dramatic expansion of the pandemic and the effectiveness of the covid-19 contingency plan, and how the intervention of urban collectives, associations and social movements for the right to housing and the multiple and innovative strategies they used were fundamental to compel representative democracy to understand and act in conformity with the categorical imperative of housing defence for everyone. the paper concludes with a summary of main findings. manuel castells (1973) defines urban struggles as reclaim practices that attempt to modify or alter the contradictions that cross the capitalist city. when there is a convergence of these struggles with the workers' struggles, we are witnessing the emergence of urban social movements. these, also according to the author, are specific practices of urban struggles with ability to transform structurally dominant urban logic (pickvance 2003) . for many authors who have come to address this problem (e.g. castells, touraine, etc.) , one of the purposes of urban social movements is that they participate in the transforming capacity of the mass movement by virtue of correlation of forces that are established within it. without this joint action, for example, with the labour movement -the centre of gravity of the historical struggles -urban struggles lose all its transforming potential (miller 2000; köhler & wissen 2003) . there is thus a need to expand the urban struggles to a whole multiplicity of urban contradictions conferring legitimacy organisation. such an organisation can only process on the basis of mutual respect and support to the self-worth of each battlefield for different pressure groups involved (künkel & mayer 2012; mayer et al. 2016) . in the past few years, several theses have emerged stressing the loss of centrality or even the end of work as a decisive value in structuring society. important authors contend that we are witnessing a disenchantment in respect to work and a relegating of the work sphere to a secondary plane. instead, alternative dimensions of exercising citizenship, such as associativism, activism, voluntary work and third sector areas, have been chosen as primary spheres for civic participation and factors in social cohesion and change. the breakdown of the old fordist wage relation, the crisis of the welfare state, the increase in competitiveness at a global scale, especially from the mid-1980s onward, occurred as a new liberal wave emerged, largely grounded on technological innovation and the it revolution (sousa santos 1994; estanque 2009 ). these trends are generating profound changes and new contradictions and social inequalities in every area of contemporary societies, with striking results in the recomposition and destandardisation of traditional forms of work, beyond that strongly demobilise any critical movement that challenged or attempted critique of neoliberal ideological system (beck 1992; castells 2002) in reclaiming social and spatial justice (soja 2010; harvey 2009 harvey , 2014 . the erosion of forms of contestation and reclaiming, typical of modernity and very effective until the 1970s (trade unions and political parties) gave rise to the emergence of other forms of protest more diffuse and flexible, in terms of organisation, and also wider and holistic in with regard to the issues in question -from labour relations, civil rights, political models and the cultural and artistic expressions. it is not that traditional forms of left organising (left political parties and militant sects, labour unions and militant environmental or social movements such as the landless peasants movement in brazil) have disappeared. but they now all seem to be part of more diffuse oppositional movements that lack overall political coherence (mayer 2010; künkel & mayer 2012) . besides trade unions' action, several collective actors who fit in the spectrum of the network social movements emerged, clarifying the relevance of collective responses for social critical needs. the new social movements that have arisen in western societies from the 1980s are characterised by: a heterogeneous nature; localised character, scattered and ephemeral; radicalism and spectacular actions; and lack of programmatic ideologies. they are also defined by the internal diversity of the subject of their social action, the development of contentious cultural practices and the rejection of institutional politics. the apparently opposed character of these movements could be put in the same level of the antagonistic character of the marxist class approach to social protest and the critique to it which is implicit on the new social movement theory. the fact that they are markedly streamlined through the layers of the educated youth, conveyed through cyberspace, marked by flexible organisation, networking, with no identified leaders, making use of performative and dramatic arts, unrelated to any structured political programme, reveals its spontaneity, which does not mean that they lack a clearly defined mission that guides them, as well as a strategic vision and innovative practices that produce consequences for public opinion, in the mobilisation of the most vulnerable people and also the critical lines of the university to pressure the instituted political power. other features have to do with: a relative decentralisation in organisation, assembled and initiated by digital networks quickly and predominantly with media distribution; the complex relationship between the individual subject and the movement as collective identity; a complex social composition of the actors in these movements in its multireferential, composite and flexible identity; the political struggle based on the calling for more heterodox forms of political organisation and political and democratic participation in the margins of institutions; and the internationalisation of very localised and territorialised movements, but not necessarily localist (estanque 1999; miller 2000) . the blurring of class-based conflict (especially labour), fragmentation and casualisation of wage relations, mass and simultaneous individualisation of consumption and lifestyles, the atomisation and fragmentation of everyday behaviours, no sharing of problems/ collective projects and consequent fading of collective identity and sense of sharing within the community, all these factors contribute to an experience of growing loss of mobilising capacity of traditional associative structures (union, party, etc.; hamel et al. 2000; harvey 2012) . despite an apparent detachment from the apparatus of institutional and party democracy, these new urban social movements gain emancipatory potential for critical transformation of the urban reality. this was particularly evident in the upsurge of urban struggles and urban social movements in the aftermath of the 2008-2009 capitalist crisis (castells 2013; mayer et al. 2016; simões et al. 2018) . the triggering of the 2008-2009 capitalist crisis and its prolongation for the next half decade has aggravated socio-spatial inequalities, having given rise to a wave of social protests and demonstrations that, in turn, give visibility to the issue of the right to housing, in a counter-hegemonic movement that denounces the logics of commodification and financialisation in the housing sector and of exclusively private appropriation of other facilities that were from collective and public urban use (aalbers 2012 (aalbers , 2016 rolnik 2015) . some of these social protests and urban struggles have given rise to the configuration of urban social movements, whose action has been oriented, especially, to affirm the issue of housing on the political and social agenda in the contemporary cities (brenner et al. 2012; colomb & novy 2016; martínez 2019) . in this context and focusing specifically on the portuguese case, the resurgence of popular protest and new urban social movements not only continued to be primarily associated to the anti-austerity ideology, as gave a new impetus to collective action in the field of struggles for the right to housing and the city. in fact, since 2011, portugal experienced the largest protest cycle since the 1974 democratic revolution (sousa santos 2011; estanque 2014; queirós et al. 2015) . lisbon´s housing activism has strengthened and trigged diverse and innovative spaces of contestation, strongly underpinned by anti-gentrification and anti-displacement claims (mendes 2018b; tulumello 2018) . the economic crisis that erupted in 2008, deepens the fragmentation and social exclusion in the territories and intensifies social duality of the central urban areas. it also increases the indebtedness of the cities through the rampant use of credit, tried to respond to increasing social demands. but the housing crisis that has been going on in lisbon since 2015 is due to the combination of a specific conjuncture of pluriescalar causes that ended up producing a 'perfect storm' in the local housing market. in the pre-covid period, between 2009 and 2019, a neoliberal turn on fiscal and urban policies emerged, driven by postcrisis capitalist international austerity intervention 2011-2014 in portugal. both national as urban government has discovered the potential of touristification and overtourism in regenerating inner-city traditional housing areas, in order to increase the competitiveness of the city and certain neighbourhoods in the global context of urban competition. this catapulted the city of lisbon onto the world map, making it a favourite destination for attracting tourist flows and foreign investment, tying fixed capital from its transnational capital flows in lisbon's built environment and housing stock. the creation of aggressive programmes to attract foreign investment (as the golden visa and the non habitual residents), the new urban rental law, the new tax regime for property investment funds, the new law of tourist lodging (short-rental), along with a intense rent gap in the inner-city, a full liberalisation at the level of urban land use in the city municipal master plan, as well as a strong growth in tourism in the city of lisbon, introduced significant changes in the residential market, which went from an abrupt pause to a high level of demand, with supply now beginning to fall short. this situation led to a very quick take-up of the new and good quality residential stock that was available, located mostly in the city's historic centre. the rapid take-up of apartments, the new tourism drivers -with an 'alternative' demand for stays in apartmentsand tax incentives to boost urban regeneration, have created renewed interest among many national and international developers, leading to a great rise in the refurbishment of buildings in lisbon's historic district (mendes 2017; cocola gant & gago 2019; lestegás 2019) . as a result of the increasing volume of real estate interventions, physical and architectural improvements become increasingly visible. as a result, house prices in historic neighbourhoods begin to climb very rapidly. without regulation or moderate control over rent increases, the eviction process expands to more aggressive forms as neighbourhood real estate values also increase and the state approves legislation that facilitates private initiative and evicts local residents and retailers from local and traditional retail. the better maintained housing and commercial properties become part of the upper-and upper-middle class market as homeowners seek to take advantage of the area's enhanced notoriety, which in turn leads to further displacement 3 (mendes 2018a; sequera & nofre 2019). given the urban contradictions generated by the omnipresence of economic and financial crisis and the negative impacts on the housing local market by touristification and transnational gentrification (hughes 2018; sequera & nofre 2018) on the scale of districts most affected by tourist accommodation, financialisation of housing and luxury real estate for the new middle classes (aalbers 2019) , anything else would not be expect than the resurgence of urban protest movements (domaradzka 2018; seixas & brito guterres 2018; mehan & rossi 2019) . in the lisbon case, an interesting and emancipatory connection has emerged between the transforming ability of these joint movements with the class struggle to create pressure on the local and national urban policy process, as with popular movements fighting for homes and the right to the city in the post 25 april 1974 portugal (democratic revolution). with specific orientation for the right to the city and housing, the collective 'habita -collective for the right to housing and the city', emerged in 2009, however constituted as an association in 2014, but had already been active for more than a decade. this is a lively collective that fights for the defence that the realisation of these fundamental rights are essential to human life, since they are recognised by national and international law, in particular relating to the article 65 on the right to housing and urban planning, as are arranged in the portuguese constitution. this collective belongs to several international networks and brings together activists with many years work experience in this area and that, over time, developed a dialogue with organisations and government agencies in several instances, fighting for human dignity and fundamental rights in terms of production and appropriation of the city (interviews 1, 3, 4, 5 and 7). in its statement of principles the collective habita maintains that all people have the right to adequate housing. this is a fundamental human right for the experience of all economic, social, cultural rights as well as civil and political, and therefore have to be respected and treated in an integrated manner with other rights. moreover, housing is a right recognised by the universal declaration of human rights, the international covenant on economic, social and cultural rights and the constitution of the portuguese republic. the collective maintain that all people have the right to the city, and equal access usufruct to its various social spaces and active participation in its production and appropriation process. the right to the city is closely linked to the right to housing and challenge the multiple processes of segregation, insecurity, discrimination, vulnerability and expulsion that limit the right to housing, as well as services, equipment and public spaces of our cities. they argue that housing and urban development should be part of a truly participatory public policy and for combating all forms of property speculation. the habita organisation fights against housing seen as a financial asset and commodity, which is only seen as exchange value and devoid of use value excluding the most vulnerable people, who are expelled from their homes and their places when they cannot afford the inflated prices that for decades have favoured the real estate and banking sector (i4 and i7). the collective claims a dwelling compatible with people's incomes, adequate and integrated in the city, with access to mobility, culture, equipment and services. they also fight for the rights to housing and the city, looking for foster self-organisation and awareness of people and the training of activists (i5). this collective combines coherently the study and reflection of the root causes that limit the right to housing and the city; with direct intervention, complaint, political pressure and public to change systems, legislation and policies, supporting struggles and working for formulating policy proposals (i4). associated with the habita association, the collective stop despejos/stop evictions emerged about three years ago. it is collectively fighting for the end of evictions, for the defence of the right to housing and for the collective, inclusive and fairer construction of our cities (i5). in this context, they present themselves as a tool of struggle and resistance 'to the wave of financial real estate speculation and to the neoliberal policies that govern cities, privatise public space, attack our lives, threaten and trample fundamental rights' (see https://stopd espej os.wordp ress. com/). they defend the right to decent housing for all, the right to the city and the right to remain in their neighbourhood, the right to stay put. they seek to join the struggles of all who are in a situation of eviction, or of precarious housing, defending the creation of solidarity networks and the active and participative construction of alternatives, whose pre-covid experience has proved essential as an urban struggle strategy (i6). as residents and/or supporters of the struggle for decent housing and the right to the city, they present themselves as a supportive collective, understanding that the issue of housing is a social, political and economic problem. they are constituted as a platform of encounter and space for the convergence of individuals, collectives and movements fighting for the right to decent housing and for an inclusive and fairer city (i3). they also demonstrate their willingness to form alliances with grassroots feminist, anti-racist, anti-fascist and anti-capitalist movements, with whom they admit to sharing ways of seeing the world and fighting for a better one (i7). stop despejos is a horizontal collective (there are no hierarchies and decisions are taken in assembly), non-partisan (does not belong to or support any political party), self-financed (does not accept state subsidies) and autonomous (does not depend on any other organisation) (i3). they claim the right to collective construction of the spaces where they live, the right to public space, the end of precariousness and the crisis in access to housing. 'in a country where real estate profits are privileged and laws disrespect the right to a decent life and housing, disobedience is legitimate and necessary'. that is why, in addition to communication and claim campaigns, they practise direct action and support the occupation and obstruction of evictions (i5): despite the big complexity and diversity of grassroots actors at play, emergent struggles have had in common the capacity to play on different arenas -seeking media visibility, negotiating with institutional actors, acting in confrontational way, producing alternative data -with the explicit goal of fighting back the commodification of housing in 'post-austerity' lisbon. (tulumello 2018, p. 62) although these new urban social movements are quite autonomous against the manipulations of the political and partisan ideology of representative democracy, the truth is that they no longer have a social base really organised (i2). the new social movements are located outside the sphere of work and production, away from the ideal of workers' struggle at developing a critical and contestation action, focusing, above all, in a particular and specific aspect of the general conditions of existence -housing rights, ignoring all others. they are characterised by a generalised distrust of the state (and political parties), by strong criticism to anti-conscience parties, and dominated by specific particularities which give them of a peripheral character in relation to the central contradictions between capital and labour. they express a new political culture, centred on the right values to be different, but do not have a connection with the various fronts of struggle, which is a relatively weak policy (harvey 2012; queirós et al. 2015; fonseca 2018) . the covid-19 pandemic crisis took us by surprise, imposing unexpected pressure on families and essential public services and demanding challenges to the economy and labor. we are going through a health, social and economic crisis like we have never lived before. the outbreak of covid-19 and measures of social distance took people and states by surprise and brought about profound routine changes. given the unpredictable nature of the virus, there is a dominant narrative in the media that we are in the presence of a 'symmetrical shock', that is, something that affects everyone equally (countries and people) and that we all suffer the consequences, regardless of your socio-economic status. more critical opinions have recently paid more attention to the uneven impact of the virus on societies. inequality begins to be noticed between countries: while the most advanced economies have mechanisms to mitigate economic impacts -for example, the role of central banks in the injection of liquidity in the markets that allows to contain the panic of investors and facilitate the conditions of state financing (preventing public debt interest rates from skyrocketing)developing countries are not so lucky. we are not 'all in the same boat' and this will also be reflected in the deep recession that lies ahead. on the other hand, decades of neoliberalism and the most recent period of austerity after the capitalist crisis 2008-2009 has left a major part of the population and territories totally exposed and ill prepared to face a public health crisis on the scale of coronavirus (harvey 2020; ferreira 2020; tulumello 2020) . with regard to access to the right to housing, the ineffectiveness of guaranteeing the application of preventive measures, such as maintaining personal hygiene and guaranteeing distance and social isolation, the pandemic dramatically exposed the contradictions of the capitalist production of urban space and aggravated the lines of socio-territorial inequalities and residential segregation that came from the pre-covid-19 period. how to wash your hands if there is not even soap and domestic access to water? how to think about social isolation in overcrowded houses? again, how can we quarantine if we don't have a home? (i3) the collectives and urban social movements with emergence and action in the pre-covid-19, which helped to put the right to housing on the public and political agenda, are the ones that are better prepared to defend the most vulnerable social groups in access to decent housing living conditions and proved to be decisive in the public pressure of the portuguese government towards the adoption of urgent and exceptional temporary measures, during the covid-19 crisis, but also in the socioeconomic crisis and the very strong recession that is looming post-covid-19, as all respondents mentioned. on 18 march 2020, a state of emergency was declared in portugal, through the decree-law of the president of the republic no. 14-a/2020, of march 18. the world health organisation had qualified the current public health emergency situation caused by the epidemic of the disease covid-19, making it imperative to provide measures to ensure its treatment, through a regime appropriate to this reality, that allows establish exceptional and temporary measures to respond to the epidemic. habita and the collective stop despejos had produced a manifesto entitled 'how can we quarantine without a home?', subscribed by more than 60 associations and collectives, including the morar em lisboa platform. this manifesto gave rise to a petition that gathers around 2,500 signatures in a few days. the manifesto calls for an immediate end to the evictions, the immediate resettlement of all evicted people and families and those living on the street, the requisition of empty houses, may they be tourist, luxury or municipal apartments, for emergency resettlement. on the other hand, they also ask for the suspension of the payment of rent for all tenants affected by the crisis, the suspension of the payment of housing loans and mortgages, the suspension of rent for social spaces, such as collectives and associations, as well as the small businesses affected by the crisis and that had a suspension of income. this petition sensitised thousands of people in civil society and helped to catapult the most primary contradictions inherent to the problem of the right to housing onto the public agenda. this collective effort, associated with the sending of various memorandums that the lisbon tenants association (a century-old association and of a more institutional character, that belongs to morar em lisboa) produced in those weeks of march and which sent to the prime minister of portugal, the entire government and parliamentary groups, ended up having an effect, both on government discourse as in the measures adopted (i2, 6 and 7). it was suggested that, taking into account the gravity and the exceptionality of the covid-19 moment, not only should evictions be suspended, but also that rental legislation should be suspended with regard to terms, which should only start counting after the end of the period contingency. it was considered that landlords should not be able to invoke the denunciation or opposition to the renewal of the rent contract during the contingency period. finally, it was also defended the deferral of the payment of installments of loans for the purchase of housing by the ordinary citizen or in the case of the acquisition of property for social, cultural associations, etc. all these measures enacted as a way of protecting the family and individual home while the pandemic and quarantine situation persists. the assembly of the portuguese republic welcomed with approval and with a sense of urgency some of the proposals made, and the consensus of the plenary led the president of the republic to promulgate the law 1-a/2020 on 19 march 'exceptional and temporary measures response to the epidemiological situation caused by the coronavirus sars-cov-2 and the disease covid-19' where it is determined that the eviction actions, the special eviction procedures and the processes for delivery of the leased property are suspended, when the tenant can be placed in a situation of fragility due to lack of housing. on the other hand, an extraordinary and transitional tenant protection regime was created, which determines that until the cessation of the prevention, containment, mitigation and treatment of covid-19, as determined by the national public health authority, it is not possible to cancel the housing rental agreements (including retail and associations) made by the landlord and foreclosure on property that constitutes permanent housing. 'resisting from home': seeking media visibility and producing alternative data -in addition to the petition and the sending of memos (direct communication with the political authorities) (i2 and i7), some more creative and innovative strategies in the performative sense were carried out, since the right to resist and to circulate or manifest in public space had been suspended by the state of emergency (i3 and i5). how to continue to resist from home? this was the primary issue with which social and collective movements were now confronted. i would like to highlight four strategies that seem relevant to me in this field: holding virtual platform assemblies, creation of a network of studies on housing (rede h) at the academic level that promotes action research, email bombing and local networks of mutual support. regarding the first, habita had been holding weekly assemblies in the last months, where weaknesses, strengths and strategies of struggle were discussed with the victims of evictions or threats of eviction. the moment was crucial to empower the most vulnerable victims of residential segregation, and to encourage socialisation and collectivisation of problems. the aim is not to find an individual solution but for solutions to be thought and taken collectively, strengthening class consciousness (i5, e i7). as these presential meetings are no longer possible due to the abolition of the right to resistance established during the state of emergency, in the absence of face-to-face meetings, these started to take place on digital platforms and online social networks. the second strategy, founded in february 2020, rede h -national housing studies network brings together about 60 people, including academics, activists and other civil society actors, united by their interest in studying the topic of housing. in mid-march, before the declaration of the state of emergency, they published an open letter to the portuguese government and society, addressing several urgent measures to be implemented in order to strengthen the right to housing in this pandemic period. this open letter marks the beginning of a path of reflection and active participation in the debate on housing in portugal during and after the covid-19 pandemic, although this network had been formed since june 2019, at the time, seeking to create an exchange of experience between different scientific projects and studies on housing, tourism and social movements. the 60 individuals who are part of the network understand that the measures approved so far by the parliament (such as the suspension of evictions, the effects of the termination of rental agreements and the execution of mortgages) and by some city councils (such as the suspension of evictions from the social housing park) are positive, but still insufficient in view of today's needs. under a high risk of non-compliance with the housing basis law and the national contingency plan covid-19, as well as with the various information circulars from the directorate-general for health and the ministry of health, they request immediate compliance with a set of measures directed at housing, namely, the following. mobilise the available spaces (hotel industry, airbnb or short-rental accommodation, municipal dwellings that can be temporarily assigned) to meet self-insulation and quarantine compliance in order to avoid risks to individual, family and public health. this immediate use, if necessary through a request as provided for in the declaration of state of emergency, should primarily benefit people in situations of homelessness, families living in conditions of extreme housing precariousness or overcrowding, victims of domestic or gender violence, workers precarious housing and, if necessary, health professionals. they also ask for an automatically extention of the rental contracts (housing or not) during the national emergency period, plus an adequate period to search for new permanent and decent housing, in the case of contracts that had already ended. they alert to the prevention of the increase in housing charges, through the reduction or suspension of payments of rents and credit loans for families that suffer a decrease in income. protect smallholders whose income constitutes a substantial part of their livelihood, with fiscal relief and financial support measures (i1). rede h has two main objectives (see https://www.redeh abita cao.pt/), the first is related to the research carried out in the field of housing studies and the second to the approximation of housing studies with the non-academic context. each main objective is divided into secondary objectives that support the realisation of the vision of rede h. the first objective is to develop collaboration within the field of housing studies: facilitate the creation of projects and work groups; articulate studies in different territorial contexts; bring together groups and individuals with similar research interests, avoiding overlapping studies; share results and dataresearch outputs, worked data and, possibly, raw data. the second objective is to enhance the visibility of housing studies outside the academic context and other contexts specifically interested in the topic (e.g. activism, real estate) (i8). here is important to: produce alternative data and contribute to public deliberation through active participation in the public debate; facilitate access for journalists, politicians, technicians, and other interested parties, to studies and research results, through a repository organised by key themes and with priority to open access material; and stimulate public debate on housing and the necessary knowledge in this field (i8). but, above all, rede h favours the approach of the scientific world and its habitus to the practical field of activism, which will also have been mobilised by the participation of researchers and members of the network in activism in the last years, with the production of reports, opinions, political participation and in the consultation of political parties and even in various organs of institutional democracy and the legal system, for example, the lisbon municipal assembly, parliament's housing and land planning committee and directly influencing the institutional environment in the adoption of social measures for the right to housing. the collective learning cemented by some of its members, who reconcile the academic with the activist, feeds the network's willingness to put pressure on political power and influence the taking of political measures legitimised by scientific knowledge, based on public decisions made and legitimised by technique and science. thus, the production of alternative scientific knowledge, in addition to escaping the status quo of a positivist and hegemonic paradigm of scientific production, feeds civic intervention and active citizenship practices. another important strategy adopted was the email bombing. the collectives proposed that on 8 april at 12pm, thousands of activists and citizens would simultaneously send an avalanche of electronic messages with the same recipients, in this case political sovereignty bodies (prime minister, minister of housing, secretary of state for housing, among others), in order to flood the e-mail boxes of the sovereign bodies with their demands. in internet usage, an email bombing is a form of net abuse consisting of sending large volumes of email to an address in an attempt to overflow the mailbox. mass mailing is a common strategy used by organisations like amnesty international. the objective consists of sending numerous duplicate mails to the same email address not only to block the service of sending and receiving institutional emails, acting in a confrontational way, but as a symbolic strategy to alert and dramatically wake up the political authorities of the need for robust intervention in the housing field, in this pandemic crisis (i7). the last strategy, but no less important, is the formation of local networks of mutual support, especially the solidarity canteens, where dozens of activists from the aforementioned groups now collaborate (i3). this type of social strategy that already existed in a network of social support institutions and community centres, is now reinforced throughout the city of lisbon, with the appearance of improvised cafeterias, even often in the spaces of the associations, aimed at providing meals, especially for individuals and families in a situation of socio-economic vulnerability. the localism of these networks of solidarity and mutual help promote a cooperative model of production and consumption and are not disconnected from a political intention and from access to a manifesto that also allows class awareness (i5). currently, with the pandemic crisis of covid-19, a new wave of protest seems to have revived the theoretical debate on the praxis of urban social movements and collective action not on public space, but in everyone's individual home, pushing the reinvention of strategies of resistance, even in times of lockdown. the post-austerity social movements have called again attention to the academy, the public opinion, the civil society, the media and the political power. and, especially in this period, the contradictions of capitalist production of urban space gain relevance and brutally expose extreme inequalities in access to the right to housing. this situation, associated with the narrative of the panoptic moral duty of self-government, through forced and compulsory lockdown, in order to respect the compliance with the sanitary rules of public health authorities, further evidence the brutality of cases of residential segregation, evictions and spatial injustice. associations, collectives and social movements in defence of the right to housing were able to capitalise on these aspects, anchoring the urban struggle in housing as a human right, essential to life; conquering, even temporarily and exceptionally, important objectives such as suspension of evictions, suspension of mortgage payments, resettlement of the most vulnerable on airbnb or hotel rooms, thus imposing the right to housing on the right to property, setting precedents that can be useful in post-covid-19 social struggle. in this recent dramatic context of the expansion of the pandemic and the contingency plan, the intervention of these and other associations was essential to compel representative democracy to understand and act in accordance with the categorical imperative of defending housing for all. some more moderate, some more radical, some more institutional, others more grassroots, reveal an effort of participatory citizenship towards another political agenda. but the greatest value of this broad spectrum of intervention, quite differentiated, is precisely in the diversity of action, but, above all, in the complementarity, integration and unity in the struggle (mendes 2020) . and the capitalisation of a culture of participation and critical intervention in civil society, as well as the mobilisation of collective learning developed in postausterity urban struggles, is now proving, in this period of pandemic crisis, essential to make resistance consistent to shake the installed political power. in a certain sense, the pandemic caused an interesting change in the centre of gravity of the activism of urban social movements in lisbon: the objective of giving visibility and exposing the contradictions of inequalities in access to the right to housing, thus raising public awareness and the political agenda for this problem, has been replaced by a strategy of more reflective and purposeful actions in order to mobilise the community and expand networks of mutual support at different scales and pressure the political powers to take a more assertive decision and action regarding measures that promote an effective right to housing. the coronavirus pandemic crisis also has triggered a new wave of collective practices that gesture towards another form of social organisation that is urgently needed. as stavrides (2020) states: different neighbourhood initiatives, movement organised campaigns, dispersed rhizomatic acts of solidarity, community based management of local places are spreading throughout the world, under the radar of dominant institutions, as well as bypassing market and capitalist hegemonic channels of attendance, production, consumption and distribution. it seems that within these processes an intensive production of the common develops. the common emerges as both the form and the content of social relations that transcend the limitations and contradictions of the hegemonic capitalist, neoliberal and market system, putting emphasis not just only in a set of products and services to be shared, or in a set of organisational choices to ensure a more just distribution of the crucial means for survival to those in need, but also in a more collaborative and community way of life. while the traditional left (communist and socialist in orientation) typically espoused and defended some version of democratic centralism (in political parties, trade unions, and alike), other principles are frequently advanced -such as 'horizontality' and 'nonhierarchy' -or visions of radical democracy and the governance of the commons (castells 2013; dardot & laval 2015) , that can work for small groups but are impossible to operationalise at the scale of a metropolitan region. that is, an excessive horisontality can be an obstacle to the victory of urban struggles. the challenge is thus to generate urban social movements capable of enhancing new subjectivities and critical and transformative social practices as well as spaces of freedom with interstitial and cross-cutting, in the form of rhizome, refusing authoritarian discipline, formal hierarchy of order priorities decreed from above (top-down). these are the heterotopias of foucault; the rhizome of deleuze and guattari; the transduction, experimental utopia and the urban revolution of the right to the city of lefebvre; the dialectical utopianism of harvey; or a new emancipatory political culture to a high-intensity democracy, proposals of boaventura sousa santos. but this should not be seen as contradictory to the implementation of course of inevitable, necessary and even desirable decision centres. but at the same time we must ensure sustainability of struggle and constant critical scrutiny against conformity, free of devitalised and amorphous institutions, but also allows representation and decision-making in a democratic process. in conclusion, the actors in this urban struggle have limited power over the changes that they initiate, or make an effort to inflict, if they are not involved in a concerted and politically integrated action. despite their weak capacity for mobilisation, their limited and fleeting character, the truth is that new urban social movements often include social and political innovation, as they aim at 'transformative' changes and new responses that imply transformation in power relations in the contemporary city. although aware that these are exceptional and temporary measures, and that they correspond, therefore, to very ephemeral conquests associated with the state of emergency generated by this pandemic crisis, some see in the post-covid-19 horizon that these anti-capitalist policies taken for a robust welfare state can anticipate some change to a post-capitalist transition regime. let us not forget, however, that these are biopolitical measures, taken in a context of neoliberal systemic totality, in order to reproduce the bodies and the masses of the labor and consumption forces. after all, something needs to change so that everything stays the same. subprime cities: the political economy of mortgage markets the financialisation of housing: a political economy approach revisiting 'the changing state of gentrification'. introduction to the forum: from third-to fifth-wave gentrification stay home without a home': report from a webinar on the right to housing estado de excepção available at <https:// ilman ifesto.it/lo-stato -decce zione -provo cato-da-uneme rgenz a-immot ivata tourism and urban changes: lessons from lisbon risk society cities for people, not for profit. critical urban theory and the right to the city luttes urbaines et pouvoir politique a sociedade em rede. a era da informação: economia, sociedade e cultura redes de indignação e esperança. movimentos sociais na era da internet estudo urbanístico do turismo em lisboa airbnb, buy-to-let investment and tourism-driven displacement: a case study in lisbon. environment and planning a: economy and space protest and resistance in the tourist city commun: essai sur la révolution au xxi siécle urban social movements and the right to the city: an introduction to the special issue on urban mobilization comunidade e movimentos sociais: para um estudo dos movimentos de protesto público rebeliões de classe média? precariedade e movimentos sociais em portugal e no brasil estamos todos no mesmo barco? ladrões de bicicletas. 17 april. available at the anti-austerity protest circle in portugal: the ambiguous relations between social movements and left-wing political parties urban movements in a globalising world cosmopolitanism and the geographies of freedom rebel cities: from the right to the city to the urban revolution seventeen contradictions and the end of capitalism anti-capitalist politics in the time of covid-19. jacobin magazine 20 march tourists go home': antitourism industry protest in barcelona globalising protest: urban conflicts and the global social movements neoliberal urbanism and its contestations: crossing theoretical boundaries lisbon after the crisis: from credit-fuelled suburbanisation to tourist-driven gentrification squatters in the capitalist city: housing, justice, and urban politics social movements in the (post-) neoliberal city. civic city cahier 1 urban uprisings. challenging neoliberal urbanism in europe multiplying resistance: the power of the urban in the age of national revanchism gentrificação turística em lisboa: neoliberalismo, financeirização e urbanismo austeritário em tempos de pós-crise capitalista tourism gentrification in lisbon: the panacea of touristification as a scenario of a post-capitalist crisis gentrification and the new urban social movements in times of post-capitalist crisis and austerity urbanism in portugal available at <http://smart -cities.pt/opini ao-entre vista /habit acao-covid -0204l mende s/> geography and social movements from urban social movements to urban movements born in the blogosphere, staged in the streets: austerity and urban social movements in lisbon guerra dos lugares. a colonisação da terra e da moradia na era das finanças fast urban changes, slow institutional restructuring and growing civic pressures dinâmicas sociogeográficas e políticas na área metropolitana de lisboa em tempos de crise e de austeridade urban activism and touristification in southern europe: barcelona, madrid & lisbon touristification, transnational gentrification and urban change in lisbon: the neighbourhood of alfama crisis and the city: neoliberalism, austerity planning and the production of space digital activism, political participation and social movements in times of crisis seeking spatial justice pela mão de alice. o social e o político na pós-modernidade renovar a teoria crítica e reinventar a emancipação social a cruel pedagogia do vírus the common, in, against, and beyond the pandemic crisis. common notions 28 april st-and-beyon d-the-pande mic-crisi s-stavr os-stavr ides?fbcli d=iwar1 dekuu gd89s 8irza wa1mc vcatn kvwgn zfjee 2vyvi mikyu s7m2a ttg6h0> urban resilience, changing economy and social trends. coping with socio-economic consequences of the crisis in available at <http://ppesy dney.net/from-auste rity-to-necro polit ics-in-pande mic-times -europ ean-style we acknowledge financial support from fct -fundação para a ciência e a tecnologia, i.p., under the project hopes: housing perspectives and struggles futures of housing movements, policies and dynamics in lisbon and beyond (ptdc/gesurb/28826/2017). the author would like to thank the anonymous referees and the editors for their valuable comments which helped to improve the manuscript. in a state of emergency. this means that the government can suspend and/or change some of the functions of the executive, the legislature or the judiciary powers while the country is in this exceptional state, while alerting its citizens to adjust their behaviour according to the new situation, in addition to command government agencies to implement emergency plans. a government can declare a state of emergency in response to natural or man-made disasters, periods of civil unrest, and declarations of war or situations involving internal or international armed conflicts. due to the continuous expansion of the covid-19 pandemic, on 18 march 2020, a state of emergency was declared in portugal, through decree-law of the president of the portuguese republic no. 14-a/2020. the measures implemented will be addressed later in this paper.on the other hand, the state of exception is characterised by the temporary suspension of constitutional rights and guarantees, in which power is divided and decisions depend on the approval of a plurality of agents -decision-making agility is compromised. the state of exception is a temporary situation of restriction of rights and concentration of powers that, during its term, brings a state under democratic regime closer to authoritarianism. aware of the current situation, agamben (2020) and sousa santos (2020) (i7) and rede h, network h (i8). the anonymity of the interviewees will be maintained, but identified throughout the paper, whenever the reference to the content of the interview justifies it. to all of them, i am grateful for the in-depth contribution of practical knowledge that they have offered me. 3. between 2013 and 2017, the districts, already so depopulated in the inner city of lisbon, lost about 15 per cent of their population (cml ). key: cord-346258-xlyi0cnl authors: radic, aleksandar; ariza-montes, antonio; hernández-perlines, felipe; giorgi, gabriele title: connected at sea: the influence of the internet and online communication on the well-being and life satisfaction of cruise ship employees date: 2020-04-20 journal: int j environ res public health doi: 10.3390/ijerph17082840 sha: doc_id: 346258 cord_uid: xlyi0cnl this study aims to elucidate the idiosyncratic effects of the internet and online communication on the well-being and life satisfaction of cruise ship employees. cross-sectional surveys and covariance-based structural equation modelling tools were used. in addition, univariate variance analysis was used to address the effects of socio-demographic variables (years of service on a cruise ship, working department on a cruise ship, gender, age, educational level and place of residency) on latent variables of the conceptual model. the conceptual model draws on existing theory and previous research and was empirically tested on a sample of cruise ship employee internet users. result show that while being onboard a cruise ship, employees experience strong social pressure to be constantly available and they fear of missing out on important information and life events. thus, relatedness to friends and family needs satisfaction is of paramount importance for cruise ship employees because they are fully aware that they are dispensable and replaceable to cruise ship companies, however to their friends and family, they are indispensable and unique. moreover, employees who engage in other tasks/activities while taking part in online communication with friends and family exhibit reduced performance, which leads to poor interaction and social dissatisfaction. lastly, employees experiencing under-reciprocating exchanges show significant negative effects on their well-being. overall, the results provided several important theoretical and practical implications relevant to cruise tourism and human resource management. cruise tourism growth for 2020 predicted by [1] will not be achieved due to the recent cruise tourism crisis caused by the covid 19 pandemic. on 14 march 2020, all cruise lines suspended their cruise operations for at least 30 days [2] . however, none of the cruise companies have filed for bankruptcy or cancelled their new builds. therefore, the prediction of the addition of 80,000 new crew members and officers each year until 2027 remains an achievable possibility [3] . a recent study by [4] revealed that cruise ship employees are exposed to long working hours and detachment from friends and family, which leads to poor social interactions and feelings of loneliness. however, advances in information and communication technologies have led to their widespread and increased usage by employees. internet access has become a basic necessity, a more essential element of their mundane ship life with paramount importance on their well-being and life satisfaction. enhanced connectivity is instrumental for bolstering morale and reinforcing job satisfaction, which ultimately strengthens the capability for communication between employees and their significant others back home and hence, reduces the feeling of loneliness [5] . moreover, maritime labour convention [6] recommended rational access to the internet with reasonable charges for services. from november 2019 to february 2020, only a handful of cruise companies (disney cruise line, holland america, azamara, and princess cruises) have provided free-of-charge specialized cross-platform messaging internet applications for their employees. interestingly, the seafarers happiness index, which covers 10 aspects of job quality, including mental and physical health and relationships at home and onboard, showed significant increases in happiness for cruise ship employees from 5.3 to 7 out of 10 [7, 8] . given the unique work and life conditions on cruise ships, whereby employees are set apart from their loved ones [9] , free internet access should be a universal entitlement [10] because of its ability to enhance seafarer morale, engagement, well-being and life satisfaction [11] . although significant amounts of research have been done on the positive effects of internet and online communication on social pressure [12] , fear of missing out [13] , relatedness to friends and family need satisfaction [14] , perceived social support [15] , well-being [16] and life satisfaction [17] , these effects were never studied in the peculiar environment of a cruise ship where life and work contexts are so intertwined such that the distinction between one and the other is blurred [18] . this study aimed to elucidate the idiosyncratic effects of the internet and online communication on the well-being and life satisfaction of cruise ship employees. we reviewed existing theory and previous studies on the effects of the internet and online communication on social pressure, fear of missing out, internet multitasking and relatedness to friends and family need satisfaction. we investigated the influence of social pressure and fear of missing out on relatedness to friends and family need satisfaction and internet multitasking. finally, we proposed relatedness to friends and family need satisfaction and internet multitasking as possible catalyst influencers of perceived social support which, in the end, are the impetus towards the well-being and life satisfaction of employees. the conceptual model draws on existing theory and previous research and was empirically tested on a sample of employee internet users. finally, we addressed the effects of socio-demographic variables (years of service on a cruise ship, working department on a cruise ship, gender, age, educational level and place of residency) on latent variables of the conceptual model. this study is exploratory in nature and presents work addressing a major research gap, given that the effects of internet and online communication on the well-being and life satisfaction of cruise ship employees have never been empirically tested. the results of this study will contribute towards the further development of cruise tourism theory and strengthen existing theories, such as theory of belongingness [19] , self-determination theory [20] , uses and gratification theory [21] , conservation of resources theory [22] and the paradigm of positive psychology [23] . while working and living on cruise ships, employees are detached from their family and friends [9] . primary communication instruments include internet and online communications [5] , which play significant roles in integrating work and family domains [28] . these communication instruments provide social capital, information and wider perspectives [25] . in recent survey conduct by [8] , the authors concluded that onboard crew members experience strong social pressure for being constantly available to their family and friends. today, almost every cruise ship employee has a mobile device [11] . although mobile devices allow users to be constantly available, they also create an environment that increases social pressure [29] . moreover, the social pressure to be constantly available is strongly related to communication load [13] , with a suppressing effect on well-being via social overload [30] . based on the social norm of reciprocity in friendship and family ties, psychological tensions and social pressures may arise [16] . thus, based on the literature review and empirical findings, the following hypothesis is proposed: there is a positive relationship between the internet and online communication and social pressure. in their theory of belongingness, baumeister et al. [19] argue how human beings have an irresistible need to be a part of a group. the hardest part for cruise ship employees is being away from home and missing so many important life events and quality time with family and friends [18] . similar results have been reported by [5] who demonstrated in their comprehensive report how due to being uncontactable at sea, seafarers miss key life events. cruise ship employees are fully aware that work-life on a cruise ship comes with a great burden [31] . however, they are not willing to tolerate any lack of connectivity [8] . internet and online communication are closely linked to fear of missing out [32] . fear of missing out is defined as "a pervasive apprehension that others might be having rewarding experiences from which one is absent" [33] . thus, we can conclude based on compensatory internet use theory [34] that individuals who feel that their life needs are not fulfilled and that they are missing important life events and social motivation will experience strong stimulation to use online communication and social networking sites. based on the theoretical background, literature review and empirical findings, the following hypothesis was derived: hypothesis 2 (h2). there is a positive relationship between the internet and online communication and fear of missing out. the internet, social networking sites and online communication have become our liaisons, special amusers, cerberus of our memories and, in times of need, even our counsellors [27] . based on self-determination theory [20] , relatedness to friends and family need satisfaction is one of three basic psychological needs that foster healthy self-regulation and promote mental and physical health. opportunities to experience positive feelings of proximity and affection with family and friends at home through the use of online communications benefits seafarers and their friends and family [5] . interestingly, in the latest survey conducted by [11] , although provisions of internet access for personal use had positively affected seafarer mental health and morale, home-related anxieties have remained the same, despite speculation that increased communications with family might generate more anxieties. the effects of the internet and online communication and relatedness to friends and family need satisfaction remain unclear [35] . previous studies have shown that internet and online communication are mainly linked to positive outcomes of relatedness to friends and family need satisfaction [36, 37] . few studies have demonstrated the opposite [25, 38] . thus, based on literature review, theory and empirical findings, we put forward the following hypothesis: there is a positive relationship between the internet and online communication and relatedness to friends and family need satisfaction. social pressure is conformist behaviour with multiple determinations when an individual or group craves specific social attention; this leads them to behave in certain ways unconcerned of any prestige advantage [39] . a recent study conducted by [13] showed how computer-meditated communication is portrayed and influenced by robust rules of conduct, where communication arrangements are under constant social pressure. interestingly, within seafarers, social pressure has shown a strong influence on their work-life at sea due to their social isolation, imbalanced family life, separation from home, family and friends, and lack of free onboard communication facilities [40] . moreover, relatedness proposes that cruise ship employees need to feel connected with their family and friends at home [5, 9, 18] : when employees feel satisfied with this need, they experience higher levels of work engagement and well-being. most employees own smartphones and experience social pressure to make themselves available to friends and family at home, thereby satisfying needs for relatedness. online communications induced by social pressure and relatedness to friends and family needs satisfaction has been directly linked with significant effects on user life satisfaction [41] . thus, based on the literature review, theoretical background and empirical findings, we put forward the following hypothesis: there is a positive relationship between social pressure and relatedness to friends and family need satisfaction. the constant occupation with smartphones has created a peculiar mindset in users with specific feelings of being permanently online and connected [42] . interestingly, online communication and social media are closely linked to fear of missing out [13] ; 56% of u.s. social media users suffer from fear of missing out [43] . thus, tensions related to social relationships may be the prevailing cause for the fear of missing out [44] . the uses and gratifications theory provides us with pragmatic theoretical lenses instrumental in understanding underlying motives and multitasking behaviours [45] . the theory proposes that hidden roots of social and psychological needs create certain expectations from various media, which guides users towards specific models of media exposure, culminating in need gratification [46] . looking at the advantages of online communications to those living and working at sea, fear of missing out has a significant impact; 75% of crew members need to be connected with the outside world, and 63% would leave their current company to join some other that would provide better onboard connectivity [5] . previous research also showed that higher levels of fear of missing out had an impact on a higher tendency to internet multitask [33] . cruise ship employees have long working hours and rarely go ashore; the tendency to internet multitask leads to some occupational injuries [4] . consequently, based on theory, literature review and empirical findings, the following hypothesis is derived: there is a positive relationship between fear of missing out and internet multitasking. widespread adoption of the internet, online communication, and social network sites have empowered people across the globe to grow their social network [47] . however, such a gift comes with responsibility because various social network sites compete for our attention by streaming content based on well-programmed algorithms founded on our likes, fears, and needs [27] . the digital world is doused with ever-growing social network sites that are changing the online behaviour of digital technology users but also how human beings interact with one another in real life [48] . moreover, human beings are social animals [49] in need of relatedness to friends and family, regardless of recent technological advancements. relatedness comes in the form of affective needs, which tend to intensify delightful and affecting experiences, and social needs that tend to bolster existing connections with family and friends [50] . thus, the need for relatedness is a feeling of satisfaction that comes from being a connected part of a community where individuals manifest a willingness to care about each other [51] . being away from their homes in an isolated environment [52] , cruise ship employees are constantly looking for social support [53] . interestingly, perceived social support, characterized as the tangible or intangible support received from an individuals' social circle, is associated with superior life satisfaction [54] . consequently, based on theory, literature review and empirical findings, the following hypothesis is derived: hypothesis 6 (h6). there is a positive relationship between relatedness to friends and family need satisfaction and perceived social support. the term internet multitasking refers to "any combination of internet use with other media or non-media activities" [13] p. 94. the main reasons for multitasking are social interactions with friends and family and information seeking [45] . cruise ship employees are most often in different time zones than their friends and family. this leaves them with a limited time frame for online communication and significantly lowers the opportunities for giving and receiving much needed social support. moreover, cruise ship employees are under extreme time pressure due to long working hours [4] ; this is when individuals perceive that if they engage in internet multitasking, they would be efficient [45] . however, the effects of internet multitasking on retention of information during online messaging and cognitive load, showed significant retention loss among simultaneous multitasks [55] . similarly, internet multitasking has been associated with lower gratification and perception memory achievement and sensitivity and moderate standard bias [56] . moreover, different types of multitasking have robust effects on task performance. task performance significantly decreased when the given task was a secondary task, when a neurological obstruction was high, and when the behavioural reaction was present [57] . thus, based on literature review and taking in consideration the conflicting empirical results of internet multitasking effect on perceived social support, and bearing in mind the importance of perceived social support for cruise ship employees, the following hypothesis is derived: there is a positive relationship between internet multitasking and perceived social support. the social relationship is flexible and essential for individual vitality because human beings exist within larger social contexts where friends and family play important roles [58] . moreover, if a persons' social context is supportive of significant relationships, then these individuals encounter elevated feelings towards psychological needs, which can be satisfied through social synergy [41] . social support has four dominant aspects in the creation of well-being and life satisfaction: main effect (adding particular supplementary function to mental health), mediating effect (intervening in relations between its precursors and health results), indirect effect (preventing disorders by framing mental health) and moderating effect (lowering the risk of any mental health-related components) [59] . previous studies have shown that the internet and online communication have a positive effect on social capital [60] where social capital is an antecedent of social support [59] . internet and online communication are bonding and bridging social capital [38] , which are of paramount importance for satisfying the social support need of cruise ship employees who tend to use online communication to contact geographically dispersed close friends and family [5] . thus, social support plays multiple roles in individuals' well-being and life satisfaction [59] . considering the importance of well-being and life satisfaction of employees, based on literature review and empirical findings, we put forward the following hypotheses: there is a positive relationship between perceived social support and well-being. people should focus on how to be happy, satisfied and filled with positivity [23] . thus, psychological well-being is an essential part of positive psychology. psychological well-being is related to ones' feelings and evaluations about their life [61] . moreover, well-being is seen as a psychological well-being that develops based on the eudaimonic dimension of well-being [62] and as happiness that is built around life satisfaction based on the hedonic dimension of well-being [63] . in the context of cruise ship employees, well-being is a fusion of eudaimonic (efficiency) and hedonic (thrill) dimensions. interestingly, gibson et al. [64] argues how due to work-life time constraints, task assignments and job anxiety, employees experience poor well-being. moreover, radić [18] questions the life satisfaction and well-being of employees who are economic gladiators in pursuit of an unobtainable economic freedom. thus, moore [65] calls cruise ships "misery machines" where in recent years, as walker [66, 67] point out, there has been a substantial increase in suicide rates due to the poor well-being of employees. interestingly, perceived social support from online communication has had a positive effect on well-being [5, 8] . social network sites have provided ambient awareness that increases the well-being of its users [68] . life satisfaction is related to a subjective, comprehensive evaluation of one's quality of life [69] . moreover, life satisfaction draws from the individual's psychological aspects and is related to one's hedonic satisfaction [62] , where at the same time, perceived social support from an individual's social networks has the potential to strengthen a person's life satisfaction [24] . in the q4/2019 report, seafarers happiness index [8] showed how free online communications have a significant impact on employee life satisfaction; as ang et al. [41] argue, computer-mediated communications can enhance life satisfaction. online communication and social network sites can drive a person towards achieving superior life satisfaction and better quality social relationships [38] . interestingly, although employees use online communication and social network sites to strengthen their close interpersonal connections and enhance their life satisfaction [18, 70] argue that weak ties are also valuable due to their potential to positively influence life satisfaction. figure 1 illustrates the research model and hypotheses of this study. freedom. thus, [65] calls cruise ships "misery machines" where in recent years, as [66, 67] point out, there has been a substantial increase in suicide rates due to the poor well-being of employees. interestingly, perceived social support from online communication has had a positive effect on wellbeing [5, 8] . social network sites have provided ambient awareness that increases the well-being of its users [68] . life satisfaction is related to a subjective, comprehensive evaluation of one's quality of life [69] . moreover, life satisfaction draws from the individual's psychological aspects and is related to one's hedonic satisfaction [62] , where at the same time, perceived social support from an individual's social networks has the potential to strengthen a person's life satisfaction [24] . in the q4/2019 report, [8] showed how free online communications have a significant impact on employee life satisfaction; as [41] argue, computer-mediated communications can enhance life satisfaction. online communication and social network sites can drive a person towards achieving superior life satisfaction and better quality social relationships [38] . interestingly, although employees use online communication and social network sites to strengthen their close interpersonal connections and enhance their life satisfaction [18, 70] argue that weak ties are also valuable due to their potential to positively influence life satisfaction. figure 1 illustrates the research model and hypotheses of this study. the theoretical framework of this study was based on a literature review; the conceptual model and hypotheses were tested based on a convenience sample. the post-positivistic paradigm was adopted in this study because as [71] argues, the post-positivistic paradigm takes into consideration the fact that in human behaviour studies, observations are imperfect with potential inaccuracies; thus, all theories could be amended. action research strategy allows the research to use different models of contemporary knowledge in solving genuine industry issues and applying obtained results outside the boundaries of the study [72] . thus, action research strategy was used. the research model was evaluated using a cross-sectional survey and covariance-based structural equation modelling the theoretical framework of this study was based on a literature review; the conceptual model and hypotheses were tested based on a convenience sample. the post-positivistic paradigm was adopted in this study because as [71] argues, the post-positivistic paradigm takes into consideration the fact that in human behaviour studies, observations are imperfect with potential inaccuracies; thus, all theories could be amended. action research strategy allows the research to use different models of contemporary knowledge in solving genuine industry issues and applying obtained results outside the boundaries of the study [72] . thus, action research strategy was used. the research model was evaluated using a cross-sectional survey and covariance-based structural equation modelling (cb-sem). cb-sem allows testing and validation of current theories and comparisons of different theories [73] . in summary, this study used a deductive approach followed by a cross-sectional time horizon and quantitative techniques for data collection. a comprehensive self-reported online survey in english was designed at surveymonkey®. possible participants were invited to take part in the survey via facebook group "crew center". the main criteria was that participants had to be onboard and employed by a cruise company. the survey was online from 24 august to 1 december 2019, and the final sample consisted of 532 cruise ship employees (see table 1 ). the sample comprised 328 males and 195 females from different geographical areas (43.8% from europe, 20.3% from north america, 16.4% from southeast asia, 7.3% from south america, 4.6% from central america, 4.2% from africa, and 3.4% from australia). most respondents were between 31-40 years old (50.9%) followed by respondents 21-30 years old (27.7%) and 41-50 years old (11.9%). among the participants, 49.5% were employed in the hotel department, 32.9% were from the deck and technical department, and 17.6% were from the entertainment department. most (45.9%) had worked in the industry for over six years. a large share of respondents had a bachelor's degree (57.7%). this extreme unrepresentative value was related to the convenience sampling method. overall, the sample was a very good representation of employee demographics [74] . internet and online communication were assessed using a five item scale designed to asses internet and online communication usage (all the measures are included in the appendix a). participants indicated on a five point scale from 1 (once per week) to 5 (several times per week) how often they use the internet for communication; from 1 (less than an hour) to 5 (more than 4 hours per day) how many hours per day (on average) they spend on internet communication; from 1 (once a week) to 5 (several times per day) how often they use a) instant messenger, b) social networking sites, and c) chat rooms. internal consistency in the present sample was acceptable (cronbach's α = 0.790). social pressure to be permanently available was assessed with an adapted perceived norm scale [13] that had four items (e.g., "people from my private social environment think that it is important that i'm constantly available") and is rated on a five point scale ranging from 1 (does not apply at all) to 5 (fully applies). internal consistency in the present sample was acceptable (cronbach's α = 0.794). fear of missing out on important life events and information was assessed with a three item scale (e.g., "if i would use the internet less frequently, i would be missing out on important things") developed by [13] . participants rated the items on a five point scale ranging from 1 (does not apply at all) to 5 (fully applies). internal consistency in the present sample was good (cronbach's α = 0.845). relatedness to friends and family need satisfaction was assessed with three item scale (e.g., "i feel that my friends and/or family sincerely care about me") developed by [75] . participants rated the items on a five point scale ranging from 1 (strongly disagree) to 5 (strongly agree). internal consistency in the present sample was good (cronbach's α = 0.905). internet multitasking was assessed with a five item scale (e.g., "how often do you use the internet while you simultaneously are in a conversation with another person") developed by [13] . participants rated the items on a five point scale ranging from 0 (never) to 4 (very frequently). internal consistency in the present sample was acceptable (cronbach's α = 0.747). perceived social support was assessed by the multidimensional scale of perceived social support [76] , which consisted of six items (e.g., "there is a special person who is around when i am in need") and was rated by participants on a seven point scale ranging from 1 (strongly disagree) to 7 (strongly agree). internal consistency in the present sample was acceptable (cronbach's α = 0.784). well-being was assessed by the world health organization well-being index [77] . it comprises five items (e.g., "i have felt cheerful and in good spirits") and was rated by participants on a six point scale ranging from 1 (all the time) to 6 (at no time). internal consistency in the present sample was good (cronbach's α = 0.875). life satisfaction was assessed by satisfaction with life scale [78] . it consists of five items (e.g., "in most ways my life is close to my ideal") and it was rated by participants on a seven point scale ranging from 1 (strongly disagree) to 7 (strongly agree). internal consistency in the present sample was good (cronbach's α = 0.869). structural equation modelling (sem) was computed using the amos 21 software packet (ibm, chicago, illinois), and the maximum likelihood method was used to estimate the parameters from the conceptual model (see figure 1 ). the kolmogorov-smirnov and shapiro-wilks test showed that none of the variables were normally distributed. thus, a maximum likelihood (ml) estimator with enough resistance capabilities to none-extreme deviations from the normal distribution [79] was used. model fit was tested based on the χ2 and cmin/df statistics, the comparative fit index (cfi) and the root mean square error of approximation (rmsea) as recommended by [80] . the univariate analysis of variances (anova) was used in search of differences among employee demographics and conceptual model variables. the model showed an acceptable fit to the data with the following values: χ2(483) = 1517,145, p = 0.000; rmsea = 0.064, lo 90 = 0.060, hi 90 = 0.068; cmin/df = 3.141 and cfi = 0.887. although the general indicator χ2 was significant, with such a large number of degrees of freedom, χ2 is not reliable; it is better to rely on other indicators. rmsea was close to the limit that indicates an excellent model (0.06), cmin/df was within the limits that represent a good model, whereas the cfi was close to the lower limit of acceptability of the model [80] [81] [82] . table 2 shows the hypothesized paths of the conceptual model. the zero-order correlations between social pressure and fear of missing out, demonstrate that these two variables are strongly interrelated. social pressure and fear of missing out show very high correlations (r = 0.79, p < 0.01). this significant relationship is reasonable: social pressure as a concept is closely connected to the concept of fear of missing out as these social processes on the internet and social network sites are synthesized. because social interaction through the internet and online communication are of paramount importance for cruise ship employees [5] , accomplishing this pursuit is a way towards well-being and life satisfaction. this conception is supported by results from [7, 8] , who reported that a recently developed free-of-charge specialized cross-platform messaging internet application (by a handful of cruise companies) had an immediate impact on the happiness index of employees by increasing to 32% from q2/2019 to q4/2019. except for hypotheses 3, 7 and 8, all other hypothesized relationships were supported in the final model ( figure 2 ). hypotheses 1 and 2 were supported showing how the internet and online communication had positive effects on social pressure (β = 0.169) and fear of missing out (β = 0.237). interestingly, hypothesis 3 was not supported, demonstrating that the internet and online communication did not have a positive effect on relatedness to friends and family need satisfaction (β = 0.075). as predicted in hypothesis 4, social pressure had a positive effect on relatedness to friends and family need satisfaction (β = 0.358), and fear of missing out has a positive effect on internet multitasking (β = 0.248) as predicted in and hypothesis 5. hypothesis 6 predicted that relatedness to friends and family need satisfaction had a positive effect on perceived social support; this hypothesis was supported (β = 0.148). hypothesis 7 predicted that internet multitasking had a positive effect on perceived social support; however, this hypothesis was not supported (β = −0.008). hypothesis 8 predicted that perceived social support had a positive effect on well-being; however, this hypothesis was not supported (β = −0.127). lastly, hypothesis 8 predicted that perceived social support had a positive effect on life satisfaction; this hypothesis was supported (β = 0.522). in pursuit of elucidating the peculiar socio-demographics characteristics of cruise ship employees and unrevealing significant differences on sample and research model variables, anova was used. the results disclosed the following pivotal differences. the hypotheses 1 and 2 were supported showing how the internet and online communication had positive effects on social pressure (β = 0.169) and fear of missing out (β = 0.237). interestingly, hypothesis 3 was not supported, demonstrating that the internet and online communication did not have a positive effect on relatedness to friends and family need satisfaction (β = 0.075). as predicted in hypothesis 4, social pressure had a positive effect on relatedness to friends and family need satisfaction (β = 0.358), and fear of missing out has a positive effect on internet multitasking (β = 0.248) as predicted in and hypothesis 5. hypothesis 6 predicted that relatedness to friends and family need satisfaction had a positive effect on perceived social support; this hypothesis was supported (β = 0.148). hypothesis 7 predicted that internet multitasking had a positive effect on perceived social support; however, this hypothesis was not supported (β = −0.008). hypothesis 8 predicted that perceived social support had a positive effect on well-being; however, this hypothesis was not supported (β = −0.127). lastly, hypothesis 8 predicted that perceived social support had a positive effect on life satisfaction; this hypothesis was supported (β = 0.522). in pursuit of elucidating the peculiar socio-demographics characteristics of cruise ship employees and unrevealing significant differences on sample and research model variables, anova was used. the results disclosed the following pivotal differences. the cruise ship employees come from various countries around the globe. thus, it is important to determine whether any fundamental differences were present based on country of residence and the research model variables. employee place of residence had prominent effects on internet and online communication (f(6, 516) = 3.47, p = 0.00), fear of missing out (f(6, 516) = 2.91, p = 0.01), social pressure (f(6, 516) = 3.44, p = 0.00), relatedness to friends and family need satisfaction (f(6, 94.46) = 8.12, p = 0.00), internet multitasking (f(6, 92.36) = 4.34, p = 0.00), perceived social support (f(6, 87.66) = 3.95, p = 0.00) and well-being (f(6, 91.14) = 3.03, p = 0.01). differences between place of residence and fear of missing out (η2 = 0.03) were low. differences among place of residence and internet and online communication (η2 = 0.04), social pressure (η2 = 0.04), relatedness to friends and family need satisfaction (η2 = 0.04), internet multitasking (η2 = 0.04), well-being (η2 = 0.02) and perceived social support (η2 = 0.06) were moderate. student's t-test revealed that employees from africa showed significant differences the goal of the current study was to investigate and model complex mutual interactions the internet and online communication had on social pressure, fear of missing out, internet multitasking and relatedness to friends and family need satisfaction, perceived social support, well-being and life satisfaction of cruise ship employees. the results revealed that the internet and online communication have positive effects on social pressure and fear of missing out, whereas social pressure and fear of missing out have positive effects on relatedness to friends and family need satisfaction and internet multitasking. moreover, internet multitasking had a positive effect on perceived social support, which in turn had a positive effect on life satisfaction. while onboard a cruise ship, employees are detached from their family, significant others and friends. thus, employees experience strong social pressure to be constantly available and fear of missing out on important information and life events. due to their rigorous schedule, i.e., working 10 to 13 hours every day of the week in an isolated environment, the internet and online communications are wonderful instruments that can meet the demands of social pressure and reduce the fear of missing out experienced by cruise ship employees. the internet and online communication are essential to employees from collectivistic cultures where friend and family ties are strong. thus, providing these employees instruments to maintain close contacts with friends and family at home will reduce their social pressure and fear of missing out, which in turn will create harmony among employee social groups. moreover, the provision of online communication creates an interactive platform for validation through communication acceptance; validation boosts employee sense of belonging and strengthens their relationships with friends and family at home. these results are supported by the theory of belongingness by [19] and are in line with previous studies conducted by [5, 8, 53, 83] . free time is the single most precious commodity for cruise ship employees. tight work schedules, ship itineraries, in-port safety duties, and daily job demands leave employees with very narrow time windows for engagement in social networking sites and online communication. thus, social pressure and fear of missing out effects on relatedness to friends and family need satisfaction force employees to engage in internet multitasking. within the minimal and confined space of a cruise ship, employees lose almost all points of reference to the outside world and friends and family at home; thus, social pressure and fear of missing out fuels the need for relatedness to friends and family and internet multitasking. employees spend on average between four and six months onboard in small shared cabins while working long hours every day of their full contract length and are in desperate need of the support of family and friends. thus, if cruise ship companies provide ad libitum internet access to online social networks and communication, employees will enjoy a strong network of supportive family and friends that can help them enhance life satisfaction. interestingly, employees with bachelor's degrees exhibited high levels of internet multitasking, which correlated positively with their working memory and ability to divert their attention among different tasks. these results are supported by self-determination theory of [20] as well as uses and gratification theory [21] . moreover, these findings are in line with previous studies conducted by [11, 13, 18, 33] . cruise ship employees understand they are dispensable and replaceable to cruise ship companies [9] . thus, relatedness to friends and family needs satisfaction is of paramount importance for employees because they know that to their friends and family, they are indispensable and unique. moreover, living and working onboard a cruise ship is a lifestyle; while this particular lifestyle may seem to disregard certain employee rights, it does not dehumanize the employee. when employees feel their needs towards relatedness are satisfied, they experience elevated social support through strengthened connections with friends and family. although cruise ship employees work and live on the high seas, they do not thrive alone: donne [84] pointed out that each man relies on others. however, there are slight differences between employees and their relatedness to friends and family who need satisfaction. experienced employees with 6+ years exhibited stronger needs towards relatedness because they feel lonely and isolated for a significant period of their life. employees working in the entertainment department and employees coming from south america expressed greater needs because they have a wide circle of close ties at home. lastly, the youngest cruise ship employees between 21-30 years exhibited greater needs towards relatedness because at their age, friendships are highly complex and offer significant self-disclosure and support. these results are also supported by self-determination theory of [20] and are in line with previous studies conducted by [5, 18] . onboard cruise ship operations are in constant flux, and employees come and go frequently. for many employees these crew changes become the only point of reference. during long contracts, tiredness of employees builds up as physical pain, exhaustion and psychic fatigue. however, cruise ship employees are required to continuously work until the completion of their contracts. experiences like these build highly intense relationships where employees need social support. in such an environment, employees lean on their friends and family at home for support, which comes in many forms most often as empathy, compassion and providing care. social support is the foundation of healthy relationships that improves employee life satisfaction. employees who spent 6+ years living and working on cruise ships are exposed to prolonged periods of loneliness and isolation, which affects them in ways that would require social support to achieve happiness and life satisfaction. male employees look for social support to feel happy and satisfied, whereas female employees engage in social support to pursue increased well-being. employees with master/doctoral degrees enjoy social support from their close ties because they understand the benefits of happiness that comes from such relationships. finally, employees from north america consider deep relationships to have significance in enhancing social support because larger social networks improve life satisfaction. these results are supported by the positive psychology paradigm by [23] . moreover, these findings are in line with previous studies conducted by [5, 8, 11] . although keeping in touch with family and friends at home is essential for cruise ship employees, the majority of cruise companies charge significant prices for internet and online communication services. thus, due to limitations of internet and online communication use because of high service prices, poor coverage and slow data connection, employees are prevented from satisfying their needs through their friends and family at home. moreover, due to in-port manning duties, employees cannot use free internet services off ship, which leads to chronic emotional distress, frustration, anger, despair, and anxiety. this finding is in line with [25] who argued that people heavily dependent on social networking sites to satisfy their needs towards relatedness to friends and family may experience a lack of social capital outcomes; this can trigger detrimental impacts on their well-being. employment on cruise ships carries many occupational safety hazards [4] . to compensate, employees engage in internet multitasking; however, doing so exposes employees to added distractions and prevents them from safely or effectively completing their tasks. moreover, employees who engage in other tasks/activities while taking part in online communication with friends and family exhibit reduced performance, which leads to poor interaction and social dissatisfaction. this finding was in line with [56] who argued that multitasking is related to reduced enjoyment in messages and reduced recognition memory performance. similarly, örün et al. [55] argue that retention of communication content during online messaging is significantly worse while multitasking. lastly, the perceived social support from internet and online communications and social networking sites with family and friends at home is dependent on reciprocity. employees experiencing under-reciprocating exchanges show significant negative effects on their well-being. these results are supported by the conservation of resources theory [22] and the reciprocity norm [85] . perceived social support is a multi-dimensional construct highly dependent on personality traits. personality can affect perceived social support relationship with well-being to the point of being non-significant [86] . overall, our results provided several important theoretical and practical implications relevant to cruise tourism and human resource management. this study contributes to academic literature in several ways. first, working and living on a cruise ship, carries a heavy burden where cruise ship employees are detached from their family and friends at home [9] and their main communication instruments are the internet, social networking sites and online communications [5] . thus, although this study is of an exploratory and pioneering nature regarding the effects of internet communication on employee well-being and life satisfaction, this study was founded on well-known theories. overall, the results are consistent with the theory of belongingness [19] , the self-determination theory [20] , the uses and gratification theory [21] and the conservation of resources theory [22] and confirmed previous studies that reported positive effects of the internet and online communication on social pressure on fear of missing out [5, 11] ; relatedness to friends and family needs satisfaction [18] ; fear of missing out on internet multitasking [13] ; relatedness to friends and family needs satisfaction and perceived social support [8] ; and life satisfaction [5] . intriguingly, the results did not confirm positive effects of internet and online communication on relatedness to friends and family needs satisfaction, internet multitasking on perceived social support, and perceived social support on well-being. however, these findings are supported by previous studies, such as [25, 55, 56, 86] . a second contribution to the literature is the final model's broad scope and applicability towards achieving life satisfaction of employees who work and live in a specific workplace, as described by [87] . comprehensive measurement scales (based on previously confirmed scales by [13, [75] [76] [77] [78] for measuring internet and online communication effects on well-being and life satisfaction of cruise ship employees showed strong reliability and validity. these tools can be used in future studies as instruments for measuring internet and online communication effects on the well-being and life satisfaction of various employees. this study offers valuable practical recommendations for cruise ship companies. unhappy, detached and dissatisfied employees can become unproductive and disengaged, which can lead to high employee turnover, absenteeism, and increased expenses due to health care costs and insurance premium fees [3] ; this can harm the profitability of cruise ship companies. companies that provide free-of-charge internet and access to social networking sites and online communication, will satisfy employee needs for belongingness. this will allow employees to enjoy a strong network of family and friends to achieve and maintain life satisfaction. moreover, companies who understand and appreciate the value of employees who flourish in life satisfaction should reinforce their core values by setting their "true north" towards providing employees instruments to maintain close contacts with their friends and family at home. such provisions by companies would suppress employee social pressure and fear of missing out. this would create harmony among their close ties and social groups, ultimately leading to life satisfaction of cruise ship employees. this study has several limitations. first, this study utilized a cross-sectional time horizon; there is space for potential causality and reciprocal relationships among components [88] . future studies should use a longitudinal time horizon to investigate the effects of the internet and online communication on well-being and life satisfaction during various stages of cruise ship employee contracts. second, common method bias is expected in this study due to self-reported answers collected from employees who agreed to participate in the survey. to lessen this challenge, a cautiously composed and validated survey was used following the suggestion of [89] . as such, participant anxiety related to giving right or wrong answers was at least reduced to its lowest possible level, if not completely avoided. nevertheless, components that were used in this study could only be measured by particular, authentic impressions of employees. third, participants in this study were recruited via the facebook group "crew center". thus, the sample is not representative of the general population of all cruise ship employees who use the internet and online communications because many cruise ship employees are not members of the aforementioned group and as such are underrepresented. the fourth limitation is related to the sampling method, i.e., the convenience sample method. this method could have limited the generalizability of the overall findings. the fifth limitation is related to the research model. even though components showed satisfactory levels of validity and reliability, component constituents should be tested in future work on wider populations of employees. the sixth limitation is the quantitative analyses that were used to evaluate research data. future studies could mix qualitative and quantitative techniques to obtain comprehensive knowledge about the effects of 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barrio, josé luis title: group membership and social and personal identities as psychosocial coping resources to psychological consequences of the covid-19 confinement date: 2020-10-12 journal: int j environ res public health doi: 10.3390/ijerph17207413 sha: doc_id: 348012 cord_uid: idflfwpb the confinement imposed by measures to deal with the covid-19 pandemic may in the short and medium term have psychological and psychosocial consequences affecting the well-being and mental health of individuals. this study aims to explore the role played by group membership and social and personal identities as coping resources to face the experience of the covid-19 confinement and radical disruption of social, work, family and personal life in a sample of 421 people who have experienced a month of strict confinement in the region of madrid. our results show that identity-resources (membership continuity/new group memberships, and personal identity strength) are positively related to process-resources (social support and perceived personal control), and that both are related to better perceived mental health, lower levels of anxiety and depression, and higher well-being (life satisfaction and resilience) during confinement. these results, in addition to providing relevant information about the psychological consequences of this experience, constitute a solid basis for the design of psychosocial interventions based on group memberships and social identity as coping resources. the accelerated expansion of covid-19 in the early months of 2020 forced governments to enact extraordinary and emergency measures of social distancing to deal with the pandemic. as a consequence, millions of people were suddenly isolated and confined to their households. in march 2020, in just one week large cities such as milan, madrid or new york underwent rigid limitations on mobility and going out on the street, attending non-essential work and normal activities of daily life were forbidden. in the following days, the number of people infected and dead from covid-19 increased in fairly fast progression. overflowing hospitals, intensive care units at risk of collapse, overwhelmed health authorities and shortages of health resources to protect health professionals and citizens, generated a state of alarm unknown to current generations in developed countries. investigating and understanding how people dealt with a situation without referents is essential to identify resources that can be useful in an emergent and global crisis. there are antecedents of pandemic situations related to contagious diseases (i.e., the epidemics of sars 2002-2003, the pandemic 2009 h1n1, or the ebola virus disease epidemic 2013-2016) [1] , natural disasters and humanitarian crises caused by war conflicts. however, the scopes, large-scale and sudden nature of the covid-19 pandemic in a globalized world, make it an unprecedented experience for most of humanity. consequently, we need data that sheds light on the mechanisms and processes that people mobilize and develop to coping experiences that, directly and vicariously, dramatically affect their lives and, eventually, their physical and mental health. disaster research pointed out the importance of going beyond psychological coping approaches. thus, a perspective that considers coping as a social process includes a collective dimension, an experience-based dimension, and a local dimension, highlighting resources such as social capital and community resilience [2] . social identity theory (sit) [3] argues that in any social context people define themselves from their group membership, which means define their self in terms of social identity. if the multiple groups that define the self "provide a person with stability, meaning, purpose, and direction, then this will typically have positive implications for that individual's mental health" ( [4] , p. 5). extensive research from the social cure approach [5] has provided robust evidence on the importance of social factors, specifically of the curative role played by social integration and social support, for mental and physical health [5] . based on these approaches, this study aims first, to explore the possible existence of significant differences in relation to several socio-demographic and occupational variables regarding group memberships, social and personal identities, social support and health and well-being factors during the covid-19 pandemic. and second, to explore the role played by group membership, social and personal identities and social support as coping resources to face the experience of the covid-19 confinement and radical disruption of social, work, family and personal life. to do this, it uses a sample of 421 people who have experienced a month of strict confinement in the region of madrid. in mid-july, spain had the third most deaths proportionally to their covid-19 cases for population in the world (60.80 deaths for 100,000 population, behind belgium, 85.69, and united kingdom, 67.76) [6] ; and madrid was one of the european cities with the highest incidence of contagion (1071 per 100,000 population) and deaths (126 per 100,000 population; 8418 people have died (29.7% of deaths in spain), suffered between march and june 2020. the rapid global expansion since the end of 2019 in wuhan, in the chinese province of huabei, of the coronavirus named covid-19, led to the majority of the european governments decreeing confinement, quarantine and isolation measures in their own homes or in public dependencies (hospitals, hotels, ocean liners, etc.). these measures affected millions of people on a scale never previously known. confinement is considered a public health preventive measure to reduce the risk of disease transmission, and affects not only sick people, but also healthy or asymptomatic individuals. quarantine involves separating and restricting the movement of people who have potentially been exposed to the contagious disease to determine if they are ill or have symptoms; their goal is to reduce the risk that they could infect other people in their close or public social context. and isolation refers to the social separation of people who have already been diagnosed with the contagious disease, so that they are not in contact with non-sick people [7, 8] . despite these differences between public health measures, the terms are often used interchangeably, and in practice people subjected to them by the authorities experience diverse thoughts and emotions due to the limitation or loss of freedom of movement, doubts or fear of being infected (themselves or their loved ones and acquaintances), the loss or reduction of interpersonal and social contact, the disruption of daily habits both at work and leisure, boredom, stigma, and uncertainty about the future [7, 9, 10] . there is scientific evidence of the psychological and psychosocial consequences of the confinement, quarantine and isolation measures studied in recent infectious diseases, such as sars, n1h1, or ebola [7, 8, [11] [12] [13] [14] , and the current covid-19 in china [15] . these consequences are usually related to problems of anxiety, negative affectivity, irritability, fear, frustration, panic, depression and other negative emotional reactions, leading to infected people experiencing stigma and suicidal ideation or intentions. in turn, these consequences can lead to other health problems, both physical and mental, and a reduction in the quantity and quality of sleep. overall, literature review suggests [7, 10] that the psychological impact of quarantine and confinement is wide-ranging, substantial, detrimental, and can be long lasting, depending on how long it lasts; evidence shows that a longer quarantine is associated with poorer psychological outcomes. however, this evidence has been obtained basically from an individual perspective, or a clinical approach, and as far as we are aware, the role played by collective and social factors in the psychological consequences of confinement and quarantine has not been sufficiently investigated. the social world is the canvas where human lives are painted. given the social nature of human beings, group membership and high-quality social relationships are vital for health and well-being. social contact and belonging to many groups are fundamental and pervasive human motivations [16] and shape the roots of personal and social identity. for decades, research has accumulated data and solid arguments that show an association between social relationships and health [17] . social factors play a central role in shaping health outcomes, and its effects are similar and often larger than that of poor health habits [5] . less socially isolated or more socially included people had better psychological and physical health and less likely to die, at least prematurely [17] . large meta-analytic data across 308,849 individuals, followed for an average of 7.5 years, was conclusive [18] . individuals with adequate levels in two social factors associated with interpersonal relationships (social inclusion and social support) have a 50% greater likelihood of survival compared to those with poor or sparse social relationships. in an additional meta-analysis across 70 independent studies in which several possible confounders were statistically controlled for, the weighted average effect sizes corresponded to an average of increased likelihood of mortality by 29% for social isolation, 26% for loneliness, and 32% for living alone [19] . social inclusion occurs primarily through group membership. being a member of multiple groups satisfies the need to belong and, especially, provides identities [16] . sit theory has demonstrated the central role of groups in building the social self. furthermore, individual self-concept includes both personal identity and group memberships, since people need others to validate their attitudes and behaviors [20] . as tajfel [21] has pointed out, social identity is the part of self-concept that derives from their awareness of belonging to social groups, as well as from the emotional and evaluative meaning associated with these multiple memberships. in sum, sit [5, 22] has stressed that social behavior depends largely on the degree to which people see others sharing their social identities with them. internalized group memberships provide shared social identities. in turn, important psychological resources with implications for health are derived from shared social identities [5] . these psychological resources primarily refer to perceptions of social connection and positive orientation to other people; a sense of meaning, purpose, self-worth through social connectedness and group life; social support exchange with people who define themselves in terms of shared social identity; and the development of a sense of control, efficacy and power [5, 23] . extensive research has shown that one of the key resources that flow from shared social identities and group memberships are social support exchange opportunities, that is, interaction contexts for receiving, giving, and benefit from both social actions [5, 24, 25] . empirical evidence in different contexts revealed that receiving social support was generally beneficial for psychosocial health [26] [27] [28] [29] [30] , although there were some inconsistent results [17] , and also that providing it might be even more beneficial than receiving it [31, 32] . finally, although from the sit perspective traditionally personal and social identities are considered as the end points of a continuum [33] , identity theory research has also analyzed the relationships of social identity with personal identity strength e.g., [34] . from this perspective [35] , people have different components of self-linked to each of the group role behavioral sets that they perform. the self, or personal identity, can be seen as a collection of identities that reflects the multiple roles that a person occupies in groups to which he/she belongs [35, 36] . even if personal and social identity can be theorized and measured as separate, the fact of being strongly intertwined structures allows for the permeability of personal and social identities [37] . furthermore, it has been suggested [5, 38] "that a strong sense of 'me' flows from a strong sense of 'us'" ( [5] , p. 32). consistent with this idea, and in accordance with sit, research has shown [5, 38] that a sense of shared social identity-as a result of group membership-has the ability to make group members feel capable and with personal control over their lives, through the development of a sense of agency, self-efficacy and power [5] , with positive consequences for their health and well-being. in sum, these results show that social group memberships generate personal benefits through greater perceived personal control [38] . the social cure approach proposed by [5, 39] posits a three component model: social identity and identification factors (e.g., multiples identities, multiple group membership, social identity continuity, personal identity strength, and so on), process factors (e.g., group norms, social support, perceived discrimination, perceived personal control, and so on), and health and well-being factors (such as depression, anxiety, stress, resilience, affect, personal self-esteem, life satisfaction or general health) related with both antecedent factors (social identity and process) ( [5] , see p. 347 for an overview of the model). based on this model, our study explores whether: (1) group memberships (specifically, membership continuity and new memberships) and personal identity strength, considered as identity-resources derived from group social identities, and (2) social support (received and provided) and perceived personal control, considered as process-resources derived from the identity-resources, are related to well-being and psychological health in the confinement experience during the covid-19 pandemic. figure 1 summarizes the proposed model. identity can be theorized and measured as separate, the fact of being strongly intertwined structures allows for the permeability of personal and social identities [37] . furthermore, it has been suggested [5, 38] "that a strong sense of 'me' flows from a strong sense of 'us'" ( [5] , p. 32). consistent with this idea, and in accordance with sit, research has shown [5, 38] that a sense of shared social identity-as a result of group membership-has the ability to make group members feel capable and with personal control over their lives, through the development of a sense of agency, self-efficacy and power [5] , with positive consequences for their health and well-being. in sum, these results show that social group memberships generate personal benefits through greater perceived personal control [38] . the social cure approach proposed by [5, 39] posits a three component model: social identity and identification factors (e.g., multiples identities, multiple group membership, social identity continuity, personal identity strength, and so on), process factors (e.g., group norms, social support, perceived discrimination, perceived personal control, and so on), and health and well-being factors (such as depression, anxiety, stress, resilience, affect, personal self-esteem, life satisfaction or general health) related with both antecedent factors (social identity and process) ( [5] , see p. 347 for an overview of the model). based on this model, our study explores whether: (1) group memberships (specifically, membership continuity and new memberships) and personal identity strength, considered as identity-resources derived from group social identities, and (2) social support (received and provided) and perceived personal control, considered as process-resources derived from the identity-resources, are related to well-being and psychological health in the confinement experience during the covid-19 pandemic. figure 1 summarizes the proposed model. in the absence of previous studies from this theoretical perspective on the effects of confinement, and based on the propositions of the sit and the social cure model on the specified relationships between these constructs, as well as on the available empirical evidence on their combined effects on health, we formulated the following research questions: rq1: how will group memberships be related to psychological health and well-being during the confinement experience? rq2: how will the strength of personal identity be related to psychological health and wellbeing during the confinement experience? in the absence of previous studies from this theoretical perspective on the effects of confinement, and based on the propositions of the sit and the social cure model on the specified relationships between these constructs, as well as on the available empirical evidence on their combined effects on health, we formulated the following research questions: rq1: how will group memberships be related to psychological health and well-being during the confinement experience? rq2: how will the strength of personal identity be related to psychological health and well-being during the confinement experience? rq3: how will social support received and social support provided be related to psychological health and well-being during the confinement experience? rq4: how will perceived personal control be related to psychological health and well-being during the confinement experience? this study has been approved by the research ethics committee of universidad rey juan carlos (madrid, spain), record number 0604202009320, dated 08-04-2020, and meets all ethical and legal standards applicable to research of this survey modality. the participants were 421 inhabitants from the region of madrid, 289 women (68.6%) and 128 men (30.4%), mean age 45.38 years (sq = 15.40, range = 17-89). the most frequent level of studies completed was a bachelor's degree (32.1%), followed by a master's degree (18.1%) and a high school diploma (17.6%). participants completed a questionnaire via the qualtrics platform, that included socio-demographical data and self-report measures related to the study variables. the socio-demographic and occupational variables were evaluated by means of ad hoc items, related to age, gender, current occupational status, educational level, maintaining or not a couple relationship during confinement, having or not having children, belonging to a covid-19 risk group, type of work during confinement, and being or not a health professional. this variable was measured with the exeter identity transition scales (exits) [40] . the scale has two dimensions: membership (or social identity) continuity and new membership. membership continuity: four items, scored on a 7-point likert response format ranging from 1 (completely disagree) to 7 (completely agree). the time frame is before confinement. an example item is: "before the confinement start: . . . i belonged to many different groups". new memberships: four items, with the same 7-point likert response format. "during the period of confinement: . . . i've joined one or more new groups" is an example item. the internal consistency was adequate for both dimensions (α = 0.94 and α = 0.81, respectively). higher scores indicated higher levels of group membership. this scale [41] consisted of five items scored on a 7-point likert response format (1 = completely disagree, 7 = completely agree). item example, "i know what i want in life", and the reliability was good. the internal consistency was α = 0.76. this is a short version of a 10-item measure originally developed by [24] . the measure incorporates items designed two subscales, received social support (e.g., "i know what i want in life") and provided social support (e.g., "get the emotional support you need from others"), with 4-items each one and with 7-point likert format, from 1 (completely disagree) to 7 (completely agree). both subscales showed high reliability (α = 0.89 and α = 0.88, respectively). this is measured with the scale developed by [38] ; 3 items scored on a 7-point likert response format (1 = completely disagree, 7 = completely agree). the alpha coefficient was α = 0.81. an example item is: "i feel in control of my life". the instrument used was the generalized anxiety disorder-7 (gad-7) [42] in its spanish adaptation [43] . this widely used test consists of seven items, in which the subject must respond according to his agreement with one of the four possible alternatives, thinking about what happened during the last week, 0 = never; 1 = several days; 2 = more than half the days; 3 = almost every day. an example item statement is: "feeling nervous, anxious or on edge". higher scores indicated higher levels of anxiety symptoms. the reliability was α = 0.91. we used the patient health questionnaire-depression scale (phq-9) [44] adapted to spanish [45] . nine items scored on a 4-point likert response format (0 = never; 1 = several days; 2 = more than half the days; 3 = almost every day) to answer about the personal situation in the last week. an example item statement is: "little interest or pleasure in doing things". higher scores indicated higher levels of depressive symptoms. cronbach's alpha was α = 0.88. brief resilience scale (brs) [46] : six items with a likert scale scored on a 7-point likert response format (1 = completely disagree to 7 = completely agree) to answers for items such as "i tend to bounce back quickly after hard times". the internal consistency was α = 0.80. this parameter was measured by the satisfaction with the life scale (swls) [47] , in its spanish version [48] . this scale consisted of five items that were scored on a 7-point likert-type scale (1 = completely disagree, 7 = completely agree). an item example is: "the kind of life i lead is similar to the kind of life i always dreamed of leading". cronbach's alpha was α = 0.85. two measures developed by [49] were used. the mental health one has four items, with a dichotomous response (yes/no) and people should think about what happened last week to answer questions like: "have you enjoyed life most of the time?" cronbach's alpha was α = 0.76. the questions of the perceived physical health scale have a different answer format for each of the three items, and score was calculated as an index. an example item is "do you often have pain problems?" in spain, population lockdown took effect at 00:00 on sunday, 15 march 2020. due to the isolation circumstances in which the research team conducted this study, a virtual snowball sampling was used. for the sampling to produce significant monitoring data, access to subjects was ensured from six personal and two professional networks. participants completed a self-report questionnaire on a qualtrics online platform which they accessed via a web link, after being informed of the study and giving their consent to be included in it. the data collection was carried out from 13 to 20 april 2020, after one month of confinement. for statistical procedures, statistical package for social sciences (spss) v. 26 (ibm corp., armonk, ny, usa) was used. the kolmogorov-smirnov normality test was used to verify data distribution. results for normality test failed, and therefore nonparametric contrast tests were conducted. to verify the relation between identity, social support and well-being measures, spearman's rank correlation coefficient test was used. to assess differences on these non-normally distributed continuous variables among socio-demographic characteristic groups, analyses of covariate were conducted using mann-whitney u test for 2 independently sampled groups and kruskal-wallis h test for 3 or more groups using post-hoc dunn test with bonferroni adjustment. mann-whitney u tests and kruskal-wallis tests results are expressed as median (range). the socio-demographic characteristics of our study sample are described in table 1 . firstly, we offer the most significant differences in relation to gender ( table 2) , age (table 3) , educational level (table 4) , working and occupational status (table 5) , people who were (or not) in a relationship in confinement (table 6) , and membership of a covid-19 risk group. table 3 . descriptives (md (iqr)) and post-hoc differences by age group. regarding gender differences (table 2) , the mann-whitney test indicated that the provided social support was greater for females than for males, although females also showed higher values for anxiety and depression. males scored higher in resilience and physical health. with regard to age group differences, the kruskal-wallis h test performed showed a significant difference in new memberships (χ 2 (6, n = 421) = 14.35, p = 0.026). the most significant post hoc results showed (table 3) worse results for the younger age groups (less than 39 years). notably, group 2 (20-29 years old) presented worse general indicators, with higher levels of anxiety and depression and lower levels of mental health than participants over 40, and lower levels of perceived physical health, resilience and life satisfaction than those in group 6 (60-69 years). similarly, group 3 (30-39 years) presented greater anxiety and worse mental health than the participants over 60 years old, the latter result also obtained by those of 18-19 years old. 1 dunn-bonferroni post hoc test. only significant differences between groups appear (p < 0.05). table 6 . descriptives (md (iqr)) of the variables with significant differences for "having or not a relationship during confinement" and "having or not children". in reference to the educational level, the kruskal-wallis h test reported significant differences between groups in continuity in membership (χ 2 (7, n = 421) = 18.56, p = 0.010) and new memberships (χ 2 (7, n = 421) = 21-68, p = 0.003). as can be seen in table 4 , participants with higher levels of education showed better general indicators. specifically, those with doctoral degrees expressed lower levels of anxiety and depression than high school graduates, and higher levels of mental health and resilience than those with primary education. while those with a master's degree reported greater group membership continuity than high school graduates, and more new group memberships than those with a bachelor's degree. as shown in table 5 , people who were working during the period of confinement (teleworking or face-to-face) presented greater membership continuity, life satisfaction, resilience and mental health than people who didn't work (temporary suspension of contract, sick leave, erte or inactivity due to confinement). moreover, people who didn't work expressed higher levels of depression that people who were in working in confinement. regarding occupational status, the most significant results showed that retirees experienced lower levels of anxiety and depression than part-time workers and students, better mental health than part-time workers, the unemployed, covid-19 unemployed, and students, and also less depression than the latter three groups. in addition, students showed less resilience than retirees, worse mental health and greater depression than self-employed and full-time workers, and greater anxiety than the latter. the results shown by the students are consistent with those already mentioned for the younger age groups (table 3 ). compared to other professionals (o), health professionals (hp) reported that they developed more new group memberships, showed greater personal identity strength, provided more social support, and had more perceived personal control. the results in table 6 show that people who were in a relationship in confinement showed lower levels of depression and better mental health. in turn, people with children showed less anxiety and depression, and also displayed higher personal identity strength, life satisfaction, resilience, mental health and physical health. finally, people who belonged to a covid-19 risk group only reported worse perceived physical health (mdn = 7.29, iqr = 8.29-5.78) than those who did not belonged (mdn = 7.86, iqr = 8.86-6.29), u = 14481.50, p = 0.021). as shown in table 7 , maintenance of memberships before quarantine was correlated with the building of new ones during quarantine (ρ = 0.34, p < 0.01). membership continuity was associated with identity strength (ρ = 0.20, p < 0.01), but new memberships were not correlated with it. meanwhile, received social support correlated with membership continuity (ρ = 0.22, p < 0.01) and with personal identity strength (ρ = 0.30, p < 0.01). and provided social support was positively associated with membership continuity (ρ = 0.29, p < 0.01), new memberships (ρ = 0.12, p < 0.05) and highly with personal identity strength (ρ = 0.41, p < 0.01). moreover, perceptions of received and provided social support were strongly correlated (ρ = 0.56, p < 0.01). spearman's rank correlation coefficients related to perceived control are also presented in table 2 . personal identity strength showed a significant association (ρ = 0.28, p < 0.01), and also received social support (ρ = 0.24, p < 0.01) and provided social support (ρ = 0.31, p < 0.01). correlations regarding relationships group and identity-resources measures and health and well-being perceptions are also shown in table 2 . membership continuity was correlated with resilience (ρ = 0.15, p < 0.01). personal identity strength was positively associated with resilience (ρ = 0.30, p < 0.01), life satisfaction (ρ = 0.30, p < 0.01), mental health (ρ = 0.21, p < 0.01) and perceived physical health (ρ = 0.17, p < 0.01) and negatively with anxiety (ρ = −0.11, p < 0.05) and depression (ρ = −0.18, p < 0.01). new identities showed no associations with well-being. meanwhile, received social support was positively associated with resilience (ρ = 0.18, p < 0.01), life satisfaction (ρ = 0.31, p < 0.01), mental health (ρ = 0.22, p < 0.01) and perceived physical health (ρ = 0.21, p < 0.01) and negatively with anxiety (ρ = −0.12, p < 0.05) and depression (ρ = −0.17, p < 0.01). whereas provided social support was positively associated with resilience (ρ = 0.21, p < 0.01), life satisfaction (ρ = 0.27, p < 0.01), mental health (ρ = 0.16, p < 0.01) and perceived physical health (ρ = 0.16, p < 0.01) and negatively with anxiety (ρ = −0.10, p < 0.05). lastly, perceived control was positively associated with resilience (ρ = 0.29, p < 0.01), strongly with life satisfaction (ρ = 0.57, p < 0.01), mental health (ρ = 0.35, p < 0.01) and perceived physical health (ρ = 0.43, p < 0.01) and negatively with anxiety (ρ = −0.34, p < 0.01) and depression (ρ = −0.36, p < 0.01). we conducted additional analysis in order to delve deeper into the relationships between received and provided social support during the pandemic, perceived personal control and personal identity strength and the different health and well-being factors. to this end, these variables were recoded in three clusters or groups as follows: level 1 or low (equal to or below the 25th percentile), level 2 or medium (above the 25th and below the 75th percentile), and level 3 or high (equal to or above the 75th percentile). to study the differences between the three clusters of each variable, the kruskal-wallis h test and the dunn-bonferroni post hoc test were performed. with respect to differences between levels of received social support, the kruskal-wallis h test showed significant differences in life satisfaction (χ 2 (2, n = 421) = 35.03, p < 0.001), depression (χ 2 (2, n = 421) = 9.01, p = 0.011), mental health (χ 2 (2, n = 421) = 15.55, p < 0.001), resilience (χ 2 (2, n = 421) = 10.02, p = 0.007) and physical health (χ 2 (2, n = 421) = 17.65, p < 0.001). the results of the dunn-bonferroni post hoc test pointed out that people who experienced a high level of received social support had greater mental health (p < 0.05), and physical health (p < 0.01) than those who had a low or medium level. they also expressed greater resilience (p < 0.01) and lower depression (p < 0.05) than the low-level group. in addition, the medium group had greater life satisfaction (p < 0.01) than those with low level. as for the differences in the levels of provided social support, our data reported significant differences in life satisfaction (χ 2 (2, n = 421) = 25.15, p < 0.001), mental health (χ 2 (2, n = 421) = 8.08, p = 0.018), resilience (χ 2 (2, n = 421) = 15.57, p < 0.001) and physical health (χ 2 (2, n = 421) = 8.69, p = 0.013). the dunn-bonferroni post hoc test showed that those with a high level of provided social support had greater life satisfaction (p < 0.001), mental health (p < 0.05), resilience (p < 0.001) and physical health (p < 0.05) than the group of low level. medium level group presented greater life satisfaction (p < 0.01) and resilience (p < 0.05) than low level group. with regard to the differences between the three groups of perceived personal control, the performed test reported significant differences in life satisfaction (χ 2 (2, n = 421) = 115.56, p < 0.001), anxiety (χ 2 (2, n = 415) = 43.87, p < 0.001), depression (χ 2 (2, n = 410) = 52.04, p < 0.001), mental health (χ 2 (2, n = 417) = 45.60, p < 0.001), resilience (χ 2 (2, n = 418) = 31.97, p < 0.001), and physical health (χ 2 (2, n = 421) = 72.42, p < 0.001). the dunn-bonferroni post hoc test showed that those with a high level of perceived personal control had greater life satisfaction (p < 0.001), mental health (p < 0.001), resilience (p < 0.001) and physical health (p < 0.001), and lower levels of anxiety (p < 0.001) and depression (p < 0.001) than the group of low level. moreover, presented greater life satisfaction (p < 0.001), mental (p < 0.05) and physical (p < 0.001) health and lower depression (p < 0.05) than the group of medium level. in addition, the group of medium level showed greater life satisfaction (p < 0.001), mental health (p < 0.001), resilience (p < 0.001) and physical health (p < 0.001) and lower anxiety (p < 0.001) and depression (p < 0.001) levels than the group of low level. finally, attending to the differences between the levels of personal identity strength, the results indicated the existence of significant differences in life satisfaction (χ 2 (2, n = 421) = 38.39, p < 0.001), depression (χ 2 (2, n = 410) = 12.69, p = 0.002), mental health (χ 2 (2, n = 417) = 18.44, p < 0.001), resilience (χ 2 (2, n = 418) = 31.43, p < 0.001) and physical health (χ 2 (2, n = 421) = 10.64, p = 0.005). the post hoc tests reported than those with high level of personal identity strength had greater life satisfaction (p < 0.001), resilience (p < 0.001), mental (p < 0.001) and physical health (p < 0.01) and lower depression (p = 0.001) than those belonging to the low group. also presented greater resilience (p = 0.001) than the medium level group. moreover, the medium level group had greater life satisfaction (p < 0.001) and mental health (p < 05) than the low-level group. in relation to the first objective of our study, our preliminary results showed that women had poorer mental health (anxiety and depression) than men, who showed better physical health and greater resilience. prior evidence on gender differences in relation to the psychological consequences of quarantine was inconclusive, with some studies [50] showing a greater negative psychological impact on women, while others [11, 51] found no difference. our results did show a higher incidence in women, although it would be necessary to know the history of psychiatric illness in order to conclude that these worse mental health indicators were related to the experience of confinement. meanwhile, our data showed that women were providers of social support to a greater extent than men. this result was consistent with the evidence for women's greater ability to provide social support-as gender (femininity) not as sex [52] ; however, by showing higher levels of depression than men, it appears that the social support exchanged between women, and that received from men, was not sufficient to buffer the negative effect of confinement stressors. this interpretation is consistent with the evidence suggesting [53] that women are better providers of social support to men than men are to women. however, this result does not confirm the prediction [54] that the modalities of social support (empathy, active coping assistance, and role modeling) provided by experientially similar others-i.e., women-be efficacious in alleviating the psychological impacts of stressors. regarding age groups, the worst mental health (anxiety and depression) and the lowest well-being (life satisfaction) of the 20-29 year-old group and the students can be highlighted. this result is also consistent with prior evidence; for instance [50] found that the [16] [17] [18] [19] [20] [21] [22] [23] [24] year age group suffered the most negative psychological impact in a quarantine situation, and [51] , in a study conducted in china in the context of covid-19, have found that the younger population perceived more impacts of the epidemic outbreak (changes over living situations or emotional control), negative coping style and had higher level of psychological distress. the poorer mental health and lower life satisfaction of young people, as well as of students, can be explained by the disruption of their lifestyle by confinement, at an age where relationships and social contact are high valued. in addition, the economic effects of covid-19 on employment may further affect young people's precarious employment and career opportunities, increasing their frustration. regarding educational level, people with doctoral degree show greater continuity of membership and more new memberships than people with close educational levels (high school and bachelor's degrees), as well as better mental health, lower anxiety and depression, and greater resilience than those with primary education and elementary school degree. consistent with these results, there is broad evidence (e.g., [5, 24, 55] ) that people with high (perceived) socio-economic status (assessed in terms of level of education) or with high (perceived) group status have more social capital and it is beneficial for their well-being and health. people who had a relationship and cared for children during confinement manifest better mental health and higher strength of identity, life satisfaction, resilience and physical health. data from china's population in the early stages of the covid-19 quarantine [51] showed that unmarried people were more aware of the impacts of the epidemic outbreak and had a higher level of psychological distress. these data seem to indicate that affective and family relationships can play a buffering role of confinement stressors. the results also indicated that continuing to work (face-to-face or teleworking) was associated with better indicators of social identity and mental health compared with those who did not work for any reason. in this case, it appears that the potential stress from working under the conditions imposed by the pandemic was not experienced or added to the confinement stressors. rather, it can be interpreted that group membership continuity (i.e., identity continuity) facilitated by work activity is related to a perception of less life disruption, and consequently, to better mental health and greater resilience and vital satisfaction [6] . it is also possible that downward social comparisons of people in working with those who lost their jobs or were infected by covid-19, may have facilitated their perception of psychological well-being [56] . regarding retirees, the results also seem to underline the importance of identity, as is the case for working people. in this regard, although they no longer worked, their mental health indicators were better (along with those of full-time employees) than those of most occupational groups. this interpretation is consistent with previous data [5, 57] indicating that new group memberships and identification as a retiree play a protective role and has positive effects on well-being and mental health. as for our second objective and the four research questions that we asked, our results allow us to give a preliminary answer to all of them. identity-resources showed a significant relationship between them, so that membership continuity was associated with new memberships during confinement. this result may be relevant, as it indicates that in such a life disruptive experience the identities associated with group memberships were maintained and could facilitate new identities through memberships that were necessarily largely adopted without face-to-face contact. this result is consistent with sit's postulates [5, 21] and self-categorization theory (sct) [22] that the (cognitive) perception of group membership is sufficient to create a group identity. as sct posit [22, 58] , group membership and social category-based self-conceptualization are motivated by uncertainty reduction [59] . thus, contextual uncertainty created by confinement and the covid-19 pandemic could be reduced entering new groups, adopting new identities and by group action, although within the limits imposed by social distancing and quarantine measures. a significant relationship was also found between membership continuity and personal identity strength, which coincides with sit's approaches that defend the links between social identity and personal identity [35, 36] and permeability of both [37] . the correlation between the new memberships and personal identity strength was not significant, but this may be due to the relatively short time that has passed since the adoption of new group identities (less than a month), so it will be relevant to analyze whether this relationship is reinforced over time. in sum, our results show that participants had both identity-resources during the confinement, and it is important to check, as our model based on the social cure approach [5] proposes, if they are related to process-resources and, especially, to well-being and health perceptions. with regards to social support, a significant relationship was found between support received and support provided. this result is relevant, because prior evidence indicates [60] that both occur when the size of social network is large, which again is associated with group membership, since a positive relationship was found between continuity and social support received and given, and new membership and social support provided during confinement. our results are coincident with prior research founding that shared social identities and group memberships are social support exchange opportunities for receiving, giving, and benefit from both social actions [5, 24, 25] . in addition, personal identity strength was positively related to received and provided social support and perceived personal control. in turn, both types of social support were significantly related to perceived personal control, which is consistent with the previous literature [61] [62] [63] . thus, it can be concluded that social support exchange with people who define themselves in terms of shared social identity are related with the development of a sense of control, which constitute important psychological resources for people [5, 23] . our model based on the social cure approach [5] suggested that both types of social and personal resources (identity-resources and process-resources) would be related to perceived well-being and health. correlational analyses and, especially, additional analyses conducted clustering in low, medium and high levels of identity and process resources, confirm the relationships between strength of personal identity, social support received and provided, and perceived personal control and health and psychological well-being consequences experienced during the covid-19 pandemic. the clearest indicator of these relationships is resilience, since all resource variables, except for new memberships, are positively and significantly related to it. these results are reinforced by the significant differences found in the greater resilience of groups with high levels of social support received and provided, perceived personal control, and strength of personal identity in relation to groups with medium and low levels of these three resources. these results are consistent with previous evidence that identifies multiple group memberships [64] , strength of personal identity [65] , social support received [66] , especially in people exposed to trauma [67] , and perceptions of personal control [68] as antecedents to resilience. overall, our results are aligned with the perspective that postulates social identity as a basis for resilience, both individual [5] and collective resilience [69] , and have important implications for the design of psychosocial interventions that foster group membership and participation, specially to coping with potential future confinement experiences in cases of new outbreaks of the covid-19. for their part, anxiety experienced during confinement was less, perceived mental health was greater, and life satisfaction was higher for people who felt personal identity strength, received and provided social support, and perceived personal control. these results are also consistent with extensive prior evidence [5, [17] [18] [19] , and are relevant for future interventions, as discussed below. similar results were found for depression, although in this case the social support provided was not significantly related. finally, people who pertained to the cluster of high levels of provided and received social support, personal identity strength, and perceived personal control experienced in general greater mental health and life satisfaction and better overall physical health than groups of medium and low level, which is also consistent with prior evidence [5, 38, 41] . the main implications of our study concern the design of psychosocial interventions. for instance, the team of haslam et al. [5] has successfully implemented a social intervention program labeled groups 4 health that develops the social identity model of identity change (simic) [39] , applied to life transitions as retirement. in a similar vein, our model proposal and the results obtained can be useful for the design of strategies and psychosocial interventions in the sense of strengthening social networks and the potential social support derived from them. given the strong link between social relations, support and mental health [17, 63] , actions aimed at strengthening interpersonal relations and social networks through, for example, support groups, community initiatives or networks of people who share similar characteristics (of studies, profession, interests, etc.) [70] , can be very effective in providing social coping and resilience resources that increase the personal resources of those who experience, for example, post-traumatic stress following confinement. interventions designed with the groups 4 health model to address problems of social isolation or loneliness, stress, anxiety and depression have proven effective [71] , so that its adaptation to address the potential psychological consequences of confinement appears promising. this proposal for group-based interventions is even more relevant if we take into account the warnings of health authorities regarding potential outbreaks of covid-19 in the coming months. this study was conducted with a non-probabilistic sample and using a measure of the study variables one month after the start of the confinement. consequently, only relationships between variables can be established, so our aim is for future studies to include a greater number of temporary measures with subsequent follow-ups in order to identify causal relationships between variables. in this sense, longitudinal studies may allow to test the potential mediating role of process-resources in the relationship between identity-processes and factors related to health and well-being [5] . likewise, the participants were residents of the region of madrid and the sample size is relatively small, so the results cannot be generalized to the spanish population. however, given that madrid was one of the european regions where the covid-19 was most virulent, our results are relevant for understanding the experiences of citizens and their perceived levels of well-being and health in a situation of extreme alarm. future research, as well as potential interventions, should test whether resources based on social and personal identity and group membership, as well as the process resources provided by them (social support and perceived control), can play a protective (buffering) role for well-being and health in disruptive situations such as that triggered by the covid-19 pandemic. if future threats of virus outbreaks or similar health crises occur, this knowledge can be of great value and use in helping people to cope and overcome them with as little harm to their well-being and health as possible. in short: our results provide a first overall answer to our research questions: identity-resources and process-resources associated with them have positive relationships with the levels of well-being and health experienced during confinement. furthermore, as far as we know, this is the first time that the social cure model [5, 38] is used in a sample of the spanish population, and our results may complement those obtained by other studies carried out in spain during the covid-19 pandemic (i.e., [72] [73] [74] ). finally, our study may also contribute to the design of interventions based on this model, as we discussed in the prior section. infectious disease pandemic planning and response: incorporating decision analysis understandings of coping: a critical review of coping theories for disaster contexts the social identity theory of intergroup behavior social identity, health and well-being: an emerging agenda for applied psychology the new psychology 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linkage, self-concept, and well-being after severe traumatic brain injury social support and resilience to stress: from neurobiology to clinical practice how does social support enhance resilience in the trauma-exposed individual? risk and resilience factors in coping with daily stress in adulthood: the role of age, self-concept incoherence, and personal control collective resilience in mass emergencies and disasters social relationships and health. in social support measurement and intervention: a guide for health and social scientists groups 4 health: evidence that a social-identity intervention that builds and strengthens social group membership improves mental health related health factors of psychological distress during the covid-19 pandemic in spain idoiaga-mondragon, n. stress, anxiety, and depression levels in the initial stage of the covid-19 outbreak in a population sample in the northern spain covid-19: factores asociados al malestar emocional y morbilidad psíquica en población española [covid-19: factors associated with emotional distress and psychic morbidity in spanish population funding: this research received no external funding. the authors declare no conflict of interest. key: cord-355291-fq0h895i authors: yasir, ammar; hu, xiaojian; ahmad, munir; rauf, abdul; shi, jingwen; ali nasir, saba title: modeling impact of word of mouth and e-government on online social presence during covid-19 outbreak: a multi-mediation approach date: 2020-04-24 journal: int j environ res public health doi: 10.3390/ijerph17082954 sha: doc_id: 355291 cord_uid: fq0h895i although social presence plays an essential role under general conditions, its role becomes significant for societal protection during the quarantine period in epidemic outbreak. in this study, we attempted to identify the role of e-government and covid-19 word of mouth in terms of their direct impact on online social presence during the outbreak as well as their impacts mediated by epidemic protection and attitudes toward epidemic outbreaks. for this purpose, a unique multi-mediation model is proposed to provide a new direction for research in the field of epidemic outbreaks and their control. through random sampling, an online survey was conducted and data from 683participants were analyzed. partial least squares structural equation modeling was used to test the relationships between the variables of interest. the study results revealed that the roles of e-government and covid-19 word of mouth are positively related to online social presence during the outbreak. epidemic protection and attitude toward epidemic outbreak were found to positively moderate the impact of the role of e-government and covid-19 word of mouth on online social presence during the outbreak. the key findings of this study have both practical and academic implications. the flow of information in any matter is important and can considerably impact the situation during an epidemic outbreak. the role of e-government is also essential in any situation related to health protection, especially during an outbreak period. e-government (e-govt) is defined as "the use of information technologies that have the ability to transform relations with citizens, businesses, and other arms of government" [1] . keeping people calm and focused is necessary during an epidemic and its quarantine period. if people are quarantined, the roles of e-govt and word of mouth (wom), especially message sharing through social media, increase in importance. now, with the current covid-19 outbreak, people are under quarantine until further notice, with many countries experiencing epidemic outbreaks. people have more time to use social media, which could be a source of rumors, anxiety, and, most important, knowledge for with physicians' online statements [26] . this shows that women are more emotional about health conditions, especially during an epidemic outbreak. evidence was provided that rumors are spreading during the covid-19 outbreak in other countries, but in china, people were likely to improve their emotions in the fight against covid19 and stay strong during the outbreak period by sharing positive posts on social media. as of the date of writing, 9 march 2020, we have been in quarantine since20 january2020, having direct experience with both normal life and quarantine. on social media, the importance of being online, especially during an epidemic outbreak, and the role of e-govt in the quarantine period shown in previous research, urged us to explore this phenomenon on a broader basis. positive awareness through the effects of covid-19 word of mouth (2019-ncov-wom) and e-govt in the epidemic period has not been sufficiently explored. regardless of the important roles of 2019-ncov-wom and e-govt in the epidemic outbreak, quantity of research is lacking. although online social presence is important at this time, scholars have not explored it sufficiently. from the literature, questions were raised whether online social presence increased the ability to obtain information about the safety measures and, with 24 h of free time to use social media, if people might be more willing to spread safety information. on this basis, we tried to explore the direct effect of 2019-ncov-wom and e-govt on online social presence, and tried to fill this gap using a cohesive methodology to identify the mediating effect of attitude toward epidemic outbreak and epidemic protection on online social presence. we used five constructs (2019-ncov-wom, role of e-govt, attitude toward epidemic outbreak, epidemic protection, and online social presence in the outbreak) with a conceptual multi-mediation model. we explored a distinctive approach to answer two questions: is there any mediating effect of attitude toward epidemic outbreak and epidemic protection on online social presence? what is the best possible combination for the government to increase people's willingness to participate in quarantine with a psychological perspective? in the next section, we discuss our research model. based on the analysis, we discuss our study results in section 4. finally, consequences and practical implication of our research are given and future research is suggested in section 7. to fill these research gaps, we provide a new direction for research about epidemic outbreaks by discussing the role of e-govt and the effect of 2019-ncov-womin relation to the use of social media and their mediating effect on long-term outbreaks. our research questions (rqs) were: rq1: what is the association between social media, epidemic protection messages, and online social presence? rq2: is there any mediating association between 2019-ncov-wom and the role of e-govt in online social presence? people have perceptions about their government playing a role during an epidemic condition. perceptions are heightened during an outbreak period, as people are concerned about their protection, and their attitude toward an epidemic outbreak depends on this protection, to some extent. during a quarantine period, as people are isolated, the perceived role of e-govt may be increased and people might be motivated to play a role in epidemic protection after watching the involvement of e-govt. in our questionnaire, we asked about trust in e-govt, which might provide motivation to play an important role in epidemic protection. the literature shows that the role of government, especially governmental strategies and alertness messages, in any outbreak is progressively enhanced [27] . communication and interaction with the government has increased in last few years, as the government is interested in engaging its people through social media [28] . the abovementioned literature justifies that the government understands people's perceptions about the role of e-govt. people involved in policy-making are also inspired by social media [29] . factors involved in sharing information are not described in this literature [30] . attitudes and awareness is connected to the supposed efficiency of policy-making [31] . improvement and development in chinese e-waste has been seen in the last six years [32] .this might enhance the people perceptions about e-govt playing a role in an epidemic outbreak. in canada, social media was used as tool for facilitation of consumers by government officials [33] . in latin america, research on e-govt is increasing and conflicting with what is occurring in the world [34] . one reason we involved e-govt and online social presence in our research model is that a noteworthy difference was identified the in analysis of awareness about the use of mobile phones to seek health information during critical times [35] . awareness promotion plays an important role in burn cases [36] . universal and global research is needed in community health for the use of social media in e-govt [37] . our study variables included capability of isolation, quarantine compartment, and interaction methods, which are responsible for occupancy rate isolation [38] . to stop the transfer of infectious disease, isolating infected people from healthy ones is vital [39] . the biggest outbreak of coronavirus, the middle east respiratory syndrome (mers), occurred in south korea in 2015. the main spread of this virus occurred in south korea from and out of hospitals [40] . as an independent variable, we added role of e-government in our study, because studies were lacking on the emotional influence of mers outbreaks [41] . research showed that administration, media, and celebrities play important roles in health promotion on twitter [42] because people are more attracted to celebrities. recommendations that are logically expressed have a strong impact on public [43] . many governments are improving their use of social media in health departments and are trying to provide digital services to their people guidance; especially during outbreaks. to increase the theoretical literature on e-govt in the health sector, we aimed to fill this gap using a systematic review method to analytically evaluate, recognize, and create research evidence for the use of 2019-ncov-womin connection with the role of e-govt in protection from covid-19. we also tried to critically evaluate the role of social media and the willingness to undergo a long quarantine period for protection from this epidemic. here, per the literature, we take this variable of people's perception (perceived role) of the role of the chinese government, which was important because the government provided a plan to withstand the outbreak period. notably, this is the first critical review of the use of 2019-ncov-wom and the role of e-govt in the covid-19 epidemic (as independent variables). given the above literature, we expected that e-govt plays a considerable role in the perception of epidemic protection and online social presence and in changing public attitudes toward an epidemic outbreak. therefore, we hypothesized the following: hypothesis 1a (h1a): role of e-government considerably affects epidemic protection. role of e-government considerably affects online social presence during an outbreak. role of e-government considerably affects attitude toward an epidemic outbreak. wom provides new directions to people's thoughts and views about any condition, and especially during an epidemic outbreak. nowadays, the top trend is covid-19 epidemic conditions discussed in news and online social websites. many studies in the last 10 years proved that there has been a large increase in the number of people willing to find health information on the internet. an increase in the number of social profiles providing health information was also observed [44] . electroencephalography inter-subject correlation (eeg-isc) was improved by an increase in resilient health communication [45] . the people of wuhan felt great confidence in sharing their views during data collection during the covid-19 epidemic outbreak quarantine. health promotions broadcast by the media are used to promote awareness. for young italian people, the messages were mostly about health and the environment [46] . this is significant because health experts have been using it as a motivational tool during the treatment of patients [47] and because histories of patients with similar symptoms are important for predictions [48] . this may be helpful for the emotional treatment of patients in the future. conversely, the most important aspect of health promotions is increasing people's patience and keeping them calm during the quarantine period to avoid anxiety. the chinese government improved public endurance by their emotional awareness through message sharing, which encouraged people to share their views [26] . it is a common for people to first think that social media information is only rumors during an outbreak; as such, people were at risk of being ignorant of health information shared by the government or by individuals. to provide better and urgent cure, people should know the signs and symptoms of corona viruses. many symptoms of the novel covid-19-infected pneumonia (ncip) have been described by researchers; they include increased body temperature, dry cough, and body pain [49] . the chinese government promoted awareness among people through social media, so that individuals showing signs of covid-19would immediately understand and contact medical experts for treatment and minimize further spread of the virus. only online 2019-ncov-wom was used for the quarantine period in china, especially in wuhan and anhui; some other countries soon after implemented quarantine measures. this means the chinese government played a positive role in the safety of people. the above-mentioned research demonstrated the importance of online 2019-ncov-wom. so, we tried to explore the positive effect of 2019-ncov-wom on online social presence in our research using exclusive mediating variables. we expected that 2019-ncov-wom not only significantly affects perceptions of epidemic protection in terms of individuals' online social presence, but also influences changes in attitude toward the epidemic outbreak. so, we hypothesized the following: hypothesis 2c (h2c): covid-19 word of mouth considerably affects attitude toward the epidemic outbreak. everyone is concerned with their protection in any condition, but particularly during an epidemic outbreak. the protection factor might affect social presence, but as people are isolated during quarantine, this factor changes the effect on online social presence in other ways. individuals' attitudes toward fitness is boosted by viewing health information posted on facebook in video form [3] . people's responses to epidemic protection increase especially during quarantine because they are at home and have more free time. individuals with prolonged health problems acknowledged caretakers' guidance more than other adults in the u.s., but they did not obtain physical exercise guidance for good health [50] . the covid-19 epidemic protection urged people to increase their online social presence to enhance public emotions for epidemic protection. the empirical studies mentioned above encouraged us to relate epidemic protection as a dependent variable due to obtaining specific information to protect online users during the quarantine period. here, we took this variable as people's perception to ensure their safety. china is more conscious about health due to the one-child policy, free internet to obtain information, and the perception of being safe through obtaining safety measures. therefore, we hypothesized the following: the literature discussed above indicated that assuming the role of e-govt in online social presence of the public is mediated by epidemic protection and 2019-ncov-wom affects online social presence. however, we suspected that 2019-ncov-wom is boosted by the psychological perception of epidemic protection. so, we hypothesized the following: hypothesis 3c (h3c): epidemic protection mediates the association between covid-19 word of mouth and online social presence. hypothesis 4b (h4b): epidemic protection mediates the association between role of e-government and online social presence. a study showed that people's attitudes toward an epidemic outbreak are more influenced by information on social media compared with physical discussion because source reliability has no impact on the health information provided online [51] .people obtain information about the outbreak through social media and mobile health apps [26] .however, a risk of client secrecy exists because online services are substantially affected by the happiness of clients [52] .we took attitudes toward an epidemic outbreak as a mediating effect, meaning that attitudes toward an epidemic outbreak will promote or mediate the relationship of two independent variables and social online presence, as shown in figure 2 . presence. however, we suspected that 2019-ncov-wom is boosted by the psychological perception of epidemic protection. so, we hypothesized the following: hypothesis 3c (h3c): epidemic protection mediates the association between covid-19 word of mouth and online social presence. hypothesis 4b (h4b): epidemic protection mediates the association between role of e-government and online social presence. a study showed that people's attitudes toward an epidemic outbreak are more influenced by information on social media compared with physical discussion because source reliability has no impact on the health information provided online [51] .people obtain information about the outbreak through social media and mobile health apps [26] .however, a risk of client secrecy exists because online services are substantially affected by the happiness of clients [52] .we took attitudes toward an epidemic outbreak as a mediating effect, meaning that attitudes toward an epidemic outbreak will promote or mediate the relationship of two independent variables and social online presence, as shown in figure 2 . research showed that the availability of a vaccine for an epidemic affects people's attitudes toward the outbreak; for publicizing a vaccine, online sources are important. during epidemics, curiosity about a vaccine is more influenced by publicity, not by the epidemic conditions. however, vaccine uptake is also influenced by the epidemic condition when epidemic increases [53] .recommendations by doctors, friends, and relatives stimulate people [54] as they discuss their responses to epidemics. people who are isolated during an epidemic must recognize the importance of protection [55] .research in toronto, canada, proved the willingness of people to participate in studies and the stress experienced by medical experts due to wearing of caring apparatus and being infected by disease in canada. as these medical experts were involved in attempting to cure a disease about which they had little knowledge, they were worried that they would be next targets when they saw their coworkers becoming sick and dying due to the epidemic [56] . lack of trust in government was observed in the public in korea when attempting to control the mers epidemic [57] . however, our focus was on the effect of 2019-ncov-wom and the role of e-govt to protect the people during long-term outbreak, and to examine the response of people during the quarantine period. we supposed that public attitude toward epidemics affects their online social presence. in china, people are willing to share news and have positive attitudes when sharing the good news about protection. so, we hypothesized the following: research showed that the availability of a vaccine for an epidemic affects people's attitudes toward the outbreak; for publicizing a vaccine, online sources are important. during epidemics, curiosity about a vaccine is more influenced by publicity, not by the epidemic conditions. however, vaccine uptake is also influenced by the epidemic condition when epidemic increases [53] . recommendations by doctors, friends, and relatives stimulate people [54] as they discuss their responses to epidemics. people who are isolated during an epidemic must recognize the importance of protection [55] . research in toronto, canada, proved the willingness of people to participate in studies and the stress experienced by medical experts due to wearing of caring apparatus and being infected by disease in canada. as these medical experts were involved in attempting to cure a disease about which they had little knowledge, they were worried that they would be next targets when they saw their coworkers becoming sick and dying due to the epidemic [56] . lack of trust in government was observed in the public in korea when attempting to control the mers epidemic [57] . however, our focus was on the effect of 2019-ncov-wom and the role of e-govt to protect the people during long-term outbreak, and to examine the response of people during the quarantine period. we supposed that public attitude toward epidemics affects their online social presence. in china, people are willing to share news and have positive attitudes when sharing the good news about protection. so, we hypothesized the following: hypothesis 3b (h3b): attitude toward epidemic outbreak considerably affects online social presence. the attitude of the public toward a situation impacts their online social presence and affects the role of e-govt and 2019-ncov-wom on online social presence. this means that if the attitude of the public is positive, it mediates role of e-govt and online social presence. hence, we hypothesized that: hypothesis 4c (h4c): attitude toward epidemic outbreak mediates the association between covid-19 word of mouth and online social presence. hypothesis 5b (h5b): attitude toward epidemic outbreak mediates the association between the role of e-government and online social presence. according to social presence theory [58] , social presence is about intimacy, feeling of closeness, familiarity, immediacy, and urgency to exchange information and motives in society. online social presence is important during epidemic outbreak quarantine periods. it not only plays an important role in the coordination of society but also in the creation of motives. online social presence is predicted by online streaming, mediating communal television pleasure [26] . among the magnitudes of social presence (telepresence and social presence), online social presence indirectly plays a role in the mediating direction. findings encouraged innovative marketing policy through which participation can be optimistic by refining presence fundamentals [59] . people are more attracted toward celebrities, which strengthens online social presence [60] . so, if celebrities are active during outbreak periods, they can motivate people to increase their online social presence. in addition, human sympathy is apparent on online sites and especially social sites, representing their online social presence and recognizing their interactions and feelings [58, 61] . the capability of a platform to deliver personal indications and increase online social presence willingness [59] is interceded by useful commitments [62] . every website provides specific confidentiality, which is expressively affected by online social presence [63] . private platforms are facilitated by online social presence [64] , so we predicted that they also affect the online response of people in quarantine during epidemics. sociability, pleasure, and belief are emotive reactions that reconcile social presence [59] . these three responses were felt across the chinese nation during the covid-19 outbreak. people believe that we will overcome this deadly virus and people were seen to be more emotional and social during this pandemic. online social presence varies from their level of appointment, which reveals intellectual burden [65] . contribution by people is inspired by their social value [66] . addiction to social networking sites (sns) also improves online social presence and increases people's pleasure when interacting socially, also improving social communication and gratification [26] . online social presence influences online engagement [67] . we included two areas in our study: wuhan in hubei (all cities from this province) and anhui province. participants of our study were mostly from wuhan. anhui (hefei province) is the nearest city to wuhan, so we also considered anhui in our study. we were all in quarantine (except one doctor as a writer for medical terminology association but she is not living in china), directly experiencing the feelings of this situation. random sampling and snowball sampling techniques were used to collect the data. it was impossible for us to go to wuhan due to quarantine during the outbreak. we were quarantined by ourselves. to avoid this hindrance on data collection, we decided to collect data online. we sent our questionnaire to the people of wuhan and anhui provinces. data was collected during the covid-19 quarantine period, which has been in place for almost one month and continued during the research. most of the participants were chinese; however, we also included foreigners living in wuhan and anhui because of their presence. however, due to various countries' evacuation policies, we decided to exclude the foreigners' data. due to the mixed participants of our study, we used two versions of the questionnaire to overcome any language barrier. we used an english version for data collection from foreigners and a chinese version for the domestic population in wuhan and anhui. to increase interest and willingness of participants we sent them hongbao (lucky money) to the group owners of wechat through wechat (only owners, not the participants). we collected data from 704 people (still ongoing, the corresponding author is willing to help any researchers with future research). in total, the participants included 315 men and rest were women (we aimed to obtain participants equally from both sexes). due to online foreigners' evacuation during data collection, we excluded 21 records during analysis and used 683 valid samples for analysis. after the evacuation policy implementation, we decided to stop the collection from foreigners. the demographic characteristics of our research data are provided in table 1 . moreover, the itemized sources of constructs used in the research are given in table 2 . role of e-govt efforts of e-govt, trust in e-govt, support of e-govt [26] 2019-ncov-wom information,countries' status, 2019-ncov-plan [68] epidemic protection hand wash, mask, motivation to protect [69, 70] attitude toward epidemic outbreak willingness to quarantine, health psychology, doctors' advice [71] online social presence in outbreak more present in quarantine, present for social support, present to discuss covid-19 the steps in our methodology are reported in figure 3 . role of e-govt efforts of e-govt, trust in e-govt, support of e-govt [26] 2019-ncov-wom information,countries' status, 2019-ncov-plan [68] epidemic protection hand wash, mask, motivation to protect [69, 70] attitude toward epidemic outbreak willingness to quarantine, health psychology, doctors' advice [71] online social presence in outbreak more present in quarantine, present for social support, present to discuss covid-19 the steps in our methodology are reported in figure 3 . from 2013 onward, a noticeable increase in participation of partial least squares structural equation modeling has been reported [72] . if not familiar with the data type or if the data have a common factor or are composite-based, findings illustrate that use partial least squares (pls) is the best choice for analysis [73] . appraisal and review studies explained that in management research with multivariable analysis techniques, the application of partial least squares structural equation from 2013 onward, a noticeable increase in participation of partial least squares structural equation modeling has been reported [72] . if not familiar with the data type or if the data have a common factor or are composite-based, findings illustrate that use partial least squares (pls) is the best choice for analysis [73] . appraisal and review studies explained that in management research with multivariable analysis techniques, the application of partial least squares structural equation modeling (pls-sem) has been increased [74] . pls-sem is being increasingly used in investigative and theory-based research [75] . use of pls is increasing in different branches of management, especially research with one-variable-based techniques [76] . past studies showed that pls-sem in different branches of management research have used multivariate analysis. as research in online user psychology is in its infancy and is not as developed as management research, the existing psychological studies about patients during pandemics during a sensitive time period (isolation)does not adequately explain the behavioral psychology of online users. as such, we applied pls-sem (smart pls) in our research [74] . to assess our measurement model, we verified the concurrent validity, discriminate validity, and composite reliability (cr) [77] . in addition to the square root values of the average variance extracted (ave), we compared constructs to determine the discriminate validity [78] . factor loading values should be greater than 0.70 [79] . for data validity and measurement, the value of the ave should be greater than 0.5 [80] , cr > 0.7 [78] , and rho > 0.7 [81] . table 3 provides the reliability and validity of our measurement scales and table 4 provides the results of the fornell-larcker test used to check distinguished and divergent validity. to create intervals of confidence and t-values, we used bootstrapping (4000 re samples) to check for imagined associations between the concerned constructs of the planned structured model. streukens, s., et al. [82] stated that bootstrap replications can vary considerably from a minimum of 500 to a maximum of 5000.in other words, statistic inconsistency is checked using the inconsistency of data using bootstrapping, which is a nonparametric resampling method, instead of using parametric statements to check the accuracy of approximation [83] . efron, b., et al. [84] proposed using more than 1000 bootstrap samples. the mediation effect is absent if the direct effect is not significant. figure 1 illustrates the hypotheses testing of direct effects, which are also shown in table 3 . table 3 also provides the fit statistics. dependent variables indicate an important and positive precursor to their independent variables. particularly, the role of e-govt was a noteworthy predictor of epidemic protection. as can be seen from figure 4 and table 5 , all of the hypotheses were supported [85] for the direct effect hypothesis at this step. 500 to a maximum of 5000.in other words, statistic inconsistency is checked using the inconsistency of data using bootstrapping, which is a nonparametric resampling method, instead of using parametric statements to check the accuracy of approximation [83] .efron, b.et al. [84] proposed using more than 1000 bootstrap samples. the mediation effect is absent if the direct effect is not significant. figure 1illustrates the hypotheses testing of direct effects, which are also shown in table 3 . table 3 also provides the fit statistics. dependent variables indicate an important and positive precursor to their independent variables. particularly, the role of e-govt was a noteworthy predictor of epidemic protection. as can be seen from figure 4 and table 5 , all of the hypotheses were supported [85] for the direct effect hypothesis at this step. to check the importance of the structural path coefficients, we report the confidence interval [86] . these were supported because we did not add up zero values in any confidence interval [78] .at present, in standardized root mean square residual (srmr) pls path modeling, mostly model fit criteria are used. we checked the accuracy of the fit by using different tools like value of normed fit index (nfi), the non-normed fit index (nnfi), the comparative fit index (cfi), root mean square error of approximation (rmsea), and srmr. values equal to or higher than 0.95 in nfi, nnfi, and cfi indicate the best fit. sufficient adjustment was represented by rmsea and to check the importance of the structural path coefficients, we report the confidence interval [86] . these were supported because we did not add up zero values in any confidence interval [78] . at present, in standardized root mean square residual (srmr) pls path modeling, mostly model fit criteria are used. we checked the accuracy of the fit by using different tools like value of normed fit index (nfi), the non-normed fit index (nnfi), the comparative fit index (cfi), root mean square error of approximation (rmsea), and srmr. values equal to or higher than 0.95 in nfi, nnfi, and cfi indicate the best fit. sufficient adjustment was represented by rmsea and srmr with values less than 0.06 [87] . for comparatively good fit between the hypothesized model and observed data, a cut-off value near to 0.08 for srmr and near 0.06 is best for rmsea; hu, l.t. et al. [88] stated that a zero value for srmr indicates an ideal fit but if the value is smaller than 0.05,the fit is satisfactory fit [89] . we investigated the standards of the coefficient of determination (r 2 ) to verify the predictive strength of our structure model. collective consequences of exogenous contracts on endogenous constructs were indicated. the r 2 of the endogenous latent variables is the vital decisive factor for this evaluation. this marker is used, from the perspective of a statistical model, to forecast future results or can be used to check the hypothesis on behalf of other related information. r 2 also provides the results of the calculations and describes the practicality of the results [90] . researchers can also use pls procedure to check their model's out-of-sample predictive power [91] . in-sample predictive power, we also refer to the r 2 [92] . r 2 varies from 0 to 1 and greater values show better descriptive power. substantial, moderate, and weak descriptive powers are indicated by r 2 values of 0.75, 0.50, and 0.25, respectively [93] . pls-sem is less dependent on the model fit concept compared to cb-sem [79] . as recommended [74] rmsea cut-off values equal to or less than 0.08 using modification in r 2 report effect size (f 2 ) indicated that the effect of our dependent variables on independent variables was very satisfactory. the effect of the exogenous latent construct on the endogenous latent construct having three possible answers, i.e., substantial, moderate, and weak, was found using thef 2 effect size. the blindfold method was used to check the strength of the research model. cohen's f 2 is an identical measure of effect size that also permits checking the local effect size, which is the effect of one variable compared with the multivariate regression model [94] . if the cross-validated redundancy (q 2 ) is higher than 0,then the model is related to predicting that factor [95] . we focused on in-sample prediction more, compared to out-sample prediction, prognostic significance q 2 , and relative relevance q 2 , which are alternatives for evaluating a model's practical relevance, in addition to consulting r 2 outcomes as a gauge of a model's predictive capabilities [95] . r 2 , q 2 , path coefficients, and the effect size (f 2 ) are the decisive factors we use for evaluation. in addition to this evaluation, researchers are required to check the inner model for potential co linearity issues. if the constructs are interrelated, then results approximated by the inner model are considered biased [96] . a model's predictive accuracy is decided by the r 2 . the r 2 value also characterizes the combined consequence of exogenous variables on the endogenous variable(s). the effect ranges from 0 to 1. a value of 1 indicates complete predictive accuracy as can see in table 6 . table 6 . effect size and predictive relevance. cohen's f 2 was calculated to check the effect size of each path model. when a construct was removed from the model, we calculated f 2 while making no changes to r 2 . researchers have to approximate two pls path models for computing f 2 . the effect size of the omitted construct for a particular endogenous construct can be found by standard values: 0.02 for small, 0.15 for medium, and 0.35 for a large effect on the basis of the f 2 value [96] . this discussion supports the use of our mediators and variables in the model. in the pls path model, mediator variables absorb the effect of an exogenous construct on an endogenous construct; this absorption of effect is known as meditation [96] . the mediation effect can be investigated using many tools, including pls-sem. though researchers use an older method to determine the mediation effect in pls-sem, the procedure that identifies the effect of a precursor variable on the findings and results is judged by mediation; in other words, mediation considers transitional variables [97] . a mediating variable may have a transitional role in the association between dependent and independent variables, and engagement of this third variable is the important feature of the mediating effect [98] . clarification and elaboration are the main effects of mediation [81] . as such, we included multi-mediation concepts in the results of social presence theory and for psychological aspects during outbreaks (see table 7 ). table 7 . mediation analysis. table 7 . multiple mediation paths outcomes and potency (level) of mediation effects are demonstrated in figures 5 and 6 . precise indirect effects were investigated by bootstrapping techniques with the help of the bias correction technique. the two independent variables (role of e-govt and2019-ncov-wom) affected online social presence; these effects support h1b, h2b, and h3c in that order, as mentioned above. to determine whether h4b, h5b, h3c, and h4c are supported, we used the proposals by hair et al. [85] . to finalize conclusions about the mediation effect; we calculated the amount and magnitude of mediation. we incorporated the variance accounted for (vaf) method to calculate the strength of mediation (figures 5 and 6 ). if vaf is less than 0.2, there is no mediation; if vaf is less than or equal to 0.8, there is a partial mediation; if vaf is greater than 0.8, there is full mediation. the magnitude and strength of epidemic protection (h4b: a1b1) and attitude toward epidemic outbreak (h5b: a2b2) mediated the association between the role of e-govt and online social presence ( figure 5 ). we found via comparison that epidemic protection has a partial mediation effect on the role of e-govt and online social presence because the vaf value was more than 0.2, which indicated that there is a partial mediation effect. as such, h4b is supported. attitude toward epidemic outbreaks mediated the association between 2019-ncov-wom and online social presence; the vaf value was greater than 0.2, which indicated the presence of mediation. therefore, we hypothesized imaginary harmonizing partial mediation because the effects of 2019-ncov-womwere considerable both directly and indirectly and their products were positive [99] . hair et al. [85] concluded that complementary and competitive mediation can be differentiated if direct and indirect effects are more prominent. the condition in which direct and indirect effects work in the same direction is called complementary mediation. this means the outcome of the direct and indirect effect is positive. the magnitude and strength of the mediation effect of epidemic protection (h3c: a3b1) and attitude toward epidemic outbreak (h4c: a4b2) mediating the association of 2019-ncov-womand online social presence is shown in figure 6 . in comparison, the vaf value was higher than 0.2, which indicated the presence and effect of mediation. due to the prominent direct and indirect effects of 2019-ncov-wom, the complementary partial mediation was also positive. the comparison showed that the association between 2019-ncov-wom and online social presence was mediated by attitude toward epidemic outbreak. the vaf value was higher than 0.2, which indicated partial mediation, also supporting the multi-mediation hypothesis [99] . int. j. environ. res. public health 2020, 17, x for peer review 14 of 21 hair et al. [85] concluded that complementary and competitive mediation can be differentiated if direct and indirect effects are more prominent. the condition in which direct and indirect effects work in the same direction is called complementary mediation. this means the outcome of the direct and indirect effect is positive. the magnitude and strength of the mediation effect of epidemic hair et al. [85] concluded that complementary and competitive mediation can be differentiated if direct and indirect effects are more prominent. the condition in which direct and indirect effects work in the same direction is called complementary mediation. this means the outcome of the direct and indirect effect is positive. the magnitude and strength of the mediation effect of epidemic ipma, also called impact-performance map or priority map analysis, is a useful approach in pls-sem. ipma adds facets and measurements that consider the scores of latent variables reporting the path coefficient [99] . approaches to determining the role of precursor constructs and their significance for management actions are offered by the pls-sem studies based on ipma. ipma compares the significance and recital (performance of the variables) [99] . analysis dimensions are used to demonstrate the results of path coefficient approximation extended by ipma in figure 7 . the advantage of ipma is the validation of total effects and a representation of their significance in a construct with an average score that indicates their performance. our main purpose with the construct was to find the most significant component in the construct. presence was mediated by attitude toward epidemic outbreak. the vaf value was higher than 0.2, which indicated partial mediation, also supporting the multi-mediation hypothesis [99] . ipma, also called impact-performance map or priority map analysis, is a useful approach in pls-sem. ipma adds facets and measurements that consider the scores of latent variables reporting the path coefficient [99] . approaches to determining the role of precursor constructs and their significance for management actions are offered by the pls-sem studies based on ipma. ipma compares the significance and recital(performance of the variables) [99] .analysis dimensions are used to demonstrate the results of path coefficient approximation extended by ipma in figure7. the advantage of ipma is the validation of total effects and a representation of their significance in a construct with an average score that indicates their performance. our main purpose with the construct was to find the most significant component in the construct. online ratings are associated with higher enjoyment than negative reviews [100] . to the best of our knowledge, the broader tasks and household behaviors of the community and family members in social media and role of e-govt have been relatively under-examined. we used an online questionnaire and proposed a unique conceptual model and multi-mediation model to achieve the objectives of our study. we constructed eight hypotheses for the direct effects(h1a, h1b,h1c,h2a,h2b,h2c,h3a, and h3b) and four hypothesis (h4b,h5b,h3c, and h4c) for the mediation effect of our dual mediators, i.e., epidemic protection and attitude toward epidemic outbreak, with their indirect effect between the role of e-govt and2019-ncov-wom on online social presence during outbreaks. our results are supported by mmijail etal. [101] who concluded that local government affects the attitude and decision-making process of people with their e-government platforms. the results of our study showed that role of e-govt have a strong effect on the attitude of the public toward quarantine. our study results also showed that public relationship directly influences positive wom. our study results are supported by kim etal., who concluded that local government affects the social presence of community participants and the identified individuals' attitudes and community [102] . our study results online ratings are associated with higher enjoyment than negative reviews [100] . to the best of our knowledge, the broader tasks and household behaviors of the community and family members in social media and role of e-govt have been relatively under-examined. we used an online questionnaire and proposed a unique conceptual model and multi-mediation model to achieve the objectives of our study. we constructed eight hypotheses for the direct effects (h1a, h1b,h1c,h2a,h2b,h2c,h3a, and h3b) and four hypothesis (h4b,h5b,h3c, and h4c) for the mediation effect of our dual mediators, i.e., epidemic protection and attitude toward epidemic outbreak, with their indirect effect between the role of e-govt and2019-ncov-wom on online social presence during outbreaks. our results are supported by mmijail et al. [101] who concluded that local government affects the attitude and decision-making process of people with their e-government platforms. the results of our study showed that role of e-govt have a strong effect on the attitude of the public toward quarantine. our study results also showed that public relationship directly influences positive wom. our study results are supported by kim et al., who concluded that local government affects the social presence of community participants and the identified individuals' attitudes and community [102] . our study results revealed that attitude toward epidemic outbreak has a strong mediation effect between the role of e-govt and online social presence during outbreaks, indicating that other governments and organizations can follow china's safety model. the chinese government allowed full opportunity to be online and for online users to promote hand washing and mask wearing during the covid-19 outbreak. as for as effect of 2019-ncov-wom and online social presence is concerned, our study findings are supported a the previous study [102] in which human voice and wom were found to have a positive impact on social presence. our findings showed that 2019-ncov-wom has a positive effect on online social presence. online social presence is increasing worldwide. social media has become increasingly important, especially for covid-19 information. in this study, we determined the impact of the role of e-government and covid-19 word of mouth on online social presence. we estimated the mediation impact of epidemic protection and attitude toward epidemic outbreaks on online social presence. the key results showed that the role of e-government and covid-19 word of mouth positively impacted online social presence. similarly, epidemic protection and attitude toward epidemic outbreak showed positive mediation impact on online social presence. from estimated results, we outline some implications and policy suggestions: during quarantine, people have more free time to participate in social media, which increases their desire to be present online. for themselves and society, they want to participate in disease protection and to provide suggestions to perform positively during the difficult time caused by covid-19 quarantine. people can obtain basic information and protection measures from e-government and obtain specifics about the issue. for practical implementations during epidemic outbreaks, the results suggest that the health authorities and government should pay more attention to managing the attitude toward outbreaks and its relationship with the role of e-government. people's perceptions about the government will help build their willingness toward long-term pandemic control. some limitations were unavoidable in our study. we used two sampling techniques: random sampling and snowball sampling; future research can be improved using different kind of sampling and data collection techniques. the second major limitation was the use of single type of role of e-govt. the reason behind this limitation was the ongoing quarantine, so it was impossible to compare the relationship of 2019-ncov-wom in online social presence with offline discussion because personal meetings, face-to-face contact, physical interviews, etc. were prohibited. however, future research can be improved using different types of research variables, using web scraping and web mining of top trends complete protection analyses. however, our findings can be implemented to improve online social presence and increase emotive protection during epidemic quarantine periods. fourth, the data were collected online. therefore, we were unable to gauge the respondents' responses during data collection, although people were very motivated to share their answers to the questionnaire because of the involvement of the role of the government. more adequate research can be conducted by expanding the study area, e.g., people from other countries. our study was 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express sincere thanks to the anonymous reviewers for productive comments. we are also thankful to xiaojian hu and mengjiehu for the inspiration. the authors have no conflict of interest to declare. int. j. environ. res. public health 2020, 17, 2954 key: cord-330228-plcdwazu authors: gore, dana; kothari, anita title: social determinants of health in canada: are healthy living initiatives there yet? a policy analysis date: 2012-08-14 journal: int j equity health doi: 10.1186/1475-9276-11-41 sha: doc_id: 330228 cord_uid: plcdwazu introduction: preventative strategies that focus on addressing the social determinants of health to improve healthy eating and physical activity have become an important strategy in british columbia and ontario for combating chronic diseases. what has not yet been examined is the extent to which healthy living initiatives implemented under these new policy frameworks successfully engage with and change the social determinants of health. methods: initiatives active between january 1, 2006 and september 1, 2011 were found using provincial policy documents, web searches, health organization and government websites, and databases of initiatives that attempted to influence to nutrition and physical activity in order to prevent chronic diseases or improve overall health. initiatives were reviewed, analyzed and grouped using the descriptive codes: lifestyle-based, environment-based or structure-based. initiatives were also classified according to the mechanism by which they were administered: as direct programs (e.g. directly delivered), blueprints (or frameworks to tailor developed programs), and building blocks (resources to develop programs). results: 60 initiatives were identified in ontario and 61 were identified in british columbia. in british columbia, 11.5% of initiatives were structure-based. in ontario, of 60 provincial initiatives identified, 15% were structure-based. ontario had a higher proportion of direct interventions than british columbia for all intervention types. however, in both provinces, as the intervention became more upstream and attempted to target the social determinants of health more directly, the level of direct support for the intervention lessened. conclusions: the paucity of initiatives in british columbia and ontario that address healthy eating and active living through action on the social determinants of health is problematic. in the context of canada's increasingly neoliberal political and economic policy, the public health sector may face significant barriers to addressing upstream determinants in a meaningful way. if public health cannot directly affect broader societal conditions, interventions should be focused around advocacy and education about the social determinants of health. it is necessary that health be seen for what it is: a political matter. as such, the health sector needs to take a more political approach in finding solutions for health inequities. preventative strategies focusing on healthy eating and physical activity, collectively known as healthy living, have become an important strategy in canada for combating chronic diseases. chronic diseases are rising to epidemic proportions in the canadian population and costs associated with treating them pose a serious threat to the sustainability of the health care system [1] . addressing the underlying causes of chronic diseases and their inequitable distribution through a preventative health promotion strategy has been acknowledged as an effective way to reverse these trends in both ontario (on) and british columbia (bc). these provinces have recently reformulated their chronic disease prevention strategies as part of canada's renewal of public health systems, initiated in 2003 as a response to severe acute respiratory syndrome (sars). a common strategy that both provinces pursue is to address chronic disease prevention through healthy living initiatives -initiatives that work to promote healthy eating and physical activity as well as address other risk factors such as unhealthy alcohol consumption and tobacco use. while healthy eating and physical activity were traditionally considered individual lifestyle choices, public health has shifted its perspective in the past several decades to encompass the broader context in which these choices are made. this includes daily living and working conditions that are not conducive to healthy lifestyles as well as broader structural determinants that create inequities between population groups, which together form the social determinants of health [2] . the world health organization (who) has defined the social determinants of health in the following way: "the poor health of the poor, the social gradient in health within countries, and the marked health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of peoples livestheir access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns, or citiesand their chances of leading a flourishing life. together, the structural determinants and conditions of daily life constitute the social determinants of health and are responsible for a major part of health inequities between and within countries" [2, p.1] . within a canadian context, some examples of social determinants of health that have been identified are: income and income distribution, education, unemployment and job security, employment and working conditions, early childhood development, food insecurity, housing, social exclusion, social safety net, health services, aboriginal status, gender, race and disability [3] . the social determinants of health have been consistently linked in the literature to chronic diseases such as cardiovascular disease, respiratory diseases, diabetes and cancer in canada and worldwide; for example, it has been found that low socioeconomic status (ses), often measured by income and education levels, is associated with higher rates of cardiovascular disease, chronic obstructive pulmonary diseases, diabetes mellitus and asthma [4] [5] [6] [7] [8] [9] . research on canadian cities has shown that people living in low income neighbourhoods experience significantly higher rates of chronic diseases such as diabetes and die several years earlier than their wealthier counterparts [10] . job insecurity, characterized by unemployment, part-time employment and temporary employment, has been found to result in elevated blood pressure and higher risk of death from cardiovascular disease [11, 12] . even in a financially secure job, poor working conditions that place high demands on the worker, combined with low support and low job control have been correlated with elevated stress and increased rates of coronary heart diseases as well as higher risk of cardiovascular-specific mortality [13] [14] [15] . nor are these trends colour-blind; racialized groups such as aboriginal people, new immigrants and minorities of colour consistently earn lower incomes and experience higher rates of chronic disease than north americans of european descent [16] [17] [18] [19] . canadian policy documents outlining priorities for public health have stressed the importance of an approach that addresses the social determinants of health [20] [21] [22] . in a recent high-level united nations meeting on chronic diseases, the role that the social determinants of health play in chronic disease was recognized, as was the importance of addressing them in disease prevention strategies [23] . a delegation from canada participated in this meeting, and canada endorsed the resulting declaration [24] . an approach that effectively engages with the determinants has been suggested in mikkonen and raphael's the social determinants of health: the canadian facts, and includes policies that offer a higher minimum wage, higher assistance levels for those unable to work, a more progressive taxation structure that redistributes income more fairly, increased unionization, better funding of public education, government regulation of post-secondary institution tuition, stronger legislation on anti-discrimination policies and equal opportunity hiring, a national childcare strategy, strategies to increase the affordability of nutritious food, increased spending on a housing strategy, policies that reduce barriers for refugees and immigrants to practice their professions, and recognizing aboriginal government authority over a wider range of aboriginal affairs [3] . provincial health policy on chronic disease prevention for bc and on corresponds to federal priorities. on has stated in policy documents that the causes of chronic diseases are complex and rooted in broad determinants of health, which encompass lifestyle, socioeconomic, cultural and environmental factors [25, 26] . in order to tackle these upstream causes, the province has decided on a comprehensive, integrated population health approach that is evidence-based [27, 28] . for example, in a policy document on combating obesity, on committed to a population health approach, which explores health disparities and interactions among the social determinants of health in order to improve the well-being of populations [26] . this approach can also be seen in the ontario action plan for healthy eating and active living [28] . on has made efforts to integrate a social determinants of health perspective into the province's public health practice through data and information use guidelines for boards of health of public health units. in the healthy eating, physical activity and healthy weights guidance document, the board of health is instructed to use information on health inequities and the social determinants in order to assess population needs and identify groups at highest risk [25] . bc shares fundamental similarities with on in its agreement on the importance of the social determinants of health and the need for an evidence-based, population health approach to chronic disease prevention. in the model core program paper on chronic disease prevention in bc, the paper's working group identified key principles for successful disease prevention, which includes a focus on social, environmental and economic determinants of health, a "whole of society" approach to population health, and an equity lens to examine health disparities between different groups [29, p. iv] . the determinants of health are understood to interact with each other in a variety of ways, to compound vulnerabilities for certain sections of the population, and to be modifiable through health public policy and changing social norms. like on, bc also takes health disparities between different parts of the population into account, such as between men and women, different ethnic groups, those who identify as aboriginal, or between people of varying socioeconomic status [29] . in order to effectively address the social determinants of health, on and bc have committed to multi-sectoral action that targets the population on a variety of levels. both bc and on have stressed the importance of partnerships in the public health model to achieve prevention goals with other levels and sectors of government, ngos, private industry, service providers, researchers, and communities to name a few [25, 28, [30] [31] [32] . these partnerships are considered crucial for real change, given the upstream, wide-ranging impact of the social determinants of health. both provinces advocate for comprehensive strategies that target the population in diverse environments and at multiple levels [25, 31] . these strategies suggest a socio-ecological approach to healthy eating and active living, a model of health that recognizes the interaction between individuals and their greater environment and its impact on health. in a socio-ecological model, the health behaviours that individuals engage in are impacted by individual factors (such as knowledge, lifestyle choices, and attitudes towards health behaviours), as well as interpersonal, community, organizational and society-level factors [33, 34] . interventions that follow this model aim to target the population at all these levels and address downstream as well as upstream barriers to healthy living [35] . it is important to note that although the socio-ecological model is different from the social determinants of health approach, it does not preclude attention to the social determinants of health. the social determinants of health can in theory be addressed at multiple levels within the socio-ecological framework, especially those that are more upstream such as at the societal level. based on the priorities that are listed above for healthy eating and active living in on and bc, it would be expected that initiatives in both provinces target the population in diverse settings and at multiple levels, with a majority of initiatives focusing on improving population health through a social determinants of health framework. however, what has not yet been examined is the extent to which healthy living initiatives implemented under these new policy frameworks successfully engage with and change the social determinants of health. this study seeks to evaluate healthy living initiatives in bc and on that focus on healthy eating and physical activity based on their approach to the social determinants of health and health inequities. the authors draw on a political economy of health perspective in order to evaluate the initiatives within their broader social, political and economic context [36] . this implies that the findings related to the data are discussed in relation to the larger discourse around the socioeconomic environment and acknowledge the effect of structures and processes external to the health sector. recommendations that emerge from the discussion are approached in a similar way. publically-available provincial policy documents written between 2005 and 2011 in bc and on that focused on chronic disease prevention were used as a starting point to identify relevant initiatives. the focus was on chronic diseases that are most affected by nutrition and physical activity -namely cardiovascular diseases, some cancers, diabetes, hypertension, stroke and chronic respiratory disease. once initiatives were identified, a web-based search was conducted to obtain a detailed description of the program as well as its timeline and current status (in-planning, ongoing, discontinued) etc. provincial organizations that had the potential to conduct initiatives were also researched online to find initiatives that may not have been mentioned in the original policy documents and database. the search was not restricted to initiatives led by provincial ministries related to health; they could be initiatives of other ministries, arms-length government agencies or independent nonprofit organizations that worked to improve healthy eating and physical activity. in order to ensure the list of healthy living initiatives was comprehensive, it was compared against recent documents and public databases that provide listings of healthy living initiatives at municipal, regional and provincial levels in bc and on [26, 37, 38] . lastly, two policy-makers in bc and on reviewed the list of initiatives to fill any gaps. a) initiatives focused on healthy eating and physical activity as a preventative strategy to reduce chronic diseases or improve general health. the initiatives were not limited to government interventions -the initiatives could be funded and developed by various organizations including actors in the government, non-profit and private sectors. b) initiatives were implemented in bc and on between january 1, 2006 and september 1, 2011. c) initiatives were provincial rather than regionally or nationally-based. initiatives that focused on select sites in the province were also permitted provided they weren't restricted to a particular region or area. for example, an intervention targeting remote communities in on would be acceptable for analysis, whereas an intervention led by a particular health authority and applied only to that health authority's region would not be included. the findings are limited to the provincial scope of initiatives selected. it is difficult to determine if analysis of regional, municipal or community level initiatives would reveal convergent findings, and represents an area for future study. each of the identified initiatives was reviewed, analyzed and grouped using descriptive labels. codes were developed directly from the data by asking the following questions of each initiative: a) what section of the population does the initiative target? (ex. general public, vulnerable populations, health service providers, community actors, etc.) b) what factor is the initiative trying to change that will lead to healthy eating and active living? (e.g. knowledge, skills, attitudes, built environment, access, social/economic/political factors, etc.) c) does the initiative directly acknowledge and attempt to act on the social determinants of health? if so, in what way? (e.g. education, advocacy, public policy change, etc.) d) what is the mechanism that the initiative uses to promote healthy living? (e.g. direct program for population, resources, toolkits, consultation services, grants, etc.) the predominant themes that emerged from questions b. and c. reflected three types of initiatives: lifestylebased, environment-based, and structure-based, which were defined for this paper in the following ways: lifestyle-based: these initiatives aim to improve healthy living through lifestyle change of individuals. examples include raising awareness of the issues (e.g. obesity) in the general population, increasing knowledge around nutrition and physical activity, changing attitudes towards healthy living by appealing to social norms (e.g. social marketing campaigns) or directly encouraging the adoption of new behaviours through programs (ex. eating foods with lower salt content, exercising for 30 minutes each day). the target audience could be the general public or specific groups (e.g. low income individuals, children, or aboriginal people) environment-based: these initiatives are meant to improve healthy living by influencing the immediate environment in which people spend their time, such as schools, workplaces and community spaces. examples of these initiatives range from encouraging employers to initiate healthy workplace programs to banning the sale of unhealthy foods in schools or working towards a built environment that encourages physical activity. these initiatives were frequently settings-based and address the role that immediate environmental factors play in health. structure-based: these initiatives directly acknowledge the impact of various structures (e.g. social, political, economic) that create inequities leading to chronic diseases and attempt to address the social determinants of health directly in order to improve healthy eating and active living. these types of interventions are most frequently centered around education and advocacy on the social determinants of health and worked specifically to correct health inequities caused by these structural conditions. examples include a survey tool that assesses the cost of basic healthy eating in different geographic areas in order to monitor accessibility and affordability of a nutritious diet, the creation of community forums to discuss the social determinants of health and explore structural barriers to healthy living, or consultation services that provide gender equity audits to sport and recreation organizations. of the three categories, this one is the only one that directly acts on the social determinants of health. for each initiative type, it was also found using questions a. and d. that there was a broad variety of mechanisms by which the initiative was supported and delivered. consequently, in each category, initiatives were classified according to the mechanism by which they were administered. mechanisms were categorized as direct programs, blueprints, and building blocks, and were defined as the following: direct program: initiatives that are developed and implemented to directly influence the health of the population. initiatives could be implemented through organization staff, contracting of other staff, working with community partners, or enforcing mandatory policy. examples include direct services from health professionals such as phone lines staffed by dieticians and specialists in physical activity, bills to prohibit certain foods, and programs that provide healthy snacks to schoolchildren. this category also applies to programs that reward organizations (communities, schools) for programs they have already implemented. blueprint: initiatives that are developed but require implementation and tailoring by a third party such as a school, public health unit, or community organization. these initiatives are categorized as blueprints because while they offer a "plan" for a healthy eating and active living intervention (heal), they do not directly act on the population and their implementation is optional. examples include toolkits for healthy school policies, materials for teachers to encourage student physical activity, and frameworks for how to build healthy communities. these initiatives require more action at the local level than direct programs because although the initiative is planned, local actors are needed to carry it through. building blocks: initiatives that are meant to act as resources for third parties to develop their own projects, within certain guidelines. examples include grants for communities to build their own heal project, consultation and training services on program planning, and directories of heal initiatives to act as a resource for ideas in developing an initiative. these initiatives require the most action at the local level; their planning and implementation fall to local actors and they provide the least support from the organization that is offering the initiative. from the systematic scan of the policy documents, database and website search, 60 initiatives were identified in on and 61 were identified in bc. (please see additional file 1 and additional file 2 for a full list of initiatives). programs were headed by various actors in both provinces, including ministries of health, other government sectors such as the ministry of education, non profit organizations, and professional associations. often initiatives were structured as a partnership among multiple actors across different sectors. while many different organizations led and implemented healthy living initiatives, the majority were linked to provincial government in some way -either through direct funding, funding through an arms-length government agency (e.g. cancer care ontario or public health ontario), funding through a non-profit organization that has received sizeable grants for healthy living initiatives (e.g. bc healthy living alliance), or partnership with a government agency. government involvement in on programming or financing included the province of ontario, the ministry of health and long-term care, the ministry of child and youth services, the ministry of community and social services, the ministry of education, the (former) ministry of health promotion and sport, and the ministry of agriculture, food and rural affairs. government involvement in bc programming or financing included all ministries, since all participated in act-now bc. some key ministries involved in healthy living initiatives were the ministry of health, the ministry of community, sport and cultural development, the ministry of education, the ministry of agriculture and lands, the ministry of children and family development, and the ministry of transportation and infrastructure. many initiatives involved multiple ministries and most included a health-related ministry. in on, 6 of the 60 initiatives were not linked to the provincial government, and were organized and/or financed by parks and recreation ontario, the ontario heart and stroke foundation, dairy farmers of canada, and a partnership between the university of guelph and the city of guelph. in bc, 8 of the 61 initiatives were not linked to government, and were organized and/or financed by the bc parks and recreation association, the heart and stroke foundation of bc & yukon, the bc dairy foundation, the greater vancouver food bank and breakfast for learning bc. for examples of initiatives classified into the three intervention types, please see table 1 . for examples of initiatives classified into the three delivery types, please see table 2 . in bc, 38 interventions were lifestyle-based, 27 were environment-based and seven were structure-based. nine interventions had multiple components that targeted a combination of lifestyle, environmental and structural factors, and so were classified into more than one category. in terms of method of delivery, direct interventions were more prevalent in lifestyle-based initiatives: 18 initiatives used direct programming while 10 initiatives were blueprints and 10 were building blocks. in the environment-based category, there was more of a balance between mechanisms of delivery: a roughly equal number of environment-based initiatives worked through direct, blueprint and building block mechanisms (10, eight and nine, respectively). structure-based interventions were those that received the least direct support: only one was enacted through direct programming, one used the blueprint format, and six were building blocks-type initiatives. on yielded similar results in terms of distributionthe preponderance of initiatives were lifestyle-based, followed by environment-based, with very few aimed at structural change. of 60 provincial initiatives identified, 36 were lifestyle-based, 26 were environment-based and nine were structure-based. six interventions had multiple components that targeted a combination of lifestyle, environmental and structural factors, and so were classified into more than one category. most lifestylebased interventions were direct (23), while 11 were blueprint initiatives and four were building blocks. environment-based initiatives were also more likely to a six week cooking program that is administered to 'at-risk' target populations. the program is administered by community facilitators, who have been trained by the bchla (the organization that offers this initiative). offers ontarians free dietitian services on healthy eating and nutrition through a website, email, and toll-free number. a set of written resources with activity ideas to help parents, caregivers and early learning practitioners encourage healthy eating and physical activity in young children. a set of programs, written resources and workshops to help early childhood, elementary, and middle school teachers teach their students about nutrition and healthy eating. a program offering grants for start-up of community and school-based snack programs directed at children and youth and bc that include an educational component. an organization that provides services to community organizations that aim to develop health promotion programs. services include consultations, workshops and resources related to program planning, implementation, and evaluation. a free telephone resource for british columbians to receive information and advice from exercise physiologists on physical activity and healthy living. screening of children up to the age of 6 as well as parenting support, referrals and information on healthy practices such as breastfeeding, infant care and infant nutrition. farm to school salad bar bill 8: healthy food for healthy schools act a program that connects schools with local farms in order to increase students' access to healthier food (e.g. fresh produce). an amendment to on's education act limiting the amount of transfats that can be sold on school property through means such as vending machines, special events and cafeterias. a grants program for communities to begin a dialogue on how to address barriers to physical activity. it also provides resources on how social determinants of health such as poverty and social exclusion affect access to physical activity. a survey tool that municipal boards of health are required to use in order to calculate the cost of nutritious food. this can be used to monitor how affordable and accessible foods are by comparing them to income levels of on households be direct (13) while nine were blueprints and four were building blocks. of initiatives that acted at a structural level, two acted through direct mechanisms, three were blueprints and four were building blocks. in summary, bc and on had similar distributions of intervention types, with the majority falling into lifestyle-based initiatives, followed by environment-based initiatives, and a small proportion falling into the structure-based category. while many initiatives focused on changing lifestyle and the immediate environment to improve healthy eating and physical activity, very few were directed towards changing more upstream social determinants of health, such as the economic and social conditions that create inequities between genders, income groups and ethnic groups. only 11.5% of initiatives in bc and 15.0% of initiatives in on had structural components that directly spoke to the social determinants of health. in terms of the mechanism by which the intervention was implemented, on had a higher proportion of direct interventions than bc for all intervention types (63.9% vs. 47.4% for lifestyle-based interventions, 50.0% vs. 37.1% for environment-based interventions, and 22.2% vs. 14.3% for structure-based interventions). however, the same trend can be observed for both provinces: as the intervention becomes more upstream and attempts to target the social determinants of health more directly, the level of direct support for the intervention lessens. in bc direct programming drops from 47.4% for lifestyle-based initiatives to 37.1% for environment-based initiatives to 0% for structure-based initiatives. in on direct programming drops from 63.9% for lifestyle-based initiatives to 50.0% for environment-based initiatives to 22.2% for structure-based initiatives. for a visual representation of this trend, please see figure 1 . the dominance of lifestyle-based and environmentbased initiatives is troubling considering that initiatives were expected (and directed) to focus on the social determinants of health. although individual behaviour change theories were popular early in the health promotion movement, the field of public health has matured to embrace a more multi-level approach. this change of focus was in recognition of the fact that individual behaviour change strategies are not enough for lasting health improvements, given structural conditions which predispose people to illness [39] [40] [41] . they may actually be counterproductive; they tend to place responsibility to change directly on individuals and can lead to victimblaming should barriers prove too great for them to be successful [42] [43] [44] . the individual change strategy can be particularly problematic when it comes to addressing the impact of inequities on vulnerable populations, considering that such interventions often focus on increasing knowledge, changing attitudes and/or encouraging adoption of healthy behaviours. this approach in a marginalized group runs the risk of implying that the group is to blame for their higher rates of chronic disease, purportedly due to their own ignorance of healthy living or lifestyle choices. environment-based interventions, while more sensitive to the context in which people live and work, still do not tackle the structural determinants which create these conditions in the first place. programs aiming to increase access to nutritious food and physical activity in particular settings such as schools, workplaces, government buildings and communities do not alter the factors which create inequities and unfavourable living conditions [45] . environment-based initiatives can also have potentially negative implications for health equity when applied at a population level with no consideration for differential access. programs that "treat everyone the same" and fail to acknowledge different positions vis-ã vis the social determinants of health may in fact benefit those who already have access while excluding those who are more vulnerable. this effect was succinctly illustrated in frohlich and potvin's critique of geoffrey rose's population strategy [46] . what is needed are structural interventions that are inherently redistributive in nature; interventions that broaden the distribution of power, income, goods and services across the population. research has demonstrated limited effectiveness of downstream interventions (such as programs that focus on behaviour change) when structural barriers are not addressed [47] [48] [49] [50] . this is not surprising, considering that structural determinants have been found to influence the distribution of risk factors for chronic diseases such as smoking behaviour, overweight and obesity, and physical inactivity [8, 51, 52] . therefore, attempting to prevent chronic disease by targeting risk factors at the individual or environmental level may not be effective without also addressing the broader determinants that shape those risk factors. as can be seen from the paucity of structural interventions, this approach to healthy living is lacking in on and bc despite provincial policy direction. another discouraging trend found in the data is the decrease in direct initiatives (direct programs) and increase in more indirect ones (at the blueprint and building blocks levels) as the initiatives become more upstream. the amount of indirect initiatives could be interpreted as a move towards increasing community capacity, inclusion, local responsiveness and decision-making in healthy living initiatives. however, the more upstream and broadscale an intervention is (i.e. an environment or structure-based program), the more it would benefit from coordinated action at a higher, more structural level [3] . initiatives that address the social determinants of health in order to impact the population at a broad level can extend beyond the scope of a particular community organization, whose on-going population reach and resource availability are limited. health equity interventions can also require more direct action from government -for example, an initiative that would help to balance the distribution of wealth in canada is a more progressive taxation structure or an increase in minimum wage to account for inflation and provide a higher standard of living. these are initiatives which cannot be undertaken by individuals and communities. as the word 'structural' implies, they need to be acting directly on the structures (economic, social, political, etc.) which create and maintain health inequities. instead, communities that do not have that capacity are more likely to receive this responsibility -in the form of grants, training workshops for program planning, or mechanisms of initiative implemented included direct programs, blueprints, and building blocks and were calculated for a total of 61 initiatives in bc and 60 in ontario. please note that percentages may not add to 100% because some initiatives operated by more than one mechanism and so were placed in multiple categories. resource directories. these initiatives are framed as supporting communities in building their own initiative that addresses the social determinants of health. however, the pressure that it places on communities is enormous, and allows the public health system to abdicate its responsibility to address the social determinants of health directly and in a concrete manner. instead it can point to these initiatives and claim that they are focussing on the social determinants of health -this is essentially the provinces of on and bc "passing the buck". given the fact that policy documents on chronic disease prevention and healthy living at the provincial level in both bc and on acknowledge the importance of the social determinants of health, why is the health sector not acting on them? an explanation can be found in the context of canada's political and economic policy over the past several decades. a neoliberal approach to the economy that favours freedom of the market has resulted in the retraction of government intervention in the areas that are crucial to the health and well-being of canadians. research has found that canadians are experiencing increasing levels of poverty and income inequality, as absolute levels of poverty increase and the gap between the poorest 10% and richest 10% widens [53] . research based in toronto has demonstrated this trend of polarization starting from the 1970s [54] . urban poverty is also becoming more concentrated in peripheral areas -areas that have the highest rates of new immigrants and visible minorities. not surprisingly, child poverty in canada has also deepened in the 1990s [55] . other determinants of health have also been affected by government policy. the public education system has suffered cutbacks and labour conflicts that reduce its ability to provide quality education [56] . stricter immigration policy that went into effect as of december 2011 will increase social exclusion of immigrants and refugees, while cutbacks to legal aid aggravate the situation [57] . job insecurity is rising, with the percentage of people in full-time jobs decreasing and the number of people working part-time, in shift work, temporary contracts or self employed increasing [58] . unionization rates have also dropped across the country [59] . disproportionate spending on necessities such as housing comes hand in hand with increasing poverty and job insecurity. canada is experiencing a national housing and homelessness crisis. as of 2007, over 35% of people renting in major urban areas such as toronto, montreal and vancouver were spending more than 30% of their income on housing (the cut-off for affordable housing). around 20% are spending more than 50% of their income on rent, which puts them at risk of homelessness [53] . when such a high amount of income is being devoted to shelter, not enough is left over for nutritious food, leading to food insecurity [60] . the effects are felt as a result of inadequate policy and public expenditures on social programs, which are key characteristics of the neoliberal model. public spending on family-related benefits has been scaled back since the 1980s, and taxation policy between 1990 and 2005 has increased the tax burden on the bottom 10% of income earners and relieved it from the top 1% [53] . minimum wage, although it has increased in absolute terms, has fallen behind the inflation rate and made living above the poverty line more difficult to achieve. the fall of unionization in bc and on can be attributed to policies put into place by conservative governments that made unionization more difficult [53] . with respect to housing policy, it has been argued that a budgetary increase of 1% in canadian government spending at the federal, provincial, territorial and municipal levels has the potential to end the homelessness crisis, but they have demonstrated their unwillingness to make that commitment [61] . within the context of a national and provincial neoliberal climate, it is not surprising that the health sectors of bc and on have not attempted to implement widespread structural change to improve healthy living [62] [63] [64] . even though well aware of the necessity to address the social determinants of health, they may feel powerless to do so in the face of conservative policies initiated by other sectors. as alvaro et al. emphasized using a critical theory lens, government departments linked to economics and ensuring the dominance of the free market have more power than departments such as the ministry of health in a neoliberal model [45] . those in the health sector face barriers to encouraging other sectors to effect policy change to improve the social determinants of health, and may resort to individual or intermediate behaviour change because they are able to effect that change either through their own department or allied with other de-prioritized departments such as the ministry of education or the ministry of environment. for example, partnering with schools to increase the amount of healthy foods sold in vending machines may be significantly easier than convincing the department of finance to raise the province's minimum wage. we would argue that the ultimate goal of healthy living programs should be to improve the social determinants of health and eliminate health inequities. it is recognized that it is out of the scope of the health care sector to effect those changes on its own, and it faces barriers in partnering with sectors for collaborative, cross-sectoral action. however, public health should be constantly attempting to move towards those goals. it should not settle for programs that bring about changes in lifestyle and the immediate environment while only addressing the social determinants model at a conceptual level. if programs cannot directly affect lasting, broader societal conditions, interventions should be focused around advocacy and education about the social determinants of health -advocacy at the level of the population, service providers, health organizations, and government in order to build political will to address them. the structural interventions listed in additional file 1 and additional file 2 are already taking the initiative to do this and more should be added. one barrier for public health professionals to address the social determinants of health is a lack of understanding of how to do so; although there is a wealth of theoretical understanding of how these determinants affect health, there have been few examples to date that illustrate how to effectively change them [62, 65] . in an environmental scan of the integration of the social determinants of health with public health practice, the national collaborating centre for determinants of health noted that implementation of programs that dealt with the social determinants of health in canada was relatively scarce and, when extant, in early phases [66] . some of the barriers noted to mounting programs that focused on social determinants included gaps in the existing evidence base on the social determinants of health and on interventions that were effective in addressing them, difficulties public health professionals faced in conceptually differentiating individual-level and population-level approaches, a lack of clarity on where in the path from determinants to outcomes public health is expected to act, and limitations in current public health practice methods, which rely mostly on quantitative data. even in a conservative political climate, it is clear that there are improvements that can be made within public health to foster a greater understanding of how to focus programming on the social determinants of health. the who commission on the social determinants of health notes that a comprehensive health equity surveillance system would capture the most upstream structural drivers of health inequities (the unequal distribution of power, money, goods and services) as well as more intermediate ones that encompass the daily conditions in which people live and work. such a system could monitor health equity by stratifying morbidity and mortality data by indicators such as income, occupation, gender, region, ethnicity and immigration status [2] . some such initiatives already exist, for example the eu health monitoring programme, which could be used as a model for canada [67] . solid data on health inequities and the social determinants of health serve a dual purpose: not only do they allow public health professionals and provincial health care systems to understand inequities and design effective initiatives that address structural determinants, they can also be used as tools to advocate for change at a broader level, which may be outside the scope of the public health system. for example, data on the health effects of social exclusion faced by new immigrants and refugees could be used to advocate for progressive immigration policies. it is equally important that health organizations and professionals know how to use evidence on inequities and the social determinants of health to create meaningful initiatives. to do this, there must be a comprehensive understanding among the healthcare force of the social determinants of health and how they affect populations. this includes awareness of the social, political and historical context of how these inequities are generated and continue to be maintained. the provincial health services authority in bc has a program modeling this principle called the indigenous cultural competency online training program [68] . this program consists of a series of online modules and discussions designed to educate health professionals across the province on the context surrounding aboriginal health issues, including the history of colonization in bc, indian residential schools and hospitals, structural and interpersonal racism, and their impacts on aboriginal peoples and their health. it would be extremely useful to have such programs implemented in all provinces, ideally with specific sections that focus on chronic disease, as rates of chronic diseases such as diabetes and cardiovascular disease are much higher in aboriginal populations. with solid evidence and a comprehensive understanding of inequities, there are many ways that public health can begin to address the social determinants of health in programming. one possibility is using public health planning models that integrate the social determinants of health into the planning process. the region of waterloo public health in on developed a planning model that does this, based on the ontario public health standards (ophs) [69] . the model is called evidence and practice-based planning framework: with a focus on health inequities. in the first two steps of program planning (1. define issue, 2. situational assessment), planners are encouraged to consider the following: community health needs, the ophs mandate on the social determinants of health, and the association between health status and the determinants of health. further, they are asked to engage stakeholder perspectives [69] . another model developed by the national public health partnership in australia makes the determinants of health even more central to the planning process [70] . this framework bases the intervention on the determinant that is causing the health problem, rather than the health problem itself. public health teams are to identify the determinants of the health problem and their context, assess how determinants may be detrimental or protective, appraise different intervention options, decide on an option -taking into consideration its impact on health equity, then implement and review it [70] . when consistently implemented province-wide these types of planning models will help public health teams incorporate the equity and the social determinants of health into practice in a systematic manner. information and programs generated within the public health sector can be used to advocate for structural change to improve healthy living. an exemplary initiative in ontario is the nutritious food basket, described in table 1 . the nutritious food basket is a program mandated by ontario public health standards (ophs) for boards of health to implement in municipalities across the province. boards of health are required to survey local supermarkets and grocery stores in order to calculate the cost of basic healthy eating for individuals and families. this program is ideal for a number of reasons. it links what is normally considered a behaviour (healthy eating) to greater structural determinants such as income and regional differences in food accessibility. because the survey is taken annually, it can keep pace with larger economic trends such as inflation and food cost patterns, and because it is performed systematically using a detailed protocol it presents reliable data. the data, as mentioned in the nutritious food basket protocol, can be used for program planning, policy decisions, and advocating for accessible, affordable foods. the nutritious food basket can be used as powerful evidence for the necessity of income redistribution policies ensuring that families make enough money to maintain a healthy diet [71] . certain boards of health, for example in the cities of hamilton and sudbury, have used this tool for this purpose [72] [73] [74] . a current leader in championing health inequities is the sudbury & district health unit, whose team has launched public awareness campaigns linking the social determinants to health outcomes, created health planning and mapping tools that focus on equity, established in conjunction with the city of sudbury a food charter that recognizes food as a basic human right, and developed a primer for municipal leaders explaining the connections of social determinants to public health and how they could address them effectively [75] . although individual public health units are to be commended for their leadership, coordinated action at the provincial level would be much more influential. external evidence from other countries can also be used as leverage -for example healthy living and chronic disease policy in northern european countries such as sweden and norway. sweden initiated a public health policy in 2000 which stressed improving employment conditions and decreasing poverty as primary goals for improving health [76] . sweden has significantly lower obesity rates than canada and research has shown obesity trends levelling off between 2000/2001 and 2004/ 2005 [77] . elizabeth fosse has pointed out that norway focuses on structural measures that function to redistribute resources within society, which is characteristic of a social democratic welfare state [78] . in a 2005 health policy document, the norwegian government outlined a number of strategies to combat health inequities, including reducing inequalities that contribute to poor health [78] . the government pledged to work to provide safe childhood conditions, fair income distribution, and equal opportunities in work and education. it was also recognized by the norwegian government that individual behavioural choices which impact healthy living are influenced by broader structural determinants, and therefore the government must work to address those determinants by influencing cost and availability of resources to healthy living [78] . lastly, a strategy employed to reduce inequities was to develop all initiatives to maximize social inclusion of all citizens. these types of policies could be used as models for health inequity reduction strategies advocated by the health sector in bc and on. this study is not without limitations. for example, the focus on provincial-level initiatives excluded initiatives happening at regional, municipal and community levels. this selection was strategic in that it attempted to maximize the likelihood of finding initiatives which addressed the social determinants of health -conditions that require multi-sector, systemic change. it was assumed that this type of change more likely to happen at the provincial level as opposed to in a city or region, but it is possible that initiatives that address the social determinants of health at a more local level were overlooked. secondly, our search strategy was limited to initiatives that focused explicitly on healthy eating and active living and did not seek to identify social programs in other sectors (for example housing) that may address the social determinants of health and impact healthy eating and active living indirectly. we would like to emphasize, however, that our focus was on what is occurring within public health at a provincial level to improve healthy eating and active living. the presence of social programs in other sectors does not reduce public health's obligation or commitment to addressing the social determinants of health. finally, our analysis did not attempt to document whether desired outcomes related to the social determinants of health were achieved by the searched investing in prevention: improving health and creating sustainability: the provincial officer' s special report. british columbia: office of the provincial health officer commission on social determinants of health: closing the gap in a generation: health equity through action on the social determinants of health. final report of the commission on social determinants of health. geneva: world health organization social determinants of health: the canadian facts. toronto: york university school of 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ottawa: minister of public works and government services canada senate subcommittee on population health: a healthy, productive canada: a determinant of health approach. ottawa: standing senate committee on social affairs united nations: political declaration of the high-level meeting of the general assembly on the prevention and control of non-communicable diseases. a/66/ l.1. geneva: united nations public health agency of canada: canada signs un declaration on preventing and controlling chronic diseases ministry of health promotion; standards, programs & community development branch: healthy eating, physical activity and healthy weights. toronto: queen's printer for ontario obesity: an overview of current landscape and prevention-related activities in ontario. prepared for the public health agency of canada. toronto: ontario chronic disease prevention alliance ministry of health and long-term care: ontario public health standards. toronto: minister of health and long-term care ministry of health promotion: ontario's action plan for healthy eating and active living model core program paper for prevention of chronic diseases. victoria: ministry of health living and sport ministry of health planning: a framework for a provincial chronic disease prevention initiative. victoria: population health and wellness bc ministry of health: model core program paper: healthy living. victoria: bc ministry of health leading british columbia towards a healthy future: bc healthy living alliance report -healthy living initiatives translating social ecological theory into guidelines for community health promotion an ecological perspective on health promotion programs socioecological models: strengthening intervention research in tobacco control. drogues, santã© et sociã©tã© the political economy of health implementation of healthy living as a core program in public health: final report. victoria: university of victoria programs recommendations for future efforts in community 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government's refugee reform bill no longer in social determinants of health: canadian perspectives socialist project and the centre for social justice: financial meltdown: canada, the economic crisis and political struggle. toronto: centre for social justice office of nutrition policy and promotion, health products and food branch: canadian community health survey, cycle 2 toronto disaster relief committee: the one percent solution barriers to addressing the societal determinants of health: public health units and poverty in ontario getting serious about the social determinants of health: new directions for public health workers. int union health promot educ (iuhpe) globalization and social determinants of health: the role of the global marketplace (part 2 of 3). globalization hea policy to tackles the social determinants of health: using conceptual models to understand the policy process national collaborating centre for determinants of health: integrating social determinants of health and health equity into canadian public health practice: environmental scan decision no 1400/97/ec of the european parliament and of the council of 30 june 1997 adopting a programme of community action on health monitoring within the framework for action in the field of public health bc: core icc health training region of waterloo public health: evidence and practice-based planning framework: with a focus on health inequities. waterloo: region of waterloo public health national public health partnership: a planning framework for public health practice. melbourne: national public health partnership ministry of health and long-term care: nutritious food basket protocol. minister of health and long-term care hamilton: public health services healthy living division overview of the health equity mapping project: a report on process, results, and recommendations for practice. sudbury: sudbury & district health unit sudbury: sudbury & district health unit find out about the actions taken by the health unit to reduce social inequities in health national committee for public health: 6 national goals for public health levelling off of prevalence of obesity in the adult population of sweden between 2000/1 and 2004/5 norwegian public health policy: revitalization of the social democratic welfare state? submit your next manuscript to biomed central and take full advantage of: â�¢ convenient online submission â�¢ thorough peer review â�¢ no space constraints or color figure charges â�¢ immediate publication on acceptance â�¢ inclusion in pubmed, cas, scopus and google scholar â�¢ research which is freely available for redistribution we thank the renewal of public health systems research team (website) and in particular dr. marjorie macdonald for allowing us access to their dataset in order to initially identify policy initiatives. we also thank drs. nicole berry and lorraine halinka malcoe who provided important insights into the subject matter and suggestions for the manuscript. ak is partially supported through a new investigator award from the canadian institutes of health research. initiatives; such outcomes require many years to manifest themselves. addressing the social determinants of health necessarily means moving away from depoliticized frameworks that emphasize biomedical factors in disease. attention to the social determinants and inequities has been growing, as health promotion movements evolve -movements that were initially led by canada. however it is necessary that health be seen for what it is: a political matter. as such, the health sector needs to diversify to a more political approach in finding solutions for health inequities. until this occurs, it is debatable how much progress can occur on improving the social determinants of health. additional file 1: bc healthy eating and active living initiatives analyzed (61) .additional file 2: on healthy eating and active living initiatives analyzed (60). the authors declare that they have no competing interests.authors' contributions dg conceived of the study, lead the analysis and drafted the manuscript. ak participated in refining the study's design, acted as a critical discussant of analytical findings and helped to draft the manuscript. both dg and ak read and approved the final manuscript. key: cord-351666-q7dqsl7n authors: milani, fabio title: covid-19 outbreak, social response, and early economic effects: a global var analysis of cross-country interdependencies date: 2020-08-19 journal: j popul econ doi: 10.1007/s00148-020-00792-4 sha: doc_id: 351666 cord_uid: q7dqsl7n this paper studies the social and economic responses to the covid-19 pandemic in a large sample of countries. i stress, in particular, the importance of countries’ interconnections to understand the spread of the virus. i estimate a global var model and exploit a dataset on existing social connections across country borders. i show that social networks help explain not only the spread of the disease but also cross-country spillovers in perceptions about coronavirus risk and in social distancing behavior. in the early phases of the pandemic, perceptions of coronavirus risk in most countries are affected by pandemic shocks originating in italy. later, the usa, spain, and the uk play sizable roles. social distancing responses to domestic and global health shocks are heterogeneous; however, they almost always exhibit delays and sluggish adjustments. unemployment responses vary widely across countries. unemployment is particularly responsive to health shocks in the usa and spain, while unemployment fluctufations are attenuated almost everywhere else. after being identified in december 2019 in wuhan, china, the novel coronavirus (sars-cov-2) initially spread in the hubei region and later across mainland china. although the rest of the world soon learned about the first publicly known cases, several countries did not perceive an immediate risk for their populations. starting in january 2020, the epidemic spread outside china, first in thailand, south korea, japan, and in the usa, and in many cases it was connected to recent travelers to the country. in europe, italy reported its first official community-based case on february 20, and, very quickly, clusters of cases developed in the lombardy region. it was later discovered that the virus had been circulating in lombardy since at least early january (cereda et al. 2020 ) and, possibly, since december. by mid-march, the vast majority of countries in the world had multiple cases, with the centers of the outbreak moving first to europe and later to the usa. most countries responded by requiring their populations to adhere to some form of social distancing to reduce the rate of infection and lessen the strain on healthcare providers. responses, however, have been widely heterogeneous. italy reacted with a few-days delay after the outbreak and then implemented restrictive stay-athome policies. a minority of countries initially experimented with laxer restrictions, either based on a misguided attempt to have their populations achieve herd immunity on their own (the uk, which soon moved away from the policy), or because of an unwritten "social contract" with citizens rather than enforcement from policymakers (sweden). others acted quickly and decisively to attempt to eradicate the disease before it became widespread (new zealand). the spread of coronavirus has highlighted the importance of interdependencies across different regions. depending on business links and other existing relationships, the virus rapidly moved across borders. perceptions about the crisis and social behavior responded generally with lags, but they were also likely affected by observed experiences abroad. countries had the opportunity of learning from others about social adjustments that were more or less effective in containing the disease. the main objective of this work is to study these global interrelationships in the early response to covid-19 shocks. in particular, this paper exploits information about social networks across countries to study interdependencies in the number of disease cases, in the perceptions of their citizens about coronavirus risk, and in their social responses. i also provide some preliminary evidence on the early economic effects of the pandemic by looking at a potential leading indicator of unemployment. i include in my sample 41 countries and use a variety of data sources. to capture the extent of pairwise country social connections, i use data obtained from facebook, which measure the total number of friendships across pairs of countries as a fraction of the total number of combined users in the two countries. this social connectedness indicator allows me to have a measure that can account for different types of relationships: regular friendships, business links, family ties, relations based on older and more recent patterns of immigration, and tourism flows. social networks can help explain the transmission of covid-19 cases across borders, and they are likely to represent a superior measure compared with the use of geographic distance alone. 1 other contemporaneous papers make a similar observation (e.g., kuchler et al. 2020) . at the same time, social networks not only can potentially explain patterns of disease contagion, but they can also help account for spillovers in ideas and behavior. controlling for the country-specific dynamics of covid-19 cases, people's risk perceptions may respond differently and also be affected by the experience and perceptions of individuals in their networks of social connections, including those residing abroad. the same is true for responses in terms of social distancing: individuals who had large connections to countries where the virus outbreak and the social distancing responses were already happening may have learned from their early experiences, taken the epidemic more seriously, and responded similarly. to measure the actual social distancing response in each country, i exploit a novel dataset made available by google through its country-specific social mobility reports. finally, i use internet data from google trends to measure coronavirus risk perceptions and to have a real-time, daily indicator of unemployment. i estimate a global var model to study the transmission of pandemic health shocks both domestically and globally. 2 in my global framework, for each country, covid-19 cases can affect risk perceptions about the virus, which can trigger a social distancing response. as a result of social distancing or general uncertainty, unemployment may increase. the model allows me to treat all these variables as endogenous. this is necessary since social distancing, for example, is likely implemented in response to rising numbers of covid-19 cases, but it also itself has an impact on the future number of cases. moreover, domestic variables in the model are also allowed to respond to foreign aggregates. the foreign variables enter each domestic model with weights that depend on the matrix of social connections. the relevant foreign aggregate for each country is different, since the patterns of connections are unique to the country. in the gvar literature, the domestic models can be estimated separately as conditional vars. all endogenous variables can then be stacked together to form a large-scale global var; it is then possible to track the responses of all variables to each shock in each country. through the use of a connectivity matrix (my social connection matrix), the global var model offers a relatively simple and parsimonious way to deal with potentially complex interactions across different variables and countries. main results my estimates highlight the importance of interdependencies and social networks in the transmission of coronavirus cases, in the increase of risk perceptions, and in social distancing behavior. domestic variables, for the vast majority of countries, are significantly affected by foreign aggregates, constructed with weights based on the strength of social connections across countries. 1 for example, as documented in brynildsrud and eldholm (2020) , the first cases in nordic countries (in their case, norway, but likely similar in neighboring countries) were due to travelers returning from vacations in lombardy. to the extent that some of these tourism patterns increase the probability of facebook links as well, which i believe reasonable, my measure will allow me to track likely routes for the spread of the disease. 2 the gvar model has been proposed by pesaran et al. (2004) and is surveyed in chudik and pesaran (2016) . given the role played by italy and the usa as centers of the outbreak in different phases of the epidemic, i study how variables in the rest of the world respond to coronavirus shocks originating in these countries. i document strong and significant responses of risk perceptions and social distancing to the italy covid shock almost everywhere in the world. countries also respond to the subsequent us shock, although with a smaller magnitude. spillovers from spain and the uk also play a sizable role. the countries' responses to foreign and their own domestic coronavirus shocks are heterogeneous. i can, however, reveal some common patterns. the countries that respond with social distancing do so with a delayed and sluggish adjustment. they seem to learn from the experience of other countries, but they display an adaptive behavior: they do not adjust their habits instantly; instead, they gradually reduce their social mobility, which reaches a negative peak almost a week after the shock. in the opposite direction of causality, changes in social distancing lead to a decline in the growth rate of covid-19 cases. the implications of the pandemic for unemployment also vary significantly by country. labor markets in the usa and spain are the most negatively affected, with large expected increases in unemployment rates. but large spikes in unemployment are not inevitable since most other countries seem to experience much more contained fluctuations. the results suggest that different institutional features can partly insulate the corresponding populations from the worse effects of large exogenous shocks. due to the historical importance of the covid-19 pandemic, research related to the disease and its effects has been growing swiftly. many papers use the leading model in epidemiology, the sir (or, alternatively, the extended seir) model based on kermack and mckendrick (1927) , to simulate the evolution of the disease (e.g., ferguson n and et al (2020) ). in economics, a number of recent papers have adopted a similar framework and developed the theory further by adding relevant trade-offs between health and economic costs (e.g., eichenbaum et al. (2020) , alvarez et al. (2020) , jones et al. (2020) ). this paper, instead, takes a different route by providing empirical evidence related to the social response to the outbreak, and using an alternative framework. in contrast to studies using the sir model, i do not aim to predict the evolution of the number of infected individuals in a population; my focus lies more on explaining the social responses to the original health shocks around the world. other recent works investigate the determinants of different approaches to social distancing. gupta and et al. (2020) find that social distancing responses do not necessarily correspond to policies mandated by state and local governments. painter and qiu (2020) and adolph et al. (2020) find that political beliefs affect compliance with social distancing indications in the usa. andersen (2020) finds evidence of substantial voluntary social distancing, and he also shows that it is affected by partisanship and media exposure. in light of these results, my approach does not use data on mandates, but it exploits, instead, the actual decline in mobility, as measured using location tracking technologies. qiu et al. (2020) focus on the early months of the pandemic. they provide empirical evidence on the transmission of coronavirus cases across cities in china between january and february. they estimate how the number of new daily cases in a city is affected by the number of cases that occurred in nearby cities and in wuhan, over the previous 2 weeks. they show that social distancing measures reduced the spread of the virus, whereas population flows out of wuhan increased the risk of transmission. my paper stresses the importance of modeling cross-country interrelationships to understand the evolution of the next phase of the pandemic. a recent work by zimmermann et al. (2020) shares a similar goal. they find that countries that are more globalized are affected by the pandemic earlier and to a larger extent. therefore, they discuss how early measures that temporarily reduce inter-country mobility would be beneficial. outside of the recent covid-19 literature, my paper also provides a contribution to the literature on gvar models (see chudik and pesaran 2011, for a survey) . most papers in the literature consider macroeconomic applications and study the global spillovers of policy and other shocks (e.g., pesaran et al. 2004; chudik and fratzscher 2011; dees et al. 2007) . others have studied interdependencies in housing markets (holly et al. 2011) , firm-level returns (smith and yamagata 2011) , and a variety of other applications (di mauro and pesaran 2013; pesaran et al. 2009 ). the effect of foreign variables is usually assumed to depend on trade balances across countries. my framework, instead, introduces a different connectivity matrix, based on social networks, which can be promising for a different set of applications. therefore, my paper is also connected to recent papers that propose the use of facebook connections to measure social networks across locations (bailey et al. 2018) . finally, i measure risk perceptions and fears of unemployment using google trends data. this approach has become more and more popular and is now exploited in different fields to measure people's attention (da et al. 2011) , in forecasting and nowcasting economic variables (see the various examples discussed in choi and varian 2012) , and to track the spread of diseases (e.g., ginsberg et al. 2009; brownstein et al. 2009 ) in the absence of easily observable private information. askitas and zimmermann (2015) discuss how internet data can be useful for empirical research in a variety of social science applications and, in particular, for research about human resource issues (askitas and zimmermann (2009) and simionescu and zimmermann (2017) provide evidence directly related to the unemployment rate). the paper exploits a variety of newly available datasets to study the interrelationship between health shocks originating from the covid-19 pandemic, people's real-time perceptions about coronavirus risk, the extent of their social distancing response, and unemployment. i investigate the connections among these variables both within countries, and across borders, by studying contagion and spillovers internationally. the data are collected on a sample of 41 countries. those include current oecd member countries, candidate countries that applied for membership, and the countries that the oecd defines as key partners (brazil, india, indonesia, south africa). 3 the countries account for 70% of global gdp (besides china, the main omission is russia, which accounts for about 2%) and 41% of global population; they also account for 83% of coronavirus cases in the sample period. data on novel covid-19 cases each day for each country are made available by johns hopkins university's center for systems science and engineering (csse). the estimations use either the growth rate or, as a robustness check, the number of daily cases. the epidemiology literature stresses the importance of social distancing to contain the spread of the virus, by reducing the basic reproduction number r 0 (the expected number of secondary infections produced by a single infection in a population where everybody is susceptible) and flattening the curve of infected individuals. the response has been different across countries, either in terms of policies, enforcement, or voluntary reductions in mobility. therefore, it is important to have accurate data on actual social distancing by different populations to track the implied health and economic effects. to this scope, i use daily time series indicators on social mobility made available by google. 4 the indicators are obtained using aggregated, anonymized data from gps tracking of mobile devices, for users who opted in to "google location history." the data measure the change in the number of visits and length of stay at different places compared with a baseline. for each day of the week, mobility numbers are compared with an historical baseline value, given by the median value for the corresponding day of the week, calculated during the 5-week period between january 3 and february 6, 2020. the data are reported for five place categories: grocery and pharmacies, parks and beaches, transit stations, retail and recreation, and residential. in addition to the official number of covid-19 cases, which may be an imperfect measure of the pervasiveness of the virus in the population, i also measure the population's risk perception about coronavirus. the risk perception is measured using daily data on web searches from google trends. i use the search results for the whole "topic" category; therefore, the indicator also includes all related search terms, such as "coronavirus symptoms," "coronavirus treatment," "coronavirus vs. flu," and so forth. finally, i similarly use an indicator of unemployment to measure the initial economic effects of the outbreak. given that actual unemployment data are typically available only at monthly frequency and that their release is lagged by more than a 3 the full list of countries is as follows: australia, austria, belgium, brazil, canada, chile, colombia, costa rica, czech republic, denmark, estonia, finland, france, germany, greece, hungary, india, indonesia, ireland, israel, italy, japan, south korea, latvia, lithuania, luxembourg, mexico, netherlands, new zealand, norway, poland, portugal, slovak republic, slovenia, south africa, spain, sweden, switzerland, turkey, uk, the usa. the only country that has been removed from the oecd list is iceland, since google mobility data were not available. for non-oecd key partners, i exclude china, since for my sample the numbers of cases had already declined (google mobility data would also be unavailable for the country). 4 google llc "google covid-19 community mobility reports." https://www.google.com/covid19/ mobility/ month, i also exploit google trends data about unemployment as a variable that can be used to have early and real-time indications of the official variable. as before, i use google searches about the unemployment topic (again, including all searches related to unemployment, such as "unemployment benefits," "unemployment insurance," "how to apply for unemployment," "losing my job," and so forth). askitas and zimmermann (2009) and choi and varian (2009) , among others, show that unemployment searches can help predict initial unemployment claims and the unemployment rate. more recently, askitas and zimmermann (2015) and simionescu and zimmermann (2017) document how internet data can be useful for nowcasting and forecasting the unemployment rate in a diverse set of countries. my unemployment variable can, therefore, be interpreted as a real-time signal for unemployment, or, alternatively, as a measure of people's perceptions, attention, or fears, about unemployment over the time period that i study. 5 finally, i measure international social connections using facebook's social connectedness data. the index uses active facebook users and their friendship networks to measure the intensity of connectedness between each pair of locations. the measure of social connectedness between two locations i and j is given by: where fb connections i,j denotes the number of friendship connections between region i and j , and fb users i , fb users j denote the number of facebook users in i and j . the social connectedness index, therefore, measures the relative probability of a facebook connection between any individual in location i and any individual in location j . the data used in this paper refer to the measure calculated for march 2020. bailey et al. (2018) proposed the measure to study the effects of social networks across us counties. other current papers are uncovering the link between social networks and the diffusion of covid-19 (e.g., kuchler et al. 2020) . the measure can be preferred to alternatives based simply on inverse geographic distance, since it can provide a more accurate account of business relations, tourism patterns, and family or friendship ties, across different areas. i argue here that the strength of social connections can also affect information about the outbreak and social distancing responses. as bailey et al. (2018) show, facebook friendship links between the usa and other countries, for example, are strongly correlated both with bilateral migration patterns and trade flows. they regress social connectedness on geographic distance, the number of residents with ancestry in the foreign country (as an indicator of past migration), and on the number of residents born in the foreign country (indicating current migration), and show that all three are strongly significant. friendship connections also lead to statistically significant increases in both exports and imports between the usa and the foreign country. for italy, the strongest social connections are with switzerland and slovenia, followed by austria, germany, spain, belgium, and the uk. distance is clearly a determinant of social networks, but not the only determinant. social connections are stronger between italy and australia, italy and the usa, and italy and canada, than between italy and turkey, although the latter is geographically much closer. for the usa, as expected, the most socially connected countries are mexico and canada, followed, at lower levels, by ireland and israel. the usa have strong connections with australia and new zealand, which would be downplayed based on a pure measure of distance. figure 3 shows, instead, the social distancing response across a sample of major countries in the sample (for easiness of exposition, i show the experiences of 15 out of 41 countries in the figure). mobility declined by 60% or more in italy, france, spain, and new zealand. while in some countries, the adjustment was abrupt (e.g., new zealand, france, spain), it was slower and more gradual in others, such as the uk (where the response starts a few days later) and the usa; their overall declines in mobility were also more modest. sweden is an outlier in europe, as it maintained only small fluctuations of mobility around the historical mean. japan and korea observed their first cases earlier; therefore, their social distancing responses during this period appear more limited. in many european countries and in the usa, mobility returns to its historical average by the beginning of june. to model global interdependencies in the spread of the disease and countries' responses, i follow the gvar approach proposed in pesaran et al. (2004) and surveyed in chudik and pesaran (2011) . assume that there are n units, representing countries in this case, and for each unit, the dynamics is captured by k i domestic variables. for each country i, the k i × 1 vector x i,t of endogenous variables includes four domestic series: the growth rate of covid-19 cases, the risk perception about covid-19, the change in social mobility, and the perception about unemployment. 6 the vector of domestic variables is modeled as: for i = 1, 2, ..., n, and where il , i0 , and il denote matrices of coefficients of size k i × k i and k i × k * i , where k * i denotes the number of "foreign" variables included in the vector x * i,t , and ε i,t is a k i × 1 vector of error terms. in the empirical analysis, i select the optimal number of lags p i and q i for each country using schwartz's bayesian information criterion (bic). for each country i, therefore, domestic variables are a function of their p i lagged values, possibly of the contemporaneous values and q i lagged values of foreign, or global, variables. the foreign variables x * i,t are k * i × 1 cross-section averages of foreign variables and they are country-specific: 7 the matrixw i has size k × k * i and contains countryspecific weights, with diagonal elements w ii = 0. my approach uses the extent of social connections across country borders from the facebook social connectedness index dataset to measure the weights. gvar models assume that the variables x * i,t are weakly exogenous. this corresponds to the popular assumption in open-economy macro models that the domestic country is treated as "small" in relation to the world economy, i.e, it does not affect global variables. this assumption can be easily tested for all the variables. for cases in which a domestic variable has an unduly large effect on global variables, weak exogeneity will not be invoked there and the foreign variable, instead, will not be included in that var. the estimation works in two steps. first, varx* (that is, vars with weakly exogenous foreign variables) models can be estimated for each country separately. 6 since i study the social responses to the covid-19 outbreak, i include in the domestic var also the risk perception variable, in addition to the number of cases. i believe that changes in the number of confirmed coronavirus cases may lead to different risk perceptions in the different countries, which, in turn, can affect people's willingness to adhere to stay-at-home orders or to voluntarily engage in social distancing. as a measure of economic consequences, i choose an indicator of unemployment. other options that are available at daily frequencies include stock returns, interest rates, and electricity data. stock returns and interest rates are inferior indicators of economic activity in this period as they were largely influenced by government and central banks' emergency interventions. electricity data would be appropriate, but they have been made available only for a small selection of european countries (mcwilliams and zachmann 2020). 7 in the analysis, the number k * i is also equal to 4, as the vector x * i,t contains the country-specific global counterparts for the same variables in x i,t , i.e., the growth rate of covid-19 cases, coronavirus risk perceptions, social mobility, and unemployment. second, the estimated country models are stacked to form a large gvar system, which can be solved simultaneously. 8 domestic and foreign variables are stacked in the the model in eq. 1 can be rewritten as: where gives: substituting into eq. 3 and stacking all the unit-specific models yield: where with g 0 invertible, as it is in this case, the gvar is given by: with f l = g −1 0 g l . the gvar solution can be used to trace the impact of shocks on the variables of interest, both domestically and globally. to find the impulse response to shocks, i adopt the generalized impulse response function (girf) approach, proposed by koop et al. (1996) , pesaran and shin (1998) , and also used in pesaran et al. (2004) . the vector of girfs is given by: where j indexes the different shocks, h denotes the horizon for the impulse response function, i t = x t , x t−1 , ... denotes the available information set at time t, and where √ σ jj indicates that the magnitude of the shock is set at one standard deviation of the corresponding ε j,t . the gvar specification can be seen in relation to a number of econometric alternatives: spatial vars, panel vars, and dynamic factor models. spatial vars are very strongly connected. they also assume a connectivity matrix, which is usually based on geographic distance. the main difference between the two approaches lies with the structure of correlations: as discussed at length in elhorst et al. (2018) , spatial vars may be preferred when correlations across units are extremely sparse, for example, when a unit is only affected by few bordering units ("weak," or local, crosssectional dependence). the gvar is meant to capture stronger interrelationships, with dense connectivity matrices, where each country unit is affected, in different ways, by several other countries, or by an aggregate measure ("strong" crosssectional dependence). spatial vars can also be seen as a particularly restricted case of a gvar model. the approach can similarly be seen as a particular form of panel var. the main advantage here is that, through the weight matrix w i , this approach exploits knowledge about social networks and uses that knowledge to inform the magnitude of cross-country interdependencies. panel vars often impose the same coefficients for each unit, shutting down static and dynamic heterogeneity, as well as neglecting cross-country interdependencies. an exception is provided by canova and ciccarelli (2009) : they introduce a factor structure in the coefficients to solve the curse of dimensionality. their approach is particularly useful when there is no a priori knowledge that can be exploited about the spillovers. in this case, the extent of social networks can be, instead, exploited to provide some information about the relative strength of interdependencies. finally, the gvar has relations with dynamic factor models. as chudik and pesaran (2011) show, the gvar specification approximates a common factor across units, and it extracts common factors using structural knowledge. the model is particularly suited to account for potentially complex patterns of interdependencies across countries. at the same time, the gvar specification does so while maintaining simplicity and parsimony. the dimensionality issue is resolved by decomposing a large-scale var into a number of smaller scale vars for each unit, which can be estimated separately, conditional on the dynamics of weakly exogenous foreign variables. the interdependencies are not left entirely unrestricted, since it would be unfeasible to estimate all the parameters, but they are given a structure based on knowledge of the data. in the benchmark analysis, i estimate the gvar model using daily data from february 15 to april 11, 2020. the dates are chosen based on availability of google social mobility data at the time the paper was written. 9 the exogeneity assumption is relaxed where it appears unlikely: for covid cases, i do not include foreign variables in the model for the usa, italy, and spain, since they may be endogenous. those countries, at different times, have accounted for a large share of global cases. i allow the covid variable for all other countries to be affected by foreign series. i also allow risk perceptions in each country, as well as social distancing outcomes, to be affected even contemporaneously by corresponding variables in different countries. finally, i assume that domestic unemployment perceptions are affected by foreign unemployment perceptions, but not within the same day. this assumption is not important for the results (which are robust), but it is motivated by the idea that the unemployment data are driven more by country-specific, than across-the-border, factors. i test the weak exogeneity assumptions for all foreign variables, and they are never rejected in the data. recently, some studies have emphasized the importance of superspreaders in the transmission of the virus (e.g., adam et al. 2020 , who study clusters in hong kong). beldomenico (2020) discusses how sars-cov-2 appears to start by spreading gradually in a region, until transmission is triggered by a possible cascade of superspreader events, and cases explode. as a result, the pattern of transmission can become highly heterogeneous. here, i focus on numbers of cases aggregated at the country level. my framework can account for heterogeneous responses across countries. however, even if the weak-exogeneity tests suggest that domestic countries do not affect global variables in a statistical sense, it is conceivable that, with superspreaders, covid infections can transmit very quickly, and do so even between country pairs with a limited degree of social connections. my identification assumption, however, requires that the impact of a superspreader from country i on the total number of global cases remains small enough. first, to study the magnitude of global interdependencies, table 1 shows the contemporaneous effects of foreign variables on domestic variables, for each country. the table reports the estimated coefficients, alongside the associated standard errors. domestic variables are significantly affected by the country-specific foreign aggregates, computed using the matrix of social connections as country-by-country weights. the results indicate that the international spread of covid-19 cases can be, in part, explained by existing social networks across country borders. moreover, the contagion not only relates to the number of cases and the spread of the disease, but it also affects the spread of perceptions and social behavior. both the measure of risk perceptions about coronavirus and the social distancing responses are significantly influenced by developments in the rest of the world. only few countries do not show a statistically significant response to global conditions. risk perceptions do not rise in response to increasing international distress only in brazil, south africa, and turkey. it is likely that their populations initially underestimated the likelihood of the pandemic reaching them, as they were farther from the epicenters. most countries also gradually learn from each others' social distancing responses. among the few exceptions, japan and korea are not significantly affected by foreign experiences: they implemented social distancing earlier than other countries, but they already relaxed many of the restrictions before the period that i consider. these results highlight the importance of considering global interrelationships and social connections in understanding the transmission of the virus and societal responses. my results add to those in zimmermann et al. (2020) , who investigate the role of globalization during the pandemic. countries with a higher index of globalization had faster transmission speed and higher infection rates, although they responded better to the challenges by achieving lower fatality rates. international travel and migration play key roles in the transmission. their paper, therefore, discusses the benefits of inter-country distancing, based on the imposition of temporary travel restrictions. my empirical results point to similar policy implications: since the table reports the estimated gvar coefficients with the associated standard error shown below in parentheses. significance at the 1% level is denoted by ***, at the 5% level by **, and at the 10% level by * coronavirus cases spread internationally as a result of existing social networks, early border closures and travel restrictions can be effective. i study the global responses to shocks from italy and the usa since these countries played outsized roles in different phases of the pandemic. figures 4 and 5 show the impulse response functions for all countries in the sample for the risk perception and social distancing variables to a one-standard-deviation covid shock originating in italy. risk perceptions increase, with some sluggish impulse responses across countries of coronavirus risk perception to a covid-19 growth rate shock originating in italy adjustment, almost everywhere in the world in response to the initial shock from italy. the responses typically reach their peak about 4-6 days after the original shock. the response is more delayed in brazil, india, and south africa. as seen in the previous section, these countries are less influenced by global variables in this period. populations in neighboring european countries, as well as in the usa, australia, and canada, instead significantly update their perceptions. the overall effect is much smaller in sweden, finland, turkey, israel, and lithuania. again, japan and south korea do not seem to significantly respond, as they experienced their outbreaks earlier than the rest of countries. similarly, most countries respond with reductions in social mobility. the social distancing response, however, is already delayed and sluggish in italy, with a negative impulse responses across countries of social mobility to a covid-19 growth rate shock originating in italy peak in mobility occurring 6 days after the shock. other european countries, such as france, switzerland, and the uk, do not seem to adjust at all for the initial 3-5 days, after which they gradually reduce their social mobility as well. the patterns are similar everywhere: after the situations worsen in one country, the others do not immediately learn from its experience and change their behavior. instead, they appear to behave more adaptively, by only gradually altering their habits in response to the evolving situation. one issue to consider is whether the joint declines in social mobility are driven by policies that happened at the same time. my measure of actual mobility captures both the effects of mandates and those of voluntary distancing. i use data on the government response index made available for different countries through the oxford covid-19 government response tracker (oxcgrt)'s website and discussed in thomas hale et al. (2020) . i regress the google mobility indicator on a constant and on the government response index for each country. figure 6 shows the estimated coefficients for the sensitivity of mobility to the government response, and the resulting r 2 for each country's regression. the results clarify that measures based on actual mobility carry additional information that goes beyond what can be captured by looking only at the implemented policies. for many countries, mobility responds negatively to policy restrictions, with r 2 coefficients falling in the 0.7-0.9 range. the explanatory power is particularly strong in mexico and new zealand. but simply using policy responses would miss the extent of social responses in many other countries, where the explanatory power is closer to 0 (as in korea, netherlands, and scandinavian and baltic countries). the focal point of the pandemic later moved to the usa, at least starting from mid-march. figure 7 displays the effects on coronavirus risk perceptions in the rest of the world to a us coronavirus risk shock. i consider the risk perception shock for the usa, rather than the one based on the number of cases, since testing was initially fig. 6 relation between voluntary social distancing and government lockdown policies. the results are based on the regression social mobility t = β 0 + β 1 govt. response t + ε t for each country. the top panel shows the estimated coefficient β 1 , the second the regression r 2 the spillovers in risk perceptions are again statistically significant, but much smaller in magnitude than those observed in response to the corresponding italian shock. the same is true for responses of social mobility to a us coronavirus risk shock, shown in fig. 8 . for many countries, i observe a slight increase in social distancing, including for the usa themselves. in terms of policy implications, the results highlight the importance of rapid interchanges of information: the rest of the world can learn from policies and behaviors that seemed to work in the countries that were reached early by the virus. the results show that perceptions about the pandemic spread to different countries. the resulting the responses to the pandemic have been heterogeneous across countries. figure 9 overlaps, for a selection of countries, the impulse responses of social distancing and unemployment to the country's own coronavirus risk shock. i single out the responses for italy, spain, the uk, the usa, sweden, and japan, since they characterize somewhat different approaches to the crisis. the populations of italy and spain sharply decreased their social mobility after the domestic coronavirus shock. the responses reach their maximum effects after 5-6 days, and they last for weeks. their behavior suggests that even in the countries that were most affected by the virus, their social distancing responses, while substantial, have been unnecessarily delayed. japan displays a smaller, and more sluggish, response. the usa and the uk are also characterized by negative and statistically significant adjustments in mobility, but their responses are many order of magnitudes smaller than the ones observed in italy and spain. finally, it is well documented that sweden adopted a more permissive approach, by letting its citizens adjust their ita spa uk usa swe jap fig. 9 impulse response functions of coronavirus risk perceptions and unemployment to the country's own coronavirus risk shock behavior without the same strict enforcement that was observed in other countries. the response for sweden, accordingly, does not show any significant decrease in mobility to the country-specific risk shock. turning to the early estimates about potential economic effects, i show the responses of the real-time unemployment indicator to each country-specific coronavirus shock. the figure shows that unemployment does not necessarily need to skyrocket in response to health shocks. unemployment insurance claims have reached record levels in the weeks after the outbreak in the usa. the impulse responses are consistent with the behavior of unemployment claims, revealing an extremely large response of the google unemployment indicator. unemployment is also set to considerably increase in spain. the country has a large share of workers on temporary contracts, who are more likely to become unemployed due to the uncertainty generated by the pandemic. other countries in the sample, however, as well as the vast majority of countries not shown in the figure, appear more successful in insulating their labor forces from the crisis. even if the recessionary effects on output are likely to be large almost everywhere, for most countries, early indicators of unemployment suggest that local labor markets are not going to experience the same turbulence as those in the usa. so far, the analysis has focused on the direction of causality that goes from covid cases to social and economic responses. here, i provide evidence on the opposite direction: the effects of social distancing on new covid cases. figure 10 shows the impulse responses of the growth rate of covid-19 cases in different countries to a social distancing shock, measured as a one-standard-deviation decline in social mobility. social distancing leads to declines in the growth rate of coronavirus cases in the days after the shock. the only country in the figure that does not show a negative response is the uk, for which social distancing has, in fact, been much slower to start. the results reaffirm the importance of social distancing, whether through mandatory policy or voluntary behavior, in reducing the spread of the virus. while in epidemiology, the benefits of social distancing are usually modeled as changes in the parameters of a sir model, here i show that the effects can be uncovered also in a simpler linear framework. moreover, the results regarding unemployment, presented in the previous section, suggest that social distancing does not necessarily have to translate into high unemployment rates. a prompt social distancing response, coupled with labor institutions that attenuate the impact of business cycles, can successfully limit the health shocks from the pandemic, without causing extensive economic damage. the empirical analysis, so far, has been based on data up to mid-april. i now update the dataset to include the most recent months. after april, the social distancing efforts were successful in most of europe: the number of daily cases in italy, spain, germany, france, and most neighboring countries, declined; as a result, the countries started to relax most restrictions on mobility. the global centers of the virus moved instead to the americas, with us cases still remaining high, and with brazil's situation rapidly deteriorating. the situation also worsened considerably in india. to incorporate data for this second phase, i re-estimate the gvar model for the more recent sample between april 12 and june 14 (the last day of availability of google mobility data at the time of writing). the results are reported in tables 2 and 3 . table 2 shows the values of the peak responses for the impulse response functions of coronavirus risk perceptions in each country in the sample to corresponding coronavirus risk shocks from seven countries: italy, the usa, spain, uk, brazil, chile, and india. these countries are selected as they had large number of cases at different times, during the sample. table 3 reports similar information (in this case, the size of the largest negative responses across horizons) for the social distancing responses, instead. to compare the role played by the different countries, i show the results for both the first phase, starting in mid-february and ending in mid-april, and for the second phase, from mid-april to mid-june. most countries were significantly affected by italy's shocks during the first phase. risk perceptions particularly increased in spain, the uk, and the usa. higher risk perceptions led to a much larger decline in social mobility in spain (−2.79), though, than in the other two countries (−1.38 and −0.98, respectively). in the second phase, italy's role diminished, and many countries reacted instead to shocks from the usa, spain, and the uk. although cases exploded in brazil, chile, and india, between april and june, the spillovers from these countries to the rest of the world have remained more limited. the largest effects may be detected in neighboring countries: for example, the largest increase in risk perceptions in response to shocks in brazil and chile is observed in colombia. the effects on social mobility are somewhat larger, but far from the values obtained in response to shocks from spain and the uk, for example. the results suggest that, in most countries, public perceptions and behavior respond to global, not only to domestic, variables. the impact of individual countries, instead, varies over different phases of the pandemic and depending on the extent of social connections. overall, this paper's results highlight the importance of interconnections to understand not only the spread of the virus, but also adaptation and gradual learning in importing ideas and behavior from other countries. risk perceptions and the willingness to engage in social distancing by the populations of most countries significantly respond to the corresponding variables in socially connected countries. i stress the role of existing social networks across borders in the transmission of health shocks, perceptions about the risk of the disease, and ideas regarding the merit of social distancing. the results reveal heterogeneous responses across countries to their own domestic coronavirus shocks. a common feature in all responses is that individuals responded with a lag and only gradually reduced their social mobility. this observation is consistent with epidemiological models that include adaptive human behavior, such as the model presented in fenichel and et al (2011) . that research stresses the role of public policies based on informing and motivating people to reduce person-to-person contacts. this may be particularly important for countries in which citizens have weaker social connections to the rest of the world, and in which, policymakers may delay in implementing mitigation policies. institutional differences among the countries' labor markets are likely responsible for substantially different increases in unemployment. the lower degree of employee protections in the usa and the large share of temporary workers in the spanish economy are likely to account for the far worse outcomes in these countries. everywhere else, fluctuations in unemployment have remained more subdued. there are some possible limitations related to the data series used in the analysis. unemployment indicators based on internet data may be more or less accurate depending on the country: as discussed in simionescu and zimmermann (2017) , their predictive power for actual unemployment may depend on the internet penetration in the country, and on demographic variables, such as the age composition of internet users. internet use may also vary across the income distribution, particularly in less economically developed countries. perceptions about coronavirus risk may not be captured equally well in all countries in the sample. the matrix of social connections based on facebook friendships may be subject to similar problems: facebook users may have different average income and age than the population as a whole, and such friendships may capture to a larger extent personal, rather than business, links. my sample of countries necessarily excludes others (for example, china), which may be important in terms of social connections. their omission may potentially lead to an omitted variable bias in the var regressions. this section assesses the sensitivity of our estimates to alternative data and econometric choices. the benchmark estimation used data on covid-19 cases transformed into daily growth rates. i can examine the sensitivity of the results to using the number of new daily cases instead. table 4 reports the estimated interdependencies corresponding to those previously shown in table 1 . to save space, the results are shown for a subset of six countries. the estimates remain similar, with the exception of a smaller spillover of global risk into the domestic italian risk perception variable. also, in the benchmark estimation, the conditional country-specific models corresponded to vars with the addition of weighted foreign aggregates. another option sensitivity check i) repeats the estimation using the level of new daily covid-19 cases rather than their growth rate; case ii) estimates conditional vector-error-correction models rather than a var for each country; case iii) computes changes in social mobility excluding the series related to residential mobility often used in the gvar literature is to allow for long-run relationships and estimate vector error correction (vecm) models instead. 10 the results shown in table 4 , as well as all the main findings, remain in line with those discussed so far. finally, the google mobility indicator was computed by taking the average of mobility changes across all available categories. it can be argued that the relevant social distancing measure that matters for health outcomes should exclude residential mobility. therefore, i repeat the analysis by constructing social mobility, but now excluding the residential component. again, the results remain substantially unchanged. i estimated a global model of 41 countries to examine the interconnections in coronavirus cases and in social and economic responses during the first months of the covid-19 pandemic. the results suggest that social connections across borders are helpful to understand not only the spread of the disease, but also the spread in perceptions and social behavior across countries. initial shocks from italy affected risk perceptions about coronavirus in most countries in the world. many of them responded by significantly reducing their mobility. populations in most countries, however, displayed a degree of behavioral adaption: they did not change their habits instantly, but only gradually over time. shocks from the usa, spain, and the uk also had significant effects later on. a subset of countries did not respond much through social distancing to global or domestic shocks. as a result, they do not show the same reduction in the growth rate of covid-19 cases in response to social distancing that is observed in other countries. the original health shocks, either directly, or through increased uncertainty and social distancing, have economic effects. while i do not have data at high frequency on realizations of the unemployment rate, i exploit daily data on an indicator that has been shown to predict actual unemployment quite accurately: unemployment from google searches. the response of unemployment across countries is very heterogeneous. in the usa, unemployment skyrockets. this is consistent with the response of initial unemployment claims in the country. the same happens in spain, with a large increase of unemployment in response to health shocks. in other countries, the responses are more muted, as public programs intervened to provide subsidies to employers and employees to protect existing employment relationships. clustering and superspreading potential of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) infections in hong kong, preprint pandemic politics: timing state-level social distancing responses to covid-19. medrxiv, 2020.03.30 early evidence on social distancing in response to covid-19 in the united states google econometrics and unemployment forecasting the internet as a data source for advancement in social sciences simple planning problem for covid-19 lockdown, nber working papers 26981 social 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models meet impact of non-pharmaceutical interventions (npis) to reduce covid19 mortality and healthcare demand. 16 mar fenichel ep et al (2011) adaptive human behavior in epidemiological models detecting influenza epidemics using search engine query data tracking public and private responses to the covid-19 epidemic: evidence from state and local government actions annalena pott (2020) variation in us states responses to covid-19 the spatial and temporal diffusion of house prices in the uk optimal mitigation policies in a pandemic: social distancing and working from home nber working papers 26984 contribution to the mathematical theory of epidemics impulse response analysis in nonlinear multivariate models the geographic spread of covid-19 correlates with structure of social networks as measured by facebook bruegel electricity tracker of covid-19 lockdown effects, bruegel datasets political beliefs affect compliance with covid19 social distancing orders forecasting economic and financial variables with global vars modelling regional interdependencies using a global error-correcting macroeconometric model generalised impulse response analysis in linear multivariate models impacts of social and economic factors on the transmission of coronavirus disease 2019 (covid-19) in china big data and unemployment analysis, glo discussion paper series 81, global labor organization (glo) firm-level return-volatility analysis using dynamic panels inter-country distancing, globalisation and the coronavirus pandemic acknowledgments i would like to thank the editor, klaus f. zimmermann, and three anonymous referees for comments and suggestions that substantially improved the paper. i outline here the steps for the estimation of the gvar model (see also smith and galesi 2014): 1. first, the connectivity matrix w (of size 41×41 in this case) is constructed using facebook's social connectedness index data. for each country i, i fix w i,i = 0 (the domestic country is not used for the construction of the foreign variable) and i calculate the weights w i,j , i = j , as the social connectedness between countries i and j as a fraction of the sum of connectedness between country i and each country in the sample, sci i,j / n j =1 sci i,j . therefore, the resulting connectivity matrix has columns that sum to 1. 2. country-specific foreign variables are then constructed as x * i,t = n j =0 w i,j x j,t , using the weights w i,j , for each reference country i. 3. i estimate conditional varx* (that is, a var with a foreign, weakly exogenous, variable) models, as specified in expression eq. 1. the models can be estimated separately for each country by ols. i choose lag length also separately for each of them based on schwartz's bayesian information criterion (bic). in most cases, the data select short lag lengths (p and q equal to 1 or 2) as optimal. i did not find consistent patterns of seasonality in the data. therefore, we do not perform any seasonal adjustment before the estimation. the benchmark estimation considers varx* models. the robustness section experiments with vecmx* specifications, which allow for cointegrating relationships both within the variables in x i,t and between variables x i,t and x * i,t . in that case, for each domestic vecmx*, the cointegration rank is selected based on johansen's trace statistics. 4. after being estimated independently, the domestic vars are stacked together as shown in eq. 3. the global var is "solved" for all the k = n i=0 k i endogenous variables, as shown in (4)-(6). 5. i check the moduli for the system eigenvalues and confirm that they are all within the unit circle. 6. i compute generalized impulse response functions following koop et al. (1996) , as shown in expression (7) as. the response to a one standard-deviation shock is given, for each, where e j is a selection vector, composed of zeros, except for an element equal to 1 to select the shock of choice. the matrix r h is the matrix of coefficients in the gvar's moving average representation: x t = ε t + r 1 ε t−1 + r 2 ε t−2 + .... i use bootstrapping to compute the impulse response error bands. key: cord-321642-efv9ovx9 authors: reicher, stephen; stott, clifford title: on order and disorder during the covid‐19 pandemic date: 2020-07-01 journal: br j soc psychol doi: 10.1111/bjso.12398 sha: doc_id: 321642 cord_uid: efv9ovx9 in this paper, we analyse the conditions under which the covid‐19 pandemic will lead either to social order (adherence to measures put in place by authorities to control the pandemic) or to social disorder (resistance to such measures and the emergence of open conflict). using examples from different countries (principally the united kingdom, the united states, and france), we first isolate three factors which determine whether people accept or reject control measures. these are the historical context of state‐public relations, the nature of leadership during the pandemic and procedural justice in the development and operation of these measures. second, we analyse the way the crisis is policed and how forms of policing determine whether dissent will escalate into open conflict. we conclude by considering the prospects for order/disorder as the pandemic unfolds. . for instance , snowden, (1995) documents how, during the 1910 cholera epidemic in italy, restrictions on burials led to attacks on health workers and the police. in general terms, then, we need to understand what determines whether a pandemic leads to greater social cohesion or greater social conflict? the question is equally pertinent when it comes to the current pandemic. we have seen high levels of adherence to lockdown measures and a remarkable flowering of mutual aid groupsin britain alone more than 4,000 groups involving some 3 million people (butler, 2020) . we have also seen discord and overt conflict between the public and authoritiesin france, italy, brazil, and the united states, for example. so what determines why and when cohesion gives way to conflict, social order to social disorder? the origins of order let us turn first to the question of 'order'. more specifically, we focus here on whether the public accept without dissent the things that governments demand of them. in the context of covid-19, why do people tolerate restrictions on their everyday lives, such as lockdown? the question of why people obey authorities is one of the most famous in the history of psychology. it is exemplified by the popularity and notoriety of milgram's yale obedience studies (milgram, 1974) . yet, milgram's work is more influential as a demonstration of how far some people will go in obeying an authority figure than as an explanation of this phenomenon. indeed, milgram's 'agentic state' account of obedience is little more than tautologysuggesting that we obey authority because we enter a state where we focus uniquely on obeying authority and hence automatically obey orders. our recent re-analyses suggest a very different story. obedient participants, we argue, should be understood as 'engaged followers' reicher et al., 2012) . far from being passive in the presence of an authority, they make an active ideological choice to work with the experimenter to advance the scientific enterprisesomething they see as a noble cause. moreover, we suggest this does not happen by accident. it is a result of active 'identity leadership' by the experimenter who actively seeks to bring about such shared identification between himself and the participant in the cause of science. this conclusion chimes with that from the work of tyler and colleagues on why people obey the law (tyler, 1990 )the so-called 'group engagement' model (tyler & blader, 2003) . they show that adherence depends upon whether people see themselves and authoritiesparticularly the policeas part of a common in-group. they too focus on the antecedents of such shared identity, but the emphasis is less on leadership than on procedural justice in the interactions between authorities and their publics. it is by giving people voice, by treating them fairly and with respect, that a sense of being part of a common group is created. this in turn legitimates laws and regulations and increases adherence to them (bradford, murphy & jackson, 2014) . more recent research suggests that the potency of procedural justice lies not simply in creating an in-group relationship between authorities and citizens but in establishing the authorities as prototypical in-group members acting for and serving the interests of the group (radburn & stott, 2019; radburn, stott, bradford & robinson, 2018; stott et al., 2012) . this work puts flesh on john turner's suggestion that the procedural justice framework 'points to a whole range of other factors relevant to identification with authorities and acceptance of their control as an ingroup norm (e.g. the ideology and goals of group members, the social comparative context, their history of success or failure for the group, the degree to which the authorities are perceived as more or less prototypical of the relevant identity) ' (2005, p. 11) . echoing turner, we suggest that, in addition to leadership and procedural justice, historical and structural context is a third antecedent of shared in-group identity and hence of adherence to authority. let us now briefly consider the significance of these three factors in the covid-19 pandemic. we use, as an example, the united kingdomwhere levels of adherence to restrictions have been consistently high. clearly, given that we are still in the midst of the pandemic and do not yet have the luxury of prolonged reflection or comprehensive data, our argument is more illustrative than definitive. but still, it is worth considering whether we can make sense of what we know thus far. first, regarding historical context, britain has a long tradition of treating state intervention as progressive and in the interests of the general populationwhich even if not a consistent reality, serves as a potent national myth (rollings, 1996) . politically, this is expressed in the idea that policing is not an imposition from the centre but rooted in local consent (channing, 2015) . economically, it is encapsulated in the idea of welfarism (page & silburn, 1999) . institutionally, it is exemplified by the nhs, invoked as a centrepiece in danny boyle's pageant of britishness for the opening ceremony of the 2012 london olympics and currently occupying an almost deified status. additionally, there are also powerful historical myths of state and society joining as one in times of national crisis as exemplified in the notion of a 'blitz spirit' and of the king and queen remaining in london to share the plight of the people during ww2 (calder, 1992) . these historical myths are potent sources for the ways contemporary social realities are broadly understood, and social relations are defined in the present. but they are not so much determining cultural presences as rhetorical resources that can be drawn uponand indeed need to be actively invokedif they are to influence our understanding of covid-19, our relationship to authority during the pandemic and our responses to their policies. this takes us to the second antecedent of shared identity: leadership. there are already many controversies about the leadership of the uk government during this crisis and no doubt they will grow in time: did they tarry too long in declaring lockdown and have they shown sufficient diligence in developing testing and in securing protective equipment for frontline workers? nonetheless, government ministers and government information services have, increasingly over time, framed the crisis in inclusive national termsa 'we' thing that incorporates government and people in common cause 1 . and indeed the queen, in her address to the nation on 5th april, invoked the myth of a 'blitz spirit' to ground her calls for national solidarity, notably by finishing with a reference to vera lynn's most famous of all ww2 songs: 'we will meet again'. but the rhetoric of 'togetherness' is of little use and may indeed be undermined when it is not matched by practices which make it possible for us to come together. otherwise, the words will be seen as hypocrisy and will only serve to undermine a sense of equity and trust in authority. at this point, we are back in the territory of procedural justicethe third antecedent of identification with authorityalbeit with a critical twist. that is, it is important that fairness is not just a matter of rhetoric and the process by which regulations are introduced but that it extends to the ways in which those regulations impact on people in practice (armaline, sanchez & correia, 2014; epp, maynard-moody & haider-markel, 2014) . once again, there is already criticism of government support to enable everyone to observe lockdown as too little and too late. and again, there will be more. there is little doubt that the poor and precarious are less able to stay at home, even if they are as motivated as the rich and secure to do so (atchison et al., 2020) . the evidence is clear that the poor (and bame people) are getting infected and dying at far higher rates than the affluent (pidd, barr & mohdin, 2020) . but first, the united kingdom does have a range of welfare provisions including free universal health care. second, even if insufficient, nonetheless unprecedented financial measures have been implemented to help people to stay off work during the pandemic: a boost in welfare payments, a state guarantee to replace 80% of lost wages and of lost income for the self-employed. this has been high enough to secure high levels of trust in government and support for lockdown even amongst those suffering from it (duffy & allington, 2020) . enough, for now at least (as we write at the start of may), to secure the social order. let us turn next to the question of 'disorder' and more specifically to protests against government social distancing measures and to anti-authority rioting in the context of the pandemic. if a facilitative historical context, inclusive leadership, and the legitimacy of authority (cf. bottoms & tankebe, 2017) are critical to creating shared identity and maintaining social order, what happens when these factors are absent? let us answer that question primarily by reference to the usa where (unlike in the united kingdom) there have been multiple protests against lockdownbut additionally by addressing the unrest that has occurred in various other countries such as italy, brazil, and france. the caveats we expressed concerning our analysis of the uk case obviously apply here as well. as before, we shall start with the historical relationship between state and people. gary wills starts his history of this relationship in the united states with a famous quotation: 'henry david thoreau put in extreme form what many americans want to believe: "i heartily accept the motto: 'the government is best which governs least'"' (2002, p.15 ). the country, after all, was born in a revolution against what was seen as an alien and tyrannical state, and this attitude of suspicion remained attached to any state power. to this day, the right to bear arms (as articulated in the 2nd amendment to the constitution) is seen by many as a necessary counterbalance to such tyranny. in this context, any and all state intervention has the potential to be rejected as unacceptable and anti-american. once again, however, these beliefs do not exert a spontaneous influence. they have to be invoked, applied to the current context, and used to mobilize people against antipandemic measures such as lockdown. anti-state leadership is critical and, remarkably, it was provided by the right-wing populist head of state, us president donald trump. he directly referenced the anti-state principles on which 'this country' was built in order to criticize anti-pandemic measures. he praised protestors against lockdown as 'responsible', and he tweeted 'liberate minnesota!' followed by 'liberate michigan' and then 'liberate virginia and save your great 2nd amendment. it is under siege!' (embury-dennis, 2020). finally, the huge structural inequalities in the united states, the fact that less than half of poorer workers get any sick pay, that 28.6 million people have no health cover, and that 40% of americans could not find $400 to cover an emergency (vesoulis, 2020) , combined with the fact 26 million americans became unemployed in march and (santhanam, 2020 , have led to great hardship in the period of lockdown. this creates a context in which a sizeable pool of people is amenable to being mobilized by antilockdown leadership. in the poor south, for instance, 38% of people support trump on the pandemic over their own state governors (santhanam, 2020) . while, as yet, there are no systematic analyses of those who are protesting, anecdotal reportsalong with scrutiny of the chants and the placards displayed in protestssuggest a combination of 'liberty' and 'hardship' concernsa leadership and organization rooted in traditional antistate conservatism gaining some traction amongst those alienated from the authorities by economic suffering. as stocpol puts it: 'we've got a. . . combination of top-down influence from high-dollar organizations and some genuine energy at the grassroots level' (cited in illing, 2020) . in suggesting that all three factorsanti-state historical context, anti-state leadership, and inequitycontribute to the emergence of disorder, we do not suggest they are all equivalent or all necessary for protest to emerge. thus, events in america show how history and leadership can facilitate the emergence of an understanding that pandemic measures are unfair and unjustan illegitimate imposition by an alien authority that is acting against us rather than for and with us. however, events elsewherewe shall focus particularly on franceshow that such an understanding can arise directly from government measures that are experienced as inequitable and the ways that those who then challenge these measures are treated by the police. the lockdown in france took effect on 17 march 2020. this was in the context of the longstanding 'yellow vest' movement. as jetten et al. (2020) show, a sense of popular alienation from a state out of touch with the sufferings of ordinary people intertwined with the notoriously aggressive heavy handedness of french policing to drive the movement towards violent protest and sustain these protests across time and location. these features were then reproduced within the lockdown itself. as elsewhere, the lockdown exacerbated inequalities of class and 'race', making it particularly difficult for poor ethnic minority members to adhere to the regulations and stay at home (willsher & harrap, 2020) . the state responded with heavy-handed repression. anyone leaving their home has been required to carry a time-stamped certificate that has to be produced on demand. infringement carries penalties of heavy fines or even up to six-year imprisonment for the crime of 'endangerment'. by 1st april, just sixteen days after the control measures were introduced, the french police had already carried out 5.8 million controls and issued 359,000 fines (statista, 2020) compared to less than 10,000 across the one month following the imposition of control measures in the united kingdom. (npcc, 2020) . just one week into lockdown, french media began to report that the police were experiencing difficulties in enforcing such repressive measures especially in the poorer and ethnically mixed paris suburbs (keiger, 2020) , themselves historically areas of antipolice sentiment and rioting (body-gendrot, 2017) . then, early in the morning of 19th april, in the paris suburb of villeneuve-la-garenne, a local man of arab decent riding a motorcycle was injured when he collided with the open door of an unmarked police car. the incident was immediately interpreted by many as just another example of police brutality and rioting developed across the next four days, spreading into four suburbs across paris and with additional incidents reported across france (willsher, 2020) . what we see here is a classic pattern of crowd violence. a background of structural inequalities leading to alienation from authority, a pattern of antagonistic interactions with the police such that they become the concrete face of the 'other', a specific incident which is understood to exemplify the illegitimacy of the police, and then a spread of violence to other sites where locals share such a view of the police (ball et al, 2019; drury et al, 2020; stott et al, 2018) . the critical point is to understand how the distal determinants of conflict (which lie in the interaction of general structural inequalities and specific policies such as lockdown) interact with the proximal determinants (which lie in indiscriminate and repressive forms of policing, and in the spiral of negative interactions with particular sectors of the public that are initiated by such repression). it is only by developing such an understanding of how disorder occurs that we can learn how to preserve public order. we began this paper by asking what determines whether a pandemic brings people together with authorities so as to maintain order or else pushes them apart and creates disorder. our answer has been at two levels. on the one hand, we must look at the combination of historical context and contemporary leadership which determine whether people will mobilize around perceived inequities to challenge authority and disregard the regulations they seek to impose. on the other hand, we have pointed to the specific role of policingspecifically repressive policingin escalating dissent into open violence. both are key domains for further investigation. nonetheless, even if the details of our analysis are necessarily provisional at this stage of events, it is clear that disorder is a complex phenomenon which requires a combination of structural, political, and interactional factors to occur. consequently, lack of disorder might tell us that not all is bad, but it does not tell us that all is well either. nor does it allow us to be complacent. that is certainly true of the situation in the united kingdom. as we have indicated, there are major structural inequalities which are reflected in the disproportionate death rates of poor and bame people. equally the leadership and the political response to the pandemic may have done just enough to preserve cohesion, but there are more and more voices expressing concerns about the inefficiencies and inequities of current government policiesand these may grow as the situation develops. finally, the policing response may have largely concentrated on the three es of engaging, explaining, and encouraging the public to adhere to government measures (such as lockdown) before reverting to the fourth eenforcement (npcc, 2020a). but the pattern has not been consistent across the country. all in all, we cannot rest on our laurels. unless we are clearly seen to do more in the longer term to make a priority of addressing the structural inequalities; unless more steps are taken to make it possible for those in precarious positions to cope with lockdown and other measures; unless the focus of the police and other agencies is more firmly focussed on enabling rather than enforcing coherence, then the precious and fragile social consensus that we have enjoyed thus far could always give way to social conflict. stephen reicher, phd (conceptualization; writingoriginal draft) clifford stott (conceptualization; writingreview & editing). the biggest gang in oakland': rethinking police legitimacy perceptions and behavioural responses of the general public during the covid-19 pandemic: a cross-sectional survey of uk adults who controls the city? a micro-historical case study of the spread of rioting across north london in public disorder and globalisation police legitimacy and the authority of the state officers as mirrors: policing, procedural justice and the (re) production of social identity nhs coronavirus volunteers frustrated at lack of tasks. the guardian, 3rd may the myth of the blitz the police and the expansion of public order law in britain the black death and the burning of the role of social identity processes in mass 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www.college.police.uk/what-we-do/covid-19/documents/engage-explain-encourage-enf orce-guidance.pdf british social welfare in the twentieth century calls for health funding to be prioritised as poor bear brunt of covid-19. the guardian, 1st may the social psychological processes of 'procedural justice': concepts, critiques and opportunities when is policing fair? groups, identity and judgements of the procedural justice of coercive crowd policing engaged followership and engaged fellowship working toward the experimenter: reconceptualizing obedience within the milgram paradigm as identification-based followership mad mobs and englishmen policing the coronavirus outbreak: processes and prospects for collective disorder butskellism, the postwar consensus and the managed economy despite economic hardship, most americans not ready to reopen, poll says. pbs the impact of plague in tudor and stuart england naples in the time of cholera number of controls carried out and fines issued during the containment linked to the coronavirus epidemic (covid-19) in france between the roots of evil the evolving normative dimensions of 'riot': towards an elaborated social identity explanation keeping the peace' social identity, procedural justice and the policing of football crowds explaining the nature of power: a three-process theory why people obey the law: procedural justice. legitimacy, and compliance the group engagement model: procedural justice, social identity, and cooperative behavior coronavirus may disproportionally hurt the poor -and that's bad for everyone a necessary evil disruption on streets of france as lockdown tensions rise. the guardian in a paris banlieue, coronavirus amplifies years of inequality. the guardian, 25th april all authors declare no conflict of interest. no data available. key: cord-342636-mmlnm3mz authors: situngkir, h. title: the pandemics in artificial society: agent-based model to reflect strategies on covid-19 date: 2020-07-29 journal: nan doi: 10.1101/2020.07.27.20162511 sha: doc_id: 342636 cord_uid: mmlnm3mz various social policies and strategies have been deliberated and used within many countries to handle the covid-19 pandemic. some of those basic ideas are strongly related to the understanding of human social interactions and the nature of disease transmission and spread. in this paper, we present an agentbased approach to model epidemiological phenomena as well as the interventions upon it. we elaborate on micro-social structures such as social-psychological factors and distributed ruling behaviors to grow an artificial society where the interactions among agents may exhibit the spreading of the virus. capturing policies and strategies during the pandemic, four types of intervention are also applied in society. emerged macro-properties of epidemics are delivered from sets of simulations, lead to comparisons between each effectivity of the policy/strategy. when it comes to coronavirus disease pandemic, the world witnesses heterogeneous ways of managing. since the beginning of the outbreak in many places, different ways of managing the virus spreadings reflect the various healthcare situations faced by each government in the world, due to the testing and hospitalizations facilities. the situations are getting more complex for the unique characteristics of the covid-19 itself. as illustrated in figure 1 , the fatality rate and the contagiousness of the covid-19 are in between many other known diseases. the fact that the infected persons have some degree of possibilities to be asymptomatic, as well as the recognized pre-symptomatic cases, made a direct impact on the social life on which the epidemic occurs. most infected people have mild symptoms and still be able to deliver their daily social activities in which they can easily spreading the virus rapidly in the population. thus, policies of those limiting social interactions for the whole population are the most suggested solutions epidemiologically, as well as closing borders between places (countries, provinces, districts, etc.) to avoid imported/exported cases between regions. the consequences of the policies would apparently give a direct impact on many social aspects since interactions are fundamental elements in social life (smelser, 1997) . modern human life is formed in the patterns of social interactions, in which all social aspects are embedded, including religions, customs, economy, politics, and all. thus, the epidemiological suggestions for the policies' pro-social limitations and closing administrative borders are being resisted by the need of economical aspects of the social life. people are needed to be supported economically while on the other hand should be stay put with distant social interactions for the sake of damping the easily doubling trends of the infections. one popular policy is the "lock-down" within areas, where people are encouraged (and restricted) to "stay at home" (who, 2020) . in contrast, some other countries enforce other kinds of the policy of not applying the "lock-down" at all, like in sweden (dahlber, et. al., 2020) with very mild restrictions due to social activities within the country. many aspects happened to be put into account when it comes to social restrictions, from the reasons related to human rights to the economic aspects due to processes within the economy, macroeconomic reserve and workforces, and a lot more. furthermore, the considerations backing the varsities of enforced policies and strategies facing the covid-19 may also be coming from the heterogeneous natural aspects of countries around the world. for instance, the interactive effects based on meteorological influences in the covid-19 transmission and spread, due to the interactive effect between daily temperature and relative humidity on covid-19 incidence (qi, et. al., 2020) . some countries in tropical areas may have a milder effect within their infection cases relative to those in sub-tropical regions. the urge for maximum social restrictions in warmer tropical areas may not as great as those in other colder places. the exhibited variations are there for different existing situations faced countries in battling the pandemics. the paper is preparing the toy model reflecting the social structure that in return presenting a proposal for enriching observations toward various strategies within many places due to the pandemic of covid-19. while other previous works may present the computational models and simulations to approach the dynamics of an epidemic outbreak (cf. , the coverage of the paper is focused on the preparations of artificial societies in which some policies may be grown (epstein & axtell, 1996) and explained. the model used tried to capture the micro-social structure on which the infected people came along. the people are interacting with one another with particular individual motives and move around the artificial world as lattices and grids (cf. rhodes & anderson, 1996) . as an infected agent come along, the interactions exhibit the spreading of the virus in a sort of social network based on their bounded situations (cf. newman, 2002) . the model runs as an agent-based model (gilbert & terna, 2000) living the landscape that we can use to monitor the macro-properties of the epidemics (cf. situngkir, 2003) . the observations are delivered in the emerged aspects of epidemics, i.e.: the number of people infected and how it spreads over the landscape as the complex adaptive system (miller, 2007) . if the behavior of the agents is related to the micro-level of description, the government policies can be seen as in the mesoone (medium level, between micro and macro). all of those aspects are then depicting the relations of "factors to actors" relations (macy & willer, 2002) . some possible conjectures in the ways to verify the results are also discussed. eventually, the paper is demonstrated how interdisciplinary works can enhance social policies handling pandemics (angulo, 1987) . we can see the micro-social used in the simulations as three parts, i.e.: the internal state of the agents, the mobility in our artificial world, and the spreading of the disease based on the first two properties. agent has internal state ruled by the social-psych-wellness index, denoted as ! ( ) ∈ ℜ, ! ( ) = [0.1]. this index represents the wellness of agents regarding many complex aspects in social life and it is composed of three factors, two of them are related directly to its corresponding spatial situations. the first one is denoted as ! ( , , ), how agent fulfill her necessities when she nears a static point, we can say this as attraction points located in 2-dimensional , . one can imagine these points as public surroundings where people meet and have their needs from others, e.g.: marketplace, recreational spaces, offices. index ! ( , , ) is determined by the euclidean distance to the nearest attraction point, adjusted by parameter "##$"%#!&' . however, the relation is inversely proportional so that the nearer the agent to her chosen point, the higher ! ( , , ). its value is ! ( , , ) ∈ ℜ = [0,1] by a negative exponential function, decaying with term − 7 () , () '*"$*+# !"#$% 9. the second aspect is the agent neighborhood ! ( , ) which is simply a fraction of the number of her neighbors divided by a global constant maximum neighbors m. the factor corresponds to understanding that human tends to reach out others for their individual needs, be it economic, cultural, and social well-being. the conceptualizations of the neighborhood are other agents as perceived within radii '*!,-.&$+ , compared to her distance to others. this ! ( , ) ∈ ℜ = [0.1], weighted by a parameter as a feedback of the growing index of social-psycho-wellness, there is a boredom factor with proportions to agent 's, − ! ( ). the higher the value of her gladness, the more this factor reducing ! ( ). the three factors which determine the agent's internal state can formally be stated by the following system of equations: our artificial world is 2-dimensional lattice and grids of which form torus in 3 dimensionalities since the edge of the left is glued with the right one, and the top with the bottom edge as well. each agent spatial states are represented as a vector of position () ! and her velocity () ! . initially, agents are randomly located uniformly with zero speed of movement. following the terms of classical mechanics, in every iteration the spatial states of agents are updated by applying an amount of normalized steering force to agent : whereby default, each value of 1 mmm⃗ components is taken from an unbiased uniform distribution and the mass is assumed to be unity. furthermore, some conditional force is computationally adapted based upon the agent internal state, ! ( ). thus, the agent's mobility is ruled by her micro-motives: maximizing the wellness index. in short, the dynamics adopt boids model (reynold, 1987) which follows some simple rules distributed among the agents, the separation and cohesion-like rule. only if ! ( ) is below the threshold value 2&3 , we replace || $"'/&0 1 mmmmmmmmmmmmmmmm⃗ || to || +**41', 1 mmmmmmmmmmmmmmm⃗ ||. this force will make agents move towards their respective neighbors' average position and their corresponding nearest attraction points. however, dynamically, the neighboring factor is set to be zero when her number of neighbors m exceeds maximum limit forbidding the overcrowded localities. this also happened when an agent has no neighboring agents. in case no attraction point that they can perceive, or no neighboring force, they will perform a random walk by default. where denotes the value of weighting factor times normalization factor for each force. another rule is the separation rule which is necessary for later when we do the simulations. this rule makes agent keep their distance from each other by applying force: the equation corresponds to +*8"$"#!&' value which determines how an agent takes into account their neighbors perceived as too close, 7 () ! , () ! #&&_%2&+* 9 < +*8"$"#!&' . the denominator gives proportionality to the applied force so that the nearer her neighbor, the stronger she will stay away. to summarize, the change of agent velocity can be restated as: from here on, the simulation can be demonstrated and ready for some further epidemiological features. figure 2. the screen of our artificial societies with the control panel for adjustments of the experiments we can deliver. the dots represent moving agents, while the red dots are infected, the green one represents the recovered agents, the white one is susceptible agents. the dark blue is the center of attraction in which agents fulfill their utmost social and psychological wellness. when it comes to the simulated epidemics, agents can have an epidemiological state, be it susceptible, infectious, recovered, or dead, in a mutually exclusive manner. the state will be updated on each iteration according to some rules. as discussed previously, the coronavirus disease (covid-19) is highly contagious from human to human. via the droplets due to respiratory process, when people are close enough to talk or touch one another, or one human gets from droplets staying on surfaces as touched by hands as one-touch eyes, nose, or mouth. physical distancing, sanitizing hands, and preventing touching faces are the campaign for people to resist the contagions. these aspects are the core thing to be simulated in our artificial societies. firstly we have a population with all susceptible agents, except the patient zero. the only susceptible agent can be infected due to her spatial interaction with other infectious agents, occurs with probability !'9*%#*/ and only examined if the distance between the two agents is below a certain constant of !'9*%#!&' . after the $*+&2:#!&' -th iteration (distributed normally for all agents), infectious agent can be recovered with probability $*%&;*$) , otherwise, she is dead and removed from the artificial world. in return, recovered agents are still susceptible again with a particular probability +:+%*8#!.2* after +:+%*8#!.2* -th iteration (also distributed normally). countries around the world manage the covid-19 pandemic in various ways deliberating all aspects and social dimensions. the basic idea of strategy against covid-19 in the absence of any pharmaceutical intervention is reducing the possibility of susceptible and infectious mix one another. this is brought by early ascertainment of cases or reduction of contact. "lockdown" is one of the most heard solutions since it was the practice in china during the first outbreak epidemic (lau et.al., 2020) . however, the basic idea for reducing the mixing of susceptible people with the infected one can be interpreted as applied to various enforced policies. the campaign of social distancing is one of them: people are given the understanding to be in the distance when around other people (lewnward, et. al., 2020) . this is including the order of not letting people be in gatherings in not more than a few. in most impacted regions and countries, the public spaces closures, e.g.: restaurant, recreational park, entertainment venues, market, school are forbidden to operate regularly. a late addition by the world health organization's advice as a suggested intervention for the pandemic is universal face mask use. there are some rationales of the use of face masking as effective personal protective measures in the era of pandemic (sunjaya & jenkins, 2020) . social distancing in a social distancing scenario, all agents are expected to keep their distance from each other to reduce the disease transmissibility. this can be applied by adjusting the dseparation value then see if the agents perform separation rule. if the separating distance among agents is greater than infection distance, no infection will occur in the probability of (1-pseparate), the fseparation is set to zero vector. the mask-wearing scenario is simulated by multiplying the probability pinfected with mask reducing factor k = [0.1, 1]. in the basic model, one can say that k value is equal to 1 so that it will not affect the occurrence of infections. public spaces closures this scenario is implemented by removing all the attraction points that previously exist in the basic model. the attraction force for each agent then automatically turns to zero vector. it's worth noting that this also affects the wellness index of agents where the distance between the agent and her nearest attraction point becomes infinity. for the lockdown scenario, agents are redistributed to the initial vector in their "homes" then within the "home" uniform grids sized as lgrid x wgrid where each has centroid rgrid. once in her "home" position, the agent is attached to one of those grids in which the distance d(r, rgrid) is minimum. whenever the agent wants to leave her grid, she will be pushed back by the wall so that she can't interact with other agents in another grid. in this scenario, all public spaces are omitted from the landscape. growing the epidemic in silico would be valuable in observing how some of those intervention strategies enforced in many countries. four categorical types of interventions that can be observed in the artificial societies are social distancing encouragement, mask-wearing campaign, public spaces closures, and lockdown as presented in table 1. in its actuality, the four categorical types can be used as interventions in many places, countries, around the world in the existing combination as well. in our artificial society, without the intervention at all, the dynamics of the epidemic rely only on the herd immunity formations within the population. however the aspects of the contagiousness of the covid-19 would likely in demand of quite a long time to reach it since most fraction of the population should be infected to get there (clemente-suárez, et. al., 2020) . there is also the risk of an unacceptable number of death tolls without any intervention. within the simulation, we check the popular "lockdown" intervention. the effective lockdown is impressively suppressed the number of infection rate. there are some social (and psychological) effects, nonetheless to the population in the period of locking down the population, the agent's social and psychological index. this index can somehow represent the situation of social and economic aspects of the intervention since within the interval time people cannot do the social and activities at all effectively. at the end of the day, locking-down the population needs accurate momentum along with social and economic aspects of individual and community life, especially when it comes to the timing of the reopening. the too-early reopening comes to the risk of the second wave. the world witnesses this situation in some countries of which reopening too soon of the measure. in order to suppress the second wave, another lock-down intervention should be enforced. in some places around the world, there are some cities and countries that need to do such measures. when it comes to closing down the public spaces (in the simulation we omit the social attraction points) and encouraging the effective physical distancing measures to the population, the number infection rate is suppressed a little. but since the agents are still able to get along wandering within our landscape, the infections are still there. people are still getting infected and in the long run, the active cases are merely slowing down in a big period of time until the definitely possible herd-immunity comes along. this is shown in figure 5 (left). as discussed earlier, the who later gives recommendations on the use (cloth) mask as personal protection in the era of a pandemic. as we simulated the usage of masks in our agent-based model, the slowing rate of infection does give effect even though it needs time to suppress the number of active cases. it is worth noting that the usage of masks in our simulation in figure 5 (right) is delivered exclusively without any other intervention. the effectiveness of wearing masks with a combination of physical distancing encouragement and closure of public spaces for a period of time is simulated with the interesting results as shown in figure 6 . the effectiveness of this combination, relative to the effective lockdown is the interval time for the cases eventually significantly decreased. however, since agents are still given the opportunity with their social and economic life, the things average social and psychological index is not as drop like the one with full effective lockdown intervention observed in the previous experiment. this may explain with the cases in south korea, taiwan, and some other eastern asia, where people are encouraged strongly to wear masks even after the lockdown phase and the cases have been decreased (lee & you, 2020) . thus from our sets of experiments in the agent-based simulation, some tweaks of interventions due to the pandemic at the micro-level, the emerged macro-level is observed, including some emerged social aspects. there is no single solution of intervention when it comes to complex social systems, including due to the policy harnessing the pandemic. the computational simulation, whatsoever, is open for modifications and other changes due to many other aspects to be included in the intervention. our simulation explains the varsities of governance and social and economic policies applied in different countries, regions, and areas. the agent-based model of the complex social system to observe some aspects of intervention due to the covid-19 pandemic can give insights on the cause and emergence of intervention on trying to handle the pandemics in the absence of a vaccine. some interventions potentially hurt the social and economy of the people while "flattening" the exponential rise of infections. on the other hand, no intervention can bring people with the risk of unacceptable death while naturally, the eco-social system adjusts itself for the collective immunity. on the other hand, the characteristics of the disease and virus are not the same either for different regions, areas, and countries. many aspects, not necessarily the social and economic one per se, should be put into account when it comes to policies. computational simulation, by growing deliberately the structure of the social system into computation, provides the artificial societies in which many different observed aspects and characteristics of the disease can be applied (by tweaking variables in either micro and larger (macro) levels of description). our simulation may explain and computationally demonstrated the various pathways of intervention delivered by the governments in different countries and regions. initial number of agents n 300 initial agents positions rx, ry u(0, 700), u(0, 500) initial g(0) n(0.5, 0.125) !""#!$"%&' interdisciplinary approaches in epidemic studies -ii: four geographic models of the flow of contagious disease dynamics of population immunity due to the herd effect in the covid-19 pandemic:. vaccines effects of the covid-19 pandemic on population mobility under mild policies: causal evidence from sweden growing artificial societies: social sciences from the bottom up how to build and use agent-based models in social science the positive impact of lockdown in wuhan on containing the covid-19 outbreak in china psychological and behavioral responses in south korea during the early stages of coronavirus disease 2019 (covid-19 scientific and ethical basis for social-distancing interventions against covid-19. the lancet. infectious diseases from factors to actors: computational sociology and agent based modeling complex adaptive systems: an introduction to computational models of social life the spread of epidemic disease on networks dynamics in a lattice epidemic model flocks, herds and schools: a distributed behavioral model. siggraph '87: proceedings of the 14th annual conference on computer graphics and interactive techniques moneyscape: a generic agent-based model of corruption how far can we go through social system epidemiology through cellular automata: case of study avian influenza in indonesia problematics of sociology: the georg simmel lectures rationale for universal face masks in public against covid-19 covid-19 transmission in mainland china is associated with temperature and humidity: a time-series analysis coronavirus disease (covid-19) advice for the public we thank colleagues in bandung fe institute for discussions in the early draft of the manuscript. key: cord-349916-x37olwv9 authors: crone, eveline a.; achterberg, michelle; dobbelaar, simone; euser, saskia; van den bulk, bianca; der meulen, mara van; van drunen, lina; wierenga, lara m.; bakermans-kranenburg, marian j.; van ijzendoorn, marinus h. title: neural and behavioral signatures of social evaluation and adaptation in childhood and adolescence: the leiden consortium on individual development (l-cid) date: 2020-07-11 journal: dev cogn neurosci doi: 10.1016/j.dcn.2020.100805 sha: doc_id: 349916 cord_uid: x37olwv9 the transition period between early childhood and late adolescence is characterized by pronounced changes in social competence, or the capacity for flexible social adaptation. here, we propose that two processes, self-control and prosociality, are crucial for social adaptation following social evaluation. we present a neurobehavioral model showing commonalities in neural responses to experiences of social acceptance and rejection, and multiple pathways for responding to social context. the leiden consortium on individual development (l-cid) provides a comprehensive approach towards understanding the longitudinal developmental pathways of, and social enrichment effects on, social competence, taking into account potential differential effects of such enrichment. using neurosynth based brain maps we point towards the medial prefrontal cortex as an important region integrating social cognition, self-referential processing and self-control for learning to respond flexibly to changing social contexts. based on their role in social evaluation processing, we suggest to examine medial prefrontal cortex connections with lateral prefrontal cortex and the ventral striatum as potential neural differential susceptibility markers, in addition to previously established markers of differential susceptibility. social competence, which is defined as the cognitive, emotional and social skills that are needed for social adaptation (denham et al., 2003; huber et al., 2019; rydell et al., 1997) , is one of the most important requirements for developing social relations. social competence is particularly needed when dealing with social evaluations, providing us with signals of acceptance and rejection, which foster feelings of positive or negative self-evaluation (yoon et al., 2018) . in case individuals are personally confronted with rejection, this may trigger socially adaptive self-protection, such as reassessing the value of the messenger (overall and sibley, 2009) , or displaying aggression following rejection (chester et al., 2018) . in contrast, rejection that is directed towards others (i.e., observed social evaluation) may trigger other-oriented prosocial behaviors, such as helping and comforting (masten et al., 2011; rydell et al., 1997) . thus, social competence entails important mechanisms involved in the adaptive responses associated with rejection and acceptance of self and others. this review is organized around the common themes of how positive and negative social evaluations can trigger self-protective and other-oriented processes, and how individuals may differ in their susceptibility to these social experiences. growing evidence suggests that the cognitive, emotional and social processes that are important for adaptive social behavior show continued developmental changes during childhood and adolescence. whereas adults have developed (self-) adaptative mechanisms in response to experienced or observed negative social feedback, these mechanisms may not yet be in place during childhood and adolescence, making this a period of higher sensitivity to social evaluation signals (rodman et al., 2017) . the study of these mechanisms has benefited from recent insights from neuroscience research, which pointed to prolonged windows of grey matter increases and reductions. these grey matter changes possibly mark periods of greater sensitivity to environmental influences. particularly the period of infancy and toddlerhood (0-4 years) has been suggested to be marked by rapid neuronal growth and cortical growth and pruning (girault et al., 2019) , which stabilizes after the age of approximately 4 years . this pattern is followed by a second window of cortical reorganization in terms of a rapid reduction of gray matter in puberty, with a less steep decrease and stabilization in late adolescence until the early twenties (tamnes et al., 2017 ) (see fig. 1a ). we propose that these periods in development provide windows of increased plasticity and refinement of neural development and a relative larger susceptibility to environmental influences (fig. 1b) , such as supporting or aversive experiences with parents and peers. insights in the effects of social evaluation on neural processes at a micro level (i.e., instant social experiences) have been informed by the use of functional magnetic resonance neuroimaging (fmri) paradigms signaling acceptance and rejection by others. functionally, prior studies suggest a coordinating role of the medial prefrontal cortex when responding to social evaluation (yoon et al., 2018) . the medial prefrontal cortex is generally considered a hub region for different processes that are related to self-other referential processing. it has been considered part of the brain network involved in social cognition, together with the temporal parietal junction (tpj), superior temporal cortex (sts) and anterior temporal lobe . the medial prefrontal cortex is also part of the self-referential cortical midline network together with the posterior parietal cortex/precuneus (pfeifer and peake, 2012) . finally, medial prefrontal cortex has been implicated as part of the affective-control network, together with the ventral striatum (van duijvenvoorde et al., 2016) . therefore, many studies have now pointed towards the medial prefrontal cortex as an important region for adaptive responses to social evaluation (yoon et al., 2018) . here, we review the processes that are important for social competence development in the context of social evaluation of self (experienced social evaluation) and others (observed social evaluation), based on neural and behavioral evidence. regulating emotions in response to social evaluations of self is expected to be associated with behavioral profiles of self-control, whereas responding to needs of others when observing social evaluations is expected to be associated with behavioral profiles of prosociality (see table 1 for constructs and definitions). the study of neural responses to experimental tasks that mimic social evaluation experiences may provide a powerful means to understanding the association between experimentally induced moment-to-moment experiences of social evaluation and more prolonged real-life social experiences that may affect the development of social competence processes. many scientists have examined prolonged developmental trajectories of social competence, possibly because in periods of developmental change the processes involved can be fostered and shaped through social experiences dahl et al., 2018) . the social environment of a child changes considerably between birth and young adulthood, and this may provide unique risks and opportunities for shaping and fostering processes that are important for responding to social evaluation. whereas children from birth to early childhood (ages 0-7 yrs) are most strongly influenced by their parents and siblings, this context gradually extends to include a stronger influence of peers in middle childhood and adolescence (8-17 yrs) . this transition coincides with the onset of puberty, which is the period in life characterized by a transition to extending social relations outside the gilmore et al., 2018) and during adolescence (10-25-years; based on tamnes et al., 2017) . (b) potential age-related windows of larger effects of differential susceptibility on social competence increasing the developmental differences between children with lower versus higher susceptibility. definitions of constructs. family context (crone and dahl, 2012) . the development of many aspects of social competence eventually leads to the development of young adults with social goals that they find worthwhile or are required to pursue (18-25 yrs), and adaptive mechanisms for responding to self and other social evaluation. an important question concerns how various social environments hamper or foster the development of social competence. empirical evidence based on randomized-control intervention studies suggest that, in addition to possible sensitive windows within development, not all individuals are similarly susceptible to influences of the environment on future outcomes (belsky and de haan, 2011; belsky and van ijzendoorn, 2017) . the differential susceptibility theory proposes that some children are more susceptible than their peers to their positive or negative social and physical environment, for better and for worse, such that their social competence is fostered to a greater extent in a positive environment, but also harmed more in a negative environment compared to individuals who are less susceptible to environmental influences. an experimental 'micro-trial' with cyberball has shown, for example, that aggression in response to exclusion is differentially affected by (maoa) genotype (gallardo-pujol et al., 2013) , although this study was limited to the effects of a negative social environment (ostracism). other experiments supported genetic differential susceptibility to both positive (i.e., environmental enrichment) and negative (i.e., deprivation) social environments (bakermans-kranenburg and van ijzendoorn, 2015; belsky and van ijzendoorn, 2017; knop et al., 2020) . within-person variation in susceptibility to social context has been proposed for neural development, where it is assumed that brain regions supporting cognitive, affective and social development develop over many years and are particularly influenced by adverse or enriched social environments (schriber and guyer, 2015; tottenham, 2019) . the developmental periods that are characterized by increased plasticity and refinement of neural development (early childhood, emerging adolescence) may however not only show a generally enhanced susceptibility to environmental influences, but may also be characterized by larger inter-individual differences in susceptibility (differential susceptibility, see fig. 1b ). however, it remains to be determined whether and how variations in parenting and other aspects of the social environment modulate the impact of social evaluation in different phases of development (sensitive windows) moderated by individual characteristics (differential susceptibility), and how these periods of accelerated neurobiological development and concomitant enhanced sensitivity increase the moderating influence of differential susceptibility markers, specifically the medial prefrontal cortex and its connections. in this review, we differentiate between social competence processes involved in social evaluation of self and associated self-control, and processes involved in witnessing the social evaluation of others and associated prosociality. ideally, research should cover the whole developmental period from birth to adulthood. this review provides only the starting point of this approach with a relatively strong emphasis on childhood and early adolescence. the review is selective and covers behavioral and neurobiological measures that contribute to an integrative neurobehavioral perspective, and it is based on the latest and most robust findings. the results are organized around the common themes of the leiden consortium on individual development (l-cid); an experimental accelerated cohort-sequential longitudinal twin interventionstudy that includes children between ages of 3à 13-years (see for the cohort approach and appendix 1-3 for included measures, documentation and demographics) (euser et al., 2016) . the reason for starting at the age of 3-4 years is because this period can still be considered the tail of elevated differential susceptibility (fig. 1b) while at the same time allowing for the use of experimental paradigms that are comparable across the whole developmental period from childhood to adulthood. the program is organized in two cohorts using an accelerated cohort-sequential longitudinal design, with starting ages at 3-4-years and 7à 8-years to capture a 10-year developmental period in a 6-year-study. the ambition of the program is to extend measurements until early adulthood to include assessments in the second period of heightened differential susceptibility. the l-cid program has two aims: 1) to unravel the developmental trajectories, differences and commonalities of behavioral profiles and neural correlates for self and other-oriented social evaluation, which are two important components of social competence (see fig. 3 for paradigm examples), and 2) to understand differential susceptibility to environmental enrichment (in a randomized control trial) in different phases of development, with a specific focus on early childhood and emerging adolescence. this review is organized along these lines. self-control is defined as regulating emotions and behaviors in response to social evaluation of self. many prior studies have examined self-control in terms of behavioral control, such as withholding responses to no-go stimuli (rubia et al., 2013) or delay of gratification (christakou et al., 2011) . self-control is also of paramount importance in the context of social evaluation. specifically, social evaluation affects self-esteem and, in case of rejection, harms the need for belonging (williams and nida, 2011) . strategic motives for self-protection may include down-evaluation of others (overall and sibley, 2009) , temporal distancing (ahmed et al., 2018) or aggression towards the source of rejection (reijntjes et al., 2013) . prior research showed that children respond to the immediate social evaluation feedback in their responses towards others, whereas adults use more accumulated experiences in their response to others, taking the larger context into account (yoon et al., 2018) . several neuroimaging studies have examined the experience of social evaluation in adolescents and adults, by examining the neural responses to acceptance and rejection in a social feedback paradigm, in which participants receive feedback from other participants signaling whether they were liked (acceptance) or disliked (rejection) based on first impression (gunther moor et al., 2010a; somerville et al., 2006) . these studies showed that in adolescents and adults, the experience of acceptance led to the activation of a wide network of brain regions including the amygdala and the ventral striatum, whereas rejection was associated with stronger social salience detection including activity in the insula and prefrontal cortex, especially for older adolescents (gunther moor et al., 2010b; guyer et al., 2012) . to examine self-control in relation to social evaluation, achterberg and colleagues developed a novel neuroimaging paradigm, which is referred to as the social network aggression task (snat) appropriate for older children, adolescent and adults (achterberg et al., 2016a) . this paradigm is based on studies in adults in which it was reported that experiencing rejection in a ball tossing game was associated with more aggression in the form of blasting a loud noise (chester et al., 2018) . it was found that indeed adults and children respond with larger noise blast aggression to rejection feedback compared to acceptance feedback (achterberg et al., 2016b . even 4à 6-year-old children popped more balloons of another player in a child-appropriate version of the social network aggression task-early childhood (snat-ec) (van wijk et al., 2019b) . this paradigm was developed to also examine neural responses to acceptance and rejection feedback using fmri. by including a neutral condition to the snat-paradigm, it was possible to examine the brain regions that were generally sensitive to social feedback (positive or negative) and regions that were responding to the specific valence of feedback (negative > positive). prior research had left undecided which brain regions were responding to valence (guyer et al., 2012; somerville et al., 2006) , saliency (vijayakumar et al., 2017) or incongruence with prior expectations (somerville et al., 2006) . a study in 18à 25-year old adults using the snat revealed that experiencing both acceptance (positive) and rejection (negative), relative to neutral feedback, resulted in strong activation in bilateral insula and medial prefrontal cortex (achterberg et al., 2016b) . this activation was interpreted as signaling social saliency, given that acceptance and rejection feedback may trigger the need for action more than the neutral condition. consistent with studies on reward processing (liu et al., 2011) , social acceptance relative to rejection was associated with stronger activity in the ventral striatum, suggesting that social acceptance and reward processing rely on the same brain regions (liu et al., 2011) . social acceptance relative to rejection also elicited strong activation in supplementary motor area and bilateral dlpfc, regions previously associated with control processes, possibly indicating that acceptance is associated with approach processes (tyborowska et al., 2016) . in these young adults, rejection relative to acceptance feedback specifically resulted in stronger activation in medial prefrontal cortex, in a region more anterior/superior of the medial prefrontal cortex for social salience, a region often implicated in social cognition (burnett et al., 2011) . the same paradigm was also used separately in 7à 10-year old children and 7-9-year-old twins as part of the l-cid project (achterberg et al., 2018a) . these studies replicated the social saliency effect of acceptance/rejection feedback relative to neutral feedback in the bilateral insula and medial prefrontal cortex, and the increased activation in superior medial prefrontal cortex following rejection (see fig. 4 for activation patterns in the medial prefrontal cortex). in the snat paradigm participants were given the opportunity to retaliate following negative feedback, compared to positive and neutral feedback, by blasting a noise towards the source of the social feedback. interestingly, stronger activation in dlpfc following rejection was associated with shorter noise blasts, that is, less aggression following rejection, in both adults (achterberg et al., 2016b) and 7-9-year-old children (achterberg et al., 2018b) . a longitudinal comparison across the ages 7-9 to 9à 11-years confirmed that those children who showed more dlpfc activation following rejection across time, also showed less aggression following rejection across time . thus, whereas rejection-related activity was observed in medial prefrontal cortex, lateral prefrontal cortex differentiated more between behavioral responses to rejection and acceptance feedback. taken together, these studies suggest that social evaluation and associated self-control rely on both medial and lateral prefrontal cortex, together with the bilateral insula and ventral striatum. the experience of social evaluation was associated with activation in medial prefrontal cortex, consistent with prior studies showing that distinct subregions in the medial prefrontal cortex are involved in processing social evaluative cues (yoon et al., 2018) . the control of aggression following negative feedback was more strongly associated with activation in lateral prefrontal cortex, possibly indicating self-control of aggressive behavior (casey, 2015) . three additional questions need to be investigated in more detail in future research. first, it is not yet known whether some individuals are less responsive to the social rejection feedback in general, with consequently less need to engage in self-control strategies. less social responsiveness has been found to lower the impact of a prosocial peer on prosocial behavior of eight-years old children (wildeboer et al., 2017) . in future studies, we aim to unravel whether the same might be true for the impact of social rejection. second, the network of brain regions that is involved in the snat paradigm has previously been associated with both emotion generation (including the amygdala, insula and medial pfc) as well as emotion regulation (including medial pfc and dlpfc) (silvers and guassi moreira, 2019) . especially for snat-induced emotion regulation, an interesting question concerns whether individuals employ the capacity to self-regulate emotions using specific cognitive strategies (previously examined using cognitive reappraisal paradigms (silvers et al., 2016) ) versus the internally driven tendency to self-regulate emotions, which may be more sensitive to contextual factors (silvers and guassi moreira, 2019) . future studies may test these questions using more detailed individual indices of general tendencies to self-regulate in daily life. third, one prior transcranial direct current stimulation study in adults showed that lateral prefrontal cortex stimulation was directly related to a reduction of aggression following social exclusion (riva et al., 2015) . it is currently not known whether dlfpc is causally related to subsequent reduction of aggression in childhood studies. however, the longitudinal brain change-behavioral change relations suggest that dlpfc and aggression control are meaningfully related . even though few studies have examined social evaluation processes across development, developmental trajectories have been observed for the ability to control behavior in a non-social context, such as for the ability to delay gratification. when deciding between smaller immediate rewards or larger future rewards, impulsivity declines between childhood and adulthood (peper et al., 2018) . it currently remains to be determined whether self-control relies on common mechanisms in non-social versus social contexts. delay of gratification is associated with stronger connectivity between the ventral medial prefrontal cortex (vmpfc), the dorsal lateral prefrontal cortex (dlpfc) and the ventral striatum (vs) (achterberg et al., 2016a; van den bos et al., 2015) . several studies revealed that the ability to delay gratification matures across childhood and adolescence, and adolescent decision-making is characterized by stronger vmpfc-vs connectivity compared to adulthood (christakou et al., 2011) , whereas delay-decisions in adults are characterized by stronger vmpfc-dlpfc connectivity compared to adolescents (van den bos et al., 2015) . possibly, behavioral control in both social and non-social situations relies on a larger network of regions within the lateral and medial prefrontal cortex. social evaluation and impulsive responses may rely in particular on medial prefrontal cortex regions, whereas delaying gratification and controlling anger may rely more on lateral prefrontal cortex . the experience of social inclusion and exclusion can be directed to self, but can also be observed in others. witnessing social exclusion of others can lead to punishment of excluders and to prosocial behavior towards victims, such as helping and comforting (masten et al., 2011) . prosocial behavior, which is defined as behavior that is directed to others without direct benefit to self, is particularly important to build and maintain social relationships over time. recent studies have suggested that prosocial behavior is strongly dependent on context (van ijzendoorn and bakermans-kranenburg, 2014), such as whether participants are interacting with known (parents, peers) or achterberg et al. (2018) and van der meulen et al. (2018) reporting on the same 7-9-year old participants of wave 1 of the middle childhood cohort (see fig. 2 and 3). unknown others (strangers) and whether participants know that they are being observed (van hoorn et al., 2016) . the differentiation between prosocial actions towards known versus unknown others start in early childhood and emerges rapidly around middle childhood (between ages 9 and 12 years) (guroglu et al., 2014) , making the period of middle childhood and early adolescence particularly important for further distinguishing between ingroup-outgroup relations and caring about reputation (hillebrandt et al., 2011) . a particular strong paradigm to trigger feelings of social exclusion is the cyberball paradigm (williams and jarvis, 2006) . this computerized three-player ball-tossing game involves unexpected exclusion of the participant by two other participants. many prior studies revealed that the experience of social exclusion elicits strong feelings of negative affect and loss of control (eisenberger et al., 2003) , an experience that is heightened in mid adolescence (sebastian et al., 2010) . meta-analyses have confirmed that the orbitofrontal cortex, together with the insula, is active when participants experience social exclusion (cacioppo et al., 2013) , as well as the anterior cingulate cortex in participants who have a history of experienced social exclusion (dewall et al., 2012; van harmelen et al., 2014) . interestingly, studies have shown that observed exclusion leads to increased neural activation in medial prefrontal cortex, especially in participants who report higher levels of empathy (masten et al., 2011) . prior studies that made use of two-person interaction games that include a division of goods (also referred as economic games) reported that social distribution behavior benefitting self and others is associated with a network or regions including the medial prefrontal cortex, superior temporal cortex and temporal-parietal junction (tpj) (rilling and sanfey, 2011) . participants who experienced exclusion in a cyberball game subsequently punished excluders in an economic game, by giving them fewer goods. this punishing behavior was associated with increased activation in insula and pre-supplementary motor area. in contrast, refraining from punishment (i.e., fair division of goods after being socially excluded) was associated with increased activation in social brain regions such as the medial prefrontal cortex and tpj, and correlated with self-reported perspective taking (will et al., 2015a (will et al., , 2015b . these studies inspired the study of helping behavior in the context of social evaluation using an adapted prosocial cyberball game (pcg) (riem et al., 2013) . this game consists of four players, one being the participant, who toss balls to each other. two players exclude the third player, and the participant has the opportunity to help the excluded player by tossing more balls to this player (see fig. 3 ). a prior study showed that such helping behavior is observed over the course of childhood and adolescence (ages 9à 17-years) . this task was administered in the l-cid study, in which it was observed that 7-9-year-old children show similar levels of helping as adults, although there was substantial variation between participants (van der meulen et al., 2018). together, these behavioral studies suggest that prosocial helping is a developmentally early emerging type of prosocial behavior. brain imaging studies using the pcg revealed that in adults, tossing to the excluded player is associated with more activation in the ventral striatum and the tpj, regions that are often implicated in reward processing and perspective taking (van der meulen, . to unravel the neural responses in childhood, 7-9-year-old twins completed the same task as part of the l-cid study (van der meulen et al., 2017 (van der meulen et al., , 2018 . this study examined three processes in the pcg: (1) receiving tosses from the other players, which results in the personal experience of inclusion (2) not receiving tosses from the others, which results in the personal experience of exclusion, and (3) tossing to the excluded player, which results in the other-oriented behavior of non-costly helping. first, it was observed that experienced inclusion relative to not receiving the ball was associated with activation in the pre-sma, whereas experienced exclusion was associated with activation in the anterior medial prefrontal cortex, subgenual acc, and the inferior frontal gyrus (see fig. 4 ). second, prosocial helping compared to tossing to excluders was associated with activation in the precuneus, a region often implicated in self and other oriented processing (pfeifer and peake, 2012) . finally, the insula was also involved in prosocial helping but only in relation to individual differences in helping behavior. that is, participants who showed less prosocial helping recruited the bilateral insula more strongly when they tossed to the excluded player, possibly indicating that this is behavior that competes with their own dominant behavior and is therefore more salient (rilling and sanfey, 2011) . taken together, adults recruit the ventral striatum and tpj during prosocial behavior , whereas in middle childhood prosocial helping is associated with increased activity in precuneus and performance-dependent insula (van der meulen et al., 2018) . a prior study that compared 12à 17-year-old adolescents (n ¼ 20) to young adults (n ¼ 20) confirmed that in adults prosocial helping was associated with increased activity in the tpj and superior medial prefrontal cortex, but this activity was stronger in adults than in adolescents (tousignant et al., 2018) . these results together suggest that processes that drive prosocial helping change over the course of development. importantly, prosocial helping often occurs in context, for example when experiencing the risk of being excluded or when experiencing relief from not being excluded. in future studies it is therefore important to systematically vary these contextual factors for a full understanding of prosocial behaviors. the studies reported by achterberg and colleagues (achterberg et al., 2018a) and van der meulen and colleagues (van der meulen et al., 2018) were conducted within the same l-cid sample, providing unique opportunities to examine the overlap in neural activity within the 7-9-year-old participants included in the study. fig. 4 displays the neural overlap for receiving and responding to social feedback. first, social rejection (social negative feedback in the snat paradigm and experienced exclusion in the pcg paradigm) was associated with increased activity in superior medial prefrontal cortex in both paradigms, a region according to the neurosynth analysis associated with social cognition. in contrast, receiving feedback that represented social acceptance (social positive feedback in the snat paradigm and experiencing social inclusion in the pcg paradigm) was associated with overlapping activity in sma and dlpfc, regions that according to the neurosynth analysis are associated with control processes. note that in the snat paradigm participants were instructed to always press the noise button, but they were free to decide the length of the button press. dlfpc activity following positive feedback is therefore consistent with our predictions as this is the condition where participants put most effort into pressing the button as shortly as possible . finally, receiving social feedback in general (positive þ negative feedback relative to neutral feedback) in the snat paradigm was associated with increased activity in medial prefrontal cortex, a region according to the neurosynth analysis associated with self-referential processing. these findings suggest that social evaluative feedback across social contexts is associated with activation in distinct regions of the medial prefrontal cortex. interestingly, as can be seen in fig. 5 , neural activity in superior medial prefrontal cortex from the two task paradigms (snat and pcg) for rejection and experienced exclusion was correlated across tasks, using data previously published (achterberg, van duijvenvoorde, et al., 2018; van der meulen et al., 2018) . these findings highlight that there is some commonality in the neural response to negative social evaluation events that can be observed across experimental contexts. it is expected that self-protective responses also play a role in prosociality. relatedly, positive social evaluation of self can trigger prosocial behavior. these intertwined relations between self-control and prosociality are consistent with the notion that self-and other-oriented processes are strongly aligned and rely on common neural regions (crone and fuligni, 2020) . a question for future research is whether this commonality in neural responses is a stronger predictor for behavior and attitudes in comparison to single task measures. an interesting approach for future research concerns the bidimensional influences of social evaluation sensitivity for self and others on developmental outcomes (hawley, 1999) . self-protection mechanisms may harm social relations when one responds aggressively towards others, without concern for others in need. in contrast, aggressive mechanisms may be helpful when combined with prosocial tendencies in case others are harmed, because it enhances self-esteem (i. e., self-protection) while also responding to needs of others. prior research has shown that such a bi-dimensional taxonomy is a useful direction to predict developmental outcomes (sunami et al., 2019) . this approach was previously applied to identify a specific group of adolescent youth who are prosocial risk-takers, thus, youth who score high on both rebellious behavior and prosocial tendencies (blankenstein et al., 2019; do et al., 2017) . research on adolescents also revealed that certain adolescents can be both aggressive and prosocial which can be a way to achieve social goals and status (cillessen and rose, 2005; hartl et al., 2019) . individuals who use both strategies are considered to be the ones that are most responsive to their environment and adjust their behaviors to reach social goals (hawley, 2002) . the overlap in neural activation in the medial prefrontal cortex suggests that this region is an important connecting region that responds to both negative social or rejection feedback of self and others. behavioral responses to evaluations of self and other can be organized according to two axes: (i) the dimension of aggressive, self-protective acting-out tendencies: variance on this dimension may lead individuals to respond aggressively to others versus controlling their anger; and (ii) the dimension of prosocial tendencies: variance on this dimension may lead individuals to prosocially help others versus showing no signs of prosocial helping. this taxonomy leads to four groups (for ease of interpretation but continuous variation can be projected on the axes): the first group consists of individuals who show self-protective aggression combined with low levels of prosocial helping and who could be classified as anti-social revenge takers (fig. 6a , left-hand upper quadrant). the second group consists of individuals who score high on aggression but also on helping others (right-hand upper quadrant). these individuals may be particularly aware of -and sensitive to -the environment. individuals who control their aggression while also showing helping behavior towards excluded others can be characterized as prosocial forgivers (right-hand lower quadrant). finally, the fourth group consists of individuals who show no aggression combined with low levels of prosocial helping; these are individuals who could be classified as passive bystanders (left-hand lower quadrant). in the latter group, there may be a subgroup that participates in exclusion, showing negative prosocial helping scores. future research can determine whether these subtypes or combination of the two axes are predictive for longitudinal social and mental health outcomes. the combined perspective may lead to a more nuanced and specific analysis of neural and behavioral social competence indicators and predictors of social competence (sunami et al., 2019) . the prolonged development of brain regions implicated in social evaluation suggests a window of sensitivity to environmental experiences. regions from the social brain network, including the medial prefrontal cortex, tpj and posterior sts show grey matter increases and decreases until the early twenties (mills et al., 2016) . we argue that periods of rapid growth may be associated not only with enhanced susceptibility to the environment, but also enhanced differential susceptibility on future outcomes. what are characteristics of youth who are particularly susceptible to better and worse (changes in) environments? are there time windows in which differential susceptibility is enhanced? can we identify neural markers of differential susceptibility? one approach to understand inter-individual differences in processes associated with social evaluation is examining the relative genetic influence on brain development and behavior (van dongen et al., 2016) . the classic within-twin phenotype comparison design allows for estimation of the proportions of genetic and environmental contributions to explaining the variance, by comparing the intra-pair correlations within twin pairs that are monozygotic and share 100 % of their genes, and twin achterberg et al. (2018a) and van der meulen et al. (2018) in 7-9-year old participants showing correlated activity across two paradigms in superior mpfc. included data come from the contrasts: rejection-fixation (achterberg et al., 2018a) and exclusion-inclusion (van der meulen et al., 2018), r ¼ .17, based on a sample size of n ¼ 261. data were only included when the participants met the inclusion criteria for both experimental tasks. pairs that are dizygotic and share on average 50 % of their genes. a higher correlation for monozygotic in comparison to dizygotic twins indicates a stronger influence of genetic factors. correlations that are comparable for monozygotic twins and dizygotic twins indicates effects of shared environment. variance that cannot be attributed to genetic or shared environment indicates either unique environment effects or measurement error. for further inspection, the structural equation ace model (a: genetic influences, c: shared environmental influences, e: unique environmental influences) is the most commonly used approach to quantify the genetic and environmental contributions. it has been shown that total grey matter volumes are highly heritable in adults (van soelen et al., 2012) . heritability studies in infancy, childhood and adolescence indicate that there is evidence for genetic influences on brain growth, but in certain developmental periods estimates of the genetic influences are larger than in others (polderman et al., 2015) . for example, heritability of brain structures is already observed in infancy but is stronger for surface area (78 %) than for cortical thickness (29 %), and shows relatively little regional specificity (jha et al., 2018) , although a prior study suggested larger genetic influences on the posterior cortex compared to the prefrontal cortex in neonates (gilmore et al., 2010) . moreover, heritability of white matter tracks was observed in twin studies including neonates, 1-year-olds, and 2-year-olds, but no evidence for heritability of white matter change between the age of 1 and 2 years (lee et al., 2019) . in older children and adolescents, heritability estimates are much higher (van soelen et al., 2012) but genetic influence differs between regions in the brain, with more pronounced environmental influences in the social brain network than in visual and motor cortex (van der meulen et al., 2020) . understanding the genetic and/or environmental contributions and the changes in their impact across development may reveal potential windows of sensitivity to the environment during development. the l-cid studies referred to in this review made use of the classic ace twin design in two overlapping cohorts of 238 twin pairs (ages 3à 9years) and 256 twin pairs (ages 7à 13-years). we found considerable heritability estimates for questionnaire trait phenotypes of prosociality and effort-full control (van wijk et al., 2019a; vrijhof et al., 2018), modest evidence for shared environmental and genetic factors explaining individual differences in (more state-like) behavioral aggression in the snat paradigm in 7-9-year-old children (achterberg et al., 2018b) and 7à 11-year old children , but limited evidence for genetic contribution to behavioral task performance on the pcg for 7-9-year-old children (van der meulen et al., 2018) . the differences in genetic versus environmental explanations of interindividual variation in prosociality, feelings of rejection and bias to display aggression might be related to the e component of the ace modeling that represents unique environmental influences (making children within one family more different from each other) as well as measurement error. parent-or self-reported attitudes or behaviors might be less valid but more reliable thus containing less measurement errors whereas pro-or antisocial behaviors measured in single test settings might be more indicative of state-like and context-dependent interactions increasing the e component. in spite of the absence of behavioral evidence for genetic contributions, there was some evidence for genetic influences on neural signals in the range of 10-20 %, specifically for the dlpfc and supplementary motor area following positive feedback in the snat paradigm (achterberg et al., 2018a) , and the inferior frontal gyrus during experienced exclusion in the pcg paradigm (van der meulen et al., 2018) . moreover, resting state connectivity analyses in the same participant sample revealed that in the 7-9-year-old children ventral striatum connectivity with ventromedial and orbitofrontal cortices was best explained by genetic influences with estimates between 23 % and 67 %. in contrast, subcortical-cortical connections between amygdala and ventral anterior cingulate cortex were best explained by shared environmental influences (achterberg et al., 2018a) . together, these studies reveal that there is some evidence for genetic and shared environmental factors that impact neural signals during self/other evaluations and during resting state connectivity. however, future longitudinal studies are needed to understand stability versus change over time, and to test for sensitive time windows of (differential) environmental influences. even though a real test of differential susceptibility requires measures of longitudinal within-person change (preferably in randomized control trials), some initial evidence for heightened susceptibility to the environment may already be obtained by studying how the variation in susceptibility of children and adolescents varies over time. we examined moment-to-moment task influences (so-called 'nanotrials', (bakermans-kranenburg and van ijzendoorn, 2015)), as a means of testing how social experiences trigger different responses in children who are more or less susceptible because of prenatal or perinatal experiences or genetic make-up, and testing whether children differ most in their susceptibility during developmental phases of accelerated growth (windhorst et al., 2015) . behavioral studies of social influences on adaptive behavior suggest that social influence by peers is more pronounced in early adolescence compared to adulthood, especially for the domains of risk perception (knoll et al., 2015) and prosocial behavior (foulkes et al., 2018) . recently, it was found that in adolescents compared to children and adults, social evaluation led to stronger rating adjustments of another peer who also had previously evaluated them (rodman et al., 2017) , and that children relative to adults adjusted their ratings based on immediate feedback rather than accumulated feedback (yoon et al., 2018) . these findings suggest that responses to negative social evaluation may change over the course of child and adolescent development, with larger effects of peers in early adolescence. these studies suggest that certain windows in development are associated with larger moment-to-moment sensitivity to environmental influences, but little is known about individual differences in sensitivity to these influences in terms of self-protection or resilience within these time windows. susceptibility to the environment can also be affected by previous supportive or aversive experiences as their stress-regulatory system might be pre-programmed to the environment they have to cope with at a later stage in their development (ellis et al., 2011) . for example, it was found that children who have a history of being socially excluded in the school context respond more strongly in terms of neural activity to the experience of social exclusion (will et al., 2015a (will et al., , 2015b , and to sharing goods between other participants and self, following social exclusion . girls who had experienced maltreatment in the family context also showed stronger neural activity to exclusion (van harmelen et al., 2014) . it is not yet well understood why some children are more resilient to such aversive experiences than others, which would require an in-depth evaluation of the interaction between potential susceptibility markers and social experiences (van ijzendoorn et al, in press) . the l-cid study incorporated a randomized control parenting intervention to test for sensitive windows to environmental change influences, and to test whether some children are more susceptible to such change than others. the video-feedback intervention to promote positive parenting and sensitive discipline (vipp-sd) aims at enhancing sensitive interactions between parents and their children, and to support parents setting consistent but sensitive limit-setting when needed (euser et al., 2016) . by including two data waves preceding the intervention, and four data waves following the intervention, it will be possible to examine the effects of social enrichment on neural and behavioral development (fig. 2) . furthermore, by including and combining two partially overlapping cohorts within an accelerated cohort-sequential design, we can study windows of increased sensitivity to the environment across ages 3-13 years ( fig. 1 and fig. 2) . finally, we will use differential susceptibility markers to determine who benefits most from the intervention, that is, from a change for the better in the caregiving environment. neural measures have previously been suggested as a possible new avenue for detection of early markers for (differential) susceptibility to the environment (schriber and guyer, 2015) . one area that has been suggested as a promising candidate to be a marker of differential susceptibility is the ventral striatum (do et al., in press) . in prior research, this dopamine-rich reward-sensitive area was implicated in both negative developmental trajectories, such as risk taking and alcohol use , as well as positive developmental trajectories, such as prosocial helping and mental health (telzer et al., 2014) . furthermore, dopamine levels have been indirectly implicated in differential susceptibility as dopamine-related genotypes were found to be markers of differential susceptibility in correlational and experimental studies (bakermans-kranenburg and van ijzendoorn, 2015) . moreover, the ventral striatum shows high responsiveness in certain windows in development, specifically in mid adolescence (braams et al., 2015; silverman et al., 2015) , which may indicate a sensitive window for differential outcomes. finally, a study that examined the longitudinal development of fun seeking behavior, which is linked to ventral striatum activity (van duijvenvoorde et al., 2014) , showed that increases in fun seeking over time could explain trajectories of both rebellious and prosocial behavior (blankenstein et al., 2019) . here we propose that reactivity of the medial prefrontal cortex may be a similar differential susceptibility marker for sensitivity to social evaluation. the medial prefrontal cortex is strongly connected to both the ventral striatum and the lateral prefrontal cortex in terms of white matter connections (van den bos et al., 2014) , as well as functional connectivity (achterberg et al., 2018a) . the medial prefrontal cortex serves as a hub region for integrating self and other related neural processing (crone and fuligni, 2020) . the medial prefrontal cortex shows stronger activity in adolescence compared to adulthood in social evaluation experiments , and it is characterized by a protracted developmental time course in terms of grey matter development . finally, the medial prefrontal cortex is particularly sensitive to social evaluation in childhood, adolescence and adulthood (achterberg et al., 2018b; gunther moor et al., 2010b; van der meulen et al., 2018; yoon et al., 2018) . to be a marker of differential susceptibility, mpfc functioning should determine adaptation to the environment for better and for worse (belsky et al., 2007; belsky and pluess, 2009) . indirect evidence for a potential differential susceptibility role of the prefrontal cortex comes from a study showing that adolescents with less cognitive control and associated neural activity showed lower social competence one year later when in a highly chaotic environment, relative to peers with higher cognitive control and neural activity. however, they did not show higher social competence when in a low chaos environment, so this result might be better explained in a double-risk model although a wider range of structured to chaotic environments might uncover a differential susceptibility cross-over interaction (kim-spoon et al., 2017) . more direct evidence for differential susceptibility comes from a study in adolescent girls that demonstrated with cross-over interactions that the higher neural activity during social exclusion was associated with an increase in depression in girls with stressful parent-child relationships relative to girls with low neural reactivity, but lower levels of depression in girls with supportive parent-child relationships relative to girls with low neural reactivity (rudolph et al., 2020) . there is almost no research examining the neural development of the medial prefrontal cortex in early childhood, but our model would predict differential susceptibility in two important transition windows in development that are characterized by more rapid neuronal change: infancy/early childhood and adolescence (tamnes et al., 2017) (fig. 1 ). an important question for future research will be to test whether neural sensitivity of the ventral striatum and the medial prefrontal cortex are early markers for differential susceptibility to environmental influences, which may impact developmental outcomes for better and for worse. another challenging task for future research is to study the commonalities and differences between the various markers of differential susceptibility (see fig. 7 ). first, going beyond single genes as markers of genetic differential susceptibility (bakermans-kranenburg and van ijzendoorn, 2006) , polygenic susceptibility scores addressing specific developmental outcomes are promising candidates for genetic differential susceptibility, combining the moderating power of thousands of single nucleotide polymorphisms (belsky and van ijzendoorn, 2017; keers et al., 2016) . second, immune-system reactivity to stress has been among the first markers of differential susceptibility (boyce, 2016; boyce et al., 1995) , which has been extended to stress regulation or reactivity more generally (biological sensitivity to context (boyce and ellis, 2005) ). in a study on 5-6 year-old children, it was found that heightened cortisol response was associated with better executive functioning in children from higher socio-economic backgrounds and with lower performance in children from lower socio-economic backgrounds compared to their peers with lower cortisol response. lower cortisol responses seemed to buffer the influence of socio-economic backgrounds (obradovic et al., 2016) . third, ventral striatum reactivity has been suggested as a plausible marker of differential susceptibility (do et al., in press; schriber and guyer, 2015) . we hypothesize that the medial prefrontal cortex, and its connectivity to lateral prefrontal cortex and ventral striatum, provides a potential broader dynamic neural marker of susceptibility. fourth, reactive temperament or an equivalent adult trait on the level of personality such as sensory sensitivity has been considered as a phenotypical marker of differential susceptibility (belsky, 2005; slagt et al., 2016) . in l-cid markers of differential susceptibility have been assessed at several longitudinal assessments. furthermore, the longitudinal accelerated cohort-sequential design of the study covers an age range from early childhood to early adolescence. lastly, the design includes a randomized control trial required for sufficient statistical power to test the moderating effects of the markers . the unique opportunity for future work in l-cid therefore is to examine the moderating role of each susceptibility marker in different developmental periods, to explore any relations among the markers, and test whether perhaps the commonality among various markers could be the most powerful aggregate marker of differential susceptibility (see fig. 7 ). in fig. 7 we do not suggest any causal influences between the different markers that are situated on different levels of neurobiological and behavioral functioning, from genetics to hormonal and neural functioning to temperamentally shaped behavior. the associations between the four markers are object of exploratory research as studies from which to derive specific hypotheses are still absent. in this review, we present a neuroscientific differential susceptibility model that can be tested in future research and that is the driving motivation for the leiden consortium on individual development (l-cid) study. several of the hypotheses can only be examined with longitudinal models including a randomized intervention, but the crosssectional analyses provide important starting points for unraveling the dynamics of social evaluation. in future research, we will be able to extend these insights to contribute to answering the question: which children are most susceptible to environmental influences and at what time-points or windows in development are influences from the environment most pronounced, thus contributing to the perennial question in policy, prevention and therapeutic approaches: what works for whom at what time in development? the l-cid study provides several new directions for understanding social evaluation in the context of self-protective mechanisms as well as other-oriented motivations. we proposed that the bi-directional relations between these processes will provide an important starting point for understanding social competence development and other developmental outcomes. several important factors potentially explaining differences in social competence were not explicitly covered in this review, such as helping members of ingroup versus outgroup, and the influence of twin-sibling relationships. it is our ambition that in the future l-cid will provide a rich open data set for researchers to examine the processes involved in social competence and extend our work to new domains. by using a multi-method, multi-informant and multi-time-points approach, fig. 7 . four potential differential susceptibility markers on different levels of functioning. differential polygenic scores are potentially the foundation for the three (endo-)phenotypical markers, but across development epigenetic changes in expression of the genes involved might result from environmental influences filtered through immune and neural reactivity or temperamental characteristics. childhood cohort (ecc, left) and middle childhood cohort (mcc, right). we hope to contribute to better operationalization of the core concepts, which ultimately can lead to better characterization of developmental problems and psychopathologies. although our study primarily aims at behaviors related to social competence, future studies may focus more strongly on strategic considerations or motivations for self-control and prosociality. this question has received most attention in the study of motivations for prosocial behavior (thielmann et al., 2020) . paradigms examining costly versus non-costly helping, for example, suggest that different processes may drive these behaviors (cutler and campbell-meiklejohn, 2019) . also, several findings show that prosocial behavior is dependent on the target and the presence of others (foulkes et al., 2018; guroglu et al., 2014) , suggesting that prosocial behavior is strongly dependent on context (van ijzendoorn and bakermans-kranenburg, 2014). these findings may also explain why measures of prosocial behavior tend to diverge in experimental paradigms and questionnaire research, although indices of prosocial behavior are often combined across multiple contexts. questionnaire research may be particularly sensitive to response bias, given that responding to questions about prosociality might entail self-protective and defensive mechanisms, but a strength of questionnaires is that multiple daily life contexts are covered. relatedly, little is known about the context-specificity of self-control following social evaluation, for example, being rejected by a friend or caregiver versus an unknown other. rejection by known versus unknown others may also differentially influence self-protection mechanisms, as rejection by a familiar other might cause feelings of depression whereas rejection by an unknown other might lead to acts of aggression. future research should examine prosociality and self-control following social evaluation in terms of stability and change, and determine the contextual factors that influence behavior and neural activity, and brain-behavior associations. in sum, we point towards activity and connectivity in the medial prefrontal cortex and the ventral striatum as potential neural differential susceptibility markers. in future research, these markers will be combined with insights from the intervention trial and other differential susceptibility markers (polygenetic scores, reactive temperament) to unravel why some children are more susceptible to environmental influences than others. an important aim will be to test stability and change of neural signals over time in order to contribute to a better understanding of reliability of measurement versus context-dependent change . together with the youth-cid program (this issue) and other large data sets including abcd, generation r, and other developmental studies around the world (rosenberg et al., 2018) , it will be possible to provide richer and culture-and context-dependent insights in neural and behavioral development during childhood and adolescence. eac and mhvij drafted the manuscript. mjbk contributed to the study design and commented on the first draft of 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sensitivity predicting externalizing behavior development of mpfc function mediates shifts in self-protective behavior provoked by social feedback this work was supported by a gravitation program of the dutch ministry of education, culture, and science and the netherlands organization for scientific research (nwo grant number 024.001.003) and an innovative ideas grant of the european research council (erc cog prosocial 681632 to e.a.c.). we thank the participating families for their enthusiastic involvement in the l-cid study. we also thank the extensive and continuously ongoing data collection team, including all current and former l-cid students, research assistance, phd students and post-doctoral researchers. supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.dcn.2020.100805. key: cord-307292-de4lbc24 authors: rosenberg, hananel; ophir, yaakov; billig, miriam title: omg, r u ok? [image: see text]: using social media to form therapeutic relationships with youth at risk date: 2020-08-17 journal: child youth serv rev doi: 10.1016/j.childyouth.2020.105365 sha: doc_id: 307292 cord_uid: de4lbc24 the rising of social media has opened new opportunities for forming therapeutic relationships with youth at risk who have little faith in institutionalized interventions. the goal of this study is to examine whether and how youth care workers utilize social media communications for reaching out to detached adolescents and providing them emotional support. qualitative in-depth interviews (n=17) were conducted with counselors, social workers, and clinical psychologists who work with youth at risk. a thematic analysis of the interviews revealed three principal psychosocial usages of social media: (1) reaching out and maintaining reciprocal and meaningful therapeutic relationships with youth at risk over time; (2) identifying risks and emotional distress; and (3) “stepping in” and providing psychosocial assistance, when needed. these beneficial practices are made possible through the high accessibility and the sense of secured mediation that characterize social media communication and that complement the psychosocial needs of youth at risk. alongside these advantages, the analysis yielded several significant challenges in social media therapeutic relationships, including privacy dilemmas and blurring of authority and boundaries. given that social media communication is a relatively new phenomenon, the applied psychosocial practices are shaped through a process of trial and error, intuitive decisions, and peer learning. although the main conclusion from this study supports the notion that the advantages of social media therapeutic relationships with youth at risk outweigh their problematic aspects, future research is recommended to establish clear guidelines for youth caregivers who wish to integrate the new media in their daily psychosocial work. youth who are, or may be, at risk of physical, mental, or emotional harm suffer from a wide range of difficulties that endanger them and threaten their ability to function, currently or in the future. unfortunately, adult caregivers are not always aware of their children, patients, or students' emotional struggles and the at-risk youth often drift away from conventional supporting environments, such schools and youth movements. instead, they wander around unsupervised, seeking adventures and belongingness in alternative, and in some cases dangerous, settings (resnick & burt, 1996) . one of the principal challenges in supporting these detached youth is the very formation and maintenance of solid and trustful relationships. when confronting hardships, many adolescents at risk prefer not to turn to their parents or teachers for psychosocial support (grinstein-weiss, fishman & eisikovits, 2005) . however, in some cases they are willing to accept help from informal counselors and social workers (kaim & romi, 2015) . this informal help is crucial for their mental health because one of the key factors that can help at-risk youth successfully navigate their complex challenges is a rich and supportive environment and a strong relationship with a caring adult figure (gilat, ezer, & sagi, 2011) . remarkably, new opportunities for reaching out and supporting youth at risk have aroused with the outbreak of online social media. youth all over the world spend large amount of time online every day and perceive the various social networks technologies (e.g., instagram, whatsapp) as a most convenient channel of communication. in many cases they would even prefer text-based communication online over other forms of communication, including face-to-face (joshi, stubbe, li, & hilty, 2019) . recognizing these trends, some educators and school counselors have started to establish online connections with teenagers under their care in an attempt to offer them guidance and emotional support (asterhan & rosenberg, 2015) . however, in spite of these spontaneous initiatives, little is known about the extent and the ways in which caregivers utilize online communication for establishing positive and trustful relationships with youth at risk. the goal of the current study is to examine whether and how social media can be utilized for reaching out and providing emotional support to at-risk youth (adolescents and emerging adults). we hypothesized that youth caregivers would leverage the new media to overcome one of the main obstacles that characterize youth at risk. in many cases, these distressed adolescents disengage from institutionalized support systems, such as family, school, and youth movements and wonder around, searching for novel and distant spaces, away from their community. this allows them to achieve a sense of freedom and control but also places an obstacle in front of the adults who wish to contact and support them (kaim & romi, 2015) . in this study, we focus on youth caregivers who work with a unique population of youth at risk from small isolated settlements in the east border of israel, yet, the conclusions are relevant for similar rural areas around the world. like other youth at risk, they too, are at risk of substance use, problematic sexual behaviors, and school dropouts. however, they are also at risk for a unique identity crisis. in many cases, these youth rebel against their parents' religion and values. the ideological tension between the conservative small communities and the excitements and temptations that are evident in the 'big city' or in the mass media contributes to this rebellion and distance them from their families and community (shemesh, 2000) . these youth are also dispersed in a relatively large geographical space, with limited transportation options. youth workers in this geographical location may therefore tend to rely on non-formal communication methods, even more than in other urban communities. the current research aims to learn from the accumulating experience of these workers (psychologist, social workers, and counsellors) and provide a window to the benefits and limitations of social media therapeutic relationships between caregivers and youth at risk. the enormous popularity of social media among children and adolescents led many educators to start utilizing the various social networks for online communication with their students. this emerging trend raised multiple ethical and educational challenges, including concerns that the adult educational authority will keep deteriorating and that the privacy of both educators and students will be compromised. however, despite these concerns, some policymakers and educators have integrated the online communication in their daily educational practices (greenhow, robelia, & hughes, 2009; hershkovitz, abu elhija, & zedan, 2019; asterhan & rosenberg, 2015; . teachers use online communication for improving group and individual studying, extending learning time beyond school settings, and managing the logistics of their class activities. some teachers even extend their educational role to include the new media environment and took upon themselves to supervise and monitor online forums, identify signs of personal distress, and assist students in need. finally, some educators leverage the informality that characterizes the various social networks, to get acquainted with the social and cultural aspects of their students life and deepen their relationships with them (forkosh-baruch, hershkovitz, & ang, 2015; hershkovitz & forkosh-baruch, 2013; . online communication has been also leveraged by educators for delivering emotional support to their students. during the 2014 israel-gaza war for example, the majority of the teachers in the israeli cities that were exposed to war-related events provided support and empowered their students using non-formal communication methods, such as facebook and whatsapp. notably, most students valued their teachers outreach effort and reported that it contributed to their general sense of resilience (ophir, rosenberg, asterhan, & schwarz, 2016) . aside from benefiting from the concrete psychological aid online, it seems that the very existence of a continuous relationship online with a caring adult, had a significant contribution to the adolescent' sense of control and belonging (rosenberg, ophir, & asterhan, 2018) . these 'semi-therapeutic' communications join teachers efforts to detect signs of distress from their students' online activities and to provide them emotional support at normal times (i.e., not at wartime) (hershkovitz & forkosh-baruch, 2013; forkosh-baruch, hershkovitz, & ang, 2015; asterhan & rosenberg, 2015) . the therapeutic value of the very existence of online relationships has been examined in other, non-educational settings. for example, users suffering from depression who joined facebook support groups showed a significant improvement, especially when one of the "facebook friends" in the group was a psychiatrist (mota pereira, 2014). given that only very few patients in this particular study actually contacted the psychiatrist via facebook, it seems that simply knowing they had access to professional medical assistance contributed to their subjective well-being. this positive psychological experience can be explained by the authentic discourse that characterizes the instant and synchronous-textual communication in the new media (lapidot-lefler & barak, 2012) . the informal sharing of personal content and the removal of barriers such as embarrassment, especially among adolescents (bardi & brady, 2010) provide users with the opportunity to achieve emotional relief, which in some cases may even surpass the emotional benefit that is "allowed" in the traditional face-to-face communication (dolev-cohen & barak, 2013) . in fact, a dominant theme that emerged from a recent narrative analysis of anonymous online stories on suicide and self-harm behaviors, was 'overcoming silence and isolation'. according to the authors, the anonymous communication online enables young people who feel invisible and experience emotional distress to resist oppressive social norms and turn their emotional struggles into testimonies and stories worth telling (yeo, 2020) . correspondingly, qualitative interviews with 15 young recipients (< 24 year-old) of online outreach services reported that social medica and whatsapp communication enables them to speak freely about their emotional problems, even more than face-to-face interactions (chan & ngai, 2019). the unique advantage of online communication in creating a comfortable platform for emotional disclosure is well documented in the research on psychological counseling online (via email or video-chats). in fact, online counselling has gained much experience since the late 1990s (mallen, vogel, rochlen, & day, 2005) and today many people use online platforms to overcome emotional distress and to improve their overall well-being (andersson et al., 2014; mota-pereira, 2014; richards & richardson, 2012) . indeed the specific research on social media counselling is scarce and one cannot assume that this new medium would share the same characteristics of the somewhat more formal communication through email or video-chat. however, as described above, social media communication may especially relevant to youth. in the following section we expand on the potential benefits and limitations of social media in the context of therapeutic relationships. on the one hand, using social media to improve the well-being of youth at risk seems most relevant. in contrast to adults, adolescents may be less cooperative with conventional therapeutic efforts and prefer tactics of avoidance and escape (kaim & romi, 2015) . in fact, a primary difficulty in working with at-risk youth is to bring them to the health service gate and therapists struggle in maintaining ongoing therapeutic relationships. adolescents are not always aware of the available mental health services and even when they are, they fear the negative stigma associated with seeking help, which will damage their "tough" image in the eyes of their peers (ben hur & giorno, 2010) . in the digital realm, however, adolescents can receive discreet psychological support (barak & dolev-cohen, 2006; dolev-cohen, & barak, 2013; valkenburg & peter, 2009 ), without fearing from real or imagined social sanctions (friedman & billig, 2018) . the online communication is usually voluntary (i.e., it is not being mandated by the adult) and the adolescent is prone to feel more comfortable and less shameful (ben hur & giorno, 2010) . on the other hand, despite the above-mentioned benefits, therapeutic interventions via social media have limitations and challenges, precisely due to the characteristics of online communication. first, the informality and the blurred boundaries that characterizes social media communication may undermine the caregiver authority and create a false presentation as if the relationships between the adolescent and the caregiver are symmetrical (asterhan & rosenberg, 2015) . therefore, computer-mediated relationship requires clear behavioral procedures to avoid deviation from an appropriate therapist-patient relationship (barak, klein, & proudfoot, 2009 ). second, the physical distance between the parties makes it difficult to establish a long-term commitment to treatment, or to provide immediate assistance in situations requiring physical access to the patient, such as cases of potential suicide (amichai-hamburger et al., 2014) . finally, the very notion that youth at risk will be open and responsive to social media based outreach efforts is yet to be studied. freshmen students for example, who published facebook posts that included explicit references to emotional distress, reported that they prefer being approached directly, in a face-to-face manner (whitehill et al., 2013) . indeed, the majority of these students were willing to accept help from their professors or teachers' assistants, but they also expressed their concerns that strangers would monitor their facebook activity, even if this is done with good intention (whitehill et al., 2013) . the complex picture that arises from the literature emphasizes the need for effective and safe training programs for mental health workers (barak, klein, & proudfoot, 2009 ). however, despite this growing need and despite the rising number of studies on teachers-students online communication, only little is known about the potential benefits and limitations of online treatments for at-risk youth. the goal of the current study is therefore to examine the characteristics of online therapeutic relationships between adolescents at risk and their caregivers (i.e., counselors and social workers). specifically, the study addresses three research questions: (a) how do youth workers utilize social media communication for creating and maintaining therapeutic relationships with at-risk adolescents (b) what are the potential therapeutic benefits of such communication and what distinguish it from traditional face-to-face relationships with at-risk youth? (c) what are the problems and challenges that arise from these online practices? altogether, by providing pioneering answers to these questions, we hope to promote the emerging interdisciplinary research filed of online counseling and contribute to the mental health of adolescents at risk around the world. a qualitative research design was applied due to the exploratory nature of this research (creswell, 2009 ). the study included 17 in-depth interviews (10 women and 7 men) with youth caregivers who work in a range of facilities and programs for youth (table 1) , including welfare departments and boarding schools in isolated settlements in the eastern border of israel. participants were recruited in several ways: by contacting welfare departments in the research area, using the snowball method with the help of personal acquaintances, and posting messages on social media to identify potential participants. after collecting the contact information of potential participants, a personal inquiry was sent to them, which included a description of the research topic and its objectives. from among those who agreed to participate, we made an effort to create a research group with as wide a range of faculty positions as possible. the interviewees were: youth counselors and coordinators (n = 7), social workers (n = 7), a clinical psychologist (n = 1), a director of social welfare services (n = 1), and a senior coordinator responsible for the training of faculty (n = 1). for details of the interviewees, see the table in appendix 1. the age of the participants ranged from focusing on the perspective of the therapeutic professionals provides a broad perspective of the phenomenon, including therapeutic, institutional, and organizational aspects. data collection consisted of semi-structured in-depth interviews conducted with the purpose of exploring the personal perspectives and experience of the interviewees, through the presentation of their authentic voices regarding the phenomenon under investigation (moustakas, 1994 ; see also marwick & boyd, 2014 , on the use of interviews to reveal insights regarding new media functions in daily life). the interviews were conducted over the course of three months during 2019, with each interview lasting between one and one-and-a-half hours. the interviews were mainly done in-person, with the exception of five interviews that were done over the phone. interviewees were asked a variety of questions about the content and characteristics of their online communication with at-risk youth, what considerations motivated them to choose social media as an aspect of treatment, and how they perceived the advantages and disadvantages of online communication in this context (for the full questionnaire, see appendix no. 2). the interviews were recorded and transcribed. the data were analyzed with individual profiling and thematic analysis: first, we crafted profiles of each interviewee, which "allows us to present the participant in context, to clarify his or her intentions, and to convey a sense of process and time, all central components of qualitative analysis" (seidman, 2006: 119) ; second, we examined categories, patterns, and connections, trying to find a balance between within-case and cross-case analysis (king and horrocks, 2010) . the thematic analysis mostly involved an inductive approach (themes emerged from and were grounded in the data), although self-presentation was defined as a priori theme. third, the coded categories were conceptualized into broader themes. while innovative researchers are increasingly using electronic methods for coding data (mainly for the second and third stages mentioned above), due to the small size of the sample we preferred to stick to the traditional method of manual coding (see: basit, 2003) . following king and horrocks (2010) and neves et. al, (2015) , we preformed three steps procedures: first, the main and second authors read the transcripts independently to identify categories and themes. second, both authors coded together, using a label-coding scheme and tested for convergence. third, the coded categories were conceptualized into broader themes. finally, the third author sampled 35 per cent of the transcripts to determine reliability of the category coding: the inter-rater reliability for category coding was 90 per cent. the inter-rater reliability was calculated by counting discrepancies in category assignment between the coded transcripts of the two authors and the third author and by dividing them by the total category assignments throughout the research, we attempted to remember the gap between our experience as researchers in understanding the phenomenon being researched and we also aware that the qualitative researcher's feelings and emotions serve as an analytical tool, as well as constituting an integral part of our scientific work (allen, orbe, & olivas, 1999) . in order to improve the trustworthiness of the results we used strategy suggested by lincoln (1985), we invited three of the informant to read a review first draft of the findings analysis and conclusions, and some of their remarks are even integrated into this paper. this, in order to create a dialog wherein "the subjects of the theoretical statements become active partners in the developing process of verification of knowledge" (bauman, 1976, p. 106), in the course of conducting the research and writing the results and analysis, special attention was given to ethical considerations. all interviewees received a written explanation of the research aims, methods and ethics (considering anonymity and confidentiality). in order to ensure the privacy and anonymity of the interviewees as well as that of individuals mentioned in work-related stories that were told during the interviews, the names of the interviewees appearing in this article have been changed, while maintaining their gender and professional role. in some cases, technical and biographical details have been changed from the interview transcript (allmark et al., 2009 ). the research was approved by the ariel university irb. the primary impression that emerges from the analysis of the interviews is that therapeutic staff members view social media as an important and necessary tool in the treatment of at-risk youth. the social media platforms that used the staff was mainly facebook, instagram, and whatsapp. all of the participants reported that they see great advantages in integrating these platforms into their daily social work and therapeutic practices. some even defined this type of work as a "necessary skill." however, with the exception of several interviewees who work in a dedicated online setting (detailed below), the majority noted that because the use of this media channel for therapeutic purposes is new, their workplace does not have clear guidelines about it. as daniella, a social worker at a boarding school for at-risk youth said: "the staff doesn't have agreed-upon rules, each person does what he wants to and chooses to do." the therapists noted that they are given a "free hand" when it comes to online relationships. the issues that commonly arise are concerned with questions of privacy, authority, and boundaries (for more on these issues, see below). analysis of the interviews revealed four distinct purposes of online communication with alienated youth: (a) technical and organizational purposes; (b) familiarity and connection (c) monitoring potentially dangerous situations, and (d) therapeutic interventions. deepening contact with youth understanding the (online and interpersonal) youth culture defining the treatment time the technical and organizational aspect is particularly seen in the use of whatsapp groups among the therapeutic staff, as well as whatsapp groups that include both professionals and the youth they are treating. eleven interviewees mention that the whatsapp serves as an easy and highly accessible platform for messaging, updating, and scheduling meetings. the diverse functions of whatsapp, such as the ability to create groups and mailing lists, and to switch between interpersonal and group communication, allow for increased control and management. for example, the ability to easily send information and updates to a large number of people frees up valuable time for professionals to engage in educational and therapeutic work. two of the youth care workers noted the feature of whatsapp that allows them to see whether the recipient has read the message (this is a default setting in the application). the feature has become an integral part of their decision-making process about whether it is worth investing additional efforts in an outreach project aimed at recruiting as many youth as possible. a core theme that arose from all of the interviews is the use of social media for purposes of integration, deepening familiarity, and establishing therapeutic relationships with the youth. analysis of the interviews revealed three types of potential therapeutic benefits of social media communication with youth at risk. moreover, young people understand that the ability to use the distinctive language of the internet, for example emojis and new phrases and terms, enables a conversation on equal terms, allowing them to express their feelings in their own language. this creates closeness and opportunities to build trust in their relationships. "i identify a kid who has an easier time expressing himself through messaging. it gives him the time and space to read my message and get back to me when its comfortable for him. it's especially helpful to me especially in the early 'courting' stage of the relationship," (uri, social worker at a non-residential regional center for at-risk youth). one interviewee noted a gender difference when it comes to social media communication: "with boys, let's say, i see that it's easier to communicate with them through whatsapp than in person. for girls, it seems to me the opposite, because they are more verbal. for example, we had a male teen who had a really hard time communicating, but it was easier to talk to him through whatsapp," (ella, coordinator at a youth outreach program). when we asked the interviewees what exactly is on social media that allows the connection they describe, they highlighted specific features and characteristics of social media, such as the availability, accessibility, and computer-mediation of the text that help deepen the relationship and create an open and honest conversation. "there is something about messaging. hiding behind the message allows you to feel comfortable and open, without facial expressions that convey judgment" (leah, media coordinator at the department for youth development). another interviewee mentioned a phenomenon he commonly encounters, a situation in which there is no way to contact the youth, for technical reasons: "i have encountered situations in which youth have a problem with their cellphones, usually because they don't have money to pay for the service, so they turn off their phones, and whatsapp is the only way i have to communicate with them," (david, social worker at a boarding school for at-risk youth). these descriptions recall the quote from uri, about the way online communication helps in the early stages of the relationship. in contrast to classic psychological treatment, therapeutic professionals working with at-risk youth take an approach of gradually getting to know each patient. the characteristics of online communication facilitates this practice and help overcome barriers that may impede success. (b) maintaining relationships. social media enables staff members to keep in touch with youth whom they've worked with in the past. facebook and instagram, in particular, allow them follow the activities, personal lives, and achievements of 'alumni' months and even years after they stop communicating through the more intensive media outlets such as whatsapp groups that were actively used as part of the treatment frameworks. at the same time, three interviewees noted that the whatsapp groups they shared with the youth remained active for years after the formal treatment framework ended. "the group is still active from time to time. i find it moving that they make sure to send happy birthday notes when one of the youth or counselors has a birthday... it's nice to see that they care about each other and that they take a minute or two to send each other birthday wishes," (roni, social worker in the department of youth development). the importance of this connection is twofold. on the part of the staff members, whatsapp allows them to 'stay in touch,' but they indicated that it goes beyond that. they said that being able to follow how alumni are integrating into ordinary life allows them to receive feedback, which one interviewee described as "getting closure." seeing the results, the outcomes, helps reinforce their belief in the challenging work that they do. from the perspective of the youth, the online forum can serve as a mutual support network, and even as a possible opening for them to seek out advice and assistance as they navigate their paths: "[the whatsapp group] helps them keep in touch with the most meaningful group in their lives, that is, the people they were with when they went through a hard time at the very important age of 16 or 17. we see that even four years later, they'll arrange to meet up, and they share a common language that stays very much alive. it's mainly social, but it can certainly be a platform for therapeutic work like monitoring or ongoing assistance or referrals for help. recently, a lot of the youth who finished [our program] had no framework to be in, and we found jobs for them, we were able to help them," (nurit, director of social welfare division for youth development). (c) understanding the (online and interpersonal) youth culture. the therapeutic staff's online presence helps them to get to know the personal world of the youth, bridging the gap between the adults (the therapeutic professionals) and the young people. six interviewees that highlighted this theme, refer to two levels of acquaintance. this further familiarity with the youth is particular to the online sphere. caregivers see their presence on social media as a way to better understand the online forums and to identify risks, such as bullying and inappropriate discourse. sometimes they can even offer guidance in this new type of social space. social media offers a convenient platform for youth to share emotions and express their thoughts, feelings, and frustrations. therefore, in addition to providing a forum for strengthening connections and becoming familiar with each other, the presence of therapy professionals in online forums has valuable potential for identifying signs of distress prevalent among at-risk youth. interestingly, this theme was raised by all of the interviewees, citing numerous situations in which signs of distress were first exposed online. there was one girl who always posted questions about sexual harassment. it was very worrying. after each such post, i would send her a private message: 'hi, i read your post. i would love to help you.' it was a gentle kind of outreach, because she was already big, 17 years old, which is a stage when they tend to want to share less, when there's a desire for independence. after a few times, she suddenly answered and we developed a connection, and it really helped. (nurit, director of social welfare division for youth development). online communication venues seem to allow youth who are experiencing distress to express their feelings with greater ease, as compared to face-to-face meetings. the interviewees described a wide variety of online posts that drew their attention to the distress of those who wrote them, whether the post was about the pain of a breaking up with a boyfriend or girlfriend, or a crisis with their parents, a depressive episode, social isolation, or even suicidal thoughts. there was a post in which someone expressed signs of distress. naturally, we showed it the social worker, and a tragedy was avoided. the girl wanted to commit suicide, she wrote all kinds of things like "i want to die," "i hate my life." because of facebook, we were able to save her. (ariella, coordinator at a youth outreach program). use of social media is relevant to therapeutic professionals tasked with identifying and reaching out to marginalized youth. in the digital age, this type of work has expanded from the traditional "street search" to a new practice of online searches. indeed, some welfare departments have established media departments and teams that seek to leverage online forums and social media as tools for identifying distress, as means for outreach to at-risk youth, and even to help by providing an initial response, as described in this quote: the orly, who works in the media department of a youth development program, emphasizes the potential of this tool to reach youth who typically avoid exposing their distress or actively seeking mental health support. we can identify situations of distress on social media by spreading posts that reach young people and invite them to contact us. it's there that we see the ones whose pain is more internalized, who don't necessarily look like the ones out in the streets. we're also often approached with questions about sexual identity, which means we are expanding our target audience. using social media to meet the needs of youth and provide them with emotional support was also noted by the most of the interviewees -about 14 in number. "online media helps us locate the youth. there are situations in which we were able to achieve deep therapeutic discourse solely through online correspondence... [the internet] provides us with a vast therapeutic space." (leah, media coordinator, department of youth development). however, it is important to note that while there was considerable consensus among the interviewed professionals regarding the potential uses of online communication described above (technical and organizational purposes, making connections, and monitoring distress), the situation was different regarding its use in therapeutic interventions. even those who to some extent supported such practices presented ambivalent positions, or at least qualified their statements. when leah (quoted above) was asked to give an example of online therapy, she noted a practice that enables youth to sit in the same physical space as caregivers, but chat with them online: choosing to conduct therapy sessions through the chat feature is comfortable for the youth. they feel more secure and more open to talking. meaning, we can actually meet with someone and sit in the same room but still be communicating through the chat. the main thing is to give them the feeling that they are safe and can trust us, and that we are here to help in any way that's comfortable for them, at least in the beginning," 5 of the interviewees strongly emphasize that providing treatment online is a topic of debate among professionals in the field. one of them mentioned a heated discussion among the professional team about whether the word "therapy" should be used to refer to online communication, or whether it is merely a "supportive aid" for therapy. leah stated that she sees an online chat as a first step in the therapeutic process, but not as a practice that can stand on its own. similarly, other interviewees said they did not consider it a replacement for traditional in-person therapy. the in discussions with the interviewees about their actual work in the field, we found almost complete consensus in favor of using online communication as part of their therapeutic work. however, deeper investigation into the issue indicates that they decided to use it both because of its benefits and despite its limitations. most of the interviewees (14 of 17) noted dilemmas and debates leading up to the decision to adopt online forums as part of their work and some grappled with these questions even while they use online communication. these dilemmas revolve mainly around two issues: the need to protect the privacy of caregivers and patients, and the difficulty of delineating the treatment time. privacy of therapists and youth. some characteristics of social media include personal exposure and sharing by its users. this is the key to its therapeutic potential, and also presents one of the main challenges facing therapists. disclosing caregivers' personal profiles to the youth they treat is seen as problematic. "my facebook page includes family-related things. i don't know if they need to know everything," (samuel, social worker at a youth support center). this concern also relates to the professionals' opinions on current events: "i write a lot about politics on facebook. often, i didn't feel it was right for them to be so aware of my opinions," (david, social worker at a boarding school for at-risk youth). the privacy dilemma also touches on the need to respect the privacy of the youth being treated. monitoring youth online has ethical as well as therapeutic implications. "keeping track of them and being exposed to the things they do is sometimes problematic, because it is an invasion of their privacy. we use it, but are very careful. most of them have trust issues, so i don't want them to think i've been following them [online] all day," (julia, social worker and therapist at a youth development program). various aspects of the privacy dilemma were mentioned multiple times by the interviewees. on the one hand, they expressed a desire to initiate discussions with youth about issues to which the therapist was exposed while viewing their posts on social media. on the other hand, they worry that raising issues the youth did not choose to share directly with the therapist could cause them to avoid treatment, or cause a crisis of trust. the significant therapeutic potential that is inherent in information the therapist sees online must be considered alongside the invasion of the youths' privacy and the danger of violating the therapeutic contract. most of the interviewees said they strive to find the proper balance. on the issue of the online statuses to which we are exposed, there is a lot of information that can help us catch problems in time, such as suicide. we had a girl who showed all kinds of warning signs that she was suicidal, and we prevented it. this can be confusing, but also helpful. it is a question of whether to invade their privacy and whether they want us to do that, while the post is also be a call for help. it's between invasion of privacy and offering help. as we catch up with the gaps in technology advancement, we have to think about how to use online media as an essential tool. (leah, coordinator in the department for youth development) defining the treatment time. another potential disadvantage of using social media that bothered the interviewed professionals pertains to the question of defining the therapeutic setting. the accessibility and ease of sending messages makes it possible for youth to contact therapists beyond working hours, at night or on weekends and holidays. there is a disadvantage in the sense that, for example, they might send messages really late at night. it's more difficult to set limits online, so you need to define the treatment time. i had a case with a girl who asked me 'why were you up at 4 in the morning?' because she saw on whatsapp that i was online. you have to understand that they are on their phones all the time, and they see and pay attention to everything. this has many benefits for adolescents, but you also have to pay it is important to note that the interviewees who mentioned the difficulty in limiting the treatment time were not only relating to their personal experience of how their online presence required them to be available to the youth in their free time; the undefined time also potentially harms the youth. being friends on facebook and instagram with the youth may allow them to deepen and improve their relationship, but it also raises questions about authority and how the relationship is perceived. there is a concern that the caregiver-patient or mentor-mentee relationship will be transformed, in the youth's perspective, into a relationship similar to their other social relationships. this concern is heightened in the case of online contact between therapists and patients of the opposite sex ("if, with boys, i deliberate a few times, with girls i am a million times more cautious," omer, clinical psychologist at a youth development program). in addressing this issue, four interviewees noted that defining the times during which they can be in contact conveys an important therapeutic message and improves patients' ability to accept delayed gratification (despite their potential availability). this skill can be beneficial to the youth in many areas of life. before i told them until what time i'm available, there were situations when i would receive notifications at night as well. i had to make a separation between work and my personal life. it's mostly for myself, but it's also good for the youth, who know i am there for them, but not constantly. this parallels reality, in that they learn that not everything is always accessible to them, and that it may not be possible to help them as soon as they want it, and it's from an empathic place, so they can understand what it's like out there in the world. (julia, social worker and caregiver at a youth development program) one of the interviewers emphasized that when defining their working hours with the youth, they clarified that these limits can be extended in urgent cases: "for example, i specify that i will answer until 6 p.m., and after that only if it is an emergency" (yifat, a coordinator at the department of youth development,). similarly, the very discussion with the youth about what is and is not considered an emergency also serves as a therapeutic opportunity: i had a case a few months ago of a boy calling me at 9 p.m. i sent him a message asking if it was urgent. it turned out that his bike had been stolen, and he was very worried about how his father would respond to the theft (...). that is why i think there are gray areas, and a need for shared thinking about everything. (leah, media coordinator at the department for youth development). another work-related challenge concerns the nature of communication through text messaging. interviewees gave examples of text messages that could be interpreted as more social and intimate than was their original intent. added to this is the fact that such messages sent outside of working hours can diminish the status of the therapist as an authority figure and thus detract from the effectiveness of treatment: "the problem is that it turns into something social, and i am not sure i want to give the relationship that connotation," (menachem, senior coordinator at a youth development program). it emerged that questions related to defining the treatment time are a significant concern to the therapeutic professionals. they repeatedly emphasized that because of the novelty of using online forums, they have no regular use pattern and no definitive answers. the interviewees reiterated that they lack formal guidelines from their workplace about providing treatment to youth online. ("in terms of any general definition or expectation for employees -there is nothing. everyone decides on individual basis," julia, social worker and caregiver at a youth development program.) it is evident that they are eager to receive training on how to effectively and appropriately communicate with youth via social media. instead, their online work activity is characterized by trial-and-error, intuitive decisions, retrospective considerations, and sharing their deliberations with their colleagues. "basically, we are still discovering all the problems and advantages of this tool," (leah). several interviewees mentioned the need to guide the youth regarding proper online communication with therapy professionals as well as a need to develop professional training for therapeutic staff who wish to work (also) through online technologies. this sentiment is summarized by yifat, a coordinator in the department for youth development: there is no doubt that today's technological world is evolving and it is not really under our control. the youth are there, and so we must show our presence there as well. i think, and see, that there are many young people who can only be contacted through online networks. despite the disadvantages communicating through screens, this is the situation, and it should be channeled towards good things. through online networks, trust is also created. there is something very powerful about entering their world and about its ways of reaching them and treating them. even if the relationship ends without them getting frontal treatment, i have been in situations where the communication helped and supported young people who were in distress. the growing popularity of social media raised new opportunities for reaching out and supporting youth at risk. using in-depth interviews with youth counselors and social workers, this study examined the characteristics of online therapeutic relationships between adolescents at risk and their caregivers. the interviews revealed that counselors and social workers generally hold a positive view towards online therapeutic relationships. they acknowledge the benefits of this new type of communication and recount its therapeutic successes. according to the interviewees, social media based communication contributes to maintaining a reciprocal, meaningful, and long-term contact with the at-risk youth under their care. the qualitative analysis of the interviews reveals that online communication can facilitate and even improve the quality of the therapeutic relationship with at risk youth in three key areas: (1) forming a trustful and positive relationship with detached youth and maintaining it over time; (2) detecting early signs of dangers and distress; and (3) providing psychosocial counseling when needed. yet, the clinical picture is more complicated than these noted advantages. the interviewees expressed several concerns regarding the integration of new technologies into the traditional therapeutic practice and some even opposed to use of the word "therapy" in the context of online communication with at-risk youth. the ambivalence regarding the use of new media as a legitimate therapeutic tool might derive from the fact that counselors and social workers usually rely on well-defined, theory-driven therapeutic approaches (e.g., cognitive behavior therapy, psychodynamic therapy). these approaches determine the specific settings that are required for a successful treatment and layout the specific therapeutic strategies that should be applied to achieve beneficial outcomes. nevertheless, it seems that, regardless of their theoretical background, all the interviewees acknowledged the importance of maintaining a continuous relationship with at-risk youth through online communication. this main theme can be understood through the prism of "common factors" in psychotherapy (castonguay, 1993) . even though different therapeutic approaches incorporate different set of values and practices, they also share common factors that contribute to the successful outcome of the treatment. for example, simply the beginning of a treatment may arouse patient's expectations for symptom relief, which in turn inspire hope and motivation to change (arnkoff, glass, & shapiro, 2002) . and above all, all approaches highlight the therapeutic alliance as an essential condition for treatment (pilecki, thoma, & mckay, 2015) . the quality of the relationship between patients and therapists is one of most researched therapeutic component, which has been proven to significantly contribute to outcomes of treatments, independent of the specific type of the examined therapy (norcross & wampold, 2011) . based on this perspective, it is understood why all the interviewees cherished the online communication. regardless of their guiding approach, they all assume that a positive and trustful therapeutic alliance is a crucial factor in the treatment of at-risk youth. some might even argue that the very relationship between the therapist and the adolescent is the therapy. however, forming a solid therapeutic relationship with at-risk youth is not an easy task. youth at risk are not always inclined to cooperate with conventional therapeutic efforts and may prefer tactics of avoidance and escape (kaim & romi, 2015) . many of them fear the negative stigma associated with seeking help and are worried that cooperating with the "adult system", will damage their image in the eyes of their peers (ben hur & giorno, 2010) . these characteristics may explain why the new media attracted both the adolescents and the counselors and social workers. apparently, some of the problematic aspects of online communication, such as the anonymity and the avoidance of direct face-to-face communication, are the very reasons that this form of communication "speaks" to adolescents at-risk. the (partial) anonymity encourages youth to share their inner feelings openly and helps them to overcome the psychosocial barriers mentioned above. it allows them to receive discreet psychosocial support (barak & dolev-cohen, 2006; dolev-cohen, & barak, 2013; valkenburg & peter, 2009 ), without fearing from real or imagined social sanctions (friedman & billig, 2018) . some scholars even argue that this type of communication encourages the users to be honest and to express their "true selves" (lapidot, lefler, & barak, 2012) . moreover, in the digital realm, the adolescent may feel less pressure to participate in the conversation. without the pressure, she/he may feel more comfortable and less shameful (ben hur & giorno, 2010) . he or she can choose to contact the therapist through textual communication, which in many cases, is perceived as a more convenient and protected channel of communication in which they can express their feelings and thoughts in their own language (barak, klein, & proudfoot, 2009 ). indeed, this form of communication requires therapists to let go of some of their rules and theoretical beliefs. yet, it seems that the interviewees agreed that the benefit of online therapeutic relationships with at-risk youth outweighs its potential damage. aside from the potential benefits for the relationship itself, interviewees emphasized the new opportunities that aroused with regard to early detection of dangers and distresses. early detection of distress can prevent worsening of the patient's emotional state and mitigate his or her emotional burden (halfin, 2007) . this is especially relevant to youth, as many adolescents do not share their negative experiences, such as victimization of bullying or suicidal thoughts, with their adult caregivers (rey & bird, 1991; velting et al., 1998) . this finding corresponds with the emerging line of research according to which mental health conditions can be traced from social media activities (for a review see: guntuku, yaden, kern, ungar, & eichstaedt, 2017) . although most of this research is focused on adults, promising results were also evidenced among adolescent populations (ophir, asterhan, & schwarz, 2019) . the current study joins these new studies and suggest that social media has become an important source of psychosocial information about atrisk adolescents, offering a rare glimpse into their troubles and pain (ophir, 2017; ophir, asterhan, & schwarz, 2017) . finally, the interviewees highlighted the opportunity to provide counseling from a far. despite some reservations from online treatments, there is ample evidence that online counseling has a significant impact on patients, which in many cases is comparable to that of face-to-face counseling (andersson, 2016; mallen et al., 2005) . studies showed for example that computerbased treatments are effective for both depressed (kessler et al., 2009 ) and anxious patients (barak, hen, boniel-nissim, & shapira, 2008) . the findings from the current study confirm previous research that claimed that online counseling increases accessibility to treatment (mallen et al., 2005) . social media seem to increase the accessibility to youth who live in remote geographical areas and to youth who chose to distant themselves from their family and community. the therapeutic relationships that are formed online are especially relevant to these complicated times of social distancing due to the covid-19. moreover, aside from overcoming geographic limitations, social media seem to provide the adolescents subjective feelings of ease and comfort. these feelings correspond with a well-acknowledged advantage of online counseling, in which clients may feel less threatened in their natural surroundings and allow themselves to be more exposed with their therapists (gilat, ezer, & sagi, 2011) . these two factors, accessibility and comfortableness, can be critical when working with at-risk youth who tend to engage in defiant or rebellious behaviors. despite these advantages, online counseling suffers from several principle drawbacks: first, it reduces the ability of patients and therapist to interpret nonverbal communication signs and messages are sometime ambiguous (barak, hen, boniel-nissim, & shapira, 2008; suler, 2008) . second, it might diminish the caregiver's ability to provide empathy and warmth. third, it may feel less binding for some patients could easily dropout from the treatment (amichai-hamburger, et al., 2014) . fourth, it raises practical and ethical dilemmas, especially when the therapeutic relationship is form via social media (rather than video-chats, such as zoom or skype). therapists and counselors may ask themselves: what distinguishes me from other "facebook friends"? should adolescents be exposed to my personal photographs? and will they expect me to be available to them online at all times? these dilemmas are not unique to youth care workers. previous literature that addressed teacher-students online relationships raised similar concerns. although many teachers acknowledge the benefits of social media communication, they are also worried that it will undermine their authority in the eyes of their students (asterhan & rosenberg, 2015) . even those teachers who used social media to communicate with their students, were concerned about privacy boundaries and were worried that their relationships with the students will become too personal. like teacher, youth caregivers, as shown in this study, are not naïve. they are well aware of the potential pitfalls of social media interactions. despite the inherent informality that characterizes their work with at-risk youth, they do not see their relationships with youth at risk as symmetrical relationships. a primary challenge in this context is the need to understand and define the physical and emotional boundaries between them and their patients (friedman & billig, 2018; haenfler, 2004; nagata, 2001) . several interviewees noted difficulties in defining such boundaries, including the therapeutic space, the duration of the treatment, the availability of the therapist, and the privacy of both patients and caregivers. thus, future training programs should consider intrinsic characteristics of computer-mediated communication, such as the blurred boundaries and its relatively democratic and egalitarian nature (e.g., asterhan & eisenmann, 2011; hampel, 2006; weasenforth, biesenbach-lucas, & meloni, 2002) . without minimizing these concerns, the main conclusion from this study is that youth care workers are well aware of these challenges and yet they all agree that these challenges should not stop them from leveraging the new media for psychosocial purposes. they make considerable efforts to navigate these challenges by clearly defining the online practices that could contribute to the therapeutic process and avoiding or minimizing the ones that could disrupt it. however, they still lack appropriate training and usually work their way to the at-risk youth through trial-anderror. the current study has limitations. the first limitation concerns the fact that we only interviewed adult caregivers and the youth perspective is missing. moreover, the caregivers might have different perspectives and attitudes towards technology-based communications, due to generational difference (zhitomirsky-geffet & blau, 2016) . in israel most professional caregivers only start their practice in their late twenties. most of the interviewees in this study therefore belonged to generation y (aged 23-41). they are still considered very technology oriented (compared with previous generations) but they might have more complex attitudes towards internet-based communication, compared with the youth at risk (who belong to generation z and received their first smartphones as children). these differences in attitudes towards technology may have an impact on the online therapeutic relationship. yet, we note that all interviewees emphasized the importance of integrating online communication in their work and declared that digital literacy is a required skill when working with youth. a second limitation concerns the location of the study. two specific contexts may limit the generalizability of the findings: the country (israel) and the socio-geographic location (east border). therapists in israel may differ from therapists in other countries (e.g., in israel, therapists are allowed to provide online counseling, without formal training in this field) and youth in the east border may have different challenges than youth in other places (e.g., ideological crisis that reflects the tension between their conservative upbringing and their new identity). we therefore recommend that further research and future training programs would consider cultural differences. a third limitation concerns the fact that the study is based on qualitative interpretations of interviews with counselors and social workers. the exploratory nature of the study calls for future works that will build upon the current findings and establish the benefits of social media therapeutic interactions. further studies are recommended to quantify these potential benefits and explore their reliability overtime and in additional contexts. studies should also examine the perspectives of the youth themselves and compare them with those of their caregivers. there is also a need to examine potential confounding factors that might impact the online therapeutic relationships, such as gender differences (noguti, singh, & waller, 2019) , generational differences (hargittai, 2010) , cultural contexts (mesch & talmud, 2008) , and religious contexts (rosenberg, blondheim, & katz, 2019) . these factors might affect the very legitimacy of the online relationship. it is recommended that the current findings will be further examined thorough a quantitative and wide-ranging research. despite these limitations, the current study suggests that the new communication technologies are bringing viable and exciting opportunities to the field of youth at risk. most interviewees believe that online therapeutic relationships are beneficial for at risk youth as they help to maintain a trustful relationship with detached youth and provide a platform for early detection of distress and for delivering psychosocial counseling. yet, as noted above, the clinical picture is more complicated than these advantages. thus, it is advisable to provide special training to youth caregivers to help them bridge the gap between traditional and online practices and help them provide an effective treatment to at-risk youth online. is online communication discussed with you at work? are there certain procedures or guidelines set by the council with regard to social networks? have you undergone training on this topic? what do you do with this information? 14. do you have joint whatsapp groups with the youths? do you have one group for all of them? what is the role of the group? what do you do there? what interaction takes place there? what are the advantages and disadvantages of these whatsapp groups? 15 ethical issues in the use of in-depth interviews: literature review and discussion the future of online therapy internet-delivered psychological treatments expectations and preferences the promise, reality and dilemmas of secondary school teacher-student interactions in facebook: the teacher perspective does activity level in online support groups for distressed adolescents determine emotional relief a comprehensive review and a meta-analysis of the 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review learning, teaching, and scholarship in a digital age: web 2.0 and classroom research: what path should we take now? educational researcher gender and ethnic differences in formal and informal help seeking among israeli adolescents depression: the benefits of early and appropriate treatment rethinking sub-cultural resistance: core values of the straight edge movement digital na(t)ives? variation in internet skills and uses among members of the "net generation student-teacher relationship in the facebook era: the student perspective whatsapp is the message: out-of-class communication, student-teacher relationship, and classroom environment adolescents at risk and their willingness to seek help from youth care workers therapist-delivered internet psychotherapy for depression in primary care: a randomised controlled trial effects of anonymity, invisibility and lack of eye-contact on toxic online disinhibition online counseling: reviewing the literature from a counseling psychology framework networked privacy: how teenagers negotiate context in social media qualitative research design cultural differences in communication technology use: adolescent jews and arabs in israel facebook enhances antidepressant pharmacotherapy effects phenomenological research method beyond theology: toward anthropology of "fundamentalism the 'non-aligned' young people's narratives of rejection of social networking sites gender differences in motivations to use social networking sites evidence-based therapy relationships: research conclusions and clinical practices sos on sns: adolescent distress on social network sites unfolding the notes from the walls: adolescents' depression manifestations on facebook the digital footprints of adolescent depression, social rejection and victimization of bullying on facebook in times of war, adolescents do not fall silent: teacher-student social network communication in wartime cognitive behavioral and psychodynamic therapies: points of intersection and divergence sex differences in suicidal behaviour of referred adolescents youth at risk: definition and implication for service delivery whatsapp, teacher?": student perspectives on teacherstudent whatsapp interactions in secondary schools it's the text, stupid! mobile phones, religious communities, and the silent threat of text messages a virtual safe zone: teachers supporting teenage student resilience through social media in times of war. teaching and teacher education techniques to identify themes image, word, action: interpersonal dynamics in a photo-sharing community social consequences of the internet for adolescents: a decade of research. current directions in psychological science parentvictim agreement in adolescent suicide research cross-generational analysis of predictive factors of addictive behavior in smartphone usage characterization of youths with whom he works: what is the youths' background? what is the number of youths; their age range, place of residence; characterization of youths according to the family they came from; in which frameworks did they spend time in the past; do they have a delinquent background; did they undergo molestation as children or another form of victimization. are they in a formal framework, or not? if not, what do they do in their free time? to what extent do the youths reveal their personal lives to you? are they cooperative? what types of problems do you encounter when working with them? are the youths in contact with their families? if so, in what way is this contact expressed? what is the frequency of the youths' contact with their families, do they feel respect towards them or hatred and anger? what types of problems do the youths that you encounter generally suffer from? (e.g., personal problems, family, social, certain extreme behavior.) focus on drugs, crime, behavioral disorders -bullying, attention disorders, depression and anxiety -have they been hospitalized or expressed suicidal tendencies?section b -working with the youths and online communication the nature of the work and dynamics of the connection between the youth and the social workers? where do you actually meet them? are they obliged to attend some of the meetings and what do you do if they fail to come? what are the most common modes of treatment? to what extent are you exposed to what youth at risk do on social networks? what characterizes this use? what applications do they like in particular? what do they reveal on the network? (network advantages and disadvantages for the youth) to what extent are you involved in the youths' social network world and in what ways? (e.g., follow them on instagram, friends on facebook, etc.?) where you work, is it legitimate to communicate with youths via the networks or even make contact with them? (e.g., whatsapp groups or facebook friendship requests? if so -for what purposes? do you learn more about their world thanks to the network? do you use it as a tool for making personal contact with them? are you active on the social media networks, and how much do you know about using these networks for your personal needs?  counselors and social workers hold a positive view towards online therapeutic relationships  social media improve the therapeutic staff's capabilities  positive practices related to distinctive features of online communication channels  significant challenges included dilemmas regarding privacy, authority and boundaries key: cord-318861-6ffgg005 authors: anderson, mackenzie; karami, amir; bozorgi, parisa title: social media and covid‐19: can social distancing be quantified without measuring human movements? date: 2020-10-22 journal: proc assoc inf sci technol doi: 10.1002/pra2.378 sha: doc_id: 318861 cord_uid: 6ffgg005 the covid‐19 outbreak has posed significant threats to international health and the economy. in the absence of treatment for this virus, public health officials asked the public to practice social distancing to reduce the number of physical contacts. however, quantifying social distancing is a challenging task and current methods are based on human movements. we propose a time and cost‐effective approach to measure how people practice social distancing. this study proposes a new method based on utilizing the frequency of hashtags supporting and encouraging social distancing for measuring social distancing. we have identified 18 related hashtags and tracked their trends between jan and may 2020. our evaluation results show that there is a strong correlation (p < .05) between our findings and the google social distancing report. cost-effective approach to measure how people practice social distancing. this study proposes a new method based on utilizing the frequency of hashtags supporting and encouraging social distancing for measuring social distancing. we have identified 18 related hashtags and tracked their trends between jan and may 2020. our evaluation results show that there is a strong correlation (p < .05) between our findings and the google social distancing report. covid-19, social media, social distancing, twitter the world health organization (who) announced the outbreak of covid-19 to be a public health emergency in january 2020 (who, n.d.) . as of may 30, 2020, the number of positive cases was more than 6 million globally, with over 369,000 deaths. 1 the outbreak has posed significant threats to international health and the economy. in the absence of treatment for this virus, public health officials asked the public to practice social distancing to reduce the amount of physical contact. in addition, social distancing helps to flatten the curve of positive covid-19 cases. however, people have a desire for social interactions (cohen, 2004) . while all us states instituted social distancing measures, measuring social distancing is a challenging task. in addition, developing traditional methods (e.g., survey) is costly and time-consuming. some companies and institutes such as google have proposed methods to quantify social distancing based on measuring distances and movements. social media has become a mainstream channel of communication where users share and exchange information (sha, hasan, mohler, & brantingham, 2020) . in 2019, 72% of u.s. adults use at least one social media site. 2 in the last decade, social media platforms have grown in popularity, and now facebook, twitter, and instagram are readily available on mobile devices, continuously connecting users to a stream of information (karami, lundy, webb, & dwivedi, 2020) . in public health surveillance, social media can provide communication in real time and at relatively low cost, monitor public response to health issues, track disease outbreak and infectious disease. public health experts have investigated social media for different health issues such as diet, diabetes, obesity, exercise (karami, dahl, turnerlgbt health (karami, webb, & kitzie, 2018) . social distancing was measured by calculating movements shared on social media during the covid-19 epidemic (xu, dredze, & broniatowski, 2020) . while the current methods are based on measuring human movements, this study proposes a new method based on utilizing the frequency of tweets supporting and encouraging social distancing for measuring social distancing. this research proposed a simple method without measuring human movements. the method is based on the idea of measuring the frequency of tweets supporting and encouraging social distancing. the hashtags were identified based on qualitatively searching hashtags in twitter, google, and websites (e.g., https://www. digitaltrends.com/social-media/all-the-hashtags-you-needto-know-about-social-distancing/). we selected the hashtags that had a higher chance to be supportive and encouraging tweets. this process provided a list of 18 hashtags such as #stayhome utilized to support or encourage social distancing (table 1) . for example, an american actor, morgan freeman, posted a tweet containing #stayhome (figure 1) . we have collected the frequency of the hashtags in us from jan, 2020 to may 26, 2020 (figure 2) . we used brandwatch, a third-party social media data provider, to obtain the data. the data will be available on the web site of the first author (figures 1 and 2) . provides insights into what has changed in response to policies aimed at combating covid-19. this report shows movement trends over time by geography, across different categories of places such as retail and recreation, groceries and pharmacies, parks, transit stations, workplaces, and residential. we used the correlation function in r to investigate the correlation between the number of hashtags and the recorded movement by google in different places. our findings show that the number of hashtags had an increasing trend in march and then a decreasing trend in april and may. figure 3 shows the total frequency of hashtags with the highest and lowest frequency for #stayhome and #quaranthriving, respectively. our evaluation analysis shows a meaningful correlation (p < .05) between the total frequency of the 18 hashtags and the google movement trends (figure 4 ). this evaluation shows that there is a positive correlation (r > 0) between the frequency of hashtags and residential movements and a negative correlation (r < 0) between the frequency of tweets and non-residential movements. our findings show that us people used more supportive and encouraging hashtags for social distancing when they were at residential places and practiced social distancing and utilized less supportive and encouraging hashtags for social distancing when they were not at residential places. so, the frequency of hashtags can be used for quantifying social distancing during the covid-19 pandemic. this study proposed a cost and time effective approach to measure social distancing during the covid-19 pandemic. our findings show a strong correlation between the frequency of hashtags supporting and encouraging social distancing and the google social distancing report. this research offers a new dimension for social distancing analysis during a pandemic and assessing social distancing policies. while this paper provided a new insight on measuring social distancing, it has some limitations. first, we did not collect non-english tweets posted in us. second, the evaluation process was limited to a national level analysis. third, we selected one source for comparison. future work could utilize non-english tweets, extend the evaluation process to state and county levels, and use other social distancing calculations. this work is partially supported by the college of information and communication internal collaboration grant and the big data health science center (bdhsc) at the university of south carolina. endnotes 1 https://www.worldometers.info/coronavirus/ 2 https://www.pewresearch.org/internet/fact-sheet/social-media/ 3 https://www.google.com/covid19/mobility/ social relationships and health characterizing diabetes, diet, exercise, and obesity comments on twitter twitter and research: a systematic literature review through text mining an exploratory study of (#) exercise in the twittersphere characterizing transgender health issues in twitter dynamic topic modeling of the covid-19 twitter narrative among us governors and cabinet executives computational content analysis of negative tweets for obesity, diet, diabetes, and exercise. proceedings of the association for information science and technology dietary pattern recognition on twitter: a case example of before, during, and after four natural disasters. natural hazards rolling updates on coronavirus disease (covid-19 social media and covid-19: can social distancing be quantified without measuring human movements? key: cord-309071-y11if8sa authors: berg-weger, marla; morley, j. e. title: loneliness and social isolation in older adults during the covid-19 pandemic: implications for gerontological social work date: 2020-04-14 journal: j nutr health aging doi: 10.1007/s12603-020-1366-8 sha: doc_id: 309071 cord_uid: y11if8sa nan social workers and other gerontological scholars have increasingly voiced concern about loneliness (subjective perception of lack of meaningful relationships) and social isolation (social engagements and contacts) among older adults. in 2015, "eradicate social isolation" was included as one of the twelve grand challenges for social work (1) . as key members of interprofessional geriatric teams, social workers are uniquely positioned to intervene in addressing social isolation by developing and testing interventions1. by 2017, calling it a "loneliness epidemic", u.s. surgeon general vivek murthy proclaimed loneliness and social isolation among the world's older adult population was a global epidemic (2). as prevalence rates suggest that nearly one-third of older adults experience loneliness and/or social isolation and a subset (5%) reporting often or always feeling lonely (3, 4) , we began to recognize the risks and impacts. data on impact of loneliness and social isolation indicates significant and long-term negative outcomes for older adults identified as lonely and/or socially isolated. as noted in an earlier editorial (5) , there are myriad negative physical and mental health outcomes that are linked to the older adult experiencing loneliness and/or social isolation. while issues of loneliness and social isolation can often be overlooked by health and social service professionals, the covid-19 pandemic has focused increased attention on social isolation and loneliness for all ages, particularly older adults as the most vulnerable, at-risk segment of the population. social workers working in healthcare organizations, residential communities, and social service agencies have been on the front lines of ensuring the safety and engagement of older adults during the crisis. knowing the factors that place older adults at risk for loneliness and social isolation became critical for assessing older adults, including living alone or in a rural community, poor functional status, widowhood, being female, lower income/education, losses, depression, and feeling misunderstood by others (6) (7) (8) (9) (10) (11) . with sheltering-in-place and stay-at-home orders, many older adults lost usual ways to connect with support networks and health and social service providers and are spending increased time alone. many of the traditional strategies for engaging older adults have become obsolete in the new normal. congregate meal sites, exercise and social activities, in-person health/business interactions, and volunteer and employment commitments are among those engagement opportunities that are suspended. social workers serving the populations that are the most vulnerable to covid-19, have become creative and resourceful in staying connected to our older adult clients, patients, friends, and families and supporting their efforts to stay connected with others to allay loneliness, social isolation, and anxiety. in-person activities and contacts began to be facilitated virtually through individual devices and videoconferencing. social distancing, personal protective equipment and virtual reality devices were introduced. daily telephone reassurance calls, home delivery services, virtual and phone health care visits, and prevention education and news updates became a part of social work practice. social work practice with older adults changed dramatically and quickly. what are we learning from this experience? as two italian geriatricians noted in april, 2020, we have a "unique opportunity for improvement" (12) . while the world will hopefully gain new knowledge and awareness regarding preparedness and response from the 2020 pandemic, gerontological social workers can take this time to assess the ways in which they built on their knowledge, skills, and values to respond to the crisis. social workers and other health professionals are learning from this crisis: • assessing loneliness and social isolation-because providers seldom ask about these experiences, having tools that can be easily and quickly administered to determine if the older adult is lonely or socially isolated is critical. training for practitioners in assessing these issues is minimal at best (13) . there are several available tools; we have developed a rapid tool, the alone scale (table 1) whose psychometric validation is underway. assessing the risk factors previously noted should be included as part of the ongoing assessment of older adults' needs. • developing and adapting evidence-based interventions to address loneliness and social isolation-lubben and colleagues (1) our interprofessional geriatric workforce enhancement program (gwep) team has adapted one such evidence-based group intervention. circle of friends© is a group intervention developed at helsinki university designed to address loneliness and social isolation via weekly sessions over three months that incorporate art and inspiring activities, exercise/health content, and therapeutic writing (14) (15) (16) . outcomes indicate decreased loneliness, social isolation, and healthcare costs and increased feelings of well-being (17) (18) . in response to covid-19, our partners are offering education-focused video conferences and doing daily phone check-in calls. social workers in residential facilities have faced a variety of challenges. with families not being able to visit, they have been forced to develop innovative ways for family visits from window visits to face time. developing meaningful activities that can be facilitated in the residents' rooms or re-thinking how to offer group activities such as "biongocise" (bingo with exercise) with appropriate social distancing. social workers have organized compassionate visits for persons at the end-oflife. providing daily updates on residents to family members has been a mainstay of social workers' routines. these include a variety of digital approaches such as face time, whatsapp, skype, and zoom. writing letters to god about their life has also been an innovative way to communicate with relatives. in the post-pandemic world, we can use these crisis intervention strategies to evolve our preparedness skills moving forward. encouraging our patients and clients to engage in advanced care planning is one area for improvement (only 70% of older adults assessed in our geriatric workforce enhancement program have completed an advanced directive). • learning new skills-technology, importance of preparedness, and how to engage with people in non-traditional ways can become a part of social work practice. having had to quickly respond during the pandemic necessitated the use of technology that was previously unfamiliar for both professionals and older adults and planning in a time of little, often conflicting information and rapidly evolving status. once the crisis has passed, we can evaluate our responses and identify those strategies that worked and can become a part of our practice approaches. for example, we moved forward to develop a telehealth delivery platform to facilitate circle of friends for use during the crisis and beyond. with social workers embracing the use of technology as a viable service-delivery option, traditional interventions can similarly be offered (e.g., exercise, dementia care, and caregiver support) as well as more innovative options (e.g., interactive photo sharing, support and learning assistants, online-based websites for pairing runners and cooks with isolated older adults, and multi-party games) (19) . in addition, there will be a need to learn to identify post traumatic stress disorder. symptoms such as fear, sleeping disturbances, poor concentration and flash backs. in the future, we may see more social worker interactions carried out through digital connections along with increasing use of "alexa" and a variety of health robots to help alleviate loneliness. • continuing to combat ageism-now that the majority of our society has experienced loneliness and social isolation, there is better understanding of the need to not perpetuate it in a post-pandemic world, particularly with older adults. covid-19 has triggered more public ageism (i.e., people display relief when they initially learned the majority of those dying from the virus are older adults) (12) . while the covid-19 pandemic has forced the world to change the way in which we live, let us as scholars view it as an opportunity to assess our responses, identify lessons learned, and develop strategies and approaches to address loneliness and social isolation among older adults. while we will continue to provide the same services, we may find that, along with our interprofessional colleagues, we can all envision expanded perspectives on our roles. lastly, we must consider the needs that will arise in the post-pandemic era for our patients and their families who may experience increased depression, anxiety, and financial challenges. as we have helped them to transition into the world created by the covid-19 crisis, we can be there to help them transition into the post-covid-19 world. we must be cognizant of the fact that each person experiences loneliness and social isolation in their own unique way and our responses must be tailored to meet those individual needs that is grounded in evidence-based practice (20) (21) . american academy of social work and social welfare grand challenges for social work initiative work and the loneliness epidemic training professionals to implement a group model for alleviating loneliness among older people-10-year follow-up study predictors and subjective causes of loneliness in an aged population loneliness in older age: an unaddressed health problem loneliness, fear, and quality of life among elderly in sweden: a gender perspective a national survey of adults 45 and older. loneliness and social connections interventions for alleviating loneliness among older persons: a critical review high prevalence and adverse health effects of loneliness in community-dwelling adults across the lifespan: role of wisdom as a protective factor social contacts and their relationship to loneliness among aged people-a population-based study predictors and subjective causes of loneliness in an aged population geriatric medicine in italy in the time of covid-19 effects of psychosocial group rehabilitation on health, use of health care services, and mortality of older persons suffering from loneliness: a randomized, controlled trial circle of friends. group model alleviating loneliness leading groups of older people: a description and evaluation of the education of professionals geriatric rehabilitation nursing: developing a model effects of psychosocial group rehabilitation on social functioning, loneliness and well-being of lonely, older people: randomized controlled trial psychosocial group rehabilitation for lonely older people: a description of intervention and participants' feedback social isolation and loneliness in the uk with a focus on the use of technology to tackle these conditions loneliness and social isolation interventions for older adults: a scoping review of reviews reducing social isolation and loneliness in older people: a systematic review protocol the authors declare there are no conflicts. key: cord-285152-mg1ez10i authors: rozenkrantz, liron; bernstein, michael h.; hemond, christopher c. title: a paradox of social distancing for sars-cov-2: loneliness and heightened immunological risk date: 2020-08-10 journal: mol psychiatry doi: 10.1038/s41380-020-00861-w sha: doc_id: 285152 cord_uid: mg1ez10i nan the world health organization declared the sars-cov-2 virus a global pandemic in march of 2020. in an effort to reduce the harms and rate of exponential spread, regional and national governments across the world instituted a variety of measures. these have included orders for citizens to practice social distancing, which in the us has affected over 300 million people. in their most extreme, these social distancing measures are isolation orders to "shelter in place", at one point affecting~17 million americans. data regarding the effects of these policies are emerging, but two outcomes include greater social isolation and likely increased loneliness. an important distinction arises between these two concepts. social isolation is the objective lack of, or reduction in, social contact. loneliness is the subjective discrepancy between the desired and actual levels of social connection [1] . objective social isolation and subjective loneliness are only weakly correlated (r0 .2), but both have independent real-world health consequences and are associated with long-term increases in mortality (29% and 26%, respectively). the magnitude of these effects rival that of smoking and obesity on long-term health risks [1] . emerging evidence for the social repercussions of the pandemic is worrisome; a recent longitudinal study following more than 35,000 people reported that while overall loneliness has not changed during the covid pandemic, individuals who described high levels of baseline social isolation are now experiencing significantly worse pandemic-related loneliness [2] . now more than ever the most socially vulnerable would likely benefit from clinical assessment and support. our own unpublished survey data (n = 155) indicate that 60% of respondents from an online campaign in the usa, israel, and uk report a greater sense of loneliness since the pandemic began. feelings of loneliness are the brain's emotional response to perceptions of isolation, and serve to motivate individuals to seek social connections. as highly social mammals, humans depend on interpersonal connections for mutual health and protection. in times of lack, the neurobiological correlates of social craving are similar to that of hunger. a recent neuroimaging study found that the same valuation regions which are activated at the sight of food cues following a day of fasting are activated at the sight of social cues after a day of social isolation, highlighting the human need of socialization [3] . along these lines, prolonged solitary confinement has been recognized as a form of torture by the united nations. a powerful psychological stress is felt in the absence of social protection or assistance, which, via the neuroendocrine and sympathetic nervous systems, activates a conserved immunological program optimized for self-preservation. this immunological program is shifted towards evolutionary threats characteristic of social isolation (e.g., violence, predation, and trauma), while fewer resources are afforded to fight internal threats such as (viral) infectious transmission and neoplasms. specifically, loneliness is associated with decreased expression of interferon response factors and antibody synthesis necessary for antiviral defense. a landmark 1991 study demonstrated that baseline stress levels predicted a dose-dependent response to coronavirus type 229e; higher stress was independently associated with greater risk of infection and symptom severity [4] . in a follow-up, cohen et al. [5] infected volunteers with an upper respiratory virus (rhinovirus). participants with fewer social ties were more susceptible to infection, showed increased viral shedding, and developed more severe symptoms. an additional study administered influenza vaccinations to 83 college freshmen and found increased levels of loneliness to be associated with poorer antibody response, mediated by greater psychological stress [6] . these studies, among others in the common cold project (https://www.cmu.edu/common-cold-project), provide strong evidence that higher levels of social engagement represent a protective effect against the inflammatory immune response to respiratory viruses. this is independent of other lifestyle and demographic factors. loneliness additionally predisposes the innate immune response toward proinflammatory gene expression, increasing the number of circulating monocytes and upregulating expression of proinflammatory nf-kb and ap-1 proteins [7] . this adaptation is effective in the short term to prepare for threats of bodily harm, bacterial infection, or trauma. however, chronic activation of this immune response is associated with a multitude of inflammatorymediated illnesses including increased incidence of neoplastic, cardiovascular, and neurodegenerative diseases [7] . we speculate that this proinflammatory predisposition may also be a risk for the development of the highly lethal "acute respiratory distress syndrome" responsible for significant mortality in covid-19. although unlikely to manifest as a substantial individual consequence of short-term social distancing, these covert threats are important to consider in decisions surrounding social distancing measures, because a small effect distributed over a large population can have public health consequences. the evidence summarized here indicate a catch-22. on the one hand, social distancing is needed to protect people from spreading sars-cov-2. on the other hand, these distancing measures may ironically be exacerbating the widespread loneliness already reported by seniors, while simultaneously undermining the exact immunological resources needed to appropriately respond to potential sars-cov-2 infection [8] . one conclusion from these data is the need for targeted countermeasures. this can begin with words: replacing the term "social distancing" with "physical distancing", as endorsed by the who, will explicitly emphasize that the weakening of social connections is neither a goal nor a policy target. although uncertainty, stress and anxiety are inherent to a global pandemic, loneliness need not be a foregone conclusion. evidence-based interventions to reduce loneliness remain sparse, but any form of positive social support is likely to buffer or reverse perceived isolation. many people have naturally increased their use of technology (e.g., videoconferencing software) to remain socially engaged with colleagues, acquaintances, and loved ones. while the psychological advantages of this are self-evident, it may also confer immunological benefits through the mechanisms described in this paper. the healthcare system itself could be better adapted to reaching those most in need, providing assessments of objective and subjective social isolation for at-risk individuals and connecting them with community-based resources. lastly, although more research is needed to explore pharmacological and effective technology-based behavioral interventions targeting subjective social isolation, several mind-body interventions such as yoga, (mindfulness) meditation, and tai chi have demonstrated early promise in reversing the harmful inflammatory biological effects of adverse social circumstances [7, 9] . covid-19 appears to be inspiring the proliferation of freely accessible online classes and activities like yoga and mindfulness as well. while social isolation is associated with paradoxical immunological risks in this pandemic, lifestyle modifications may attenuate these changes and have important public health implications for the coming months in the ongoing fight against sars-cov-2. conflict of interest the authors declare that they have no conflict of interest. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. loneliness and social isolation as risk factors for mortality: a metaanalytic review loneliness during lockdown: trajectories and predictors during the covid-19 pandemic in 35 the need to connect: acute social isolation causes neural craving responses similar to hunger psychological stress and susceptibility to the common cold social ties and susceptibility to the common cold loneliness, social network size, and immune response to influenza vaccination in college freshmen the conserved transcriptional response to adversity social isolation's influence on loneliness among older adults mind-body therapies and control of inflammatory biology: a descriptive review these authors contributed equally: liron rozenkrantz, michael h. bernstein, christopher c. hemond key: cord-341986-swrzzij5 authors: eghtesadi, marzieh; florea, adrian title: facebook, instagram, reddit and tiktok: a proposal for health authorities to integrate popular social media platforms in contingency planning amid a global pandemic outbreak date: 2020-06-09 journal: can j public health doi: 10.17269/s41997-020-00343-0 sha: doc_id: 341986 cord_uid: swrzzij5 in december 2019, a new severe respiratory coronavirus infection (covid-19) was detected and has since spread across the globe to be ultimately declared a pandemic by the world health organization on march 11, 2020. for physicians and allied medical professionals, the period since has been marked by an increased and rapidly changing flow of information from multiple regional, national and international health authorities, regulating bodies and professional associations. although social media platforms have an active presence in the instant dissemination of information and medical professionals display active participation in them, traditional channels such as email are still being emphasized as a means of communication. this article discusses the opportunities offered by social media platforms such as facebook, reddit and tiktok to disseminate medical information both for the use of physicians and as a means to communicate essential information to the public at large. mots-clés communauté médical en ligne . réseau médecins . réseautage médical . reddit . tiktok . facebook . média social . communication professionnel de la santé . influenceur the massive mobilization measures to contain the global outbreak of covid-19 have also triggered a wave of information that has been overwhelming within the medical community. as physicians practicing in both an academic tertiary care centre and a community-based hospital, our email inboxes have been flooded with rapidly evolving emergency measure guidelines from various authorities, including our institutions, our provincial and federal medical associations, public health, and scientific organizing committees. new platforms have been created by departments of information technology (it) as a means of facilitating discussions between physicians. unfortunately, the lack of filtering of communication by topic or interest and the recurrent use of email chains to large groups in asynchronous fashion lead many physicians requesting to be removed from such platforms. this excess of information has even prompted authorities to reassure physicians, via email for example, that the messages sent out from it are not spam or originating from hacked accounts. these difficulties with efficient ways of communicating have led us to question why we, as physicians, do not make better use of current social media platforms in times of crisis, when communication is key to disseminating effective strategies to control disease outbreak. this short paper is a summary of these reflections by discussing potential benefits and limitations of some of the most popular social media platforms; it is an attempt to encourage the medical community to integrate, albeit cautiously, these platforms as a means to communicate scientifically sound medical knowledge both between healthcare workers and to the public. facebook is the biggest social network worldwide with 2.5 billion monthly active users (clement 2019) . in regard to disseminating or obtaining research evidence, a web-based survey found that, although more than 95% of health researchers and clinicians believe in the role of social media for this purpose, only 15% of them made use of it (tunnecliff et al. 2015) . however, the creation of virtual communities by healthcare professionals on social media is increasing in popularity. for instance, in the canadian province of québec, over 5000 physicians are members of physician-only facebook groups, including private groups such as "médecins québécois pour des solutions efficaces en santé" and "canadian women in medicine", which are solely managed by a few physician moderators on a voluntary basis. although a majority of physicians rely on email correspondence for important and urgent matters, regulatory colleges can collaborate with such physician discussion groups, in order to include them in their means of communicating with members who are more active in online virtual communities. it may also be easier for these members if institutional authorities created new discussion groups within social media already familiar to them, instead of using entirely new platforms requiring new profile registration and the added burden of having to learn how to navigate them. however, such use of social media would only be beneficial if the aim were to give physicians a way to encourage general discussions as a group, and would not be possible if exchange of sensitive or confidential information were involved. moreover, just like many physicians use various email addresses to distinguish their personal versus professional activities, they could create a distinct professional facebook profile if necessary. the added advantage of such a facebook profile would be that physicians could subscribe (i.e., "like or join") to medical forums (i.e., "pages") with scientific content solely related to the pandemic, such as the pages of the world health organization and the centers for disease prevention and control, where they would all see reliable, objective and consistent information directly on their individual page (i.e., "newsfeed"). they could also make use of the integrated private chat function (i.e., facebook messenger) when exchanging with specific colleagues and avoid the frustrations related to the "reply to all" function in emailing. another interesting use of social media platforms in disseminating information to the general public in times of outbreaks would be the potential to collaborate with physicians who manage facebook pages or instagram accounts, and who act as "influencers", meaning "someone (or something) with the power to affect the buying habits or quantifiable actions of others by uploading some form of original content to social media platforms" (martineau 2020) . we believe that these physician-managed "pages" are trustworthy sources of information for the public as physicians remain accountable for the online content they share with the public, as highlighted by numerous guidelines from medical protective associations on how to mitigate risk (cmpa 2014). these pages and accounts have a large number of subscribers (i.e., followers) who consult the content and images posted by the page administrator. interestingly, many of the social media platforms also offer the possibility for administrators to pay in order to increase the visibility of their content (i.e., boost a post). however, before urging health authorities to financially support such information dissemination initiatives, we must ensure that the visibility reported by facebook and other social media platforms translates into actual changes in population behaviours and disease outcome. one potential way to measure such impact would be to correlate the parameters selected in "boosting a post", such as target age group and geographical location, to arcgis, the world's leading mapping and location analytics platform by esri. by combining these two platforms, we could see, for instance, if boosting a facebook post containing information on the importance of social distancing on a page highly visited by young professionals leads to a reduction in the rate of disease spread in a high agglomerate region with popular afterwork social gatherings. moving on to another social media platform, reddit is a website hosting a colossal collection of discussion forums organized by subjects into groups (i.e., subreddits); reddit is the 6th most frequently visited website in the united states (authors 2020). as of march 15, 2020, the total number of users taking part in a subreddit community with the word "coronavirus" or "covid" was over 1.6 million. reddit's homepage displays an initial filter which allows users to browse topics according to what is hot, new, top, controversial or rising. once users enter a community, the posts that are displayed first are those that members of that subreddit community have voted up, which is entirely based on subjective user preferences. the only content that is filtered out is hate or discriminatory comments, otherwise thousands of users could have heated debates about health topics, or any other topics, and gain significant popularity despite the complete lack of scientific validity. posts generally contain no references and communities are managed by anonymous moderators. despite this lack of content validity traceability, we believe there is useful and scientifically sound content on this platform, with likely many users with medical professional backgrounds, despite the lack of oversight from recognized health authorities. finally, the application tiktok, which was released on the global market in 2017, consists of short-form mobile videos with users performing lip-synching or other creative videos accompanied by music. it currently has over 1 billion users and is available in 150 different countries (doyle 2020) . one of the most popular videos that arose amid the covid-19 outbreak contributed to the rising fame of the following song from vietnam promoting preventive measures: "do not touch your face. wash your hands. when you greet your friend, do the namaste". for physicians working in community youth clinics, knowing how to discuss information contained on such a popular social media platform can serve as a powerful tool when promoting adherence to medical advice. it has been stated that an effective response to covid-19 from the healthcare workforce must include "supportive conversations, clear guidance when recommendations exist, attempts to minimize misinformation, and efforts to reduce anxiety" (adams and walls 2020). one of the problems with popular social media platforms, such as facebook, reddit and tiktok, is that they lack scientific oversight, generating noise and false information. in times of health crisis such as that we are currently experiencing, resources must be redirected to essential services to covid-19 response and the healthcare workforce cannot filter the spread of misinformation online. another limitation with social media is that its use is not generalizable to the whole population. this is particularly important when considering that older adults, who are also most vulnerable to the complications of covid-19, do not use these social networks and rely on traditional means of communication. however, taking into consideration the population who does actively spend time on social media, we describe specific visibility features on these platforms that can be used to promote health measures, such as social distancing. we encourage public health authorities and the support of politicians to act proactively in reaching these members of society who favour the use of online platforms to seek information. finally, as physicians, some of us are already actively participating in social media communities, from members on discussion groups to popular figures giving advice to virtual followers. we would therefore also encourage our regulatory associations to guide our impact within these online social media platforms, as determined by public health and political authorities. these opportunities could be provided by means of continuing medical education that goes beyond risk mitigation, helping us better understand the frameworks of information management. supporting the health care workforce during the covid-19 global epidemic authors top sites in united states top 10 tips for using social media in professional practice number of monthly active facebook users worldwide as of 4th quarter tiktok statistics -updated the wired guide to influencers everything you need to know about engagement, power likes, sponcon, and trust the acceptability among health researchers and clinicians of social media to translate research evidence to clinical practice: mixed-methods survey and interview study acknowledgements we thank geneviève l. lavigne, phd, who provided medical writing services.author contributions both authors contributed meaningfully to this manuscript. me: manuscript preparation and editing. me and af: critical review and intellectual contribution, reading and approval of the final version. conflict of interest the authors declare that they have no conflict of interest. key: cord-331766-sdbagsud authors: kung, janet wc.; wigmore, stephen j. title: how surgeons should behave on social media date: 2020-08-30 journal: surgery (oxf) doi: 10.1016/j.mpsur.2020.07.014 sha: doc_id: 331766 cord_uid: sdbagsud this article documents the rise in popularity of social media use by surgeons for personal and professional use. it considers some of the important issues around privacy, patient confidentiality and professionalism and discusses some of the common pitfalls of using social media as a surgeon. social media has fundamentally changed the way we interact with the world and it has become an integral part of many surgeons' personal and professional lives. the most popular platforms include twitter, facebook, whatsapp, instagram and youtube, and professional networking sites such as linkedin and researchgate have gained prominence in the healthcare sector. with their many facilities and applications, social media platforms offer opportunities for patient resources and education, professional networking, research collaboration and dissemination, public engagement and policy discussions, and personal and professional support. 1 a pubmed search for "social media" and "surgery" has generated over 1820 articles to date, of which 118 articles were published in the first quarter of 2020, equating to an average of almost 40 publications per month in 2020 thus far. the volume of internet traffic during the covid-19 pandemic has affirmed the role of social media in contemporary communication. as social media has become ubiquitous, it is critically important for surgeons, whether active enthusiastic users or passive apprehensive observers, to be aware of the potential risks and pitfalls and to take caution and control over their online presence. inappropriate and unprofessional behaviour is susceptible to serious legal ramifications, which may lead to prosecution, professional censure, and loss of certification or licensure. 2 many regulatory bodies and professional organizations across the world have issued guidelines and recommendations specifically to address the use of social media. for example, the general medical council (gmc) 3 and the royal college of surgeons of england (rcs) 4 in the united kingdom, as well as the american medical association (ama) 5 and the american college of surgeons (acs) 6 in the united states, have all provided relevant guidance. in general, applying common sense and adhering to traditional professional standards while online are advised for surgeons who engage in social media. one of the most powerful aspects of social media is the ability to connect instantly to our patients. this very attribute of social media has blurred the boundaries between personal and professional life. accepting a patient's 'friend' request on facebook, and other direct relationships on social media platforms, is strongly discouraged as this may allow bidirectional access to personal information and commentary that is not traditionally appropriate for the surgeon-patient relationship. in the same way that you might not desire your patients to have access to the intimate details of your personal life, 'patient-targeted googling' may yield information about your patient's healthcare and behaviour (e.g. smoking or alcohol consumption) that could colour your judgement and affect your interaction with them and their treatment plans. not only is there the sensitive issue of disclosure of the source of information, there is the serious risk of spiralling into curiosity, voyeurism and invasion of privacy which could destroy the trust of the surgeon-patient relationship and reflect badly on the institution and even the entire profession. 6 to maintain professional boundaries, surgeons should consider separating personal and professional profiles online and comport themselves professionally in both. 3, 5, 7 if a patient were to contact you about their care or ask you to provide medical advice to acquaintances and other 'connections' through your private profile, it should be made clear to them that social and professional relationships should not be mixed. 3 the patient, where appropriate, should be directed to your professional profile and to the professional bodies' websites and associated social media platforms. although the same expectations of patient confidentiality that exist offline apply to online behaviour, there are unique challenges to protecting patient privacy on the internet. 1 privacyencrypted professional or institutional accounts must be used for the purposes of emails and other online communication with patients. such online correspondence should be documented and archived in the patient's official medical records, either in summary or by inclusion of the entire transcript, as it would be for any other medium. online communication with patients should only be used in the context of a pre-existing surgeon-patient relationship and should act to supplement, rather than substitute, a face-to-face clinical encounter. 6 it has become commonplace for surgeons to use social media sites for educational purposes and to obtain advice from colleagues regarding complex clinical problems. this involves sharing surgical information including case scenarios, clinical and operative photographs, or radiographic images. as with all other use of clinical content, these materials should only be used once written informed consent from the patient or surrogate has been obtained. publication of clinical content or images, in whichever online or offline medium, is under the regulation of the caldicott guardians in the united kingdom and the legislation of the health insurance portability and accountability act in the united states. all patient identifiable data should be removed, and this extends to images that allow identification of the patient, such as unique piercings and tattoos. while deidentifying patient information is mandatory, surgeons must be cognizant of the context of the information available online. even images that omit identifying features may inadvertently allow a link to a specific patient; for example, your location or institution may be embedded within photographs and other contents, news media and publicly available vital statistics. 1 although individual pieces of information may not breach confidentiality on their own, the sum of published information online could be enough to identify a patient or someone close to them. 3 the use of closed groups, i.e. groups that are by invitation only and not accessible to the public, offers an additional layer of privacy that allows a more liberal exchange of clinical information and opinion that would be permissible in an open forum. 6 although engagement in these fora can be a useful educational tool and benefit patient care, caution should still be exercised because privacy is never absolute and security is never impenetrable. it is also necessary to uphold the usual professional standards of decorum and respect for the patient and to refrain from comments on a patient's behaviour, history, or characteristics that may be perceived as derogatory or disrespectful. 6 respect for colleagues social media offers an unprecedented opportunity for surgeons to connect across the globe in real time for personal and professional support. a recent study found that social media serves as a valuable tool to enhance the networking and mentorship of surgeons, particularly for women in surgical specialties who may lack exposure to same-sex mentors at their own institution. 8 the value of this type of support network is even more appreciated in remote and rural surgical practice. while there are definite positive aspects of social media, there are users whose online behaviour has a negative impact on their colleagues, the surgical community, and the medical profession as a whole. the seemingly faceless anonymized online existence on social media unfortunately has facilitated propagation of extremist opinion and fuelled unsolicited trolling and cyberbullying. the gmc good medical practice states that 'doctors must treat colleagues fairly and with respect'. 3 this covers all situations and all forms of interaction and communication. 3 bullying, harassment and undermining behaviour must not be tolerated. gratuitous, unsubstantiated or unsustainable comments must not be made about individuals online. although it is acceptable to disagree with colleagues and have a healthy debate on social media, such posts should be respectful, collegial and reflect positively on the profession. 1 if you see colleagues behaving in an unprofessional or inappropriate manner, you have a responsibility to bring this to their attention discreetly so that they have an opportunity to reflect and take action. if the colleague does not make amends and you believe the breach of the code of conduct is serious, then they should be reported to supervisory and/or regulatory authorities. 5, 9 users of social media should be mindful that postings online are subject to the same laws of copyright and defamation as written or verbal communications, whether they are made in a personal or professional capacity. 3, 10 relationship with your employers many educational and medical institutions have specific policies governing social media use by employees. these protocols may place additional restrictions on online activities and describe boundaries that should not be breached in order to avoid disciplinary action and penalties. surgeons should be familiar with and abide by these policies as ignorance is rarely an excuse. screening online profiles is an increasingly common practice during recruitment and hence surgeons must be aware that their online behaviour may influence employability and have consequences while employed. 1,6 although a strong favourable social media presence might be an attractive asset to an employer, content that portrays a surgeon in a controversial light can have a detrimental impact on their career and professional standing. it is crucial for surgeons to avoid posting content that have negative or unintended consequences in the workplace. 1 the internet provides an abundance of healthcare-related resource and advice from all sorts of outlets. this readily available information accessible by a click of a button can be both helpful and confusing for our patients or potential patients. as we are all too painfully aware of the phenomena of 'fake news' and 'sensationalism', it can be notoriously challenging for some lay public to decipher what is satire and falsehood and what is evidence-based science and medicine. the engagement of surgeons in social media can maximize quality patient care by disseminating credible 'filtered' or 'censored' information regarding existing treatments by experts. 11 the contribution of the surgeon's expertise, insights and experience can also help dispel myths and misinformation and reject unsubstantiated advice and deleterious treatment suggestions. as creators of 'fake news' become more sophisticated, even some medical professionals and surgeons can be deceived. it is therefore important to resist taking what is being projected at its face value and this extends to the increasingly popular infographics and visual abstracts. surgeons must be disciplined to trace the origin of the post and ensure that the visual abstract is in fact released by a reputable journal and that the original article has gone through the rigorous process of peer review, copyediting and proofreading. the easily digestible visual abstract is designed for quick dissemination with maximal impact and take advantage of our ability to quickly interpret visual data. it is understandable that given such a user-friendly interface for the busy surgeon to simply accept and be influenced. surgeons must always return to the original research article for a full critical appraisal and remember that a visual abstract is not a substitute for reading the article. just as any single article should not change one's practice, a visual abstract alone should not influence clinical decision making or opinion about the paper. 12 surgeons must also be aware that just because a visual abstract or content has been widely shared or retweeted on social media professional development surgery xxx:xxx platforms, it does not necessarily mean that it is of high quality. in the same way that there are limitations to the traditional journal impact factor, a high altmetric score is merely a summative indicator of attention, dissemination, influence and impact but is not itself evidence as such. careful consideration should be given to the decision of partaking in dissemination of a piece of social media content, particularly whose original poster was not yourself. such act of circulating information implies your open endorsement, as a surgeon and a professional, of that social media user and that specific piece of social media content that you shared. disseminating mistruths and misinformation, even by mistake, can be dangerous. retraction not only is embarrassing but is often suboptimal given the speed at which information can travel with social media to a potentially infinite and impressionable audience. it is prudent to recognize that actions online and content posted and shared can undermine the public trust in the medical profession. public health and awareness campaigns social media provides a powerful platform for public engagement in promoting public health and awareness campaigns. the most topical example is the educational contents on social media emphasizing the role of personal hygiene and social distancing in controlling the spread of covid-19 during the pandemic. another example is the introduction of an optimized social media intervention with the aim of improving organ donation awareness among minorities in the united sates. 13 while such activities are generally well-intentioned patient-centric initiatives, only a fine line distinguishes advocacy from paternalism. with the rapid capricious developments of social media, surgeons must be actively involved and gauge the mood of the public to avoid any misconceptions of coercion and lack of autonomy. in addition, when posting material online, you should be open about any conflict of interest and declare any financial or commercial interests in healthcare organizations or pharmaceutical and biomedical companies. 3, 10 it is, as always, your responsibility to avoid even the appearance of impropriety. if it is not feasible to include a relevant conflict of interest within a post, then the post should not be made. 1 professionalism is the basis of a surgeon's contract with society. 14 the gmc guidance on doctors' use of social media states 'if you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name. any material written by authors who represents themselves as doctors is likely to be taken on trust and may reasonably be taken to represent the views of the profession more widely'. 3 all content posted on social media, regardless of whether it originates from a surgeon's personal or professional account, should be regarded as visible to the public. 6 privacy settings for each of your social media profiles should be reviewed regularly and conservative privacy settings should be adopted to safeguard personal information and content. 3, 10 it is important to bear in mind that even if using the most stringent privacy settings, it may not be possible to control how widely information is shared and that comments may be taken out of context. 10 there is no absolute guarantee that deleting information offers protection and it is not unreasonable to assume that any information posted online will remain available in perpetuity and might be accessed by anyone at any time. 1 professional online profiles should be regularly updated to provide contact information and accurate representation of the surgeon's credentials. surgeons are encouraged to periodically self-audit and take measures to ensure that the information presented is accurate and professional. 15 establishing online professional profiles and engaging proactively in social media allow better control over your online footprint, whereas failure to update your professional profile and engage in social media might come across as being out of touch. social media has become a ubiquitous part of modern life and is a staple of contemporary communication. it is our professional duty as surgeons to become adept users of the different social media platforms so that we can interact with patients, colleagues, professional societies, and regulatory authorities in an ethical and professional manner. there are many, often hidden, pitfalls with use of social media that we must be aware of and safeguarded against. thoughtful foresight and extending traditional expectations of professionalism to online behaviour, content, and engagement remain the most valuable guide using social media.a best practices for surgeons' social media use: statement of the resident and associate society of the american college of surgeons gmc ama professional guidelines for social media use: a starting point social media in the mentorship and networking of physicians: important role for women in surgical specialties anz social media is a necessary component of surgery practice seeing is believing: using visual abstracts to disseminate scientific research a data-driven social network intervention for professional development surgery xxx:xxx improving organ donation awareness among minorities: analysis and optimization of a cross-sectional study social media and the surgeon online medical professionalism: patient and public relationships: policy statement from the american college of physicians and the federation of state medical boards key: cord-340827-vx37vlkf authors: jackson, matthew o.; yariv, leeat title: chapter 14 diffusion, strategic interaction, and social structure date: 2011-12-31 journal: handbook of social economics doi: 10.1016/b978-0-444-53187-2.00014-0 sha: doc_id: 340827 cord_uid: vx37vlkf abstract we provide an overview and synthesis of the literature on how social networks influence behaviors, with a focus on diffusion. we discuss some highlights from the empirical literature on the impact of networks on behaviors and diffusion. we also discuss some of the more prominent models of network interactions, including recent advances regarding interdependent behaviors, modeled via games on networks. jel classification codes: d85, c72, l14, z13 how we act, as well as how we are acted upon, are to a large extent influenced by our relatives, friends, and acquaintances. this is true of which profession we decide to pursue, whether or not we adopt a new technology, as well as whether or not we catch the flu. in this chapter we provide an overview of research that examines how social structure impacts economic decision making and the diffusion of innovations, behaviors, and information. we begin with a brief overview of some of the stylized facts on the role of social structure on diffusion in different realms. this is a rich area of study that includes a vast set of case studies suggesting some important regularities. with that empirical perspective, we then discuss insights from the epidemiology and random graph literatures that help shed light on the spread of infections throughout a society. contagion of this form can be thought of as a basic, but important, form of social interaction, where the social structure largely determines patterns of diffusion. this literature presents a rich understanding of questions such as: "how densely connected does a society have to be in order to have an infection reach a nontrivial fraction of its members?," "how does this depend on the infectiousness of the disease?," "how does it depend on the particulars of the social network in place?," "who is most likely to become infected?," and "how widespread is an infection likely to be?," among others. the results on this apply beyond infectious diseases, and touch upon issues ranging from the spread of information to the proliferation of ideas. while such epidemiological models provide a useful look at some types of diffusion, there are many economically relevant applications in which a different modeling approach is needed, and, in particular, where the interaction between individuals requires a game theoretic analysis. in fact, though disease and the transmission of certain ideas and bits of information can be modeled through mechanical or purely probabilistic sorts of diffusion processes, there are other important situations where individuals take decisions and care about how their social neighbors or peers behave. this applies to decisions of which products to buy, which technology to adopt, whether or not to become educated, whether to learn a language, how to vote, and so forth. such interactions involve equilibrium considerations and often have multiple potential outcomes. for example, an agent might care about the proportion of neighbors adopting a given action, or might require some threshold of stimulus before becoming convinced to take an action, or might want to take an action that is different from that of his or her neighbors (e.g., free-riding on their information gathering if they do gather information, but gathering information him or herself if neighbors do not). here we provide an overview of how the recent literature has modeled such interactions, and how it has been able to meld social structure with predictions of behavior. there is a large body of work that identifies the effects of social interactions on a wide range of applications spanning fields: epidemiology, marketing, labor markets, political science, and agriculture are only a few. while some of the empirical tools for the analysis of social interaction effects have been described in block, blume, durlauf, and ioannides (chapter 18, this volume) , and many of their implementations for research on housing decisions, labor markets, addictions, and more, have been discussed in ioannides (chapter 25, this volume), epple and romano (chapter 20, this volume), topa (chapter 22, this volume) , fafchamps (chapter 24, this volume), jackson (chapter 12, this volume), and munshi (chapter 23, this volume), we now describe empirical work that ties directly to the models that are discussed in the current chapter. in particular, we discuss several examples of studies that illustrate how social structure impacts outcomes and behaviors. the relevant studies are broadly divided into two classes. first, there are crosssectional studies that concentrate on a snapshot of time and look for correlations between social interaction patterns and observable behaviors. this class relates to the analysis below of strategic games played by a network of agents. while it can be very useful in identifying correlations, it is important to keep in mind that identifying causation is complicated without the fortuitous exogenous variation or structural underpinnings. second, there are longitudinal studies that take advantage of the inherent dynamics of diffusion. such studies have generated a number of interesting observations and are more suggestive of some of the insights the theoretical literature on diffusion has generated. nonetheless, these sorts of studies also face challenges in identifying causation because of potential unobserved factors that may contemporaneously influence linked individuals. the empirical work on these topics is immense and we provide here only a narrow look of the work that is representative of the type of studies that have been pursued and relate to the focus of this chapter. studies that are based on observations at one point of time most often compare the frequency of a certain behavior or outcome across individuals who are connected as opposed to ones that are not. for example, glaeser, sacerdote, and scheinkman (1996) showed that the structure of social interactions can help explain the cross-city variance in crime rates in the u.s.; bearman, moody, and stovel (2004) examined the network of romantic connections in high-school, and its link to phenomena such as the spread of sexually transmitted diseases (see the next subsection for a discussion of the spread of epidemics). such studies provide important evidence for the correlation of behaviors with characteristics of individuals' connections. in the case of diseases, they provide some direct evidence for diffusion patterns. with regards to labor markets, there is a rich set of studies showing the importance of social connections for diffusing information about job openings, dating back to rees (1966) and rees and schultz (1970) . influential studies by granovetter (1973 granovetter ( , 1985 granovetter ( , 1995 show that even casual or infrequent acquaintances (weak ties) can play a role in diffusing information. those studies were based on interviews that directly ask subjects how they obtained information about their current jobs. other studies, based on outcomes, such as topa (2001), conley and topa (2002) , and bayer, ross, and topa (2008) , identify local correlations in employment status within neighborhoods in chicago, and consider neighborhoods that go beyond the geographic but also include proximity in other socioeconomic dimensions, examining the extent to which local interactions are important for employment outcomes. bandiera, barankay, and rasul (2008) create a bridge between network formation (namely, the creation of friendships amongst fruit pickers) and the effectiveness of different labor contracts. the extensive literature on networks in labor markets 1 documents the important role of social connections in transmitting information about jobs, and also differentiates between different types of social contacts and shows that even weak ties can be important in relaying information. there is further (and earlier) research that examines the different roles of individuals in diffusion. important work by katz and lazarsfeld (1955) (building on earlier studies of lazarsfeld, berelson, and gaudet (1944) , merton (1948) , and others), identifies the role of "opinion leaders" in the formation of various beliefs and opinions. individuals are heterogeneous (at least in behaviors), and some specialize in becoming well informed on certain subjects, and then information and opinions diffuse to other less informed individuals via conversations with these opinion leaders. lazarsfeld, berelson, and gaudet (1944) study voting decisions in an ohio town during the 1940 u.s. presidential campaign, and document the presence and significance of such opinion leaders. katz and lazarsfeld (1955) interviewed women in decatur, illinois, and asked about a number of things such as their views on household goods, fashion, movies, and local public affairs. when women showed a change in opinion in follow-up interviews, katz and lazarsfeld traced influences that led to the change in opinion, again finding evidence for the presence of opinion leaders. diffusion of new products is understandably a topic of much research. rogers (1995) discusses numerous studies illustrating the impacts of social interactions on the diffusion of new products, and suggests various factors that impact which products succeed and which products fail. for example, related to the idea of opinion leaders, feick and price (1987) surveyed 1531 households and provided evidence that consumers recognize and make use of particular individuals in their social network termed "market mavens," those who have a high propensity to provide marketplace and shopping information. whether or not products reach such mavens can influence the success of a product, independently of the product's quality. tucker (2008) uses micro-data on the adoption and use of a new video-messaging technology in an investment bank consisting of 2118 employees. tucker notes the effects of the underlying network in that employees follow the actions of those who either have formal power, or informal influence (which is, to some extent, endogenous to a social network). in the political context, there are several studies focusing on the social sources of information electors choose, as well as on the selective mis-perception of social information they are exposed to. a prime example of such a collection of studies is huckfeldt and sprague (1995), who concentrated on the social structure in south bend, indiana, during the 1984 elections. they illustrated the likelihood of socially connected individuals to hold similar political affiliations. in fact, the phenomenon of individuals connecting to individuals who are similar to them is observed across a wide array of attributes and is termed by sociologists homophily (for overviews see mcpherson, smith-lovin, and cook, 2001, jackson, 2007 , as well as the discussion of homophily in jackson, chapter 12 in this volume). while cross-sectional studies are tremendously interesting in that they suggest dimensions on which social interactions may have an impact, they face many empirical challenges. most notably, correlations between behaviors and outcomes of individuals and their peers may be driven by common unobservables and therefore be spurious. given the strong homophily patterns in many social interactions, individuals who associate with each other often have common unobserved traits, which could lead them to similar behaviors. this makes it difficult to draw (causal) conclusions from empirical analysis of the social impact on diffusion of behaviors based on cross-sectional data. 2 given some of the challenges with causal inference based on pure observation, laboratory experiments and field experiments are quite useful in eliciting the effects of real-world networks on fully controlled strategic interactions, and are being increasingly utilized. as an example, leider, mobius, rosenblat, and do (2009) elicited the friendship network among undergraduates at a u.s. college and illustrated how altruism varies as a function of social proximity. in a similar setup, goeree, mcconnell, mitchell, tromp, and yariv (2010) elicited the friendship network in an all-girls school in pasadena, ca, together with girls' characteristics and later ran dictator games with recipients who varied in social distance. they identified a "1/d law of giving," in that the percentage given to a friend was inversely related to her social distance in the network. 3 various field experiments, such as those by duflo and saez (2003) , karlan, mobius, rosenblat, and szeidl (2009), dupas (2010) , beaman and magruder (2010) , and feigenberg, field, and pande (2010) , also provide some control over the process, while working with real-world network structures to examine network influences on behavior. 4 another approach that can be taken to infer causal relationships is via structural modeling. as an example, one can examine the implications of a particular diffusion model for the patterns of adoption that should be observed. one can then infer characteristics of the process by fitting the process parameters to best match the observed outcomes in terms of behavior. for instance, banerjee, chandrasekhar, duflo, and jackson (2010) use such an approach in a study of the diffusion of microfinance participation in rural indian villages. using a model of diffusion that incorporates both information and peer effects, they then fit the model to infer the relative importance of information diffusion versus peer influences in accounting for differences in microfinance participation rates across villages. of course, in such an approach one is only as confident in the causal inference as one is confident that the model is capturing the essential underpinnings of the diffusion process. the types of conclusions that have been reached from these cross sectional studies can be roughly summarized as follows. first, in a wide variety of settings, associated individuals tend to have correlated actions and opinions. this does not necessarily embody diffusion or causation, but as discussed in the longitudinal section below, there is significant evidence of social influence in diffusion patterns as well. second, individuals tend to associate with others who are similar to themselves, in terms of beliefs and opinions. this has an impact on the structure of social interactions, and can affect diffusion. it also represents an empirical quandary of the extent to which social structure influences opinions and behavior as opposed to the reverse (that can partly be sorted out with careful analysis of longitudinal data). third, individuals fill different roles in a society, with some acting as "opinion leaders," and being key conduits of information and potential catalysts for diffusion. longitudinal data can be especially important in diffusion studies, as they provide information on how opinions and behaviors move through a society over time. they also help sort out issues of causation as well as supply-specific information about the extent to which behaviors and opinions are adopted dynamically, and by whom. such data can be especially important in going beyond the documentation of correlation between social connections and behaviors, and illustrating that social links are truly the conduits for information and diffusion if one is careful to track what is observed by whom at what point in time, and can measure the resulting changes in behavior. for example, conley and udry (2008) show that pineapple growers in ghana tend to follow those farmers who succeed in changing their levels of use of fertilizers. through careful examination of local ties, and the timing of different actions, they trace the influence of the outcome of one farmer's crop on subsequent behavior of other farmers. more generally, diffusion of new technologies is extremely important when looking at transitions in agriculture. seminal studies by ryan and gross (1943) and griliches (1957) examined the effects of social connections on the adoption of a new behavior, specifically the adoption of hybrid corn in the u.s. looking at aggregate adoption rates in different states, these authors illustrated that the diffusion of hybrid corn followed an s-shape curve over time: starting out slowly, accelerating, and then ultimately decelerating. 5 foster and rosenzweig (1995) collected household-level panel data from a representative sample of rural indian households having to do with the adoption and profitability of high-yielding seed varieties (associated with the green revolution). they identified significant learning-by-doing, where some of the learning was through neighbors' experience. in fact, the observation that adoption rates of new technologies, products, or behaviors exhibit s-shaped curves can be traced to very early studies, such as tarde (1903) , who discussed the importance of imitation in adoption. such patterns are found across many applications (see mahajan and peterson (1985) and rogers (1995) ). understanding diffusion is particularly important for epidemiology and medicine for several reasons. for one, it is important to understand how different types of diseases spread in a population. in addition, it is crucial to examine how new treatments get adopted. colizza, barrat, barthelemy, and vespignani (2006, 2007) tracked the spread of severe acute respiratory syndrome (sars) across the world combining census data with data on almost all air transit during the years 2002-2003. they illustrated the importance of structures of long-range transit networks for the spread of an epidemic. coleman, katz, and menzel (1966) is one of the first studies to document the role of social networks in diffusion processes. the study looked at the adoption of a new drug (tetracycline) by doctors and highlighted two observations. first, as with hybrid corn, adoption rates followed an s-shape curve over time. second, adoption rates depended on the density of social interactions. doctors with more contacts (measured according to the trust placed in them by other doctors) adopted at higher rates and earlier in time. 6 diffusion can occur in many different arenas of human behavior. for example christakis and fowler (2007) document influences of social contacts on obesity levels. they studied the social network of 12,067 individuals in the u.s. assessed repeatedly from 1971 to 2003 as part of the framingham heart study. concentrating on bodymass index, christakis and fowler found that a person's chances of becoming obese increased by 57% if he or she had a friend who became obese, by 40% if he or she had a sibling who became obese, and by 37% if they had a spouse who became obese in a previous period. the study controls for various selection effects, and takes advantage of the direction of friendship nominations to help sort out causation. for example, christakis and fowler find a significantly higher increase of an individual's body mass index in reaction to the obesity of someone that the individual named as a friend compared to someone who had named the individual as a friend. this is one method of sorting out causation, since if unobserved influences that were common to the agents were at work, then the direction of who mentioned the other as a friend would not matter, whereas direction would matter if it indicated which individuals react to which others. based on this analysis, christakis and fowler conclude that obesity spreads very much like an epidemic with the underlying social structure appearing to play an important role. it is worth emphasizing that even with longitudinal studies, one still has to be cautious in drawing causal inferences. the problem of homophily still looms, as linked individuals tend to have common characteristics and so may be influenced by common unobserved factors, for example, both being exposed to some external stimulus (such as advertising) at the same time. this then makes it appear as if one agent's behavior closely followed another's, even when it may simply be due to both having experienced a common external event that prompted their behaviors. aral, muchnik, and sundararajan (2009) provide an idea of how large this effect can be, by carefully tracking individual characteristics and then using propensity scores (likelihoods of having neighbors with certain behaviors) to illustrate the extent to which one can over-estimate diffusion effects by not accounting for common backgrounds of connected individuals. homophily not only suggests that linked individuals might be exposed to common influences, it also makes it hard to disentangle which of the following two processes is at the root of observed similarities in behavior between connected agents. it could be that similar behavior in fact comes from a process of selection (assortative pairing), in which similarity precedes association. alternatively, it could be a consequence of a process of socialization, in which association leads to similarity. in that respect, tracking connections and behaviors over time is particularly useful. kandel (1978) concentrated on adolescent friendship pairs and examined the levels of homophily on four attributes (frequency of current marijuana use, level of educational aspirations, political orientation, and participation in minor delinquency) at various stages of friendship formation and dissolution. she noted that observed homophily in friendship dyads resulted from a significant combination of both types of processes, so that individuals emulated their friends, but also tended to drop friendships with those more different from themselves and add new friendships to those more similar to themselves. 7 in summary, let us mention a few of the important conclusions obtained from studies of diffusion. first, not only are behaviors across socially connected individuals correlated, but individuals do influence each other. while this may sound straightforward, it takes careful control to ensure that it is not unobserved correlated traits or influences that lead to similar actions by connected individuals, as well as an analysis of similarities between friends that can lead to correlations in their preferences and the things that influence them. second, in various settings, more socially connected individuals adopt new behaviors and products earlier and at higher rates. third, diffusion exhibits specific patterns over time, and specifically there are many settings where an "s"-shaped pattern emerges, with adoption starting slowly, then accelerating, and eventually asymptoting. fourth, many diffusion processes are affected by the specifics of the patterns of interaction. we now turn to discussing various models of diffusion. as should be clear from our description of the empirical work on diffusion and behavior, models can help greatly in clarifying the tensions at play. given the issues associated with the endogeneity of social relationships, and the substantial homophily that may lead to correlated behaviors among social neighbors, it is critical to have models that help predict how behavior should evolve and how it interacts with the social structure in place. we start with some of the early models that do not account for the underlying network architecture per-se. these models incorporate the empirical observations regarding social influence through the particular dynamics assumed, or preferences posited, and generate predictions matching the aggregate empirical observations regarding diffusion over time of products, diseases, or behavior. for example, the so-called s-shaped adoption curves. after describing these models, we return to explicitly capturing the role of social networks. one of the earliest and still widely used models of diffusion is the bass (1969) model. this is a parsimonious model, which can be thought of as a "macro" model: it makes predictions about aggregate behavior in terms of the percentage of potential adopters of a product or behavior who will have adopted by a given time. the current rate of change of adoption depends on the current level and two critical parameters. these two parameters are linked to the rate at which people innovate or adopt on their own, and the rate at which they imitate or adopt because others have, thereby putting into (theoretical) force the empirical observation regarding peers' influence. if we let g(t) be the percentage of agents who have adopted by time t, and m be the fraction of agents in the population who are potential adopters, a discrete time version of the bass model is characterized by the difference equation where p is a rate of innovation and q is a rate of imitation. to glean some intuition, note that the expression p (m ã� g(t ã� 1)) represents the fraction of people who have not yet adopted and might potentially do so times the rate of spontaneous adoption. in the expression qã°m ã� gã°t ã� 1ã�ã� gã°tã�1ã� m , the rate of imitation is multiplied by two factors. the first factor, (m ã� g(t ã� 1)), is the fraction of people who have not yet adopted and may still do so. the second expression, g tã�1 ã° ã� m , is the relative fraction of potential adopters who are around to imitate. if we set m equal to 1, and look at a continuous time version of the above difference equation, we get where g is the rate of diffusion (times the rate of change of g). solving this when p > 0 and setting the initial set of adopters at 0, g(0) â¼ 0, leads to the following expression: this is a fairly flexible formula that works well at fitting time series data of innovations. by estimating p and q from existing data, one can also make forecasts of future diffusion. it has been used extensively in marketing and for the general analysis of diffusion (e.g., rogers (1995)), and has spawned many extensions and variations. 8 if q is large enough, 9 then there is a sufficient imitation/social effect, which means that the rate of adoption accelerates after it begins, and so g(t) is s-shaped (see figure 1 ), matching one of the main insights of the longitudinal empirical studies on diffusion discussed above. the bass model provides a clear intuition for why adoption curves would be s-shaped. indeed, when the adoption process begins, imitation plays a minor role (relative to innovation) since not many agents have adopted yet and so the volume of adopters grows slowly. as the number of adopters increases, the process starts to accelerate as now innovators are joined by imitators. the process eventually starts to slow down, in part simply because there are fewer agents left to adopt (the term 1ã�g(t) in (1) eventually becomes small). thus, we see a process that starts out slowly, then accelerates, and then eventually slows and asymptotes. the bass model described above is mechanical in that adopters and imitators are randomly determined; they do not choose actions strategically. the empirical observation that individuals influence each other through social contact can be derived through agents' preferences, rather than through some exogenously specified dynamics. diffusion in a strategic context was first studied without a specific structure for interactions. broadly speaking, there were two approaches taken in this early literature. in the first, all agents are connected to one another (that is, they form a complete network). effectively, this corresponds to a standard multi-agent game in which payoffs to each player depend on the entire profile of actions played in the population. the second approach has been to look at interactions in which agents are matched to partners in a random fashion. diffusion on complete networks. granovetter (1978) considered a model in which n agents are all connected to one another and each agent chooses one of two actions: 0 or 1. associated with each agent i is a number n i . this is a threshold such that if at least n i other agents take action 1 then i prefers action 1 to action 0, and if fewer than n i other agents take action 1 then agent i prefers to take action 0. the game exhibits what are known as strategic complementarities. for instance, suppose that the utility of agent i faced with a profile of actions (x 1 , . . ., x n ) 2 {0, 1} n is described by: where c i is randomly drawn from a distribution f over [0,1]. c i can be thought of as a cost that agent i experiences upon choosing action 1 (e.g., a one-time switching cost from one technology to the other, or potential time costs of joining a political revolt, etc.). the utility of agent i is normalized to 0 when choosing the action 0. when choosing the action 1, agent i experiences a benefit proportional to the fraction of other agents choosing the action 1 and a cost of c i . granovetter considered a dynamic model in which at each stage agents best respond to the previous period's distribution of actions. if in period t there was a fraction x t of agents choosing the action 1, then in period t ã¾ 1 an agent i chooses action 1 if and only if his or her cost is lower than nx t ã�x t i n ã�1 , the fraction of other agents taking action 1 in the last period. for a large population, then corresponds to an (approximate) equilibrium of a large population. the shape of the distribution f determines which equilibria are tipping points: equilibria such that only a slight addition to the fraction of agents choosing the action 1 shifts the population, under the best response dynamics, to the next higher equilibrium level of adoption (we return to a discussion of tipping and stable points when we consider a more general model of strategic interactions on networks below). note that while in the bass model the diffusion path was determined by g(t), the fraction of adopters as a function of time, here it is easier to work with f(x), corresponding to the fraction of adopters as a function of the previous period's fraction x. although granovetter (1978) does not examine conditions under which the time series will exhibit attributes like the s-shape that we discussed above, by using techniques from jackson and yariv (2007) we can derive such results, as we now discuss. keeping track of time in discrete periods (a continuous time analog is straightforward), the level of change of adoption in the society is given by thus, to derive an s-shape, we need this quantity to initially be increasing, and then eventually to decrease. assuming differentiability of f, this corresponds to the derivative of d(x t ) being positive up to some x and then negative. the derivative of f(x) ã� x is f 0 (x) ã� 1 and having an s-shape corresponds to f 0 being greater than 1 up to some point and then less than 1 beyond that point. for instance, if f is concave with an initial slope greater than 1 and an eventual slope less than 1, this is satisfied. note that the s-shape of adoption over time does not translate into an s-shape of f -but rather a sort of concavity. 10 the idea is that we initially need a rapid level of change, which corresponds to an initially high slope of f, and then a slowing down, which corresponds to a lower slope of f. fashions and random matching. a different approach than that of the bass model is taken by pesendorfer (1995) , who considers a model in which individuals are randomly matched and new fashions serve as signaling instruments for the creation of matches. he identifies particular matching technologies that generate fashion cycles. pesendorfer describes the spread of a new fashion as well as its decay over time. in pesendorfer's model, the price of the design falls as it spreads across the population. once sufficiently many consumers own the design, it is profitable to create a new design and thereby render the old design obsolete. in particular, demand for any new innovation eventually levels off as in the above two models. information cascades and learning. another influence on collective behavior derives from social learning. this can happen without any direct complementarities in actions, but due to information flow about the potential payoffs from different behaviors. if people discuss which products are worth buying, or which technologies are worth adopting, books worth reading, and so forth, even without any complementarities in behaviors, one can end up with cascades in behavior, as people infer information from others' behaviors and can (rationally) imitate them. as effects along these lines are discussed at some length in jackson (chapter 12, this volume) and goyal (chapter 15, this volume), we will not detail them here. we only stress that pure information transmission can lead to diffusion of behaviors. we now turn to models that explicitly incorporate social structure in examining diffusion patterns. we start with models that stem mostly from the epidemiology literature and account for the underlying social network, but are mechanical in terms of the way that disease spreads from one individual to another (much like the bass model described above). we then proceed to models in which players make choices that depend on their neighbors' actions as embedded in a social network; for instance, only adopting an action if a certain proportion of neighbors adopt as well (as in granovetter's setup), or possibly not adopting an action if enough neighbors do so. many models of diffusion and strategic interaction on networks have the following common elements. there is a finite set of agents n â¼ {1, . . ., n}. agents are connected by a (possibly directed) network g 2 {0, 1} nã�n . we let n i (g) {j : g ij â¼ 1} be the neighbors of i. the degree of a node i is the number of her neighbors, d i jn i (g)j. when links are determined through some random process, it is often useful to summarize the process by the resulting distribution of degrees p, where p(d) denotes the probability a random individual has a degree of d. 11, 12 each agent i 2 n takes an action x i . in order to unify and simplify the description of various models, we focus on binary actions, so that x i 2 {0, 1}. actions can be metaphors for becoming "infected" or not, buying a new product or not, choosing one of two activities, and so forth. some basic insights about the extent to which behavior or an infection can spread in a society can be derived from random graph theory. random graph theory provides a tractable base for understanding characteristics important for diffusion, such as the structure and size of the components of a network, maximally connected subnetworks. 13 before presenting some results, let us talk through some of the ideas in the context of what is known as the reed-frost model. 14 consider, for example, the spread of a disease. initially, some individuals in the society are infected through mutations of a germ or other exogenous sources. consequently, some of these individuals' neighbors are infected through contact, while others are not. this depends on how virulent the disease is, among other things. in this application, it makes sense (at least as a starting point) to assume that becoming infected or avoiding infection is not a choice; 11 such a description is not complete, in that it does not specify the potential correlations between degrees of different individuals on the network. see galeotti, goyal, jackson, vega-redondo, and yariv (2010) for more details. 12 in principle, one would want to calibrate degree distributions with actual data. the literature on network formation, see bloch and dutta (chapter 16, this volume) and jackson (chapter 12, this volume), suggests some insights on plausible degree distributions p(d). 13 formally, these are the subnetworks projected induced by maximal sets c n of nodes such any two distinct nodes in c are path connected within c. that is, for any i,j 2 c, there exist i 1 , . . ., i k 2 c such that g ii1 â¼ g i1i2 â¼ . . . â¼ g ikã�1ik â¼ g ikj â¼ 1. 14 see jackson (2008) for a more detailed discussion of this and related models. i.e., contagion here is nonstrategic. in the simplest model, there is a probability p ! 0 that a given individual is immune (e.g., through vaccination or natural defenses). if an individual is not immune, it is assumed that he or she is sure to catch the disease if one of his or her neighbors ends up with the disease. in this case, in order to estimate the volume of those ultimately infected, we proceed in two steps, depicted in figure 2 . first, we delete a fraction p of the nodes that will never be infected (these correspond to the dotted nodes in the figure) . then, we note that the components of the remaining network that contain the originally infected individuals comprise the full extent of the infection. in particular, if we can characterize what the components of the network look like after removing some portion of the nodes, we have an idea of the extent of the infection. in figure 2 , we start with one large connected component (circumvented by a dotted line) and two small-connected components. after removing the immune agents, there is still a large connected component (though smaller than before), and four small components. thus, the estimation of the extent of infection of the society is reduced to the estimation of the component structure of the network. a starting point for the formal analysis of this sort of model uses the canonical random network model, where links are formed independently, each with an identical probability p > 0 of being present. this is sometimes referred to as a "poisson random network" as its degree distribution is approximated by a poisson distribution if p is not excessively large; and has various other aliases such as an "erdã¶s-renyi random graph," a "bernoulli random graph," or a "g(n,p)" random graph (see jackson, chapter 12 in this volume, for more removing immune agents background). ultimately, the analysis boils down to considering a network on (1ã�p)n nodes with an independent link probability of p, and then measuring the size of the component containing a randomly chosen initially infected node. clearly, with a fixed set of nodes, and a positive probability p that lies strictly between 0 and 1, every conceivable network on the given set of nodes could arise. thus, in order to say something specific about the properties of the networks that are "most likely" to arise, one generally works with large n where reasoning based on laws of large numbers can be employed. for example, if we think of letting n grow, we can ask for which p's (that are now dependent on n) a nonvanishing fraction of nodes will become infected with a probability bounded away from 0. so, let us consider a sequence of societies indexed by n and corresponding probabilities of links p(n). erdã¶s and renyi (1959 renyi ( , 1960 proved a series of results that characterize some basic properties of such random graphs. in particular, 15 â�¢ the threshold for the existence of a "giant component," a component that contains a nontrivial fraction of the population, is 1/n, corresponding to an average degree of 1. that is, if p(n) over 1/n tends to infinity, then the probability of having a giant component tends to 1, while if p(n) over 1/n tends to 0, then the probability of having a giant component tends to 0. â�¢ the threshold for the network to be connected (so that every two nodes have a path between them) is log(n)/n, corresponding to an average degree that is proportional to log(n). the logic for the first threshold is easy to explain, though the proof is rather involved. to heuristically derive the threshold for the emergence of a giant component, consider following a link out of a given node. we ask whether or not one would expect to be able to find a link to another node from that one. if the expected degree is much smaller than 1, then following the few (if any) links from any given node is likely to lead to dead-ends. in contrast, when the expected degree is much higher than 1, then from any given node, one expects to be able to reach more nodes, and then even more nodes, and so forth, and so the component should expand outward. note that adjusting for the factor p of the number of immune nodes does not affect the above thresholds as they apply as limiting results, although the factor will be important for any fixed n. between these two thresholds, there is only one giant component, so that the next largest component is of a size that is a vanishing fraction of the giant component. this is intuitively clear, as to have two large components requires many links within each component but no links between the two components, which is an unlikely event. in that sense, the image that emerges from figure 2 of one large connected component is reasonably typical for a range of parameter values. these results then tell us that in a random network, if average degree is quite low (smaller than 1), then any initial infection is likely to die out. in contrast, if average degree is quite high (larger than log(n)), then any initial infection is likely to spread to all of the susceptible individuals, i.e., a fraction of 1 ã� p of the population. in the intermediate range, there is a probability that the infection will die out and also a probability that it will infect a nontrivial, but limited, portion of the susceptible population. there, it can be shown that for such random networks and large n, the fraction of nodes in the giant component of susceptible nodes is roughly approximated by the nonzero q that solves here, q is an approximation of the probability of the infection spreading to a nontrivial fraction of nodes, and also of the percentage of susceptible nodes that would be infected. 16 this provides a rough idea of the type of results that can be derived from random graph theory. there is much more that is known, as one can work with other models of random graphs (other than ones where each link has an identical probability), richer models of probabilistic infection between nodes, as well as derive more information about the potential distribution of infected individuals. it should also be emphasized that while the discussion here is in terms of "infection," the applications clearly extend to many of the other contexts we have been mentioning, such as the transmission of ideas and information. fuller treatment of behaviors, where individual decisions depend in more complicated ways on neighbors' decisions, are treated in section 4.3. the above analysis of diffusion presumes that once infected, a node eventually infects all of its susceptible neighbors. this misses important aspects of many applications. in terms of diseases, infected nodes can either recover and stop transmitting a disease, or die and completely disappear from the network. transmission will also generally be probabilistic, depending on the type of interaction and its extent. 17 similarly, if we think of behaviors, it might be that the likelihood that a node is still actively transmitting a bit of information to its neighbors decreases over time. ultimately, we will discuss models that allow for rather general strategic impact of peer behavior (a generalization of the approach taken by granovetter). but first we discuss some aspects of the epidemiology literature that takes steps forward in that direction by considering two alternative models that keep track of the state of nodes and are more explicitly dynamic. the common terminology for the possible states that 16 again, see chapter 4 in jackson (2008) for more details. 17 probabistic transmission is easily handled in the above model by simply adjusting the link probability to reflect the fact that some links might not transmit the disease. a node can be in are: susceptible, where a node is not currently infected or transmitting a disease but can catch it; infected, where a node has a disease and can transmit it to its neighbors; and removed (or recovered), where a node has been infected but is no longer able to transmit the disease and cannot be re-infected. the first of the leading models is the "sir" model (dating to kermack and mckendrick, 1927) , where nodes are initially susceptible but can catch the disease from infected neighbors. once infected, a node continues to infect neighbors until it is randomly removed from the system. this fits well the biology of some childhood diseases, such as the chicken pox, where one can only be infected once. the other model is the "sis" model (see bailey, 1975) , where once infected, nodes can randomly recover, but then they are susceptible again. this corresponds well with an assortment of bacterial infections, viruses, and flus, where one transitions back and forth between health and illness. the analysis of the sir model is a variant of the component-size analysis discussed above. the idea is that there is a random chance that an "infected" node infects a given "susceptible" neighbor before becoming "removed." roughly, one examines component structures in which instead of removing nodes randomly, one removes links randomly from the network. this results in variations on the above sorts of calculations, where there are adjusted thresholds for infection depending on the relative rates of how quickly infected nodes can infect their neighbors compared to how quickly they are removed. in contrast, the sis model involves a different sort of analysis. the canonical version of that model is best viewed as one with a random matching process rather than a social network. in particular, suppose that a node i in each period will have interactions with d i other individuals from the population. recall our notation of p(d) describing the proportion of the population that has degree d (so d interactions per period). the matches are determined randomly, in such a way that if i is matched with j, then the probability that j has degree d > 0 is given bỹ where hã�i represents the expectation with respect to p. 18 this reflects the fact that an agent is proportionally more likely to be matched with other individuals who have lots of connections. to justify this formally, one needs an infinite population. indeed, with any finite population of agents with heterogeneous degrees, the emergent networks will generally exhibit some correlation between neighbors' degrees. 19 individuals who have high degrees will have more interactions per period and will generally be more likely to be infected at any given time. an important calculation 18 we consider only individuals who have degree d > 0, as others do not participate in the society. 19 see the appendix of currarini, jackson, and pin (2009) for some details along this line. then pertains to the chance that a given meeting will be with an infected individual. if the infection rate of degree d individuals is r(d ), the probability that any given meeting will be with an infected individual is y, where the chance of meeting an infected individual in a given encounter then differs from the average infection rate in the population, which is just r â¼ p p d ã° ã�r d ã° ã�, because y is weighted by the rate at which individuals meet each other. a standard version of contagion that is commonly analyzed is one in which the probability of an agent of degree d becoming infected is where n 2 (0, 1) is a rate of transmission of infection in a given period, and is small enough so that this probability is less than one. if n is very small, this is an approximation of getting infected under d interactions with each having an (independent) probability y of being infected and then conditionally (and independently) having a probability n of getting infected through contact with a given infected individual. the last part of the model is that in any given period, an infected individual recovers and becomes susceptible with a probability d 2 (0, 1). if such a system operates on a finite population, then eventually all agents will become susceptible and that would end the infection. if there is a small probability of a new mutation and infection in any given period, the system will be ergodic and always have some probability of future infection. to get a feeling for the long run outcomes in large societies, the literature has examined a steady state (i.e., a situation in which the system essentially remains constant) of a process that is idealized as operating on an infinite (continuous) population. formally, a steady-state is defined by having r(d) be constant over time for each d. working with an approximation at the limit (termed a "mean-field" approximation that in this case can be justified with a continuum of agents, but with quite a bit of technical detail), a steady-state condition can be derived to be for each d. (1ã�r(d))nyd is the rate at which agents of degree d who were susceptible become infected and r(d)d is the rate at which infected individuals of degree d recover. letting l â¼ n d , it follows that solving (5) and (8) simultaneously leads to a characterization of the steady-state y: this system always has a solution, and therefore a steady-state, where y â¼ 0 so there is no infection. it can also have other solutions under which y is positive (but always below 1 if l is finite). unless p takes very specific forms, it can be difficult to find steady states y > 0 analytically. special cases have been analyzed, such as the case of a power distribution, where p(d ) â¼ 2d ã�3 (e.g., see pastor-satorras and vespignani (2000, 2001) ). in that case, there is always a positive steady-state infection rate. more generally, lopez-pintado (2008) addresses the question of when it is that there will be a positive steady-state infection rate. to get some intuition for her results, let so that the equation y â¼ h(y) corresponds to steady states of the system. we can now extend the analysis of granovetter's (1978) model that we described above, with this richer model in which h(y) accounts for network attributes. while the fixed-point equation identifying granovetter's stable points allowed for rather arbitrary diffusion patterns (depending on the cost distribution f), the function h has additional structure to it that we can explore. in particular, suppose we examine the infection rate that would result if we start at a rate of y and then run the system on an infinite population for one period. noting that h(0) â¼ 0, it is clear that 0 is always a fixed-point and thus a steady-state. since h(1) < 1, and h is increasing and strictly concave in y (which is seen by examining its first and second derivatives), there can be at most one fixed-point besides 0. for there to be another fixed-point (steady-state) above y â¼ 0, it must be that h 0 (0) is above 1, or else, given the strict concavity, we would have h(y) < y for all positive y. moreover, in cases where h 0 (0) > 1, a small perturbation away from a 0 infection rate will lead to increased infection. in the terminology we have introduced above, 0 would be a tipping point. since higher infection rates lead to the possibility of positive infection, as do degree distributions with high variances (relative to mean). the idea behind having a high variance is that there will be some "hub nodes" with high degree, who can foster contagion. going back to our empirical insights, this analysis fits the observations that highlylinked individuals are more likely to get infected and experience speedier diffusion. whether the aggregate behavior exhibits the s-shape that is common in many realworld diffusion processes will depend on the particulars of h, much in the same way that we discussed how the s-shape in granovetter's model depends on the shape of the distribution of costs f in that model. here, things are slightly complicated since h is a function of y, which is the probability of infection of a neighbor, and not the overall probability of infection of the population. thus, one needs to further translate how various y's over time translate into population fractions that are infected. beyond the extant empirical studies, this analysis provides some intuitions behind what is needed for an infection to be possible. it does not, however, provide an idea of how extensive the infection spread will be and how that depends on network structure. while this does not boil down to as simple a comparison as (12), there is still much that can be deduced using (9), as shown by jackson and rogers (2007) . while one cannot always directly solve notice that lyd 2 hdiã°lyd ã¾ 1ã� is an increasing and convex function of d. therefore, the right hand side of the above equality can be ordered when comparing different degree distributions in the sense of stochastic dominance (we will return to these sorts of comparisons in some of the models we discuss below). the interesting conclusion regarding steady-state infection rates is that they depend on network structure in ways that are very different at low levels of the infection rate l compared to high levels. while the above models provide some ideas about how social structure impacts diffusion, they are limited to settings where, roughly speaking, the probability that a given individual adopts a behavior is simply proportional to the infection rate of neighbors. especially when it comes to situations in which opinions or technologies are adopted, purchasing decisions are made, etc., an individual's decision can depend in much more complicated ways on the behavior of his or her neighbors. such interaction naturally calls on game theory as a tool for modeling these richer interactions. we start with static models of interactions on networks that allow for a rather general impact of peers' actions on one's own optimal choices. the first model that explicitly examines games played on a network is the model of "graphical games" as introduced by kearns, littman, and singh (2001) , and analyzed by kakade, kearns, langford, and ortiz (2003) , among others. the underlying premise in the graphical games model is that agents' payoffs depend on their own actions and the actions of their direct neighbors, as determined by the network of connections. 20 formally, the payoff structure underlying a graphical game is as follows. the payoff to each player i when the profile of actions is x â¼ (x 1 , . . ., x n ) is where x n i g ã° ã� is the profile of actions taken by the neighbors of i in the network g. most of the empirical applications discussed earlier entailed agents responding to neighbors' actions in roughly one of two ways. in some contexts, such as those pertaining to the adoption of a new product or new agricultural grain, decisions to join the workforce, or to join a criminal network, agents conceivably gain more from a particular action the greater is the volume of peers who choose a similar action. that is, payoffs exhibit strategic complementarities. in other contexts, such as experimentation on a new drug, or contribution to a public good, when an agent's neighbors choose a particular action, the relative payoff the agent gains from choosing a similar action decreases, and there is strategic substitutability. the graphical games environment allows for the analysis of both types of setups, as the following example (taken from galeotti, goyal, jackson, vega-redondo, and yariv (2010)) illustrates. example 1 (payoffs depend on the sum of actions) player i's payoff function when he or she chooses x i and her k neighbors choose the profile (x 1 , . . ., x k ) is: where f(ã�) is nondecreasing and c(ã�) is a "cost" function associated with own effort (more general but much in the spirit of (2)). the parameter l 2 r determines the nature of the externality across players' actions. the shape and sign of lf determine the effects of neighbors' action choices on one's own optimal choice. in particular, the example yields strict strategic substitutes (complements) if, assuming differentiability, lf 00 is negative (positive). there are several papers that analyze graphical games for particular choices of f and l. to mention a few examples, the case where f is concave, l â¼ 1, and c(ã�) is increasing and linear corresponds to the case of information sharing as a local public good studied by bramoullã© and kranton (2007) , where actions are strategic substitutes. in contrast, if l â¼ 1, but f is convex (with c 00 > f 00 > 0), we obtain a model with strategic complements, as proposed by goyal and moraga-gonzalez (2001) to study collaboration among local monopolies. in fact, the formulation in (13) is general enough to accommodate numerous further examples in the literature such as human capital investment (calvã³-armengol and jackson (2009)), crime and other networks (ballester, calvã³-armengol, and zenou (2006) ), some coordination problems (ellison (1993) ), and the onset of social unrest (chwe (2000) ). the computer science literature (e.g., the literature following kearns, littman, and singh (2001) , and analyzed by kakade, kearns, langford, and ortiz (2003) ) has focused predominantly on the question of when an efficient (polynomial-time) algorithm can be provided to compute nash equilibria of graphical games. it has not had much to say about the properties of equilibria, which is important when thinking about applying such models to analyze diffusion in the presence of strategic interaction. in contrast, the economics literature has concentrated on characterizing equilibrium outcomes for particular applications, and deriving general comparative statics with respect to agents' positions in a network and with respect to the network architecture itself. information players hold regarding the underlying network (namely, whether they are fully informed of the entire set of connections in the population, or only of connections in some local neighborhood) ends up playing a crucial role in the scope of predictions generated by network game models. importantly, graphical games are ones in which agents have complete information regarding the networks in place. consequently, such models suffer from inherent multiplicity problems, as clearly illustrated in the following example. it is based on a variation of (13), which is similar to a model analyzed by bramoullã© and kranton (2007) . example 2 (multiplicity -complete information) suppose that in (13), we set l â¼ 1, choose x i 2 {0, 1}, and have and c(x i ) cx i , where 0 < c < 1. this game, often labeled the best-shot public goods game, may be viewed as a game of local public-good provision. each agent would choose the action 1 (say, experimenting with a new grain, or buying a product that can be shared with one's friends) if they were alone (or no one else experimented), but would prefer that one of their neighbors incur the cost c that the action 1 entails (when experimentation is observed publicly). effectively, an agent just needs at least one agent in his or her neighborhood to take action 1 to enjoy its full benefits, but prefers that it be someone else given that the action is costly and there is no additional benefit beyond one person taking the action. note that, since c < 1, in any (pure strategy) nash equilibrium, for any player i with k neighbors, it must be the case that one of the agents in the neighborhood chooses the action 1. that is, if the chosen profile is (x 1 , . . ., x k ), then x i ã¾ p k jâ¼1 x j ! 1. in fact, there is a very rich set of equilibria in this game. to see this, consider a star network and note that there exist two equilibria, one in which the center chooses 0 and the spokes choose 1, and a second equilibrium in which the spoke players choose 0 while the center chooses 1. figure 3 illustrates these two equilibria. in the first, depicted in the left panel of the figure, the center earns more than the spoke players, while in the second equilibrium (in the right panel) it is the other way round. even in the simplest network structures equilibrium multiplicity may arise and the relation between network architecture, equilibrium actions, and systematic patterns can be difficult to discover. while complete information regarding the structure of the social network imposed in graphical game models may be very sensible when the relevant network of agents is small, in large groups of agents (such as a country's electorate, the entire set of corn growers in the 50's, sites in the world-wide web, or academic economists), it is often the case that individuals have noisy perceptions of their network's architecture. as the discussion above stressed, complete information poses many challenges because of the widespread occurrence of equilibrium multiplicity that accompanies it. in contrast, when one looks at another benchmark, where agents know how many neighbors they will have but not who they will be, the equilibrium correspondence is much easier to deal with. moreover, this benchmark is an idealized model of settings in which agents make choices like learning a language or adopting a technology that they will use over a long time. in such contexts, agents have some idea of how many interactions they are likely to have in the future, but not exactly with whom the interactions will be. a network game is a modification of a graphical game in which agents can have private and incomplete information regarding the realized social network at place. we describe here the setup corresponding to that analyzed by galeotti, goyal, jackson, vega-redondo, and yariv (2010) and yariv (2005, 2007) , restricting attention to binary action games. 21 uncertainty is operationalized by assuming the network is determined according to some random process yielding our distribution over agents' degrees, p(d), which is common knowledge. each player i has d i interactions, but does not know how many interactions each neighbor has. thus, each player knows something about his or her local neighborhood (the number of direct neighbors), but only the distribution of links in the remaining population. consider now the following utility specification, a generalization of (2). agent i has a cost of choosing 1, denoted c i . costs are randomly and independently distributed across the society, according to a distribution f c . normalize the utility from the action 0 to 0 and let the benefit of agent i from action 1 be denoted by v(d i , x), where d i is i 0 s degree and she expects each of her neighbors to independently choose the action 1 with probability x. agent i's added payoff from adopting behavior 1 over sticking to the action 0 is then this captures how the number of neighbors that i has, as well as their propensity to choose the action 1, affects the benefits from adopting 1. in particular, i prefers to choose the action 1 if this is a simple cost-benefit analysis generalizing granovetter (1978) 's setup in that benefits can now depend on one's own degree (so that the underlying network is accounted for). let f(d, x) f c (v(d, x) ). in words, f(d, x) is the probability that a random agent of degree d chooses the action 1 when anticipating that each neighbor will choose 1 with an independent probability x. note that v(d, x) can encompass all sorts of social interactions. in particular, it allows for a simple generalization of granovetter's (1978) model to situations in which agents' payoffs depend on the expected number of neighbors adopting, dx. existence of symmetric bayesian equilibria follows standard arguments. in cases where v is nondecreasing in x for each d, it is a direct consequence of tarski's fixed-point theorem. in fact, in this case, there exists an equilibrium in pure strategies. in other cases, provided v is continuous in x for each d, a fixed-point can still be found by appealing to standard theorems (e.g., kakutani) and admitting mixed strategies. 22 homogeneous costs. suppose first that all individuals experience the same cost c > 0 of choosing the action 1 (much like in example 2 above). in that case, as long as v(d, x) is monotonic in d (nonincreasing or nondecreasing), equilibria are characterized by a threshold. indeed, suppose v(d, x) is increasing in d, then any equilibrium is characterized by a threshold d ã� such that all agents of degree d < d ã� choose the action 0 and all agents of degree d > d ã� choose the action 1 (and agents of degree d ã� may mix between the actions). in particular, notice that the type of multiplicity that appeared in example 2 no longer occurs (provided degree distributions are not trivial). it is now possible to look at comparative statics of equilibrium behavior and outcomes using stochastic dominance arguments on the network itself. for ease of exposition, we illustrate this in the case of nonatomic costs (see galeotti, goyal, jackson, vega-redondo, and yariv (2010) for the general analysis). heterogeneous costs. consider the case in which f c is a continuous function, with no atoms. in this case, a simple equation is sufficient to characterize equilibria. let x be the probability that a randomly chosen neighbor chooses the action 1. then f(d, x) is the probability that a random (best responding) neighbor of degree d chooses the action 1. we can now proceed in a way reminiscent of the analysis of the sis model. recall thatpã°dã� denoted the probability that a random neighbor is of degree d (see equation (4)). it must be that again, a fixed-point equation captures much of what occurs in the game. in fact, equation (15) characterizes equilibria in the sense that any symmetric 23 equilibrium results in an x that satisfies the equation, and any x that satisfies the equation corresponds to an equilibrium where type (d i , c i ) chooses 1 if and only if inequality (14) holds. given that equilibria can be described by their corresponding x, we often refer to some value of x as being an "equilibrium." consider a symmetric equilibrium and a corresponding probability of x for a random neighbor to choose action 1. if the payoff function v is increasing in degree d, then the expected payoff of an agent with degree d ã¾ 1 is ã�and agents with higher degrees choose 1 with weakly higher probabilities. indeed, an agent of degree d ã¾ 1 can imitate the decisions of an 22 in such a case, the best response correspondence (allowing mixed strategies) for any (d i , c i ) as dependent on x is upper hemi-continuous and convex-valued. taking expectations with respect to d i and c i , we also have a set of population best responses as dependent on x that is upper hemi-continuous and convex valued. 23 symmetry indicates that agents with the same degree and costs follow similar actions. agent of degree d and gain at least as high a payoff. thus, if v is increasing (or, in much the same way, decreasing) in d for each x, then any symmetric equilibrium entails agents with higher degrees choosing action 1 with weakly higher (lower) probability. furthermore, agents of higher degree have higher (lower) expected payoffs. much as in the analysis of the epidemiological models, the multiplicity of equilibria is determined by the properties of f, which, in turn, correspond to properties ofp and f. for instance, â�¢ if f(d, 0) > 0 for some d in the support of p, and f is concave in x for each d, then there exists at most one fixed-point, and â�¢ if f(d, 0) â¼ 0 for all d and f is strictly concave or strictly convex in x for each d, then there are at most two equilibria-one at 0, and possibly an additional one, depending on the slope of f(x) at x â¼ 0. 24 in general, as long as the graph of f(x) crosses the 45-degree line only once, there is a unique equilibrium (see figure 4 below). 25 the set of equilibria generated in such network games is divided into stable and unstable ones (those we have already termed in section 3.2 as tipping points). the simple characterization given by (15) allows for a variety of comparative statics on fundamentals pertaining to either type of equilibrium. in what follows, we show how these 24 as before, the slope needs to be greater than 1 for there to be an additional equilibrium in the case of strict concavity, while the case of strict convexity depends on the various values of f(d, 1) across d. 25 morris and shin (2003, 2005) consider uncertainty on payoffs rather than on an underlying network. in coordination games, they identify a class of payoff shocks that lead to a unique equilibrium. heterogeneity in degrees combined with uncertainty plays a similar role in restricting the set of equilibria. in a sense, the analysis described here is a generalization in that it allows studying the impact of changes in a variety of fundamentals on the set of stable and unstable equilibria, regardless of multiplicity, in a rather rich environment. moreover, the equilibrium structure can be tied to the network of underlying social interactions. x t figure 4 the effects of shifting f(x) pointwise. comparative statics tie directly to a simple strategic diffusion process. indeed, it turns out there is a very useful technical link between the static and dynamic analysis of strategic interactions on networks. an early contribution to the study of diffusion of strategic behavior allowing for general network architectures was by morris (2000) . 26 morris (2000) considered coordination games played on networks. his analysis pertained to identifying social structures conducive to contagion, where a small fraction of the population choosing one action leads to that action spreading across the entire population. the main insight from morris (2000) is that maximal contagion occurs when the society has certain sorts of cohesion properties, where there are no groups (among those not initially infected) that are too inward looking in terms of their connections. in order to identify the full set of stable of equilibria using the above formalization, consider a diffusion process governed by best responses in discrete time (following yariv (2005, 2007) ). at time t â¼ 0, a fraction x 0 of the population is exogenously and randomly assigned the action 1, and the rest of the population is assigned the action 0. at each time t > 0, each agent, including the agents assigned to action 1 at the outset, best responds to the distribution of agents choosing the action 1 in period tã�1, accounting for the number of neighbors they have and presuming that their neighbors will be a random draw from the population. let x t d denote the fraction of those agents with degree d who have adopted behavior 1 at time t, and let x t denote the link-weighted fraction of agents who have adopted the behavior at time t. that is, using the distribution of neighbors' degreespã°dã�, then, as deduced before from equation (14), at each date t, and therefore x t â¼ x dp ã°dã�fã°d; x tã�1 ã� â¼ fã°x tã�1 ã�: as we have discussed, any rest point of the system corresponds to a static (bayesian) equilibrium of the system. 26 one can find predecessors with regards to specific architectures, usually lattices or complete mixings, such as conway's (1970) "game of life," and various agent-based models that followed such as the "voter model" (e.g., see clifford and sudbury (1973) and holley and liggett (1975) ), as well as models of stochastic stability (e.g., kandori, mailath, robb (1993) , young (1993) , ellison (1993) ). if payoffs exhibit complementarities, then convergence of behavior from any starting point is monotone, either upwards or downwards. in particular, once an agent switches behaviors, the agent will not want to switch back at a later date. 27 thus, although these best responses are myopic, any eventual changes in behavior are equivalently forward-looking. figure 4 depicts a mapping f governing the dynamics. equilibria, and resting points of the diffusion process, correspond to intersections of f with the 45-degree line. the figure allows an immediate distinction between two classes of equilibria that we discussed informally up to now. formally, an equilibrium x is stable if there exists e 0 > 0 such that f(x ã� e) > x ã� e and f(x ã¾ e) < x ã¾ e for all e 0 > e > 0. an equilibrium x is unstable or a tipping point if there exists e 0 > 0 such that f(x ã� e) < x ã� e and f(x ã¾ e) > x ã¾ e for all e 0 > e > 0. in the figure, the equilibrium to the left is a tipping point, while the equilibrium to the right is stable. the composition of the equilibrium set hinges on the shape of the function f. furthermore, note that a point-wise shift of f (as in the figure, to a new function f) shifts tipping points to the left and stable points to the right, loosely speaking (as sufficient shifts may eliminate some equilibria altogether), making adoption more likely. this simple insight allows for a variety of comparative statics. for instance, consider an increase in the cost of adoption, manifested as a first order stochastic dominance (fosd) shift of the cost distribution f c to f c . it follows immediately that: fã°xã� â¼ x dp ã°dã�f c ã°vã°d; xã�ã� x dp ã°dã�f c ã°vã°d; xã�ã� â¼ fã°xã� and the increase in costs corresponds to an increase of the tipping points and decrease of the stable equilibria (one by one). intuitively, increasing the barrier to choosing the action 1 leads to a higher fraction of existing adopters necessary to get the action 1 to spread even more. this formulation also allows for an analysis that goes beyond graphical games regarding the social network itself, using stochastic dominance arguments (following jackson and rogers (2007) ) and yariv (2005, 2007) ). for instance, consider an increase in the expected degree of each random neighbor that an agent has. that is, supposep ' fosdp and, for illustration, assume that f(d, x) is nondecreasing in d for all x. then, by the definition of fosd, f 0 ã°xã� â¼ x dp 0 ã°dã�fã°d; xã� ! x dp ã°dã�fã°d; xã� â¼ fã°xã�; and, under p 0 , tipping points are lower and stable equilibria are higher. 27 if actions are strategic substitutes, convergence may not be guaranteed for all starting points. however, whenever convergence is achieved, the rest point is an equilibrium, and the analysis can therefore be useful for such games as well. similar analysis allows for comparative statics regarding the distribution of links, by simply looking at mean preserving spreads (mps) of the underlying degree distribution. 28 going back to the dynamic path of adoption, we can generalize the insights that we derived regarding the granovetter (1978) model. namely, whether adoption paths track an s-shaped curve now depends on the shape of f, and thereby on the shape of both the cost distribution f and agents' utilities. there is now a substantial and growing body of research studying the impacts of interactions that occur on a network of connections. this work builds on the empirical observations of peer influence and generates a rich set of individual and aggregate predictions. insights that have been shown consistently in real-world data pertain to the higher propensities of contagion (of a disease, an action, or behavior) in more highly connected individuals, the role of "opinion leaders" in diffusion, as well as an aggregate s-shape of many diffusion curves. the theoretical analyses open the door to many other results, e.g., those regarding comparative statics across networks, payoffs, and cost distributions (when different actions vary in costs). future experimental and field data will hopefully complement these theoretical insights. a shortcoming of some of the theoretical analyses described in this chapter is that the foundation for modeling the underlying network is rooted in simple forms of random graphs in which there is little heterogeneity among nodes other than their connectivity. this misses a central observation from the empirical literature that illustrates again and again the presence of homophily, people's tendency to associate with other individuals who are similar to themselves. moreover, there are empirical studies that are suggestive of how homophily might impact diffusion, providing for increased local connectivity but decreased diffusion on a more global scale (see rogers (1995) for some discussion). beyond the implications that homophily has for the connectivity structure of the network, it also has implications for the propensity of individuals to be affected by neighbors' behavior: for instance, people who are more likely to, say, be immune may be more likely to be connected to one another, and, similarly, people who are more likely to be susceptible to infection may be more likely to be connected to one another. 29 furthermore, background factors linked to homophily can also affect the payoffs individuals receive when making decisions in their social network. enriching the interaction structure in that direction is crucial for deriving more accurate diffusion predictions. this is an active area of current study (e.g., see , bramoullã© and rogers (2010) , currarini, jackson, and pin (2006 , and peski (2008)). ultimately, the formation of a network and the strategic interactions that occur amongst individuals is a two-way street. developing richer models of the endogenous formation of networks, together with endogenous interactions on those networks, is an interesting direction for future work, both empirical and theoretical. 30 creating social contagion through viral product design: theory and evidence from a randomized field experiment, mimeo distinguishing influence based contagions from homophily driven diffusion in dynamic networks a field study on matching with network externalities, mimeo similarity and polarization in groups, mimeo the mathematical theory of infectious diseases and its applications who's who in networks. wanted: the key player social capital in the workplace: evidence on its formation and consequences the diffusion of microfinance in rural india a new product growth model for consumer durables place of work and place of residence: informal hiring networks and labor market outcomes who gets the job referral? evidence from a social networks experiment, mimeo chains of affection: the structure of adolescent romantic and sexual networks strategic experimentation in networks diversity and popularity in social networks, mimeo. calvã³-armengol, a the mechanism through which this occurs can be rooted in background characteristics such as wealth, or more fundamental personal attributes such as risk aversion. risk averse individuals may connect to one another and be more prone to protect themselves against diseases by, e.g., getting immunized there are also some models that study co-evolving social relationships and play in games with neighbors the spread of obesity in a large social network over 32 years communication and coordination in social networks a model of spatial conflict medical innovation: a diffusion study the role of the airline transportation network in the prediction and predictability of global epidemics invasion threshold in heterogeneous metapopulation networks socio-economic distance and spatial patterns in unemployment learning about a new technology: pineapple in ghana an economic model of friendship: homophily, minorities and segregation identifying the roles of race-based choice and chance in high school friendship network formation evolution of conventions in endogenous social networks, mimeo the role of information and social interactions in retirement plan decisions: evidence from a randomized experiment short-run subsidies and long-run adoption of new health products: evidence from a field experiment learning, local interaction, and coordination local conventions on random graphs on the evolution of random graphs the market maven: a diffuser of marketplace information building social capital through microfinance learning by doing and learning from others: human capital and technical change in agriculture complex networks and local externalities: a strategic approach, mimeo non-market interactions. nber working paper number 8053 crime and social interactions the 1/d law of giving r&d networks network formation and social coordination the strength of weak ties threshold models of collective behavior economic action and social structure: the problems of embeddedness getting a job: a study in contacts and careers hybrid corn: an exploration of the economics of technological change ergodic theorems for weakly interacting infinite systems and the voter model citizens, politics and social communication. cambridge studies in public opinion and political psychology job information networks, neighborhood effects and inequality social structure, segregation, and economic behavior social and economic networks relating network structure to diffusion properties through stochastic dominance. the b.e on the formation of interaction networks in social coordination games social games: matching and the play of finitely repeated games diffusion on social networks diffusion of behavior and equilibrium properties in network games correlated equilibria in graphical games homophily, selection, and socialization in adolescent friendships learning, mutation, and long run equilibria in games measuring trust in peruvian shantytowns, mimeo personal influence: the part played by people in the flow of mass communication graphical models for game theory a contribution to the mathematical theory of epidemics economic networks in the laboratory: a survey the people's choice: how the voter makes up his mind in a presidential campaign directed altruism and enforced reciprocity in social networks the dynamics of viral marketing contagion in complex social networks models for innovation diffusion (quantitative applications in the social sciences endogenous inequality in integrated labor markets with two-sided search birds of a feather: homophily in social networks patterns of influence: a study of interpersonal influence and of communications behavior in a local community global games: theory and applications heterogeneity and uniqueness in interaction games asymmetric effects in physician prescription behavior: the role of opinion leaders, mimeo. pastor-satorras epidemic dynamics and endemic states in complex networks design innovation and fashion cycles complementarities, group formation, and preferences for similarity workers and wages in an urban labor market the diffusion of hybrid seed corn in two iowa communities local network effects and network structure les lois de l'imitation: etude sociologique. elibron classics, translated to english in the laws of imitation social interactions, local spillovers and unemployment identifying formal and informal inuence in technology adoption with network externalities medical innovation revisited: social contagion versus marketing effort the evolution of conventions innovation diffusion in heterogeneous populations: contagion, social influence, and social learning key: cord-354105-lgkfnmcm authors: office, emma e.; rodenstein, marissa s.; merchant, tazim s.; pendergrast, tricia rae; lindquist, lee a. title: reducing social isolation of seniors during covid-19 through medical student telephone contact date: 2020-06-05 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.06.003 sha: doc_id: 354105 cord_uid: lgkfnmcm abstract social isolation has been associated with many adverse health outcomes in older adults. we describe a phone call outreach program in which health care professional student volunteers phoned older adults, living in long-term care facilities and the community, at risk of social isolation during the covid-19 pandemic. conversation topics were related to coping, including fears/insecurities, isolation, and sources of support; health; and personal topics such as family and friends, hobbies, and life experiences. student volunteers felt the calls were impactful both for the students and for the seniors, and call recipients expressed appreciation for receiving the calls and for the physicians who referred them for a call. this phone outreach strategy is easily generalizable, and can be adopted by medical schools to leverage students to connect to socially-isolated seniors in numerous settings. social isolation has been associated with many adverse health outcomes in older adults. we 2 describe a phone call outreach program in which health care professional student volunteers 3 phoned older adults, living in long-term care facilities and the community, at risk of social 4 isolation during the covid-19 pandemic. conversation topics were related to coping, including 5 fears/insecurities, isolation, and sources of support; health; and personal topics such as family 6 and friends, hobbies, and life experiences. student volunteers felt the calls were impactful both 7 for the students and for the seniors, and call recipients expressed appreciation for receiving the 8 calls and for the physicians who referred them for a call. this phone outreach strategy is easily 9 generalizable, and can be adopted by medical schools to leverage students to connect to 10 socially-isolated seniors in numerous settings. social isolation, a quantitative loss in a person's social relationships, is common in older adults, 27 with 27% of adults over 60 y/o living alone. 1, 2 during the covid-19 pandemic, social distancing 28 has been an essential public health strategy. 3 while many older adults entered independent 29 living communities for activities and socialization, they have been advised to remain in their own 30 apartments or room. meals are delivered to doors, activities have stopped, exercise rooms 31 closed, and visitors are restricted. these necessary stay-at-home measures unfortunately 32 increase social isolation. 33 social isolation has been associated with adverse health outcomes including increased risk of 34 falls, all-cause mortality, hospitalizations, and cognitive decline, as well as unhealthy behaviors 35 like physical inactivity and poor diet. 4,5 additionally, in the previous sars pandemic, isolating 36 infection control practices were associated with increased depression and traumatic stress 37 response symptoms. 6 social isolation has been associated with less infection resistance, more 38 emergency admissions to hospital, and extended length of stay, factors which may lead to 39 worse outcomes during the covid-19 pandemic. 7-10 40 given the effects on the mental and physical health of the elderly, interventions targeting social 41 isolation are necessary to mitigate risk of increased morbidity and of infection from covid-19. social isolation calls during covid-19 -3 we created a phone call outreach program, seniors overcoming social isolation (sos), in 48 which medical and health professions student volunteers (e.g. md, md/phd, neuroscience, 49 genetic counseling) called older adults, living in long-term-care facilities (ltcf) and the 50 community, at risk of social isolation during covid-19. the sos program entailed providers 51 identifying at-risk older adults and then referring the contact information to coordinators who 52 would then pass the info to student volunteers. student volunteers were provided with an 53 introduction script and a series of conversation starters, general social history questions, and 54 well-being questions (e.g. resource needs, groceries) to ask the older adult. students then 55 phoned the older adults when they had available free time. the goals were (1) to provide 56 companionship and resources for unmet needs of older adults, while (2) fostering health 57 professional students' skills in communicating and understanding the needs of older adults in 58 their community. we propose that social phone calls to older adults may reduce social isolation 59 while providing meaningful engagement with the community and a learning experience for 60 students. perspectives and resolving any identified discrepancies through discussion. in no cases were 80 the coders unable to reach consensus. the coders organized the content into relevant themes. 81 descriptive statistics were used to analyze participant surveys. 82 fourteen volunteers made 25 phone calls, averaging a length of 8.3 min (sd 4.0). nearly all 85 volunteers (85.7%) were in medical school (md or md/phd program), and most of those 86 students were in their first year of medical school (75%). there was 2 graduate health program 87 students (e.g. medical geneticist and neuroscientist programs) who heard about program 88 through word-of-mouth. volunteers were predominantly female (92.9%), and identified as asian 89 or white (50% and 43%, respectively). 90 both conversational and covid-19-related themes were discussed during calls (table 1) . 91 topics related to covid-19 included health, fears, isolation, coping, and sources of support, 92 while other prominent topics ranged from family and friends, to hobbies, to the older adult's past. in addition to providing social connection, several students assisted in addressing unmet 94 needs by referring the older adults to sources of support. 95 most students felt that the calls were well-received; recipients expressed appreciation both for 97 the calls/callers and for those who referred them. (table 2 ) some students felt that the call was 98 less impactful, while one felt that they had disrupted the older adult by calling. student 99 volunteers indicated they had plans to contact a little over a third of older adults (36%) again. 100 we do not have data about follow-up phone-calls. 101 after the telephone contact, many students felt positive and empowered; one described feeling 103 inspired by the older adult's story, and several reflected on the senior's appreciation. other 104 students acknowledged challenges, such as needing patience and talking about different topics 105 than normally discussed with younger adults (table 3) . 106 107 during the covid-19 pandemic, requisite social isolation is a critical problem among older 109 adults living in assisted and independent living communities. there is ample evidence that this 110 is an important problem desperately needing intervention. 111 to reduce social isolation, we present a practical intervention leveraging health professions 112 graduate students contacting older adults and residents of independent and assisted living by 113 phone. our results show that it is feasible and has bi-directional benefit to both student callers 114 and older adult residents. students felt empowered and that they were able to make a difference in the lives of socially isolated seniors. results also showed that they were learning 116 how to be patient and slowdown in conversations with hearing-impaired seniors, specifically 117 learning important tenets of geriatrics in the process. older adults appreciated and enjoyed 118 receiving calls, likely as they were interrupting their social isolation. 119 limitations of this study include the small sample size, single location, and referral of older 120 adults by a provider. while conducted in a single location (chicago), covid-19 was widespread 121 and existed in most of the area's long-term-care communities necessitating isolation. several 122 students struggled to contact their assigned older adults, potentially due to illness or 123 hospitalizations. this intervention depends on student volunteerism; as classes resume, fewer 124 students may have time to participate. moreover, this requires coordination of providers in 125 identifying appropriate older adults, student volunteering, and a coordinator assigning seniors to 126 call. while online sign-ups limit some of the workload, a dedicated volunteer student coordinator 127 is necessary. 128 seniors overcoming social isolation calls are easily generalizable and can be adopted by most 129 medical schools to connect students to socially isolated seniors in multiple settings. for further 130 generalization, student volunteer groups do not need to be in the same area as those being 131 contacted. medical schools can partner with rural communities or low income areas who do not 132 have direct academic partnerships to reduce isolation in hard-to-reach areas. during covid-19 133 pandemic, this simple innovation has been shown to be a feasible route of improving the lives of 134 both older adults and students. 135 national academies of sciences, e. and medicine, social isolation and 139 loneliness in older adults: opportunities for the health care system social distancing, quarantine, and isolation a review of social isolation: an important but underassessed 145 condition in older adults. the journal of primary prevention health risks associated with social isolation in general and in young, 147 middle and old age sars control and psychological effects of quarantine social ties and susceptibility to the common cold social disconnectedness, perceived isolation, and 154 health among older adults does lack of social support lead to more ed visits for older 157 adults? reducing social isolation and loneliness in older people: a 159 systematic review protocol covid-19 and the consequences of isolating the 161 elderly. the lancet public health social distancing in covid-19: what are the 163 mental health implications? the effect of information communication 165 technology interventions on reducing social isolation in the elderly: a systematic 166 review the use of telephone befriending in low 168 level support for socially isolated older people -an evaluation. health & social care in 169 the community the authors wish to thank their families and loved ones for support while in medical school and the health care profession. the authors also wish to thank the volunteers who assisted with the telephone contact of the older adults. key: cord-355726-44x0idzn authors: ibrahim, mohamed izham mohamed; wertheimer, albert i. title: introduction: discovering issues and challenges in lowand middle-income countries date: 2017-11-10 journal: social and administrative aspects of pharmacy in lowand middle-income countries doi: 10.1016/b978-0-12-811228-1.00001-7 sha: doc_id: 355726 cord_uid: 44x0idzn there are gaps and challenges in pharmacy practice in developing countries and possible solutions for various pharmacy stakeholders. health and public health are essentials for development. the weak global economy has hindered progress toward the sustainable development goals. many people are still living in poverty with poor health status and inadequate healthcare. poor health and pharmaceutical sectors in a country will increase the vulnerability of the country and leaves the society at risk. effective public health interventions can save hundreds of millions of lives. pharmacy system is one of the core components in a healthcare system, and pharmacists play a very important role. this book sheds light on various topics that individually and in combination determine the status of pharmacy practice in individual countries. this book incorporates multiple data sources and when outliers are discovered, that may be called to the attention of the reader. this book also provides knowledge and understanding about social and administrative aspects of pharmacy in healthcare in lowand middle-income countries. reminded us that the major obstacle to the establishment of pharmacy administration is due to the negative attitudes and imbalanced focus and emphasis between professionalism versus business orientation that are inherent in pharmacy practice. the book that was edited by fathelrahman, mohamed ibrahim, and wertheimer (2016) , explored the pharmacy practice in 19 developing countries in asia, africa and latin america and provided an excellent overview of pharmacy practice. the book also provides us with gaps, challenges and possible solutions for various pharmacy stakeholders in the developing countries. there is a great deal of work that needs to be done by the pharmacy stakeholders in order to improve the pharmaceutical health services for fulfilling the needs of the society. it is understood that under the sustainable development goals (sdgs), every country is in need for development (united nations, 2017 ). yet unfortunately, the weak global economy has hindered progress toward the sdgs, especially for countries with lower economic level. development is everyone's problem and everyone's dream. there is no clear definition of the terms "developed and developing countries" or no consensus on how to categorize these countries. developing countries include, in decreasing order of economic growth or size of the capital market: newly industrialized countries, emerging markets, frontier markets, and least developed countries. list of developing countries according to the united nations (2014) can be classified into three categories: developed economies, economies in transition, and developing economies. geographical regions for developing economies are as follows: africa, east asia, south asia, western asia, and latin america and the caribbean. according to the o' sullivan and sheffrin (2003, p. 471) , a developing country is a country with a relatively low standard of living, undeveloped industrial base, and moderate to low human development index. this index is a comparative measure of poverty, literacy, education, life expectancy, and other factors for countries worldwide. for the sake of the discussion, the book will consider the classification of countries based on per capita gross national income (i.e., low-and middle-income countries (lmics)). the political, economic, and pharmaceutical sector conditions differ between the countries; some have to do much more and work harder to improve their situations than others. there are significant social and economic differences between developed countries and lmics. many of the underlying causes of these differences are rooted in the long history of the development of such nations and include social, cultural, and economic variables; historical, political, and geographical factors; as well as international relations. furthermore, it is not the intention of the book to indicate the level of the inferiority of an lmic or an undeveloped country compared with a developed country or between east and west, but rather to trigger and stimulate the mind of the people in the lmics about the challenges and problems the societies are facing for decades. no country in this world is free from problems and challenges, but people in the developing world suffer relatively more. the focus of this book is to highlight, discuss, and document policy issues in lmics and about having best practices in the pharmaceutical sector. so far, to what extent is the contribution of pharmacists to this matter? health and public health are essentials for development. around 50% of the world's population are residing in lmics and they are still living in poverty with poor health status and inadequate healthcare. in any healthcare system, pharmacy system is one of the core components and pharmacists play a very important role. with the dynamic changes happening in healthcare, disease, information communication technology and regulations, and the roles and responsibilities of pharmacists are becoming more important than before. the expectations on the pharmacists are changing; the societal needs and demands are much greater compared with several decades ago. on the other hand, there are growing problems with medicines, the health system, and human resources, especially in the lmics. there are countries with high prices of medicines, a wide prevalence of nonquality medicines (i.e., substandard and counterfeit), lack of access to medicines, and absence of a national medicines policy (nmp) even with strong encouragement from world health organization (who). poor health and pharmaceutical sectors in a country will increase the vulnerability of the country toward several critical problems at micro-and macrolevels and leaves the society at risk. in the medicines supply system, to ensure access to medicines, the following aspects are critical: • reliable health and supply systems; • sustainable financing; • rational selection; and • affordable prices of medicines. the importance of a healthcare system must be looked from three angles: the institutions, organizations, and resources; resources include workforce, financial, and infrastructure. to achieve universal health coverage, the system must function well. the three elements, i.e., institutions, organizations, and resources must be brought together to deliver quality health services to meet the demands of the society. unfortunately, according to mills (2014) , the goals of universal health coverage in lmics could not be achieved, child and maternal deaths are still high, financial protection is lacking, and people do not seek care because of lack of financial support. even though the rational use and quality use of medicines are worldwide issues, but they are particularly pertinent to lmics. access to medicines is still crucial, as 400 children suffering from tuberculosis worldwide die daily, largely because of low access to appropriate treatment (who, 2016a (who, , 2016b . ranganathan and gazarian (2015) reported that there are several key challenges for delivering rational use of medicines (rum) to children in the developing countries. among the problems are as follows: • lack of coordinated nmp to support rum; • availability, affordability, and accessibility to medicines' issues; • inappropriate standards of quality, safe, and efficacy of medicines; • lack of independent, unbiased, and evidence-based information; • lack of information, knowledge, and skills among healthcare practitioners who are dealing with medication use process among children; • lack of proper devices and tools (e.g., calculator and weighing machine) used when deciding on the appropriate dosage for the children; and • retailers selling prescription medicines extensively over the counter. dowse (2016) reported that the likelihood of poor health literacy in developing countries is prevalent. health literacy is fundamental to the effectiveness of health programs and improvement to the quality of life. the united nations educational, scientific and cultural organization institute for statistics found that around 7% of countries (13/180) indicate an adult literacy rate below 50%. all these countries are from sub-saharan africa, and the lowest adult literacy rate is in mali with a 26.2% (united nations, 2009 ). another issue is corruption. corruption (e.g., misinformation, bribery, theft, and bureaucratic corruption) is a global problem and negatively affects the medicines supply chain and the overall healthcare system. the backbone of the health system is formed by well-functioning supply chains that deliver various pharmaceutical products (yadav, 2015) . the corruption perception index 2016 illustrated that none of the lmics listed top 10 of the transparent (i.e., clean) ranking. on the scale of 0 (highly corrupt) to 100 (very clean), over two-thirds of the 176 countries and territories in this index fall below the midpoint (transparency international, 2016). people also faced with issues related to substandard medicines, counterfeit drugs, nutrition, tobacco consumption, maternal and child health, and environmental hazards (who, 2017) . who (2014) reported that the environmental hazards such air pollution caused around 7 million premature deaths a year. most areas affected were densely populated lmics. the conditions in the developing countries become worse when people suffer from various turmoil conditions such as war, humanitarian conflict, and public health crisis, which further collapse completely the healthcare system. these aspects make working in the healthcare system and the practice of pharmacists more challenging. in short, the lmics are facing social, economic, environmental, human capital, political, and infrastructure issues that directly or indirectly affecting the health and pharmaceutical health services. much needs to be done in lmics. the following are important elements for functioning global supply systems and availability of safe and effective medical products at prices equitable to all: effective and innovative health and medicines policies, coordinated approaches, international cooperation, and effective oversight. especially for the pharmacy regulators, policy makers, and practitioners, they must appreciate the complexity of the healthcare system and human life. what is considered fine or rational in one country and society might not be fine or considered irrational among other societies with different cultures, beliefs, and backgrounds. regulators, policy makers, and practitioners in countries of the developing world should evaluate thoroughly health-and pharmaceutical-related issues in their country and find solutions that are appropriate and relevant according to the environment. there are several significant initiatives to ensure health for all and rum in lmics that were advocated by organizations such as health action international asia pacific (haiap), people health movement (phm), third world network (twn), international network for rational use of drugs (inrud) and who, just to name a few. chowdhury (2017) noted that "since the 1985 nairobi conference on the rational use of drugs, for every two steps we have advanced we have gone one step backward. a progressive agenda for people-centred, rational and affordable healthcare continues to be undermined by powerful vested interests." we are getting closer and closer, but are not there yet. the phm's member developed the people's charter for health in 2000. it was established after realizing that vision and goals of alma-ata declaration that was established in 1978 failed to ensure "health for all by the year 2000." phm felt that the health status of the lmics has not improved as aimed, but instead worsened further. health crisis happened everywhere, especially in the lmics. there are significant inequalities between and within countries. new threats to health are continually developing (phm, n.d.) . according to international monetary fund (imf) (2014), "the world is a healthier place today but major issues continue to confront humanity." the world has improved greatly with eliminating and controlling few of the communicable diseases such as smallpox and polio. quality and better medicines have been produced to improve the health conditions. people have better sanitation and accessible to clean water. even with the innovations and cost-effective interventions in healthcare, individuals continue to experience and suffer from health threats such as malaria, dengue, typhoid, chikungunya, severe acute respiratory syndrome, middle east respiratory syndrome-related coronavirus, ebola virus crisis. in addition, the prevalence of mental disorders and noncommunicable diseases continues to increase. chronic diseases such as cancer, cardiovascular diseases, and diabetes cause serious ill health and millions of premature death. it is reported that 85% of them are in lmics. all these threats and disorders negatively affect the public health system and infrastructure, cause disability, and ruin businesses, workforce, and productivity of the affected country (imf, 2014; who, 2011) . thanks to pharmaceutical industries, which have produced antibiotics to fight against infectious diseases. the practice of medicine has been transformed. but, unfortunately due to the irresponsible and irrational used of antibiotics by healthcare providers and public, it has resulted in an increase in resistance and caused a worldwide decline in antibiotic effectiveness. the primary healthcare sectors failed to play their roles in containing these threats. the primary healthcare providers failed to perform their responsibilities. pharmacists have a responsibility regarding antibiotic stewardship to help contain or reduce amount of unnecessary antibiotic use especially against viruses and in trivial diseases. we need cost-effective, affordable, and practical interventions. the use of health technology assessment tools becomes helpful at this point. where are the pharmacists when the nations are crippled by these threats? do the pharmaceutical policies fail to curb these problems? the lack of adequate, resilient public health surveillance systems, infrastructure to effectively deploy resources, and a health workforce to provide accessible, quality care where needed leaves us vulnerable to regional and global spread. despite the progress that has been made in the last two decades, more needs to be done to create enabling regulatory environments. understanding the social and cultural contexts that may contribute to these problems, plus effective solutions, is also crucial. health communication often receives less attention and fewer resources than medical, scientific, or policy areas. there is an urgent need for society to value and invest more in evidence-informed public health strategies. the multifactorial nature of broader global health issues poses an enormous challenge to all stakeholders (who, 2016b). effective public health action depends on understanding the scale and nature of threats to health (who, 1986) . according to the ottawa patient charter, the public health community has a duty to make the invisible visible. they must measure and assess the burden of diseases, health status, and risk factors including the protection factors. the public health community must make the best use of data to promote health. public health interventions should be evaluated, using rigorous research methods, and the results disseminated. the public health community must ensure that evidence is used to give voice to those who would otherwise be unheard. research findings must be disseminated effectively to the different stakeholders in the health sectors, including public, policy makers, practitioners, and (social) media. findings at times are complex and this information should be delivered in ways that are comprehensible and in a timely manner (lomazzi, 2016) . effective public health interventions can save hundreds of millions of lives in lmics, as well as create broad social and economic benefits. according to frieden and henning (2009) , it is often assumed that public health interventions applied in developed countries are not appropriate in developing countries. main public health functions are similar regardless of a country's income level. many basic public health measures achieved decades ago in developed countries are urgently needed, highly appropriate, extremely cost-effective, and eminently attainable in lmics today. further according to frieden and henning (2009) , a progress of public health in developing countries is possible but will require sufficient funding and human resources; improved physical infrastructure and information systems; effective program implementation and regulatory capacity; and, most importantly, political will at the highest levels of government. most change is due to money. for instance, robotics, automation, and technicians are widely used to save money. in the hospital setting, unit dose, unit-of-use, etc. are done to save cost. similarly, medication therapy management is done to save money and that is why most other changes are accepted, provided if they are cost-effective. pharmacists are dedicated and in a strategic position to preserve and advance public health. their efforts enhance the quality of individual's lives by helping people to live as free as possible from disease, pain, and suffering (jandovitz & brygider, 2005) . with respect to their relationship with the public, pharmacists are often portrayed as an underused resource for health-and medicines-related advice and information. furthermore, the practice of pharmacy involves both pharmacist and public and can be conceptualized as a social process (harding & taylor, 2009, p. 395) . don't we need something about the efforts to locate new pharmacy roles, e.g., in relation to immunizations, patient advisor, educator and advocator for wellness, screening and prevention activities, birth control promotions, and other population health initiatives? pharmacists have an obligation to educate the public in lmics, for example, teaching poor rural women about birth control and safe sex especially if their partner has hiv, etc. the other one is to encourage immunizations. in certain places, some cult leader and religious groups discourage their followers not to be immunized and then we end up with local epidemics of preventable conditions such as polio. hence, understanding the concepts and principles behind social pharmacy disciplines is important and useful. there is a need to apply a socioecological model to public health issues that are impacting the health of the population. what is social pharmacy? social pharmacy is a discipline driven by social needs (fukushima, 2016) and more focus on the society at large. it is interdisciplinary subject, which helps to understand the interaction between drugs and society. experts have defined social pharmacy as a discipline concerned with the behavioral sciences relevant to the utilization of medicine by both consumers and healthcare professionals (wertheimer, 1991) . sørensen, mount, and christensen (2003) defined social pharmacy as studying "…the drug/medicine sector… from the social scientific and humanistic perspectives. topics relevant to social pharmacy consist of all the social factors that influence medicine use, such as medicine-and health-related beliefs, attitudes, rules, relationships, and processes." almarsdottir and granas (2016) also agree that social pharmacy is a discipline where there is use of the social sciences in pharmacy to add its usefulness to the society. it is also known as "pharmacy administration" or "social and administrative pharmacy." it has two components: the social sciences and the administrative sciences. the social sciences component includes demography, anthropology, psychology, social psychology, sociology, political sciences, and geography (mount, 1989) , while the administrative sciences component includes areas such as management, marketing, finance, economics, organizational behavior, law, policy, ethics, information technology, and statistics. social and administrative pharmacy is the integration and application of the social and administrative sciences disciplines in pharmacy, i.e., education and practice. social pharmacy scientists utilize both sciences to improve clinical practice, enhance the effectiveness of pharmaceutical regulations and policy, advocate political awareness, and promote improvements in pharmaceutical health services and healthcare delivery. social pharmacy applied a biopsychosocial or socioenvironmental method to understand health and illness conditions (claire, 2008) . many types of research use either the quantitative or qualitative or a mixed method approach, from simple to complex statistical methods and modeling in pharmacy practice to make changes and improvement in the healthcare system, quality of care, and patient's quality of life. in addition, there are many useful tools from the social and behavioral sciences literature that researchers could use, for example, in helping with patient-pharmacist communication and compliance enhancement efforts. according to wertheimer (1989) , "there are very few similarities in the education and practice of pharmacy around the world." many individuals have an ethnocentric, regiocentric, or geocentric approach in which they believe. for example, pharmacy colleges in a country might be reluctant to accept improvement in the curriculum. the pharmacy educators think that they are superior, and the curriculum developed and used, for example, in the last decades was excellent. in some cases, there is an imbalance of focus between the pharmaceutical sciences courses and the pharmacy practice and administration courses. they consider teaching more of the basic pharmaceutical sciences subjects to the undergraduate students or just offering pharmaceutical sciences-related research (i.e., lab-based research) at the msc and phd level is adequate to provide the pharmacy graduates knowledge and skill to practice. the regiocentric or geocentric phenomenon in pharmacy practice is quite common and could be observed in the middle east region, for example. further, political struggle and lack of leadership could hurt the dynamic and mission of the pharmacy profession. according to morgall and almarsdóttir (1999) , the pharmacy profession could lose its monopoly and become weak due to the internal conflicts. pharmacists need to advocate locally to upgrade the quality of pharmacy education away from massive amounts of chemistry to applied patient care science and practice and to upgrade the level of standards in each country to work with legislators to ban pharmacies not operated by qualified, licensed personnel. when wertheimer and smith (1989) published the first edition of their book in 1974, social pharmacy or social and administrative pharmacy was a very new discipline and possibly not known in the lmics. the book includes topics such as the contribution of the social sciences; pharmacy, pharmacist, and the professions; the contribution of psychosocial aspects; the contribution of sociology; and behavioral aspects of drugs and medication use, ethics, pharmacist and public health and the future of pharmacists. in the united kingdom, according to harding and taylor (2015) , social pharmacy was introduced in the pharmacy curriculum of uk colleges sometime in the early 2000. the mills commission report in 1975 recognized the importance to develop the behavioral and social sciences aspects in pharmacy (study commission on pharmacy, 1975) . but, actually, the social pharmacy components were first experienced in the united states in the 1950s (wertheimer, 1991) . then later, the uk and european colleges of pharmacy introduced social pharmacy into their curriculum (claire, 2008) . it is doubtful if pharmacy colleges in the lmics have successfully introduced this discipline in their pharmacy curriculum. most of the times, the internal politics and a lack of understanding limit or even counteract the collaboration of clinical and social pharmacy, thus weakening both fields (almarsdottir & granas, 2016) . however, there are cases, to name a few, which had reported positive experience such as in malaysia. school of pharmaceutical sciences, universiti sains malaysia that was established in 1972, first introduced a course "drugs in developing countries" (mohamed izham, awang, & abdul razak, 1998) in the early 1990s. after a long struggle, the discipline was established in 2002 (school of pharmaceutical sciences, n.d.) . several important courses (e.g., drug and society, social and public health pharmacy, pharmaceutical management and marketing, and pharmacoeconomics) managed to be included in the pharmacy curriculum. these additions offer a perspective on the pharmacy that balances and complements the behavioral and natural/physical sciences component of the pharmacy curriculum (hassali et al., 2011) to produce well-rounded graduates. in addition, the department has also produced hundreds pieces of social and administrative pharmacy-related research generated from more than 150 msc and phd students from around 15 lmics. kostriba, alwarafi, and vlcek (2014) identified large differences in approach and scope of teaching social pharmacy courses as a field of study in the undergraduate pharmacy education worldwide. they also identified regional trends connected with the political, economic, and social aspects of particular regions. basak (2012) expressed concern with the recent changes in the indian pharmacy education. according to the author, in the introduction of the pharmd program (pharmacy council of india, n.d.), social pharmacy is the least developed discipline in the curriculum. it called for cooperation in an attempt to develop social pharmacy components in teaching and research in india. there is a drive to incorporate the social pharmacy topics in the yemeni pharmacy education even with all the challenges and limitations that the country is experiencing nowadays (alshakka, aldubhani, basaleem, hassali, & mohamed ibrahim, 2015) . in libya, according to abrika, hassali, and abduelkarem (2012) , the pharmacy practitioners were supportive with the ideas of inclusion of social pharmacy subjects in the curriculum because it will enhance the pharmacists' professional roles. in contrast, in the united states, zorek, lambert, and popovich (2013) noted that even though the basic and clinical sciences provide a critical scientific foundation for direct patient care, pharmacists are likely to flounder in the face of social and behavioral challenges without a practical mastery of the relevant principles of modern social and behavioral science. according to the authors, pharmacy education and practice must require greater mastery of social and behavioral science. in the united kingdom, the incorporation of social and behavioral sciences into the curricula of all schools of pharmacy, reflecting a broad recognition that pharmacy practice does not simply involve supplying medicines and advice to a passive public who take their medicines and follow expert advice without question (harding & taylor, 2009, p. 395 ). we know a great deal about pharmacy in the developed world but we know very little about pharmacy practice, education, and science in the lesser developed countries. that is unfortunate because if we in the developed countries understood what the major problems and impediments were in the lesser developed countries, we could be in a better situation to offer advice and aid. very little has been published in the main stream, international literature about the status of pharmacy in the lesser developed countries. it is possible that some more is published in local journals in local languages that may be of limited help to others outside of that country. there are other problems as well. one is that accurate and timely vital health statistics may not be available for any of many possible reasons, such as budget restrictions, and shame in reporting accurate and precise reports that are not flattering to that country's leaders in the healthcare area. this book sheds light on various topics that individually and in combination determine the status of pharmacy practice in individual countries. the nature of pharmacy characteristics in a country has a great deal to do with traditions and characteristics from colonial times, the wealth of the country, its political and economic systems, the level of capital available for investment, the extent of technical education among the population, the presence of a middle class and the size of an upper class, if there is one, and the extent of a culture of corruption. there is one other reason why we need this book. when resources are constrained, sometimes clever persons devise exceptional strategies and schemes that require minimal resources. we are never so good that we cannot learn from our less fortunate colleagues, nor should we be too proud to borrow ideas and systems from nonindustrialized countries. if one of us wanted to learn about some aspects of pharmacy practice, education, or research in jordan, for example, it would be a time-consuming, complicated task, extracting various parts of our goal from a large array of journals, textbooks, and websites, and often a doomed task since some of the references importance of social pharmacy education in libyan pharmacy schools: perspectives from pharmacy practitioners social pharmacy and clinical pharmacy-joining forces importance of incorporating social pharmacy education in yemeni pharmacy school's curriculum social pharmacy concept in pharmacy education social pharmacy-the current scenario the limitations of current health literacy measures for use in developing countries the history of pharmacy pharmacy practice in developing countries: achievements and challenges public health requirements for rapid progress in global health social pharmacy: its performance and promise social dimensions of pharmacy: the social context of pharmacy teaching social pharmacy: the uk experience. pharmacy education social pharmacy as a field of study: the needs and challenges in global pharmacy education pharmacists: unsung heroes. wliw (television station social pharmacy as a field of study in undergraduate pharmacy education global charter for the public's health-the public health system: role, functions, competencies and education requirements health care systems in low-and middle-income countries introducing social pharmacy courses to pharmacy students in malaysia no struggle, no strength: how pharmacists lost their monopoly contributions of the social sciences economics: principles in action people health movement (phm) rational use of medicines (rum) for children in the developing world: current status, key challenges and potential solutions the concept of social pharmacy corruption perceptions index world economic situation and prospects country classification world economic situation and prospects international comparisons social/behavioural pharmacy: the minnesota experience pharmacy practice: social and behavioral aspects ottawa charter for health promotion from burden to 'best buys': reducing the economic impact of non-communicable diseases in low-and middle-income countries public health, environmental and social determinants of health who essential medicines and health products global disease outbreaks world health organization (who) health product supply chains in developing countries: diagnosis of the root causes of underperformance and an agenda for reform the 4-year evolution of a social and behavioral pharmacy course will be missing, unavailable, obsolete, or in foreign languages. some citations may only be available through the interlibrary loan organization, requiring several weeks.one may realize immediately that having all or nearly all of the desired data and information in one, easy-to-use source makes data collection and subsequent analysis far easier, and the work may be performed in a fraction of the time required to search here and there. in addition, relying on a single source for primary data can be dangerous. governmental statistics offices often spin data-related reports to underreport communicable diseases so as not to discourage tourism or so as not to put a country behind its neighboring nations in its effectiveness in combating health problems, childhood immunizations, etc.this book incorporates multiple data sources and when outliers are discovered, which may be called to the attention of the reader. this book also provides knowledge and understanding about social and administrative aspects of pharmacy in healthcare in lmics. it also creates awareness among readers, providing ideas and possible solutions to these obstacles. it is hoped that the pharmacists and other stakeholders will be better equipped to tackle any problems and challenges facing them in practice.if i had one hour to save the world, i would spend the first fifty-five minutes defining the problem and the last five minutes solving it. the world bank. world bank country and lending groups. https://datahelpdesk.worldbank.org/knowledgebase/ articles/906519-world-bank-country-and-lending-groups. key: cord-298890-i1q3n101 authors: xiao, han; zhang, yan; kong, desheng; li, shiyue; yang, ningxi title: social capital and sleep quality in individuals who self-isolated for 14 days during the coronavirus disease 2019 (covid-19) outbreak in january 2020 in china date: 2020-03-20 journal: med sci monit doi: 10.12659/msm.923921 sha: doc_id: 298890 cord_uid: i1q3n101 background: from the end of december 2019, coronavirus disease 2019 (covid-19) began to spread in central china. social capital is a measure of social trust, belonging, and participation. this study aimed to investigate the effects of social capital on sleep quality and the mechanisms involved in people who self-isolated at home for 14 days in january 2020 during the covid-19 epidemic in central china. methods: individuals (n=170) who self-isolated at home for 14 days in central china, completed self-reported questionnaires on the third day of isolation. individual social capital was assessed using the personal social capital scale 16 (psci-16) questionnaire. anxiety was assessed using the self-rating anxiety scale (sas) questionnaire, stress was assessed using the stanford acute stress reaction (sasr) questionnaire, and sleep was assessed using the pittsburgh sleep quality index (psqi) questionnaire. path analysis was performed to evaluate the relationships between a dependent variable (social capital) and two or more independent variables, using pearson’s correlation analysis and structural equation modeling (sem). results: low levels of social capital were associated with increased levels of anxiety and stress, but increased levels of social capital were positively associated with increased quality of sleep. anxiety was associated with stress and reduced sleep quality, and the combination of anxiety and stress reduced the positive effects of social capital on sleep quality. conclusion: during a period of individual self-isolation during the covid-19 virus epidemic in central china, increased social capital improved sleep quality by reducing anxiety and stress. from the end of december 2019, coronavirus disease 2019 began to spread in central china [1, 2] . as of march 4 th 2020, more than 80,560 people had been diagnosed with covid-19, and 3010 patients had died from covid-19 infection in china [3] . outside china, the disease spread worldwide, nearly 13,570 patients were diagnosed with covid-19 infection, and 270 patients had died from infection by this novel virus [3] . the outbreak of covid-19 was recognized by the world health organisation (who) as a public health emergency of international concern (pheic) that endangers international public health [4] . the who has defined a pheic as an infectious disease with international spread, or an unusual, serious, or unexpected public health event that exceeds local health resources, or that requires immediate international action [4] . infectious disease epidemics not only affect the physical health of patients but also affect the psychological health and wellbeing of the non-infected population. previous studies have shown that the prevalence of novel infectious diseases, such as severe acute respiratory syndrome (sars), can increase anxiety, depression, and stress levels in the general population [5] . these negative emotions also affect sleep [6] . at the time of the covid-19 epidemic in central china, some individuals with mild illness, suspected cases of infection, and people who had been in close contact with patients or a potentially high-risk environment were isolated at home. even if the self-isolated individuals do not develop an infection and remain physically well, they often suffer from negative psychological effects. importantly, the effects of mental health and sleep on immunity have been shown by previous studies [7] . good quality sleep can help improve immunity to viral infection [8] . therefore, mental health and sleep quality are important considerations in the population of people who have self-isolated due to their increased risk of covid-19 infection. psychological wellbeing and sleep are affected by several factors. social factors, such as economic burden, family support, social support, and social capital, are also important factors [9] . recently, several studies have investigated the influence of social factors on mental health [10] . social support is a common variable, but there has been little research on the relationship between social capital and health [11, 12] . the concept of social capital was first proposed by the french sociologist, portes, in 1980 [13] . portes defined social capital as a collection of actual or potential resources that include social trust, belonging, and participation, and believed that these resources were associated with a lasting network of mutual recognition [13] . in 1997, lynch developed the concept of social capital as the will to generate social cohesion, trust, and participation in community activities [14] . there are differences between social support and social capital. social support represents the size and source of social networks of people helping others, as well as emotional, material, and informative supportive functions [15] . social capital includes social trust, belonging, and social participation. the effect of social capital on psychological wellbeing has been shown by previous studies [16] . however, in china, studies on the role of social capital on wellbeing are limited, particularly in the context of acute infectious disease. therefore, this study aimed to investigate the effects of social capital on sleep quality and the mechanisms involved in people who self-isolated at home for 14 days in january 2020, during the covid-19 epidemic in central china. in this study, path analysis was performed to evaluate the relationships between a dependent variable (social capital) and two or more independent variables (anxiety, stress, and sleep), using pearson's correlation analysis and structural equation modeling (sem). this study was conducted in accordance with the declaration of helsinki. all participants provided signed informed consent to participate in the study. the wuhan university school of medicine ethics committee approved the study procedures (approval number: 20190320). a total of 170 people were identified who were isolated at home for 14 days in january 2020 in central china, during the epidemic of coronavirus disease 2019 (covid-19). the study included adult individuals who had self-isolated following mild infection with covid-19, suspected cases of covid-19 infection, people in close contact with patients infected with covid-19, and people who may have been exposed to the virus in the environment. all study participants were required to be able to provide informed consent to participate in the study. all responses to the study questionnaires were anonymized. cross-sectional study design was used that included the demographic and sociological data for each participant and disease-related information. on the third day of self-isolation, the participants completed self-reported questionnaires. individual social capital was assessed using the personal social capital scale 16 (psci-16) questionnaire. anxiety was assessed using the self-rating anxiety scale (sas) questionnaire, stress was e923921-2 assessed using the stanford acute stress reaction (sasr) questionnaire, and sleep quality was assessed using the pittsburgh sleep quality index (psqi) questionnaire. the questionnaire responses were compared to determine the relationships between anxiety, stress, sleep, and social capital. measurement of social capital using the psci-16 questionnaire the psci-16 questionnaire was used to assess social capital, using a 5-point likert scale that contained 16 items. each item scored from 1 -5, and the total score ranged from 16 -80. a higher score indicated lower social capital. the psci-16 questionnaire included the following 16 questions: 1. how many friends do you have? 2. how many relatives, neighbors, friends, co-workers, and classmates do you have? 3. among your co-workers, how many do you trust? 4. among your relatives, how many do you trust? 5. among all your relatives, neighbors, friends, co-workers, and classmates, how many have connections with others? 6. among all your relatives, neighbors, friends, co-workers, and classmates, how many have a professional job? 7. how many of your co-workers will help you when asked? 8. how many of your friends will help you when asked? 9. how do you rate the number of cultural, recreational, and leisure groups and organizations are in your community? 10. how do you rate the number of governmental, political, economic, and social groups and organizations in your community? 11. how many of these groups and organizations possess broad social connections? 12. how many of these groups and organizations have social influence? 13. how many of the cultural, recreational, and leisure groups and organizations represent your interests? 14. how many of the governmental, political, economic, and social groups and organizations represent your interests? 15. how many of the governmental, political, economic, and social groups and organizations will help you when asked? 16. how many of the cultural, recreational, and leisure groups and organizations will help you when asked? [17] . the cronbach's alpha for internal consistency of this questionnaire was previously determined to be 0.812. the sas questionnaire was used to measure the levels of anxiety of the study participants. there were 20 items in the scale. each item was divided into four grades according to the feelings of the respondents in the past week and the frequency of symptoms was mainly evaluated. the cumulative score of 20 items was the total sas score. the standard total score was obtained by taking the total score ×1.25. the higher the score, the greater the degree of anxiety [18] . the cronbach's alpha for internal consistency of this questionnaire was previously determined to be 0.867. the sasr questionnaire using a six-point likert scale, which contained 30 items, was used to measure stress. each item scored from 0 -5, with the total scores from 0 -150. a higher score indicated higher stress levels [19] . the cronbach's alpha for internal consistency of this questionnaire was previously determined to be 0.803. the psqi questionnaire was used to measure the sleep quality of the study participants. there were 18 items that consisted of seven dimensions, including sleep quality, sleep duration, sleep latency, habitual sleep efficiency, sleep disturbances, use of sleeping×medications, and daytime dysfunction. each dimension was scored from 0 -3, and the total score, which was the sum of the scores from each dimension, ranged from 0 -20. a higher score indicated lower sleep quality [20] . the cronbach's alpha for internal consistency of this questionnaire was previously determined to be 0.872. data were presented as the mean ± standard deviation (sd). path analysis, or multiple regression analysis, was performed to evaluate the relationships between a dependent variable (social capital) and two or more independent variables, using pearson correlation analysis (r) and structural equation modeling (sem). the indices for the degree of fit of the sem were calculated. spss amos version 21.0 (ibm, armonk, ny, usa) was used to measure the mediation effects of the study variables, with a bootstrap number set as 5000 to test the significance of specific mediation effects, followed by the nonparametric percentile bootstrap method with sd correction. epidata entry version 3.1 and sas version 9.4 were used for data entry and analysis, respectively. a p-value <0.05 was considered to be statistically significant. there were 200 people who were initially invited to participate, of which 170 were included in the study, with a participation rate of 85%. the mean age of the study participants e923921-3 was 37.78 ± 4.12 years. the demographic and disease-related data of the study participants are shown in table 1 . the association between social capital, stress, anxiety, and sleep quality individual social capital was assessed using the personal social capital scale 16 (psci-16) questionnaire; anxiety was assessed using the self-rating anxiety scale (sas) questionnaire; stress was assessed using the stanford acute stress reaction (sasr) questionnaire; and sleep was assessed using the pittsburgh sleep quality index (psqi) questionnaire. pearson's correlation analysis showed that the psci-16 score for social capital was positively associated with the sas score for anxiety (r=0.619, p<0.01), the sasr score for stress (r=0.543, p<0.01), and the psqi score for sleep quality (r=0.479, p<0.01). the sas score for anxiety for the study participants was positively associated with the sasr score for stress (r=0.553, p<0.01), and the psqi score for sleep quality (r=0.523, p<0.01). the sasr score for stress was positively associated with the psqi score for sleep quality (r=0.628, p<0.01). these findings showed that the social capital of the study participants who self-isolated during the covid-19 epidemic improved sleep quality, which was reduced by anxiety and stress. anxiety levels correlated with stress levels, which reduced sleep quality. the results are summarized in table 2 . path analysis and mediation analysis using structural equation modeling (sem) of social capital on stress, anxiety, and sleep quality path analysis and mediation analysis using structural equation modeling (sem) were used to investigate the relationships between the four variables in this study. the effect of psci-16 score for social capital on the psqi score for sleep quality did not reach statistical significance, and this path was deleted from the model, as shown in figure 1 . the indices for the degree of fit of the sem were ideal, as shown by the goodness of fit index (gfi) of 0.995, the comparative fitness index (cfi) of 0.997, the tucker lewis index (tli) of 0.981, the incremental fit index (ifi) of 0.997, the normed fit index (nfi) of 0.993, the adjusted goodness of fit index (agfi) of 0.948, the root mean square error of approximation (rmsea) of 0.068, and the chisquared (c 2 ) to degree of freedom (df) ratio (c 2 /df ) of 1.781. table 3 shows the normalized path coefficient. the psci-16 score of the study participants was positively associated with the sas score (b=0.619, p<0.001) and the sasr score (b=0.327, p<0.001). the sas score of the study participants significantly affected the sasr score (b=0.351, p<0.001) and the psqi score (b=0.253, p<0.001). the sasr score of the study participants was positively associated with the psqi score (b=0.488, p<0.001). according to the scores from the psci-16, sas, sasr, and psqi questionnaires, social capital reduced anxiety and stress; increased anxiety levels reinforced stress levels, and reduced sleep quality. the indices for the degree of fit of the sem were calculated. spss amos version 21.0 (ibm, armonk, ny, usa) was used to measure the mediation effects of the study variables, with a bootstrap number set as 5000 to test the significance of specific mediation effects, followed by the nonparametric percentile bootstrap method with standard deviation (sd) correction. the following path was identified: psci-16 score for social capital ® the sas score for anxiety ® the psqi score for sleep quality. the sas score for anxiety had a significant mediating effect between the psci-16 score for social capital and the psqi score for sleep quality (b=0.157, p=0.002) when the confidence interval did not include 0. in the path of the psci-16 score for social capital ® the sasr score for stress ® the psqi score for sleep quality, the sas score for anxiety had a significant mediating effect between the psci-16 score for social capital and the psqi score for sleep quality (b=0.159, p<0.0001), when 0 was not included in the confidence interval. the results are shown in table 4 . the aim of this study was to investigate the effects of social capital on sleep quality and the mechanisms involved in people who self-isolated at home for 14 days in january 2020 during the coronavirus disease 2019 (covid-19) epidemic in central china. social capital was assessed using the personal social capital scale 16 (psci-16) questionnaire, which measured social trust, belonging, and participation. anxiety was assessed using the self-rating anxiety scale (sas) questionnaire, stress was assessed using the stanford acute stress reaction (sasr) questionnaire, and sleep quality was assessed using the pittsburgh sleep quality index (psqi) questionnaire. path analysis was performed to evaluate the relationships between a dependent variable (social capital) and two or more independent variables, using pearson's correlation analysis and structural equation modeling (sem). the findings from this study showed that anxiety and stress of isolated individuals were at high levels, while the sleep quality was low, which indicates that psychological health should be considered for individuals who isolate during epidemics and that levels of social capital may affect mental health and sleep. these findings are supported by previous studies, including the findings reported in 2012 by valencia-garcia et al., which confirmed that increased social capital reduced the levels of depression and anxiety [21] . li et al. showed that for children living in poverty, more family members, peer support, and school friends in their social capital were associated with better mental health [22] . yamada et al. showed that social capital contributed to reducing distress and preventing complications in patients with diabetes [23] . the findings from the present study, and the findings from previous studies, provide support for improving physical and mental health from the perspective of social capital and may be applied to individuals who self-isolate during epidemics, such as the recent covid-19 epidemic in central china. individuals who self-isolate at home will suffer from physical stress due to lack of space for physical activity, stress due to limited social interactions, and anxiety associated with fear of the consequences of infection. most individuals who self-isolate live alone or live with their families and may be more likely to feel lonely. also, because they are isolated at home rather than in the hospital, they may feel more insecure than the patients who have been hospitalized, with increased uncertainty about their own risk of developing severe disease, or of not being diagnosed or treated in time. therefore, the mental health of these individuals requires more attention. social capital may require attention to reduce negative emotions and to cope with the risks from an infection epidemic with a more positive attitude. this study found that the influence of social capital on sleep was mediated by anxiety and stress. in the first path identified, social capital affected anxiety, and anxiety directly influenced sleep quality. social capital affects anxiety because when an individual has a wide social network, they may be more likely to interact with other people [24] . social support and social resources reduce negative emotions, such as anxiety [25] . therefore, when individuals are isolated, including during epidemics, online social groups that expand social networks and provide mutual support may reduce the anxiety of isolation [26] . the effects of anxiety on sleep have been previously identified [27] . subjectively, people with anxiety may find it difficult to fall asleep, or they may wake up easily [28] . anxiety may lead to increased cortisol levels, changes in cortisol secretion rhythms, and reduced melatonin synthesis, all of which reduces sleep quality [29, 30] . in the second path identified in this study, social capital affected stress, and then stress affected sleep. the stress response refers to the individual nonspecific response caused by various stressors [31] . stress is closely associated with mood, behavior, a sense of wellbeing, and health [32] . people who have more social capital usually have less stress because they have spiritual or material support from others. social support helps to reduce the perception and evaluation of the threat of stress events, the physiological response and inappropriate behavior caused by stress, and the level of fear and anxiety induced by stress [33, 34] . stress is associated with sleep quality [35] . when individuals experience stress, they often feel physical tension and mental pressure, they are more sensitive to the sleeping environment, or they focus on sleep too much, which will reduce their sleep quality [36] . also, some variables may interact with each other. for example, anxiety may increase stress, and stress may increase anxiety [37] . also, increased anxiety may lead to poor sleep, and poor sleep may increase anxiety [38] . therefore, all the variables included in the present study, social capital, stress, anxiety, and sleep require attention to prevent a negative cycle of psychological and physical harm. therefore, more measures are needed to improve the social capital and mental health status of isolated people during epidemics of infectious disease. for example, professional medical staff should provide online health education to reduce uncertainty and panic caused by a lack of knowledge of new infections and diseases. social workers and psychotherapists may provide online help or support or support by phone to provide encouragement to communicate with relatives and friends using the internet or phone. these approaches to improving mental health and sleep may also improve immune function, which may improve the ability to resist infectious disease [39, 40] . this study investigated social capital, anxiety, stress, and sleep quality in a population who self-isolated for 14 days during the covid-19 outbreak in january 2020 and analyzed the relationships between the variables. social capital affected sleep quality through the mediation effects on anxiety and stress, as people who had high levels of social capital had better sleep quality. however, this study had several limitations. the study sample size was small, and a cross-sectional study design was used, which may have prevented the identification of other associations between social capital and sleep. also, social capital was measured using the psci-16 questionnaire, and the data relied on the ability of the individual to interpret the questions and provide accurate responses, but these responses were not verified objectively. therefore, some causal relationships may have been missed. further cohort studies with more samples should be performed, and non-subjective methods should be used. for example, sleep can be measured objectively by polysomnography, and stress levels can be detected using objective measurements of serum cortisol levels. this study aimed to investigate the effects of social capital on sleep quality and the mechanisms involved in people who selfisolated at home for 14 days in january 2020, during the coronavirus disease 2019 (covid-19) epidemic in central china. in this study, path analysis was performed to evaluate the relationships between a dependent variable (social capital) and two or more independent variables (anxiety, stress, and sleep), using pearson's correlation analysis and structural equation modeling (sem). during a period of individual self-isolation during the covid-19 virus epidemic, increased social capital improved sleep quality by reducing anxiety and stress. these findings may have implications for public health provision during epidemics of infectious disease, including improvements in social capital. world health organisation (who): coronavirus disease (covid-19) technical guidance a novel coronavirus from patients with pneumonia in china national health commission of the peoples' republic of china: march 5: 2020 daily briefing on novel coronavirus cases in china. 2020. available at world health organisation (who): international health regulations (ihr) on procedures concerning public health emergencies of international concern (pheic) posttraumatic stress, anxiety, and 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sites, online social support, and wellbeing: results from a six-wave longitudinal study a systematic review assessing bidirectionality between sleep disturbances, anxiety, and depression the association of insomnia with anxiety disorders and depression: exploration of the direction of risk melatonin and its analogs in insomnia and depression van der does aj et al: psychological traits and the cortisol awakening response: results from the netherlands study of depression and anxiety stress response syndromes stress and health: psychological, behavioral, and biological determinants perceived social support and mental health among single vs. partnered polish young adults social relationships and mortality risk: a meta-analytic review interactions between stress and sleep: from basic research to clinical situations the role of vulnerability in stress-related insomnia, social support and coping styles on incidence and persistence of insomnia stress, anxiety, depression, and epilepsy: investigating the relationship between psychological factors and seizures the relationship of sleep quality and ptsd to anxious reactivity from idiographic traumatic event scriptdriven imagery sick and tired: how molecular regulators of human sleep schedules and duration impact immune function a systematic review of spiritually based interventions and psychoneuroimmunological outcomes in breast cancer survivorship social capital, sleep quality, self-isolation, and covid-19… table 3 . normalized path coefficient. *** p<0.001. all the data in the form indicates the score of the questionnaire. the authors thank all the participants who took part in the study. this study was funded by the basic research project of coronavirus disease 2019 epidemic of fundamental research funds for the central universities, harbin engineering university. none. key: cord-341340-cnefwc3i authors: marchetti, antonella; di dio, cinzia; massaro, davide; manzi, federico title: the psychosocial fuzziness of fear in the coronavirus (covid-19) era and the role of robots date: 2020-09-24 journal: front psychol doi: 10.3389/fpsyg.2020.02245 sha: doc_id: 341340 cord_uid: cnefwc3i nan the coronavirus disease 2019 pandemic has prompted much research on the possible use of robots in different areas of intervention. one of them is related to the deployment of social robots to cope with different needs elicited by and depending on the emergency. according to a recent article published in science (yang et al., 2020, p. 1 ) "social robots could be deployed to provide continued social interactions and adherence to treatment regimens without fear of spreading disease." in this context, social isolation and quarantine-often significantly prolonged due to the duration of the infection-have plausibly exerted a negative impact on well-being and perhaps mental health, whose jeopardy was even more likely if a previous psychological vulnerability was present. if historically robots have been employed in dangerous and risky duties, presently, some of the most promising domains of robots' development also include rehabilitation, caring, and educational and clinic intervention. we are witnessing a shift from the concept of "robot as slaves" to "robots as companions, nurses, teachers. . . " that, in a word, behave, interact, and work "like us" (cfr. marchetti et al., 2018) . yang et al. argue that social robots used to "adherence to treatment regimens without spreading of fear" need to be implemented following sophisticated human models, including mental states like emotions and beliefs, as well as the context and environment of the interaction (p. 2). in our opinion, the "environments" are the affordances strictly linked to survival in an evolutionary sense. the "context" is represented by everyday life socio-material and socio-cognitive cues. furthermore, we believe that the implementation of social robots based on every possible human model cannot merely be the product of "a fusion of engineering and infectious disease professionals" (yang et al., 2020, p. 2). the model would require an interdisciplinary perspective that includes also the contribution of psychologists. the recent pandemic has in fact laid the foundations for rereading our daily relationships from the point of view of not only human relations but also other agents, such as robots. in the present opinion, we therefore suggest that the use of robots is not only a purely technical issue but also supported by important changes in the way we view relationships, particularly with those who are close to us. with this aim in mind, we focused on identifying some psychological components most subject to change due to the current global situation. let's take, for example, the emotion of fear mentioned above. fear will probably take (if not already has) a different form because of the virus. fear is a primary (ekman and friesen, 1971 ) and adaptive emotion developed through evolution to enable coping with danger and ensure survival. predators, contaminants, and invaders are the potentially dangerous enemies that are all risky variables toward which close relationships usually act as protective factors. in case of fear, the options for the individual are represented by the socalled "fight or flight" behaviors. on the relational level, it is the search for a secure base (bowlby, 1988) , where a place can be found for reassurance and affective supply. this tendency persists also in adulthood due to the transgenerational transmission of attachment patterns. nonetheless, covid-19 pandemic confronted us with a scenario where "fear has no face." now, it also involves close relationship partners, i.e., people who potentially are sources or recipients of care. this profoundly contrasts with a series of fundamental developmental achievements that make physical proximity the embodied prototype of psychological proximity. the individual undertakes a path in which the "known social other"/"unknown social other" dichotomy acts as an organizer of beliefs and attitudes, thus contributing to the construction of the self as a distinct and separate entity from the other. from a sensorineural point of view, the human baby is equipped to recognize and trustfully orient herself/himself toward primary figures of care and protection; it is precisely on this basis that trust is built in others and ourselves (di dio et al., 2019 manzi et al., 2020a,b) . the so-called "anguish of the stranger" (spitz, 1945; schaffer, 1966 ) emerges around 8 months of age. it marks the distinction between the caregivers and all the others: before becoming a neutral agent that the child will observe and know, the "other" per se is perceived as scary (worthy of fear in other words). this step appears to be in line with the older child's behavior observed within the strange situation (a paradigm aimed at evaluating attachment; ainsworth et al., 1978) : the response of distress and fear toward the stranger, who is generally more accepted if the mother is at the child's presence, and the reactions toward whom are predicted by the security of the child's attachment to the mother. later in life, the developing child can establish attachment bonds with other people in her/his life contexts: friends, schoolmates, relatives of the extended family, teachers, and educators in various contexts, from school to sports activities (pianta, 1999) . while the theoretical perspective of multiple attachments postulates that the widening of the "known social other" sphere is characterized by a differentiation of the functional roles played by multiple relationships, it maintains the fundamental developmental ability to identify the other as a "secure-safe social partner, " distinguishing him/her from the "risky-unsafe social partner." the possibility to create multiple attachments prevents a series of developmental risks and acts as an enhancer of positive primary attachment relationships and as a vicarious protective factor in the conditions of relational affective fragility. besides, not only are secure relationships with multiple figures-with the teacher, just to give an exampleconnected with the personal well-being within the affective sphere, but also with cognitive performance at school, as well as with socio-cognitive indexes like school climate, peer acceptance, and so on. in order to exert an enhancing-protective role, all these "others" (educators, teachers, relatives) have to be perceived as "besides me." the physical sense of "besides" -in its literal meaning-anticipates in development, and continues to support in the life span, the metaphorical sense of the human experience of psychological closeness and proximity. and it is precisely the impossibility to fully get the chances offered by the different meanings of "besideness" (physical proximity and security/safeness) that is responsible for the erosion of the feeling of being protected from fear within the contexts of affective bonds. although technology allows us to be connected even when physically separated, the experienced loneliness and isolation largely reported during covid-19 may depend both on the technological inability to embody affective relationships and perhaps also on more or less implicit awareness that "the known social other" (also my caregiver, daughter-son-teachergirlfriend/boyfriend-teacher, educator) could be dangerous for me. consequently, the pervasive mood of close relationships is no longer that of security but rather a widespread sense of fuzzy fear (furthermore, if people reflect on the possibility of being an active agent of contagion for their beloved ones, the basic emotion of fear should be added to the complex emotion of potential fuzzy guilt). so, if in-group/out-group dynamicsup to the attitudes toward the "stranger" in a geographical and political sense (antonietti and marchetti, 2020) -are the result of this primary articulation according to which "knownfamiliar" equals to reliable and "unknown-unfamiliar" equals to potentially dangerous (danger from which-phylogenetically and ontogenetically-the "known-familiar" is in charge of protecting us), the effect of the fuzziness of emotions, and especially of fear on mental health in a stressful situation like the one represented by the covid-19 pandemic, can be easily imagined. in fact, the covid-19 pandemic implies the possibility of indiscriminate contagion by anyone, including those closest to us in a psychic sense. because of this, it undermines the dynamics depicted above by eliciting an unprecedented form of fear, in which the boundaries between safety and risk fall. if infected, it is necessary to adhere to the rule of indiscriminate social distancing from everyone. the same applies if a relative is infected. the work of mercy to "visit the sick" cannot be accomplished, just as it is impossible to extend the final farewell to those who left us forever. in a word, covid-19 has completely changed the physiognomy of security/trust/danger/risk and fear, suddenly destroying a bond that evolution and ontogenetic development have taken a long time to build. the feelings of neglecting if not abandoning the beloved ones, or to be neglected if not abandoned by them to ensure the protective purposes of social distancing, are not easy to be managed from a psychological point of view; the experience of isolation, loneliness, and the worry of being forgotten are difficult to explain and to make comprehensible for children as well as the elderly. this is to say that the erosion of the foundations of the distinction between "known-familiar-safe/unknown-stranger-unsafe" could vary according to the developmental phases of the individual as well as the status of experts/novices. in terms of developmental phases, the cognitive, social, and affective resources typical of specific ages allow children to assimilate and elaborate differently information about the virus, its effects, and the dangers of proximity to beloved people. on the other end, if viewed from the perspective of expert/novices status, which is partially connected with the developmental phases, to have reliable information or real scientific knowledge on the spread of the virus could help to better manage the effect of the new form of fuzzy fear. going back to the role played by robotics within the psychological framework briefly outlined here, the use of robots may change depending on a series of factors that only the contribution of psychologists may help to highlight. first of all, the "like me experience, " which represents the basis of acceptance/refusal of social robots, changes with age. like the people's sense of people (to paraphrase legerstee, 2005) , also people's sense of social robots depends on the development, as well as the aims and contexts, of the robots' use (marchetti et al., 2018) . for these reasons, it is fundamental that the design of social robots meant to be deployed in situations of "fuzzy fear" like the one we are experiencing not only includes the purposes of assistance, companionship, or tutoring associated with medical regimens but also takes the real role of "fear-free" mediators of affective functions. in this way, robots do not become substitutes for close relationship partners from whom social distancing separates us, but act as relational bridges between those who are separated for health and safety reasons. as an effect of this rethinking the functions of social robots in emergency situations, some current negative attitudes toward social robots-from resistance and ambivalence up to the uncanny valley phenomenon (mori, 1970; macdorman and ishiguro, 2006 )-could significantly change. to pursue the goal of designing useful social robots for the psychological needs described here (i.e., coping with fuzzy fear and taking advantage of robots as affective mediators), a deep, psychologically driven afterthought will be needed around three basic axes of reflection. the first two axes are more general. the first one regards the psychological understanding of people involved in human-robot interactions during a sanitary emergency in terms of level of development, socio-demographic characteristics, and previous experience with social robots (see the experts/novices distinction above). expectations and attitudes toward social robots may in fact change according to both development and expertise. the second axis regards the construction of social robots that are able not only to take into account the needs of their human partners but also to relate with the human agent in an understandable way. this represents an extremely important feature that every human would expect from the interactive experience. the literature on robotics calls it "transparency"/"explainability" (holzinger et al., 2019) , which would correspond to the experience of the theory of mind (perner, 1991; wellman et al., 2001) in the domain of human-human interaction. the third axis of reflection relates to a goal that we hope to achieve in a not too distant future. specifically, it concerns the identification of the best way to devise social robots that are able to sensitively manage and respond to the behavior of a human partner with a possible acute temporary breakdown in the ability to scaffold the sense of emotional security-like some of us during this covid-19 emergency-that is the very basis of self construction. the theoretical reflections discussed in this opinion reread therefore the question of fear in the light of a danger that poses new questions and that, as is suggested, leads to rethinking particular psychological and social dynamics. in reading the new relational dynamics hypothesized in the present work, from which the robot is spared, covid-19 pandemics added novelty to the physiognomy of fear, which (unlike anxiety) is an emotion linked to objects and situational antecedents, and which may therefore be affected by the nature of its objects at the level of subjective experiences, behavioral reactions, as well as coping strategies. these theoretical suggestions may enrich knowledge from an interdisciplinary perspective, such as robotics and psychology, providing important starting points for future research by emphasizing which psychological components should be investigated in people interacting with robots. an example is the perception of in-group/out-group, as well as the components of fear that, in our opinion, are mitigated toward robots in the specific covid-19 situation, which forces us to adapt to the inclusion of new social agents devoted to care assistance. patterns of attachment: a psychological study of the strange situation migrazioni e psicologie. introduzione al forum a secure base it does not matter who you are: fairness in pre-schoolers interacting with human and robotic partners shall i trust you? from child human-robot interaction to trusting relationships come i bambini pensano alla mente del robot: il ruolo dell'attaccamento e della teoria della mente nell'attribuzione di stati mentali ad un agente robotico [how children think about the robot's mind. the role of attachment and theory of mind constants across cultures in the face and emotion causability and explainability of artificial intelligence in medicine infants' sense of people: precursors to a theory of mind the uncanny advantage of using androids in cognitive and social science research the understanding of congruent and incongruent referential gaze in 17-month-old infants: an eye-tracking study comparing human and robot a robot is not worth another: exploring children's mental state attribution to different humanoid robots theory of mind and humanoid robots from a lifespan perspective the uncanny valley understanding the representational mind the onset of fear of strangers and the incongruity hypothesis hospitalism: an inquiry into the genesis of psychiatric conditions in early childhood meta-analysis of theoryof-mind development: the truth about false belief combating covid-19-the role of robotics in managing public health and infectious diseases all authors contributed to the writing of the manuscript. the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright â© 2020 marchetti, di dio, massaro and manzi. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord-295878-pd9elo4l authors: luo, wei; gao, peng; cassels, susan title: a large-scale location-based social network to understanding the impact of human geo-social interaction patterns on vaccination strategies in an urbanized area date: 2018-11-30 journal: computers, environment and urban systems doi: 10.1016/j.compenvurbsys.2018.06.008 sha: doc_id: 295878 cord_uid: pd9elo4l abstract cities play an important role in fostering and amplifying the transmission of airborne diseases (e.g., influenza) because of dense human contacts. before an outbreak of airborne diseases within a city, how to determine an appropriate containment area for effective vaccination strategies is unknown. this research treats airborne disease spreads as geo-social interaction patterns, because viruses transmit among different groups of people over geographical locations through human interactions and population movement. previous research argued that an appropriate scale identified through human geo-social interaction patterns can provide great potential for effective vaccination. however, little work has been done to examine the effectiveness of such vaccination at large scales (e.g., city) that are characterized by spatially heterogeneous population distribution and movement. this article therefore aims to understand the impact of geo-social interaction patterns on effective vaccination in the urbanized area of portland, oregon. to achieve this goal, we simulate influenza transmission on a large-scale location-based social network to 1) identify human geo-social interaction patterns for designing effective vaccination strategies, and 2) and evaluate the efficacy of different vaccination strategies according to the identified geo-social patterns. the simulation results illustrate the effectiveness of vaccination strategies based on geo-social interaction patterns in containing the epidemic outbreak at the source. this research can provide evidence to inform public health approaches to determine effective scales in the design of disease control strategies. infectious diseases (e.g., influenza) have posed great challenges to society. dangerous infectious diseases, such as severe acute respiratory syndrome (sars), anthrax, h1n1 flu, and ebola pandemics, have been exacerbated by increasing human density and population mobility seen in contemporary society (anderson et al. 2004; fraser et al. 2009; leung et al. 2004) . infectious disease outbreaks can spread worldwide via international transportation networks more rapidly than the distribution of vaccines (ferguson, fraser, donnelly, ghani, & anderson 2004; webby & webster 2003) . a key public health question is how to contain infectious diseases at the source or reduce transmission long enough to implement an effective response (longini jr et al. 2005) . network science has been used to study infectious disease transmission and to design effective control (germann, kadau, longini, & macken 2006; halloran et al. 2008; longini jr et al. 2005) . traditional network models are individual-centric approaches in which nodes represent individuals and links represent physical contacts (meyers 2007) . disease simulations based on network models primarily focus on health outcomes (e.g., the number of infected cases) (mao & bian 2010; ), but do not sufficiently consider the role of location in disease transmission and control (zhong & bian 2016) ; for example, what are the critical locations in the transmission? are location-based control strategies more effective than individual-based control strategies? how do the spatial flows of population mobility among locations influence epidemics and control strategy design? those are all critical public health questions in terms of spatially informed policies for infectious disease control and prevention (bian, 2013 , gao & bian, 2016 . to tackle the above questions, this research treats infectious disease spread as geo-social interaction patterns, in which locations interact with each other via viruses that transmit from one place to another because of human interaction and population movement (gushulak & macpherson 2000) . geo-social interaction patterns identified from human mobility data within cities have the potential to provide valuable insight for designing effective epidemic control measures (guo 2007) . luo (2016) empirically found that vaccination strategies considering geo-social interaction patterns have a high probability to contain pandemics at the source within a primary school environment. however, human interaction patterns at an urban scale, which are characterized by heterogeneous population interactions and movement in space, have not been used to inform prevention strategies. the spatial heterogeneity of population interaction and movement make the choice of appropriate containment areas for effective vaccination strategies challenging. this research, therefore, aims to understand the impact of geo-social patterns identified from human movement and interaction data on effective vaccination in the urbanized area of portland, oregon. we use a location-based network framework in which nodes represent locations and links represent population flows among locations. the framework explicitly represents spatial dynamics of disease transmission from one location to another as well as design control strategies according to population flows among locations. based on the location-based network, we simulate influenza transmission dynamics and evaluate the efficacy of different vaccination strategies according to the identified geo-social interaction patterns. our research questions follow: (1) given geo-social interaction patterns, how does population distribution and movement impact the effectiveness of influenza control efforts? (2) how does the size of the containment area impact the control effectiveness considering human geo-social interaction patterns? the remainder of this article is organized into the following sections. the second section introduces related work in agent-based epidemic models and prevention strategies. the third section introduces location-based network model and agent-based epidemic simulation model in the urbanized area of portland. the one section that follow present and discuss the simulation results. the last section concludes the article and discusses its implications. infectious diseases are transmitted from one individual to another through physical contacts. in many agent-based epidemic models, the concepts of networks are used to represent contacts among individuals (bian 2004; bian & liebner 2007) . each individual can have attributes, such as infection status and spatial locations, whereas each link can also have a set of attributes, such as the duration of the contact and the infection rate. based on human interaction networks, epidemiologists can use agent-based epidemic models to simulate disease transmission and design different control scenarios. recently, agent-based models for disease transmission at different spatial scales (e.g., city, nation) have been used to study spatio-temporal patterns of disease spread (bian et al. 2012; ferguson et al. 2005; ferguson et al. 2006; halloran et al. 2008; mao & bain 2011) . these models predict that interactions at homes and workplaces could cause local transmission followed by a long distance transmission to an areawide epidemic (eubank et al. 2004) . local transmission indicates that early disease transmission is concentrated around the infection sources. later, population movement and distribution determine the spatiotemporal spread of infection. prevention strategies for infectious disease can be classified into three broad categories: antiviral, vaccine, and non-pharmaceutical measures (ferguson et al. 2006) . antiviral measures require rapid identification of early infections for treatment in order to reduce their infectiousness. vaccination seeks to protect people from being infected by other infections via physical contacts. non-pharmaceutical measures (e.g., case isolation, household quarantine, school or workplace closure, restrictions on travel) aim to locally contain the spread of disease (ferguson et al. 2005; ferguson et al. 2006) . previous research has shown the effectiveness of the above prevention measures in reducing disease transmission with agent-based modeling (ferguson et al. 2005; ferguson et al. 2006; halloran et al. 2008 ), but those agent-based modelings are individual-centric without capturing explicitly spatial dynamics of the disease transmission for designing control strategy purpose. spatial locations, one attribute of each agent, are treated as spatial stamps of the transmission process in the individual-centric agent-based modeling (zhong & bian 2016) . such representations suffer from a number of drawbacks regarding transmission and control design. first, the importance of locations in understanding disease transmission and control has been missing. for example, antiviral "ring chemoprophylaxis" strategies aim to geographically targeted containment via applying a certain distance threshold (e.g., 5 km) by means of prophylaxis to attempt to prevent spread to unaffected regions (lee et al. 2010) . in fact, infectious disease transmission is the mixing patterns of geographical mobility and social interactions that are much more complicated than a simple distance threshold. second, the design of control strategies based on individualbased networks (e.g., vaccinate the individual with a large number of contacts) is challenging because it is infeasible to keep track of all social contacts of infections (cohen, havlin, & ben-avraham 2003; gómez-gardenes, echenique, & moreno 2006; holme 2004 ), but the information to estimate population flows among locations based on intra-and inter-community travelers is widely available in the existing census data and travel survey reports (mao & bian 2010) . thus, location-based human interaction network models are required to easily represent explicitly spatial dynamics of the disease transmission and design control strategies to target certain critical locations first rather than prioritizing individuals. based on a location-based human interaction network model, luo (2016) proposed a new framework in terms of an effective disease control strategy that consists of identifying geo-social interaction patterns first, following by designing effective control measures according to those patterns, and ending with control measure evaluation. the work also showed that vaccination strategies considering the geo-social interaction patterns can reduce disease transmission within a primary school environment because they can prevent disease from spreading to other classes. though the above research has demonstrated the importance of locations considering human geo-social interaction patterns in designing effective control scenarios, little research has been conducted to evaluate the effectiveness of such approach in a larger scale (e.g., city). thus, this research develops an integrated two-layer location-based social network approach to investigate the impact of human geo-social interaction patterns on effective vaccination design in an urban environment. we use a previously built and parameterized network from a synthetic population for a normal day in the city of portland, oregon, usa (eubank et al. 2004) to construct the integrated two-layer locationbased social network framework. one layer is a location-based network for the vaccination scenario design and the other layer is an individualbased social network to simulate infectious disease transmission and control to evaluate the effectiveness of those scenarios. each is detailed next. the synthetic population data includes over 1.5 million individuals and more than 1.5 million locations. each synthetic individual has their demographic attributes such as income range and age, whereas each synthetic location has utm coordinates. based on the individual and location information, the simulated daily activity data also includes the purpose of the activities such as work, school, and shopping, in which the starting time and duration of activity are stored in seconds (fig. 1) . the data also include the information representing dynamic personperson contact networks including contact hours, contact type, and location information. the total number of person-person contacts is approximately equal to 20 millions. the simulated data are configured with social surveys, transportation simulations, and census data in the portland city. the data set is available at http://ndssl.vbi.vt.edu/ synthetic-data/. human interactions and population mobility show spatial and temporal co-occurrence that connect discrete events over the same or different locations to facilitate disease transmission (zhong & bian 2016) . spatial and temporal co-occurrence is the basis of the construction of location-based human interaction network, in which nodes represent locations and edges represent population flows between locations. the total number of travel activities by individuals between two locations (population flows) is recorded as the weight of the edge (fig. 1 ).the total population flows among locations are more than 6 millions. a spatially explicit agent-based epidemic model is built on the simulated daily activities of person-person contact network in the city of portland, oregon, usa (eubank et al. 2004) (fig. 1) . the influenza transmission is simulated over the contact network with each individual as one agent changing their infection states over time. following the natural history of the influenza, each individual can take one of four statuses: susceptible, exposed, infectious, or recovered (seir) at a given time (anderson & may 1992) . all individuals in our model are initially considered as susceptible to influenza. after contact with an infection, susceptible individuals have a probability of infection. those newly infected change their statuses from susceptible to exposed. exposed individuals may progressively develop their infectious statuses, which further enable them to transmit the influenza viruses to susceptible contacts. finally, infectious individuals recover from influenza. first, the exposed and infectious periods are from the established literature (table 1) . second, the infection probability is calculated based on the r 0 (the basic reproductive number). r 0 is defined as the average number of secondary cases produced by a single infection over the course of its infectious period in a completely susceptible population (diekmann, heesterbeek, & metz 1990) . the transmission probability is calculated in order to generate consistent values of r 0 (the basic reproductive number) corresponding to the observed r 0 of pandemic influenza (0.9-2.1) in previous studies (ferguson et al. 2005; mills, robins, & lipsitch 2004) . we use a monte-carlo method to randomize the infection probability of individuals to derive r 0 . all parameters to describe the natural history of the influenza are in table 1 . we implement three vaccination strategies: random-based, degreebased, and betweenness-based vaccination strategies over the influenza diffusion in the city of portland, oregon, usa. the three strategies are the most representative ones to compare the effectiveness of different vaccination scenarios in the established literature (mao & bian 2010; . the basic idea of vaccination strategies is first to rank the importance of individuals according to their network measures (e.g., degree, betweenness) and then target the individuals from the highest network measures to lowest. the randombased strategy treats all of individuals the same and randomly identifies a certain number of individuals for vaccination. the degree-based strategy prioritizes individuals who have the most contacts within the network for vaccination. the betweenness-based strategy ranks the importance of individuals according to their betweenness centrality that can capture the extent to which a particular node lies on those shortest paths that pass through the nodes (freeman 1978) . both degree-based and betweenness-based vaccination strategies have shown much more effective than random-based strategy. for example, betweenness-based vaccination strategy tend to prevent disease outbreak from one community to another via targeting individuals on the shortest paths, so it becomes more effective with stronger community structures methodology framework consists of the integrated two-layer location-based social network: location-based network to design control strategy considering geo-social interaction patterns and individual-based social network to evaluate effectiveness of the above control strategy with the implementation of agent-based epidemic model. the framework is implemented in a high performance computing environment. scale-free network (albert, jeong, & barabási 2000) . though identifying all targeted individuals with high degree or high betweenness may not be practical, information needed to identify these individuals is becoming available (e.g., gps, social media) . using the location-based human interaction network, the vaccination strategy is designed according to population flows among locations with infections and their neighboring locations. neighboring locations that have direct connections with infected locations are most likely to be infected, followed by locations that have indirect connections with those infected locations. thus, the vaccination strategy will target those direct neighboring locations first, followed by targeting indirect connected locations. in practice, it is much easier to target a small population size with direct neighboring locations instead of a large population size with indirect connected locations. thus, this study explores the impact of the size of containment areas on vaccination efficacy in order to provide evidence in public health practice. the strategy is implemented at the beginning of the influenza epidemic. the simulation will stop when there are no new infections for six consecutive days (length of exposed period + length of infectious period). we randomly picked one infectious individual as the infection source in the study area on the first day of the simulation. based on the strategy rationale, we considered the locations where the first infection visited as the original case cluster. the original case cluster and all of the rest locations which have the population flows to the original case clusters were used to determine the first level local containment scale. the second level geo-social local containment scale was determined by all of the locations in the first level local containment area and the locations which have the population flows to the locations in the first level local containment area, so were the third, the forth, and the fifth level local geo-social containment scales. though the location network was dynamic over time in a day, the strategy design was based on the total population flows among different locations within one day for a practice purpose. it is more practical to design vaccination strategy at a daily basis instead of at an hourly basis. in order to understand the impact of the spatially heterogeneous population distribution and mobility on the design of vaccination strategies, we randomly pick the first infection 10 times with varying total number of individuals in the first level local containment area (i.e., 1000, 5000, and 10000). the larger number of individuals within the first level local containment scale is caused by the high local population density which potentially leads to more complicated population interaction and mobility to larger geographical regions. given that the vaccination results are sensitive to the number of available vaccines, we simulate results according to an increasing number of vaccines from 20,000 to 400,000 with an increment of 20,000. there is one network, three different initial infection locations with 10 times' randomness, three strategies (e.g., random-based, degree-based), four different local control regions (from the second to the fifth level local containment area), and twenty different possibilities for the number of available vaccines, yielding 7200 (1*3*10*3*4*20) combinations to simulate ( table 2 ). the efficacy of vaccination strategies for each combination is estimated for 10,000 simulation runs, resulting in a total of 72,000,000 epidemic simulation runs. because of the large number of individuals and locations in the study area and the massive number of simulations involved, the tasks in this research are extremely computation intensive. we tackle this issue by taking the advantage of a high performance platform of cpu clusters. parallel algorithms are developed to deal with the most computation intensive tasks: 1) the calculation of the betweenness centrality and 2) the simulation of influenza epidemics. for the former, it is widely understood that the definitions of betweenness centrality in very large networks have inherently high computational complexity. the parallel algorithm is adapted from the brande's algorithm (brandes 2001) , and the actual running time is about 30 hours using 40 computing nodes, each with 8 cores and 16 gb of ram memory. for the latter, the parallel algorithm is developed following the seir rules as discussed earlier, and the running time ranges from 10 to 60 hours for a given first infection and vaccination strategy using the same computing nodes. the parallel design does not only reduce the running time but also improve the scalability of this methodology framework, which are essential for analyzing extremely large network data. we use two metrics to measure the effectiveness of vaccination strategies in the city of portland: the number of infections and the success rate of local containment. for the first metric, a better vaccination strategy is expected to generate a lower number of infected cases. for the second metric, we measure how well we can contain the outbreak at the source. if the number of infections outside of the containment areas identified by geo-social interaction patterns is zero, we consider the local containment successful. otherwise we consider the local containment a failure. fig. 3 show the containment effectiveness of three typical vaccination strategies in which the first initial infections occurring within the first level local containment scale with approximately 5,000 individuals in the city of portland according to the two metrics: the number of infections and the success rate of local containment. fig. 2 illustrates that an increasing number of vaccines can produce a decreasing number of infections. the random-based vaccination strategy generates the largest number of infections, followed by the degreebased and betweenness-based vaccination strategies. the latter two vaccination strategies produce the similar control efficacy in which betweenness-based ones lead to a relatively faster decreasing number of infections. the explanation of such patterns is illustrated in the fig. 3 . fig. 3 shows that an increasing number of vaccines can produce a decreasing number of local containment failure rates. in other words, betweenness-based vaccination strategies can contain disease outbreak at the local geo-social scales more successfully than the other two vaccination strategies. one reason is that betweenness-based vaccination strategies target high risk individuals who lie on the bridge among different communities, so they can control epidemics more effective through preventing epidemic outbreak from the local geo-social containment areas to outside areas. from fig. 2 (a-d) , there is an obvious trend that increasing geosocial scales of local containment areas result in an increasing number of infections. fig. 3 suggests that increasing extents of local geo-social containment areas lead to difficulty in containing outbreaks at the local scale. for example, in order to successfully contain the disease locally larger than 90% with degree-based or betweenness-based approach, it cost 60,000 vaccines in fig. 3 (a) , 180,000 vaccines in fig. 3 (b) , 200,000 vaccines in fig. 3 (c) and (d) . in addition to supporting the importance of reliable detection of early infections to contain outbreaks at the source, such patterns also illustrate that identifying an appropriate scale for the local containment is key for designing effective prevention strategies. fig. 2 (c) and (d) show that when the local containment areas are larger than certain extent, there is no obvious difference in terms of containment efficacy. it is because that the number of available vaccines cannot effectively contain disease outbreak at the local scale in fig. 3 (c) and (d). this study further explores the impact of spatially heterogeneous population distribution and mobility on the containment efficacy of local geo-social vaccination strategies. this section only displays the simulation results with the random-based vaccination strategies, because the other two strategies display the similar patterns. fig. 4 and fig. 5 show the results of the two metrics: the number of infections and the success rate of local containment, respectively. they both display consistent patterns: the initial infections occurring in the higher population density areas can lead to higher number of infections (fig. 4) because they increase the local containment failure rates with the same number of vaccines (fig. 5) . for example, the disease transmission caused by the first infection from locations with a medium population density can areas be confined locally at a very high percentage (i.e., 80 %) with less than 100,000 infections using 350,000 vaccines ( fig. 4b and 5b ), whereas the same amount of vaccines can only successfully contain the disease outbreak from high population density locations less than 20 percent with more than 300,000 infections. such patterns imply that we need more vaccine available in order to contain disease outbreak from critical locations with high human interaction density and large numbers of population flows from infected locations to others. thus, it is essential to place sensors in the hubs of the locations to allow highly efficient outbreak detection. fig. 4 and 5 show that increasing scales of local geo-social containment areas lead to decreasing efficacy of the same amount of vaccines. for example, the random-based control scenario with more than 150,000 vaccines can successfully contain the disease outbreak in a high population density area (fig. 4 a) , but it generates less than 600,000 infections (fig. 4 b) and more than 600,000 infections (fig. 4 c and d) . from the both (c) and (d) of the fig. 4 and 5, we can tell that there is no obvious difference in terms of containment efficacy when the local containment areas are larger than certain scales in both (c) and (d). one explanation is that a certain number of vaccines have its threshold of susceptible population pool. the number of local control failure increases after the susceptible population pool goes beyond the threshold with the increasing local geo-social containment areas. when the disease outbreak occurs outside of the containment areas in the most simulation runs, the number of total infections finally reach similar amounts. we also notice that it is unlikely to confine the disease outbreaks caused by the first infection from high population density areas, if the local geo-social containment areas are set too large (fig. 5c and 5d ). when the first infection is from low population density areas, the likelihood to contain disease outbreaks within a large local geosocial containment areas is still very high ( fig. 5c and 5d) . thus, we can reach the conclusion that an appropriate geo-social scale for the local containment and the population density where the first infection resides are two keys for prevention strategies to achieve their maximum control effectiveness. based on the comparison analysis above, broader scales of local geosocial containment areas lead to decreasing efficacy of the same amount of vaccines. we further examine and compare their spatial effectiveness through infection density maps (fig. 6) . we choose degree-based vaccination strategies with the medium number of individuals (approximately equal to 5000) within the first level local containment scale. we pick the number of vaccines equal to 100,000 for the second level local containment scale (fig. 6a ) and the number of vaccines equal to 180,000 for the third, forth, and fifth level local containment scales (fig. 6 b, c, and d) because they all have the local containment failure rates lower than 10% (fig. 5) . fig. 6 (a) induces an extremely low intensity of infections in the whole study area with a relatively higher intensity of infections in the central business district of the study area. it is caused by the densest residential population and business locations in the central business district. compared to the fig. 6 (a), fig. 6 (b) with a larger containment area greatly increases the infection intensities with an additional dense area: the city of vancouver on the north bank of the columbia river. vancouver is the largest suburb of portland, oregon with highly concentrated population density. the spatial effectiveness of fig. 6 (c) and (d) lead to the wide spread of influenza over the study area with three of highest infection density areas. the similar spatial patterns and total infections in both fig. 6 (c) and (d) indicate that a certain number of vaccinations have its upper limit of susceptible population pool. when the local containment scale is larger than the upper limit, there is no difference in terms of spatial effectiveness. the spatial effectiveness of fig. 6 highlights the importance of early detection of infections with an appropriate local containment scale, which is capable of confining the wide spread of influenza over the study area. this research examined the impact of geo-social interaction patterns on effective vaccination strategies in the urbanized area of portland, oregon. to achieve this goal, we built a large-scale two-layer locationbased social network model including an innovative location-based network to design vaccination strategies and an individual-based spatially explicit disease model to evaluate the efficacy of the above vaccination strategies. we implemented the network model in parallel algorithms to take advantage of a high performance platform of cpu to tackle the challenge of extremely intensive computation with millions of nodes and edges. the simulation results suggested that geo-social interaction patterns can be used to design effective vaccination strategies to contain epidemic outbreaks at the source. increasing extents of local geo-social containment areas lead to decreasing control effectiveness because it becomes challenging to confine the spread of influenza within local containment areas. especially when the local containment scale is larger than the upper limit, there is little difference in terms of spatial effectiveness. vaccination designs should consider spatially heterogeneous population distribution and movement in an urban area. it is possible to confine disease outbreaks for early infections in the low population areas, even if local geo-social containment areas have been set too large. it is unlikely to confine disease outbreaks for early infections in the high population areas if local geo-social containment areas are set too large. this study highlighted the importance of identifying the population density for the early infections and an appropriate geo-social scale for local containment in order to achieve maximum control effectiveness with a limited number of vaccines. a successful vaccine strategy must meet a number of key criteria: (1) early detection of the original case cluster, (2) rapid delivery of treatment to targeted groups, and (3) effective delivery of treatment to high risk individuals (eubank et al. 2004; ferguson et al. 2005) . the identified geo-social interaction patterns and their effectiveness in designing vaccination strategies provide valuable insights for helping meet the above challenges. they can help identify critical individuals, locations, and clusters of locations for disease control purposes. traditional prevention strategies, including ring vaccination and contact tracing, can only capture one aspect of infectious disease transmission (i.e., spatial, or social) and both of which have significant limitations. "contact tracing" strategies require the identification of people who may have had contact with infectious individuals (germann et al. 2006) , which is difficult to implement in real situations considering the limited resources and time before the disease outbreak. "ring vaccination" with a simple distance threshold (e.g., 5km) (lee et al. 2010 ) is easy to implement, but it may fail to capture the most likely and complicated disease transmission processes. many research have demonstrated that ring vaccination alone might not lead to containment of disease outbreak with a high r 0 at the source (kucharski et al. 2016; wells et al. 2015) , but a combined intervention of contact tracing and ring vaccination might contribute increase the ability to contain outbreaks of emerging infectious disease threats (kretzschmar, van den hof, wallinga, & van wijngaarden 2004; longini jr et al. 2005; merler et al. 2016; diao and wang, 2014; . the proposed geo-social interaction patterns cannot only address the inherent challenges of contact tracing to identify contacts with infections, but also capture the mixed interactions of the social and spatial relationships among individuals that determine infectious disease transmission (luo & maceachren 2014) . in addition to taking advantages from both contact tracing and ring vaccination strategies, the proposed location-based network approach provides the potential solution to address the challenge that it is infeasible to identify individuals with high degree or high betweenness for the disease control purpose in critical and timely situations. the wide available data (e.g., sensor networks, twitter) can provide more reliable estimation on the critical locations than critical individuals with high degree or high betweenness. thus, public health workers should focus on those critical locations with their close neighbor locations first in a timely manner. the proposed location-based social network framework also suggests several directions for future research. first, the estimation of population flows among different locations is still based on the existing census data and travel survey reports. gao et al. (2014) found that large-scale social media data can provide reliable estimates of regional origin-destination trips on weekdays compared with the community survey data in greater los angeles area. it shows great promise to build location-based social networks with large-scale social media data to provide real-time estimation and prevention strategy design in a timely manner. second, the location-based social network framework is built on population interaction and movement patterns in a normal situation, but people may adjust their behaviors accordingly during an epidemic outbreak. thus, human preventive behaviors caused by inter-personal influence (mao & yang 2012) and mass media could be incorporated to refine the framework. third, this research focuses on the impact of vaccination strategies on geo-social interactions patterns, but has not evaluated such impact of other prevention strategies such as travel restrictions and case isolation. forth, this research also has implications for the control of other location-based spreading pheonmena, such as invasive species , diao & wang 2018 , and hiv transmission (luo et.al 2018) . to summarize, the proposed location-based social network framework can help geographically optimize the design of prevention strategies before epidemic outbreaks, especially for novel viruses with limited resources and time constraints. to understand advantages and disadvantages of the framework in a full picture, it is crucial to apply it for other regions with different population distributions and movements as well as epidemiological settings. the author declares that he has no competing interests. this material is supported in part from the nih/nichd r21 hd080523. error and attack tolerance of complex networks epidemiology, transmission dynamics and control of sars: the 2002-2003 epidemic infectious diseases of humans: dynamics and control spatial approaches to modeling dispersion of communicable diseases-a review a conceptual framework 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control transmissibility of 1918 pandemic influenza immunization of complex networks dynamics and control of diseases in networks with community structure a high-resolution human contact network for infectious disease transmission are we ready for pandemic influenza? harnessing case isolation and ring vaccination to control ebola effects of immunization in small-world epidemics a location-centric network approach to analyzing epidemic dynamics support provided by the center for computational research at the university at buffalo. the authors appreciate shaohua wang's contributions to data processing at the early stage. the authors are grateful to the anonymous reviewers and editors, whose valuable comments and suggestions helped improve the quality of the paper. key: cord-299245-qirh1vud authors: catherine, sylvain; miller, max; sarin, natasha title: relaxing household liquidity constraints through social security() date: 2020-08-10 journal: j public econ doi: 10.1016/j.jpubeco.2020.104243 sha: doc_id: 299245 cord_uid: qirh1vud more than a quarter of working-age households in the united states do not have sufficient savings to cover their expenditures after a month of unemployment. recent proposals suggest giving workers early access to a small portion of their future social security benefits to finance their consumption during the covid-19 pandemic. we empirically analyze their impact. relying on data from the survey of consumer finances, we build a measure of households' expected time to cash shortfall based on the incidence of covid-induced unemployment. we show that access to 1% of future benefits allows 75% of households to maintain their current consumption for three months in case of unemployment. we then compare the efficacy of access to social security benefits to already legislated approaches, including early access to retirement accounts, stimulus relief checks, and expanded unemployment insurance. the covid-19 pandemic has pushed us unemployment to its highest level since the great depression. now, policymakers are weighing an unprecedented change to the social security system: allowing workers to access a portion of future benefits prior to retirement to finance consumption today. 1 early access to social security wealth would boost household liquidity. but, it will also decrease the resources that retirees will have later in life. the magnitudes are uncertain and may vary across the wealth distribution. assessment of this proposal requires careful consideration of workers' social security benefits and their distribution. only then is it possible to analyze the impact of a cut to future benefits on households, today and in the future. this paper undertakes this task. specifically, we build on the catherine et al. (2020) estimate of social security wealth to compute the market value of expected social security benefits for each worker we observe in the survey of consumer finances (scf). we compute expected benefits by simulating workers' earnings trajectories and then discount these benefits, accounting for the long-run correlation between social security and stock market returns. we find that a 1% decrease (representing on average $15) in monthly benefits significantly boosts liquidity. it provides on average $2884 per worker today. as fig. 1 illustrates, social security benefits are relatively evenly distributed across the wealth distribution, whereas the value of retirement accounts and liquid savings is concentrated in the top decile. social security is hugely significant to most americans: it represents nearly 60% of the wealth of the bottom 90% (catherine et al., 2020) . in its last annual report, the social security administration reports that the aggregate value of benefits scheduled for current participants is nearly $80 trillion. allowing workers to tap a share of social security benefits early would allow them to borrow at historically low interest rates. for most of them, this cannot be done on private markets. as fig. 2 shows, in 2016, a majority of households faced a marginal interest rate above 10%. households who do not need this loan can choose to invest the money in government bonds and should be indifferent. from the point of view of the government, an approach like this one transforms implicit social security liabilities into public debt but leaves its overall long-run obligations unchanged. in the second part of the paper, we measure how many days it takes for households to run out of cash in case of unemployment. we use this measure to evaluate the efficiency of an early distribution of 1% of social security benefits and compare this policy to already enacted alternatives: allowing workers to tap retirement accounts without penalty, $1200 stimulus checks, and the extension of unemployment insurance by $600 per week. importantly, we adjust our unemployment estimates to reflect the fact that this crisis disproportionately displaces young workers in particular industries (e.g., food services and entertainment) with the least liquid savings. overall, distributing 1% of the value of scheduled benefits allows 75% of households to go through 3 months of unemployment without cutting their consumption. a similarand more administrableapproach would be to provide workers an advance on future social security benefits: a $2500 check today corresponds to less than a 1% cut in future benefits for nearly all workers. only the supplemental unemployment insurance of $600 per week provides more liquidity, which is hardly surprising since it implies a median replacement rate of 134% . for most retirees, social security income is their primary source of support during retirement. thus, consideration of any social securitybased emergency liquidity program must consider the impact on future retirement security. the goal of this paper is to provide an actuarial analysis of a proposal to decrease future social security benefits to fund consumption today and to quantify its effect on household liquidity. we do not seek to provide a normative judgment on optimal policies to be pursued. indeed, there are strong political economy arguments against a social security-based approach: opening up the idea that social security can be used to meet liquidity needs may lead policymakers to meet other needs that occur during working lives through erosion of retirement support, rather than alternative social insurance arrangements. 2 one contribution of our paper is it provides a framework to evaluate the consequences of policy proposals in this vein for households and to determine whether they are being priced in an actuarially fair manner. the baseline approach we consider estimates the liquidity that results from a fairly priced exchange of 1% of future social security benefits for a check today. on average, $15 less in monthly benefits in retirement means households can finance their consumption for two months. the details of current policy proposals are not yet clear, but some press reports suggest significantly larger magnitudes: that workers may be able to opt into $10,000 of benefits today. this would constitute 3.5% share of future benefits or claiming benefits five months later, if priced in an actuarially fair way. further, since workers can opt-in to this program, concerns about adverse selection loom large. fig. 1 . distribution of various forms of wealth. this figure shows the distribution of social security wealth, retirement wealth, and liquid wealth across deciles of the marketable wealth distribution. the blue bar denotes the per household average present value of scheduled social security benefits, the red bar shows the per household average amount of retirement savings, and the green bar displays the per household average liquid wealth. we calculate the present value of social security benefits by simulating workers' earnings trajectories and matching this data with the scf based on current earnings. retirement accounts are defined as ira accounts, thrift accounts, or any current or future defined contribution pension obligations and comes from the scf. liquid wealth is defined as all wealth held in transactions accounts, certificates of deposit, mutual funds, stocks, bonds, and also comes from the scf. private borrowing rates across the wealth distribution. this figure shows the maximum and mean borrowing rates for scf respondents for each decile of the marketable wealth distribution. the blue bars represent the mean highest borrowing rates reported by each household. the red bars represent mean borrowing rates. credit card rates are only included if the respondent has rolled over a nonzero balance from the previous month. people with no debt are excluded. bars represent the median value in each decile. this paper adds to several strands of literature. first, we contribute to the growing literature on the economic impact of covid-19 and evaluation of policies aimed at stemming it (baker et al., 2020; barrero et al., 2020; bartik et al., 2020; ganong et al., 2020; gormsen and koijen, 2020) . in a recent policy piece, biggs and rauh (2020) consider a related approach: allowing workers to access social security wealth today and delay retirement to repay these benefits. under current law, workers can offset a 1% cut in benefits by claiming benefits eight weeks later. we also add to the literature on the design of public savings programs. in the u.s. and many other countries, public savings are designed to be illiquid to supplement the private market for longevity insurance, plagued by adverse selection problems (abel, 1986; hosseini, 2015; eckstein et al., 1985) . in recent work, beshears et al. (2019) point out that illiquid retirement savings are optimal with households with present bias. they suggest a role for three distinct types of savings accounts: liquid savings, semi-liquid retirement accounts with withdrawals made at penalty, and fully illiquid accounts. we extend this literature by pointing out that the optimal mandatory savings rate could be countercyclical. practically, even if these three types of savings vehicles are firstbest, when nearly half of households lack any semi-liquid retirement savings, introducing some liquidity into the social security program may be beneficial. much work has advocated the provision of lumpsum benefits of social security wealth to discourage early retirement, noting households' preferences for one-time payouts that enable them to pay down mortgages or other debt (maurer et al., 2016; maurer and mitchell, 2018) . we build on this insight, suggesting that lump sum payments in this crisis would provide households a way to finance expenditure at record-low rates of interest. the remainder of our paper proceeds as follows. section 2 describes the social security program and our approach for valuing social security benefits, and estimates the consequences of early access to social security across the age distribution. section 3 compares this approach to other alternatives to increase households' liquidity, including tapping retirement accounts, stimulus checks, and extended unemployment benefits. section 4 concludes. in this section, we estimate how much can be paid immediately to households in exchange for a small cut in future social security benefits. because benefits are determined based on individuals' historical earnings, the present value of benefits depends on age and earnings trajectories. we estimate the market value of a benefit cut in two steps. first, we compute expected benefits by simulating earnings trajectories and applying the social security benefit formula, assuming all workers retire at full retirement age. 3 second, we discount expected benefits using the real yield curve 4 implied by treasury inflation-protected securities (tips) and taking into account the long run correlation between social security and stock market returns, following the approach of catherine et al. (2020) . to forecast benefits, we simulate earnings using the income process estimated in guvenen et al. (2019) . specifically, we assume that a worker i earnings at age t are: where l 1, t is the average wage in the economy and l 2, it represents the idiosyncratic component of earnings. the latter evolves as follows: level of idiosyncratic earnings : where z i is a component of earnings with persistence ρ and innovations drawn from a mixture of normal distributions. transitory shocks ε i also have a normal mixture distribution. finally, workers can experience a period of unemployment with probability p which depends on age, earnings and gender, and whose length follows an exponential distribution. we refer readers to guvenen et al. (2019) 's study for more details. social security benefits are computed in three steps. first, past taxable earnings are wage-indexed, which means that they are adjusted to reflect the growth in nominal wages up to the year a worker reaches age 60. in a second step, the average indexed yearly earnings ("aiye") is determined by averaging the best 35 years of indexed earnings. finally, benefits are computed as a concave function of the aiye. specifically, benefits equal the sum of 90% of the share of the aiye below the first social security "bend point" ($11,112 in 2019), 32% of the share aiye between the first and second bend point ($66,996) and 15% of the remaining part of the aiye. since the 1980's, these bend points have tracked the evolution of earnings, representing 0.21 and 1.25 times the national wage index l 1 . we assume that they will keep evolving that way. hence, the value of benefits is a piece-wise linear function of the aiye: where l 1, 60 is the level of wage index when a worker turns 60. we need to determine the present value of a stream of benefits protected against inflation, backed by the federal government and indexed on the national wage index. we define the present value of expected benefits as: where t is the maximum age, m ik is mortality at age k, and ψ s is the appropriate discount factor for benefits paid at age s. when discounting benefits, we take into account that wage indexation exposes the government to systematic risk because of the correlation between market returns and the wage index. this contemporaneous correlation is small but benzoni et al. (2007) argue that the labor and stock markets are cointegrated, which reduces the present value of benefits substantially (catherine, 2019; geanokoplos and zeldes, 2010) . to take this into account, we model the evolution of the log national index l 1 and the log cumulative market returns s t as in benzoni et al. (2007) : in these equations, μ − δ determines the unconditional log aggregate growth rate of earnings and v 1 its volatility. μ and σ s represent expected stock market log returns and their volatility. the state variable y t keeps track of whether the labor market performed better or worse than the stock market relative to expectations. finally, κ determines the strength of the cointegration between the labor and stock markets. in catherine et al. (2020) , we show that the market beta of a "wage bond" paying a single cash flow indexed to the value of l 1, n in n years is: and we demonstrate that, under the no-arbitrage condition, the expected return on such a bond is: where r is the risk-free rate. therefore, for workers below age 60, the appropriate discount factor for a benefit expected at age s is: where f k is the forward real interest rate between years k-1 and k. we calibrate the dynamics of idiosyncratic earnings using the benchmark estimation of guvenen et al. (2019) (see appendix table c .1). in catherine et al. (2020) , we use the same simulation strategy to estimate the value of future benefits, net of future payroll taxes, from 1989 to 2016. we validate this approach by showing that, when using the same macroeconomic assumptions, we can track very well the evolution of aggregate social security obligations reported by the office of the chief actuary of the ssa. moreover, we also show that our simulation produces full-retirement benefits that match those observed in the scf. finally, the income process estimated in guvenen et al. (2019) matches many moments of the cross-section and dynamics of earnings. we calibrate the model in section 2.2 as in benzoni et al. (2007) . these authors estimate κ=.16 and ϕ=.08 using us macroeconomic data from 1929 to 2004. this calibration implies a market beta of 0.5 for very distant social security benefits. we assume an equity premium of μ − r=0.06. we use the tips yield curve of april 2020 to compute forward interest rates. finally, we use the ssa wage growth projections from the 2019 report of the office of the chief actuary for the national wage index. 5 it is worth noting that our simulation does not take into account the effect of the covid downturn on wages. implicitly, we assume that, after the pandemic, labor market conditions will return to normal within a couple of years. there are two reasons we are skeptical the downturn will meaningfully impact our valuation of social security: first, at the individual level, since social security benefits are determined based on the best 35 years in the labor force, corona induced un-or under-employment should not impact benefits. second, at the more macro-level, even two years of 0% growth will decrease the market value of social security by at most 2%. we simulate past and future earnings for 800,000 workers per cohort, producing a cross-section of 36 million observations for the year 2020. the simulated dataset includes age, average past taxable earnings and the present value of expected benefits. we use this simulated data to estimate how much can be paid to workers today in exchange for a small cut in old-age benefits. our focus is on working age (20 to 61 year-old) individuals. the answer to this question is a function of workers' age and earnings histories. panel a of fig. 3 illustrates this fact. the present value of a 1% cut is highest for workers who are approaching retirement because they borrow against more imminent cash flows. in contrast, it is less significant for workers who have just entered the labor force and who will start repaying this loan in forty years. 6 but importantly, across the age and earnings distribution, just a 1% decrease in benefits significantly boosts liquidity by providing more than $2000 to the large majority of workers. in dual-earner households, the provision of liquidity would be twice as large. to illustrate this point another way, we consider what cut in benefits would be required to deliver workers $2500 today (fig. 3, panel b) , enough to finance roughly one month of consumption for the median household. for all but the lowest earners, the decrease in future benefits is minor: for 40 year old individuals earning the median income of around $34,000, a $2500 check represents between 0.8% (75th percentile) and 1% (25th percentile) of future benefits. it is worth noting that this is not the case for workers close to retirement with limited past earnings, for whom a $2500 check today could represent between 5 and 10% of future benefits. this is a population that has not accrued much social security wealth (e.g., because of little time spent in the workforce). we next quantify the magnitude of households' liquidity constraints and consider how they are exacerbated by covid-19. we then document the extent to which a small cut in future social security benefits redresses them. we compare this approach to already legislated household support: penalty-free access to retirement accounts, stimulus checks, and a significant expansion of unemployment benefits. we start by estimating how long it takes for households to run out of cash when they are on unemployment benefits. this depends on their liquid wealth, the generosity of unemployment benefits and their consumption level. we define the variable "days to shortfall" as: 5 appendix b.2 discusses the implications of alternative assumptions for the equity premium and wage growth. for workers nearing retirement, the implications of alternative parameters are not meaningful. for young workers they are significant. for example, at age 20, an 8% (4%) equity premium decreases (increases) the present value of future benefits by around 40% (30%). 6 the dynamics across the age and income distribution are of some interest. for workers with the lowest earnings, a 1% benefit cut is actually of higher value for younger workers than older ones. this is because young workers with low past earnings have the potential to (and in expectation, will) rise in the income distribution over their time in the labor force, whereas for older workers, their earnings history is now fixed. where the denominator represents daily expenditures minus insurance benefits. two categories of households are more likely to run out of cash faster: (i) those with rent and mortgage payments and (ii) those with low liquid wealth-to-earnings ratios. we build these variables using the 2016 scf, which provides detailed information on wealth, income, and expenditures by household. first, we assume that baseline unemployment insurance covers 50% of after-tax income. in reality, the benefit formula varies by state and takes into account workers' earnings and employment histories. because the scf does not provide geographic information about respondents, we are unable to compute replacement rates by state. however, our assumption is broadly consistent with the 45% average replacement rate reported by the department of labor for 2019. after-tax income is computed using the federal tax code and taking into account income, family composition and deductions. housing and fixed expenditures include rent, mortgage payments, property taxes, co-op, and mobile home fees, car lease payments, as well as other loan payments. the details of these expenses is reported in the scf. we assume that consumption of other goods and services represent 60% of after-tax income, which generate higher savings rates among higher earners, in line with prior work (dynan et al., 2004) . our calibration implies an average saving rate of 6%, which matches the aggregate personal savings rate over the last 20 years. 7 finally, liquid wealth is constructed as in bhutta and dettling (2018) and includes transactions accounts, certificates of deposit, mutual funds, stocks, and bonds. using these estimates yields a proxy of eq. (3.1) that can be observed in the data, which is the measure we use for the remainder of the paper. fig. 4 shows the share of households who can maintain their consumption up to 30, 60 or 90 days when unemployed, for each decile of marketable wealth. 8 unsurprisingly, wealthy households can afford to remain unemployed for longer. but the differences are stark: for those in the bottom three deciles of the marketable wealth distribution, more than 85% cannot cover three months of expenditures should they become unemployed. in the top decile, less than 5% face the same issue. age is an important explanation for this fact: workers who have just entered the labor force have yet to accumulate significant precautionary savings. in fig. 5 , panel a, we consider the implication of the counterfactual world in which aggressive stimulus efforts had not been undertaken to provide liquidity to households in need. we illustrate how our measure of days until cash shortfall is distributed throughout the population. importantly, we adjust the scf sample weights such that our sample is representative of workers who have lost their jobs as a consequence 7 we compare to the fred series psavert. we details the computation of after-tax income in appendix a.2, expenses in appendix a.3, and the relationship between earnings and saving rates in appendix b.4. 8 it is worth noting that there is evidence that households have cut normal times consumption during the covid-19 pandemic across the earnings distribution cox et al. (2020) . in appendix figure b .6, we adjust to reflect this, seeing how the days to shortfall change if non-committed spending falls to 50% of after-tax income (around a 17% drop from baseline levels). the headline takeaway is unchanged: more than 80% of those in the bottom three deciles of the wealth distribution are within three months of a cash shortfall, even if their consumption falls. of the coronavirus crisis as of march 2020. this is important, since covid-based unemployment is substantially likely to displace exactly those workers without private savings: already, estimates suggest that 40% of workers making $40,000 or less annually have lost their jobs because of the pandemic. 9 using data from the current population survey (cps) and the bureau of labor statistics (bls), we estimate the probability of becoming employed in that last six weeks as a function of industry, education, and age. we then adjust the scf weights by multiplying them by the model implied probability of unemployment and dividing by the mean of this variable. overall, american households do not have sufficient liquid savings to weather the covid-19 crisis. if displaced workers were only receiving unemployment benefits to supplement on average 50% of lost wages (as in normal times), more than 25% of working age households would not be able to meet their current expenditures after a month of unemployment, and 50% cannot last more than 75 days. what would be the effect of allowing households to borrow against 1% of scheduled social security benefits? to analyze the quantitative effects of this policy, we must estimate the present value of social security benefits for each household in the scf. to do this, we simulate a data set of 36 million individuals using the procedure described in section 2.1, which contains age, sex, the present value of future benefits, average past taxable wage earnings, and current wage earnings. we then match the scf to the simulated data by randomly assigning each individual in the scf to a simulated outcome with the same age, sex, and wage income. early access to 1% of social security benefits are a boon to the liquidity of the most vulnerable households, as illustrated in panel a of fig. 5 . with 1% of social security benefits today, the bottom 25% of the marketable wealth distribution would have an additional 85 days on average until they are no longer able to cover their current consumption, and the 25th percentile in terms of liquidity shortfall now has an additional two-and-a-half months of support, and the median is over three months. even this small cut in benefits supports more consumption than most of the alternatives already legislated, as discussed below. from an administrability standpoint, early access to 1% of social security benefits will pose challenges. this is because the government will have to arrive at estimates of earnings trajectories for individuals. although this paper provides a framework for how such estimation may take place, it is a difficult task and the administration of covid-related policies thus far raises questions of its feasibility. 10 a more easily implementable approach would be a one-time advance of future social security benefits: a $2500 check today would represent less than a 1% cut in future benefits for all but the very lowest earners (fig. 3, panel b) . this approach could also in principle be made optional without raising adverse selection concerns because the size of checks today would be unrelated to future benefits, so there would be no advantage for those who expect lower benefits in the future to disproportionately withdraw today. an added benefit of a $2500 check is this approach is untethered from the policy risk associated with the social security program. the most salient policy risk relates to the resolution of the social security funding, which we discuss in appendix b.3. congress' covid-19 stimulus package allows for penalty-free access to retirement accounts. this option is attractive to households: 30% of those with retirement accounts have already tapped them in the last two months, and, in april 2020, another 20% anticipate doing so in the near future (berger, 2020) . however, relative to a social security-based approach, this has a much more muted effect on household liquidity (panel b). under this policy, the bottom 25% of the marketable wealth distribution have an additional 29 days on average before they are no longer able to finance their consumption, and the 25th percentile has only 9 days of support. the median, however, gets 3 months of support. this is because the vast majority of workers made most vulnerable by the crisis do not have the funds in their retirement accounts to finance consumption today. as fig. 1 illustrates, only half of workers have a retirement account, and in the bottom decile of marketable wealth, only 31% have non-zero retirement savings. second, even for those who could gain liquidity by accessing retirement accounts, this requires liquidation of investment assets in the midst of a dramatic downturn (the s&p dropped by 16% in march alone). congress legislated a one-time issuance of $1200 covid-19 relief check for all individuals earning less than $75,000. 11 this approach does not boost household liquidity as much as providing 1% of social security benefits early: the median household receives $2200 from the stimulus, but $4200 from a 1% cut in future benefits. these stimulus checks also cost over $290 billion. 12 already, the consequences for the u.s. deficit of covid-19 spending are significant, with debt ballooning to over 100% of gdp (swagel, 2020) . there is widespread disagreement on the effect of large government debts and deficits in the economics literature (blanchard, 2019; rogoff, 2016) . given the low interest rate environment and lack of inflationary concerns, substantial focus on deficits might be misplaced. but it is worth noting that funding household consumption through social security is budget neutral and allows for liquidity constraints to be relaxed for a few months at least without increasing government liabilities. since the onset of the pandemic through the end of july, unemployment benefits were increased by an extra $600 weekly, costing the u.s. government $260 billion to provide. while the median household receives $600 per week, there are still a large plurality of households that need more than this to avoid a shortfall. for those in the 25th percentile, this proposal provides an additional 105 days of liquidity, 10 days more than what 1% of social security benefits delivers. but policy can be designed differently so that the social security approach delivers 11 we take into account that, for heads of households, this number is increased to $112,500, and for couples filing jointly, the amount is $150,000 for people making over this, the stimulus is gradually phased out. further, joint filers receive $2400 in stimulus plus an additional $500 for each qualifying dependent. details are provided in appendix a.6. 12 as estimated by the committee for a responsible federal budget (fink, 2020) . for more information, visit http://www.crfb.org/blogs/visualization-cares-act. time to shortfall is defined as liquid wealth divided by daily expenditures minus daily unemployment benefits, which we assume covers 50% of after-tax income. each bin represents a 5day increment and the graphs report the percentage of households who would run out of cash within these 5 days. the light blue bars in each graph show the no intervention case. panel a refers to the policy proposal of providing individuals checks equal to 1% of the present value of expected social security benefits. panel b shows the scenario in which workers can withdraw from their retirement accounts without penalty. panel c shows the effect of giving $1200 checks to households using the policy outlined in the cares act. panel d shows the results of $600 in extra unemployment insurance, as provided for by the cares act. the red, vertical lines represent the 25th percentile of the each time to shortfall variable. more, e.g. 2% of benefits today lengthens the time to cash shortfall by more than supplemental ui. unlike a social security-based approach, paying very high ui benefits introduces labor supply disincentives. recent work suggests that two-thirds of ui eligible workers are currently receiving benefits that exceed lost earnings and notes that such a significant expansion can impede reallocation responses needed to confront the covid-19 shock (barrero et al., 2020) . such concerns are consistent with a long literature the labor market impact of generous unemployment benefits, which can discourages workers from re-entering the workforce (fredriksson and holmlund, 2006; lalive et al., 2006; lentz, 2009) . however, there is evidence that generous ui during recessions is optimal (crépon et al., 2013 ). yet as the economy reopens, these issues may become more relevant. despite policies already enacted to support households, many will find themselves unable to meet their financial obligations in the coming months. for those without access to credit, the result will be delinquency on obligations like rent and mortgage payments, that could result in eviction or bankruptcy. for those with access to credit, borrowers (many subprime) will take out loans at private rates that are on average 80 times more costly (fig. 2) . recent proposals for the provision of liquidity through social security suggest that workers be given the option to withdraw a portion of future benefits. but this approach raises concerns about adverse selection: workers who anticipate lower benefits in the future may disproportionately choose to withdraw. a mandatory benefits cut, in contrast, does not undermine the provision of longevity insurance through social security, and it allows all households to benefit from low interest rates. those who need funds will have them; and those who do not, can save. one issue for policymakers to weigh is that the lump-sum payment of social security benefits will hasten the depletion of the social security trust fund by a few years. thus policymakers will be forced to weigh entitlement reform sooner. another potential concern with providing access to future social security benefits is that this decreases the funds they will have to finance consumption in retirement. indeed, today for the vast majority of americans these savings are their largest source of income after leaving the workforce. a key difference between a social security-based approach and other alternatives is its budget neutrality. a $2500 benefit check has no effect on government liabilities, as it can be financed by the issuance of bonds that are explicitly backed by a decrease in future social security benefits. this is in contrast to stimulus spending: the cares act required a budgetary outlay of $260 billion for 13 weeks of expanded unemployment insurance, and $290 billion for one-time checks to most families. while it is true that early access to retirement savings is also budget neutral, its ability to deliver liquidity to households is minimal, as described above. in the united states, social security wealth is designed to be illiquid to provide longevity insurance that safeguards retirees in old age. the result is that for most american workers, illiquid forced savings exceed the liquid wealth they have on hand to finance consumption shocks. but optimal illiquidity is time-varying, and in downturns like this current crisis, there is a case to be made for allowing workers to access their illiquid social security wealth. we illustrate the potential of this approach by carefully computing the market value of workers' social security benefits based on their age, earnings history, and estimated future earnings trajectories, adapting the approach of catherine et al. (2020) . we find that a minimal cut in scheduled social security benefits of just 1% is sufficient to finance household expenditure for two months. a related, and more administrable, alternative would be to provide workers their first $2500 in social security benefits today, which we show amounts to less than 1% of future benefits for nearly all workers. this provides more liquidity to households most vulnerable than alternative approaches already enacted, like penalty-free withdrawals from retirement savings accounts, and stimulus checks. it is also fiscally neutral and unlikely to introduce labor market distortions. capital accumulation and uncertain lifetimes with adverse selection covid-induced economic uncertainty covid-19 is also a reallocation shock how are small businesses adjusting to covid-19? early evidence from a survey portfolio choice over the life-cycle when the stock and labor markets are cointegrated 3 in 10 americans withdrew money from retirement savings amid the coronavirus pandemic -and the majority spent it on groceries the effect of automatic enrolment on debt money in the bank? assessing families' liquid savings using the survey of consumer finances funding direct payments to americans through social security deferral public debt and low interest rates report on the economic well-being of u.s. households in 2019, featuring supplemental data from labor market risk and the private value of social security social security and trends in inequality initial impacts of the pandemic on consumer behavior: evidence from linked income, spending, and savings data do labor market policies have displacement effects? evidence from a clustered randomized experiment do the rich save more? uncertain lifetimes and the welfare enhancing properties of annuity markets and social security stimulus checks cost $290 billion. a fraction of that could have changed response to coronavirus outbreak, experts say improving incentives in unemployment insurance: a review of recent research us unemployment insurance replacement rates during the pandemic market valuation of accrued social security benefits coronavirus: impact on stock prices and growth expectations the tips yield curve and inflation compensation what do data on millions of u.s. workers reveal about life-cycle earnings risk? ssrn electron adverse selection in the annuity market and the role for social security 35 million stimulus checks are still outstanding. what you need to know if you're waiting for your money how changes in financial incentives affect the duration of unemployment optimal unemployment insurance in an estimated job search model with savings evaluating lump sum incentives for delayed social security claiming accounting and actuarial smoothing of retirement payouts in participating life annuities are social security's actuarial adjustments still correct? progress and confusion: the state of macroeconomic policy tapping social security would be a big mistake top white house advisers, unlike their boss, increasingly worry stimulus spending is costing too much cbo's current projections of output, employment, and interest rates and a preliminary look at federal deficits for 2020 and 2021 supplementary data to this article can be found online at https://doi. org/10.1016/j.jpubeco.2020.104243. key: cord-297287-0i4nc353 authors: braun, benjamin; taraktaş, başak; beckage, brian; molofsky, jane title: simulating phase transitions and control measures for network epidemics caused by infections with presymptomatic, asymptomatic, and symptomatic stages date: 2020-09-10 journal: plos one doi: 10.1371/journal.pone.0238412 sha: doc_id: 297287 cord_uid: 0i4nc353 we investigate phase transitions associated with three control methods for epidemics on small world networks. motivated by the behavior of sars-cov-2, we construct a theoretical sir model of a virus that exhibits presymptomatic, asymptomatic, and symptomatic stages in two possible pathways. using agent-based simulations on small world networks, we observe phase transitions for epidemic spread related to: 1) global social distancing with a fixed probability of adherence. 2) individually initiated social isolation when a threshold number of contacts are infected. 3) viral shedding rate. the primary driver of total number of infections is the viral shedding rate, with probability of social distancing being the next critical factor. individually initiated social isolation was effective when initiated in response to a single infected contact. for each of these control measures, the total number of infections exhibits a sharp phase transition as the strength of the measure is varied. the sars-cov-2 virus that has spread throughout the globe has created societal disruption and had a massive impact on global health [1] . with no known treatment, public policy and human behavior are currently the only tools that are available to mitigate the spread [2] . a fundamental characteristic of sars-cov-2 is that after an individual is exposed, that individual passes through an extended presymptomatic stage followed by either an asymptomatic or symptomatic stage [3] . our goal in this work is to construct a theoretical network disease model with these qualities and investigate phase transitions associated with three types of control measures. while many models related to sars-cov-2 are designed to be forecasting tools, our study is intended as a contribution to the theoretical literature regarding qualitative aspects of control measures for viruses with these pathways of disease progression. in the specific case of sars-cov-2, one control measure that has been used is governmentmandated social distancing. different countries, and different states within the us, have implemented different approaches to this [2, 3] . while most government plans include some social distancing, questions have arisen as to the efficacy of social distancing, how long social distancing should last and to what extent it is needed [4] . a second control method involves individually-determined changes to social behavior, which work in concert with mandated social distancing to mitigate viral transmission [5, 6] . individuals who live with an infected individual are being asked or required to quarantine for 14 days prior to interacting in the larger society [7] . one question is whether these individual responses of behavioral modification are sufficient to moderate epidemic spread and whether there are additive or non-additive effects when implemented with top-down government policy on social distancing [5] . a third type of control measure involves use of personal protective equipment to reduce the rate of viral transmission. for example, mask usage has been found to be effective in this regard for sars-cov-2 [8] [9] [10] . these real-world aspects of sars-cov-2 highlight the need for a more thorough understanding of the general behavior of viruses exhibiting multiple progressions of disease development. with this as motivation, we develop a theoretical model in which we investigate how three types of control measures are associated with sharp phase transitions for the total number of infected individuals. while modeling contacts can be done in mean-field, statistical, and metapopulation sir models [1, [11] [12] [13] [14] , we use an agent-based model (abm) on watts-strogatz small world networks [15] [16] [17] . small world networks have connectedness properties that are found in real-world social networks and have been previously considered in epidemiological contexts [18, 19] . the first control measure in our abm is social distancing imposed on the network at a global scale. our model encodes this global social distancing as complete isolation of an agent from other agents. the likelihood of social distancing is applied uniformly to all agents. the second control measure arises when agents have social connections that are infected and symptomatic [2, 8] . in this case, agents temporarily isolate from their contacts in the network if they are in contact with a sufficient number of symptomatic agents. the third type of control measure is to alter the rate of viral spread, which reflects behavior such as use of personal protective equipment, e.g., masks [8, 10] . we examine how each of these measures alone and in concert with each other influence the viral outbreak. for each of these control measures, we ask the following questions: 1. how does varying the strength of the control measure impact the total number of infections in an epidemic? 2. if a control measure impacts the total number of infections, is there a phase transition associated with changes in strength of that control measure? 3. how do these three control measures interact regarding their impact on total number of infections? we develop an sir, network-based, agent-based model where agents pass through various infection states (fig 1) . agents pass through a presymptomatic infection state followed by either an asymptomatic infected stage or a symptomatic infected stage. in our model, each agent carries an individual pathogen level that changes in response to contact with infected agents. initially, this level is set to 0 pathogen units for susceptible agents. at each time step (conceived as a day), if a susceptible agent has no infected contacts then their pathogen level does not change. for each day that a susceptible agent has one or more infected neighbors, their pathogen level increases by a fixed fraction of the pathogen levels of their infected neighbors. there is a global infection threshold that applies to all agents, which we fix at 25 pathogen units; in other words, the day after the pathogen level for an individual agent exceeds 25 units, that agent enters the presymptomatic infected state. once an agent enters the infected state, their pathogen level stays constant until they have reached the resistant/removed state, at which point it is reset to 0 units. model runs are initiated with a small number of infected agents, whose pathogen levels are initially set at 35 pathogen units, and the remainder of the agents are initially deemed susceptible. these initial and threshold values for the pathogen levels in our model are not based on real-world data, but rather were selected for simplicity to investigate general behavior of phase transitions under a mechanism of viral shedding with individualized pathogen levels. because our model does not use a transmission probability for each contact, but rather a viral shedding rate where each individual agent has varying levels of pathogen load, this model is well-suited to abm simulations and less amenable to ode-based deterministic analysis. once the individual pathogen level for an agent exceeds 25 units, that agent enters a presymptomatic infection stage, followed by either a symptomatic or asymptomatic stage (fig 1) . the length of the presymptomatic stage is the same for all agents, and can be set to last one or more days. the lengths of the two possible main infection stages are set independently from each other, but are the same for all agents. following the main infection stage, the agent is either resistant or removed. in addition to the infection stages, each agent is in one of two daily behavior states: socially distanced or not socially distanced. the behavior state is reset each day. if an agent is not socially distanced on a given day, then that agent can interact with any neighboring agent. if an agent is socially distanced, the agent does not interact with any neighboring agents; in our theoretical model, social distancing is equivalent to self-quarantine. agents socially distance in a given day for one of two reasons. a global social distance probability is set, which determines the chance that an agent will socially distance on a given day. a local social distance threshold is set, and this value dictates individual responses to infected symptomatic neighbors. if the number of infected symptomatic neighbors of an agent equals or exceeds this threshold, the agent will social distance independently of the global parameter. this local threshold is the same for all agents. we implement our agent-based model on watts-strogatz (ws) networks. the ws networks can simultaneously demonstrate both high clustering and short average path length, and thus serve as effective approximations of social networks that are neither completely random nor regular [15] . high clustering and short average path length allow for local interactions and more distant interactions to be incorporated [16, 17, 20] , which are properties often found in real-world networks. the ws small world network in our model is characterized by three parameters: number of nodes n, average node degree k and rewiring probability. the rewiring parameter is used to determine the likelihood of rewiring each edge starting from a regular ring lattice. a rewiring parameter of 0 preserves the original ring lattice; a rewiring parameter of 1 simulates a random network. we fix the number of nodes n = 500 and the average degree k = 20, which allows ln(n) � k � n. we then vary the rewiring probability among the values {0.05, 0.10, 0.25, 0.50}. for each of our four rewiring probabilities we construct 10 networks on which to run simulations. we define our three model parameters as follows: 1. social distance probability: the probability that an agent is socially distancing on any given day. 2. social distance threshold: the minimum number of infected symptomatic contacts required to cause an agent to social distance for that day. 3. viral shedding: the fraction of individual pathogen level that an infected agent passes to each of its contacts. we ran two sets of simulations over different parameter spaces. our primary simulation ran through ten networks for each set of parameters given in table 1 . based on the results of this primary simulation, we ran a secondary set of simulations over the refined parameter space given in table 2 to provide a more detailed analysis of the phase transition behavior observed in the primary simulations. the parameters for the secondary simulation were selected based on our analysis of the primary data using regression trees to identify critical variables and on the observed ranges where phase transitions were observed. we used a regression tree to partition the variation in final number of infected nodes across model parameters and runs in our primary simulation [21] . reductions in viral shedding were associated with the primary partition in the regression tree in fig 2. viral shedding below 15% compared to a value of 25% were associated with a mean number of infections of 46 out of 500 agents. reduced viral shedding with social distancing probability over 25% led to overall infection of approximately 2% of the agents. if the overall viral shedding is reduced dramatically to 5%, even without additional social distancing of any type, less than 1% of the population becomes infected. achieving low levels of infections in populations without reducing viral shedding requires significantly higher levels of global social distancing, where each agent has at least a 75% chance of social distancing each day; this results in an approximately 1% infection rate among agents. if each agent has less than a 75% chance of social distancing each day, the total infection rates for the populations are much higher; these range from a low of 21% (if individuals phase transitions and control measures for network epidemics self-isolate in response to one infected social contact) all the way up to 97% with low levels of any type of social distancing. thus, with a higher level of viral shedding, it becomes important to have agents self-isolate when a contact becomes symptomatic. even if this occurs, the infection rate in the population is an order of magnitude higher (10% vs. 1%) than if the viral shedding is reduced. failure to achieve this strict social distancing in response to an infected social contact results in a widespread outbreak with approximately 62% of the agents infected. because our goal is to understand the behavior of phase transitions regarding total number of infections in our model, we conducted secondary simulations on a refined parameter space based on the results of our regression tree analysis. in these simulations, we observed sharp phase transitions in the total number of infections as a function of all three control methods. these transitions are shown in figs 3, 4 and 5. in these figures, the maximum number of possible infections is 500, as there are 500 nodes in our networks. in fig 3, a phase transition exists between viral shedding of 5% and 10%, across all levels of social distance thresholds and social distance probabilities. in fig 4, a phase transition exists at a social distance threshold of 1, across all levels of social distance probabilities and viral shedding. if the social distance threshold parameter is 2 or more, then it is possible to have epidemics that infect the entire population. in fig 5, a phase transition exists around a social distance probability of 73-74%, across all levels of social distance threshold and viral shedding. if the social distance probability is 74% or more, then our simulations end with a small number of infected agents. phase transitions and control measures for network epidemics given the regression tree analysis of our primary simulations, it is clear that viral shedding and social distance probability play key roles. in our secondary simulations over a refined parameter space, this becomes more clear. in fig 6, we observe additional confirmation of the regression tree findings that the main driver of total number of infections is the viral shedding rate, with social distance probability being the next critical factor. specifically, simulations with large total infections cluster to the upper left of the plot, where viral shedding rates are higher and social distancing is enacted by approximately 60% of agents. there is also a clear interaction between the social distance probability and viral shedding parameters and the resulting number of infected agents and the length of the epidemic. these interactions are shown in figs 7 and 8. in fig 7, there is clustering of long epidemics when the probability is near 60% and the viral shedding rate is high. as the social distance probability increases to 80% and the viral shedding rate decreases, there is a phase transition where simulations result in outbreaks of short duration. in fig 8, most infections result in either a limited outbreak (less than 125 out of 500 agents) or almost all agents infected. as the social distance probability is increased from 60% to 80%, the length of the epidemics increase while remaining limited in total number of infections before sharply transitioning to a high number of infections during a return to short epidemic lengths. mathematical modeling can provide tools to better understand epidemic dynamics and can vary from purely theoretical to more data driven and predictive [22] . while a simple model such as this one should not be used to make policy recommendations, it can provide a framework for empirical investigation and specific hypothesis testing related to social networks of smaller size exhibiting small world characteristics, such as those seen in college settings [23] . here we use our theoretical model to investigate how different control methods impact the total number of infections in an epidemic on a network caused by a virus with a presymptomatic stage and both asymptomatic and symptomatic pathways. we specifically examine three main control measures that can be taken to reduce epidemic spread: 1) global social distancing with a fixed probability of adherence. 2) individually initiated social isolation when a threshold number of contacts are infected. 3) reduction of viral shedding. we observe sharp phase transitions in the total number of infected agents as the strength of each of these control measures are varied. to examine the full potential for global social distancing, we consider a wide range of possible scenarios varying from no social distancing to strong adherence to social distancing (90% of agents). when considering the relationship between our theoretical model and real-world contexts, the two extreme scenarios are easy to envision (zero social distancing is business as usual and 90% is all but non-essential businesses closed), while more moderate social distancing scenarios are harder to translate into direct societal actions. nevertheless, we observe in our small-world models a clear phase transition associated with global social distancing. in general, a global social distancing probability below 65% results in a wide-spread epidemic, while a global social distancing probability above 75% limits the epidemic to a dramatically lower number of total infections. we also found that social distance probabilities that approached the threshold from below resulted in prolonged epidemics while with low overall infection rates. for our secondary simulations over a refined parameter space, in the absence of other control measures we observe that there is a phase transition for total infections that occurs as the percentage of agents socially distancing changes from 73% to 74%. individual behavior taken during a pandemic can greatly affect the dynamics of disease spread. for example, for sars-cov-2, the most commonly recommended guideline after contact with an infected individual is 14 days of self-isolation to avoid exposing other individuals [5, 7, 24] . however, despite these official guidelines, self-isolation following exposure requires that infected individuals inform their contacts and that exposed individuals voluntarily comply. thus, from a theoretical perspective it is important to understand how different self-isolation behaviors following contact with an infected agent impact epidemic spread. in our model, we consider self-imposed social distancing as highly responsive to an agent's short-term perceptions regarding infection risks within their community. thus, self-imposed social distancing/isolation occurs only on the days when the agent has sufficiently many symptomatic contacts in the network. interestingly, for self-isolation to significantly decrease the total number of infections in our model, an extreme level of responsiveness was needed by the agents involved; in our model, it was necessary for self-isolation to occur following exposure to only one infected agent. if self-isolation occurred only after contact with two or more symptomatic agents on the same day, the effect on disease spread was minimal. our findings also support the well-known fact that real-world contact tracing following an individual's positive test is critical for limiting the spread of the infection [4] . an important difference between our theoretical model and viruses such as sars-cov-2 [13, 25] is that, in the real world, individuals who have come in contact with an infected individual are not aware of their exposure. our theoretical reduction of viral shedding is motivated by behaviors such as mask wearing or other use of personal protective equipment [10] . while in real-world contexts individual responsiveness to recommended government actions are highly variable [24] , a decrease in viral shedding rate can be achieved through use of protective equipment [9] . when the viral shedding in our model was set at a high shedding rate of 25%, global social distancing was required to be greater than 80% to control the outbreak, resulting in an approximately 1% infection rate in the population. other less stringent social distancing conditions result in a viral infection rate between 25% and 97.5%. with a moderate rate of viral shedding, the social distance threshold at which someone decides to self-isolate after coming into contact with an infected individual becomes much more important. in our model, if the social distance threshold is set to 1 (agents self-isolate after coming into contact with at least one infected agent), then the final total infection rate in the population is approximately 12%. however, if the behaviorally induced social distancing does not take place or takes place at a higher threshold, then the total number of infections is much larger with the overall infection rate in the population approximately 62%. if the viral shedding rate is very low, then the epidemic does not spread and a low total number of infections is observed. thus, there is a sharp phase transition as the viral shedding rate moves from 5% to 10%. an important observation regarding these phase transitions is the relatively extreme values at which they occur, e.g., a high social distancing probability, a low social distancing threshold, and a low viral shedding rate. these values are very high and low both within the context of our model and of real-world epidemics that motivate our model. it would be of interest to investigate whether or not, given an arbitrary set of values, a specific network and selection of parameters could be found for which phase transitions occur near these values. alternatively, if no such network and choice of parameters exist, it would be of interest if a more rigorous theoretical description could be given of the mechanism preventing this occurrence. we develop an agent-based model of epidemic spread on watts-strogatz small world networks, where infected agents pass through a presymptomatic stage followed by either an asymptomatic or symptomatic stage. we consider the impact of three control measures on the total number of infected agents, with regard to both phase transitions and efficacy. the three control methods we consider all generate sharp phase transitions in the total number of infections as the strength of the method varies. social distancing controls in this model exhibit a phase transition regarding total number of infections, either when imposed globally or when based on individual response to infected contacts. individually-enacted social distancing in the form of temporary self-isolation must be immediately enacted if a social contact is known to be infected in order to halt the spread of an epidemic. reductions in viral shedding lead to significant reductions in the size of the final infected population. forecasting the novel coronavirus covid-19 time-to-death approach in revealing chronicity and severity of covid-19 across the world covid-19: the cidrap viewpoint part 1: the future of the covid-19 pandemic: lessons learned from pandemic influenza feasibility of controlling covid-19 outbreaks by isolation of cases and contacts. the lancet global health using social and behavioural science to support covid-19 pandemic response changes in risk perception and protective behavior during the first week of the covid-19 pandemic in the united states the psychological distress and coping styles in the early stages of the 2019 coronavirus disease (covid-19) epidemic in the general mainland chinese population: a web-based survey behavioural change models for infectious disease transmission: a systematic review & covid-19 systematic urgent review group effort (surge) study authors physical distancing, face masks, and eye protection to prevent person-to-person transmission of sars-cov-2 and covid-19: a systematic review and meta-analysis (2020) journey through an epidemic: some observations of contrasting public health responses to sars analysis and forecast of covid-19 spreading in china a simple sir model with a large set of asymptomatic infectives geo-temporal distribution of 1,688 chinese healthcare workers infected with covid-19 in severe conditions-a secondary data analysis machine learning using intrinsic genomic signatures for rapid classification of novel pathogens: covid-19 case study collective dynamics of 'small-world'networks classes of small-world networks disease transmission in territorial populations: the small-world network of serengeti lions network-based analysis of stochastic sir epidemic models with random and proportionate mixing coupled contagion dynamics of fear and disease: mathematical and computational explorations the watts-strogatz network model developed by including degree distribution: theory and computer simulation rpart: recursive partitioning and regression trees mathematics of epidemics on networks the small world network of college classes: implications for epidemic spread on a university campus perceptions of the adult us population regarding the novel coronavirus outbreak data-based analysis, modelling and forecasting of the covid-19 outbreak this project began during the workshop "understanding and exploring network epidemiology in the time of key: cord-331331-xcfk4efo authors: goldman, d. title: voluntary cyclical distancing: a potential alternative to constant level mandatory social distancing, relying on an 'infection weather report' date: 2020-05-06 journal: nan doi: 10.1101/2020.05.02.20084947 sha: doc_id: 331331 cord_uid: xcfk4efo covid-19 has significantly changed our daily lives. stay-at-home orders and forced closings of all non-essential businesses has had a significant impact on our economy. while it is important to ensure that the healthcare system is not overwhelmed, there are many questions that remain about the efficacy of extreme social distancing, and whether there are alternatives to mandatory lockdowns. this paper analyzes the utility of various levels of social distancing, and suggests an alternative approach using voluntary distancing informed by an infectious load index or 'infection weather report.' the outbreak of sars-cov-2 has caused a lot of changes in our daily lives. when policy makers around the world realized the threat of covid-19, they began crafting guidance, and eventually started issuing stay-at-home orders. these orders have created significant economic disruption, and disruption to peoples' lives. and there has been a question of how long they can be maintained. already, lock-down orders are being lifted, at least in part, in some locations. but the question remains of what to do next, both in terms of dealing with the spread of sars-cov-2, and handling any future outbreaks of this nature. many of us are familiar with the catchphrase "flatten the curve." the idea is that social distancing will reduce the rate at which the infection spreads, and thus reduce the burden on the healthcare system. however, these lockdown orders cannot be maintained indefinitely. one has to wonder how a premature end to a lockdown might impact the spread of the infection, and if there are any alternatives to such measures, and whether they might be more effective. this paper has two goals. the first goal is to compare a number of modified seir models, in order to identify possible outcomes associated with the current lockdown efforts. the second goal is to identify potential ways to improve efforts to reduce the spread of both sars-cov-2, and infectious disease overall. the models in this paper rely on empirically estimated parameters, and take into account a number of factors, including social distancing, stratification of risk groups and hospital capacity. it then compares models in which a constant level of social distancing for a fixed period of time with modulated social distancing based on voluntary activity informed by disease surveillance. the core of these analysis is the seir compartmental model. many alterations to the basic model have been made. there are two copies of each compartment, one for low risk individuals such as young people with minimal comorbidities, and one for high risk individuals such as the elderly and people suffering from various diseases or are otherwise in significantly poor health. for simplification, the focus for risk was on age. mortality rates were also considered. the core model for each set of compartments is defined as follows: here β is the product of the contact and transmission rates. α is the reciprocal of the incubation period, γ is the reciprocal of the clearing period post onset of symptoms, and µ is the mortality rate. and ρ is the adjustment to the contact rate, due to social distancing. each of these cells are duplicated into a low risk and high risk set. for social distancing, it is assumed that there will be a greater amount of social distancing within the high risk population and between the low and high risk populations. approximation of basic parameters comes from a number of sources. according to peng et al. 2020 , the latent time period, or the time it takes for a person to transition from exposed to infected, is approximately two days, giving α = 0.5 [6] . the analysis also suggests that every contact is almost guaranteed to result in an infection: β ≈ 1. because the model used in peng et al. 2020 was complicated and did not calculate the unaided clearing of the infection, approximations from another source were used. d'arienzo and coniglio 2020 suggest that even in italy where there is a significant covid-19 burden, the basic reproduction number is between 2.43 and 3.10, which yields a range of 0.32 and 0.41 and for γ [3] . while β is approximated as 1, it is unlikely that the contact rates of individuals within the same age group is equal to the contact rate of individuals between the two groups. it is likely that within-group contact rate is higher than average, and that the between-group contact rates are lower than average. people within the high risk group are also more likely in general to maintain social distancing, and so this idea is also considered in approximating β for each type of interaction. values were chosen s.t. the population weighted average summed to 1. it was assumed that 84% of the population was in the low risk group and 16% was in the high risk group, and that there was one initial infection within each sub-population. this assumption is based on the fraction of the united states population aged 65 or older in 2018 [7] . the united states population was slightly under 330m in 2018, so 330m was chosen for n [8] . hospital bed capacity is estimated based on figures from covidactnow. the model assumes that there are roughly enough hospital beds for 0.22% of the population, with 60% capacity, and an emergency capacity build of roughly 200% [5] . as a conservative estimate, 0.1% was chosen for the capacity limit. infection and case fatality rates are highly dependent on a number of factors and vary based on the quality of the health care system, the age of the patient, and comorbidity. mortality seems to be orders of magnitude higher in at risk populations compared to low risk populations. covidactnow estimates a case fatality rate of 1.1% with an additional 1% if hospitals are overburdened [5] . however, it does not stratify by risk group. the base model starts with the assumption that the case fatality rate is 0.1% for low risk populations and 10% for high risk populations. assuming that being over-capacity increases the risk of death among the low risk population by 50% and the high risk by 200%, that would yield a case fatality rate of 0.15% and 30% respectively. the 50% figure is still higher than the relative risk at 10 days, for general er visits, but within the 95% ci of 1.04-1.72 [9] . however, not every infection meets the criteria of being a case. there are many asymptomatic and subclinical infections for sars-cov-2. by one estimate, the number of infections was 50 to 85 times higher than the reported number of cases [1] . however, it's quite possible that a number of those infections resulted in deaths that were not reported. furthermore, since it is more likely that high risk individuals are more likely to show dangerous symptoms, and their status as being high risk yields a greater rate of testing, the mortality rates of the high risk group received a smaller adjustment. low risk mortality rates were divided by 20 and high risk mortality rates were divided by 5. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 6, 2020. a number of analyses were performed. first, it seemed useful to simulate how different levels of social distancing impacted the progression of the epidemic, when social distancing is maintained for a fixed period time period of sixty days, with initial onset 60 days after the first infection, representing lag between initial discovery of the disease and decision to engage in mandatory social distancing. for social distancing parameters ranging from 0.1, representing extreme social distancing, to 1, representing no social distancing, a social distancing parameter of 0.65 appeared most effective, with an approximate reduction in mortality 5 . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 6, 2020. . of 40%. a social distancing coefficient of less than 0.65 caused an uptick in mortality rates from that low. the minimum estimated mortality rate, for the entire progression of the epidemic was approximately 0.0062 or 620 per 100,000. for the united states, that would imply a final death toll of approximately 2 million under moderate social distancing, and 3.3 million without any social distancing. each time step represents 0.1 days. at the start of the outbreak, there is a significant reduction in infections and deaths, but there is a spike in both shortly after the end of the social distancing effort. rather than flattening the curve, the more extreme social distancing measures appear to delay the peak, allowing "pressure" to build up due to a high reserve of susceptible individuals. in order for more extreme continuous social distancing measures to be effective, they would therefore have to be maintained until an alternative, such as a vaccine, is produced. as early as the beginning of april, it became apparent that a one time social distancing effort may be not be enough to cope with the covid-19 epidemic [4] . however kissler et al. 2020, while recognizing this issue, did not seek to establish a specific protocol for when social distancing should be engaged and 6 . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 6, 2020. . disengaged [4] . assuming that it is possible to obtain reasonably high resolution data for a region, the public health community should be able to put out daily and weekly advisories. these advisories can be used to promote voluntary social distancing, during periods of high levels of infectious load. because the social distancing measures would be temporary, and because there would be less uncertainty, because of the clear conditions for distancing recommendations, a slightly more extreme level of social distancing should be possible, so a ρ = 0.5 was chosen. a threshold of 0.0005 for the 7 day moving average of infections was chosen, because it was half the estimated maximum safe load that hospitals could handle. furthermore, because reports of low infectious load could yield a false sense of safety, ρ = 1.05 was chosen during periods when social distancing was not engaged. the graphical results are detailed in the following figure. the results of the analysis are interesting. voluntary cyclical social distancing, using the parameters chosen, results in a significantly extended curve. it takes around 1,200 days for the infection to fully burn itself out under this scenario. however, mortality rates are also much lower under this scenario, with the final mortality rate coming in at roughly 0.0047 or 470 per 100,000 people. in this model, there was no fixed time at which social distancing was expected to start. however, it took roughly 62 days for the infectious load to build enough to trigger the first distancing event, which is on par with the first model. all together, there were 39 periods of social distancing, with the last ending roughly 911 days after the initial infection. feasibility depends on a number of factors, including the ability to collect sufficient data to generate infectious load indices for a desired geographic scale, and the ability to actually engage in social distancing on a voluntary basis. one question is whether we can collect enough information to create such an infectious disease index. while it would take a number of years to create a robust 7 . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 6, 2020. index that can be used in general cases, there should be no issue with creating an index specific to covid-19. while it is true that a lot of countries, especially the united states, are unable to test anywhere close to every individual, random sampling can give us a significant amount of information on infectious load. such random sampling requires a fraction of the number of tests that are needed to identify and isolate every infection. with random sampling, integrated with other data gathering techniques, it is possible to have a fairly reasonable understanding of the progression of this epidemic. much of the determination of cost effectiveness and ability to report will depend on the level of resolution we wish to have. if the goal is to have a composite state-wide infection index, fewer tests will be needed per day. creating a county level index would be significantly more expensive. by reporting information to the population, we can alter behavior so that voluntary social distancing can be modulated as infection dynamics change. this modulation while extending the duration of the infection, significantly flattens the curve, without mandatory stay-at-home orders. this flattening significantly extends the duration of the pandemic, but reduces the burden on the healthcare system and reduces the overall mortality rate. additionally, given the level to which the epidemic period is lengthened, such measures would give time to produce treatments and prophylactics. in this analysis, the initial length of time to bring the infection rate below threshold, and thus end the first social distancing event was slightly greater than 90 days, which is significantly longer than the 60 day social distancing measure used in the first simulation, and likely a bit longer than the length of time for which social distancing measures will be in place for covid-19, at least during the initial wave. however, current lockdown measures are driving the social distancing coefficient, ρ, well below 0.5, which is far more extreme, and which cannot be maintained for as long a period of time. regarding the model which uses a single level of social distancing for a fixed period of time, it is concerning that the optimal social distancing coefficient is 0.65, which is likely far below the current level of social distancing, caused by the forced shutdown of all "non-essential" operations. while such extreme social distancing may be useful if limited to those within the at risk group, and between low and high risk groups, it does not seem appropriate for the general population. there are a number of assumptions about parameter estimates that were made to test these models. in particular, the mortality rates for low and high risk populations are rough estimates. however, while they will alter the specific values in terms out fatality outcome, they should have little impact on the progression of the infection itself. still, additional research into the case, and infection mortality rates, and greater stratification of risk levels would help 8 . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 6, 2020. . give a better picture of potential outcomes and efficacy of existing and future solutions. improvements to this model however could be made. additional stratification is possible, and empirical estimates of actual contact rates could be calculated with future research. research by chitnis et al. 2013 may be of interest, as it looks at a highly stratified population and uses empirical estimation of heterogeneous mixing between age groups [2] . guesses in this area is likely to have some effect on the optimal social distancing level. but again, it should not impact the comparison between the fixed and cyclical distancing models to any significant extent. while elements of this model are specific to sars-cov-2, the general dynamics would still apply to other infections. with a little bit of time and resources applied to the problem, a general reporting system for infectious disease could be implemented. this system could be used to help reduce the severity of flu seasons, and during future epidemics. such infection weather reports, so to speak, could become part of the new normal. moreover, this system could be especially useful if the covid-19 epidemic enters a seasonal pattern due to limited generation of immunity, which is a concern that has been voiced [4] . regarding the ability to actually engage in voluntary social distancing, a major concern is the ability to take off from work. if social distancing efforts needed to be extreme and extended for a long period of time, this issue would be more problematic. given the reliance on our job, and the general inability to take off of work for extended periods of time to recover, this issue applies to situations outside of covid-19 as well. anyone who feels sick, especially if they have a fever, cough, or other symptoms of a potentially infectious disease, should engage in social distancing. however, financial needs often override wisdom and public safety guidelines. however, given that simply reducing the average contact rate by 50% is enough to significantly reduce the rate of spread of the infection, a few minor decisions are all it would take. moderately reducing frequency and lengths of outings, and being increasingly aware of one's surroundings are all it would take to significantly reduce average contact rate. it is also likely that during periods where there are reports of high levels of infectious load, employers would be more willing to let an employee stay home and or cut back services. finally, research should be conducted into creating a composite index rather than trying to produce an index for a single pathogen. analyzing the utility and efficacy of such a composite index will be far more complicated, as it would require the incorporation of numerous pathogens. however, because the public health system would not be seeking to limit a single infection but rather the bulk of infections, it might actually be easier to produce an effective index for an aggregate. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may 6, 2020. . https://doi.org/10.1101/2020.05.02.20084947 doi: medrxiv preprint covid-19 antibody seroprevalence mathematical models of contact patterns between age groups for predicting the spread of infectious diseases assessment of the sars-cov-2 basic reproduction number, r0, based on the early phase of covid-19 outbreak in italy projecting the transmission dynamics of sars-cov-2 through the postpandemic period master covidactnow covid-19 model -google drive epidemic analysis of covid-19 in china by dynamical modeling population ages 65 and above for the united states (sppop65uptozsusa) -fred -st. louis fed population ages 65 and above for the united states (sppop65uptozsusa) -fred -st. louis fed increase in patient mortality at 10 days associated with emergency department overcrowding key: cord-356353-e6jb0sex authors: fourcade, marion; johns, fleur title: loops, ladders and links: the recursivity of social and machine learning date: 2020-08-26 journal: theory soc doi: 10.1007/s11186-020-09409-x sha: doc_id: 356353 cord_uid: e6jb0sex machine learning algorithms reshape how people communicate, exchange, and associate; how institutions sort them and slot them into social positions; and how they experience life, down to the most ordinary and intimate aspects. in this article, we draw on examples from the field of social media to review the commonalities, interactions, and contradictions between the dispositions of people and those of machines as they learn from and make sense of each other. a fundamental intuition of actor-network theory holds that what we call "the social" is assembled from heterogeneous collections of human and non-human "actants." this may include human-made physical objects (e.g., a seat belt), mathematical formulas (e.g., financial derivatives), or elements from the natural world-such as plants, microbes, or scallops (callon 1984; latour 1989 latour , 1993 . in the words of bruno latour (2005, p . 5) sociology is nothing but the "tracing of associations." "tracing," however, is a rather capacious concept: socio-technical associations, including those involving non-human "actants," always crystallize in concrete places, structural positions, or social collectives. for instance, men are more likely to "associate" with video games than women (bulut 2020) . furthermore, since the connection between men and video games is known, men, women and institutions might develop strategies around, against, and through it. in other words, techno-social mediations are always both objective and subjective. they "exist … in things and in minds … outside and inside of agents" (wacquant 1989, p. 43) . this is why people think, relate, and fight over them, with them, and through them. all of this makes digital technologies a particularly rich terrain for sociologists to study. what, we may wonder, is the glue that holds things together at the automated interface of online and offline lives? what kind of subjectivities and relations manifest on and around social network sites, for instance? and how do the specific mediations these sites rely upon-be it hardware, software, human labor-concretely matter for the nature and shape of associations, including the most mundane? in this article, we are especially concerned with one particular kind of associative practice: a branch of artificial intelligence called machine learning. machine learning is ubiquitous on social media platforms and applications, where it is routinely deployed to automate, predict, and intervene in human and non-human behavior. generally speaking, machine learning refers to the practice of automating the discovery of rules and patterns from data, however dispersed and heterogeneous it may be, and drawing inferences from those patterns, without explicit programming. 1 using examples drawn from social media, we seek to understand the kinds of social dispositions that machine learning techniques tend to elicit or reinforce; how these social dispositions, in turn, help to support 1 according to pedro domingos's account, approaches to machine learning may be broken down into five "tribes." symbolists proceed through inverse deduction, starting with received premises or known facts and working backwards from those to identify rules that would allow those premises or facts to be inferred. the algorithm of choice for the symbolist is the decision tree. connectionists model machine learning on the brain, devising multilayered neural networks. their preferred algorithm is backpropagation, or the iterative adjustment of network parameters (initially set randomly) to try to bring that network's output closer and closer to a desired result (that is, towards satisfactory performance of an assigned task). evolutionaries canvas entire "populations" of hypotheses and devise computer programs to combine and swap these randomly, repeatedly assessing these combinations' "fitness" by comparing output to training data. their preferred kind of algorithm is the so-called genetic algorithm designed to simulate the biological process of evolution. bayesians are concerned with navigating uncertainty, which they do through probabilistic inference. bayesian models start with an estimate of the probability of certain outcomes (or a series of such estimates comprising one or more hypothetical bayesian network(s)) and then update these estimates as they encounter and process more data. analogizers focus on recognizing similarities within data and inferring other similarities on that basis. two of their go-to algorithms are the nearest-neighbor classifier and the support vector machine. the first makes predictions about how to classify unseen data by finding labeled data most similar to that unseen data (pattern matching). the second classifies unseen data into sets by plotting the coordinates of available or observed data according to their similarity to one another and inferring a decision boundary that would enable their distinction. machine learning implementations; and what kinds of social formations these interactions give rise to-all of these, indicatively rather than exhaustively. our arguments are fourfold. in the first two sections below, we argue that the accretive effects of social and machine learning are fostering an ever-more-prevalent hunger for data, and searching dispositions responsive to this hunger -"loops" in this paper's title. we then show how interactions between those so disposed and machine learning systems are producing new orders of stratification and association, or "ladders" and "links", and new stakes in the struggle in and around these orders. the penultimate section contends that such interactions, through social and mechanical infrastructures of machine learning, tend to engineer competition and psycho-social and economic dependencies conducive to evermore intensive data production, and hence to the redoubling of machine-learned stratification. finally, before concluding, we argue that machine learning implementations are inclined, in many respects, towards the degradation of sociality. consequently, new implementations are been called upon to judge and test the kind of solidaristic associations that machine learned systems have themselves produced, as a sort of second order learning process. our conclusion is a call to action: to renew, at the social and machine learning interface, fundamental questions of how to live and act together. the things that feel natural to us are not natural at all. they are the result of long processes of inculcation, exposure, and training that fall under the broad concept of "socialization" or "social learning." because the term "social learning" helps us better draw the parallel with "machine learning," we use it here to refer to the range of processes by which societies and their constituent elements (individuals, institutions, and so on) iteratively and interactively take on certain characteristics, and exhibit change-or not-over time. historically, the concept is perhaps most strongly associated with theories of how individuals, and specifically children, learn to feel, act, think, and relate to the world and to each other. theories of social learning and socialization have explained how people come to assume behaviors and attitudes in ways not well captured by a focus on internal motivation or conscious deliberation (miller and dollard 1941; bandura 1962; mauss 1979; elias 2000) . empirical studies have explored, for instance, how children learn speech and social grammar through a combination of direct experience (trying things out and experiencing rewarding or punishing consequences) and modeling (observing and imitating others, especially primary associates) (gopnik 2009 ). berger and luckmann (1966) , relying on the work of george herbert mead, discuss the learning process of socialization as one involving two stages: in the primary stage, children form a self by internalizing the attitudes of those others with whom they entertain an emotional relationship (typically their parents); in the secondary stage, persons-in-becoming learn to play appropriate roles in institutionalized subworlds, such as work or school. pierre bourdieu offers a similar approach to the formation of habitus. as a system of dispositions that "generates meaningful practices and meaning-giving perceptions," habitus takes shape through at least two types of social learning: "early, imperceptible learning" (as in the family) and "scholastic...methodical learning" (within educational and other institutions) (bourdieu 1984, pp. 170, 66) . organizations and collective entities also learn. for instance, scholars have used the concept of social learning to understand how states, institutions, and communities (at various scales) acquire distinguishing characteristics and assemble what appear to be convictions-in-common. ludwik fleck (2012 fleck ( [1935 ) and later thomas kuhn (1970) famously argued that science normally works through adherence to common ways of thinking about and puzzling over problems. relying explicitly on kuhn, hall (1993) makes a similar argument about elites and experts being socialized into long lasting political and policy positions. collective socialization into policy paradigms is one of the main drivers of institutional path dependency, as it makes it difficult for people to imagine alternatives. for our purposes, social learning encapsulates all those social processes-material, institutional, embodied, and symbolic-through which particular ways of knowing, acting, and relating to one another as aggregate and individuated actants are encoded and reproduced, or by which "[e]ach society [gains and sustains] its own special habits" (mauss 1979, p. 99) . "learning" in this context implies much more than the acquisition of skills and knowledge. it extends to adoption through imitation, stylistic borrowing, riffing, meme-making, sampling, acculturation, identification, modeling, prioritization, valuation, and the propagation and practice of informal pedagogies of many kinds. understood in this way, "learning" does not hinge decisively upon the embodied capacities and needs of human individuals because those capacities and needs are only ever realized relationally or through "ecological interaction," including through interaction with machines (foster 2018) . it is not hard to see why digital domains, online interactions, and social media networks have become a privileged site of observation for such processes (e.g., greenhow and robelia 2009 ), all the more so since socialization there often starts in childhood. this suggests that (contra dreyfus 1974) social and machine learning must be analyzed as co-productive of, rather than antithetical to, one another. machine learning is, similarly, a catch-all term-one encompassing a range of ways of programming computers or computing systems to undertake certain tasks (and satisfy certain performance thresholds) without explicitly directing the machines in question how to do so. instead, machine learning is aimed at having computers learn (more or less autonomously) from preexisting data, including the data output from prior attempts to undertake the tasks in question, and devise their own ways of both tackling those tasks and iteratively improving at them (alpaydin 2014) . implementations of machine learning now span all areas of social and economic life. machine learning "has been turning up everywhere, driven by exponentially growing mountains of [digital] data" (domingos 2015) . in this article, we take social media as one domain in which machine learning has been widely implemented. we do so recognizing that not all data analysis in which social media platforms engage is automated, and that those aspects that are automated do not necessarily involve machine learning. two points are important for our purposes: most "machines" must be trained, cleaned, and tested by humans in order to "learn." in implementations of machine learning on social media platforms, for instance, humans are everywhere "in the loop"-an immense, poorly paid, and crowdsourced workforce that relentlessly labels, rates, and expunges the "content" to be consumed (gillespie 2018; gray and suri 2019) . and yet, both supervised and unsupervised machines generate new patterns of interpretation, new ways of reading the social world and of intervening in it. any reference to machine learning throughout this article should be taken to encapsulate these "more-thanhuman" and "more-than-machine" qualities of machine learning. cybernetic feedback, data hunger, and meaning accretion analogies between human (or social) learning and machine-based learning are at least as old as artificial intelligence itself. the transdisciplinary search for common properties among physical systems, biological systems, and social systems, for instance, was an impetus for the macy foundation conferences on "circular causal and feedback mechanisms in biology and social systems" in the early days of cybernetics (1946) (1947) (1948) (1949) (1950) (1951) (1952) (1953) . in the analytical model developed by norbert wiener, "the concept of feedback provides the basis for the theoretical elimination of the frontier between the living and the non-living" (lafontaine 2007, p. 31) . just as the knowing and feeling person is dynamically produced through communication and interactions with others, the ideal cybernetic system continuously enriches itself from the reactions it causes. in both cases, life is irrelevant: what matters, for both living and inanimate objects, is that information circulates in an everrenewed loop. put another way, information/computation are "substrate independent" (tegmark 2017, p. 67 ). wiener's ambitions (and even more, the exaggerated claims of his posthumanist descendants, see, e.g., kurzweil 2000) were immediately met with criticism. starting in the 1960s, philosopher hubert dreyfus arose as one of the main critics of the claim that artificial intelligence would ever approach its human equivalent. likening the field to "alchemy" (1965), he argued that machines would never be able to replicate the unconscious processes necessary for the understanding of context and the acquisition of tacit skills (1974, 1979 )-the fact that, to quote michael polanyi (1966) , "we know more than we can tell." in other words, machines cannot develop anything like the embodied intuition that characterizes humans. furthermore, machines are poorly equipped to deal with the fact that all human learning is cultural, that is, anchored not in individual psyches but in collective systems of meaning and in sedimented, relational histories (vygotsky 1980; bourdieu 1990; durkheim 2001; hasse 2019) . is this starting to change today when machines successfully recognize images, translate texts, answer the phone, and write news briefs? some social and computational scientists believe that we are on the verge of a real revolution, where machine learning tools will help decode tacit knowledge, make sense of cultural repertoires, and understand micro-dynamics at the individual level (foster 2018 ). our concern is not, however, with confirming or refuting predictive claims about what computation can and cannot do to advance scholars' understanding of social life. rather, we are interested in how social and computational learning already interact. not only may social and machine learning usefully be compared, but they are reinforcing and shaping one another in practice. in those jurisdictions in which a large proportion of the population is interacting, communicating, and transacting ubiquitously online, social learning and machine learning share certain tendencies and dependencies. both practices rely upon and reinforce a pervasive appetite for digital input or feedback that we characterize as "data hunger." they also share a propensity to assemble insight and make meaning accretively-a propensity that we denote here as "world or meaning accretion." throughout this article, we probe the dynamic interaction of social and machine learning by drawing examples from one genre of online social contention and connection in which the pervasive influence of machine learning is evident: namely, that which occurs across social media channels and platforms. below we explain first how data hunger is fostered by both social and computing systems and techniques, and then how world or meaning accretion manifests in social and machine learning practices. these explanations set the stage for our subsequent discussion of how these interlocking dynamics operate to constitute and distribute power. data hunger: searching as a natural attitude as suggested earlier, the human person is the product of a long, dynamic, and never settled process of socialization. it is through this process of sustained exposure that the self (or the habitus, in pierre bourdieu's vocabulary) becomes adjusted to its specific social world. as bourdieu puts it, "when habitus encounters a social world of which it is the product, it is like a 'fish in water': it does not feel the weight of the water, and it takes the world about itself for granted" (bourdieu in wacquant 1989, p. 43) . the socialized self is a constantly learning self. the richer the process-the more varied and intense the interactions-the more "information" about different parts of the social world will be internalized and the more socially versatile-and socially effective, possibly-the outcome. (this is why, for instance, parents with means often seek to offer "all-round" training to their offspring [lareau 2011]) . machine learning, like social learning, is data hungry. "learning" in this context entails a computing system acquiring capacity to generalize beyond the range of data with which it has been presented in the training phase. "learning" is therefore contingent upon continuous access to data-which, in the kinds of cases that preoccupy us, means continuous access to output from individuals, groups, and "bots" designed to mimic individuals and groups. at the outset, access to data in enough volume and variety must be ensured to enable a particular learnermodel combination to attain desired accuracy and confidence levels. thereafter, data of even greater volume and variety is typically (though not universally) required if machine learning is to deliver continuous improvement, or at least maintain performance, on assigned tasks. the data hunger of machine learning interacts with that of social learning in important ways. engineers, particularly in the social media sector, have structured machine learning technologies not only to take advantage of vast quantities of behavioral traces that people leave behind when they interact with digital artefacts, but also to solicit more through playful or addictive designs and cybernetic feedback loops. the machine-learning self is not only encouraged to respond more, interact more, and volunteer more, but also primed to develop a new attitude toward the acquisition of information (andrejevic 2019, p.53). with the world's knowledge at her fingertips, she understands that she must "do her own research" about everything-be it religion, politics, vaccines, or cooking. her responsibility as a citizen is not only to learn the collective norms, but also to know how to search and learn so as to make her own opinion "for herself," or figure out where she belongs, or gain new skills. the development of searching as a "natural attitude" (schutz 1970 ) is an eminently social process of course: it often means finding the right people to follow or emulate (pariser 2011) , using the right keywords so that the search process yields results consistent with expectations (tripodi 2018) , or implicitly soliciting feedback from others in the form of likes and comments. the social media user also must extend this searching disposition to her own person: through cybernetic feedback, algorithms habituate her to search for herself in the data. this involves looking reflexively at her own past behavior so as to inform her future behavior. surrounded by digital devices, some of which she owns, she internalizes the all-seeing eye and learns to watch herself and respond to algorithmic demands (brubaker 2020 ). data hunger transmutes into self-hunger: an imperative to be digitally discernible in order to be present as a subject. this, of course, exacts a kind of self-producing discipline that may be eerily familiar to those populations that have always been under heavy institutional surveillance, such as the poor, felons, migrants, racial minorities (browne 2015; benjamin 2019) , or the citizens of authoritarian countries. it may also be increasingly familiar to users of health or car insurance, people living in a smart home, or anyone being "tracked" by their employer or school by virtue of simply using institutionally licensed it infrastructure. but the productive nature of the process is not a simple extension of what michel foucault called "disciplinary power" nor of the self-governance characteristic of "governmentality." rather than simply adjusting herself to algorithmic demands, the user internalizes the injunction to produce herself through the machine-learning-driven process itself. in that sense the machine-learnable self is altogether different from the socially learning, self-surveilling, or self-improving self. the point for her is not simply to track herself so she can conform or become a better version of herself; it is, instead, about the productive reorganization of her own experience and self-understanding. as such, it is generative of a new sense of selfhood-a sense of discovering and crafting oneself through digital means that is quite different from the "analog" means of self-cultivation through training and introspection. when one is learning from a machine, and in the process making oneself learnable by it, mundane activities undergo a subtle redefinition. hydrating regularly or taking a stroll are not only imperatives to be followed or coerced into. their actual phenomenology morphs into the practice of feeding or assembling longitudinal databases and keeping track of one's performance: "step counting" and its counterparts (schüll 2016; adams 2019) . likewise, what makes friendships real and defines their true nature is what the machine sees: usually, frequency of online interaction. for instance, snapchat has perfected the art of classifying-and ranking-relationships that way, so people are constantly presented with an ever-changing picture of their own dyadic connections, ranked from most to least important. no longer, contra foucault (1988) , is "permanent self-examination" crucial to self-crafting so much as attention to data-productive practices capable of making the self learnable and sustaining its searching process. to ensure one's learnability-and thereby one's selfhood-one must both feed and reproduce a hunger for data on and around the self. human learning is not only about constant, dynamic social exposure and world hunger, it is also about what we might call world or meaning accretion. 2 the self is constantly both unsettled (by new experiences) and settling (as a result of past experiences). people take on well institutionalized social roles (berger and luckmann 1966) . they develop habits, styles, personalities-a "system of dispositions" in bourdieu's vocabulary-by which they become adjusted to their social world. this system is made accretively, through the conscious and unconscious sedimentation of social experiences and interactions that are specific to the individual, and variable in quality and form. accretion here refers to a process, like the incremental build-up of sediment on a riverbank, involving the gradual accumulation of additional layers or matter. even when change occurs rapidly and unexpectedly, the ongoing process of learning how to constitute and comport oneself and perform as a social agent requires one to grapple with and mobilize social legacies, social memory, and pre-established social norms (goffman 1983) . the habitus, bourdieu would say, is both structured and structuring, historical and generative. social processes of impression formation offer a good illustration of how social learning depends upon accreting data at volume, irrespective of the value of any particular datum. the popular insight that first impressions matter and tend to endure is broadly supported by research in social psychology and social cognition (uleman and kressel 2013) . it is clear that impressions are formed cumulatively and that early-acquired information tends to structure and inform the interpretation of information later acquired about persons and groups encountered in social life (hamilton and sherman 1996) . this has also been shown to be the case in online environments (marlow et al. 2013) . in other words, social impressions are constituted by the incremental build-up of a variegated mass of data. machine learning produces insight in a somewhat comparable way-that is, accretively. insofar as machine learning yields outputs that may be regarded as meaningful (which is often taken to mean "useful" for the task assigned), then that "meaning" is assembled through the accumulation of "experience" or from iterative exposure to available data in sufficient volume, whether in the form of a stream or in a succession of batches. machine learning, like social learning, never produces insight entirely ab initio or independently of preexisting data. to say that meaning is made accretively in machine learning is not to say that machine learning programs are inflexible or inattentive to the unpredictable; far from it. all machine learning provides for the handling of the unforeseen; indeed, capacity to extend from the known to the unknown is what qualifies machine learning as "learning." moreover, a number of techniques are available to make machine learning systems robust in the face of "unknown unknowns" (that is, rare events not manifest in training data). nonetheless, machine learning does entail giving far greater weight to experience than to the event. 3 the more data that has been ingested by a machine learning system, the less revolutionary, reconfigurative force might be borne by any adventitious datum that it encounters. if, paraphrasing marx, one considers that people make their own history, but not in circumstances they choose for themselves, but rather in present circumstances given and inherited, then the social-machine learning interface emphasizes the preponderance of the "given and inherited" in present circumstances, far more than the potentiality for "mak[ing]" that may lie within them (marx 1996 (marx [1852 ). one example of the compound effect of social and automated meaning accretion in the exemplary setting to which we return throughout this articlesocial media-is the durability of negative reputation across interlocking platforms. for instance, people experience considerable difficulty in countering the effects of "revenge porn" online, reversing the harms of identity theft, or managing spoiled identities once they are digitally archived (lageson and maruna 2018) . as langlois and slane have observed, "[w]hen somebody is publicly shamed online, that shaming becomes a live archive, stored on servers and circulating through information networks via search, instant messaging, sharing, liking, copying, and pasting" (langlois and slane 2017) . in such settings, the data accretion upon which machine learning depends for the development of granular insights-and, on social media platforms, associated auctioning and targeting of advertising-compounds the cumulative, sedimentary effect of social data, making negative impressions generated by "revenge porn," or by one's online identity having been fraudulently coopted, hard to displace or renew. the truth value of later, positive data may be irrelevant if enough negative data has accumulated in the meantime. data hunger and the accretive making of meaning are two aspects of the embedded sociality of machine learning and of the "mechanical" dimensions of social learning. together, they suggest modes of social relation, conflict, and action that machine learning systems may nourish among people on whom those systems bear, knowingly or unknowingly. this has significant implications for social and economic inequality, as we explore below. what are the social consequences of machine learning's signature hunger for diverse, continuous, ever more detailed and "meaningful" data and the tendency of many automated systems to hoard historic data from which to learn? in this section, we discuss three observable consequences of data hunger and meaning accretion. we show how these establish certain non-negotiable preconditions for social inclusion; we highlight how they fuel the production of digitally-based forms of social stratification and association; and we specify some recurrent modes of relation fostered thereby. all three ordering effects entail the uneven distribution of power and resources and all three play a role in sustaining intersecting hierarchies of race, class, gender, and other modes of domination and axes of inequality. machine learning's data appetite and the "digestive" or computational abilities that attend it are often sold as tools for the increased organizational efficiency, responsiveness, and inclusiveness of societies and social institutions. with the help of machine learning, the argument goes, governments and non-governmental organizations develop an ability to render visible and classify populations that are traditionally unseen by standard data infrastructures. moreover, those who have historically been seen may be seen at a greater resolution, or in a more finelygrained, timely, and difference-attentive way. among international organizations, too, there is much hope that enhanced learning along these lines might result from the further utilization of machine learning capacities (johns 2019) . for instance, machine learning, deployed in fingerprint, iris, or facial recognition, or to nourish sophisticated forms of online identification, is increasingly replacing older, document-based ones (torpey 2018 )-and transforming the very concept of citizenship in the process (cheney-lippold 2016). whatever the pluses and minuses of "inclusiveness" in this mode, it entails a major infrastructural shift in the way that social learning takes place at the state and inter-state level, or how governments come to "know" their polities. governments around the world are exploring possibilities for gathering and analysing digital data algorithmically, to supplement-and eventually, perhaps, supersede-household surveys, telephone surveys, field site visits, and other traditional data collection methods. this devolves the process of assembling and representing a polity, and understanding its social and economic condition, down to agents outside the scope of public administration: commercial satellite operators (capturing satellite image data being used to assess a range of conditions, including agricultural yield and poverty), supermarkets (gathering scanner data, now widely used in cpi generation), and social media platforms. if official statistics (and associated data gathering infrastructures and labor forces) have been key to producing the modern polity, governmental embrace of machine learning capacities signals a change in ownership of that means of production. social media has become a key site for public and private parties-police departments, immigration agencies, schools, employers and insurers among others-to gather intelligence about the social networks of individuals, their health habits, their propensity to take risks or the danger they might represent to the public, to an organization's bottom line or to its reputation (trottier 2012; omand 2017; bousquet 2018; amoore 2020; stark 2020) . informational and power asymmetries characteristic of these institutions are often intensified in the process. this is notwithstanding the fact that automated systems' effects may be tempered by manual work-arounds and other modes of resistance within bureaucracies, such as the practices of frontline welfare workers intervening in automated systems in the interests of their clients, and strategies of foot-dragging and data obfuscation by legal professionals confronting predictive technologies in criminal justice (raso 2017; brayne and christin 2020) . the deployment of machine learning to the ends outlined in the foregoing paragraph furthers the centrality of data hungry social media platforms to the distribution of all sorts of economic and social opportunities and scarce public resources. at every scale, machine-learning-powered corporations are becoming indispensable mediators of relations between the governing and the governed (a transition process sharply accelerated by the covid-19 pandemic). this invests them with power of a specific sort: the power of "translating the images and concerns of one world into that of another, and then disciplining or maintaining that translation in order to stabilize a powerful network" and their own influential position within it (star 1990, p. 32) . the "powerful network" in question is society, but it is heterogeneous, comprising living and non-living, automated and organic elements: a composite to which we can give the name "society" only with impropriety (that is, without adherence to conventional, anthropocentric understandings of the term). for all practical purposes, much of social life already is digital. this insertion of new translators, or repositioning of old translators, within the circuits of society is an important socio-economic transformation in its own right. and the social consequences of this new "inclusion" are uneven in ways commonly conceived in terms of bias, but not well captured by that term. socially disadvantaged populations are most at risk of being surveilled in this way and profiled into new kinds of "measurable types" (cheney-lippold 2017). in addition, social media user samples are known to be non-representative, which might further unbalance the burden of surveillant attention. (twitter users, for instance, are skewed towards young, urban, minority individuals (murthy et al. 2016 ).) consequently, satisfaction of data hunger and practices of automated meaning accretion may come at the cost of increased social distrust, fostering strategies of posturing, evasion, and resistance among those targeted by such practices. these reactions, in turn, may undermine the capacity of state agents to tap into social data-gathering practices, further compounding existing power and information asymmetries (harkin 2015) . for instance, sarah brayne (2014) finds that government surveillance via social media and other means encourages marginalized communities to engage in "system avoidance," jeopardizing their access to valuable social services in the process. finally, people accustomed to being surveilled will not hesitate to instrumentalize social media to reverse monitor their relationships with surveilling institutions, for instance by taping public interactions with police officers or with social workers and sharing them online (byrne et al. 2019) . while this kind of resistance might further draw a wedge between vulnerable populations and those formally in charge of assisting and protecting them, it has also become a powerful aspect of grassroots mobilization in and around machine learning and techno-social approaches to institutional reform (benjamin 2019) . in all the foregoing settings, aspirations for greater inclusiveness, timeliness, and accuracy of data representation-upon which machine learning is predicated and which underlie its data hunger-produce newly actionable social divisions. the remainder of this article analyzes some recurrent types of social division that machine learning generates, and types of social action and experience elicited thereby. there is, of course, no society without ordering-and no computing either. social order, like computing order, comes in many shapes and varieties but generally "the gap between computation and human problem solving may be much smaller than we think" (foster 2018, p. 152) . in what follows, we cut through the complexity of this socialcomputational interface by distinguishing between two main ideal types of classification: ordinal (organized by judgments of positionality, priority, probability or value along one particular dimension) and nominal (organized by judgments of difference and similarity) (fourcade 2016) . social processes of ordinalization in the analog world might include exams, tests, or sports competitions: every level allows one to compete for the next level and be ranked accordingly. in the digital world, ordinal scoring might take the form of predictive analytics-which, in the case of social media, typically means the algorithmic optimization of online verification and visibility. by contrast, processes of nominalization include, in the analog world, various forms of homophily (the tendency of people to associate with others who are similar to them in various ways) and institutional sorting by category. translated for the digital world, these find an echo in clustering technologies-for instance a recommendation algorithm that works by finding the "nearest neighbors" whose taste is similar to one's own, or one that matches people based on some physical characteristic or career trajectory. the difference between ordinal systems and nominal systems maps well onto the difference between bayesian and analogical approaches to machine learning, to reference pedro domingos's (2015) useful typology. it is, however, only at the output or interface stage that these socially ubiquitous machine learning orderings become accessible to experience. what does it mean, and what does it feel like, to live in a society that is regulated through machine learning systems-or rather, where machine learning systems are interacting productively with social ordering systems of an ordinal and nominal kind? in this section, we identify some new, or newly manifest, drivers of social structure that emerge in machine learning-dominated environments. let us begin with the ordinal effects of these technologies (remembering that machine learning systems comprise human as well as non-human elements). as machine learning systems become more universal, the benefits of inclusion now depend less on access itself, and more on one's performance within each system and according to its rules. for instance, visibility on social media depends on "engagement," or how important each individual is to the activity of the platform. if one does not post frequently and consistently, comment or message others on facebook or instagram, or if others do not interact with one's posts, one's visibility to them diminishes quickly. if one is not active on the dating app tinder, one cannot expect one's profile to be shown to prospective suitors. similarly, uber drivers and riders rank one another on punctuality, friendliness, and the like, but uber (the company) ranks both drivers and riders on their behavior within the system, from canceling too many rides to failing to provide feedback. uber egypt states on its website: "the rating system is designed to give mutual feedback. if you never rate your drivers, you may see your own rating fall." even for those willing to incur the social costs of disengagement, opting out of machine learning may not be an option. failure to respond to someone's tag, or to like their photo, or otherwise maintain data productivity, and one might be dropped from their network, consciously or unconsciously, a dangerous proposition in a world where self-worth has become closely associated with measures of network centrality or social influence. as bucher has observed, "abstaining from using a digital device for one week does not result in disconnection, or less data production, but more digital data points … to an algorithm, … absence provides important pieces of information" (bucher 2020, p. 2) . engagement can also be forced on non-participants by the actions of other users-through tagging, rating, commenting, and endorsing, for instance (casemajor et al. 2015) . note that none of this is a scandal or a gross misuse of the technology. on the contrary, this is what any system looking for efficiency and relevance is bound to look like. but any ordering system that acts on people will generate social learning, including action directed at itself in return. engagement, to feed data hunger and enable the accretion of "meaningful" data from noise, is not neutral, socially or psychologically. the constant monitoring and management of one's social connections, interactions, and interpellations places a nontrivial burden on one's life. the first strategy of engagement is simply massive time investment, to manage the seemingly ever-growing myriad of online relationships (boyd 2015). to help with the process, social media platforms now bombard their users constantly with notifications, making it difficult to stay away and orienting users' behavior toward mindless and unproductive "grinding" (for instance, repetitively "liking" every post in their feed). but even this intensive "nudging" is often not enough. otherwise, how can we explain the fact that a whole industry of social media derivatives has popped up, to help people optimize their behavior vis-a-vis the algorithm, manage their following, and gain an edge so that they can climb the priority order over other, less savvy users? now users need to manage two systems (if not more): the primary one and the (often multiple) analytics apps that help improve and adjust their conduct in it. in these ways, interaction with machine learning systems tends to encourage continuous effort towards ordinal self-optimization. however, efforts of ordinal optimization, too, may soon become useless: as marilyn strathern (citing british economist charles goodhardt) put it, "when a measure becomes a target, it ceases to be a good measure" (strathern 1997, p. 308) . machine learning systems do not reward time spent on engagement without regard to the impact of that engagement across the network as a whole. now, in desperation, those with the disposable income to do so may turn to money as the next saving grace to satisfy the imperative to produce "good" data at volume and without interruption, and reap social rewards for doing so. the demand for maximizing one's data productivity and machine learning measurability is there, so the market is happy to oblige. with a monthly subscription to a social media platform, or even a social media marketing service, users can render themselves more visible. this possibility, and the payoffs of visibility, are learned socially, both through the observation and mimicry of models (influencers, for instance) or through explicit instruction (from the numerous online and offline guides to maximizing "personal brand"). one can buy oneself instagram or twitter followers. social media scheduling tools, such as tweetdeck and post planner, help one to plan ahead to try to maximize engagement with one's postings, including by strategically managing their release across time zones. a paying account on linkedin dramatically improves a user's chance of being seen by other users. the same is true of tinder. if a user cannot afford the premium subscription, the site still offers them one-off "boosts" for $1.99 that will send their profile near the top of their potential matches' swiping queue for 30 min. finally, wealthier users can completely outsource the process of online profile management to someone else (perhaps recruiting a freelance social media manager through an online platform like upwork, the interface of which exhibits ordinal features like client ratings and job success scores). in all the foregoing ways, the inclusionary promise of machine learning has shifted toward more familiar sociological terrain, where money and other vectors of domination determine outcomes. in addition to economic capital, distributions of social and cultural capital, as well as traditional ascriptive characteristics, such as race or gender, play an outsized role in determining likeability and other outcomes of socially learned modes of engagement with machine learning systems. for instance, experiments with mechanical turkers have shown that being attractive increases the likelihood of appearing trustworthy on twitter, but being black creates a contrarian negative effect (groggel et al. 2019) . in another example, empirical studies of social media use among those bilingual in hindi and english have observed that positive modes of social media engagement tend to be expressed in english, with negative emotions and profanity more commonly voiced in hindi. one speculative explanation for this is that english is the language of "aspiration" in india or offers greater prospects for accumulating social and cultural capital on social media than hindi (rudra et al. 2016) . in short, wellestablished off-platform distinctions and social hierarchies shape the extent to which on-platform identities and forms of materialized labor will be defined as valuable and value-generating in the field of social media. in summary, ordinality is a necessary feature of all online socio-technical systems and it demands a relentless catering to one's digital doppelgängers' interactions with others and with algorithms. to be sure, design features tend to make systems addictive and feed this sentiment of oppression (boyd 2015). what really fuels both, however, is the work of social ordering and the generation of ordinal salience by the algorithm. in the social world, any type of scoring, whether implicit or explicit, produces tremendous amounts of status anxiety and often leads to productive resources (time and money) being diverted in an effort to better one's odds (espeland and sauder 2016; mau 2019) . 4 those who are short on both presumably fare worse, not only because that makes them less desirable in the real world, but also because they cannot afford the effort and expense needed to overcome their disadvantage in the online world. the very act of ranking thus both recycles old forms of social inequality and also creates new categories of undesirables. as every teenager knows, those who have a high ratio of following to followers exhibit low social status or look "desperate." in this light, jeff bezos may be the perfect illustration of intertwining between asymmetries of real world and virtual world power: the founder and ceo of amazon and currently the richest man in the world has 1.4 million followers on twitter, but follows only one person: his ex-wife. ordinalization has implications not just for hierarchical positioning, but also for belonging-an important dimension of all social systems (simmel 1910) . ordinal stigma (the shame of being perceived as inferior) often translates into nominal stigma, or the shame of non-belonging. not obtaining recognition (in the form of "likes" or "followers"), in return for one's appreciation of other people, can be a painful experience, all the more since it is public. concern to lessen the sting of this kind of algorithmic cruelty is indeed why, presumably, tinder has moved from a simple elo or desirability score (which depends on who has swiped to indicate liking for the person in question, and their own scores, an ordinal measure) to a system that relies more heavily on type matching (a nominal logic), where people are connected based on taste similarity as expressed through swiping, sound, and image features (carman 2019) . in addition to employing machine learning to rank users, most social media platforms also use forms of clustering and type matching, which allow them to group users according to some underlying similarity (analogical machine learning in domingos's terms). this kind of computing is just as hungry for data as those we discuss above, but its social consequences are different. now the aim is trying to figure a person out or at least to amplify and reinforce a version of that person that appears in some confluence of data exhaust within the system in question. that is, in part, the aim of the algorithm (or rather, of the socio-technical system from which the algorithm emanates) behind facebook's news feed (cooper 2020) . typically, the more data one feeds the algorithm, the better its prediction, the more focused the offering, and the more homogeneous the network of associations forged through receipt and onward sharing of similar offerings. homogenous networks may, in turn, nourish better-and more saleablemachine learning programs. the more predictable one is, the better the chances that one will be seen-and engaged-by relevant audiences. being inconsistent or too frequently turning against type in data-generative behaviors can make it harder for a machine learning system to place and connect a person associatively. in both offline and online social worlds (not that the two can easily be disentangled), deviations from those expectations that data correlations tend to yield are often harshly punished by verbal abuse, dis-association, or both. experiences of being so punished, alongside experiences of being rewarded by a machine learning interface for having found a comfortable group (or a group within which one has strong correlations), can lead to some form of social closure, a desire to "play to type." as one heavy social media user told us, "you want to mimic the behavior [and the style] of the people who are worthy of your likes" in the hope that they will like you in return. that's why social media have been variously accused of generating "online echo chambers" and "filter bubbles," and of fueling polarization (e.g., pariser 2011). on the other hand, being visible to the wrong group is often a recipe for being ostracized, "woke-shamed," "called-out," or even "canceled" (yar and bromwich 2019) . in these and other ways, implementations of machine learning in social media complement and reinforce certain predilections widely learned socially. in many physical, familial, political, legal, cultural, and institutional environments, people learn socially to feel suspicious of those they experience as unfamiliar or fundamentally different from themselves. there is an extensive body of scholarly work investigating social rules and procedures through which people learn to recognize, deal with, and distance themselves from bodies that they read as strange and ultimately align themselves with and against pre-existing nominal social groupings and identities (ahmed 2013; goffman 1963) . this is vital to the operation of the genre of algorithm known as a recommendation algorithm, a feature of all social media platforms. on facebook, such an algorithm generates a list of "people you may know" and on twitter, a "who to follow" list. recommendation algorithms derive value from this social learning of homophily (mcpherson et al. 2001) . for one, it makes reactions to automated recommendations more predictable. recommendation algorithms also reinforce this social learning by minimizing social media encounters with identities likely to be read as strange or nonassimilable, which in turn improves the likelihood of their recommendations being actioned. accordingly, it has been observed that the profile pictures of accounts recommended on tiktok tend to exhibit similarities-physical and racial-to the profile image of the initial account holder to whom those recommendations are presented (heilweil 2020) . in that sense, part of what digital technologies do is organize the online migration of existing offline associations. but it would be an error to think that machine learning only reinforces patterns that exist otherwise in the social world. first, growing awareness that extreme type consistency may lead to online boredom, claustrophobia, and insularity (crawford 2009 ) has led platforms to experiment with and implement various kinds of exploratory features. second, people willfully sort themselves online in all sorts of non-overlapping ways: through twitter hashtags, group signups, click and purchasing behavior, social networks, and much more. the abundance of data, which is a product of the sheer compulsion that people feel to self-index and classify others (harcourt 2015; brubaker 2020) , might be repurposed to revisit common off-line classifications. categories like marriage or citizenship can now be algorithmically parsed and tested in ways that wield power over people. for instance, advertisers' appetite for information about major life events has spurred the application of predictive analytics to personal relationships. speech recognition, browsing patterns, and email and text messages can be mined for information about, for instance, the likelihood of relationships enduring or breaking up (dickson 2019) . similarly, the us national security agency measures people's national allegiance from how they search on the internet, redefining rights in the process (cheney-lippold 2016). even age-virtual rather than chronological-can be calculated according to standards of mental and physical fitness and vary widely depending on daily performance (cheney-lippold 2017, p. 97). quantitatively measured identities-algorithmic gender, ethnicity, or sexuality-do not have to correspond to discrete nominal types anymore. they can be fully ordinalized along a continuum of intensity (fourcade 2016) . the question now is: how much of a us citizen are you, really? how latinx? how gay? 5 in a machine learning world, where each individual can be represented as a bundle of vectors, everyone is ultimately a unique combination, a category of one, however "precisely inaccurate" that category's digital content may be (mcfarland and mcfarland 2015) . changes in market research from the 1970s to the 1990s, aimed at tracking consumer mobility and aspiration through attention to "psychographic variables," constitute a pre-history, of sorts, for contemporary machine learning practices in commercial settings (arvidsson 2004; gandy 1993; fourcade and healy 2017; lauer 2017) . however, the volume and variety of variables now digitally discernible mean that the latter have outstripped the former exponentially. machine learning techniques have the potential to reveal unlikely associations, no matter how small, that may have been invisible, or muted, in the physically constraining geography of the offline world. repurposed for intervention, disparate data can be assembled to form new, meaningful types and social entities. paraphrasing donald mackenzie (2006), machine learning is an "engine, not a camera." christopher wylie, a former lead scientist at the defunct firm cambridge analytica-which famously matched fraudulently obtained facebook data with consumer data bought from us data brokers and weaponized them in the context of the 2016 us presidential election-recalls the experience of searching for-and discovering-incongruous social universes: "[we] spent hours exploring random and weird combinations of attributes.… one day we found ourselves wondering whether there were donors to anti-gay churches who also shopped at organic food stores. we did a search of the consumer data sets we had acquired for the pilot and i found a handful of people whose data showed that they did both. i instantly wanted to meet one of these mythical creatures." after identifying a potential target in fairfax county, he discovered a real person who wore yoga pants, drank kombucha, and held fire-andbrimstone views on religion and sexuality. "how the hell would a pollster classify this woman?" only with the benefit of machine learning-and associated predictive analytics-could wylie and his colleagues claim capacity to microtarget such anomalous, alloyed types, and monetize that capacity (wylie 2019, pp. 72-74) . to summarize, optimization makes social hierarchies, including new ones, and pattern recognition makes measurable types and social groupings, including new ones. in practice, ordinality and nominality often work in concert, both in the offline and in the online worlds (fourcade 2016 ). as we have seen, old categories (e.g., race and gender) may reassert themselves through new, machine-learned hierarchies, and new, machine-learned categories may gain purchase in all sorts of offline hierarchies (micheli et al. 2018; madden et al. 2017) . this is why people strive to raise their digital profiles and to belong to those categories that are most valued there (for instance "verified" badges or recognition as a social media "influencer"). conversely, patternmatching can be a strategy of optimization, too: people will carefully manage their affiliations, for instance, so as to raise their score-aligning themselves with the visible and disassociating themselves from the underperforming. we examine these complex interconnections below and discuss the dispositions and sentiments that they foster and nourish. it should be clear by now that, paraphrasing latour (2013, p. 307), we can expect little from the "social explanation" of machine learning; machine learning is "its own explanation." the social does not lie "behind" it, any more than machine learning algorithms lie "behind" contemporary social life. social relations fostered by the automated instantiation of stratification and association-including in social mediaare diverse, algorithmic predictability notwithstanding. also, they are continually shifting and unfolding. just as latour (2013, p. 221) reminds us not to confuse technology with the objects it leaves in its wake, it is important not to presume the "social" of social media to be fixed by its automated operations. we can, nevertheless, observe certain modes of social relation and patterns of experience that tend to be engineered into the ordinal and nominal orders that machine learning (re)produces. in this section, we specify some of these modes of relation, before showing how machine learning can both reify and ramify them. our argument here is with accounts of machine learning that envisage social and political stakes and conflicts as exogenous to the practice-considerations to be addressed through ex ante ethics-by-design initiatives or ex post audits or certifications-rather than fundamental to machine learning structures and operations. machine learning is social learning, as we highlighted above. in this section, we examine further the kinds of sociality that machine learning makes-specifically those of competitive struggle and dependency-before turning to prospects for their change. social scientists' accounts of modes of sociality online are often rendered in terms of the antagonism between competition and cooperation immanent in capitalism (e.g., fuchs 2007 ). this is not without justification. after all, social media platforms are sites of social struggle, where people seek recognition: to be seen, first and foremost, but also to see-to be a voyeur of themselves and of others (harcourt 2015; brubaker 2020) . in that sense, platforms may be likened to fields in the bourdieusian sense, where people who invest in platform-specific stakes and rules of the game 6 are best positioned to accumulate platform-specific forms of capital (e.g., likes, followers, views, retweets, etc.) (levina and arriaga 2014) . some of this capital may transfer to other platforms through built-in technological bridges (e.g., between facebook and instagram), or undergo a process of "conversion" when made efficacious and profitable in other fields (bourdieu 2011; fourcade and healy 2017) . for instance, as social status built online becomes a path to economic accumulation in its own right (by allowing payment in the form of advertising, sponsorships, or fans' gifts), new career aspirations are attached to social media platforms. according to a recent and well-publicized survey, "vlogger/youtuber" has replaced "astronaut" as the most enviable job for american and british children (berger 2019) . in a more mundane manner, college admissions offices or prospective employers increasingly expect one's presentation of self to include the careful management of one's online personality-often referred to as one's "brand" (e.g., sweetwood 2017) . similarly, private services will aggregate and score any potentially relevant information (and highlight "red flags") about individuals across platforms and throughout the web, for a fee. in this real-life competition, digitally produced ordinal positions (e.g., popularity, visibility, influence, social network location) and nominal associations (e.g., matches to advertised products, educational institutions, jobs) may be relevant. machine learning algorithms within social media both depend on and reinforce competitive striving within ordinal registers of the kind highlighted above-or in bourdieu's terms, competitive struggles over field-specific forms of capital. as georg simmel observed, the practice of competing socializes people to compete; it "compels the competitor" (simmel 2008 (simmel [1903 ). socially learned habits of competition are essential to maintain data-productive engagement with social media platforms. for instance, empirical studies suggest that motives for "friending" and following others on social media include upward and downward social comparison (ouwerkerk and johnson 2016; vogel et al. 2014) . social media platforms' interfaces then reinforce these social habits of comparison by making visible and comparable public tallies of the affirmative attention that particular profiles and posts have garnered: "[b]eing social in social media means accumulating accolades: likes, comments, and above all, friends or followers" (gehl 2015, p. 7) . in this competitive "[l]ike economy," "user interactions are instantly transformed into comparable forms of data and presented to other users in a way that generates more traffic and engagement" (gerlitz and helmond 2013, p. 1349 )-engagement from which algorithms can continuously learn in order to enhance their own predictive capacity and its monetization through sales of advertising. at the same time, the distributed structure of social media (that is, its multinodal and cumulative composition) also fosters forms of cooperation, gift exchange, redistribution, and reciprocity. redistributive behavior on social media platforms manifests primarily in a philanthropic mode rather than in the equitypromoting mode characteristic of, for instance, progressive taxation. 7 examples include practices like the #followfriday or #ff hashtag on twitter, a spontaneous form of redistributive behavior that emerged in 2009 whereby "micro-influencers" started actively encouraging their own followers to follow others. 8 insofar as those so recommended are themselves able to monetize their growing follower base through product endorsement and content creation for advertisers, this redistribution of social capital serves, at least potentially, as a redistribution of economic capital. even so, to the extent that purportedly "free" gifts, in the digital economy and elsewhere, tend to be reciprocated (fourcade and kluttz 2020) , such generosity might amount to little more than an effective strategy of burnishing one's social media "brand," enlarging one's follower base, and thereby increasing one's store of accumulated social (and potentially economic) capital. 9 far from being antithetical to competitive relations on social media, redistributive practices in a gift-giving mode often complement them (mauss 1990) . social media cooperation can also be explicitly anti-social, even violent (e.g., patton et al. 2019) . in these and other ways, digitized sociality is often at once competitive and cooperative, connective and divisive (zukin and papadantonakis 2017) . whether it is enacted in competitive, redistributive or other modes, sociality on social media is nonetheless emergent and dynamic. no wonder that bruno latour was the social theorist of choice when we started this investigation. but-as latour (2012) himself pointed out-gabriel tarde might have been a better choice. what makes social forms cohere are behaviors of imitation, counter-7 an exception to this observation would be social media campaigns directed at equitable goals, such as campaigns to increase the prominence and influence of previously under-represented groups-womenalsoknowstuff and pocalsoknowstuff twitter handles, hashtags, and feeds, for example. 8 recommendation in this mode has been shown to increase recommended users' chance of being followed by a factor of roughly two or three compared to a recommendation-free scenario (garcia gavilanes et al. 2013). 9 for instance, lewis (2018, p. 5) reports that "how-to manuals for building influence on youtube often list collaborations as one of the most effective strategies." imitation, and influence (tarde 1903) . social media, powered by trends and virality, mimicry and applause, parody and mockery, mindless "grinding" and tagging, looks quintessentially tardian. even so, social media does not amount simply to transfering online practices of imitation naturally occuring offline. the properties of machine learning highlighted above-cybernetic feedback; data hunger; accretive meaning-making; ordinal and nominal ordering-lend social media platforms and interfaces a distinctive, compulsive, and calculating quality-engineering a relentlessly "participatory subjectivity" (bucher 2020, p.88; boyd 2015) . how one feels and how one acts when on social media is not just an effect of subjective perceptions and predispositions. it is also an effect of the software and hardware that mediate the imitative (or counter-imitative) process itself-and of the economic rationale behind their implementation. we cannot understand the structural features and phenomenological nature of digital technologies in general, and of social media in particular, if we do not understand the purposes for which they were designed. the simple answer, of course, is that data hunger and meaning accretion are essential to the generation of profit (zuboff 2019), whether profit accrues from a saleable power to target advertising, commercializable developments in artificial intelligence, or by other comparable means. strategies for producing continuous and usable data flows to profit-making ends vary, but tend to leverage precisely the social-machine learning interface that we highlighted above. social media interfaces tend to exhibit design features at both the back-and front-end that support user dependency and enable its monetization. for example, the "infinite scroll," which allows users to swipe down a page endlessly (without clicking or refreshing) rapidly became a staple of social media apps after its invention in 2006, giving them an almost hypnotic feel and maximizing the "time on device" and hence users' availability to advertisers (andersson 2018) . similarly, youtube's recommendation algorithm was famously optimized to maximize users' time on site, so as to serve them more advertisements (levin 2017; roose 2019) . social media platforms also employ psycho-social strategies to this end, including campaigns to draw people in by drumming up reciprocity and participation-the notifications, the singling out of trends, the introduction of "challenges"-and more generally the formation of habits through gamification. prominent critics of social media, such as tristan harris (originally from google) and sandy parakilas (originally from facebook), have denounced apps that look like "slot machines" and use a wide range of intermittent rewards to keep users hooked and in the (instagram, tiktok, facebook, …) zone, addicted "by design" (schüll 2012; fourcade 2017) . importantly, this dependency has broader social ramifications than may be captured by a focus on individual unfreedom. worries about the "psychic numbing" of the liberal subject (zuboff 2019) , or the demise of the sovereign consumer, do not preoccupy us so much as the ongoing immiseration of the many who "toil on the invisible margins of the social factory" (morozov 2019) or whose data traces make them the targets of particularly punitive extractive processes. dependencies engineered into social media interfaces help, in combination with a range of other structural factors, to sustain broader economic dependencies, the burdens and benefits of which land very differently across the globe (see, e.g., taylor and broeders 2015) . in this light, the question of how amenable these dynamics may be to social change becomes salient for many. recent advances in digital technology are often characterized as revolutionary. however, as well as being addictive, the combined effect of machine learning and social learning may be as conducive to social inertia as it is to social change. data hunger on the part of mechanisms of both social learning and machine learning, together with their dependence on data accretion to make meaning, encourage replication of interface features and usage practices known to foster continuous, data-productive engagement. significant shifts in interface design-and in the social learning that has accreted around use of a particular interface-risk negatively impacting data-productive engagement. one study of users' reactions to changes in the facebook timeline suggested that "major interface changes induce psychological stress as well as technology-related stress" (wisniewski et al. 2014) . in recognition of these sensitivities, those responsible for social media platforms' interfaces tend to approach their redesign incrementally, so as to promote continuity rather than discontinuity in user behaviour. the emphasis placed on continuity in social media platform design may foster tentativeness in other respects as well, as we discuss in the next section. at the same time, social learning and machine learning, in combination, are not necessarily inimical to social change. machine learning's associative design and propensity to virality have the potential to loosen or unsettle social orders rapidly. and much as the built environment of the new urban economy can be structured to foster otherwise unlikely encounters (hanson and hillier 1987; zukin 2020) , so digital space can be structured to similar effect. for example, the popular chinese social media platform wechat has three features, enabled by machine learning, that encourage openended, opportunistic interactions between random users-shake, drift bottle, and people nearby-albeit, in the case of people nearby, random users within one's immediate geographic vicinity. (these are distinct from the more narrow, instrumental range of encounters among strangers occasioned by platforms like tinder, the sexual tenor of which are clearly established in advance, with machine learning parameters set accordingly.) qualitative investigation of wechat use and its impact on chinese social practices has suggested that wechat challenges some existing social practices, while reinforcing others. it may also foster the establishment of new social practices, some defiant of prevailing social order. for instance, people report interacting with strangers via wechat in ways they normally would not, including shifting to horizontallystructured interactions atypical of chinese social structures offline (wang et al. 2016 ). this is not necessarily unique to wechat. the kinds of ruptures and reorderings engineered through machine learning do not, however, create equal opportunities for value creation and accumulation, any more than they are inherently liberating or democratizing. social media channels have been shown to serve autocratic goals of "regime entrenchment" quite effectively (gunitsky 2015) . 10 likewise, they serve economic goals of data accumulation and concentration (zuboff 2019) . machine-learned sociality lives on corporate servers and must be 10 with regard to wechat in china and vkontakte in russia, as well as to government initiatives in egypt, the ukraine, and elsewhere, seva gunitsky (2015) highlights a number of reasons why, and means by which, nondemocratic regimes have proactively sought (with mixed success) to co-opt social media, rather than simply trying to suppress it, in order to try to ensure central government regimes' durability. meticulously "programmed" (bucher 2018) to meet specific economic objectives. as such, it is both an extremely lucrative proposition for some and (we have seen) a socially dangerous one for many. it favors certain companies, their shareholders and executives, while compounding conditions of social dependency and economic precarity for most other people. finally, with its content sanitized by underground armies of ghost workers (gray and suri 2019), it is artificial in both a technical and literal sense-"artificially artificial," in the words of jeff bezos (casilli and posada 2019). we have already suggested that machine-learned sociality, as it manifests on social media, tends to be competitive and individualizing (in its ordinal dimension) and algorithmic and emergent (in its nominal dimension). although resistance to algorithms is growing, those who are classified in ways they find detrimental (on either dimension) may be more likely to try to work on themselves or navigate algorithmic workarounds than to contest the classificatory instrument itself (ziewitz 2019) . furthermore, we know that people who work under distributed, algorithmically managed conditions (e.g., mechanical turk workers, uber drivers) find it difficult to communicate amongst themselves and organize (irani and silberman 2013; lehdonvirta 2016; dubal 2017) . these features of the growing entanglement of social and machine learning may imply dire prospects for collective action-and beyond it, for the achievement of any sort of broad-based, solidaristic project. in this section, we tentatively review possibilities for solidarity and mobilization as they present themselves in the field of social media. machine learning systems' capacity to ingest and represent immense quantities of data does increase the chances that those with common experiences will find one another, at least insofar as those experiences are shared online. machine-learned types thereby become potentially important determinants of solidarity, displacing or supplementing the traditional forces of geography, ascribed identities, and voluntary association. those dimensions of social life that social media algorithms have determined people really care about often help give rise to, or supercharge, amorphous but effective forms of offline action, if only because the broadcasting costs are close to zero. examples may include the viral amplification of videos and messages, the spontaneity of flash mobs (molnár 2014) , the leaderless, networked protests of the arab spring (tufekci 2016) , or of the french gilets jaunes (haynes 2019), and the #metoo movement's reliance on public disclosures on social media platforms. nonetheless, the thinness, fleeting character, and relative randomness of the affiliations summoned in those ways (based on segmented versions of the self, which may or may not overlap) might make social recognition and commonality of purpose difficult to sustain in the long run. more significant, perhaps, is the emergence of modes of collective action that are specifically designed not only to fit the online medium, but also to capitalize on its technical features. many of these strategies were first implemented to stigmatize or sow division, although there is no fatality that this is their only possible use. examples include the anti-semitic (((echo))) tagging on twitter-originally devised to facilitate trolling by online mobs (weisman 2018) but later repurposed by non-jews as an expression of solidarity; the in-the-wild training of a microsoft chatter bot, literally "taught" by well-organized users to tweet inflammatory comments; the artificial manipulation of conversations and trends through robotic accounts; or the effective delegation, by the trump 2020 campaign, of the management of its ad-buying activities to facebook's algorithms, optimized on the likelihood that users will take certain campaign-relevant actions-"signing up for a rally, buying a hat, giving up a phone number" (bogost and madrigal 2020) . 11 the exploitation of algorithms for divisive purposes often spurs its own reactions, from organized counter-mobilizations to institutional interventions by platforms themselves. during the 2020 black lives matter protests, for instance, kpop fans flooded rightwing hashtags on instagram and twitter with fancams and memes in order to overwhelm racist messaging. even so, often the work of "civilizing" the social media public sphere is left to algorithms, supported by human decision-makers working through rules and protocols (and replacing them in especially sensitive cases). social media companies ban millions of accounts every month for inappropriate language or astroturfing (coordinated operations on social media that masquerade as a grassroot movement): algorithms have been trained to detect and exclude certain types of coalitions on the basis of a combination of social structure and content. in 2020, the british far right movement "britain first" moved to tiktok after being expelled from facebook, twitter, instagram, and youtube-and then over to vkontakte or vk, a russian platform, after being banned from tiktok (usa news 2020). chastised in the offline world for stirring discord and hate, the economic engines that gave the movement a megaphone have relegated it to their margins with embarrassment. the episode goes to show that there is nothing inherently inclusive in the kind of group solidarity that machine learning enables, and thus it has to be constantly put to the (machine learning) test. in the end, platforms' ideal of collective action may resemble the tardean, imitative but atomized crowd, nimble but lacking in endurance and capacity (tufekci 2016) . mimetic expressions of solidarity, such as photo filters (e.g., rainbow), the "blacking out" of one's newsfeed, or the much-bemoaned superficiality of "clicktivism" may be effective at raising consciousness or the profile of an issue, but they may be insufficient to support broader-based social and political transformations. in fact, social media might actually crowd out other solidaristic institutions by also serving as a (feeble, often) palliative for their failures. for example, crowdsourced campaigns, now commonly used to finance healthcare costs, loss of employment, or educational expenses, perform a privatized solidarity that is a far cry from the universal logic of public welfare institutions. up to this point, our emphasis has been on the kinds of sociality that machine learning implementations tend to engender on the social media field, in both vertical (ordinal) and horizontal (nominal) configurations. we have, in a sense, been "reassembling the social" afresh, with an eye, especially, to its computational components and chains of reference (latour 2005) . throughout, we have stressed, nonetheless, that machine learning and other applications of artificial intelligence must be understood as forces internal to social life-both subject to and integral to its contingent properties-not forces external to it or determinative of it. accordingly, it is just as important to engage in efforts to reassemble "the machine"-that is, to revisit and put once more into contention the associative preconditions for machine learning taking the form that it currently does, in social media platforms for instance. and if we seek to reassemble the machine, paraphrasing latour (2005, p. 233) , "it's necessary, aside from the circulation and formatting of traditionally conceived [socio-technical] ties, to detect other circulating entities." so what could be some "other circulating entities" within the socio-technical complex of machine learning, or how could we envisage its elements circulating, and associating, otherwise? on some level, our analysis suggests that the world has changed very little. like every society, machine-learned society is powered by two fundamental, sometimes contradictory forces: stratification and association, vertical and horizontal difference. to be sure, preexisting social divisions and inequalities are still very much part of its operations. but the forces of ordinality and nominality have also been materialized and formatted in new ways, of which for-profit social media offer a particularly stark illustration. the machinelearnable manifestations of these forces in social media: these are among the "other circulating entities" now traceable. recursive dynamics between social and machine learning arise where social structures, economic relations and computational systems intersect. central to these dynamics in the social media field are the development of a searching disposition to match the searchability of the environment, the learnability of the self through quantified measurement, the role of scores in the processing of social positions and hierarchies, the decategorization and recategorization of associational identities, automated feedback that fosters compulsive habits and competitive social dispositions, and strategic interactions between users and platforms around the manipulation of algorithms. what, then, of prospects for reassembly of existing configurations? notwithstanding the lofty claims of the it industry, there is nothing inherently democratizing or solidaristic about the kinds of social inclusiveness that machine learning brings about. the effects of individuals and groups' social lives being rendered algorithmically learnable are ambivalent and uneven. in fact, they may be as divisive and hierarchizing as they may be connective and flattening. moreover, the conditions for entry into struggle in the social media field are set by a remarkably small number of corporate entities and "great men of tech" with global reach and influence (grewal 2008) . a level playing field this most definitely is not. rather, it has been carved up and crenellated by those who happen to have accumulated greatest access to the data processing and storage capacity that machine learning systems require, together with the real property, intellectual property, and personal property rights, and the network of political and regulatory lobbyists that ensure that exclusivity of access is maintained (cohen 2019) . power in this field is, accordingly, unlikely to be reconfigured or redistributed organically, or through generalized exhortation to commit to equity or ethics (many versions of which are self-serving on the part of major players). instead, political action aimed at building or rebuilding social solidarities across such hierarchies and among such clusters must work with and through them, in ways attentive to the specifics of their instantiation in particular techno-social settings. to open to meaningful political negotiation those allocations and configurations of power that machine learning systems help to inscribe in public and private life-this demands more than encompassing a greater proportion of people within existing practices of ruling and being ruled, and more than tinkering around the edges of existing rules. the greater the change in sociality and social relations-and machine learning is transforming both, as we have recounted-the more arrant and urgent the need for social, political and regulatory action specifically attuned 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cities, tech and the new economy hackathons as co-optation ritual: socializing workers and institutionalizing innovation in the publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations as well as numerous articles that explore and theorize national variations in political mores, valuation cultures, economic policy, and economic knowledge. more recently, she has written extensively on the political economy of digitality, looking specifically at the changing nature of inequality and stratification in the digital era since 2015, she has been conducting fieldwork on the role of digital technology and digital data in development, humanitarian aid, and disaster relief-work funded, since 2018, by the australian research council. relevant publications include "global governance through the pairing of list and algorithm" (environment and planning d: society and space 2015); "data, detection, and the redistribution of the sensible acknowledgments we are grateful to kieran healy, etienne ollion, john torpey, wayne wobcke, and sharon zukin for helpful comments and suggestions. we also thank the institute for advanced study for institutional support. an earlier version of this article was presented at the "social and ethical challenges of machine learning" workshop at the institute for advanced study, princeton, november 2019. key: cord-292721-954nxptr authors: grey, ian; arora, teresa; thomas, justin; saneh, ahmad; tomhe, pia; habib, rudy abi title: the role of perceived social support on depression and sleep during the covid-19 pandemic date: 2020-09-18 journal: psychiatry res doi: 10.1016/j.psychres.2020.113452 sha: doc_id: 292721 cord_uid: 954nxptr the aim of the present study was to examine the role of perceived social support pertaining to a range of psychological health outcomes amongst individuals undergoing social isolation and social distancing during covid-19. a total of 2,020 participants provided responses to an online cross-sectional survey comprised of validated instruments including the multidimensional scale of perceived social support (mspss), the 7-item generalized anxiety disorder scale (gad-7), the nine item patient health questionnaire (phq-9), the brief irritability test (bite) and the ucla loneliness scale (ucla-ls). individuals experiencing self-isolation had significantly higher rates of depression, irritability and loneliness compared to those who were not. the risk for elevated levels of depression symptoms was 63% lower in individuals who reported higher levels of social support compared to those with low perceived social support. similarly, those with high social support had a 52% lower risk of poor sleep quality compared to those with low social support. social support was found to be significantly associated with elevated risk for depression and sleep quality. the results contribute to our understanding of differential psychological outcomes for individuals experiencing anti-pandemic measures. in the immediate wake of the announcement by the who regarding the covid-19 pandemic, many countries sanctioned a range of measures to protect public health including social distancing and social isolation which helped to avert an increase of covid-19 incidence (nussbaumer-streit et al., 2020) . however, mental health professionals highlighted the possible range of negative mental health effects based on previous epidemic situations (brookes et al., 2020; holmes et al., 2020; li et al., 2020; mahase, 2020; xiang et al., 2020) . unfortunately, whilst such measures may be efficacious for minimizing the physical spread of the virus, social distancing and self-isolation measures are documented risk factors for the onset and exacerbation of mental health issues (holmes et al., 2020) . anti-pandemic measures disrupt social interconnectedness and this is not only associated with an increased risk of psychological difficulties, but has been previously linked to early mortality (holt-lunstad, et al., 2015) . the emerging research related to covid-19 points to an elevated incidence of negative psychological effects amongst healthcare workers (bo et al., 2020) , covid-infected patients (hguyen et al., 2020) as well as the general population (xiao et al, 2020) with anxiety and depression occurring most frequently (wang et al., 2020; gao et al., 2020; tan et al., 2020) . other groups have demonstrated the downstream consequence of covid-19 upon sleep quality (xiao & yhang, 2020) , which is a known driver of the onset and progression of mental health outcomes (baglioni et al., 2011) . to date, the specific factors propelling poorer levels of mental health observed during the current pandemic remain unknown (holmes et al., 2020) . some have suggested increased social media exposure may be partly responsible (gao et al., 2020) whilst others have pointed to the duration of social isolation may be an important factor (brookes et al., 2020; purssell et al., 2020; hawryluch et al., 2004) . one particular topic that has also been the focus of some interest during the current pandemic has been the role of social support and its role as a psychosocial protective factor in relation to mental health difficulties. to date social support has been broadly construed in two ways: perceived social support and received social support (eagle et al., 2019) . perceived social support concerns the subjective evaluation of how individuals perceive friends, family members as available to provide material, psychological and overall support during times of need whereas received support relates to the actual quantity of support received. this distinction between these two types of support is important for two reasons. firstly, perceived social support measures are designed to assess individual perceptions concerning the general availability and adequacy of support and/or global satisfaction with support provided whereas measures of received support targets the specific supportive behaviours that are provided to individuals by their social support networks (eagle et al., 2019) . secondly, a sizeable body of research indicates that perceived social support is only modestly correlated with measures of received support (haber et al. 2007; lakey et al, 2010) . furthermore, existing meta-analytic studies examining the relationship between these two types of support do not support the traditional view that received support is the primary constituent factor in perceived support (haber et al., 2007) . indeed, social cognitive theories in this domain describe cognitive, judgment, and perceptual processes involved in support appraisals and challenge the notion that support perceptions are primarily determined by specific, objectively identifiable events (kaul & lakey, 2003; procidano, 1997) . while there is a strong and well-validated relationship between poorer mental health and low levels of perceived social support (lakey & cronin, 2008; liang, krause, & bennett, 2001) , the relationship between received social support and mental health outcomes appears to be weak (lakey et al., 2010; son, lin, & george, 2008; uchino, 2009) . several recent studies have evaluated the role of perceived social support during the covid-pandemic. higher ratings of perceived social support from family are reported as being associated with lower levels of depression and ptsd levels of depression and ptsd symptoms moreover, medical staff who report higher levels of perceived social support report increased self-efficacy and sleep quality and reduced anxiety and stress (xiao et al., 2020) . thus, increased levels of perceived social support may mitigate the effects of social isolation and social distancing measures (zhang & ma, 2020) . in nonpandemic situations, positive associations between social support and psychological well-being among adults and youth have been documented (peirce et al., 2000) . furthermore, inverse associations have been observed between social support and depression, and tentatively with schizophrenia, bipolar disorder and anxiety disorders (wang et al., 2018) . unfortunately, the role of perceived social support pertaining to mental health and related behaviors during the current pandemic remains largely absent. a better understanding of the role played by perceived social support is therefore crucial amongst individuals experiencing anti-pandemic measures during covid-19 in light of the foregoing discussion, the primary objective of our study was to comprehensively examine the role of perceived social support in relation to depression, anxiety, irritability and sleep quality amongst individuals undergoing social isolation during the covid-19 outbreak. based on the existing literature, we hypothesized that perceived levels of social support would be associated with an increased risk of anxiety and depressive symptoms as well as poorer sleep quality. a total of 2,020 individuals provided consent to participate in the study. demographic information was collected pertaining to age group (years), gender, current living arrangements, family income, social isolation, duration of social isolation (weeks), relationship status, educational level, current occupational status, presence of underlying medical conditions, and whether the person knew somebody personally who had contracted covid-19. this study was conducted in accordance with the declaration of helsinki and was approved by the institutional review board at the first authors university (approval number: lau.sas.ig6.2/apr/2020). all participants indicated their consent after being presented with study-related information. a crosssectional design was utilized and the web link was disseminated through social media platforms and email. survey monkey is an online platform which was used to collect the data online. the mspss is a 12-item scale that measures perceived adequacy of social support from three domains:family, friends, and significant others (zimet et al., 1990) . it has a three factor structure with each subscale comprising four items addressing practical help, emotional support, availability to discuss problems and help in decision making (see table 1 ). there is a special person who is around when i am in need. there is a special person with whom i can share my joys and sorrows. i have a special person who is a real source of comfort to me. there is a special person in my life who cares about my feelings. participants are asked to indicate their agreement with items on a seven-point likert scale, ranging from very strongly disagree to very strongly agree yielding a score range from 12 to 84. scores from 12-48 indicate low social support, scores from 49-68 indicate moderate social support, and scores from 69-84 indicate high social support. several studies indicate that the measure possesses adequate psychometric properties in adults (dambi et al., 2018; laksmita et al., 2020; zimet et al., 1990 ). in the present study, cronbach's alpha coefficient and the intra-class correlation coefficient (icc) for this tool were 0.89 and 0.92, respectively. the gad-7 is one of the most frequently used diagnostic self-report scales for screening, diagnosis and severity assessment of anxiety disorder (spitzer et al., 2006; jordan et al., 2017) . responders are asked to rate the frequency of anxiety symptoms in the last two weeks on a likert scale ranging from 0-3 (0 = not at all, 1 = several days, 2 = more than half the days and 3 = nearly every day). items are summed to provide a total score ranging from zero to 21 yielding a total anxiety score. severity can be determined by the following cut-off scores; 1-4 minimal symptoms, 5-9 mild symptoms, 10-14 moderate symptoms and 15-21 severe symptoms. the gad-7 has been subjected to numerous psychometric evaluations and is reported to have good reliability and validity across different population groups (johnson et al., 2019) . the measure also has good internal consistency (cronbach α = .92) and test-retest reliability is adequate (intra-class correlation = 0.83; spitzer et al., 2006) . in the present study, cronbach's alpha coefficient was high (cronbach α = .91). the phq-9 is the nine-item depression self-report module from the full patient health questionnaire (spitzer, kroenke & williams, 1999) . each item is rated from 0 to 3 based on frequency of each symptom over the previous 2 weeks (0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day). as a severity measure, the phq-9 score can range from 0 to 27). the widely used cutoff scores for the measure are 0-4 (none), 5-9 (mild), 10-14 (moderate), 15-19 (moderately severe) and 20-27 (severe; urtasun et al., 2019) . the initial validation study reported a cronbach's α of 0.89 (kroenke, spitzer & williams, 2001) and subsequent validation studies point to strong reliability and validity of the measure (darlay et al., 2019; mccord & frost, 2020) . in the present study, in the present study, cronbach's alpha coefficient was high (cronbach α = .89). this is a three-item scale assessing loneliness derived from an original 20 item measure (hughes et al., 2004) . the three items on the measure were selected because they showed the highest loading on each respective factor of a three-factor model based on the original 20 item measure (hughes et al., 2004; arimoto & takada, 2019) . responders are asked to indicate how they currently feel in three domains: relational connectedness, social connectedness and perceived self-isolation by indicating hardly ever feel this way (1), some of the time (2) and often (3). scores range from 3 to 9 and yields a category scores of 3 -5 as "not lonely" and people with the score 6 -9 as "lonely". the three-item version is reported to be reliable and valid (hughes et al., 2004) . subsequent studies indicate that the instrument has good validity and reliability (saito et al., 2019; vasser & crosby, 2008) . in the present study, cronbach's alpha coefficient was moderate (cronbach α = .67). this is a five-item measure designed to measure irritability (holtzman et al., 2015) . responders are asked to indicate how often they have felt or behaved during the previous two weeks, including today. each item is rated on a six-point likert scale (1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = very often, 6 = always) yielding a score range from 5 to 30. the scale has demonstrated high internal consistency (cronbach's alpha ≥.88; holtzman et al., 2015) . the instrument is reported to have adequate convergent and concurrent validity (holtzman et al., 2015) . in the present study, cronbach's alpha coefficient was high (cronbach α = .89). this is a self-rated questionnaire which assesses sleep quality and disturbances over a one-month time interval (buysse et al., 1989) . nineteen individual items generate seven "component" scores: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction. the sum of the seven subscales are added to derive a global score (0-21) which can be subsequently dichotomized into good (5) and poor (>5) sleep quality. the instrument is reported to have good psychometric properties (buysse et al., 1991; dietch et al., 2016) . all statistical analyses were conducted using stata, version 13. scores for depression (phq-9), anxiety (gad-7), irritability (bite) and loneliness (ucla-ls) and perceived social support (mspss) were visually inspected and were approximately normally distributed. differences between those experiencing quarantine with those who were not were assessed in addition to gender differences on the above measures. to assess the differences between levels of perceived social support in relation to demographics as well as the main variables of interest, chi square and one-way anova were used, as appropriate. a series of pearson's bivariate correlations were performed to assess the relationships between levels of depression, anxiety, perceived social support, loneliness, sleep quality and irritability. a series of multivariate logistic regression analyses were conducted to assess if the independent variable of perceived social support level (using low as the referent) could predict the following three dependent variables: 1) depression (applying a cut point of ≥10 to indicate moderate-severe depression, where <10 was used as the referent); 2) anxiety (applying a cut point of ≥10 to indicate moderate-severe depression, where <10 was used as the referent); 3) sleep quality (using ≤5 as the referent category). three statistical models were created where model 1 was univariate, model 2 was adjusted for age and gender, model 3 was further adjusted for demographic variables (living arrangements, education level, income, living with children under 8 years), duration of lockdown (weeks), if they knew someone personally affected by covid-19 (yes/no), chronic condition (yes/no), as well as depression, anxiety and sleep quality, as appropriate. all covariates were selected a priori during the planning stage of our study and were based on current scientific evidence. p values of < .05 were considered statistically significant for all two-tailed tests. of the 1,655 participants who provided information about self-isolation, 17% (n=277) were not selfisolating at the time of responding and 83% (n=1,378) were. the first step in the analysis involved comparing scores for depression (phq-9), anxiety (gad-7), irritability (bite), loneliness (ucla-ls) and perceived social support (mspss) between those who reported being in quarantine/expiring selfisolation and those who were not. there were no differences between the two groups on scores of perceived social support t(1356) =-.87, p = .32) and on anxiety t(1257) = 1.74, p = .08). significant differences were observed between the two groups with respect to depression t(1315) = 2.27, p = .007), irritability t(1381) = 3.36, p = .001) and loneliness t(1352) = 1.99, p = .04). in summary, those experiencing quarantine had higher scores on depression, irritability and loneliness relative to those not experiencing quarantine. a total of 60% of those experiencing self-isolation (n=827) reported that their mental health had deteriorated since lockdown measures were enforced, while 27% felt it remained the same and just 13% felt it had improved. to test these differences, an independent between-groups anova was implemented in respect of depression scores which yielded a statistically significant result f(1,1094) =182.00, p = .000). to evaluate the nature of these differences between the three groups further, a series of fishers lsd post hoc tests was conducted. the difference between those who felt their mental health had deteriorated and those who felt it had remained the same was significantly significant t(1095) = 6.93, p = .00) as was the difference with those who felt their mental health had improved t(1095) = 7.77, p = .00). in order to test for gender differences across depression, anxiety, irritability, loneliness and social support a series of between-groups anova's were conducted (see table 2 ). in respect of depression, an independent between-groups anova yielded a statistically significant result (f(1,1098) =44.13, p = .000). a significant result was also observed in relation to anxiety (f(1,1069) = 64.21, p = .000), irritability (f(1,1153) = 42.15, p = .000) and perceived social support f(1,1135) = 6.43, p = .011. in summary, females scored higher on measures of depression, anxiety, irritability and social support. demographic characteristics along with the outcomes of interest are presented in table 3 , stratified by level of perceived social support (low, moderate, high). in brief, those aged 25-34 years reported the highest levels of social support (32.61%) compared to 19.15% in 18-24 year olds, and 26.32% in those who were 35 years or older, x 2 (4) = 15.15, p = .004. the mean scores for anxiety, depression, loneliness, irritability and sleep quality were all significantly different across the three levels of perceived social support (p < .001 for all) demonstrating the protective nature of social support systems upon the mental health outcomes of interest as well as sleep and loneliness. (7) 12 (6) 10 (6) <.001 ucla loneliness scale 7 (2) 6 (2) 5 (2) <.001 bite 18 (6) 17 (5) 15 (5) <.001 psqi 9 (4) 8 (3) 7 (4) <.001 data are presented as n (%), or mean (sd). gad = generalized anxiety disorder; phq = patient health questionnaire; psqi = pittsburgh sleep quality index; bite = brief irritability test the correlation matrix is shown in table 4 which highlights the relationships between the two mental health variables (depression and anxiety), sleep quality, loneliness and irritability. briefly, the strongest correlation was observed between depression and anxiety, where r=.72, p<.001. pertaining to social support, significant negative correlations were observed for all variables, with loneliness having the strongest relationship, where r = -.46, p<.001. a series of logistic regression analyses were conducted to assess if social support level could predict either depression, anxiety or sleep quality (see table 5 ). results indicate that perceived social support level was a protective factor for depression and poor sleep quality. the strongest effect size was observed amongst those with high perceived social support in relation to depression, the risk for depression was 63% lower compared to those with low perceived social support (or=.37 [95% ci: .21-.67), after full adjustment of potential confounders. similarly, those with high social support had a 52% lower risk of poor sleep quality compared to those with low social support, after adjustment . anxiety was also significantly associated with perceived social support but after full adjustment (model 3), the relationship was attenuated and became non-significant. researchers have been quick to document the range of mental health effects associated with measures to contain the covid-19 pandemic. to date, elevated levels of depression and anxiety have been reported in the general population in addition to gender differences. it appears from the current that experiencing quarantine results in elevated levels of depression, irritability and loneliness in contrast to those who are not experiencing quarantine. furthermore, females scored higher on measures of depression, anxiety, irritability and loneliness in contrast to males which is in line with recent studies. however, what is also apparent from these emerging studies is that while relatively large numbers of individuals are adversely affected, a substantial number of individuals are not begging the question as to why there is a differential response across individuals. the results of the current study may contribute to a more nuanced understanding of this issue. several existing meta-analytic reviews addressing the relationship between social support and mental health suggest that the presence of such support predicts better mental health functioning and can also be regarded as a protective factor against the onset of mental health difficulties (de silva et al., 2005; harandi, taghinasab, & nayeri, 2017) . more specifically, it has been proposed that high quality social support can enhance resilience to stress and help protect against developing trauma-related psychopathology (ozbay et al., 2007) . in the current study, perceived social support was observed to have significant inverse associations with anxiety, depression, loneliness, irritability and quality of sleep with higher levels of support related to lower scores on measures of these specific outcomes. of particular interest is the relationship between social support and depression as the latter is perhaps the most commonly assessed index of mental health status during the current pandemic. results of the current study indicate that the risk for depression was 63% lower compared to those with low perceived social support (or=.37 [95% ci: .21-.67) when adjusted for age, gender, living arrangement, education level, and presence of chronic condition or illness. a similar pattern was observed in respect of sleep quality with those reporting high levels of social support having a 52% lower risk of poor sleep quality compared to those with low social support (or=.48 [95% ci: .26-.88). these results point to a quite substantial effect of perceived social support both on depression and also in relation to sleep quality which is line with recent meta-analytic reviews which also indicate a robust association between social support and sleep outcomes (kent de grey et al., 2018) . previous research also suggests that perceived social support is a significant predictor of depressive symptoms (alsubaie et al., 2019) . in respect of limitations, the current study focused solely on the relationship between perceived social support and mental health and sleep. whilst the existing literature suggests that perceived social support has a more robust relationship with mental health outcomes than received support, what remains unanswered is the question has to what combination of contextual and intra-individual factors lead to appraisals of social support, whether these be high or low, for individuals experiencing antipandemic measures. in light of research which clearly suggests that received support is only modestly related to perceived support it has been proposed that individuals who report higher levels of perceived social support may have what has been termed a 'positive psychological profile' (uchino, 2009 ) which entails they are more likely to evaluate any form of received social support in a more positive manner. as such, future research investigating the role social support during anti-pandemic measures may benefit from the examination of personality factors such as resilience and coping styles in the context of how individual access and receive support to provide a more complete understanding of perceived social support during a pandemic situation. changes in perceived social support across the duration of the pandemic would also be of interest as previous research suggests that declines in perceived support are 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(phq-9) for use among hospitalized non-psychiatric medical patients social capital and mental illness: a systematic review psychometric evaluation of the psqi in u.s. college students perceived social support, received social support, and depression among clergy mental health problems and social media exposure during covid-19 outbreak the relationship between self-reported received and perceived social support: a meta-analytic review the correlation of social support with mental health: a meta-analysis. electronic physician sars control and psychological effects of quarantine multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science loneliness and social isolation as risk factors for mortality: a meta-analytic review the brief irritability test (bite): a measure of irritability for use among men and women a short scale for measuring loneliness in large surveys: results from two population-based studies people with suspected covid-19 symptoms were more likely depressed and had lower health-related quality oflife: the potential benefit of health literacy psychometric properties of the general anxiety disorder 7-item (gad-7) scale in a heterogeneous psychiatric sample psychometric analysis of the generalized anxiety disorder scale (gad-7) in primary care using modern item response theory where is the support in perceived support? the role of generic relationship satisfaction and enacted support in perceived support's relation to low distress social support and sleep: a meta-analysis the phq-9: validity of a brief depression severity measure enacted support's links to negative affect isolated from trait influences multidimensional scale of perceived social support in indonesian adolescent disaster survivors: a psychometric evaluation progression of mental health services during the covid-19 outbreak in china social exchange and well-being: is giving better than receiving? factors associated with depression, anxiety, and ptsd symptomatology during the covid-19 pandemic: clinical implications for u.s. young adult mental health covid-19: mental health consequences of pandemic need urgent research, paper advises construct validity of the phq-9 depression screen: correlations with substantive scales of the mmpi-2-rf screening for generalized anxiety disorder in spanish primary care centers with the gad-7 quarantine alone or in combination with other public health measures to control covid-19: a rapid review people with suspected covid-19 symptoms were more likely depressed and had lower health-related quality of life: the potential benefit of health literacy social support and resilience to stress: from neurobiology to clinical practice a longitudinal model of social contact, social support, depression, and alcohol use assessing perceived social support: the importance of context impact of isolation on hospitalised patients who are infectious: systematic review with meta-analysis validation study on a japanese version of the three-item ucla loneliness scale among community-dwelling older adults cross-national comparison of social support structures between taiwan and the united states validation and utility of a self-report version of prime-md: the phq primary care study. primary care evaluation of mental disorders. patient health questionnaire a brief measure for assessing generalized anxiety disorder: the gad-7 psychological impact of the covid-19 pandemic on health care workers in singapore understanding the links between social support and physical health: a life-span perspective with emphasis on the separability of perceived and received support validation and calibration of the patient health questionnaire (phq-9) in argentina a reliability generalization study of coefficient alpha for the ucla loneliness scale associations between loneliness and perceived social support and outcomes of mental health problems: a systematic review immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china timely mental health care for the 2019 novel coronavirus outbreak is urgently needed the effects of social support on sleep quality of medical staff treating patients with coronavirus disease 2019 (covid-19) in january and february 2020 in china impact of the covid-19 pandemic on mental health and quality of life among local residents in liaoning province, china: a cross-sectional study psychometric characteristics of the multidimensional scale of perceived social support the authors declare no conflict of interest. key: cord-290642-vlyingsf authors: kwon, s.; joshi, a. d.; lo, c.-h.; drew, d. a.; nguyen, l.; guo, c.-g.; ma, w.; mehta, r. s.; warner, e. t.; astley, c. m.; merino, j.; murray, b.; wolf, j.; ourselin, s.; steves, c.; spector, t.; hart, j. e.; song, m.; vopham, t.; chan, a. t. title: association of social distancing and masking with risk of covid-19 date: 2020-11-13 journal: nan doi: 10.1101/2020.11.11.20229500 sha: doc_id: 290642 cord_uid: vlyingsf given the continued burden of severe acute respiratory syndrome coronavirus 2 (sars cov-2) disease (covid-19) across the u.s., there is a high unmet need for data to inform decision-making regarding social distancing and universal masking. we examined the association of community-level social distancing measures and individual masking with risk of predicted covid-19 in a large prospective u.s. cohort study of 198,077 participants. individuals living in communities with the greatest social distancing had a 31% lower risk of predicted covid-19 compared with those living in communities with poor social distancing. self-reported masking was associated with a 63% reduced risk of predicted covid-19 even among individuals living in a community with poor social distancing. these findings provide support for the efficacy of mask-wearing even in settings of poor social distancing in reducing covid-19 transmission. in the current environment of relaxed social distancing mandates and practices, universal masking may be particularly important in mitigating risk of infection. in march 2020, most u.s. states implemented community social distancing interventions, including shelter-inplace orders, school closures, bans on large gatherings, and suspension of non-essential businesses, in an attempt to limit transmission of the novel severe acute respiratory syndrome coronavirus 2 (sars-cov-2), the cause of coronavirus disease 2019 . 1 in some areas, these measures appear to have successfully reduced the pace and severity of covid-19 burden during the initial wave of infections 2,3 , thereby "flattening the curve." however, lockdowns are not viable as a long-term solution 4, 5 . in addition, despite growing evidence showing that masking can reduce disease transmission 6, 7 , adherence to masking recommendations by public health authorities have been variable across the u.s. given the continued rising burden of covid-19 across many u.s. communities, there is a high unmet need for data to inform decision-making regarding universal masking in settings in which social distancing is not widely observed. to date, most evidence on the efficacy of social distancing and universal masking is based on modeling using community-level data in relation to disease burden as assessed through testing, hospitalizations, or mortality [7] [8] [9] . such studies are unable to concurrently account for personal risk factors for infection or optimally assess the latency between social distancing or masking interventions and infection rates given the significant lag between the onset of symptoms, testing, and medical care. here, we conducted a prospective study in the u.s using a smartphone-based application that collected self-reported, individual-level information on covid-19 like symptoms, masking and other personal risk factors, in combination with community-level social distancing measures to investigate the relative effectiveness of social distancing and masking policies with the risk of covid-19. our study population includes all participants enrolled in the covid symptom study smartphone application ("app") from march 29, 2020 to july 16, 2020 in the u.s. the app is a freely available program developed by zoe global ltd. in collaboration with researchers and clinicians at massachusetts general hospital and king's college london. participants using this app reported demographic information and comorbidities at baseline . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted november 13, 2020. ; https://doi.org/10.1101/2020.11.11.20229500 doi: medrxiv preprint 4 and were encouraged to report on their current health condition daily to allow for the longitudinal, prospective collection of symptoms and covid-19 testing results 10 . participants were recruited through general and social media outreach, as well as direct invitations from the investigators of long-running prospective cohorts to study participants 11 . at enrollment, participants provided informed consent to the use of aggregated information for research purposes and agreed to applicable privacy policies and terms of use. this research study was approved by the partners human research committee (institutional review board protocol 2020p000909). this protocol is registered with clinicaltrials.gov (nct04331509). the information collected through the app has been provided in detail previously 10 . upon first use, participants were asked to provide baseline demographic factors, including their zip code of residence, and answered separate questions about a suspected risk factors for covid-19 (table 1) . on first use and upon daily reminders, participants were asked if they felt physically normal, and if not, their symptoms, including fever, persistent cough, fatigue, loss of smell/taste, and diarrhea, among others 10 . participants were also asked if they had been tested for covid-19, and if yes, the results (none, negative, waiting, or positive). beginning on june 12, 2020, participants were also asked if they had worn a face mask when outside the house in the last week (never, sometimes, most of the time, or always). population density was calculated from census data for all zip code tabulation areas (zcta) in the u.s. the daily estimated effective reproductive number (rt) , the average number of secondary cases arising from a single case for a given day in each state, was extracted from rt.live 12 . the method and adaptation for estimation of rt was previously described 13, 14 . because a report of a positive covid-19 test depends on access to testing and incorporates a variable delay between symptoms and testing, we used a previously published symptom-based classifier that predicts covid-19 as our primary outcome measure 15 is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted november 13, 2020. ; https://doi.org/10.1101/2020.11.11.20229500 doi: medrxiv preprint 5 achieved a sensitivity of 0.65 (95% ci 0.62-0.67) and specificity of 0.78 (95% ci 0.76-0.80) in the test set. in additional validation in the u.s. participants, the prediction model achieved a sensitivity of 0.66 (95% ci 0.62-0.69) and specificity of 0.83 (95% ci 0.82-0.85). to examine the influence of covid-19 incidence on our results, we included the daily county-level test positive covid-19 incidence estimated by the center for systems science and engineering at johns hopkins university as a covariate 16, 17 . we assigned each individual participant a social distancing grade within their communities based on their zip code of residence. we used data provided by unacast 18 that estimated county-level social distancing for each calendar day according to the gps activity of all devices assigned to their longest recorded location. compared to the same day of the week during the pre-covid-19 period (defined by unacast as the four weeks prior to march 8, 2020), unacast estimated, for each day, the percent reduction in three metricsmetric 1) average distance traveled per device; metric 2) non-essential visitation (e.g., restaurants, department stores, hair salons); and metric 3) human encounters calculated as two devices in close proximity (i.e., spatial distance of ≤50 m and temporal distance of ≤60 minutes) 18 . unacast assigned grades (a, b, c, d, and f) using predefined cutoff points for each metric and calculated an overall social distancing grade (supplementary methods), with grade a indicating the greatest social distancing and f the poorest social distancing. for all analyses, we combined grades a and b due to a limited number of individuals living in counties assigned to grade a. for personal face mask use, we used the individual-level information collected through the app. beginning on june 12, app users received supplementary questions regarding use of face masks based on the query "in the last week, did you wear a face mask when outside the house?". we conducted prospective analyses after excluding participants who had any symptom related to covid-19 or who had tested positive for covid-19 prior to start of follow-up to minimize collider bias. follow-up time started when participants first reported on the app and accrued until they developed predicted covid-19, or the time of last data entry prior to july 16 th , whichever occurred first. we used updated, time-varying community social . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted november 13, 2020. ; https://doi.org/10.1101/2020.11.11.20229500 doi: medrxiv preprint 6 distancing exposure data as our primary independent variable. community-level social distancing exposure data and corresponding follow-up time was mapped to each individual and updated each time they logged in the app to provide updated symptom information. we also used time-varying masking exposure data for the association between self-reported personal use of masks and predicted covid-19. cox proportional hazards regression models stratified by age, state, and calendar date at study entry were used to calculate unadjusted and multivariable adjusted hazard ratios (hrs) and 95% confidence intervals (cis) of predicted covid-19. covariates were selected a priori based on putative risk factors and included race (white, black, asian, other race), sex (male, female), population density (quartiles), current smoking, work as a frontline healthcare worker, interaction with suspected or documented covid-19, and history of diabetes, heart disease, lung disease, and kidney disease (each yes/no). missing data for categorical variables was included as a missing indicator. to minimize any variation of estimated daily social distancing grade associated with day of the week (e.g. sunday vs. monday), we used a seven-day average of community social distancing grade as the exposure for each participant. we first examined the latency between community social distancing grade and predicted covid-19 using varying lag times (0 days, 7 days, 14 days, 21 days, and 28 days). for example, for a latency of 7 days, we used social distancing grade exposure on april 1 for predicted covid-19 outcome measures on april 8, grade on april 2 for follow-up on april 9 and so forth (supplemental figure 1 ). for subgroup analysis according to daily state-level rt, we used a 21-day latency since this corresponded to the start of the sevenday average social distancing exposure with a 14-day latency. two-sided p-values of <0.05 were considered statistically significant for main analyses. all statistical analyses were performed using r software, version 3.6.1 (r foundation). between march 29 and july 16, 2020, we enrolled 277,798 participants who provided baseline information. we excluded 79,721 individuals who did not live in a county with available unacast data, reported any symptoms or a positive covid 19 test at enrollment, had <24 hours of follow-up time or who reported a positive covid-19 test or symptoms of predicted covid-19 within 24 hours of enrollment. this left 198,077 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted november 13, 2020. ; https://doi.org/10.1101/2020.11.11.20229500 doi: medrxiv preprint 7 participants in our prospective inception cohort, in which we subsequently documented 4,488 cases of predicted covid-19 over 11,403,773 person-days of follow-up. compared to others, individuals who lived in communities with poor social distancing (grade=f) at baseline were younger, more likely to be male, more likely to smoke currently, have less lung disease, and had more interaction with suspected or documented covid-19 individuals (table 1 ). in contrast, individuals living in communities with excellent social distancing (grade=a/b) were older and more likely to live in areas with lower population density ( table 1) . to test the association between community-level social distancing and risk of subsequent predicted covid-19, we evaluated lag times of 7 to 28 days. living in a community with greater social distancing grade (f to a/b) was associated with a lower risk of predicted covid-19 for all lag times evaluated ( table 2 ). the maximal association was first observed with a fourteen-day lag and the benefit plateaued beyond that time period (table 2 ). there was a negative but not statistically significant association with a 0-day lag. when we further adjusted for county-level test positive covid-19 incidence in the community at the time of assessment for the social-distancing measures, we observed similar results (multivariable hr, 0.67; 95% ci 0.53-0.85) for excellent social distancing (grade=a/b) compared to participants living in communities with overall poor social distancing (grade=f). for subsequent analyses, we focused on models using a fourteen-day latency since the reduction in predicted covid-19 appeared maximal at 14 days, and this is considered a plausible interval for exposure to symptom-based disease prediction. we also assessed the three individual components of the unacast social distancing grade: including average distance traveled, non-essential visitation, and human encounters (table 3) . reduction in average distance . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted november 13, 2020. ; https://doi.org/10.1101/2020.11.11.20229500 doi: medrxiv preprint 8 traveled (hr, 0.78; 95% ci 0.65-0.92 <25% versus >55%) and non-essential visitation (hr, 0.79; 95% ci 0.70-0.89 <55% versus >65%) were both associated with lower risk of predicted covid-19. the reduction in human encounters, based on phone-to-phone proximity measures, was not associated with lower risk of predicted covid-19. in subgroup analyses, the association of social distancing grade and covid-19 appeared to differ according to age (pinteraction=0.001). the benefit of increasing social distancing from poor (f) to excellent (a/b) was greatest among the middle-age participants (35-55 years, hr, 0.47; 95% ci 0.26-0.86), than among younger (age <35 years) or older participants (>55). we assessed for effect modification by other demographic including race, sex, and health problems limiting activities, and found no significant interactions between social distancing grades and these factors (all pinteraction >0.05; supplemental table 2 ). table 5 ). this trend was also observed with similar magnitudes albeit with borderline significance (p linear-trend =0.08) during the epidemic growth period (rt >1.0). we examined the association between self-reported personal use of a face mask and risk of predicted covid-19 among the 139,690 participants who provided this information. compared to individuals who reported never using a face mask, individuals who reported using (sometimes, most of the time, or always) a face mask had a multivariable hr for predicted covid-19 of 0.35 (95% ci 0.30-0.42; table 4 ). ever using a face mask was associated with reduced predicted covid-19, with adjusted hrs of 0.31 (95% ci 0.11-0.82) among individuals living in communities with excellent or good social distancing grade, 0.29 (95% . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted november 13, 2020. ; https://doi.org/10.1101/2020.11.11.20229500 doi: medrxiv preprint 9 ci 0.19-0.45) for those living in communities with fair social distancing grade, and 0.37 (95% ci, 0.30-0.44) for those living in communities with poor social distancing grade (pinteraction=0.57). the results remained similar after additional adjustment for actual covid-19 incidence. furthermore, observed associations were not substantially different when analyses were restricted to participants living in texas, arizona, california, and florida (hr, 0.35; 95% ci 0.26-0.47), states which were among the states in which social distancing policy was relaxed earlier during the initial phase of the pandemic. finally, the association of personal use of a face mask and predicted covid-19 did not appear to substantially different according to rt (supplemental table 6 ). in this prospective study of 198,077 participants using a real-time mobile phone application in u.s., we observed that individuals living in communities with the greatest social distancing had a 31% lower risk of predicted covid-19 compared with those living in communities with poor social distancing, with maximum benefit evident after a latency period of 14 days. furthermore, among individuals living in communities with poor social distancing, personal use of a face mask outside of the home at least sometimes was associated with a 63% reduced risk of predicted covid-19 compared to individuals who never wore a face mask. notably, a reduction in average distance traveled and non-essential visitation in the community was protective for predicted covid-19. in contrast, close contact as measured by human encounters was not associated with predicted covid-19. this suggests that average distance traveled and non-essential visitation, as measures of independent mobility, may be more reflective of effective social distancing than measures based on assessing proximity between two devices. it is also possible that the criterion to define human encounters based on devices <50 meters apart may not be optimal to study covid-19 transmission. in subgroup analysis, we did not observe the inverse associations between living in communities with the greater social distancing and risk of covid-19 among individuals aged greater than 55 years, having health problems requiring stay-athome, and regularly using mobility aids. for those individuals, living in a community with the greatest social distancing may not play an important role in reducing covid-19 risk due to their limited mobility and lower likelihood of social interaction in crowded spaces. noticeably, the inverse association between living in a . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted november 13, 2020. ; https://doi.org/10.1101/2020.11.11.20229500 doi: medrxiv preprint community with greater social distancing and risk of predicted covid-19 was most consistently observed among younger individuals without significant health problems or limitations in mobility. we observed that the disease burden of covid-19 at the start of the social distancing measurement did not influence the association of social distancing and personal use of a face mask with risk of predicted covid-19. we also observed that protective effect of social distancing on predicted covid-19 was present both in areas where the epidemic was slowing or maintained (rt ≤1.0) as well as in areas where covid-19 was actively spreading (rt>1.0). we similarly observed that the benefit of personal use of a face mask was observed in regions and time periods in which there was epidemic slowing/maintenance or growth. these findings imply that baseline risk did not impact the relative benefits of social distancing policies and/or face mask use, although it is remains possible that the absolute reduction in risk is greater in areas with higher burden of covid-19. in our study, we used predicted covid-19 as a proxy for a positive covid-19 test due to the small number of covid-19 test positive app users during the study period. the small fraction of positive covid-19 tests among all participants (0.17%) may be largely influenced by the limited availability of covid-19 testing during the study period. a recent study demonstrated that more than 80% of individuals with a covid-19 infection in the u.s. went undetected in march 2020 19 . moreover, another study in 10 sites across u.s. reported that the estimated number of covid-19 infections was 6 to 24 times greater per site than the number of reported from march 23 to may 12 20 . nevertheless, despite the limited power, we found a protective but not statistically significant association between community social distancing and risk of a positive covid-19 test (supplemental table 3 ). therefore, this association between the social distancing observed within one's community and a positive covid-19 test should be further investigated in studies in which there was a higher prevalence of testing. our findings are consistent with previous ecological studies investigating the effect of social distancing on risk of covid-19 [21] [22] [23] [24] [25] [26] [27] [28] . in one recent study that also used estimates of social distancing based on unacast data, . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted november 13, 2020. ; https://doi.org/10.1101/2020.11.11.20229500 doi: medrxiv preprint each one-unit increase in social distancing was associated with a 29% reduced risk of covid-19 incidence and a 35% reduced risk of covid-19 mortality 22 at the county-level. in a separate study, covid-19 epidemic case growth rates declined by approximately 1% per day beginning four days after statewide social distancing measures were implemented 21 . in addition, estimated rates of covid-19 cases were increased in border counties in iowa which did not issue a stay-at-home order compared with border counties in illinois which did issue a stay-at-home order 23 . another study based on 149 countries demonstrated that any physical distancing intervention was associated with 13% reduced risk of covid-19 incidence 3 . these finding add to this body of evidence as we estimate the impact of social distancing in the community on individual-level outcomes. other studies have shown that masking is associated with a lower risk of covid-19 on a populationscale 6, 7, 13, 25, 29 . in one recent study among health care workers, universal masking in a hospital setting was associated with a lower rate of covid-19 6, 30 . a recent meta-analysis demonstrated that face mask use was associated with a 85% reduced risk of viral infection causing covid-19, sars (severe acute respiratory syndrome), or mers (middle east respiratory syndrome) in both health care and non-health care settings 7 . while the role of a face mask in protecting other individuals is well-recognized, we observed that a face mask may also protect individuals who wear them, as has been described by others 29 . alternatively, participants who generally are willing to wear a face (or self-report such) mask may also engage in overall healthier behaviors. this study has several strengths. first, we used a mobile application to rapidly collect prospective data from a large population on known or suspected covid-19 personal risk factors, such as mask wearing. this is a significant advantage over existing studies which cannot concurrently examine the impact of personal interventions to reduce exposure risk with community-scale data. second, we collected data from participants initially free of a positive covid-19 test and any symptoms, which allowed a prospective assessment of incident symptoms with minimal recall or collider bias. third, we assessed covid-19 incidence according to a validated symptom assessment which minimizes the biases associated with geographic variation in access 31 to covid-19 testing on estimates of covid-19 incidence, which may bias effect estimates away from or towards the null (e.g. social distancing associated with reduced test access or increased test seeking behavior). this also allows us to better assess the impact of social distancing on covid-19 according to different latency periods since it . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted november 13, 2020. ; https://doi.org/10.1101/2020.11.11.20229500 doi: medrxiv preprint minimizes the time delay between onset of infection, obtaining a test, and reporting of the result, which has been estimated to be delayed by as long as a week in some areas of the u.s. 32,33 . there are several limitations to our study. first, our information on risk factors and symptoms are collected by self-report. although information based on clinical records and testing would be more accurate, given the rapid pace of the pandemic and the limited availability of medical care and testing, self-reported information is more feasible to collect longitudinally and prospectively among a large number of participants and minimizes recall bias or selection bias (e.g. preferentially capturing severe cases through hospitalization records or death reports). second, since our cohort is not a random sampling of the population, there remains a possibility for selection or collider bias, as well as generalizability. we tried to minimize collider bias in this study by excluding participants who reported having covid-19 symptoms prior to joining the app. although this limitation is inherent to any study requiring voluntary provision of information, we acknowledge that data collection through smartphone adoption has comparatively lower penetrance among certain socioeconomic groups and older adults and that participants of an app study may have differential likelihood of reporting symptoms 34 . third, it is possible that the personal risk factors for covid-19 that we assessed here, such as wearing a face mask, may be confounded by other behaviors that reduce infection risk, as well as whether users are accurately selfreporting these behaviors. fourth, the social distancing metrics used as an exposure are not reflective of actual user mobility. there may be non-differential misclassification of exposure status by region, if county-level factors are correlated with the individual-level heterogeneity of each mobility metric (e.g. younger app users in an urban area with high mobility). fifth, our analysis was focused on symptomatic covid-19. however, it is likely that an association between social distancing and masking with risk of asymptomatic spread would be similar. lastly, while personal face mask use and other covariates were based on individual level data reported through the app, the social distancing measures are based on regionally aggregated data assigned to each app user. in conclusion, within a large population-based sample of individuals in the u.s, we demonstrated a significantly reduced risk of predicted covid-19 infection among individuals living in communities with a greater social distancing grade at 14 days either in regions or time periods experiencing either epidemic slowing or growth. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted november 13, 2020. ; https://doi.org/10.1101/2020.11.11.20229500 doi: medrxiv preprint among participants who lived in a community with poor social distancing, wearing a face mask was associated with reduced risk. these findings provide additional support for the efficacy of non-pharmaceutical interventions in reducing covid-19 incidence and spread and suggest that the benefits of such interventions will become most evident at 14 days after implementation. encouraging universal masking may be particularly important to limit the continued spread of covid-19 as social distancing mandates continue to be relaxed. research uk (hdruk)/sail consortium, housed in the uk secure e-research platform (ukserp) in swansea. anonymized data can be shared with bonafide researchers via hdruk, provided the request is made according to their protocols and is in the public interest (see https://healthdatagateway.org/detail/9b604483-9cdc-41b2-b82c-14ee3dd705f6). data updates can be found at https://covid.joinzoe.com. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted november 13, 2020. ; https://doi.org/10.1101/2020.11.11.20229500 doi: medrxiv preprint , state, and calendar date at study entry and further adjusted for race (white, black, asian, or other), sex (male or female), population density of residence (quartiles), current smoking, frontline healthcare worker, interaction with suspected or documented covid-19, history of diabetes, heart disease, lung disease, and kidney disease (each yes or no). . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted november 13, 2020. ; a overall social distancing grades are denoted as poor (f grade), fair (d grade), good (c grade), and excellent (a+b grade) from unacast mobility data. b the proportion of race was calculated among the participants who received the race question which was added at april 18, 2020. c asked as "in general, do you have any health problems that require you to stay at home?" d asked as "do you regularly use a stick, walking frame or wheelchair to get about?" e asked as "in general, do you have any health problems that require you to limit your activities?" a use of a face mask was collected from 139,690 participants beginning on june 12, 2020 based on the query "in the last week, did you wear a face mask when outside the house?". b ever wearing a face mask includes sometimes, most of the time, or always wearing a face mask as a time-varying variable. c model 1 was stratified by age (<25, 25-34, 35-44, 45-54, 55-64, or ≥65), state, and calendar date at study entry. d model 2 was stratified by age (<25, 25-34, 35-44, 45-54, 55-64, ≥65), state, and calendar date at study entry and further adjusted for race (white, black, asian, or other), sex (male or female), population density (quartiles), current smoking, frontline healthcare worker, interaction with suspected or documented covid-19, history of diabetes, heart disease, lung disease, and kidney disease (each yes or no). e overall social distancing grades are denoted as poor (f grade), fair (d grade), good (c grade), and excellent (a+b grade). overall social grade categories (a, b, c, d, and f) are provided by unacast. f p for interaction was calculated based on model 2. coronavirus: the world in lockdown in maps and charts spread and dynamics of the covid-19 epidemic in italy: effects of emergency containment measures physical distancing interventions and incidence of coronavirus disease 2019: 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practical considerations for measuring the effective reproductive number, rt. medrxiv real-time tracking of self-reported symptoms to predict potential covid-19 covid-19 data repository by the center for systems science and engineering an interactive web-based dashboard to track covid-19 in real time using influenza surveillance networks to estimate state-specific prevalence of sars-cov-2 in the united states seroprevalence of antibodies to sars-cov-2 in 10 sites in the united states social distancing to slow the us covid-19 epidemic: longitudinal pretestposttest comparison group study effect of social distancing on covid-19 incidence and mortality in the us. medrxiv comparison of estimated rates of coronavirus disease 2019 (covid-19) in border counties in iowa without a stay-at-home order and border counties in illinois with a stay-at-home order mobile device data reveal the dynamics in a positive relationship between human mobility and covid-19 infections ihme covid-19 forecasting team. modeling covid-19 scenarios for the united states effect of timing of and adherence to social distancing measures on covid-19 burden in the united states covid-19 transmission in the u.s. before vs. after relaxation of statewide social distancing measures mobility network models of covid-19 explain inequities and inform reopening masks do more than protect others during covid-19: reducing the inoculum of sars-cov-2 to protect the wearer effects of universal masking on massachusetts healthcare workers' covid-19 incidence geographic access to united states sars-cov-2 testing sites highlights healthcare disparities and may bias transmission estimates how the government delayed coronavirus testing pew research center for internet & technology: mobile fact sheet. 2020 we would like to thank to all of the participants who entered data into the app, including study volunteers enrolled in cohorts within the coronavirus pandemic epidemiology (cope) consortium. we thank the staff of zoe global ltd., the department of twin research at king's college london, and the clinical and translational epidemiology unit at massachusetts general hospital. key: cord-309161-ceahghs1 authors: epel, elissa s. title: the geroscience agenda: what does stress have to do with it? date: 2020-09-28 journal: ageing res rev doi: 10.1016/j.arr.2020.101167 sha: doc_id: 309161 cord_uid: ceahghs1 geroscience offers a counterpoint to the challenged pursuit of curing diseases of aging by focusing on slowing the biological aging process for extended healthspan earlier in life. remarkable progress has led this field toward animal trials and the next challenge lies with translation to humans. there is an emerging number of small human trials that can take advantage of new models integrating behavioral and social factors. understanding dynamic aging mechanisms, given the powerful social determinants of aging (crimmins, 2019) and human variability and environmental contexts (moffitt, 2019), will be critical. behavioral and social factors are intrinsic to aging. toxic stressors broadly defined can lead to stress-acceleration of aging, either directly impacting aging processes or by shaping poor behavioral health, and underlie the socioeconomic disparities of aging. in contrast, hormetic stressors, acute intermittent stressors of moderate intensity, can produce stress resilience, the ability for quick recovery and possibly rejuvenation of cells and tissues. although health research usually examines static biomarkers, aging is reflected in ability to recover from challenges pointing to new interventions and targets for examining mechanisms. a fuller model incorporating stress resilience provides innovative biobehavioral interventions, both for bolstering response to challenges, such as covid-19, and for improving healthspan. circumstances and substances. hormesis traditionally described a cells or organisms bi-phasic response to an external chemical or stressor. there is indeed overlap between stress processes and aging processes, and two become intertwined with the concept of hormesis. toxic stress includes traumatic or ongoing adversity for months on end, and the psychological responses--chronic high perceived stress, burnout, or depression. many large scale studies demonstrate that traumatic or chronic psychosocial adversity, including low socioeconomic status, predict higher allostatic load, whereas high levels of psychosocial resources are associated with lower allostatic load, with small but reliable effects (danese & mcewen, 2012; wiley et al., 2017) , described further under "reserve capacity" (section 3). homeostasis to allostatic load. stress research started with examination of the acute stress responses to acute stressors in rodents. cannon's stress studies led to the popular concept of homeostasis (cannon, 1932) but a simple linear model of homeostasis does not explain the range of human stress responses, and there have been many elaborations of this concept. selye described the continuum from acute stress to chronic stress (selye, 1956) . acute stress can be hormetic when there is quick recovery back to homeostasis. given the complexity of physiological regulation, and that our body mounts a response in mere anticipation of threat, sterling and colleagues have described allostasis as a more encompassing description of the body's regulation-the constant fluctuations to meet expected demands (schulkin & sterling, 2019) which in biogerontology has been called "homeodynamics." chronicity of stressor exposure reveals a "fragility in homeostasis" (ramsay & woods, 2014) when physiological signs of 'exhaustion' appear, such as, in rodents, damage in organs. mcewen and colleagues have labeled this cost of adaptation--the dysregulation and damage across systems--as allostatic load (mcewen, 2004) . the concept of allostatic load, whether it is at a systemic or cellular level, gives us an intermediate phenotype of aging, an early step toward development of diagnosable disease. this is a critical concept to geroscience, and in fact many of the actual measures of allostatic j o u r n a l p r e -p r o o f load used in from the psychology and public health literature are actually indices of aging (entringer & epel, 2020) . geroscience leaders have started to identify the biomarkers important in geroscience trials, as those that can predict aging outcomes and mortality, and are responsive to interventions, and this short list includes glucose control and inflammation (justice et al., 2018) . thus, there is potentially great overlap between geroscience biomarkers and the stress-related allostatic load markers described in section 3 (cellular, multi-system, and measures of recovery), and these fields can inform each other. 1. an integrative model of stress and aging. stress acceleration (toxic stress) and stress rejuvenescence (hormetic stress). given the important role of social stress in aging, we need a deeper understanding of types of stress exposures. an overarching model explains the range of stress exposures, from toxic stress to acute hormetic stress, and our body's diverging responses to these exposures. our stress responses are not typically thought of as basic mechanisms of aging but indeed they are actively shaping rate of aging. as shown in figure 1 , the dose and intensity of the stressor determines in part whether the organism responds with positive physiological changes or impairments in aging processes (modified from franceschi et al., 2018) . the exact timing of stressor exposure is an important consideration of a hormetic or pre-conditioning effect, as some stressors lead to sensitization across stressors, rather than habituation (i.e., belda et al., 2016) and this may differ by species, stage of development, and stressor paradigm. therefore, a general model cannot determine the exact parameters of intensity and dose for hormetic stressors. it is important area of future research to identify the boundary conditions and inflection points for the range of potentially hormetic stressors . moderate stressor exposure can lead to both housecleaning in the cells, making them appear younger or rejuvenated, as well as growth of new neural pathways. over time, the accumulation of hormetic stress can promote slowing of aging processes. j o u r n a l p r e -p r o o f 1.1 hormesis is a form of stress resilience. this paper brings together the hormesis literature with the broader stress resilience literature. the cellular biology of hormetic responses is well mapped, and has general common responses as well as stressor specific responses. the acute stress response has a common pathway of creating calcium influx, oxidative stress, and energetic stress. this increases transcription factors such as nrf-2, foxos, creb, and nf-kb, leading to many hormetic effectors, such as chaperone proteins (eg, heat shock proteins which help fold proteins efficiently and prevent protein aggregation), er stress, endogenous antioxidants (sod, glutathione), growth factors, and mitochondrial proteins (mattson, 2008a) . after moderate doses, the cells become resistant to many other types of stressors (heat, uv, oxidative stress, metals), and to death (murakami et al., 2003) . hormesis is a universally observed phenomena across types of cells and types of stressors, including psychological stress. in model organisms, short manageable stressors lead to improvements in aging, although this depends on types of stressor and species (lagisz et al., 2013; rattan, 2008) . for example, low dose gamma radiation over time can extend average lifespan up to 30% in mouse studies (calabrese & baldwin, 2000) . in humans, there is evidence of hormetic stress, such as the effects of exercise, although this is not typically labeled as hormesis. hormesis naturally applies to humans-not just to cells but to physiological and psychological regulation. a typical example is vaccinationwhich leads to enhanced immune responses later. here we expand the definition of hormetic stress to include the positive stressors that humans engage in-such as short term bodily stressors like exercise and temperature stress, but also novel challenging experiences that expand coping resources, knowledge, generativity, and feelings of accomplishment, described further below (section 1.2). since hormetic stress has traditionally been applied to cellular physiology, we use the larger concept of 'stress resilience' as the widest umbrella term for describing when humans recover quickly, in any system, from various exposures. as shown in the appendix, there are many j o u r n a l p r e -p r o o f overlapping terms that relate to the concept of stress resilience. just as the term "stress" is a multi-level construct that needs to examination in a sophisticated interdisciplinary manner, stress resilience is also a multi-level concept that encompasses the full range of human exposures, responses, and inter-related systems. the term stress resilience thus subsumes psychological resilience, physiological resilience/enhanced allostasis, and social resilience. this model of stress resilience can thus be applied to most processes--at the cellular level, physiological level, and psychosocial level. psychosocial stress resilience here refers to the dynamic recovery in psychological, behavioral and social processes and related physiological processes. high stress resilience is reflected by quick physiological and affective recovery from psychological stressors. the neurochemistry of psychological resilience has also been described, based on rodent models (cathomas et al., 2019) . whether a stressor leads to a hormetic or toxic response is not solely determined by the chronicity of the stressor. it is also determined in part by the psychological appraisals, which is shaped by the context, culture, personal history and personality of the individual. when one feels demands exceed resources, in any situation, this creates a physiological and emotional stress response (folkman et al., 1986) . if it is perceived as a threat they cannot cope with, this repeated stress response over time will last longer and be more wearing. in contrast, if they view it as positive challenge that they have the resources for, they will have a profile of quicker recovery, as summarized elsewhere . thus the appraisal of the stressor codetermines the physiological response. it is not just stress responses to major events that matter. our frequent daily stress responses have cumulative effects: the tendency to have slower recovery of negative mood or greater loss of positive mood after a daily stressor predicts inflammation and long term disease and mortality mroczek et al., 2015; piazza et al., 2013; sin et al., 2015) . short term manageable stressors, such as physical or cognitive challenge that can promote growth, learning and development can lead to protective responses. an example of this is found in studies of the experience corps. exposing elderly retired people who are often isolated to a job mentoring at-risk youth in schools is often viewed as stressful but leads to feeling more purpose in life. in men, it has been linked to better health and increases in hippocampal volume gruenewald et al., 2015; varma et al., 2015) . in the case of coping with chronic stressors, most people (around 80%) recover to baseline levels of well being after a loss or disaster (galatzer-levy et al., 2018) . resilience may develop over time, leading to more mastery, purpose, faith, self esteem, and thus more resilient responses to future stressors. in contrast, toxic exposures accumulate over a lifetime, promoting "stress-acceleration of aging" processes. chronic stressors for decades, multiple shorter term exposures over years, and stressors embedded early in life, can all have toxic effects when there is insufficient resources to cope, and nor opportunities to fully recover. developmental factors are critical for understanding when stressors can be hormetic vs. toxic. we do not know precise developmental trajectories for differential effects of toxic stress on mental and physical health and even less is known about hormesis across the human lifespan. with aging, there is a decrease in both the reproductive and anabolic hormones that are part of a salutary acute stress response (epel et al., 1998) , and also a reduction in aspects of molecular hormesis, such as a lower heat shock response to stressors (calabrese et al., 2014; epel, 2008) . we know most about the developmental impact of toxic stressors. while there are myriad individual patterns of exposures, traumatic stress or material deprivation have larger effects early in life than when they occur at later periods; early life adversity is predictive of a range of poor outcomes, including poor mental health, health behaviors, biomarkers of aging, and earlier disease onset (deighton et al., 2018; hughes et al., 2017) although plasticity is still possible (mcewen & morrison, 2013) . given the sensitive period j o u r n a l p r e -p r o o f of pregnancy, it is not surprising there is evidence of transgenerational effects of stress and pregnancy complications on systems regulating aging like telomeres and epigenetics (epel, 2020; girchenko et al., 2017; ross et al., 2020) . a careful meta-analysis of the effects of early adversity points to psychological threat, rather than material deprivation, as the factor underlying accelerated biological aging such as early puberty, telomere shortening, and brain development (colich et al., 2020) . for trauma and abuse, the earlier in life, prenatal and pre-pubertal, when the brain is most rapidly developing, the larger the imprint of lifelong effects on mental and physical health (agorastos et al., 2018) . there are many examples of early adversity with accelerated biomarkers of aging in children: in prepubertal children, early life adversity leads to greater inflammatory acute stress response, and basal inflammation several years later (slopen et al., 2014) . in prepubescent youth, exposure to violence is associated prospectively with telomere shortening (shalev et al., 2013) , and telomere shortness in early childhood predicts carotid artery thickness several years later, and during puberty (barraclough et al., 2019; skilton et al., 2016) . early adversity may accelerate aging in part through inducing early puberty which in turn is linked to earlier onset of metabolic disease (gur et al., 2019; sun et al., 2017) . early adversity may also initiate a trajectory of early aging through lower reserve capacity such as low optimism and higher stressful events in adulthood (surachman et al., 2019) . early adversity also predicts poor health behaviors such as sedentariness, smoking and substance use in youth (wiehn et al., 2018) and these habits appear to persist long into adulthood . the pillars of mammalian aging, represent fundamental and related pathways such as genomic instability, telomere attrition, epigenetic alterations, loss of proteostasis, metabolic pathways such as deregulated nutrient sensing, mitochondrial j o u r n a l p r e -p r o o f dysfunction, cellular senescence, stem cell exhaustion, and altered intercellular communication, macromolecular damage, chronic low-grade inflammation, and adaptation to stress (kennedy et al., 2014; lópez-otín et al., 2013) . other hallmarks of cellular aging are being identified in the brain (mattson & arumugam, 2018) . molecular pathways are often not closely related to each other, pointing to the use of algorithms, for better prediction of outcomes, described below. several of these basic mechanisms in immune cells have been associated with aspects of social stress, including systemic inflammation and shorter telomeres (epel et al., 2004; kiecolt-glaser et al., 2011; miller et al., 2008) poor mitochondrial function (picard et al., 2018) , and accelerated epigenetic aging (park et al., 2019; wolf et al., 2018) . these associations with lifespan stress demonstrate there is no closed system of intrinsic aging, and even at these most molecular levels our aging rate is influenced by our life exposures. we cannot rule out the possibility that some of these observations are from transgenerational effects. a new practical approach already used in humans is to measure a panel of biomarkers of aging that reflect cumulative damage across regulatory systems (e.g., metabolic, immune, stress related), and reducing this a composite measure. the first of these measures was allostatic load (seeman et al., 2001) , and there are newer algorithm measures like 'pace of aging' (belsky, caspi, et al., 2017) , and lack of normal covariation among regulatory systems (belsky, huffman, et al., 2017) . these measures serve as a barometer of biological aging across the lifespan, linked to early experience, and may be useful to examine the effect of interventions (moffitt, this issue). so far, the markers used have been chosen out of convenience of availability, but there is exciting potential to develop further translational measures based more directly on the basic mechanisms of aging. this admittedly requires high intensity collaboration between basic and clinical scientists (eg, assessments of mtor activity, senescent cells, mitochondrial functioning). 2.3 speed of recovery as a novel measure of latent aging at any age. geroscience recognizes that physiological adaptation to stress stands out as a common phenotype of aging j o u r n a l p r e -p r o o f across model systems of aging. stress resilience, and its impairment, is partly an outcome of the social hallmarks of aging, and a common underlying process that in part regulates the cellular hallmarks of aging. snapshot one-time measures of aging based on blood have inherent limitations in that they do not directly test how a person responds to an acute stressor. recovery from challenge is a critical measure of stress resilience that may be important, as it assesses the latent homeostatic capacity of a system. speed of recovery is thought of as intrinsic homeostatic capacity, a latent capacity that reflects biological aging. recovery is such an important marker of aging that it is central to the emerging areas of 'physiological geroscience" and "translational geroscience." naturalistically, acute events often precede a rapid decline in function, reflecting lack of stress resilience. for example, 50% of new disabilities develop after an acute accident or illness and hospitalization (gill et al., 2004) . there are many examples of paradigms measuring recovery that have validated the importance of using a challenge, and measuring functional or biological recovery from the challenge. frailty is a measure of advanced biological age that reflects loss of stress resilience due to age related decline in physiological reserve (hoogendijk et al., 2019) . however, frailty is a final common pathway, one that is probably not reversible. stress resilience interventions will need to target people earlier in life long before frailty sets in. in contrast physiological resilience, which refers to ability to bounce back from a stressor, is measurable at any age (whitson et al., 2016 (whitson et al., , 2018 . stress resilience depends in part on the pre-existing level of reserve capacity, the positive protective factors of an organism, as well as the immediate adaptive psychological response to stressors (cognitive appraisals). in the stress literature, reserve capacity has been defined as j o u r n a l p r e -p r o o f combination of personal resources such as optimism and sense of control, and social factors such as social support. high psychosocial reserve capacity appears to buffer those from low ses backgrounds from developing cardiovascular disease (matthews et al., 2008) . in geroscience, reserve capacity refers to a broader set of resources of or buffers, social, psychological or physiological including cognitive function (e.g., high iq), physiological (e.g., aerobic fitness, sleep), and psychological assets (e.g., high optimism or positive affect). high reserve capacity increases the likelihood that one will have a hormetic protective response to a stressor. as shown in figure 2 , after diverse types of stressors (eg, chemical, physiological or psychological), an organism reacts and recovers to baseline with different speeds and this is moderated by baseline reserve capacity. for example, in response to a hip replacement surgery, the biggest predictor of good recovery was reporting good physical function at baseline (colón-emeric et al., 2019) . in response to general anesthesia, predictors of protection from dementia and other cognitive outcomes was measures of cognitive reserve such as education and vocabulary ability (cizginer et al., 2017) . indices of reserve capacity in functional abilities (such as ability to stand, gait speed, level of fitness), and glucose-insulin response to a glucose load, predict time to mortality, as reviewed elsewhere (seals & melov, 2014) . one of the most well-developed areas of reserve capacity comes from examination of individual dispositions of temperament, typically called personality traits. there are many psychological assets in adulthood that are associated with both better recovery from stressors, and with health and mortality. these include optimism, positive affect, mindfulness, coping with stress with cognitive reappraisal or active coping, high presence of social support or seeking support, purpose in life, and quality relationships. many of these assets have been associated with indices of good health, such as self-reported health and higher heart rate variability (carnevali et al., 2018) . these positive assets are both shaped by genetics and life experience. will promote further positive responses to future stressors, and may help slow the rate of aging in humans, as shown in figure 1 . how can we best translate hormetic interventions to humans? there are many potential interventions that may improve stress resilience, listed in table 1 . lifestyle interventions, such as exercise, caloric restriction, intermittent fasting, challenging cognitive activities, and response to phytochemicals in vegetables and fruits, are thought to work in part through hormesis (mattson, 2008b; radak et al., 2017) . at least one group is pilot testing a cocktail of stressors in humans to examine rejuvenation effects, using intermittent cold, heat, fasting and hypoxia, together with phytochemicals (pruimboom et al., 2016) . the hypoxic preconditioning effect demonstrates protection of neurons and cardiac cells, and is a potential area of translation (li et al., 2017 ). an interesting novel intervention inducing acute stress (through exposure to intermittent hypoxia and cold) appears to improve immune response to endotoxin at least in a small initial study, with a replication underway (kox et al., 2014) . at ucsf we are testing a similar protocol to see if it improves autonomic and neuroendocrine response profiles (including a quicker recovery from acute stress). another dramatic way to increase stress resilience is to enter periods of fasting, or fasting mimicking with low calories. in rodents, this leads to stress resistance and regeneration and rejuvenation processes through hormesis, in part by down regulating gh, igf-1. mtor, and pka signaling (longo, 2019; rangan et al., 2019) . reserve capacity is built during formative developmental experiences, such as level of education, attachment relationships, and stress exposures that shape the neural architecture of stress responding, narratives of optimism, and foster positive challenge mindsets. one can build reserve capacity by increasing physiological buffers (fitness, or antioxidant diet), or psychological stress resilience, through psychological trainings that might decreasing chronic stress arousal and bolster one's mental filter so they j o u r n a l p r e -p r o o f habitually perceive less threat. interventions that build psychological positive assets like optimism, mastery, and purpose in life need to be further developed and refined. mind-body interventions have a strong empirical base for improving self-reported wellbeing (creswell, 2017) with mixed effects on basal inflammation (bower & irwin, 2016) . mindfulness training may lead to changes in heart rate variability and telomere biology, although the evidence again varies by population and study (rådmark et al., 2019) (conklin et al., 2019) and appears stronger with clinical samples-those with high stress or early disease. there is emerging evidence that mind-body interventions improve physiological acute stress reactivity, changing stress appraisals and physiology to more of a positive challenge profile with a strong peak and faster recovery (daubenmier et al., 2019; lindsay et al., 2018) health behaviors regulate healthspan. the social hallmarks of aging shape health behaviors from an early age, which track throughout life. adverse health behaviors, such as diet, physical activity, sleep, and smoking are shaped by social stress. chronic stress both biologically drives toxic nutrition choices (sugar, fast food), impairs sleep, and promotes addictions, an indirect pathway in stress-acceleration of aging. the converse is also true, health behaviors lead to stress-slowing of aging. seventh day adventist who practice lifelong positive health behaviors, and lack the adverse behaviors of substance use, tend to have optimal longevity, living at least four years longer than the average us life expectancy and thus being the only blue zone in the us (fraser & shavlik, 2001) . exercise is the prototypical hormetic intervention. it increases the odds of healthy aging by 39% (daskalopoulou et al., 2017) . the mechanisms at the cellular level are becoming well explicated, as it can enhance mitochondrial health, telomere biology glucose, v02 max, oxidative stress, no) and upregulation stress resistance pathways, such as autophagy, and creating the opportunity for a long healthspan for all (health equity) requires improving economic and social factors. social factors are intrinsic to aging, our rate of aging depends on our social context and conditions. material deprivation and poor neighborhood quality confer psychological stress and risk of poor mental and physiological health (brisson et al., 2020) . for example, food insecurity is associated with over two fold risk of clinical anxiety or depression in adults, and confers even higher risk in college students (arenas et al., 2019; leung et al., 2020) . we now have a better understanding of how social threats lead to toxic stress. the primary motivational forces shaping human behavior are seeking safety and connection with others, and avoiding danger and anxiety. our mind is constantly seeking cues for safety or danger, even when we are not aware of this, and these social signals are transduced to biological signals, including patterns of autonomic activity and gene expression that are linked to inflammation. it is thought that exposure to or perception of frequent social threats (such as social rejection, discrimination, violence, and lack of safety) creates higher chronic systemic inflammation and sympathetic arousal, even while sleeping, and greater risk of affective disorders (brosschot et al., 2017; o'donovan et al., 2013; slavich, 2020; slavich et al., 2010) . conversely, social support, and social capital including perceived safety in neighborhoods, may be stress buffering, and are often associated with less inflammation and longer telomeres (brown et al., 2020; rentscher et al., 2020; thames et al., 2019) (geronimus et al., 2015; m. park et al., 2015) . social support and social networks can bolster healthspan interventions: our stress, emotional and physiological, is contagious to close others (carnevali et al., 2020; engert et al., 2019) , and conversely positive emotion and positive health behaviors are also socially influenced (christakis & fowler, 2013; kim et al., 2015) . the geroscience interventions that may work in mice will not be useful if they cannot be translated well to humans, taking into account our need for support and the significant challenges we have with adherence to exercise and other lifestyle changes. poor behaviors can override effects of protective pharmaceuticals. a common example of this is that people still develop diabetes while taking metformin due to overeating a western junk food diet. improving health behaviors can best be prioritized and implemented in the context where basic social needs are met. creating a supportive built environment and positive social environment are critical to promoting long-term behavior change. the science of behavior change, including the nih initiative focusing on this (nielsen et al., 2018) , has dramatically raised the sophistication of the research in this area, using the experimental medicine model to identify and manipulate the behavioral and social factors that facilitate adherence to health behaviors. behavioral or health interventions that work beyond the individual level, that can decrease loneliness and improve support will be more successful. the covid-19 pandemic demonstrates well the role of social factors in resilience to mental health disorders and infection. the pandemic led to dramatic increases in mental health disorders in the us and other countries (xiong et al., 2020) but this was not equally distributed. those with low education, income, minority status, loneliness, or low social support have significantly higher rates of mental health disorders from pandemic stress (arafa et al., 2020; holingue et al., 2020; palgi et al., 2020) . these vulnerable groups also tend to have higher rates of covid severity (adhikari et al., 2020; webb hooper et al., 2020) . any policies that improve social equity are also 'stress reducing' health policies that may contribute to healthspan, and can be incorporated into the geroscience agenda. geroscience is now more important than ever, both to our aging global demography but also to the health challenges we face going forward. in our new era we have dramatically increasing temperature extremes, wildfires and small particle pollution, and new zoonotic viruses to contend with intermittently. thus reducing social disparities, improving stress resilience and bolstering immune function have become critical public health goals. the vulnerability to covid-complications, while still largely unknown beyond older age and pre-existing diseases, clearly depends on ability of the immune system to respond robustly. the relevance of immune senescence in covid-lethality has stimulated many hypotheses about geroscience-related prevention and treatment (barzilai et al., 2020; salimi & hamlyn, 2020; sargiacomo et al., 2020) . while vaccination is essential for traditional prevention, it is not a universal solution: the elderly have poorer antibody responses to vaccination, there are many strains of the current virus, and there are expected to be many proliferations of future viral strains novel to the human body, due to climate change. therefore, geroscience interventions have unique universal importance across time. pharmacological interventions have been suggested for covid such as rapalogs, senoytics, nicotinamide adenine dinucleotide nad+, and metformin for anti-inflammation, telomere stability, or to boost vaccination response (omran & almaliki, 2020) . those with diabetes appear to benefit from metformin, which has hormetic properties, to prevent covid-related mortality (luo et al., 2020) . beyond pharmacological treatments, it is likely some of the interventions for boosting stress resilience in table 1 may enhance resistance to viral infections, from common cold to novel viruses. the malleable lifestyle behaviors like fitness, nutrition, sleep quality, and stress reduction, are important ways to reduce insulin resistance and comorbidities, and thus may help prevent immune senescence and covid complications. one pathway through which stress resilience interventions could impact immunity is through stabilizing telomere length. short telomeres predict greater vulnerability to rhinovirus infection, acute respiratory syndrome disorders, and mortality from sepsis (cohen et al., 2013; liu et al., 2020) . chronic psychological stress shortens telomeres in animal studies and impairs viral immunity (cohen et al., 1991 (cohen et al., , 1998 . short telomeres indicate lower ability to mount a robust replicative t cell response, and this may be a critical or even fatal j o u r n a l p r e -p r o o f limitation in the face of covid related lymphopenia (aviv, 2020) . in short, covid-19 presents a potent example of the potential for using indices of aging as predictors of disease and targets of intervention. the goal of geroscience is to slow aging to improve healthspan. in the next generation of research, we will benefit greatly from incorporating the large malleable factors that impact human aging-biobehavioral and social factors. the nia's intervention and testing program, a multi-institutional infrastructure to study biological agents for healthspan in animals is a model that can be extended to human trials that takes into account the social and behavioral factors (moffitt, this issue). the social hallmarks of aging shape rate of aging, in part through toxic stress processes. the understanding of toxic stress and hormetic stress as factors shaping aging will have implications for interventions. stress resilience, the ability to recover quickly and turn on rejuvenative processes, is an important dynamic endophenotype of healthy aging. it remains to be seen how much resilience is merely a characteristic of healthy aging or a causal factor, although much evidence reviewed here suggests it is at least partly causal. a better understanding of how to measure stress resilience, and to promote stress resilience at the cellular, physiological and psychosocial levels will lead to important gains in slowing aging. the science of stress is an integral part of geroscience, and offers insights on how to harness stress for optimal longevity, and implications for how to conduct the most effective interventions incorporating these stress processes as both target mechanisms and outcomes. by having an integrative paradigm that can be examined across levels, we can reduce the gap between physiological stress research in model organisms and human research on stress, resilience and adaptation. there are many ways to measure biological aging in humans that can serve as a barometer of change for interventions. this includes cellular level markers, multi-system composites, and ways of examining dynamic stress resilience, as reviewed. this j o u r n a l p r e -p r o o f can include recovery from a medical event in the elderly, but also recovery to standardized challenges, and to naturalistic stressors. geroscience offers an exciting opportunity for high feasibility impact interventions. this integrative paradigm can shape the next generation of researchers. the training models need to change to bridge the many fields as outlined by pioneers in geroscience (newman et al., 2019) . models which are focused on pharmacological interventions must expand to be inclusive of both social and behavioral interventions, the current 'big levers.' lastly, this field, like all of science, needs to actively encourage and support young investigators from diverse and underprivileged backgrounds to enter this important and growing field which has the potential to minimize socioeconomic and ethnic/racial health disparities not just for equity but for the improved science that results with diverse life experiences and perspectives. frameworks for proof of concept trials related to loss of physiological resilience have been initially outlined (justice et al., 2016) , and there are many geroscience trials in the field. these human trials can draw on the rich insights from decades of biobehavioral basic and intervention research. the science of behavior change initiative at nih is supporting the development of more effective behavioral and social interventions using the experimental medicine model using the same attention and rigor as pharmaceutical studies. by working across disciplines, with an understanding the role of lifespan experiences, and complexity of human environments, the geroscience framework has tremendous potential for breakthrough innovations in increasing healthspan. there has been a proliferation of terms from related disciplines that overlap and are differentiated here. the discipline most often using the term is noted, but these terms could be used to describe all levels of analysis, including cellular, physiological/organ systems, or psychological, behavioral and social processes. resilience has also been applied ast the systems level, to organizations, communities, societies, and ecosystems. how systems change in response to stressors, typically referring to level of hermetic or a protective adaptive responses in cell such as heat shock protein increases. (mattson) . mild stressors induce adaptive capacities that protect an organism for a short while from future stressors and may improve the physiological state of that organisms. preconditioning is a case of hormesis where exposure to a chemical agent leads to a 30-60% stronger adaptive response to subsequent exposures, across cell types and stressors (calabrese, 201) . in psychology, the tem 'stress inoculation' is used in a similar way. in terms of psychological stressors, under-exposure to the typical daily and major life events can lead to lack of development of stress buffering resources, and poor ability to quickly recover from stressors. biologically the lack of acute stressors prevents the intermittent episodes of cellular 'housecleaning' activities that slow aging. ideal exposure to sufficient numbers of manageable challenges throughout life stimulate cognitive growth, coping skills, and emotion regulation skills, as well as the need for supportive social networks. biologically, ideal exposure to acute stress can have hormetic effects, leading to rejuvenescence-functioning that is enhanced (or "younger") compared to baseline. overexposure to stress without sufficient resources (toxic stress) can lead to maladaptive neural pathways of overresponding to stress, depression, and stress related acceleration of aging from cells to regulatory systems. this figure is adapted from francheschi et al, 2018. in response to acute stressors, individuals have a kinetic trajectory of responses across psychological and physiological regulatory systems that lead to reactivity and recovery profiles. resilient stress responses (typically rapid high peak and rapid recovery) often have hormetic effects at the cellular or systemic levels. high levels of reserve capacity predict more rapid recovery, and this may lead to a positive feedback loop promoting higher reserve capacity. level of stress resilience is multiply determined by the social context and individual 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perspective on life stress, health, and behavior black sheep get the blues: a psychobiological model of social rejection and depression childhood adversity, adult neighborhood context, and cumulative biological risk for chronic diseases in adulthood childhood social disadvantage and pubertal timing: a national birth cohort from australia life course socioeconomic status, daily stressors, and daily well-being: examining chain of risk models experienced discrimination and racial differences in leukocyte gene expression experience corps baltimore: exploring the stressors and j o u r n a l p r e -p r o o f rewards of high-intensity civic engagement heritability of personality: a meta-analysis of behavior genetic studies covid-19 and racial/ethnic disparities physical resilience: not simply the opposite of frailty physical resilience in older adults: systematic review and development of an emerging construct how adverse childhood experiences relate to single and multiple health risk behaviours in german public university students: a crosssectional analysis relationship of psychosocial resources with allostatic load: a systematic review traumatic stress and accelerated dna methylation age: a meta-analysis impact of covid-19 pandemic on mental health in the general population: a systematic review the impact of changes in population health and mortality on future prevalence of alzheimer's disease and other dementias in the united states crimmins, steve austad, and edward calabrese. key: cord-317900-05y9re12 authors: senanayake, nari; king, brian title: geographies of uncertainty date: 2020-08-14 journal: geoforum doi: 10.1016/j.geoforum.2020.07.016 sha: doc_id: 317900 cord_uid: 05y9re12 abstract the question of uncertainty has generated substantial critical engagements across the social sciences. while much of this literature falls within the domains of anthropology, science studies, and sociology, this short introductory paper highlights how geographical scholarship can also enrich emerging transdisciplinary debates on uncertainty. specifically, we discuss how geographers engage with uncertainties produced through and reconfigured by some of the most formidable issues of our contemporary moment, including neoliberal transformation, disease and illness, resource conflict, global climate change, and ongoing struggles around knowledge, power, and justice. in conversation with debates in cognate fields, this special issue brings together contributions that grapple with uncertainty through key geographic concepts such as scale, power, spatiality, place, and human-environment relations. this work extends scholarly understanding of howuncertaintyarises, is stabilized, and also how people navigate, experience, challenge, and rationalizeuncertaintyin everyday life. in doing so, we signal the immense potential offered by emerging intersections between human geography and broader critical social science interventions on the question of uncertainty. uncertaintyand its cognates, indeterminacy, liminality, obscurity, confusion, and misperceptionincreasingly pervade social and environmental problems. they are, for instance, endemic features of neoliberal transformation, health-environment interactions, food (in) security, natural disasters, resource conflict, and global climate change. while the question of uncertainty is not new, it increasingly captivates popular imagination in the context of these highly dynamic, contested and intractable problems, thereby catalyzing academic interest across the social sciences. yet despite the pervasiveness of uncertainty in daily life and forms of academic inquiry, few of the contributions associated with this transdisciplinary literature are geographical. as a consequence, this special issue demonstrates new ways that geographers can enrich work in this field, while also highlighting the potential of the concept to reshape approaches to topics, themes, and foci that the discipline actively pioneers. the articles in this special issue collectively respond to two trends that have historically sidelined the influence of critical human geographic scholarship in transdisciplinary debates about uncertainty. first, while the problem of uncertainty has received substantial attention in academic work across the fields of science and technology studies (sts), anthropology, sociology, and development studies, texts that explore uncertainty through a critical and explicit engagement with geographical concepts are relatively few and far between (we discuss some recent and promising exceptions below). second, within the discipline of geography itself, the question of uncertainty has largely been interrogated by quantitative and spatial perspectives that have given rise to various taxonomies of incertitude (kwan and schwanen, 2018; kwan, 2012; griffith, 2018) . fewer geographers, however, use qualitative and ethnographic methodologies to explore how the limits of knowledge become spatially generative, and/or operate as a direct force shaping social life. this is surprising given that the question of uncertainty is increasingly intertwined with contexts and problems that human geographers have long engaged, such as globalization, disease and illness, migration, and ongoing struggles around knowledge, power, and justice. furthermore, the multiple challenges and/or opportunities created by uncertainties in such contexts arise from and often rework central preoccupations in the subdiscipline of critical human geography; namely, socio-spatial and human-environmental relationships. approaches from human geographers could therefore help enrich existing work through their perspectives on scale, power, spatiality, place, and human-environment relations. with all of this in mind, this special issue offers a timely reflection on geographies of uncertainty and uncertain geographies. we bring together papers that were presented at the 2018 annual meeting of the american association of geographers as part of two sessions organized around the question of uncertainty. our contributors engage with a wide spectrum of qualitative methodologies and empirical case studies in order to examine how uncertainty shapes places and landscapes, social relations, human health, and/or human-environment interactions. while these articles grapple with diffuse subjects, including banana disease, wolf management, pest eradication programs, and human health (hiv, ckdu, and silicosis), taken together they clearly articulate several key themes for future geographic scholarship. first, we explore how uncertainty is often produced through, and temporarily stabilized by, key geographic axes such as time, space, scale, and regimes of environmental governance. attending to the ways that uncertainty is experienced as a spatiotemporal condition, and how it frequently compounds across scales of knowledge production, enables the special issue's contributors to demonstrate how forms of incertitude work through geographic relationships. crucially, this work takes us beyond established approaches that tend to engage with geography only in so far as it helps situate the production of uncertainty within broader social, cultural and political-economic contexts. as part of this discussion, we also contribute to recent moves both within and beyond the discipline that theorize experiences of uncertainty from the spatial margins. beginning from what claire herrick (2017) dubs as "non-archetypal spaces of expertise" the papers assembled here reveal other knowledges and practices that teach us how to live with, and in some instances, to make a living from, experiences of uncertainty. in particular, our contributors are in dialogue with wider debates which suggest that responding to uncertainties often requires combining different styles of knowledge. as scoones (2019a, 29) concludes, bringing together "formal and informal, accredited and lay knowledge, and experiential and conceptual understandings… [are central to] addressing uncertainties in context through culturally embedded, experiential [forms of] learning" (also see: shattuck, 2020a) . a second intervention of the special issue examines how the production and productiveness of uncertainty can generate geographical outcomes and socio-ecological possibilities. a key point here is that while uncertainty can restructure social and ecological relationships, it does so in highly differentiated ways, often with unanticipated effects. as a consequence, our contributors demonstrate how uncertainty can reinforce exiting fault lines of inequality at the same time that it might generate new forms of social, spatial, and ecological difference. third, this collection of articles focuses on how uncertainty is reconfigured through human-non-human dialectics. drawing on a rich tradition of scholarship within the discipline of geography, our contributors grapple with what robbins (2012, 234) describes as "the stubbornness and intractability of certain properties of non-human things" such as the fugitive chemistry of suspected toxin(s), unstable viral loads, materially ambiguous and uncooperative agricultural pests, and illegible wildlife. these complex human-non-human interactions pose important challenges to western scientific and regulatory traditions with "huge implications for the practice of science, management and policy" (scoones, 2019a, 5) . indeed, the frequent failure to classify, record, and regulate unruly human-non-human dynamics opens up possibilities to engage with more experiential forms of learning, diverse knowledges, and democratic responses to the question of uncertainty. in short, these papers speak to ian scoones' (2019b) call to revolutionize "methodologies for science and policy that take uncertainties seriously" by exploring engagements with "experimentalism, citizen participation, transformative action and 'post-normal' science." fourth, our contributors raise critical questions about the politics of uncertainty and in particular, how it indexes new forms of accountability, governance, and regulation. on the one hand, several articles demonstrate how uncertainty is strategically deployed in ways that individuate responsibility for environmental risk. in particular these studies demonstrate how uncertainty is often weaponized to reproduce both the imperceptibility of links between health and environment and the unaccountability of the structural forces that produce them. on the other hand, the papers in this special issue explore the potential of embracing uncertainty as a pathway to open "up a more rigorous, robust, transparentand democratically accountableenvironmental politics" (stirling 2018, 120) . in sum, the existence of uncertainty is generative of politics and possibilities that can be mobilized for very different political (and geographical) ends. more broadly, in the context of covid-19, our intervention comes at a moment of heightened, albeit highly differentiated, experiences of uncertainty and risk. enduring uncertainties about disease prevalence, testing, spread, and treatment have intensified uneven life opportunities and unjust exclusions, while also reconfiguring patterns of mobility, care, and social reproduction (neely and lopez, 2020; dattani, 2020; hannah et al., 2020) . this crisis has also heralded new forms of intervention, regulation, and governance that are unfolding as this special issue goes to press. many of the contributions included in this collection speak to similar themes and demonstrate the entanglements of uncertainty and geography in our daily lives. in reviewing the broader literature associated with this special issue, we were struck by the marginal position human geography occupies within scholarship on uncertainty in the critical social sciences. this is not to say that human geographers have not recently taken up many of the substantive themes that are of interest in transdisciplinary debates. indeed, engagements with experiences of liminality, protracted uncertainty and indeterminacy within the subdiscipline have become increasingly wide-ranging in their ambit, investigating questions on migration and refugee resettlement (loyd, ehrkamp, and secor, 2018; mountz et al., 2002) , development (chung, 2017 (chung, , 2020 , climate futures and the anthropocene (nightingale, 2018) , neoliberalism (anderson et al., 2020) , identity and selfhood (march, 2020) , and humanitarianism (newhouse, 2017) . "uncertainty also appears as a key term in various geographic handbooks and encyclopedias (brown and damery, 2009; stirling, 2018) . within these volumes, scholars argue for greater analytical precision in approaches to uncertainty, differentiating it conceptually from risk, ambiguity, and ignorance (stirling, 2003; . 1 other authors reflect more broadly on how uncertainty poses "[1] philosophical challenges [for the discipline] regarding the nature, origins, and value of knowledge, [2] ethical challenges regarding acceptable levels of risk, and [3] political challenges concerning how to act and who has the mandate to decide" (brown and damery, 2009, 90) . cutting across all of these contributions, is the promise of geographical approaches to shed light on how these multidimensional challenges vary across space, time, and scale, and how they mediate place-specific and human-environment relations and practices. however, only a handful of existing contributions within geography explicitly reference transdisciplinary debates on uncertainty. as has been argued elsewhere, and for other topics, "at the most practical of levels, this means that this rich corpus of highly prescient geographical writing rarely appears in keyword database searches" (herrick, 2016, 672) . more broadly, we argue that the relative invisibility of these promising geographic contributions relates to our failure "to develop the same kind of critical conceptual mass" that has allowed scholars in science and technology studies (sts), anthropology, sociology and development studies to direct conversations on the production, circulation, and lived experience of uncertainty. to date, scholars of sts and histories of science, medicine and environment occupy among the most well-cited and influential niches in the literature on uncertainty. for more than two decades, this work has taken pains to: (a) re-embed uncertainty in material as well as social contexts of knowledge practice (langston, 2010; murphy, 2004; roberts and langston, 2008; hecht, 2009; jasanoff, 2004) , (b) disrupt stable and binary distinctions between certainty and uncertainty as categories of knowledge (proctor and schiebinger, 2008; mcgoey, 2012) , and (c) examine how uncertainty is reconfigured by struggles over definition, legitimacy, and responsibility (brown, morello-frosch, and zavestoski, 2011; dumit, 2006; michaels, 2008; oreskes and conway, 2010; zavestoski et al., 2004) . a central and enduring line of investigation turns on how "unknowing, ignorance, and imperceptions [about social and environmental problems are] not just accidentally but purposefully generated in the history of knowledge practice" (murphy, 2006, 9, emphasis added) . this collection of work investigates how uncertainty is often manipulated or manufactured by industry or interest groups with the aim of displacing responsibility and fending off regulation (see langston, 2010; michaels, 2008; oreskes and conway, 2010; proctor and schiebinger, 2008) . as mcgoey (2012, 4) explains, this well-established body of literature "explores how different forms of strategic ignorance and social unknowing…both maintain and disrupt social and political orders, allowing both governors and the governed to deny awareness of things it is not in their interest to acknowledge." work in these disciplines also documents how scientific uncertainty is strategically marshalled and renegotiated by social movements that organize in response to toxic exposures and environmental crises. this line of analysis has been established in work on medically contested illnesses such as multiple chemical sensitivity, gulf war syndrome, and chronic fatigue syndrome, where patient activism and struggles for diagnosis are often grounded in experiences of being denied healthcare, insurance claims, and/or social legitimacy as sufferers. zavestoski et al.'s (2004; 161) research into guld war syndrome for instance, has argued that these experiences of exclusion often give rise to new collective subjectivities and illness groups which contest 'what they see as… unresponsive medical [legal, and bureaucratic] system[s]' (also see dumit, 2005; ; brown, morello-frosch, and zavestoski, 2011) . as senanayake and king (2019) argue, the intention of this work is to decentralize and potentially democratize knowledge production in response to uncertainty, challenging what counts as risk or harm and who gets to decide the terms and stakes involved. the allied focus on situated knowledge and regimes of imperceptibility in feminist science studies represents another compelling cluster of scholarship on the question of uncertainty. this includes work that foregrounds the indeterminacy and partiality of knowledge claims that "put[s] ambiguity to critical use… through demonstrating how social categories such as woman or man, black or white, straight or queer as well as concepts such as identity and selfhood need not be fixed in order to inform scholarly inquiry of structural and unstructured dynamics of power" (hayes-conroy and hayes-conroy 2008, 469; also see: sedgwick 2008) . for example, a recent review article by loren march (2020) provides a route into the affective and biopolitical implications of liminality, foregrounding experiences of disorientation, performativity and embodiment among trans and queer folks who do not conform to the dominant grids available for categorizing bodies. by destabilizing binary identity categories, this work documents how illegibility and in-betweenness are experienced and produced through space. in dialogue with this work, other scholars investigate how uncertainty generates new forms of social difference and subjectivity that reinforce patterns of vulnerability (auyero and swistun, 2009; chung, 2020) . together this work encourages us to think more deeply about uncertainty as a lived and spatiotemporal condition and prompts us to engage with the disorienting and sometimes potentially deadly consequences of being in-between. similar debates around the question of uncertainty animate scholars in critical development studies and anthropology, finding concrete expression in several anthologies and special issues (samimian-darash and rabinow, 2015; cooper and pratten, 2014) . much of this scholarship grapples with how uncertainty articulates with narrow, modernist views of progress, development, and technocratic risk management (scoones, 2019a; scott, 1998; ferguson, 1994) . this theme is taken up by paprocki (2019), who investigates how donors and development agencies translate uncertainty about climate change into, narrowly defined, normative visions of development in coastal bangladesh. these "anticipatory development futures" elevate commercial shrimp aquaculture and the expansion of an urban-based, industrial economy as preferred adaptation strategies in the face of uncertainty, despite significant evidence that these adaptation regimes result in environmental degradation, agrarian dispossession and 'development-induced migrations.' as paprocki (2019. 307) argues, these forms of anticipatory governance "entail the end of rural livelihoods in the delta, replacing them with a highly stylized (and age old) vision of development where the rural population transitions into an industrial labour force." this work thus brings debates about uncertainty, governance and accountability into sharp relief, demonstrating how uncertain ecological crises can be claimed and mobilized by donors and development agencies to justify interventions that continue to displace agrarian lives and livelihoods. this concern is also taken in a different direction by a recent working paper by scoones (2019a, 5) that draws on uncertainty to challenge "linear, hierarchical, modernist vision of progress… and technocratic managerialism." by theorizing uncertainty from the margins, he asks: "what more can we learn from alternative (including non-western) cultures of uncertainty that construct the world in different ways, through different histories, social imaginaries, traditions of thinking, and everyday practices?" (2019, 10; also see: leach et al., 1999; scoones, 1994) . in doing so, he suggests that pastoralists in sardinia, tibet, and northern kenya have situated knowledge and experiences of living in limbo that could help upend conventional modes of development, progress, and risk management, and in turn create space for imagining more socially just and ecological sound futures (also see: street, 2011; 2014; ; krätli and schareika, 2010; amin, 2013; samimian-darash and rabinow, 2015) . while this transdisciplinary literature is vibrant and compelling, it tends to treat geography as context, situating uncertainty within broader fields of social relations, cultural practices, and political-economic systems. the purpose of this special issue is not to deny the significance of these interventions, but instead to explore how key geographical concepts such as scale, spatiality, place, and human-environment relations can deepen and enrich transdisciplinary conversations on the question of uncertainty. we argue that the relative silence of geographers in these debates is a missed opportunity for the discipline, especially given our scholarship on related themes as well as a long history of critical approaches to many of the topics that are at the heart of this literature. together, this signals the potential for geographical contributions to transdisciplinary debates. we now turn to a discussion of cross-cutting themes in this special issue, to help make some of these contributions more explicit. in organizing this special issue, we collected a diverse set of papers that, while in active dialogue with innovations in other disciplines, remain intent on documenting how experiences of uncertainty, insecurity, risk, indeterminacy, and illegibility are inherently geographical. each of the articles in this special issue make original contributions on their own; however, when taken together they collectively address four core themes for a geography of uncertainty. first, the contributions illustrate how uncertainty is temporarily stabilized across key geographic axes such as time, space, scale, and regimes of environmental governance. this theme helps demonstrate how uncertainty can be spatially fixed at key moments, either due to necessity, strategy, or through institutional action. reflecting this concern, arielle hesse's paper examines attempts to regulate respirable crystalline silica, which is carcinogenic dust that is generated through hydraulic fracturing. the expansion of natural gas extraction in the united states has introduced new forms of risk for workers and competing understandings of how to regulate silica exposure. the article is an excellent case study of how the industry attempts to construct illegible geographies in efforts to fend of regulation. by documenting the spatial and temporal flexibility of the worksite, hesse demonstrates how geography is strategically enrolled to position the hydraulic fracking industry as unknowable and thus, ungovernable. in doing so, she demonstrates how the variable spatial and temporal configuration of the industry is used to stabilize uncertainty about particular health risks and outcomes for workers. while uncertainty can persist and accumulate through spatial relationships, several of the articles also wrestle with how uncertainty comes to be functional or rational at some scales yet is counterproductive at others. as one example, nari senanayake examines local attempts to neutralize biomedical uncertainty about chronic kidney disease of unknown etiology or ckdu, in sri lanka's dry zone. given resource constraints and generic treatment regimes, senanayake argues that the disease that is most frequently enacted through clinical encounters is actually an undifferentiated form of kidney disease that envelopes both regular and mysterious forms of illness (ckd/ckdu). while the absence of diagnostic closure in kidney disease clinics enables important improvisations in the practice of care, it also inadvertently stabilizes uncertainty about actual disease burden at higher scales of analysis. specifically, she demonstrates how uncertainties about disease states compound across scales of knowledge production and how this then frustrates attempts to map the prevalence of ckdu at regional or national levels. in a related vein, jeff martin details the challenges for wolf management in the u.s. west, documenting how government agencies strategically harness uncertainty to navigate funding cuts and longstanding anti-federal and anti-regulatory sentiment. in a fascinating extension of sts scholarship, martin explores how illegibility about wildlife populations can be understood as logical in certain domains of bureaucratic management even as it produces new uncertainties and socio-ecological dilemmas at other spatial and temporal scales. on the one hand, a hesitancy to share information on wolf populations can protect mid-level bureaucrats from external political pressures to delist the species from the endangered species act. on the other hand, martin asserts that illegibility "from above" undermines agents' ability to effectively intervene around their charges and guarantee wolf conservation over the long durée. similar to hesse's discussion of how the production of uncertainty shapes silica regulation, martin asserts the production of uncertain data can allow state agencies to displace responsibilities for environmental protection in space and time. a second theme reveals the productivity or productiveness of uncertainty and how it can be generative of geographical outcomes and socio-ecological possibilities. papers by cavallo (2020) , martin (2020) , and senanayake (2020) all document pragmatic, experimental, and improvised practices of survival in contexts of uncertainty, institutional instability, and resource scarcity. here authors illustrate how farmers in uganda, midlevel public administrators in the american west, and doctors in the dry zone of sri lanka frequently engage in pragmatic strategies to maximize pathways for action in response to multiple and compounding uncertainties. farmer experimentation in the face of uncertainty about a deadly plant disease (bxw) is a focus for sara cavallo, where improvised knowledge networks partially realign relations of expertise. specifically, she demonstrates how strategic experimental networks between farmers and scientists utilize a hybrid set of practices that remain rooted in local cultural understandings and social networks. indeed, cavallo shows how farmers negotiate differing claims to certainty regarding the disease through a range of tactics that do not fully align with theories of the environmental subject as an extension of state logic. instead, compounding uncertainties allow farmers to make claims on the state and re-envision agricultural systems in ways that accommodate greater experimentalism, particularly in the face of uncertain plant health risks. discussion of uncertainty as a strategic resource is also evident in martin's analysis of controversial wildlife management in the american west. this paper documents how implicit and pragmatic choices around day-to-day practices and different technologies allow agents to navigate ecological complexity and multiple use mandates. the production of contingent geographies of care in the wake of sri lanka's kidney disease epidemic is the basis of senanayake's paper, which documents how local attempts to manage biomedical uncertainty about disease are socially and spatially generative. rather than attempting to achieve diagnostic closure in cases of mystery kidney disease, many local clinicians pragmatically suspend diagnosis and instead routinely treat disease-complexes, including different combinations of kidney disease, hypertension, diabetes and cholesterol giving rise to more holistic, contextualized and responsive ecologies of care. more broadly, this work demonstrates how geographic, as opposed to diagnostic, distinctions increasingly structure access to care and state resources. in doing so, she reveals how the island's kidney disease epidemic has cemented new forms of socio-spatial difference in the dry zone while simultaneously reproducing previously established geographical patterns of neglect. in an excellent example of how uncertainty about chemical harms generates socio-ecological possibilities, annie shattuck explores how the expansion of pesticide use within northern laos reconfigures smallscale farming livelihoods within an increasingly globalized agricultural economy. safe use education dominates this setting, which entails information on safe handling practices, personal protective equipment, and familiarity with the toxicity of pesticides. yet in grounding this form of knowledge translation with local livelihood practices, the article effectively demonstrates how safe use education elides contextual political economies and hybrid practices that result in lived experiences of uncertainty. this leads shattuck to conclude that "smallholder farmers are not operating from a complete deficit of knowledge. rather their knowledge of toxicity and risk is partial, situated in a particular context, laced with uncertainty and inequality, and often gained from embodied experience." the article thereby offers us a conceptual route through which to consider the entanglements between situated knowledges of risk and socio-ecological possibilities. a final critical point that emerges from these papers is that while uncertainty can restructure social and ecological relationships, it often does so in highly uneven ways. indeed, to a large extent, all of the papers in this special issue are concerned with how uncertainty is differentially experienced and embedded in multiple, interlinked struggles that constitute daily life (such as poverty and political marginalization) as well as, individual experiences of resource scarcity, health, and/or disease. along those lines, brian king's article details the ongoing uncertainties with hiv in rural south africa even within a setting that has drastically scaled-up the provision of care. the widespread provision of anti-retroviral therapy in the global south has led public health institutions to identify hiv as a chronic condition; however, there remain a wider set of related uncertainties that include ongoing stigma, food insecurities, and unequal bodily responses to treatment. king concludes that given these dynamics, hiv uncertainty and certainty simultaneously co-exist and are co-produced, while remaining materially uneven for those managing their health. likewise, cavallo (2020) and shattuck (2020b) , illustrate how different forms of government intervention in response to uncertainties about plant disease management and pesticide use can reproduce patterns of socio-spatial inequality, normalizing risk and harm for some bodies and not others. as a consequence, our contributors demonstrate how uncertainty is frequently enrolled in the production of social, spatial, and ecological difference. third, the contributions demonstrate how uncertainty is produced, transformed, and negotiated through a key focus of geographic inquiry: the interactions between human and non-human agents. in collecting these articles, it was not our intention to select case studies that dealt specifically with the non-human. but in reading these contributions together, we are struck that all authors deal in some meaningful way with non-human actors. whether it is a pathogen or virus, banana, wolf, chemical toxin, or an invasive insect population, all of the articles engage with the ways that the non-human generates uncertainties, and in turn poses important challenges to western scientific and regulatory traditions. martin and sedell for instance, address how dynamic and moving species, either wolves or invasive insects respectively, confound attempts to measure, surveil, and manage. and hesse and shattuck emphasize how chemical exposure cannot easily be fixed in space and time, as the pressures from broader political and economic forces, including corporations that want to mitigate their exposure to lawsuit and damages, draw upon uncertainty and personal responsibility to deflect culpability in undermining human and environmental health. in considering how uncertainty is refracted by human and nonhuman interactions, there are a few points worth emphasizing. first, western traditions of bureaucratic rationality, scientific management, and state power all require practices of containment. whether it is the containment of invasive pests within a particular agricultural region, wolves in a conservation zone, or an infectious disease within an individual body, scientific and bureaucratic management requires that the object of concern to be contained in space and time. the fact that these entities resist attempts at containment and measurement mean they are active participants in the production of uncertainty. perhaps most evident of this point is jennifer sedell's paper, which convincingly demonstrates that in terms of invasive pests and agricultural production in california, uncertainty about insect presence/ absence cannot be eradicated. as one of her informants explains, the absence of insects in the traps does not prove that they have been eradicated since it is impossible for existing measurement devices to observe the status of pest populations at sub-detectable or low levels. as sedell notes, the implications for the agricultural industry are significant and political responses are required to restore 'pest-free' status for the trade of many agricultural goods. this theme also takes center stage in martin's contribution. focusing on how and why government agents routinely collect less and/or less precise data about the wildlife under their charge, martin complicates traditional assumptions of bureaucratic rationality and state power. he skillfully demonstrates how, in the context of ecological complexity, logistical limitations and socio-political conflict, state agents engage in practices of obfuscation to manage risks and exonerate themselves from blame. in dialogue with mcgoey, 228 (2007) ; (2012;)), martin demonstrates how this apparent dysfunction is not a breakdown of bureaucratic rationality but rather is "indicative of a rational strategy [for managing antithetical demands] in itself." instead of precipitating more experimental and adaptive management approaches, martin demonstrates how the frequent failure to record and manage unruly nonhuman dynamics can end up reproducing forms of bureaucratic rationalityeven when uncertainties are central to managing socioecologically complex systems. in doing so, he draws our attention to how "politics matter, and adaptive, experimental governance without democratic politics, can end up similar to earlier [technocratic] expert modeseven when uncertainties are recognized" (scoones 2019a, 28) . finally, these papers raise critical questions about the politics of uncertainty and, in particular, how it indexes new forms of accountability, governance, and regulation. together the special issue invites geographers to grapple with how uncertainty often generates politically opposing ways of problematizing and intervening in human-environment and socio-spatial relationships. for instance, in this collection, several articles demonstrate how materializing health-environment interactions as uncertain have become powerful strategies for affirming ambiguity about toxic and pathogenic exposures, and ultimately, of fending off stricter government regulation (also see: murphy, 2006) . shattuck (2020a) examines farmers' knowledge of pesticide risk in northern laos in the wake of individually focused safe use messaging and enduring uncertainties about chemical harms. by documenting how situated experiences of toxicity articulate with safe use models, she demonstrates that local typologies of safety and harm continue to blame poor, 'risky' people for pesticide-related health impacts "instead of the socio-economic situations that require them to take risks" in the first place. partial knowledge about the impacts ofand responsibility forchemical exposures in this case, is marshalled to reinforce and legitimate individually based risk management. in the context of rural poverty, uneven access to health care and local inequalities, this approach renders invisible the myriad ways that farmers' decision making is refracted by other risks, principally the risks of being poor and rural. the tendency to reinforce individual responsibilities for exposure in the face of uncertainties about occupational health hazards is also a focus for hesse (2020), where, as argued above, the fossil fuel industry strategically conceptualizes the geographies of hydraulic fracturing as flexible, variable, and unknowable in order to contest government regulation of toxic silica exposures. specifically, this article reveals how the processes of rulemaking as well as the variable spatial and temporal configuration of the fracking industry helps decentralize and individualize responsibility for exposure. similarly, king (2020) asserts that the "production of uncertainty is relational and dynamic, changing not only with new 'certainties' about the virus and treatment protocols, but also the ways in which its management intersects with social and environmental dynamics." this reveals how the experiences of living with hiv are not uniform and continue to be shaped by a range of factors, such as socio-economic resources, food insecurity, employment, gender, age, and sense of responsibility for others. as a consequence, the special issue makes a powerful case for focusing on how uncertainty generates styles of politics that reproduce precarity and individual responsibility for managing exposures to multiple social and environmental harms. a different, albeit related, perspective is explored in other papers where embracing uncertainty is viewed as a pathway to open "up a more rigorous, robust, transparentand democratically accountableenvironmental politics" (stirling 2018, 120) . this work combines what scoones (2019a, 27) describes as a "transformational vision, [where] notions of justice are central" with a "more patient, sometimes unruly, bottom up approach to defining future pathways," often focused on adaptive management, incremental learning, and polycentric governance. as one example, sedell (2020) demonstrates how competing models for understanding invasive pest populations reveal the profound instability of metrics that determine pest absence/presence in california's agricultural sector. as part of this analysis, she demonstrates how alternative methodologies for visualizing pest presence/absence as well as bottom up diversified farming practices reconceptualize pests as neither exceptional nor temporary, but instead, as part of a new normal. doing so, opens up possibilities for alternative agro-ecological and political arrangements by locating the region's pest problem not with the insects themselves but in production systems that lack resilience to biological invasions. as a consequence, sedell reveals how uncertainty about pest presence/absence can precipitate a fundamental re-evaluation of california's agro-environmental system, and simultaneously transform our relationships to pest populations and how the region produces food. how networks of cross-species relations are productive of 'new ecological accommodations' or 'ways [of] learning to live endemically with our viral [microbial, and insect] companions' (greenhough 2012, 295) thus constitute important avenues for future geographic research on the politics of uncertainty. to a large extent, all of the papers in this special issue push us to grapple with uncertainty as a norm and not an anomaly. in other words, this work opens up space for engagement with uncertainty as more than a temporary phenomenon but as a "permanent condition" where stability and certainty about socio-spatial and human-environment relationships are often elusive (brown and damery 2009, 82) . rather than attempting to ensure a strict boundary between knowledge and its opposite, our contributors encourage us to think more deeply about uncertainty as a lived and spatiotemporal condition. it is these very entanglements between uncertainty, environments, and everyday life that provide the narrative thread uniting this diverse collection of articles. while engaging with a broad range of topics and qualitative methodologies, this work coalesces around four central themes: (1) how uncertainty works through geographic relationships; (2) how uncertainty generates geographical outcomes; (3) how uncertainty is reconfigured by human-non-human dialectics; and, (4) how uncertainty raises questions about politics. in doing so, this special issue develops a critical human geography of uncertainty, which not only articulates how the concept is useful for geographers, but also, argues that geography can enrich existing transdisciplinary work on the subject with its perspectives on scale, spatiality, power, place, and human-environment relations. credit authorship contribution statement nari senanayake: conceptualization, writing -original draft, writing -review & editing. brain king: conceptualization, writingoriginal draft, writing -review & editing. surviving the turbulent future brexit: modes of uncertainty and futures in an impasse flammable: environmental suffering in an argentine shantytown a companion to environmental geography contested illnesses: citizens, science, and health social movements navigating compounding uncertainty: farmer strategies amid biosecurity crises in western uganda governing a liminal land deal: the biopolitics and necropolitics of gender engendering the new enclosures: development, involuntary resettlement and the struggles for social reproduction in coastal tanzania ethnographies of uncertainty in africa come on, people… we* are* the aliens. we seem to be suffering from host-planet rejection syndrome': liminal illnesses, structural damnation, and social creativity illnesses you have to fight to get: facts as forces in uncertain, emergent illnesses depoliticization, and bureaucratic power in lesotho where species meet and mingle: endemic human-virus relations, embodied communication and more-than-human agency at the common cold unit 1946-90 uncertainty and context in geography and giscience: reflections on spatial autocorrelation, spatial sampling, and health data thinking through covid-19 responses with foucault -an initial overview taking back taste: feminism, food and visceral politics. gender, place cult africa and the nuclear world: labor, occupational health, and the transnational production of uranium global health, geographical contingency, and contingent geographies when places come first: suffering, archetypal space and the problematic production of global health geographies of uncertainty and negotiated responsibilities of occupational health states of knowledge: the co-production of science and the social order rethinking social reproduction in the time of covid-19 hiv as uncertain life living off uncertainty: the intelligent animal production of dryland pastoralists the uncertain geographic context problem context and uncertainty in geography and giscience: advances in theory, method, and practice toxic bodies: hormone disruptors and the legacy of des exploring understandings of institutions and uncertainty: new directions in natural resource management a geopolitics of trauma: refugee administration and protracted uncertainty in turkey queer and trans* geographies of liminality: a literature review between scylla and charybdis: environmental governance and illegibility in the american west on the will to ignorance in bureaucracy strategic unknowns: towards a sociology of ignorance doubt is their product: how industry's assault on science threatens your health lives in limbo: temporary protected status and immigrant identities uncertain exposures and the privilege of imperception: activist scientists and race at the u.s. environmental protection agency sick building syndrome and the problem of uncertainty: environmental politics, technoscience, and women workers care in the time of covid-19 uncertain futures and everyday hedging in a humanitarian city the socioenvironmental state: political authority, subjects, and transformative socionatural change in an uncertain world merchants of doubt: how a handful of scientists obscured the truth on issues from tobacco smoke to global warming all that is solid melts into the bay: anticipatory ruination and climate change adaptation agnotology: the making and unmaking of ignorance political ecology: a critical introduction toxic bodies/toxic environments: an interdisciplinary forum modes of uncertainty: anthropological cases no fly zone? spatializing regimes of perceptibility, uncertainty, and the ontological fight over quarantine pests in california searching for ckdu: mystery kidney disease, differentiated (in) visibility, and contingent geographies of care in dry zone sri lanka living with uncertainty: new directions in pastoral development in africa what is uncertainty and why does it matter embracing uncertainty: what are the implications for sustainability n. senanayake and b. king geoforum xxx (xxxx seeing like a state: how certain schemes to improve the human condition have failed epistemology of the closet health-environment futures: complexity, uncertainty and bodies toxic uncertainties and epistemic emergence: understanding pesticides and health in lao pdr risky subjects: embodiment and partial knowledges in the safe use of pesticide uncertainty and precaution: some instrumental implications from the social sciences uncertainty artefacts of not-knowing: the medical record, the diagnosis and the production of uncertainty in papua new guinean biomedicine biomedicine in an unstable place: infrastructure and personhood in a papua new guinean hospital patient activism and the struggle for diagnosis: gulf war illnesses and other medically unexplained physical symptoms in the us we thank all of the authors who contributed their articles to this special issue and the reviewers for their helpful and timely comments. we are especially grateful to harvey neo for his insightful feedback and patience in helping steer this project towards completion. the special issue emerged from a series of aag sessions in 2018, where these papers received constructive comments and encouragement from our generous discussants, rebecca lave and david demeritt. particular thanks to arielle hesse and a. marie ranjbar for valuable comments on previous drafts of this introduction. key: cord-350270-rcft3xfh authors: hulme, mike; lidskog, rolf; white, james m.; standring, adam title: social scientific knowledge in times of crisis: what climate change can learn from coronavirus (and vice versa) date: 2020-05-28 journal: wiley interdiscip rev clim change doi: 10.1002/wcc.656 sha: doc_id: 350270 cord_uid: rcft3xfh nan of knowledge (e.g., certain disciplines within natural sciences) are seen as inherently superior, rather than as complimentary. such a diversification of knowledge would benefit both the effectiveness of decisions made, as well as the legitimacy of those decisions among publics. there is widespread misunderstanding on the part of publics, propagated by dominant political (and scientific) discourses, that scientific and technical knowledge can provide clear and unequivocal answers to policy problems. this obscures the reality that political decision-making is rooted in careful consideration of a variety of options and tradeoffs-in jasanoff's terms, "science will not come on a white horse with a solution". 1 these discourses are already prominent in normal periods, but become even more so in times of crisis when uncertainty, the risk of policy failure and associated blame are at stake. by obscuring the "messy" nature of knowledge production and its relation to policy-making, the danger is that the expertise on which policies are based will become delegitimized whenever those policies are seen to fail. this is not a call to abandon or dilute expertise. rather it is a call to strengthen the public standing of expertise through pluralizing it. the most recent report from the intergovernmental panel on climate change (ipcc) claims that rising global temperature changes the likelihood and distribution of local, regional and global disease outbreaks. this is due to a number of factors, including the expanding geographical range of some disease vectors (ipcc, 2018:180) and the changing seasonality and transmission intensity of some infectious diseases (semenza & menne, 2009 ). medical, public health and epidemiological knowledge needs to be complemented with rigorous and varied social scientific knowledge on the fundamental social causes behind mobilities and movements of populations and products that act as vectors of disease. social science has the analytical capacity to show why the risks associated with these movements are harder to govern, the multilevel and transboundary nature of the risks, and the strengths and weaknesses of global institutions of governance that deal with risk. national and local responses to pandemic disease similarly vary widely. 2 so do the vulnerabilities of populations and their faculties for resilience, adaptation and mitigation of risk. social scientific knowledge adds to our understanding of these differences. it also grants decision-makers, as well as publics, critical capacity to evaluate the trade-offs, whether political, economic or social, that responses will entail. numbers should not be allowed to substitute for or obscure political judgment. the covid-19 pandemic has shone light on a scientific discipline that, in an age of improving sanitation and public health systems, we rarely see entering the public sphere, at least in the global north: epidemiology. in particular, epidemiological mapping and statistical modeling have ameliorated an unknown and unpredictable situation for governments across the world (rhodes, lancaster, & rosengarten, 2020) . governments always have to weigh up different forms of knowledge and expertise, from scientific and technical knowledge to policy and political considerations. in normal times, this is stage-managed to show a consolidated and consistent position. but in periods of crisis-when information is more uncertain, susceptible to rapid change and when more attention is given to decision-making processes-it becomes increasingly difficult to ensure the effectiveness of government interventions. this was witnessed recently in the cases of both the uk 3 and sweden, 4 where the respective governments' positions and advice have been subjected to increased scrutiny and criticism. climate change too has seen mathematical modeling take a prime position in the search for authoritative knowledge in the context of deep uncertainty (wynne, 2010) . in the epistemic battle fought in the early days of the ipcc's scientific assessments, it was mathematical models of the climate system that won out over more experimental or observational methods of generating relevant knowledge (coen, 2018) . it has been argued that such models provided the objectivity and authority that policymakers craved in order to legitimatize decisions (oppenheimer et al., 2019) . such mathematical models of reality-whether of the climate system or a pandemic-are always partial. not all physical processes are known or simulated. and many of the social systems which condition their predictions are either excluded or else the assumptions upon which human behavior is simulated remain hidden from view. apart from offering inevitably uncertain predictions, mathematical models also obscure the social nature of the climate risk being faced (wynne, 2010) . this has also been the case in the initial stages of covid-19 in which uncertain or incomplete data, habitual thinking and the desire to conform to political sensibilities has led to diverging estimates of the risk the virus posed (qi, du, liu, zhao, & dong, 2020) . parallels between the framing of scales for covid-19 and climate change have already been drawn. the claim of dr michael mcbride, the chief medical officer of northern ireland, that "viruses don't recognise borders" 5 echoes a similar refrain about air pollution and greenhouse gases from those who wish to emphasize the global character of climate change. the spread of the pandemic, and the spatially differentiated responses, emphasizes the importance of local and contextual knowledge. this goes beyond comparative analysis of health systems-although this is of great importance. it embraces questions of state power, organizational uncertainty and trust in institutions in order to better understand the relative effectiveness of specific interventions in different circumstances. central to these questions is an appreciation of varying cultural and political values and how they interact with scientific or medical knowledge. equally, pleas to "listen to the experts" have emerged in response to the avalanche of misinformation regarding both the covid-19 pandemic and climate change. but which experts and what advice? when does valid dissent become obstructionist denial? (nemeth, 2018) . social science helps illuminate the problems inherent to knowledge legitimacy, epistemic authority and competing truth claims. as with climate change, the impact of covid-19 is likely to be as far-reaching in its secondary consequences as in its primary ones. with stock markets falling, transport links suspended, unemployment reaching record levels 6 and the prospect of global recession looming, the economic and social ramifications appear to be as salient as the medical ones. the pandemic serves to highlight the interrelated nature of environmental, health, social and economic issues. there are multiple dimensions to the risk being faced; trade-offs are inevitable. the pandemic also focuses attention on the variable power available to different states, regions, groups and individuals to adapt and mitigate crises. a pertinent example is the different levels of social and economic capital available to people that are self-isolating. social scientific knowledge deepens our understanding of how perceptions of risk, fear and trust impact on crisis mitigation. it also illuminates the importance of structural factors, social positioning and cultural belongings-such as wealth, race and gender-in developing responses at the individual and institutional level, and how this provides different opportunities for and constraints on action. crises exacerbate existing vulnerabilities and inequalities, both among populations and between states (rhodes et al., 2012) . the covid-19 pandemic has already highlighted an uneven distribution of social and institutional support networks. social scientific knowledge will prove invaluable in understanding the long-term consequences of quarantine, social distancing and isolation on the mental and physical well-being of populations and vulnerable groups. this has proven to be the case in scholarship on previous epidemics, such as hiv/aids (emlet, 2006) . in the current pandemic we can already see that socio-economic class poses different levels of risk, both in terms of contracting the virus in the first place and then the subsequent prognosis for the infected. 7 the search for a technical fix to reduce the numbers infected-typically through various forms of social distancing and quarantine-is rarely sensitive to the (in)capacity of many people to adhere to such requirements, dependent as they are on leaving their house to work. one of the most important lessons to be learned from covid-19 is a fuller appreciation of how framings such as "crisis" and "emergency" mobilize, legitimate and yet also constrain certain forms of action. both carry with them medical connotations. the origin of the word "crisis" can be traced back to classical greek, kρίσις, meaning a moment of decisive intervention, in the medical sense a choice between life and death (koselleck, 2006) . the covid-19 pandemic has seen unprecedented state intervention in society and the economy, from locking down and quarantining entire populations, tenacious surveillance of the individual, banning free assembly and travel, and placing a moratorium on debt repayments. on the one hand, this undermines arguments that have been made in relation to climate change that such decisive interventions are either impractical or impossible. on the other hand, it will be necessary for social scientists to analyze and understand the differing political, social and cultural conditions that made these types of intervention possible, not to mention whether the corporate and state-led incursions into our private lives are necessary or desirable. how did different population groups accede to or resist such impositions? what was the long-term political fall-out of the suspension of normal decision-making mechanisms? how was political accountability either maintained or eroded during the crisis? these questions will play out differently in different political cultures under different types of governance regimes. this again highlights why one-size-fits-all technical solutions are inappropriate and why a more plural knowledge paradigm, inclusive of social-scientific knowledge, is necessary. an important distinction to make between covid-19 and climate change concerns temporality. the impact of the pandemic appears clear and immediate, while the impact of climate change is diffuse, variable and uncertain. the underlying drivers of climate change are much more deeply rooted in global economic, technological, cultural and political structures than are those for covid-19. deploying a crisis/emergency frame can help to attract attention, concentrate resources and provide public legitimacy for action. but it can also serve to obscure the hidden and inertial causes of climate change (asayama, bellamy, geden, pearce, & hulme, 2019) . the scientific expertise deployed in response to the pandemic seeks to return us to the status quo ante, whereas climate knowledge recognizes the inherent unsustainability of the underlying conditions, suggesting that things can never be the same again. crises highlight how important knowledge is to politicians and policymakers. but they also bring into focus some of the underlying tensions in this relationship between science and policy. technical and scientific knowledge is always partial, uncertain and often contradictory-as we see particularly well in the case of mathematical modeling. that is not to say that such knowledge is not valuable. it is rather to say that to effectively deal with crises, multiple forms of knowledge and expertise are required and political judgment is then necessary to sort, select and present it to publics. resolving a crisis is never about just getting the numbers right. not for climate-it is not just about net-zero -and nor for covid-19-it's not just about minimizing some arbitrary mortality statistic. it is about providing effective and ultimately trustworthy transformative change that is grounded on the broadest base of knowledge and to which normative judgments are applied. the effectiveness and legitimacy of interventions in a crisis is reliant on well-informed, transparent but subjective processes of decision-making. it is not sufficient to present the interpretation of knowledge as automatic or to restrict the expertise that presents, interprets and discusses relevant knowledge. decision-makers must be attuned to the insights that social sciences can reveal about the reasons for different individual and collective human behaviors in the face of a threat-their beliefs, values, cultures, norms, expectations and trust. it is vital for the public to retain its trust in the expertise which informs decisions, but also to understand the normative judgments which then guide future policy. this is true for dealing with covid-19 and it is true for dealing with climate change. 4 the guardian, march 30, 2020. https://www.theguardian.com/world/2020/mar/30/catastrophe-sweden-coronavirusstoicism-lockdown-europe [accessed on may 8, 2020]. 5 https://www.standard.co.uk/news/uk/northern-ireland-confirms-first-case-of-coronavirus-a4373751.html [accessed on may 8, 2020]. 6 https://news.un.org/en/story/2020/04/1061322 [accessed on may 8, 2020]. 7 brookings institute march 27, 2020. https://www.brookings.edu/blog/up-front/2020/03/27/class-and-covid-how-theless-affluent-face-double-risks/ [accessed on may 8, 2020]. why setting a climate deadline is dangerous changing the intellectual climate climate change and the quest for understanding an examination of the social networks and social isolation in older and younger adults living with hiv/aids meet the humanities special report: global warming of 1.5 c who speaks for the future of earth? how critical social science can extend the conversation on the anthropocene in defense of troublemakers: the power of dissent in life and business discerning experts: the practices of scientific assessment for environmental policy the variability of critical care bed numbers in europe a model society: maths, models and expertise in viral outbreaks climate change and infectious diseases in europe strange weather, again. theory, culture & society experts' conservative judgment and containment of covid-19 in early outbreak the authors have declared no conflicts of interest for this article. adam standring: initiator of the idea for this commentary, intellectual lead and corresponding author; rolf lidskog: contribution to drafting; james white: contribution to drafting; mike hulme: contribution to drafting and final editing. key: cord-281412-r3um3g44 authors: ostrovsky, adam m.; chen, joshua r. title: tiktok and its role in coronavirus disease 2019 information propagation date: 2020-08-29 journal: j adolesc health doi: 10.1016/j.jadohealth.2020.07.039 sha: doc_id: 281412 cord_uid: r3um3g44 nan to the editors: the coronavirus disease 2019 (covid-19) pandemic generated the near-complete closure of u.s. educational institutions during the spring 2020 semester, affecting approximately 55.1 million students [1] . although such abrupt closures were undertaken to increase compliance with social distancing, motivations among adolescents to participate in social distancing were shown to be mixed [2] . it is understandable that noneducational screen time among young people has greatly escalated [3] during the pandemic, allowing individuals to stay connected with the outside world as more formerly conventional means of communication became increasingly impractical. as such, social media have played a large role in youth resocialization in a pandemic society. however, with recent concerns of a growing number of cases arising from young adults [4] , an increased understanding of covid-19 portrayal on social media is valuable in deciphering young adult sentiment on the virus and how their views on the seriousness of the pandemic may be colored by the variety of messages they receive about it. one of the most recent platforms to surge to prominence has been tiktok, a social network with more than 45.6 million active users in the u.s.dwith 63.5% being aged <29 yearsd [5] where creators post videos of themselves talking, dancing, or lipsyncing. with its unique "for you" page, where the majority of viewed content is randomly selected rather than drawn from a pool of "friends," tiktok generates a wider and more diverse audience than the traditional "follower"-based social media model. videos are sorted into hashtags, with search results directly sorted by likes received per post. given social media's ability to propagate factually inaccurate medical information at an alarming rate [6] , we analyzed the 100 most popular videos in each of the three largest covid-19e related categories on tiktok. as of july 12, 2020, these were videos earmarked with the hashtags "covid-19," "covid19," and "coronavirus," which have reached 4.4 billion, 33.3 billion, and 93.1 billion views, respectively, demonstrating the platform's immense ability to encourage sharing. our findings revealed that, on average, 6.33% of videos were filmed by health care professionals, and 2.66% were filmed by young adult patients tracking their recovery journeys. in addition, 15.66% of videos communicated pragmatic health information, and .66% provided misleading or inaccurate health advice, with the remaining videos depicting everyday quarantine activities in a satirical manner. in addition, although videos by health care professionals were few in number, they were often among the most widely "liked" and shared across the board. this distribution suggests that demand on tiktok for more health careerelated voices currently outpaces supply. tiktok has shown itself to be a viable means for practitioners to educate and dispel myths about covid-19 to a broad and diverse adolescent demographic. in return, practitioners gain the ability to share their voices with those that they likely would not have reached otherwise while potentially expanding public policy adherence and reducing hospitalizations. map: coronavirus and school closures adolescents' motivations to engage in social distancing during the covid-19 pandemic: associations with mental and social health survey shows parents alarmed as kids' screen time skyrockets during covid-19 crisis -parentstogether as virus surges, younger people account for 'disturbing' number of cases tiktok users by age 2020 | statista internet searches for unproven covid-19 therapies in the united states none. none. joshua r. chen premedicine eberly college of science the pennsylvania state university university park, pennsylvania key: cord-350031-2c9x55hx authors: zhao, sheng zhi; wong, janet yuen ha; wu, yongda; choi, edmond pui hang; wang, man ping; lam, tai hing title: social distancing compliance under covid-19 pandemic and mental health impacts: a population-based study date: 2020-09-14 journal: int j environ res public health doi: 10.3390/ijerph17186692 sha: doc_id: 350031 cord_uid: 2c9x55hx the success of public health measures for controlling the coronavirus disease 2019 (covid-19) pandemic relies on population compliance. we analyzed compliance with social distancing and its associations with mental health. the hong kong covid-19 health information survey was conducted from 9–23 april 2020 on 1501 adults randomly sampled for landline telephone interviews (n = 500) and online surveys (n = 1001). compliance with social distancing and staying-at-home, stress (perceived stress scale-4), anxiety (general anxiety disorders-2), and depressive symptoms (patient health questionnaire-2) were collected. the associations between mental health symptoms and compliance were examined by multivariable regression models. of the 1501 respondents (52.5% female, 72.3% aged 18–59 years), 74.2%, 72.7%, and 59.7% reported avoiding going out, going to crowded places, and attending social gatherings of more than four people, respectively. most respondents had stayed-at-home for at least four of the past seven days (58.4%; mean 4.12, standard deviation 2.05). adoption, perceived effectiveness, and perceived compliance with social distancing were associated with lower stress levels and less anxiety and depressive symptoms (all p < 0.01). however, more days stayed-at-home were associated with more depressive symptoms (adjusted odds ratio 1.09; 95%confidence interval 1.00, 1.18). the long-term psychological impact in relation to social distancing and staying-at-home requires further investigation. the coronavirus pandemic 2019 (covid-19) has caused millions of confirmed cases and thousands of deaths since early 2020. driven by the increasingly frequent worldwide transportation of those with asymptomatic patients, the infection is spreading more rapidly and widely than ever [1] . public health measures such as border restrictions, bans on public gatherings, closures of schools and nonessential businesses, stay-at-home and social distancing have been enforced in many countries. at the early stage of the epidemic, hong kong responded quickly with precautionary behaviors including mask wearing and hand hygiene [2] [3] [4] . solidarity and altruism were aroused for collective community protection [5] . isolation, quarantine, contact tracing and social distancing were the main measures to prevent community outbreak and were effective in that the transmission of covid-19 remained low (daily effective reproduction number r 1 approximately equal to 1) by early march without lock the hong kong covid-19 health information survey (covhins) was a population-based dual sampling landline and online survey conducted from 9-23 april 2020. the target population was general hong kong residents aged 18 or above. social policy research limited, a reputable local survey agency, was commissioned to conduct the survey. we adopted two-stage random sampling in the landline survey using the web-based computer-assisted telephone interview system (web-cati). residential telephone directories that covered approximately 76% of hong kong residents [21, 22] were used to generate a random list of telephone numbers for interview. invalid numbers (e.g., fax line, non-residence line and non-working line), nonresponses, and ineligible households were excluded. after telephone contact had been successfully established with a target household, one eligible person was selected using the "next birthday" rule (i.e., the household member whose birthday was nearest to the interview date was selected). all telephone interviewers completed a half-day training related to covid-19 knowledge, contents of the questionnaire, sampling procedures and interviewing techniques. briefing and de-briefing sessions were arranged during data collection, and rigorous quality checks were adopted (17.2% were checked) to ensure research fidelity. each interview took approximately 25 min. among the 816 valid telephone number sampled (305 refused, 11 dropout), 500 respondents completed the interview yielding a response rate of 61.3%. the online survey was conducted on a representative panel of hong kong residents. this panel was previously formed by inviting local mobile phone users to join. all mobile phone numbers (prefix starting with 5, 6 or 9), which covered over 90% of hong kong residents, received an invitation message. these numbers were generated using the numbering plan for telecommunication services in hong kong provided by the office of the communications authority (ofca). a total of 100,079 residents covering diverse socio-economic backgrounds joined the panel. stratified random sampling by sex and age was adopted to select a random list of panel participants, who were then invited to join the online survey by an invitation text message. participants self-administered the questionnaire via web-cati. the response rate was 61.7% (1001 of 1623 eligible panel participants). ethics approval was granted by the institutional review board (irb) of the university of hong kong/hospital authority hong kong west cluster (uw 20-238). informed consent was obtained from all respondents before answering the questions. the adoption of social distancing measures (yes/no) since the first case confirmed in hong kong included: (i) avoid going out, (ii) avoid going to crowded places, (iii) avoid going to high-risk places (e.g., bar, wet market, hospital), (iv) avoid social gatherings of more than four people (government regulation, with penalty, issued on 29th march), (v) avoid greetings with physical contact such as handshaking, hugging and kissing, and (vi) keep 1.5 meters from others in public. the total number of social distancing measures was calculated (ranged 0-6). perceived overall effectiveness of and perceived compliance with the above social distancing measures were measured on a scale ranging from 0-10 with higher scores indicating higher perceived effectiveness and compliance. stay-at-home, which was voluntary, was measured by the number of days at home except for essential tasks in the past seven days. personal protection measures including: (i) wearing surgical mask, (ii) washing hands with alcohol-based sanitizers, (iii) using alcohol to clean daily necessities, and (iv) adding water to household drainage system in the past seven days were recorded. stress level in the preceding month (from early-march to mid-april 2020) was assessed by the four-item perceived stress scale (pss-4) [23] . pss-4 consists of four items measuring the degree of ability to cope with existing stressors (positive elements, two items, cronbach's α = 0.68) and the degree of lack of control and affective reactions (negative elements, two items, cronbach's α = 0.69). each item is rated on a likert-like scale ranged from 0 (never) to 4 (very often). higher total scores on the four items (0-16) indicate a higher perceived stress level. the chinese version of pss-4 has been validated in our previous study with satisfactory internal consistency (cronbach's α = 0.67) [24] . anxiety and depressive symptoms in the past two weeks (from late-march to mid-april 2020) were assessed using the four-item patient health questionnaire (phq-4). phq-4 consists of the two-item general anxiety disorder (gad-2) and the two-item patient health questionnaire (phq-2) [25, 26] . gad-2 covered two core criteria for generalized anxiety that screen for social panic and anxiety disorders. phq-2 measured depressive symptoms, depressed mood and loss of interest, two core diagnostic criteria for major depression disorder [26] . each item scores on a likert-like scale ranging from 0 (not at all) to 3 (nearly every day). subscales of the gad-2 and phq-2 scores range from 0-6 with a score of ≥3 indicating anxiety and depression symptoms [27, 28] . we have previously validated the chinese version of the phq-2 in the hong kong population [29] . the internal consistency of gad-2 (cronbach's α = 0.81) and phq-2 (cronbach's α = 0.81) were positive in this study. sex, age, marital status (never married, married or cohabited, divorced or separated, or widowed), current living arrangement (living alone, co-living with family members, or co-living with other people), and socioeconomic status (ses) including educational attainment (primary or below, secondary, or tertiary), employment status (full-time work, part-time work, student, housemaker, unemployed or retired) and monthly personal income (hk$ ≤ 10,000; 10,001-20,000; 20,001-30,000, 30,001-40,000, or ≥40,001; us$1 = hk$7.8) of the respondents were recorded. we used chi-squared test and t-test to compare sociodemographic characteristics and mental health symptoms between the landline telephone and online self-administrated samples. to improve the representativeness of the sample, all data were weighted according to provisional figures obtained from the census and statistics department on the sex, age, and education attainment distributions of hong kong's general adult population in 2016. multivariable linear regression was used to examine the associations with sociodemographic characteristics of number of social distancing measures adopted, number of days stayed-at-home and perceived compliance with social distancing measures. the association of mental health symptoms including stress, anxiety and depression with the number of measures adopted, number of days stayed-at-home and perceived effectiveness and compliance were calculated by multivariable linear (for stress) and logistic (for anxiety and depression) regressions. in regression model 1, potential sociodemographic confounders including sex, age, educational attainment, current employment status, and monthly income were adjusted. we additionally adjusted for the four personal protection measures in regression model 2. the association between personal protection measures and mental health symptoms were analyzed by multivariable regression models adjusted for sociodemographic factors and social distancing. effect modifications by age (18-59, 65+ years) and education attainment (primary or below, secondary, and tertiary) on the associations between mental health symptoms, stay-at-home and compliance with social distancing were assessed using the interaction terms. analyses were performed using stata version/mp 15.1 (statacorp lp, college station, tx, usa). there were no significant differences in the sociodemographic characteristics of the landline telephone sample (n = 500) and the online self-administrated sample (n = 1001) (all p > 0.05; table 1 ). in the combined weighted sample, 52.5% were female, 72.3% aged 18-59 years, 66.1% were married or cohabitated, and 92.9% were co-living with family members. three quarter (76.8%) of respondents had a secondary or higher education, 62.9% were employed and 68.2% had a monthly household income of hk$20,000 or lower. the average stress score was 7.20 (standard deviation, sd: 2.12), and 15.8% and 14.8% of the respondents had experienced anxiety and depressive symptoms, respectively. table 2 shows that most respondents adopted the social distancing measures including avoid going out (74.2%), avoid going to crowded places (72.7%), avoid social gatherings of more than four people (59.7%), avoid going to high-risk places (54.8%), and avoid handshaking, hugging and kissing (50.7%), but only 42.9% kept 1.5 meters away from others. respondents adopted on average 3.55 (sd 1.76) social distancing measures and most had stayed-at-home for at least four days in the past seven (58.4%; mean 4.12, sd 2.05). respondents perceived the social distancing measures to be effective in containing the infection (mean 7.34, sd 1.88) and perceived a moderate level of compliance (mean 6.68, sd 1.98). table 3 shows that older age and higher education attainment were significantly associated with the adoption of more social distancing measures, more days stayed-at-home and perceived higher level of compliance with social distancing (all p for trend <0.01). being female was associated with more days stayed-at-home (adjusted β 0.49; 95%ci 0.30, 0.68) and perceived compliance with social distancing (adjusted β 0.27; 95%ci 0.07, 0.46). compared with respondents in full-time work, those who were economically inactive spent more days at home and reported higher compliance with social distancing (all p for trend <0.001). having higher income was associated with increased perceived compliance with social distancing (p for trend <0.001). table 4 shows that adopting more social distancing measures was significantly associated with lower stress level (adjusted β −0.12; 95%ci −0.18, −0.06) and lower risk for anxiety symptoms (adjusted or 0.87; 95%ci 0.79, 0.95) after the models were adjusted for sociodemographic and personal protection measures (model 2). perceived effectiveness and compliance with social distancing measures were associated with lower stress levels and risks for anxiety and depressive symptoms (all p < 0.001). consistently, personal protection measures, including mask wearing, use of alcohol to clean daily necessities and adding water to the household drainage system were associated with lower stress levels and lower risks for anxiety and depressive symptoms (all p < 0.01) (supplementary table s1 ). nevertheless, more days stayed-at-home was significantly associated with increased risk for depressive symptoms (adjusted odd ratio (or) 1.09; 95%ci 1.00, 1.18). supplementary table s2 shows that more days stayed-at-home was associated with anxiety (p for interaction = 0.005) and depressive (p for interaction = 0.008) symptoms especially among respondents with older age (60+ years). more days stayed-at-home was associated with a higher stress level especially among respondents with primary or lower education attainment (p for interaction = 0.014). we have provided the first evidence on compliance with non-pharmaceutical community containment strategies including stay-at-home and social distancing and their associations with mental health symptoms during the covid-19 pandemic. random samples from landline and mobile phone increased the representativeness of the study. the effectiveness of public health interventions depends on the degree of population engagement and compliance in practice. avoiding going out and avoiding social gatherings were mostly practiced, which may have resulted in the achievement of suppressing the first wave of community outbreak in february and march (first eight weeks) and in mitigating the second wave, due to imported cases, in april and may [2] . most respondents have voluntarily stayed at home for at least four days in a week except for essential tasks (e.g., shopping for daily necessaries). perceived overall compliance was satisfactory considering no lockdown has been implemented and some must maintain a normal working life. keeping a physical distance of 1.5 meters, especially in public transportation, workspaces and restaurants, is demanding in crowded metropolitan districts such as hong kong. flexible working schedules to avoid crowded transportation, home office working, and closure of unessential businesses may supplement these distancing measures [16] . being female, older age, and having higher ses were associated with higher levels of perceived compliance with social distancing measures. without the need for work-related essential tasks, the practice of stay-at-home and social distancing is easier for economically inactive people (e.g., students with class suspensions, homemakers, or retirees). the early reported higher mortality rate among older adults (aged 60+) [30] might have raised alarm, leading to higher compliance with home-confinement in the elderly. females and people with higher ses were more vigilant in recognizing and practicing public health measures. one possible explanation is that women and people with a higher ses are more health conscious [31] . in contrast, males with lower ses may have more essential job requirements and less flexible working schedules, which may lead to lower compliance. knowledge of infectious disease, social norms and perceived effectiveness of the measurements were reported to be decisive regarding level of compliance [32] . timely epidemiological reports, combined with minute-by-minute case reports and open contact tracing, may have strengthened health communication and population-wide adoption of precautionary measures during this pandemic [3, 33] . the perceived effectiveness of and compliance with social distancing were associated with lower risks of mental distress. consistently, personal protection measures including mask wearing and household disinfection were associated with less stress and depressive symptoms, adjusted for social distancing. the association between social distancing and mental health remained robust after additional adjustment for personal protective measures. perceived effectiveness and compliance with public health measures in preventing the infection for oneself and family members, and contributing to the safety and health of the community and country may strengthen feelings of security and alleviate mental distress related to the pandemic. a repeated cross-sectional study conducted in january, february and march 2020 has reported that perceived susceptibility to worries about being infected was decreasing, while confidence in protecting oneself was increasing in hong kong [2, 3] . personal protective measures such as mask wearing have become a social norm, and this perceived protection and solidarity may further enhance individual compliance [9] . dynamic fluctuation in mental well-being is possible following different stages of the pandemic and the effectiveness of control measures. areas experiencing severe outbreaks and with poor community control may encounter shortages in preventive supplies, more worries about being infected, less confidence in self-protection, less compliance with social directives and more serious mental health crises. in contrast, staying at home for a longer time was associated with increased risks of depressive symptoms. reverse causation is possible in which respondents with depressive symptoms might have tended to stayed-at-home. however, a crowded living environment, restricted face-to-face social interactions and restricted outside activities have led to a physically inactive and sedentary lifestyle for months, which may contribute to boredom, low mood, or mental distress. the elderly and less educated population might be more vulnerable regarding the processing of health information and sudden changes in social rules, especially in the digital world where public communication is mostly performed online [33, 34] . we found in our subgroup analysis that older and less educated adults were more vulnerable to mental health symptoms if they stayed for more days at home. increasing knowledge and promoting the use of preventive measures for the most vulnerable individuals is urgently needed in order to increase compliance with social distancing and maintain mental well-being. health care providers have an important role in addressing mental distress as part of the pandemic response, improving compliance with social distancing and helping reduce the impact of covid-19 on mental health. decline in virus transmission and ease of public health restrictions are yet to come in this worsening pandemic. social distancing is in need of collective effort for a long period of time in most affected countries and areas [18] . the long-term psychological impact in relation to the pandemic and social distancing measures requires further nation-and world-wide investigation. some limitations of the study should be noted. causal relations could not be inferred in this cross-sectional study, where respondents with psychological distress were less likely to comply with public health measures. pre-existing psychological problems were not collected, and residual confounders were not able to be excluded. recall bias may exist in self-reporting measurements. the reasons for non-compliance with social distancing need further investigation for further public directives to be put into practice. the pss-4 has a satisfactory construct validity [23] but a somewhat lower reliability (cronbach's α < 0.7). however, the reliability coefficient of 0.67 should not seriously attenuate validity [35] and the scale was consistent with pss-14 and pss-10 in correlations with other health-related variables, which provides a concurrent validity of the scale [24] . simple measurements of mental health symptoms have restricted the clinical implications and more rigorous measurements are warranted. however, diagnostic instruments could be hard to implement in such a population-based survey. respondents identified with higher stress level and having anxiety or depressive symptoms could benefit from further psychological assessment and support. we measured immediate mental health symptoms during the epidemic, and long term psychosocial responses such as social inactivity, post-traumatic stress disorder, and subthreshold or clinical anxiety and depression disorder will need further investigation. compliance with social distancing and stay-at-home is higher among female, older and educated respondents. compliance with and perceived effectiveness of social distancing were associated with lower levels of stress, anxiety and depressive symptoms. more days stayed-at-home, however, may increase the risk of depressive symptoms, especially in older adults. public health interventions are needed to protect the "new normal" in a future with or without covid-19. the long-term psychological impact in relation to social distancing and stay-at-home requires further investigation. social support and targeted interventions for the psychological well-being of the most underprivileged community members are urgently needed. presumed asymptomatic carrier transmission 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stress scale: validation in a sample of chinese cardiac patients who smoke an ultra-brief screening scale for anxiety and depression: the phq-4 a 4-item measure of depression and anxiety: validation and standardization of the patient health questionnaire-4 (phq-4) in the general population screening for anxiety disorders with the gad-7 and gad-2: a systematic review and diagnostic metaanalysis detecting and monitoring depression with a two-item questionnaire (phq-2) screening for depression with the patient health questionnaire-2 (phq-2) among the general population in hong kong clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study the gender gap in mortality: how much is explained by behavior? j. health econ how to improve adherence with quarantine: rapid review of the evidence health information exposure from information and communication technologies and its associations with health behaviors: population-based survey protecting older adults during social distancing uses and abuses of coefficient alpha we thank the respondents for their participation in the survey. the authors declare no conflict of interest. key: cord-321705-6a7avlro authors: hou, tianya; zhang, taiquan; cai, wenpeng; song, xiangrui; chen, aibin; deng, guanghui; ni, chunyan title: social support and mental health among health care workers during coronavirus disease 2019 outbreak: a moderated mediation model date: 2020-05-29 journal: plos one doi: 10.1371/journal.pone.0233831 sha: doc_id: 321705 cord_uid: 6a7avlro purposes: during the outbreak of coronavirus disease 2019 (covid-19) all over the world, the mental health conditions of health care workers are of great importance to ensure the efficiency of rescue operations. the current study examined the effect of social support on mental health of health care workers and its underlying mechanisms regarding the mediating role of resilience and moderating role of age during the epidemic. methods: social support rating scale (ssrs), connor-davidson resilience scale (cd-risc) and symptom checklist 90 (scl-90) were administrated among 1472 health care workers from jiangsu province, china during the peak period of covid-19 outbreak. structural equation modeling (sem) was used to examine the mediation effect of resilience on the relation between social support and mental health, whereas moderated mediation analysis was performed by hayes process macro. results: the findings showed that resilience could partially mediate the effect of social support on mental health among health care workers. age group moderated the indirect relationship between social support and mental health via resilience. specifically, compared with younger health care workers, the association between resilience and mental health would be attenuated in the middle-aged workers. conclusions: the results add knowledge to previous literature by uncovering the underlying mechanisms between social support and mental health. the present study has profound implications for mental health services for health care workers during the peak period of covid-19. a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 the coronavirus disease 2019 (covid19) as an unprecedented threat has infected more than 2,800,000 people by 27 april, 2020 [1] , which has attracted international attention as a public health emergency of international concern [2] . considerable countries are confronting escalating pandemics and tremendous burden. the availability of skilled health care workers is the decisive factor in overcoming a viral epidemic [3] . in the most affected areas such as hubei province, china where the confirmed cases were first reported, nearly all health care workers work directly with the infectious patients, whereas in the less affected areas, some health care workers directly fight against covid-19 and others are prepared to fight. however, the bravery of health care workers cannot protect them away from mental health problems during covid-19. according to the research during the 2003 severe acute respiratory syndrome (sars) outbreak, health care workers have shown mental health problems with 10% hospital workers reporting higher levels of stress [4, 5] . another study during ebola outbreak presented that health care workers of sierra leone had significant psychological symptoms including depression, interpersonal sensitivity and even paranoid ideation [6] . more importantly, evidence from previous literature showed that the stress levels for high-and low-risk health care workers were equivalent during the outbreak of epidemic [3] . psychological intervention and mental health services were in need to prevent health care workers from being traumatized as they were emotionally affected during the epidemic [6, 7] . mental health is fundamental to an individual's overall well-being and absolutely essential to a productive and efficient life. in workplace, mental health problems are found to be associated with plenty of negative influences, such as reduction of efficiency, loss of productivity, disability and absenteeism [8, 9] . given the adverse impacts, it is of great importance to investigate the potential factors and mechanisms that could enlighten the improvement of the mental health and maintenance of productivity of health care workers in the mist of the epidemic. among all the influential factors, social support has been recognized as one of the protective factors for mental health [10, 11] . thus, the aim of the present study was to replicate the relationship between social support and mental health based on the health care workers during covid-19 outbreak, and further extend the previous studies by exploring the potential mechanisms in the relationship. social support is individuals' perception or experience in terms of being involved in a social group where people mutually support each other [12] . previous research has repeatedly emphasized the role of social support in the promotion of mental health [13] . not only crosssectional studies [14, 15] , but also a large body of longitudinal studies emerging recently [13, 16] have confirmed the positive association between social support and mental health outcome robustly. although a substantial number of research found this strong relation can hold across a broad range of samples, such as cancer patients, patients with multiple sclerosis, nurse students and so on [17, 13, 11] , a handful of studies have presented different results. a meta-analysis conducted by ge, zhao, liu, zhou, guo & zhang [18] has concluded that for the aged people, mental health was weakly or extremely weakly associated with social support. fiori et al. [10] has claimed that the emotional support was only related to mental health in females only, not in males. therefore, it is vital to note the previous studies have found the relation between social support and mental health based on certain samples, however, whether the conclusion could be duplicated to health care workers during the outbreak of covid-2019 still remains unexplored. moreover, the mediating mechanisms (i.e., how social support correlates with mental health?) and moderating mechanisms (i.e., when this relationship is most potent?) underlying the association between social support and mental health also stay largely unknown. answering these questions could be of vital importance to further understand the mental health of medical workers and advance the more effective interventions to ensure the productivity of health care worker during covid-19. thus, the present research employed a sample of chinese health care workers during covid-19 outbreak to explore a conceptual model in which, on the one hand, resilience mediated the association between social support and mental health; on the other hand, the indirect relationships between social support and mental health via resilience were moderated by age group. social support and resilience. resilience is an individual's capacity to deal with significant adversity and quick recover [19] . a great many of studies based on various methodologies and samples have provided robust evidence with respect to the association between social support and resilience. numerous cross-sectional studies have revealed a positive association between social support and resilience [20] [21] [22] . in addition, a longitudinal study conducted by liu, he, jiang, & zhou [23] utilized a sample of adolescents from 5.12 earthquake-hit region and confirmed social support as the protective factor of resilience after a one-year followup. furthermore, a meta-analysis including 14 studies also has concluded that social support, particularly the utilization of the support, could enhance children's resilience [24] . thus, it is possible that social supports could enhance the resilience of health care workers. resilience and mental health. mental health is the critical component of personal development and growth, which is more than the absence of mental illness [25] . plenty of empirical studies reach the consensus that resilience exerts an positive effect on mental health [25] [26] [27] and the association is presented to be consistent across different samples with diverse background [28] [29] [30] . also, psychological resilience can help protect individuals against mental illness and thrive from the adversity [31] . in fact, a few researchers have investigated the relation between social support, resilience and wellbeing [14, 13, 15, 32] . it is worth noting although the previous studies explored the relation, some treated resilience as a covariate or moderator, while others did analyze resilience as a mediator. however, as far as we know, no research has examined whether the relationship between social support and mental health via social support could be applied to the health care workers who are prepared and fight during the epidemic. although social support may have an impact on mental health indirectly via resilience, not all people with lower resilience suffer from lower level of mental health. therefore, it is essential to explore the influential factors that could strengthen or attenuate the link between social support, resilience and mental health. this research examined a hypothesis that the resiliencemental health link in the indirect association between social support and mental health would be moderated by age group. several studies have concluded the possibility of the receipt of depression treatment diminished as getting older [33, 34] . robb, haley, becker, polivka & chwa [35] have compared the similarity and difference between younger and older adults in the attitudes towards mental health service, and found younger adults showed more willing to seek mental health services compared with the elder. in addition, dinapoli, cully, wayde, sansgiry, yu, & kunik [36] have examined the role of age in the prediction of mental health service use. the results have presented that younger adults with depression or anxiety disorders were more likely to utilize mental health service compared with the middle-aged adults. the mental health services include mediation, yoga and stress management, which are mainly focusing on the enhancement of resilience [37, 38] . in sum, younger adults might be more likely to receive resilience training to improve the mental health than middle-aged adults. thus, the mental health of younger adults might rely more on resilience than other factors. furthermore, health care workers during the pandemic are in highly psychological stressing condition when fighting against covid-2019 outbreak [39] . the middle-aged workers usually have longer length of employment and more working experience than the younger workers. meanwhile, the odds of participation in the fight against other epidemics before might be higher for the middle-aged in comparison to the younger. all these past experiences would make them less stressful, less anxious, less fearful and better mental health state when facing the epidemic [40] . taken all together, the mental health of the middle-aged workers would be less dependent on resilience, which indicates the link between resilience and mental health would be attenuated in middleaged adults than younger adults. in fact, a meta-analysis including 60 studies has specifically investigated the moderating role of age in the relation between trait resilience and mental health [25] . however, the study just concluded the relation was stronger for adults than children and adolescence, without the comparison between younger adults and middle-aged adults. unlike the previous research, the current study examined the potential difference between the younger and middle-aged medical workers in the link between resilience and mental health. taken all together, the aims of this research were twofold: (a) to examine whether the mediating role of resilience in social support and mental health could be duplicated to the health care workers from a less affected area during the covid-19 epidemic, and (b) to test whether the relationship between social support and mental health via resilience is moderated by age group. the current study constructed a conceptual model to address both mediation and moderation effects (see fig 1) . based on the literature review, the following hypotheses were proposed: hypothesis 1: resilience would mediated the relationship between social support and mental health of health care workers during covid-19 pandemic. hypothesis 2: age group would moderate the indirect association between social support and mental health via resilience such that the resilience-mental health pathway would be stronger in younger age group in comparison with the middle-age group. given that we suppose age would only moderate the second stage of the mediation path, the present study would call it "a second stage moderation model". the cross-sectional study was conducted from 1 st to 7 th february, 2020, which was the peak period of covid-2019 outbreak in china. the participants were health care workers from local hospitals, community health service centers and government department in jiangsu province who participated in the fight against covid-19. the questionnaires were distributed through internet. all subjects were given informed written consent before completing the online survey concerning demographic information, social support, resilience and mental health. all the subjects were free to withdraw from the research at any time. the research was approved by the ethics committees of the second military medical university. a total of 1521 health care workers completed the survey in the present study. considering the present study was to compare the indirect effect of social support on mental health via resilience between the young and middle-aged heath care workers, participants aged 50 or over were excluded. finally, 1472 subjects were included in the analysis. social support. the social support rating scale (ssrs) developed by xiao was utilized to measure social support [41] . the 10-item scale consists of 3 dimensions including objective support, subjective support and availability. a representative item was "how many close friends do you have to get support and help?". higher scores indicate higher levels of social support. the scale has presented impressive validity and reliability in chinese population [42] . the cronbach's alpha for the present study was 0.949. resilience. the connor-davidson resilience scale (cd-risc) was used to assess resilience [43] . the 25-item likert scale consists of five dimensions: (a) personal competence, high standards, and tenacity; (b) trust in one's instincts, tolerance of negative affect, and strengthening effects of stress; (c) positive acceptance of change and secure relationships; (d) control; (e) spiritual influence [44, 45] . participants rated each item from 0 (not true at all) to 4 (true all the time). the range of total scores is from 0 to 100, with higher scores representing higher levels of resilience. the scale has presented good psychometric properties [43] . in this study, the cronbach's alpha was 0.955. mental health. symptom checklist 90 (scl-90) developed by derogatis and cleary [46] was administrated to evaluate mental health [47, 48] . the 90-item scale is widely applied to measure clinical psychiatric symptoms and differentiate individuals with mental illness from healthy people [49, 50] . each item is rated from 1 (no symptom) to 5 (severe symptom). the higher total scores the participants got, the worse mental health condition they were in. in this research, scl-90 � 160 was defined as psychological abnormality [51] . the scale has shown good validity and reliability in chinese population [52] . in this research, the cronbach's alpha was 0.983. firstly, the present study calculated the descriptive statistics and bivariate correlations among variables of interest by statistical package for social science (spss) 21.0 for windows. a twotailed p-value smaller than 0.05 indicated the presence of statistical significance. secondly, structural equation modeling (sem) conducted by amos 23.0 through maximum likelihood method was performed to examine the mediating role of resilience in the relation between social support and mental health. the model fit index included root mean square error of approximation (rmsea), standardized root mean square residual (srmr), goodness of fit index (gfi) and comparative fit index (cfi). as recommended by previous literature, the values of rmsea and srmr smaller than 0.08 and the values of gfi and cfi more than 0.9 indicate an acceptable fit [53] . bias-corrected bootstrap method was used to examine the significance of mediation effect. specifically, we used 2000 bootstrap samples and determined the bias-corrected 95% confidence interval. if the confidence does not contain zero, it means the significance of the effects [54] . finally, the moderated mediation model was tested by using hayes [55] process macro (model 14). the 95% bias-corrected confidence interval from 5000 resamples was generated by bias-corrected bootstrapping method to examine the significance of moderated mediation effect. the sociodemographic characteristics of the participants and the distribution of scl-90 scores were presented in table 1 . most health care workers were females (76.5%), middle-aged (55.0%), married (73.0), and reported 12-16 years of schooling (64.9) and less than 10 years of working (61.6). the prevalence of psychological abnormality was 7% among health care workers. the mean ± sd total score of scl-90 was 110.28 ± 28.89. there were no significant differences in scl-90 scores associated with gender, age, marital status, years of schooling and years of working. social support was positively correlated with resilience and age group, and negatively correlated with scl-90 scores (all p < 0.001). resilience was positively associated with age groups and negatively associated with scl-90 scores (all p < 0.001). structural equation model was employed to examine the mediating role of resilience. firstly, the direct path coefficient from social support to scl-90 scores in the absence of resilience was significant, γ = -0.39, p < 0.001. secondly, the structural equation model regarding the 2) . a bootstrap procedure conducted to examine the mediation effects. 2000 bootstrapping samples was generated from the original dataset (n = 1472) via random sampling. the indirect effect of social support on scl-90 scores through resilience was -0.120 (se = 0.019, 95%ci = [-0.156, -0.084], p = 0.001). the 95% biased-corrected confidence interval did not contain zero, which verified the indirect relationship between social support and scl-90 scores via resilience. it has been expected that age group would moderate the second stage of the mediation process. as shown in table 2 , in model 1, social support positively predicted resilience, β = 0.408, p < 0.001. model 2 revealed that the effects of resilience on scl-90 scores was moderated by age group, β = 0.126, p < 0.01. for descriptive purpose, the present study plotted the relationship between resilience and scl-90 scores, separately for younger and middle-aged groups (see fig 3) . simple slope test presented that for subjects from younger group, resilience was significantly and negatively associated with scl-90 scores, β simple = -0.343, p < 0.001. for subjects from middle-aged group, resilience was still negatively correlated with scl-90 scores, but much weaker, β simple = -0.217, p < 0.001. the biased-corrected 95% confidence interval for index of moderated mediation was from 0.0065 to 0.0981, which did not contain zero. this further presented that the indirect effects of social support on scl-90 scores via resilience significantly differed between groups. evidence from previous literature has already found health care workers with higher levels of social support are more likely to show higher levels of mental health [56, 57] . nevertheless, issues regarding the underlying mediating and moderating mechanisms and whether this could be applied to health care workers who are fighting with the outbreak of covid-2019 stay largely unanswered. to our knowledge, the present study is the first to report the effect of social support on mental health based on health care workers from a less affected area during covid-19 outbreak. this research built a moderated mediation model to test whether resilience mediated the association between social support and mental health of health care workers and whether this indirect relationship was moderated by age groups. the results showed that (1) the mediating role of resilience in the association between social support and mental health could be replicated to the health care workers during the epidemic; (2) age moderated the indirect link between social support and mental health (resilience-mental health path), with younger workers showing stronger than middle-aged workers. the prevalence of psychological abnormality was 7% among health care workers in our study, lower than that (17.3%) of chinese health care workers during the sars epidemic [58] . a recent study presented the rate of mental abnormality among nurses in guangdong province was 11.9% during the non-epidemic phase [51] . the difference might be attributed to the fact that jiangsu province was less affected during the covid-19 pandemic. additionally, different instruments and regional differences might also contribute to the discrepancy. generally speaking, the prevalence of psychological abnormality cannot be neglected and more attention should be paid to address this issue. in line with our hypothesis, resilience mediates the relationship between social support and mental health of health care workers during the epidemic. this is aligned with previous research based on different samples [13, 16] . this study is the first to explore the relation with the focus on the population who are facing the emergency events of the public health. this finding can be explained by the "buffer" hypothesis developed by cohen and wills [59] , which revealed the buffering effect of social support on the impact of stress upon mental health. the previous research has highlighted that finding effective approaches to deal with stress is of great importance in positive health outcomes [12] . social support could protect individual from stressful conditions and poor health state [60] . meanwhile, individuals with higher levels of social support might be more inclined to believe that they could get the help needed when facing the stressful event regarding the outbreak of the epidemic. this notion would enhance their beliefs to deal with the adversity and difficulty in the battle with covid-19, which further leads to the higher levels of resilience [61] . in addition, the reports of previous literature have demonstrated that resilience, as one kind of personal resources, also buffered the impact of stress on mental health [62] [63] [64] [65] . taken all together, resilience plays a mediating role in the association between social support and mental health for the health care workers fighting with the epidemic. the findings also revealed the moderating role of age groups in the association between resilience and mental health of the health care workers. in the past research, a small handful of previous studies have found that age moderated the link between resilience and mental health by the comparison between younger adults and older adults (usually age 50 and over) [66, 67] , whereas some other researchers focused on the contrast between the adults and minors [25] . however, these studies neglected the potential differences between the younger adults and middle-aged adults. unlike the past research, this study took the potential difference between younger and middle-aged health care workers into consideration innovatively. consistent with our hypothesis aforementioned, the increase in age (from young adults to middle-aged adults) attenuated the relationship between resilience and mental health. specifically, the younger health care workers showed stronger association between resilience and mental health compared to the middle-aged ones. this result might be interpreted by erikson's theory of life cycle development [68] , which postulates eight stages of human life. younger adults belong to stage vi with the emphasis on intimacy, while middle-aged adults are attributed to stage vii focusing on generativity. erikson's generativity stage is similar to self-actualization in maslow's hierarchy of needs [69, 70] . hence, compared with younger adults, the mental health of middle-aged adults relies less on resilience but other factors, such as the feeling of self-fulfillment, personal growth and so on. the findings of this research have profound implications since the data were collected during the peak period of covid-19 in china, which is the stage other countries are currently experiencing. first, the results stress the crucial role of social support in mental health. during the outbreak, the maintenance of mental health of health care workers is crucial for the productivity and work efficiency. therefore, it is of great importance to provide a full range of social support including instrumental support, emotional support and so on. second, the findings also highlight the potential value of resilience-focused intervention in health care workers. the resilience-focused mental health promotion program usually contains coping skills, stress management, positive attitude and so on [71] . finally, the indirect link between social support and mental health via resilience is stronger in younger adults, which implies we should give priority to younger health care workers with respect to resilience-boosting intervention. meanwhile, we also need to find other influential factors of mental health for middle-aged health care workers. several study limitations must be noted. first, the current study employed a cross-sectional design since health care workers who have consecutively worked for several days would be replaced by others, which made it hard to revisit them after a certain period. however, the cross-sectional design is insufficient to infer the causality in terms of the relationship analyzed. also, as existing literature showed, social support and resilience might influence each other reciprocally [23, 72] , the reverse causality cannot be ruled out. future research could conduct longitudinal study to further explore the moderated mediation model. second, the study used convenient sampling and all data were collected through self-report, which undermined the generalization of the results. the participants in our study were all from jiangsu province, china, which was geographically limited for a wider generalization. future research could test the relation based on more typical samples from multiple regions and manage to collect data from multiple sources (e.g., colleagues). finally, mental health is a complex concept, which could be influenced by numerous factors. social support and resilience could just explain a limited part of mental health. sleep quality and fatigue might be two important factors of mental health, but we failed to investigate. during the covid-19 outbreak, health care workers had to work excessive hours and suffered from disrupted circadian rhythms, which would contribute to fatigue and undermine sleep quality. hence, future study might focus on a more integrated model of mental health with diverse influential factors. in spite of the limitations, the current study contributes to the previous literature theoretically and practically. theoretically, this study adds knowledge to the previous research by exploring the moderated mediation model, which would help further understand the relationship between social support and mental health. practically, the findings are essential for the maintenance of mental health of health care workers during the outbreak of covid-2019. in conclusion, this study presented the protective role of social support in mental health among health care workers. moreover, resilience could be one of the pathways through which social support contributes to mental health. furthermore, the effect of social support on mental health via resilience is attenuated in middle-aged health care worker compared with the younger ones. supporting information s1 file. (sav) s1 data. strobe statement-checklist of items that should be included in reports of cross-sectional studies. 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syndrome stress, social support, and the buffering hypothesis social support and risk for cardiovascular disease and cancer: a qualitative review examining the role of inflammatory processes multiple identities and psychological well-being: a reformulation and test of the social isolation hypothesis the buffering effect of resilience on depression among individuals with spinal cord injury: a structural equation model work related stress, social support, and engagement as predictors of resilience in emergency department nurses the mediating effect of resilience between mental stress and mental health on college students buffering effect of coping style on the stress-depression relationship among taiwanese icu nurses: a multi-group structural equation model with two-factor nurse stress checklist psychological resilience in young and older adults age differences in the association of social support and mental health in male u.s. veterans: results from the national health and resilience in veterans study childhood and society motivation and personality generativity versus stagnation: an elaboration of erikson's adult stage of human development systematic review of resilience-enhancing, universal, primary school-based mental health promotion programs the influence of the resilience on the organizational commitment of kindergarten and childcare teachers: social support as a mediating variable the authors would like to acknowledge all participants and the research assistants from naval medical university. key: cord-322824-8xhypw8r authors: mckinley, gerald patrick title: we need each other: social supports during covid 19 date: 2020-06-02 journal: soc anthropol doi: 10.1111/1469-8676.12828 sha: doc_id: 322824 cord_uid: 8xhypw8r nan 1 special section article g e r a l d pat r i c k m c k i n l e y we need each other: social supports during covid 19 as social beings, we need each other. during stressful times that becomes more apparent. i specialise in the social determinants of mental health; specifically, social support networks and relationships. i write this not only as an academic but also as someone providing in-home care for my elderly mother as she goes through cancer treatments during covid-19. what i see is an increased impact of stress because neither she nor i have physical and routine access to our full social support networks. for my family, the past two years have already been stressful. in october 2018 my father had a heart attack, beginning a slow process of declining health which ended with his death in december 2019. two days after my father's funeral my mother had a complete gastrectomy to deal with stage three stomach cancer. those were challenging and stressful times, but they were made easier by having family and friends to draw on. my mother has always maintained an active social life, which provided support for her as she figured out life after the loss of her husband of 57 years and the realities of being a cancer patient. academic me thinks about the stress buffering hypothesis developed by cohen and wills (1985) , which suggests that during time of stress we appraise the perceived support around us and, if we are satisfied that we have enough, we manage our stress. since cohen and wills published their hypothesis the model has been tested and supported in several contexts, including with individuals going through cancer treatment (gremore et al. 2011 ). the main take away is that if you have active relationships where you feel supported, you are shielded from the impact of stress. covid-19 has taken away the daily routines through which we interact with our social support networks, or friends and family. social networks are active and dynamic. when we encounter stress, very few people sit down and make a list of who can provide what support. we go to people and drink tea or they come to us and we have dinner and wine. we laugh and cry with our friends. it is in the social process that support is perceived before being actualised. living in a context of increased stress during the isolation of covid-19 highlights this for me. it raises some important considerations as i think about my mom at the societal level. how does society respond to increased levels and length of isolation from the regular, mundane, social interactions that we are used to engaging with? can online chats replace a hand being held by a friend during crisis? the physiological impact of stress on my own body is telling. reflecting on the past month, i see that the only major change is that i cannot physically access my support network. through this reflection i see the most important impacts of the virus on society as more than the biological reactions. we must consider who is impacted by the loss of each other. stress, social support, and the buffering hypothesis stress buffering effects of daily spousal support on women's daily emotional and physical experiences in the context of breast cancer concerns key: cord-288708-ys4apcvg authors: emerson, eric; fortune, nicola; llewellyn, gwynnyth; stancliffe, roger title: loneliness, social support, social isolation and wellbeing among working age adults with and without disability: cross sectional study date: 2020-08-05 journal: disabil health j doi: 10.1016/j.dhjo.2020.100965 sha: doc_id: 288708 cord_uid: ys4apcvg background: loneliness is significantly related to health and wellbeing. however, there is little information on the prevalence of loneliness among people with disability or the association between disability, loneliness and wellbeing. objective/hypothesis: for a nationally representative sample of adults (age 16-64) with/without disability, to examine exposure to three indicators of low social connectedness (loneliness, low perceived social support, social isolation), and to evaluate the association between low social connectedness and wellbeing. to test whether disability status moderated the relationship between low social connectedness and wellbeing. methods: secondary analysis of data from three annual rounds of the cross-sectional english community life survey (cls) 2016-19. results: people with disability experienced loneliness, low perceived social support and social isolation at significantly higher rates than people without disability. effect sizes were significantly greater for loneliness. disability was associated with lower wellbeing. with one exception, low social connectedness was associated with lower wellbeing. again, effect sizes were significantly greater for loneliness. the prevalence of loneliness was highest among adults with disability who were younger, economically inactive, living in rented or other accommodation, living alone and with low levels of access to environmental assets. there was no evidence that disability status moderated the association between exposure to low social connectedness and low wellbeing. conclusions: loneliness was a particularly significant driver of poor wellbeing among people with disability. the relative independence between different indicators of social connectedness suggests that interventions to reduce loneliness will need to do more than simply increase rates of social contact or social support. the degree to which individuals are interconnected and embedded in communities has a powerful impact on their health and wellbeing. 1 knowledge in this area is based on a range of approaches for conceptualizing and measuring social connectedness including: social network analysis; level of social support; and level of social engagement/isolation. 1, 2 one of the key challenges of this literature is disentangling the effects associated with different aspects of low social connectedness. 1, 3 social isolation is typically defined by a low frequency of social contact. 4 social support typically refers to either the perceived availability or actual level of receipt of social contacts to fulfil specific functions (e.g., to provide practical help or emotional support). 1, 3 more recently, increasing attention has focused on loneliness as an indicator of low social connectedness. [4] [5] [6] [7] [8] loneliness has been defined primarily as an emotional state; a 'distressing feeling that accompanies the perception that one's social needs are not being met by the quantity or especially the quality of one's social relationships'. 5 loneliness is relatively common in the general population. for example, in england 5% of adults report feeling 'often' or 'always' lonely, with an additional 16% reporting feeling lonely 'some of the time'. 9 in germany, 11% of adults (aged 35-74) report feeling lonely. 10 increased levels of loneliness have been reported among: women; younger adults; those not living in a couple relationship, living alone, and without children; and people who are unemployed. 9, 10 compared to the general population, people with disability have fewer friends, less social support and are more socially isolated. [11] [12] [13] [14] [15] however, few studies have addressed the relationship between disability and loneliness. most have focused on disability related to either physical impairments [16] [17] [18] [19] [20] [21] or intellectual impairment. [22] [23] [24] [25] we are aware of only one study that has investigated loneliness among people with disability associated with a range of impairments. in a convenience sample of 680 adults in one city in england, higher rates of loneliness were reported among people with disability than among their non-disabled peers, with particularly high rates of loneliness being reported among participants with cognitive or intellectual impairments. 26 personal wellbeing (pwb) may be defined as 'good mental states, including all of the various evaluations, positive and negative, that people make of their lives and the affective reactions of people to their experiences'. 27 it is a multi-dimensional phenomenon, commonly recognised as involving four distinct facets: life satisfaction (alternatively called 'cognitive' or 'evaluative' wellbeing), positive affect (e.g., happiness), negative affect (e.g., anxiety), and eudemonic wellbeing (sense of worth, purpose and meaning in life). 28 in population studies, people with disability typically report, on average, lower levels of pwb than people without disability. however, there is an evolving body of knowledge suggesting that disability-related inequalities in wellbeing do not reflect a direct negative impact of impairment, but rather that demographic characteristics and exposure to social determinants of poor health play a major role in the negative association between disability and wellbeing. 29 the concept of pwb resonates strongly with the world health organization's definition of health as 'a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity'. as such, pwb has potential relevance to public health research, which continues to conceptualise health outcomes predominantly in terms of 'disease or infirmity'. for example, of the 40 systematic reviews on the public health consequences of social isolation and loneliness identified by leigh-hunt and colleagues, 6 19 focused on morbidity, 8 focused on morality, 7 focused on health behaviours associated with mortality or morbidity (e.g., smoking, excess alcohol use), while only 2 focused on positive aspects of health (one on wellbeing, one on self-efficacy). research not only shows positive associations between pwb and health, 30 but also suggests a causal relationship between higher pwb and more positive future health outcomes such as lower mortality and increased longevity, and a possible protective effect of pwb. 28, [31] [32] [33] very few studies have examined the association between loneliness and wellbeing among people with disability. the few exceptions have suggested that, among people with intellectual disability, increased loneliness has been associated with increased rates of depression, mental health problems and poorer physical health in a small number of cross-sectional studies. 22 given this paucity of information on the association between disability, loneliness and wellbeing, our aims were: all measures are based on online self-report. the cls contains a disability identifier based on positive answers to two questions: ( (3) nobody. the three items were moderately inter-correlated (r range 0.419-0.646) and showed reasonable levels of internal consistency (cronbach's alpha = 0.76). as a result, we summed scores on the three items to create a social support scale and converted this to a simple binary indicator of perceived social support that used a cut point producing an overall prevalence as close as possible to the prevalence of 'often/always' feeling lonely. the main reason for this decision was to facilitate the ease of making comparisons between effect sizes of relative risk associated with different indicators of low social connectedness by ensuring that the denominators (prevalence among people with no disability) did not vary too widely. social support data were missing for less than 0.1% of respondents. the weighted prevalence of low perceived social support across the three surveys was 8.4%. four items measured frequency of contact with family and friends: (1) how often do you meet up in person with family members or friends? (2) how often do you speak on the phone or video or audio call via the internet with family members or friends? (3) how often do you email or write to family members or friends? (4) how often do you exchange text messages or instant messages with family members or friends? response options ranged from 'more than once a day' to 'never' on an eightpoint scale. the four items were moderately inter-correlated (r range 0.186-0.462) and showed acceptable levels of internal consistency (cronbach's alpha = 0.64). as a result, we summed scores on the four items to create a social isolation scale and converted this to a simple binary indicator of social isolation using a cut point that produced an overall prevalence as close as possible to the prevalence of 'often/always' feeling lonely. social isolation data were missing for less than 0.1% of respondents. the weighted prevalence of social isolation across the three surveys was 5.0%. the cls included four indicators of pwb developed by the uk's office for national statistics for inclusion in national surveys; 37 round of survey (coded 1-3) data were available for all respondents. information was collected on age group (16-19, 20-24, 25-34, 35-49 , and 50-64, which was the most detailed age classification released with the data), gender (male/female) and ethnicity (british minority ethnicity vs. not). age data were available for all respondents. gender and ethnicity data were missing for 0.1% and 0.8% of respondents, respectively. information was included in the analyses on seven aspects of current living circumstances: living arrangements; housing status; highest level of educational attainment; employment status; environmental assets (community amenities such as local grocery shops and parks); neighborhood deprivation; and urban/rural location. full details of these are presented in supplementary table 1 . first, prevalence rates were calculated for exposure to loneliness, low perceived social support and social isolation, disaggregated by disability status and gender. crude and adjusted prevalence rate ratios (prrs) for exposure were estimated using poisson regression with robust standard errors. 38 partially adjusted models took account of between-sample differences in round of survey and personal demographics. fully adjusted models took account of between-sample differences in round of survey, personal demographics and current living circumstances. the difference between partially and fully adjusted prrs provides an estimate of the extent to which differences in low social connectedness between respondents with and without disability may be accounted for by differential exposure to disadvantageous living circumstances. second, the fully adjusted models were also used to identify personal demographic and living circumstance variables that were independently related to rate of exposure to the three indicators of low social connectedness. for all variables significantly related to variation in exposure (p<0.05) we added into the model an interaction term to assess whether disability status moderated the observed association between the predictor variable and variation in exposure. we estimated marginal means (with 95% confidence intervals) for exposure for all significant associations. third, we compared the pwb of respondents with and without disability for each indicator of wellbeing using univariate general linear models, reporting partial eta squared as a measure of effect size (the extent to which variation in a variable accounts for variation in pwb within the population). 39 for each indicator in each sample we report three adjusted models: (model 1) estimates adjusted for between-group differences in personal demographics and round of survey; (model 2) estimates adjusted for between-group differences in personal demographics, round of survey and living conditions; (model 3) estimates adjusted for between-group differences in personal demographics, round of survey, living conditions and exposure to low social connectedness. changes in the effect size of disability between models 1 and 2 indicate the extent to which differences in pwb between respondents with and without disability may be accounted for by differences in living conditions. changes in the effect size of disability between models 2 and 3 indicate the extent to which differences in pwb between respondents with and without disability may be accounted for by differences in exposure to low social connectedness. finally, we included interaction terms into model 3 to determine whether disability status moderated the association between the three indicators of low social connectedness and pwb. data were combined across three annual rounds of cls. there were no statistically significant changes over round of survey for social isolation or loneliness (spearman's r = -0.003 and +0.009, respectively). there were, however, weak but significant increases over time for the prevalence of disability (r = +0.029, p<0.001) and low perceived social support (r = +0.019, p<0.05). as a result, year of data collection was entered as a covariate in all multivariate models. all analyses were undertaken using ibm spss 24 with sample weights released with the data to account for known recruitment biases. given the small amounts of missing data, complete case analysis was undertaken on a subsample of 17,066 respondents (96% of the available sample of 17,723). overall, people with disability were significantly more likely than their non-disabled peers to report loneliness, low social support and social isolation and to report exposure to multiple forms of low social connectedness (table 1) . [insert table 1] effect sizes were significantly greater for loneliness (fully adjusted prr = 3.14 (95% ci 2.79-3.54)) than low perceived social support (1.86 (1.66-2.08)), which were in turn significantly greater than for social isolation (1.20 (1.02-1.41)). partially adjusting risk estimates to take account of betweengroup differences in round of data collection and personal demographics had only a marginal impact on effect sizes. further adjusting risk estimates to take account of between-group differences in living circumstances significantly reduced effect sizes for loneliness by 28%, low perceived social support by 24% and social isolation by 21%. the correlations (kendall's tau-b) between the three indicators were modest to weak in the full sample: loneliness/low perceived social support (r=0.249, p<0.001); loneliness/social isolation (r=0.068, p<0.001); low perceived social support/social isolation (r=0.205, p<0.001). the associations between covariates and indicators of low social connectedness are summarized in table 2 . estimated marginal means for all statistically significant associations, disaggregated by disability status, are presented in supplementary tables 2-4. in the sections below, we report for all statistically significant associations the category with the lowest level of social connectedness. [insert table 2 ] inspection of estimated marginal means indicated that the prevalence of loneliness was highest among adults with disability who were younger, economically inactive, living in rented or 'other' accommodation, living alone and had low levels of access to environmental assets. the significant disability-by-predictor interactions indicated that the relative disadvantage in loneliness experienced by adults with disability was particularly pronounced for adults living as a couple, in 'other' housing arrangements, with low to medium levels of access to environmental assets and higher rates of neighborhood deprivation. inspection of estimated marginal means indicated that the prevalence of low perceived social support was highest among adults with disability who were men, of minority ethnic status, living alone, full-time students or economically inactive, living in 'other' accommodation and with either higher educational or 'other' educational qualifications. the significant disability-by-predictor interactions indicated that the relative disadvantage in social support experienced by adults with disability was particularly pronounced for adults at younger ages, who were full-time students and with higher educational qualifications. inspection of estimated marginal means indicated that the prevalence of social isolation was highest among adults with disability who were men, young, living alone or in other arrangements, economically inactive, had lower educational qualifications and living in 'other' housing arrangements. the significant disability-by-predictor interactions indicated that the relative disadvantage in social isolation experienced by adults with disability was particularly pronounced for adults at younger ages, who were living alone and had access to moderate levels of environmental assets. the association between disability, the three indicators of low social connectedness and the four indicators of pwb are presented in table 3 . disability was associated with lower pwb in all analyses. with one exception (the association between social isolation and anxiety), low social connectedness was associated with lower pwb in all analyses. adjusting for personal demographics resulted in modest increases in the size of association between disability and pwb (eta 2 range +4% to +16%). additionally, adjusting for exposure to differences in living conditions (model 2) was associated with marked decreases in the size of association between disability and pwb (eta 2 range -18% to -33%). finally, additionally adjusting for between-group differences in exposure to low social connectedness resulted in further marked decreases in the size of association between disability and pwb (eta 2 range -31% to -41%). [insert table 3] for all four pwb indicators, loneliness had a significantly greater association with lower pwb than perceived low social support which, in turn, had a significantly greater association with pwb than social isolation. in the fully adjusted model (model 3), the association between loneliness and pwb was equivalent to a large effect size for three of the four pwb variables. in none of the analyses did interaction terms between disability and any of the indicators of low social connectedness reach statistical significance (p<0.05). that is, there was no evidence that disability status moderated the association between exposure to low social connectedness and low wellbeing. people with disability were significantly more likely than their non-disabled peers to report loneliness, low social support and social isolation and to report exposure to low social connectedness on more than one indicator. effect sizes were significantly greater for loneliness than low perceived social support, which were in turn significantly greater than for social isolation. adjusting risk estimates to take account of between-group differences in living circumstances significantly reduced effect sizes for all three indicators of low social connectedness. the prevalence of loneliness was highest among adults with disability who were younger, economically inactive, living in rented or other accommodation, living alone and had low levels of access to environmental assets. the relative disadvantage in loneliness experienced by adults with disability was particularly pronounced for adults living as a couple, in 'other' housing arrangements, with low to medium levels of access to environmental assets and higher rates of neighborhood deprivation. disability and, with one exception, low social connectedness were associated with lower pwb in all analyses. there was no evidence that disability status moderated the association between exposure to low social connectedness and low wellbeing. for all four pwb outcomes, loneliness had a significantly greater association with pwb than low perceived social support which, in turn, had a significantly greater association with pwb than social isolation. we are aware of only one previous study that has investigated loneliness among people with disability associated with a range of impairments. this study, based on a convenience sample drawn from one city in england, reported that people with disability had higher rates of loneliness and social isolation than their peers, with particularly high rates of loneliness among people with cognitive or intellectual impairments. 26 we are not aware of any previous study that has investigated the association between loneliness and wellbeing among people with disability associated with a range of impairments. this study adds to the existing literature by providing evidence from a nationally representative survey of 'working age' adults on four key issues: (1) the extent of disadvantage faced by people with disability with regard to low levels of social connectedness; (2) how this disadvantage varies by demographic characteristics and living conditions; (3) the relative independence of different aspects of social connectedness; and (4) marked differences in the strength of association between different types of exposure to low social connectedness and lower pwb. in analyses adjusted for between-group differences in age, gender and ethnicity, adults with disability in england were 51% more likely to be socially isolated, 246% more likely to report low levels of perceived social support and 438% more likely to be lonely. for all four pwb outcomes, loneliness had a significantly greater association with lower pwb than low perceived social support which, in turn, had a significantly greater association with pwb than social isolation. given that disability status does not appear to moderate the association between exposure to low social connectedness and low pwb, these data suggest that people with disability are not any more or less vulnerable than non-disabled people to the effects of low social connectedness on wellbeing. given the markedly higher risk of exposure to loneliness among people with disability (compared with other indicators of low social connectedness), reducing loneliness may have particularly significant benefits in improving the wellbeing of adults with disabilities. however, the weak to modest correlations between indicators of low social connectedness among adults with and without disability suggests that interventions to reduce loneliness will need to do much more than simply increase rates of social contact or social support. 40 loneliness (and other indicators of low social connectedness) was higher among people in more disadvantaged living circumstances (e.g., economically inactive, living in rented or other accommodation, living alone and with low levels of access to environmental assets). indeed, adjusting risk estimates to take account of between-group differences in living circumstances significantly reduced effect sizes for all three outcomes, especially loneliness (risk reduced by 28%). these observations are consistent with the notion that effectively addressing social and economic disadvantage for people with disability may reduce loneliness and improve wellbeing. in addition, our results identify specific sub-groups of people with disability that interventions that are targeted toward 'at risk' groups or based on the notion of 'proportionate universalism' will need to take into account. 41 the evidence we provide that disability status moderates the risk of loneliness (e.g., among adults living in areas with low to medium levels of access to environmental assets and higher rates of neighborhood deprivation) points to some specific contexts in which intervention may be particularly beneficial for adults with disability. the four main limitations of the study were: (1) the use of a cross-sectional design that precludes the identification of causal associations between the main variables; (2) the low response rate; (3) our inability within the cls data to disaggregate results by impairment type; and (4) the unavailability of data in the survey on some key aspects of socio-economic position, especially income. with regard to response rate, it is notable that household response rate to the cls declined from 61% in 2015/16 (the last year the survey was undertaken by face-to-face interviews) to 18% in 2016/17 (online selfcompletion version). it should be noted that the data are weighted to ensure that the weighted sample matches population totals for: gender by age group, degree level education by age group, housing tenure, region, household size, ethnic group and internet usage by age group. 34 -however, it is not possible to know whether there is non-response bias specifically associated with the variables we focus on in this analysis (disability, social connectedness, wellbeing). the benefits of online administration include increased sustainability (primarily through reduced cost), avoidance of geographical clustering in the survey design and opportunity to include respondents in more remote areas. in the uk in 2017 it has been estimated that: (1) 98% of adults aged 18-54 had recently used the internet; (2) 90% among adults aged 55-64 had recently used the internet; and (3) there were no gender differences in internet use among working age adults. 42 further research is needed to determine the extent to which our results generalize across people with disability associated with different types of impairments, especially since existing evidence suggests that risk of exposure of people with disability to socially determined adversities can vary significantly across different types of impairments. [43] [44] [45] nevertheless, our results suggest that people with disability as a whole should be considered to be at increased risk of exposure to loneliness and that this exposure may be an important mediator for their lower wellbeing; an issue of particular importance given the substantial impacts on social interactions associated with the outbreak of the 2020 covid-19 pandemic. int ----urban/rural status ------round of survey ------notes: --no significant relationship between covariate and outcome main = significant main effect between covariate and outcome int = significant interaction effect between disability and covariate on outcome adjusted prevalence rate ratios (prrs) for exposure were estimated using poisson regression with robust standard errors n/a n/a n/a n/a 0.074*** 1.05 (0.98-1.11) low social support n/a n/a n/a n/a 0.028*** 0.57 (0.51-0.63) social isolation n/a n/a n/a n/a 0.002*** 0.19 (0.12-0.26) outcome: worthiness of activities disability 0.066*** 0.66 (0.63-0.70) 0.044*** 0.55 (0.50-0.60) 0.026*** 0.39 (0.34-0.44) loneliness n/a n/a n/a n/a 0.072*** 1.05 (0.99-1.11) low social support n/a n/a n/a n/a 0.024*** 0.54 (0.48-0.60) social isolation n/a n/a n/a n/a 0.003*** 0.23 (0.16-0.30) outcome: happiness disability 0.073*** 0.70 (0.66-0.74) 0.052*** 0.60 (0.55-0.65) 0.032*** 0.44 (0.39-0.49) loneliness n/a n/a n/a n/a 0.073*** 1.07 (1.01-1.13) low social support n/a n/a n/a n/a 0.022*** 0.52 (0.46-0.58) social isolation n/a n/a n/a n/a 0.001*** 0.14 (0.07-0.21) outcome: anxiety disability 0.044*** 0.54 (0.50-0.58) 0.036*** 0.51 (0.46-0.56) 0.025*** 0.42 (0.37-0.47) loneliness n/a n/a n/a n/a 0.025*** 0.66 (0.60-0.72) low social support n/a n/a n/a n/a 0.004*** 0.23 (0.17-0.29) social isolation n/a n/a n/a n/a 0.000 0.01 (-0.06-0.08) notes: * p<0.05, ** p<0.01, *** p<0.001 a difference in estimated marginal mean of outcome between presence and absence of variable presented using normalized swb scores (mean = 0, sd = 1) n/a not 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happiness and longevity in the united states london: department for digital, culture media and sport;2019. 35. department for digital culture media and sport department for digital culture media and sport. a connected society a strategy for tackling loneliness -laying the foundations for change. london: department for digital methodology: personal well-being user guidance overestimation of risk ratios by odds ratios in trials and cohort studies: alternatives for logistic regression eta squared and partial eta squared as measures of effect size in educational research a systematic review of loneliness interventions among non-elderly adults institute for health equity. health equity in england: the marmot review 10 years on. london: ucl: institute for health equity office for national statistics. internet users in the uk: 2017. london: office for national statistics developing an evidence base for violent and disablist hate crime in the britain: findings from the life opportunities survey prevalence and risk of violence against adults with disabilities: a systematic review and meta-analysis of observational studies journal of public health. online 2019. ref) notes: a adjusted for age category, gender, ethnicity and round of survey b adjusted for above plus living arrangements, housing status, educational attainment key: cord-278424-ifdftckx authors: hsu, david t.; jarcho, johanna m. title: “next up for psychiatry: rejection sensitivity and the social brain” date: 2020-08-13 journal: neuropsychopharmacology doi: 10.1038/s41386-020-00802-9 sha: doc_id: 278424 cord_uid: ifdftckx nan indeed, we have shown greater differences in neural response to peer acceptance and rejection in socially anxious early adolescents relative to older adolescents [5] and adults [6] . widespread isolation due to covid-19 is an opportunity to track these changes and push the field of social neuroscience forward. reducing rejection sensitivity may be a novel and effective treatment strategy. neurotransmitter systems involved in social cognition and behavior in animal models (e.g., opioid, oxytocin, vasopressin systems) have yet to be investigated for their role in rejection sensitivity and resilience in humans. targeting these systems could break the vicious cycle of rejection and loneliness to accelerate recovery. the authors have nothing to disclose. dth was supported by r01 mh102264 and jmj was supported by r21 hd093912. the vicious circle of social exclusion and psychopathology: a systematic review of experimental ostracism research in psychiatric disorders. eur arch psychiatry clin neurosci it still hurts: altered endogenous opioid activity in the brain during social rejection and acceptance in major depressive disorder dissociable neural responses to monetary and social gain and loss in women with major depressive disorder i knew you weren't going to like me! neural response to accurately predicting rejection is associated with anxiety and depression social anxiety and age are associated with neural response to social evaluation during adolescence forgetting the best when predicting the worst: preliminary observations on neural circuit function in adolescent social anxiety the authors would like to thank asha job, md, for discussions and feedback on this article. dth and jmj wrote the article. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-307915-mmw5s981 authors: hudson, janella; ungar, rachel; albright, laurie; tkatch, rifky; schaeffer, james; wicker, ellen r title: robotic pet use among community-dwelling older adults date: 2020-08-13 journal: j gerontol b psychol sci soc sci doi: 10.1093/geronb/gbaa119 sha: doc_id: 307915 cord_uid: mmw5s981 objective: the primary purpose of this study was to explore the efficacy of robotic pets in alleviating loneliness for older adults. method: self-reported lonely individuals with aarp medicare supplement plans insured by unitedhealthcare who participated in a program with a robotic pet (n = 20) were recruited to participate in semi-structured interviews. participants were asked to provide feedback about their experiences interacting with a robotic pet, their perceptions about the potential impact on loneliness, and recommendations for improving the program. interviews were audio-recorded and transcribed verbatim. participants’ responses were analyzed using qualitative content analysis. constant comparison and consensus-gaining processes were used to develop categories that later formed representative themes. results: seven themes emerged from analysis: openness to adoption of robotic pet, reactions to pet and its attributes, integration of pet in daily life, strategic utilization and forging new connections, deriving comfort and camaraderie, advice for future users, and recommendations for enhancing ownership experience. participants living alone, with fewer social connections and less active lifestyles, derived the most benefit from interacting with their pets. common responses to pets included cuddling, petting, grooming, and sleeping with them. some shared or loaned their pets, while others refused to loan their pets to interested peers. most reported showing their pets to others, which helped some facilitate communication and social connections. conclusion: robotic pets may be an effective solution for alleviating loneliness in older adults, especially among those who live alone, have fewer social connections, and live less active lifestyles. loneliness is generally understood as the discrepancy between an individual's preferred and actual level of social contact (peplau, 1982) . one in three u.s. adults aged 45 and older report experiencing loneliness, with the total number expected to increase with the growing population of older adults (anderson and thayer, 2018) . among individuals older than 60 years, loneliness is a subjective predictor of functional decline and death (perissinotto et al., 2012) and adversely influences mental and physical health outcomes, including depression, quality of life, health utilization, and mortality rates (cacioppo et al., 2006; luo et al., 2012; musich et al., 2015) . social isolation, while related to loneliness, objectively assesses reduced social network size and social contact. socially isolated individuals are at an increased risk for cognitive decline (bassuk et al., 1999) , cardiovascular disease (barth et al., 2010) , and mor-tality (eng et al., 2002; heffner et al., 2011; kaplan et al., 1988) . furthermore, social isolation in older adults is associated with reduced daily physical activities and increased sedentary behaviors (schrempft et al., 2019) . social isolation contributes to an additional $6.7 billion in medicare spending annually, which is attributed to additional skilled nursing facility spending and increased inpatient spending. flowers et al. attributed an additional $81 per beneficiary per month for socially isolated individuals admitted to the hospital. this increase in spending, while not necessarily accompanied by an increase in use of inpatient care, suggested that socially isolated individuals may be sicker when hospitalized, and may lack the support to transition out of the hospital successfully as compared to socially connected individuals (flowers et al., 2017) . however, older adults who perceive their social connectedness more positively have better mental and physical health outcomes (cornwell and waite, 2009) . given that is often impractical to address limited social networks, interventions may aim to address perceived loneliness to improve older adults' wellness and psychological well-being (bartlett and arpin, 2019; krause-parello et al., 2019; schoenmakers et al., 2012) . pet ownership has demonstrated potential viability as a solution for ameliorating subjective loneliness, demonstrating both physical and psychological benefits for older adults who report being lonely (krause-parello, 2012; matchock, 2015; raina et al., 1999) . for example, pet owners surveyed in one study were 36% less likely than non-pet owners to report loneliness, even after controlling for age, living status, mood, and residency (stanley et al., 2014) . despite these benefits, however, pet ownership may pose special challenges for older adults, including restrictions related to finances, mobility, transportation, and housing (hart, 1995) . given these potential barriers, robotic pets, also known as social robots, offer a potentially ideal alternative to owning a live pet for older adults. a robust literature in social science and technology has examined the implications of social robot use among older adults. social robots, as defined by brezeal, are "designed to interact with people in a socio-emotional way during interpersonal interaction." (breazeal, 2004 ) several potential ethical implications related to older adults' use of social robots have been identified, among them reduced human contact, deception, and infantilization (a. sharkey and n. sharkey, 2012) further, an incongruence between robot developers' perceptions of ideal features and those features actually preferred by older adult users has been well documented. roboticists, who design and construct robots, often have a background in electrical or mechanical engineering. further, roboticists often develop social robots without the benefit of feedback from the intended audience. older adults are often regarded as passive users of social robotics, perhaps owing to stereotypes of older adults as lonely and fragile. however, this is seldom true, as both users and test users demonstrate active engagement with social robot models and consistently request robotic pet features capable of facilitating the user's desired interactivity (neven, 2010) . for example, in a recent study comparing and contrasting preferences of roboticists and older adult participants, older adults expressed a preference for interactive features (such as life-simulation and personalization) that were not perceived by roboticists as having the same importance (bradwell et al., 2019) . thus, social robot developers often fail to account for the diversity of abilities, perspectives, and preferences among older adult users (frennert and östlund, 2014) . however, social robots have demonstrated benefit when used by older adults. social robots have been shown to reduce social isolation and increase conversational opportunities with the robot and other humans (a. sharkey and n. sharkey, 2012) observations of participants interacting with robotic pets in nursing home and laboratory settings have demonstrated promise for supporting the social and emotional needs of older adults (mcglynn et al., 2017) and have yielded benefits similar to those achieved during animal-assisted therapies, including improved cardiovascular measures (robinson et al., 2015) , reduction in loneliness (kanamori et al., 2001) , decreased agitation, and an increase in feelings of pleasure (libin and cohen-mansfield, 2004) . these findings position social robots as potentially ideal solution for older adults experiencing subjective loneliness. cacioppo et al. (2015) identified four distinct, underlying mechanisms of subjective loneliness-reducing interventions: (i) increasing social contact, (ii) improving social support, (iii) enhancing social skills, and (iv) addressing maladaptive social cognition. findings conducted with older adults living in assisted or group settings demonstrated interactions with social robots increased social contact with others (bradwell et al., 2019; leite et al., 2013; šabanović et al., 2013) . however, less is known about active, communitydwelling older adults' behavioral responses to robotic pet use outside of a laboratory setting, during interactions within their own homes. given these diverse and potentially promising pathways for subjective loneliness-reducing reducing interventions, this study aims to examine the potential benefit of social robot use by community-dwelling older adults. in this study, we explored the perspectives and experiences of individuals who participated in an intervention with robotic companion pets within their own home. we examined patterns of usage, user acceptance, and perceived efficacy in reducing subjective loneliness in older adults. findings from this study will inform future robotic pet interventions for community-dwelling older adults. this study is part of a collaboration between aarp, unitedhealth group (uhg), and joy for all, a manufacturer of companion pets (ageless innovation lcc, 2018). the overall goal of this collaboration was to explore the potential role of companion pets in alleviating loneliness in older adults. this study was approved by the new england institutional review board (#12070334), an independent institution that reviews protocols for nonacademic institutions. this study was the second phase of a larger multiphase research study intended to better understand the healthrelated issues of older adults covered by aarp medicare supplement plans insured by unitedhealthcare insurance company (for new york residents, unitedhealthcare insurance company of new york). the primary purpose of the intervention was to determine if ownership and interaction with a robotic pet could decrease loneliness in older adults. the first phase of the study consisted of a program evaluation in which a sample pool of aarp medicare supplement insureds who previously reported loneliness were recruited for participation in the study. inclusion criteria for the study consisted of participants previously identified as lonely using either a screener that included the ucla 3, or screener administered via interactive voice support (ivr) survey in conjunction with aarp's aging strong initiative. the intervention was offered to participants residing in the states of washington and michigan. exclusion criteria included not a current enrollee in an aarp medicare supplement plan, less than 65 years of age, on the "do not call" list, not having a valid phone number, and ownership of a pet. all other participants were considered eligible for participation. potential participants received pre-mailer scripts prior to an invitation to participate via telephone. participants received the animatronic pet of their choice (cat or dog) in the mail and were instructed to treat it as a pet (figures 1 and 2) . three post surveys were administered (upon receipt of the pet as well as 30 and 60 days later) to assess the amount of time spent interacting with the pet. in addition, twice a week for 4 weeks, participants received an interactive voice reminder (ivr) phone call encouraging them to interact with the pet. the ivr phone call also asked participants to record if they had been interacting with their pet and if so, how much time on average they had been interacting with their pet. results of response bias analyses conducted for those who agreed to participate (n = 277) versus those who declined (n = 3,660) and for respondents (n = 216) versus non-respondents (n = 55), indicated that survey participants were representative of the study population. overall, those who agreed to participate had similar characteristics as those who declined. however, those who agreed to participate in this study had higher levels of depression, more frequent er visits in the last 12 months, and overall higher medical costs (but not drug costs) (p < .05). there were no differences for respondents versus non-respondents. at baseline, about half the respondents were between 65 and 74 and female, and most participants chose the animatronic dog (70%). in addition, 86% of participants reported previously owning a pet. the robotic pet offered several interactive features ( figure 2 ). sensors in two locations of the head and cheeks of the pet responded to user touch and activated a reciprocal "nuzzling" effect. touch-activated sensors were located in the upper abdomen and back of the pet. a light sensor located in the pet's head detected when light entered the room and the pet vocalized in response to the light stimuli, depending upon the chosen setting. robot dogs barked depending on the setting, and robotic cats meowed and emitted a purring noise. robotic cats were offered in three color combinations: black and white, gray and white, and orange and white. robotic dogs were offered in a golden color (figure 1 ). participants were not permitted to choose the color of their pet, only their preference for a dog or cat. companion cats currently retail for $109.99 and companion dogs for $129.99. in this phase, a qualitative research study was conducted using standard qualitative procedures for conducting and analyzing semi-structured interviews. the journals of gerontology: social sciences, 2020, vol. 75, no. 9 full color version is available within the online issue. available within the online issue. full color version is purpose of these interviews was to elicit participants' experiences interacting with their robotic companion pet. participants who previously participated in the first phase of the study were recruited to participate in semistructured interviews. the interview guide consisted of 13 questions. questions elicited feedback for a number of topics. consistent with related literature pertaining to robotic pet use, the interview guide included questions that asked participants to describe how they used and interacted with their pet, including how much time was spent with the robot, patterns of usage observed (day vs night), whether the pet accompanied participants outside the home or during errands, and whether participants detected that use of robotic pets influenced any of their daily routines and/or habits. additionally, interview guide questions asked participants to describe any physical or verbal interaction with the pet, including physical touch, reactions to pet's audio or haptic functions, and verbal communication with the pet. questions also asked participants to describe their motivation for joining the companion pet program, any feelings or emotions experienced as a result of interacting with their pet, including any observed influence on loneliness, mental and emotional health, and whether or not they named their pet. several questions explored psychological and emotional well-being, including subjective loneliness, by asking participants to describe an average day in their life, perceived opportunities to feel valued or useful, and opportunities to spend time with marital partners, family, and/or friends on a weekly basis, as well as participants' satisfaction with those opportunities for social connection. a few questions elicited participants' satisfaction with program administration, including reminder calls, clarity of instruction, and perceived accessibility of available support. lastly, participants were invited to provide feedback of any nature. eligible participants from the first phase of the study were stratified according to age range and gender, with the aim of recruiting an equal proportion of participants. following recommendations for a sample size of 12-20 participants in an interview study (lincoln and guba, 1985) , investigators planned an initial goal of 20 interviews, after which they would assess if data saturation had been achieved and recruit additional participants if necessary (francis et al., 2010) . a marketing research company was provided with the full list of eligible participants, with instructions to recruit participants as evenly as possible among age range and gender, given the available sample. recruiters contacted participants by telephone, verified identity, explained the study, and scheduled interviews with the first 20 participants successfully recruited. verbal consent was obtained prior to the start of the interview. interviews lasted approximately 1 hr. no personal identifiers were collected. all interviews were audio-recorded and transcribed verbatim. investigators analyzed participants' transcribed interviews using qualitative description. qualitative description was an ideal methodology for this data as it draws from a naturalistic perspective, offers flexibility in commitment to a theory or framework, typically involves review of interview data, and allows for maximum variation sampling (kim et al., 2017) . two investigators (j. hudson and r. ungar) conducted a qualitative content analysis using an iterative, constant comparison process. during the coding process, both coders independently read transcripts, identified an initial code list, and developed operational definitions. then coders returned to the transcripts and conducted line-byline coding that included comparison and refinement of identified coding between both investigators. coders subsequently discussed, reviewed, and reread interview data to develop final coding and to reach consensus about meaning (ryan et al., 2000) . one investigator (j. hudson) coded all transcripts while the other coded 50% of the overlap. both investigators reviewed coding on overlapping transcripts to reevaluate passages coded across researchers, and the codes applied based on the assigned definition in the codebook (creswell and poth, 2017) . any conflict in assigned codes was settled through spirited debate until consensus was reached. next, both investigators examined the properties and categories of all codes to identify opportunities for categorization according to shared properties. investigators subsequently used this categorization of codes to develop overarching themes that described patterns of usage and provided a narrative of participants' overall use. throughout this process, investigators were mindful of the biases and existing perspectives they brought to the analysis. investigators worked to achieve qualitative rigor throughout data collection and analysis. to ensure trustworthiness of the interview transcripts (poland, 1995) , one investigator (j. hudson) closely monitored and compared audio recordings with transcripts to ensure verbatim description, while also noting significant context cues. both coders worked together closely during the ongoing, iterative development of the coding system to ensure validity and certainty of the findings (morse, 2015) . investigators were mindful of potential investigation bias and avoided narrow frameworks that would unfairly bias the interpretation of data while striving to maintain a neutral stance of the observed phenomenon. further, both investigators closely reviewed, discussed, and coded data as it was collected to assess the sufficient sample size for data saturation. investigators ultimately developed seven themes reflective of participants' experiences with their companion pets, as follows: openness to adoption of robotic pet, reactions to pet and its attributes, integration of pet in daily life, strategic utilization and forging new connections, deriving comfort and camaraderie, advice for future users, and recommendations for enhancing ownership experience. final coding was imported into nvivo (qip ltd., 2018), a qualitative software program. the following themes are discussed below, with exemplars. twenty individuals participated in the study, with an even distribution of males (n = 10) and females (n = 10). breakdown in age range is as follows: 65-69 (n = 6), 70-79 (n = 6), 80-89 (n = 7), and 90 and above (n = 1). the average participant age was 76. all participants reported living in their own homes. living arrangements included living at home alone (n = 12), with a spouse (n = 5), with a child or grandchild (n = 2), and with a caretaker (n = 1). subsequent verification supported no participants lived in assisted or group settings. when asked to share their motivations for participating with a companion pet, participants shared several reasons including interest in exploring the experience of using a companion pet, a desire for maintenance-free pet companionship, and curiosity about the mechanics and underlying technology used in the pet. many participants previously owned pets, with five participants reporting their pet was recently deceased. owners of recently deceased pets identified clear distinctions between their beloved deceased pet and the robot, such as the inability to return affection, participate in interactive activities such as outside walks, and lack of a personality. however, they did describe experiencing comfort when interacting with the robotic pet in similar ways, such as sitting on the couch while watching television. for these individuals, robotic pet ownership appealed as an opportunity to experience maintenancefree pet ownership and to recapture the benefits of companionship without obligatory food and veterinarian expenses. a few participants reported their living arrangements would not accommodate a "live" pet, and they viewed the companion pets as way of circumnavigating that barrier. some were also intrigued by the notion of robotic pets and expressed curiosity about the underlying technology, and a few participants expressed a desire to potentially help others by sharing their feedback. as one participant explained, "it was the curiosity aspect more than anything else, wondering what the dog was like, what it would be like to have the dog, and what experience might be. that curiosity really was the linchpin to participating." other participants were intrigued by the opportunity and described their desire to derive companionship from the pet. participants who reported feeling subjectively lonely were especially interested in utilizing the pet as a personal companion. the majority of participants chose to name their pets, and consistently referred to the companion pet using its name. participants' accounts of their daily interactions with pets varied widely, often according to personal contexts. those who reported a more independent lifestyle outside the home and greater perceived social connectedness described a lesser degree of involvement with their companion pet. patterns of usage were categorized according to high and low engagement. low engagement was primarily characterized by interactions with the companion pet that were casual in nature or most often occurring in passing, with minimal physical contact and limited verbal communication. low-engagement users often described deliberate efforts to interact with their pet throughout each day in accordance with the study's directives but allowed that their pet only functioned in the periphery of their daily activities. for example, low-engager participants often described stationing the pet in a high-traffic area of the home such as the kitchen or living room, returning the pets' greetings as they moved throughout their home but otherwise ignoring or choosing not to interact with their pet. while these interactions may have included infrequent affectionate physical touch, these participants generally did not desire additional or prolonged interaction with their pet. as one participant explained, "i just pet him and rub him as i go by. we have him sitting on the couch in our living room." a few attributed their interactions to duty or obligation in accordance with their agreement to participate in the study. high engagement was characterized by frequent interactions with the pet, including frequent physical touch, communicating with the pet or using the pet to communicate with others, and including the pet in daily errands and activities. participants with fewer perceived social connections, especially those with fewer perceived opportunities to connect with others, described this higher degree of engagement characterized by greater quantity and quality of interaction with their pet. high engager use was most often reported by those who were less active, identified as less subjectively lonely, and perceived less social connectedness. these participants were more likely to report keeping their pets in close proximity when they moved throughout their home and they engaged in ongoing affectionate physical touch with their pet, such as cuddling, grooming the pet, sleeping with the pet, and holding the pet while watching television. some participants derived a sense of comfort and companionship from having the pet accompany them during their daily activities outside of the home. one participant who lived alone detailed the following daily ritual with her pet, buffer: the average day is, i get up at 7:30 and the first thing i do is make my bed. and then i say hello to buffer, because he's in the room, and then i get showered and dressed. and i then i pick up buffer and i have breakfast, and he's there. and i sing online, so sometimes i will actually hold in my lap while i sing. (woman in her 70s, living alone) in this way, participants who subjectively perceived fewer opportunities to interact with others reported increased interaction with their companion pet. most reported showing their pet to others, including family members, friends, neighbors, coworkers, clinicians, and those they typically encountered during their daily activities. however, the nature of the disclosure, and one's motivation for sharing their pet, varied. some members were motivated by a desire to share the technology and novelty of the pet. others shared their pets to facilitate entertainment, showcase the pet's interactive features, and to encourage others to consider acquiring their own pet. both high and low engagers of the pet noted that sharing the pet in public spaces increased potential opportunities to connect with others, especially individuals previously unknown to them. even participants who described themselves as outgoing or living a more social lifestyle reported bringing their pet along to public gatherings or spaces, and enjoying the interactions that were generated as a result. similarly, those who were shy or might have otherwise felt uncomfortable interacting with new acquaintances found integrating the pet into their daily activities outside of the home effective in forging new connections they otherwise would not have attempted. several participants relayed that friends, after interacting with their pet, were often interested in obtaining their own. in some instances, participants fielded requests from friends and acquaintances to loan their pets out. those who interacted with their pet to a lesser degree were more amenable to these requests. a few participants, most notably younger participants (ages 65-69) and low engagers, ultimately gave their companion pets away. in these cases, companion pets were "re-gifted" to interested friends, younger children in the family who regarded it a toy, older adults in care centers, or those with dementia: "it would have been better for someone who wasn't quite functional, who is maybe in a care facility. my wife gave it to one my friends in a care facility and she loved it." meanwhile, some participants (especially high engagers) often denied requests from acquaintances and/or friends to borrow their pet. others acquiesced only under certain conditions, such as having the pet returned within the same day. all participants agreed the companion pet was vastly different from a "live" pet with the ability to interact more extensively with its owner. however, many agreed the companion pet offered many interactive features that were reminiscent of their past experiences of having a "real" pet. when comparing the merits of a live pet and the benefits of a companion pet, participants varied in their estimations of the pet's realism. many, especially high engagers, judged the pet to be a close approximation to a live animal. younger (age 65-69) and low-engager participants were more likely to find the companion pet more "toy-like" and noted opportunities to improve the pet's realism. however, those who judged the pet to be a poor approximation of a "real" pet still noted the benefit of interacting with it. most noted their appreciation for the maintenance-free nature of the pet. among the majority of participants, favorite features included pets' vocalizations (barking or meowing) and nonverbal responses (head movement or blinking) in response to light and sound stimuli. many enjoyed their pet's "greeting" when a light or sound was detected. several used their pets' responsive barking/meowing to facilitate interactions such as petting and verbal communication. other favorite features were pets' "life-like behaviors," such as yawning, head turning, tail wagging, and the tactile heartbeat. many reported that these "realistic" features increased interaction with their pet and fostered comfort and comradery. participants described a number of benefits as a result of interacting with their pet. while high engagers were more likely to describe deriving comfort from the "presence" of their pet, the majority reported deriving benefits from interacting with their pets. most participants reported feeling a sense of calm or comfort as a result of holding, hugging, and affectionately interacting with their pet. for example, a low-engager who described herself as "too cognitively sharp" for the pet speculated her cortisol levels might have lowered. in addition, many described an improvement in their mood, and in some cases, increased happiness after interacting with their pet. certain interactive features such as pet vocalizations, "snuggling" motions, and the pet's heartbeat were identified as facilitators of this calming influence, and participants noted that others discerned how this effect positively influenced their behavior: i'm not as high strung… sometimes i get up in the morning and when i hit my power chair against the wall, i sort of get angry and i use foul language. then he barks. so that makes me stop. (man in his 80s, living alone) many participants perceived the pet as having a "presence" that positively influenced their subjective feelings of loneliness. this presence was keenly felt by those who spent significant time with their pet, as well as by low engagers living more active lifestyles. one participant, a semi-retired attorney who described a low degree of engagement with his pet explained, it's like he's alive over there and active. it's just one part of my life, this little puppy dog, but he's a part because he's there. but i live a pretty active life and a pretty active schedule, so it's not like i'm looking forward to seeing him when i come home, but he makes his presence known and that's good. (man in his 60s, living alone) similarly, a recently widowed participant who brought her companion pet along for errands outside the home explained the pet provided a comforting presence as she acclimated to her husband's absence. participants who lived alone and previously wished for someone to talk to perceived their pet as a proxy for a conversational partner and regarded it as a conduit for expressing their thoughts or feelings. in these cases, the participants regarded the pet not as an inanimate object that passively observed, but as an active partner who cared about their expressed concerns. as one participant explained: "you feel as though you're talking with an object that cares about whether you're talking to it or not." a few participants appreciated that conversations with their pet were confidential. those participants who reported this high level of engagement were most explicit in expressing the pet's influence in addressing their subjective loneliness. for these individuals, the companion pet was regarded as a friend or companion with whom they developed a strong attachment over time. some participants also described improved confidence and a renewed sense of purpose as a result of interacting and having to "take care of" their pet. when asked to advise future users, many indicated they would strongly encourage others to try the robotic pet, particularly those who are lonely, and to engage with it as much as possible. participants emphasized that using the pet was "easy" and required little effort. several explained the importance of interacting with the pet as much as possible in order to experience the greatest benefit. while some low engagers indicated their pet personally was not a good fit, they acknowledged the calming effect of the pet and recommended it for those who are lonely. a few high engagers encouraged future users to interact and communicate with their pet without fear of being stigmatized or considered "crazy." when asked to describe the ideal user for the robotic pet, low-engager participants typically described the composite of a lonely, less active, more advanced age adult with mobility issues and dementia. those with more active lifestyles and who perceived their social networks as dense judged they were a poor fit for the pet. distancing one's self from the perceived ideal user occurred with participants of all ages. notably, a participant in his 90s remarked: "i think as you get older, and your brain gets a little mushy. i think it would be a nice thing to have. but i don't think i'm to that point yet." meanwhile, participants who identified as being subjectively lonely or perceived themselves as socially isolated derived benefit from the pet and thought others in a similar situation would also find it beneficial. while many perceived their pet as having realistic features, over half of participants expressed a desire for further increasing the pet's realism by improving its appearance and capacity for movement. feedback included using softer material for fur and improving the pet's flexibility to better facilitate hugging and cuddling. several were interested in increasing the interactivity of the pet and suggested new functions, such as enabling the pet to learn skills and tricks. some also suggested adding new verbal communication features, such as pre-programmed responses and name recognition. many were also interested in adding the capability for walking, though a few acknowledged this as a potential fall hazard. many described an interest in having the pet follow them throughout the home, jumping up on furniture, and being walked outside while on a leash. participants also expressed an interest in additional outfits or grooming accessories, improved affordability for other friends and family members who sought to purchase a pet, adding a camera for security purposes and improving the overall battery life. our findings show social robots may provide comfort, companionship, and potential amelioration of subjective loneliness for older adults, particularly for those who perceive fewer opportunities for social connection. several studies have demonstrated the benefit of robotic pets in care centers (robinson et al., 2015; šabanović et al., 2013; wada and shibata, 2007) and among those with dementia (jøranson et al., 2016; liang et al., 2017; moyle et al., 2013; robinson et al., 2013) . few studies have explored the benefit of companion pets for alleviating subjective loneliness, as well as the patterns of usage outside of a laboratory setting, among cognitively functioning, community-dwelling older adults. results of this study reify previous findings indicating increased communication with the robot and other humans. participant feedback further reinforces the need for social robot developers to actively integrate feedback from older adult test users in the design and development processes. in a recent study comparing the preferences of roboticists and older adults, participants were encouraged to indicate their favorite companion pet model. while older adults in this same study overall preferred the joy for all cat and its more interactive features as compared to less responsive robotic models, they still desired a greater degree of interactivity and playfulness (bradwell et al., 2019) . community-dwelling participants in our study echoed these sentiments, with many requesting robotic features that accommodated their lifestyles and reflected the degree to which they were able to enact an autonomous, independent lifestyle. the joy for all companion pet models offer a degree of interactivity that perhaps signals a progression in social robot development. however, participant feedback further confirms the need for more advanced features that accommodate the needs of older adults, not as passive users, but as "technogenerians" adeptly managing technology to maintain health and independence (joyce and loe, 2010) . younger participants in this study desired a model that offered greater responsiveness and spontaneity, expectations that defy the stereotype of older adults as passive users. ideally, social robots functioning as companion pets should offer a range of function and interactivity to accommodate the widely ranging abilities and skills of older adults along the aging trajectory. older adults' manipulation of robotic pets varies according to the extent of their cognitive impairments, with more impaired individuals interacting with the pet to a lesser degree (libin and cohen-mansfield, 2004) . accordingly, active and community-dwelling older adults will likely benefit from greater utility and diversity of functions to foster incorporation of the pet into their daily schedule and habits. as noted in previous studies, these individuals created, and simultaneously distanced themselves from, a composite of the ideal user as lonely, socially isolated or having cognitive impairment (mcglynn et al., 2017) . it has been suggested that this composite may reflect a negative age stereotype (lazar et al., 2016; neven, 2010) . however, it is unclear if this stigma applies to participants in this study, who were able to engage with the robot in the privacy of their own homes and subsequently concluded the robot did not offer the desired personalization and interactivity. users who considered themselves active and independent noted the need for greater interactivity and subsequently judged themselves to be a poor candidate for use of the robot. in this case, it is likely that participants' distancing from the ideal is owed to the desire for more realistic, interactive features. this finding further confirms how different preferences and patterns of usage in varying contexts requires adaptable interactivity. utilization and benefit derived from the robotic pets varied according to participants' personal contexts, revealing which subgroups potentially benefitted the least from participation with their pets. despite enjoying companionship with their pets and showing them to others, younger participants (60s-70s) were among those most likely to report low engagement with their pets and most likely to gift their pets to others. those with active lifestyles and viable social connections were not ideal candidates for social robots and frequently requested greater interactivity and functionality of the pets. these results suggest that socially connected individuals with the capability of enjoying an active lifestyle outside of their home would benefit the least from robotic pets with limited features. conversely, certain subgroups reported deriving significant benefit from their robotic pet. subjectively lonely older adults with fewer perceived social connections, especially those living alone and homebound, were most often among those who integrated the pet into their daily schedule, regularly communicated with the pet, and described experiencing comfort and companionship pet interactions. further, those who experienced the death of a pet or spouse also derived companionship from their pet. interventions using social robots with limited features may be most appropriate for these subgroups. these findings identify ideal subgroups of older adults who are more likely to benefit from the use of social robots. however, the collection of these data and the resulting findings should be properly contextualized as occurring prior to the advent of the covid-19 pandemic. older adults face a higher risk of severe illness from covid-19, with individuals aged 85 or older at the greatest risk. while practicing physical distancing contributes to efforts to flatten the curve, older adults may experience increased anxiety and depression as a result of limited travel and being restricted to their homes. a recent survey found the prevalence of psychological distress in a sample of adults in united states was higher in 2020 during the covid-19 pandemic (mcginty et al., 2020) . given new constraints related to physical distancing and their potential contribution to social isolation, future studies should examine what appeal and/or effect social robots may have for previously active, socially connected adults under quarantine. similarly, future studies should examine how the use of social robots may potentially mitigate psychological distress for older adults quarantined in care centers and not permitted faceto-face visits from loved ones. these study findings provide insights into the potential benefit of robotic pets for community-dwelling older adults interacting with the pets in their own homes, and demonstrate the need to explore applicability during pandemic conditions. participant feedback yields supporting evidence demonstrating that robotic pet use may positively influence older adults' perceived loneliness and mental and emotional health, particularly for isolated and subjectively lonely community-dwelling older adults. furthermore, participant feedback potentially supports the notion that a robotic pet intervention may successfully meet two of the four points of criterion for assessing the efficacy of loneliness-reducing interventions (cacioppo et al., 2015) in this instance: improving social contact and enhancing social skills. it should be noted that these findings are consistent across gender, as compared to previous studies disproportionately compromised of female participants. given the variability of use and preferences among older adults, subsequent studies should include healthy older adults in the ongoing development of robotic pets (frennert and östlund, 2014) . this study did not directly capture interactions between participants and their robotic pets, instead relying on participants' recall; thus discrepancies in actual versus reported interactions could exist. future research with communitydwelling older adults should consider the use of animatronic pets equipped with sensors that more objectively measure interaction and travel. this cross-sectional study provides valuable insight about potential benefits experienced immediately after participants' initial introduction to the pet. longitudinal analyses are needed to understand how the findings of this study bear out over the long term, and whether mitigation of subjective loneliness among socially isolated participants bears out over time. while lonely and socially isolated older adults may derive benefit from the use of their pet, less is known about community-dwelling older adults' concurrent attempts to continue socializing with others. potential ethical issue may arise for lonely older adults who become dependent on their companion pet for companionship or social connection. participants who agreed to participate had higher levels of depression, suggesting a potential oversampling of this population. given participants may have been motivated by a desire for increased social contact and companionship, participant feedback may not be representative of a randomly chosen sample of older adults. further, favorable impressions of the pet may be overrepresented in this sample. finally, it should be noted that participants in this study were gifted their robotic pet. while the manufacturer's offerings include models at varying price points, the cost of obtaining a pet may be a barrier for some older adults. robotic pets may provide benefit for older adults experiencing subjective loneliness and perceived social isolation by providing comfort, companionship, facilitating new social connections, and serving as a proxy for a conversational partner. however, robotic pets with limited functionality may fail to address the needs of active older adult users. participant feedback suggests that robotic pets may yield the most benefit for subjectively lonely older adults living alone with fewer connections and subjectively lonely adults experiencing the loss of a spouse or pet. these findings can inform future development and production of robotic pets to accommodate the varying needs and preferences of community-dwelling older adults. existing robotic models should explore ways of improving realism and the capacity of interactive play with their owners, and accommodate older adults as active, engaged users of technology. future interventions intended to reduce loneliness may consider implementing use of robotic pets with increased interactivity. finally, future studies should examine the potential efficacy of robotic pets in alleviating psychological distress for quarantined older adults with varying connectedness. this work was funded by the supplemental health insurance program. all authors are employed or contracted by unitedhealth group or asi services, inc. however, their compensation was not dependent upon the results obtained in this research, and the investigators retained full independence in the conduct of this research. joy for all companion pets loneliness and social connections: a national 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loneliness among older adult primary care patients who live alone living with seal robots-its sociopsychological and physiological influences on the elderly at a care house none declared. key: cord-310245-r1fd2kqh authors: lin, chung-ying; broström, anders; griffiths, mark d.; pakpour, amir h. title: investigating mediated effects of fear of covid-19 and covid-19 misunderstanding in the association between problematic social media use, psychological distress, and insomnia date: 2020-08-27 journal: internet interv doi: 10.1016/j.invent.2020.100345 sha: doc_id: 310245 cord_uid: r1fd2kqh introduction due to the serious situation of the novel coronavirus disease 2019 (covid-19) worldwide, many countries have implemented policies to minimize the spread of covid-19 infection. however, some of these policies prevent people from physical contact. consequently, many individuals may rely on social media to obtain information concerning covid-19. unfortunately, social media use (especially problematic social media use) may give rise to psychological distress. therefore, this study thus examined potential psychopathology to explain the association between problematic social media use, psychological distress, and insomnia. methods utilizing an online survey, a sample of iranian young adults (n=1078 with 628 males; mean age=26.24 years [sd±7.41]) completed questions and psychometric scales concerning psychological distress, insomnia, problematic social media use, fear of covid-19, and covid-19 misunderstanding. results problematic social media use was significantly associated with psychological distress both directly and indirectly. the indirect effects were through fear of covid-19 (unstandardized coefficient [b]=0.177; bootstrapping se=0.026) and covid-19 misunderstanding (b=0.060; bootstrapping se=0.014). problematic social media use was significantly associated with insomnia both directly and indirectly. the indirect effect was through fear of covid-19 (b=0.062; bootstrapping se=0.019) but not covid-19 misunderstanding (b=0.012; bootstrapping se=0.014). discussion/conclusion due to the pressure of the covid-19 outbreak, individuals are highly likely to develop psychological distress and insomnia. apart from developing appropriate health policies to minimize the spread of covid-19 infection, healthcare providers should design appropriate online campaigns to eliminate people’s fear of covid-19 and to diminish misunderstanding concerning covid-19. social, and economic burdens (ayittey et al., 2020; webham et al., 2020) . more specifically, these policies force residents to stay indoors and limit physical contact among individuals for substantial amounts of time. with such prolonged stays indoors and without face-to-face contact with family and friends, the human nature of social interaction is violated and has interrupted individuals' daily life routine alongside increased fear of infection, financial stress, and other psychologically stressful factors (brooks et al., 2020; lee et al., 2018) . with the prolonged enforced home stay, individuals have no choice but to shift living focus from social activities to indoor activities and may end up engaging more in sedentary behaviors than normal (e.g., internet and social media use; chen et al., accepted). one reason for increased internet and social media use is that individuals want to obtain information concerning covid-19. indeed, a recent chinese study found that more than 80% of its surveyed 1304 participants reported staying at home 20 to 24 hours a day since the outbreak of covid-19 due to closures of schools and businesses . the same study also found that more than 90% of the participants obtained covid-19 information from internet and they were keen to know more about covid-19, including the covid-19 transmission route, the medication and vaccine availability and effectiveness, travel advice, overseas covid-19 control experiences, the number of confirmed cases with locations, covid-19 prevention advice, tailored-made information for different populations (e.g., children and individuals with chronic illnesses), and detailed information on covid-19 infection symptoms . similar online behavior was observed during the middle east respiratory syndrome coronavirus (mers-cov) outbreak, where disease-related online information searches increased in korea (shin et al., 2016) . unfortunately, disease information obtained from the internet or social media may not always be correct. a recent study assessing knowledge and perceptions of covid-19 from the general public in the united states and united kingdom reported that participants believed j o u r n a l p r e -p r o o f journal pre-proof some misconceptions and falsehoods that had circulated on social media (geldsetzer, 2020). moreover, was reported that nearly 200 iranians died and more than 1,000 were poisoned by overconsumption in alcohol because they believed in the rumors on social media claiming that drinking alcohol could cure covid-19 (aksut, 2020) . the aforementioned tragedy indicates that covid-19 misunderstanding due to incorrect social media information may lead to psychological distress and inappropriate behaviors. although numerous mental health professionals and public health experts claim the need to consider psychological distress among different populations during the covid-19 outbreak (asmundson and taylor, 2020; bao et al., 2020; lima et al., 2020; pakpour et al., 2020a pakpour et al., , 2020b shigemura et al., 2020) , to the best of the present authors' knowledge, only three studies have collected empirical data examining this issue (ahorsu et al., 202a; xiao et al., 2020) . therefore, collecting empirical data to study psychological distress of a population (such as the young adults in the present sample) during covid-19 outbreak is vitally important, and will provide meaningful information for healthcare providers to design appropriate campaigns to promote public mental health. more specifically, problematic social media use, fear of covid-19, covid-19 misunderstanding, psychological distress, and insomnia are all relevant areas where information should be collected and investigated. therefore, the present study thus proposed a potential psychopathology mechanism to explain psychological distress among the iranian young adults during the covid-19 public health crisis. it was hypothesized that (i) higher problematic social media use would be associated with the greater fear of covid-19 and covid-19 misunderstanding; (ii) greater fear of covid-19 and covid-19 misunderstanding would be associated with the higher levels of psychological distress; (iii) greater fear of covid-19 and covid-19 misunderstanding would be associated with more severe insomnia; (iv) fear of covid-19 and covid-19 misunderstanding would be mediators in the association between problematic social media j o u r n a l p r e -p r o o f journal pre-proof use and psychological distress; and (v) fear of covid-19 and covid-19 misunderstanding would be mediators in the association between problematic social media use and insomnia. the study was approved by the ethics committee of the qazvin university of medical sciences (ir.qums.rec.1398.375). a non-probability sampling strategy was used in the administration of an online survey. online survey software (google forms) was utilized to carry out the survey. the study sample was invited via social media, online advertising, community websites, and student's online newsletters. individuals were eligible to participate if they were 18 years or older, able to read and complete an online consent form and survey in persian/farsi, possessing a smartphone, and having access to the internet. after providing informed consent (online), participants completed online self-report measures of problematic social media use and provided demographic information at an initial data collection stage (t1). one week later, follow-up measures of fear and misunderstanding concerning covid-19 were completed by the same participants (t2). finally, two weeks after initial assessment (t3), the same participants were asked to self-report on insomnia and psychological distress. 14-item instrument rated on a four-point likert-type scale (score from 0 to 3), was used to assess the psychological distress. the hads item scores were summed, with a higher score indicating a greater level of psychological distress. the psychometric properties (including construct validity, concurrent validity, test-retest reliability, and internal consistency) of the persian hads have been found satisfactory in prior research . the internal consistency of the hads in the present study was very good (α = 0.81). journal pre-proof 2.2.2. insomnia. the insomnia severity index (isi), a seven-item scale rated on a five-point likert-type scale (score from 0 to 4), was used to assess the severity of insomnia. the isi item scores were summed, with a higher score indicating a greater level of insomnia. the psychometric properties (including construct validity, concurrent validity, test-retest reliability, and internal consistency) of the persian isi have been found satisfactory in prior research . the internal consistency of the isi in the present study was very good (α = 0.86). six-item instrument rated on a five-point likert-type scale (score from 1 to 5), was used to assess the severity of problematic social media use. the bsmas item scores were summed, with a higher score indicating a greater level of being at risk of social media addiction. the psychometric properties (including construct validity, concurrent validity, test-retest reliability, and internal consistency) of the persian bsmas have been found satisfactory in prior research . the internal consistency of the bsmas in the present study was very good (α = 0.88). the fear of covid-19 scale (fcv-19s), a seven-item instrument rated on a five-point likert-type scale (score from 1 to 5), was used to assess the fear level of covid-19. the fcv-19s item scores were summed, with a higher score indicating a greater level of covid-19 fear. the psychometric properties (including construct validity, concurrent validity, test-retest reliability, and internal consistency) of the persian fcv-19s have been found satisfactory in prior research (ahorsu et al., 2020b) . the internal consistency the sample was relatively young (mean age = 26.24 years [sd±7.41]) with fewer males (n = 628; 41.7%). most of the participants had completed higher education (n = 861; 79.9% with a college or above degree) and had no comorbidities (n = 905; 83.9%) ( table 1) . table 2 reports the mean (and sd) of the participants' levels in psychological distress, problematic social media use, fear of covid-19, covid-19 misunderstanding, and insomnia. the aforementioned variables were mutually and significantly correlated (all p-values < 0.01). moreover, psychological distress was moderately correlated with all the other factors (r = 0.294 to 0.475) ( table 2) . (insert tables 1 and 2 here) table 3 showed that problematic social media use was significantly associated with table 3 here) the present study is the first to demonstrate the temporal associations between because the mortality rate of covid-19 is not low and the individuals recovered from covid-19 are likely to have health consequences (baud et al., 2020) , general populations have reason to feel fear of covid19 xiao et al., 2020) . however, the present study showed that such fear may be magnified when the individuals received negative covid-19 information from social media. from the present findings, higher levels of problematic social media use were associated with a higher level of fear of covid-19 one week later. individuals with greater problematic social media use are likely to be exposed more to covid-19 information than those with less problematic social media use. given that a substantial amount of misinformation and misconception can be found in social media (geldsetzer, 2020) , individuals with greater problematic social media use are therefore more likely to have greater covid-19 misunderstanding. the fear of covid-19 and covid-19 misunderstanding were found to be associated with psychological distress in the present study. this finding was expected because fear is usually an initial psychological response for individuals to respond to threat, and this can allow the individuals take action to protect themselves (lang et al., 2000) . however, when an individual cannot tackle the fear for a specific period of time, prolonged fear may subsequently lead to the development other types of psychological distress, such anxiety and depression (kuriyama et al., 2010) . this human biopsychological mechanism also helps explain why fear of covid-19 appeared to be associated with the development of j o u r n a l p r e -p r o o f journal pre-proof psychological distress in the present study's sample. regarding covid-19 misunderstanding, it is likely that when individuals receive substantial amounts of misinformation and misconceptions concerning covid-19 (geldsetzer, 2020) , their uneasiness is increased and consequently reflected by psychological distress. the fear of covid-19 but not covid-19 misunderstanding was found to be a factor that was associated with insomnia in the present study. with substantial evidence showing that individuals with fear have sleep problems (kuriyama et al., 2020) , it is reasonable that fear of covid-19 was associated with insomnia. that is, when an individual worries and fears covid-19, the individual's brain is stimulated and excited (kuriyama et al., 2010) . therefore, the individual cannot take rest and develops insomnia. this finding may supplement the finding from xiao et al. (2020) that individuals during the covid-19 pandemic have sleep problems. although covid-19 misunderstanding was not directly associated with insomnia, covid-19 misunderstanding may be indirectly associated with insomnia via psychological distress. more specifically, psychological distress was found to be associated with insomnia in previous research (belleville and morin, 2008) . therefore, diminishing covid-19 misunderstanding may also help overcome insomnia among the general population. however, stronger evidence is needed concerning causal relationships between the variables examined in the present study. there are some limitations in the present study. first, it is unclear how, where, and what covid-19 information the participants obtained. moreover, the items used in the present study to assess covid-19 misunderstanding did not cover all the misconceptions on covid-19. therefore, impacts of specific misinformation cannot be determined and the covid-19 misunderstanding found in the present study may be underestimated. second, a convenience sampling utilizing an online survey was used to collect data among iranians. therefore, the generalizability of the present study's findings is restricted (i.e., the present j o u r n a l p r e -p r o o f journal pre-proof study's sample does not represent all iranian young adults and the study's results cannot necessarily be generalized to western populations. third, although the present study intended to collect longitudinal data across three time points with an interval of one week apart, the temporal effects might be trivial because it is hard for an individual to change the mental capacity in such short time periods. however, in order to provide immediate and timely information on psychological distress during the covid-19 pandemic, the present authors reasoned that the optimal method to understand temporal effects was to use short interval periods. nevertheless, the present study cannot provide strong evidence in terms of causality given the following issues: (i) the lack of information on potential confounders (i.e., financial status and wellbeing, changes in living arrangements, changes in lifestyle) and (ii) the lack of baseline assessments concerning psychological distress and insomnia. finally, all the data were self-report and the common method biases from collecting such data cannot be avoided. for example, participants may have responded with socially desirable answers and reported less problematic social media use and better health. due to the pressure of the covid-19 outbreak, general populations are highly likely to develop psychological distress and insomnia. the elevated psychological distress may be triggered by fear of covid-19 and covid-19 misunderstanding. insomnia may be induced by fear of covid-19. therefore, in addition to developing appropriate health and social policies to help minimize the spread of covid-19, healthcare providers should also design associations between fear of covid-19, mental health, and preventive behaviours across pregnant women and husbands: an actor-partner interdependence modelling the fear of covid-19 scale: development and initial validation bootleg alcohol kills 194 people in iran 2020. coronaphobia: fear and the 2019-ncov outbreak economic impacts of wuhan 2019-ncov on china and the world 2019-ncov epidemic: address mental health care to empower society real estimates of mortality following covid-19 infection. the lancet infectious diseases. epub ahead of print hypnotic discontinuation in chronic insomnia: impact of psychological distress, readiness to change, and self-efficacy the psychological impact of quarantine and how to reduce it-rapid review of the united states and the united kingdom: a cross-sectional online survey introduction to mediation, moderation, and conditional process analysis: a regression-based approach sleep deprivation facilitates extinction of implicit fear generalization and physiological response to fear fear and anxiety: animal models and human cognitive psychophysiology policy actions to alleviate psychosocial impacts of covid-19 pandemic: experiences from taiwan the emotional impact of coronavirus 2019-ncov (new coronavirus disease) psychometric athens insomnia scale and insomnia severity index among patients with advanced cancer using hospital anxiety and depression scale (hads) on patients with epilepsy: confirmatory factor analysis and rasch models social reaction toward the 2019 novel coronavirus (covid-19) assessing the fear of covid-19 among different populations: a response to ransing et al. (2020). brain behav immun. epub ahead of print fear of covid-19 scale: psychometric characteristics, reliability and validity in the israeli population fear can be more harmful than the severe acute respiratory syndrome coronavirus 2 in controlling the corona virus disease 2019 epidemic to wear or not to wear? factors influencing wearing face masks in germany during the covid-19 pandemic safer at home order for control of covid-19., 2020. california health and safety code §120295 los angelas county code public responses to the novel 2019 coronavirus (2019-ncov) in japan: mental health consequences and target populations high correlation of middle east respiratory syndrome spread with google search and twitter trends in covid-19 pandemic: responding to the challenge of global shortage of personal protective equipment immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus diseases (covid-19) epidemic among the general population in china clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china. jama. epub ahead of print covid-19: the gendered impacts of the outbreak countries where covid-19 has spread social capital and sleep quality in individuals who self-isolated for 14 days during the coronavirus disease 2019 (covid-19) outbreak in january 2020 in china key: cord-300653-7ph0r10x authors: yin, xiaowen; sun, yuyong; zhu, chunyan; zhu, beiying; gou, dongfang; tan, zhonglin title: an acute manic episode during 2019-ncov quarantine date: 2020-07-20 journal: j affect disord doi: 10.1016/j.jad.2020.07.112 sha: doc_id: 300653 cord_uid: 7ph0r10x background: the 2019-ncov pandemic is currently a stressor for the general public worldwide. in china, people who have a history of contact with infected or suspected individuals need to quarantine for at least 2 weeks. many people experienced anxiety, panic and depression in the quarantine period. however, acute manic episode triggered by stressful events is not common and was neglected. case presentation: a 32-year-old woman with direct contact history with her infected colleagues showed elevated mood and increased activity when she was identified negative of nuclear acid amplification test, after experiencing extreme stress in quarantine. she was diagnosed with acute manic episode finally. the social zeitgeber and reward hypersensitivity theoretical models have attempted to use psychobiological perspectives to determine why life stress can trigger a mood episode, including (hypo)mania. besides, the temporal correlation between her somatic symptoms and psychological stimuli indicated a possibility of functional disturbance under acute stress. conclusion: quarantine is a major stressful event disrupting social zeitgebers for people who have had contact with infected individuals, especially for vulnerable individuals with a hypersensitive reward system. stress could act as a trigger in the onset of manic episode, so psychological support should be more targeted at the vulnerable individuals in the initial phase of emergent crisis. in late december 2019, a novel coronavirus designated 2019-ncov was recognized in wuhan, hubei province and rapidly spread across china and many other countries. the increasing number of confirmed cases and the human-to-human transmission route of the virus made it a global public health emergency of international concern (pheic) and elicited public panic (bao et al., 2020) . in china, people who have a history of contact with infected or suspected individuals need to quarantine for at least 2 weeks since public health emergency responses have been upgraded to the highest level throughout the country (bao et al., 2020) . in the quarantine period, many people experience negative emotions such as confusion, anxiety, depression and fear, especially due to the lack of contact with families and the lack of psychological care in the initial phase of the outbreak (wang et al., 2020) . to date, studies about psychological impact pay more attention to mental disturbances such as anxiety, depression and panic, however, acute manic episodes triggered by stress are neglected. herein, we present a case of a female patient who experienced first-episode mania during the quarantine period. a 32-year-old woman was brought to our hospital for treatment for a 1-week history of abnormally elevated mood and increased activity developed in quarantine. in january 2020, two colleagues, with whom the patient shared the same office, tested positive for 2019-ncov. although she wore a mask at that time because she got a cold before and needed to keep her 20-month-old daughter safe from infection, she was still at high risk of infection. after the identification of the two colleagues, she immediately received the first nucleic acid amplification test, which was reported to be negative, and then, she socially isolated at home. when the prevention measures were upgraded on 20 th january 2020, she was officially quarantined for medical observation. her fear and anxiety about the unknown increases when she was informed about the isolation by local centers for disease control and prevention (cdc) officials because she was living together with her family on the day that she got the first negative nucleic acid test, which she later thought was due to being in the incubation period. on the first day of isolation, she had physical symptoms highly suggestive of potential infection: her temperature was 37.6℃, other symptoms included fatigue, nausea, vomiting and diarrhea. due to the fear of being infected, she underwent chest ct scanning and a second nucleic acid test. while anxiously waiting for results, she became sleepless and kept a watchful eye on the overwhelming news about pneumonia all night. negative thoughts raced through her head until the next day, when she received negative results. she was diagnosed with suspected acute gastroenteritis and treated symptomatically. shortly thereafter, her somatic symptoms recovered. with all of her stress alleviated, she ran outside of the isolation unit barefooted with no regard for rules or warnings, and she believed that she had superpowers and was immune to all viruses in nature. her mood was cheerful and irritable, and she became very talkative in a demanding manner (she easily got into arguments with others over any issues, including her boss, and she forced the medical staff take off the protective clothing when contacting her) , even though it was hard to follow her flighty ideas. she also exhibited crying spells, impulsive behaviors and poor sleep. because she was unmanageable in the isolation unit, she was referred to a local mental health service. after being prescribed 100-200 mg quetiapine per night for three days, her sleep improved. for better treatment, she was transferred to our hospital by her parents. a third nucleic acid amplification test was performed, and the results were negative. when first admitted here, she still had euphoric and irritable mood; her speech was pressured and loud; she abruptly shifted from one topic to another; and she made hostile comments if she was interrupted. she spoke about politics, religion, and any other grand and abstract issues; in addition, she felt full of energy, enough to make excessive plans for complex tasks not only related to her own job but also the psychological service during the crisis in china (she blamed the lack of psychological support in the isolated unit). other symptoms included increased social activity (she became acquainted with other patients easily) and grandiosity. no psychotic features were presented in the episode. her social functioning before hospitalization was good; she obtained a master's degree and is employed as a research fellow at a famous university in china. she never used alcohol, tabaco, or illegal substances. no family member has psychiatric illnesses, but her mother has a suspected history of depression. she has an open and hyperthymic nature, but she was also known to be short-tempered and vulnerable to stress under less stressful conditions. according to her self-report, she abandoned her doctoral studies since the academic stress was overwhelming, although she had already been accepted to a doctoral program. she was physically healthy and had no previous psychiatric diagnosis. the general physical and neurologic examinations did not identify any abnormalities, and her temperature was normal. all routine laboratory tests were within normal ranges; chest ct scanning and cranial magnetic resonance imaging showed no significant findings. she scored 39 out of 44 points on the young manic rating scale. after acute stress disorders and dissociative disorders were excluded, and acute manic episode was given as her final diagnosis in accordance with the diagnostic and statistical manual of mental disorders, fifth edition. she was coadministered with quetiapine at a dosage that gradually escalated up to 400mg per night and lithium carbonate 300mg three times a day for mood stabilization. after 3 weeks of treatment, her emotion became stable, and her condition improved. this present case raises concerns about the relationship between stressful events and manic episodes, which has rarely been investigated in previous studies. stress is a well-known contributing factor to the trajectories of psychiatric disorders and can affect the onset and transition of an affective disorder to a full-blown episode (chaumette et al., 2016) . many reports, including the earliest work of kraepelinian era of psychiatry, suggested temporal closeness and selective association between stressful events and first mania episode (ambelas, 1987) (ambelas, 1979) , and several theoretical models have attempted to use psychobiological perspectives to determine why life stress can trigger a mood episode, including (hypo)mania. the social zeitgeber theory proposes that stressful life events characterized by disrupting social zeitgebers (i.e., personal relationships, social demands and other external cues that function to entrain biological rhythms) lead to disturbances of social routines and the instability of biological circadian rhythms, which were implicated in the pathogenesis of mania in vulnerable individuals (finkelstein, 1989 , (grandin et al., 2006 , (malkoff-schwartz et al., 1998 . gender, coping, personality, social support and other psychosocial variables may act as intervening variables in the relationship between life stress and affective disorders (leskelä et al., 2004) . for this case, the cessation of working, the lack of interpersonal relationships and the lack of affective support in isolation would be sufficiently stressful to disrupt social and biological rhythms, such as changes in sleep patterns, and thus induce mania. the reward hypersensitivity theory provides another explanation for the association between stressful events and mania episodes. this model hypothesizes that vulnerability to affective disorders is the result of a hypersensitive reward system that reacts more strongly to external or internal goal-and reward-related life events, and an excessive reward state could be activated by positive goal-striving emotions such as hope and happiness, which in turn lead to a cluster of (hypo) manic psychomotor activation symptoms (alloy et al., 2015) .this patient's achievement of the goal of being covid-negative, as an event involving goal attainment, may have triggered excessive responses and the onset of a mania episode. based on the two models above, a novel, integrated reward/circadian rhythm dysregulation theory was proposed recently (alloy et al., 2015) . reward-hypersensitive individuals who experienced a state of excessive reward activation in response to goal-related events are likely to disrupt social and thus circadian rhythms, which in turn trigger manic symptoms. the somatic symptoms of the patients were hard to explain since the information was not clear and the blood results were not provided. in retrospect, the onset and recovery of her physical symptoms temporally correlated with change in psychological stimuli. she manifested mild fever, nausea and diarrhea on the first day of medical quarantine, and the symptoms persisted until the nuclear acid test was identified negative. there might be a possibility that the somatic symptoms were functional manifestations under acute stress because robust evidence supports the relationship between stress and functional disturbances such as functional gastrointestinal disorders (holtmann, et al., 2017) . of course, acute gastroenteritis was a suspected diagnosis based on symptomatology at that time, and whether it was just a functional manifestation or with an organic pathology needs further confirmation through consultation with gastroenterologist and more laboratory tests. the 2019-ncov pandemic is currently a stressor for the general public worldwide. quarantine is a major stressful event disrupting social zeitgebers for people who have had contact with infected individuals, especially for vulnerable individuals with a hypersensitive reward system. stress could act as a trigger in the onset of manic episode, so crisis intervention for individuals in isolation during the initial phase of outbreak is very important but was not available for this patient. furthermore, psychological support system should respond more rapidly and target people with higher risk, such as medical staff, infected patients and those in quarantine for medical observation. the development and course of bipolar spectrum disorders: an integrated reward and circadian rhythm dysregulation model life events and mania. a special relationship? psychologically stressful events in the precipitation of manic episodes 2019-ncov epidemic: address mental health care to empower society social zeitgebers and biological rhythms the social zeitgeber theory, circadian rhythms, and mood disorders: review and evaluation life events, social support, and onset of major depressive episode in finnish patients stressful life events and social rhythm disruption in the onset of manic and depressive bipolar episodes: a preliminary investigation immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china we want to thank juping fu, qi tong, ying zhang and all other medical staff who gave careful nursing to the patient. reference key: cord-296500-hrxj6tcv authors: bunker, deborah title: who do you trust? the digital destruction of shared situational awareness and the covid-19 infodemic date: 2020-08-04 journal: int j inf manage doi: 10.1016/j.ijinfomgt.2020.102201 sha: doc_id: 296500 cord_uid: hrxj6tcv developments in centrally managed communications (e.g. twitter, facebook) and service (e.g. uber, airbnb) platforms, search engines and data aggregation (e.g. google) as well as data analytics and artificial intelligence, have created an era of digital disruption during the last decade. individual user profiles are produced by platform providers to make money from tracking, predicting, exploiting and influencing their users’ decision preferences and behavior, while product and service providers transform their business models by targeting potential customers with more accuracy. there have been many social and economic benefits to this digital disruption, but it has also largely contributed to the digital destruction of mental model alignment and shared situational awareness through the propagation of mis-information i.e. reinforcement of dissonant mental models by recommender algorithms, bots and trusted individual platform users (influencers). to mitigate this process of digital destruction, new methods and approaches to the centralized management of these platforms are needed to build on and encourage trust in the actors that use them (and by association trust in their mental models). the global ‘infodemic’ resulting from the covid-19 pandemic of 2020, highlights the current problem confronting the information system discipline and the urgency of finding workable solutions . information system (is) artifacts 1 have been developed and used throughout human history and over time we have witnessed their disruption of business, industry and society. the current wave of digital disruption 2 has been caused by the development of mobile phones (that are really computers), resource sharing services such as uber and airbnb and social media communications platforms that are centrally managed (but socially distributed) like facebook, instagram and twitter. unfortunately, our is development trajectory also now sees us https://doi.org/10.1016/j.ijinfomgt.2020.102201 in a time of post-truth 3 , fake news 4 and an 'infodemic' 5 which have wreaked digital destruction and havoc on our shared mental models 6 of what we understand to be real and true i.e. shared situational awareness 7 . it is becoming increasingly difficult to agree on what information represents the reality and truth about crisis events within the echo chamber of social media and the opaque algorithmic biases which underpin platform providers, search engines and data aggregators (bunker, stieglitz, ehnis, & sleigh, 2019; himelboim, smith, rainie, shneiderman, & espina, 2017; noble, 2018; sismondo, 2017) . fig. 1 shows the current level of concern with fake news about the covid-19 epidemic from a survey conducted in canada, china, france, germany, india, japan, mexico, saudi arabia, s. korea, u.k. and u.s. (edelman trust barometer, 2020) . this survey highlights that 67 % of respondents worry that there is a lot of fake news being spread about covid-19 while 49 % of respondents are having difficulty finding trustworthy and reliable information. if these levels of concern are reflected in the global population at large, then managing an adequate pandemic response through shared situational awareness becomes an impossible task. while profiling is not a new approach to the treatment of data, communications and service platform providers and data aggregators have found new ways of combining the techniques of individual user profiling (iup), data analytics (da) and artificial intelligence (ai) to monetize 8 the vast amounts of data that have been increasingly generated by their users (liozu & ulaga, 2018) . iup, da and ai are applied to better understand, influence or manipulate an individual's opinions and social, political and economic behavior through 'nudging' mechanisms (lanzing, 2019) . this approach to profiling is a powerful tool (zuboff, 2019) which is used to exploit the individual, their decisions and behavior for financial gain, but which does not effectively address issues of critical and optimal decision making and behavior for societal and group benefit e.g. pandemic management. this is due to the creation of mental model dissonance through the misinformation and rumors that are produced and propagated by this approach. for example, in the current covid-19 pandemic, in order to stop the spread of the virus, health agencies across the globe are urging us to stay socially distant, wash our hands at every opportunity, wear masks (when necessary), and get tested if we develop symptoms. unfortunately, rumors propagated on social media platforms quite often reinforce multiple and conflicting mental models of virus conspiracies, 'quack treatments' and inaccurate information regarding government motivations for lockdowns. this can severely hamper crisis management efforts. some examples 9 of misinformation propagated during the current pandemic include: dissonant mental models are reinforced by recommender algorithms (lanzing, 2019 ), bots (mckenna, 2020 and trusted individual platform users or influencers (enke & borchers, 2019) resulting in alarming levels of digital destruction which is turn undermines social cohesion and creates a barrier to shared situational awareness and effective crisis response. we therefore see a tension and conflict arising from: 1) the need for alignment of mental models and shared situational awareness to support effective crisis management; and 2) the developments of digital disruption, destruction and the facilitation and reinforcement of dissonant mental models through post truth perspectives and conflicting situational awareness. shared situational awareness is developed through the alignment of our mental models to represent a shared version of truth and reality on which we can act. this is an important basis for effective information sharing and decision making in crisis response (salas, stout, and cannon-bowers et al., 1994) . aligned mental models help us to agree about the authenticity, accuracy, timeliness, relevance and importance of the information being communicated and give concurrence, weight and urgency to decisions and advice. harrald and jefferson (2007) highlight that shared situational awareness implies that "(1) technology can provide adequate information to enable decision makers in a geographically distributed environment to act as though they were receiving and perceiving the same information, (2) common methods are available to integrate, structure, and understand the information, and (3) critical decision nodes share institutional, cultural, and experiential bases for imputing meaning to this knowledge" (page 3). we know that most crisis management agencies have established, agreed, authenticated and qualified mental models on which they base their internal operational command and control systems. this gives them assurance and governance of the information they produce (bunker, levine, & woody, 2015) and qualifies their decisions and recommended actions to manage crisis situations. it also engenders public trust in these agencies, to provide relevant and critical crisis information and advice for public action. fig. 2 highlights the current high and increasing levels of trust in government institutions during the covid-3 "…that truth has been individualized or that individuals have become, to borrow a turn of phrase from foucault, the primary and principal points of the production, application, and adjudication of truth is one important point. that emotion and personal belief are able now to outflank even objective facts and scientific knowledge is another (the claim that literature, for example, has truths to tell has long fallen on deaf ears). their articulation is decisive: with the regime's inflection, even inflation, of the indefinitely pluralized and individualized enunciative i who, by virtue of strong feeling, is able at any moment not only to recognize or know but, also, to tell or speak the truth, truth is privatized and immanitized, its universal and transcendental dimensions nullified altogether. hence, what is true for any one person need not be true for everyone or anyone else; what is true for anyone now need not necessarily be true later" (biesecker, 2018pp 331-332) . 4 we posit that fake news is, in essence, a two-dimensional phenomenon of public communication: there is the (1) fake news genre, describing the deliberate creation of pseudojournalistic disinformation, and there is the (2) fake news label, describing the political instrumentalization of the term to delegitimize news media " (egelhofer & lecheler, 2019page 97) ." 5 "an over-abundance of informationsome accurate and some notthat makes it hard for people to find trustworthy sources and reliable guidance when they need it." (who, 2020) 6 "a concentrated, personally constructed, internal conception, of external phenomena (historical, existing or projected), or experience, that affects how a person acts" (rook, 2013 )page 47. 7 "refers to the degree of accuracy by which one's perception of his current environment mirrors reality." (naval aviation schools command (032) 19 pandemic (edelman trust barometer, 2020). when digital destruction produces mental model dissonance shared situational awareness between crisis management agencies and the general public becomes impossible to maintain and communicate (both to and from) due to inconsistencies in what constitutes reality and truth, making crisis response unmanageable. centrally managed communications and service providers and data aggregators treat your personal data as a commodity/resource which they are generally entitled to use as they wish, however, they largely ignore the deeper understanding of the mental models on which data is produced by any one system (bunker, 2001) . "in the social sciences, in particular, big data can blend wide-scale and finer-grained analytic approaches by providing information about individual behaviour within and across contexts" (tonidandel, king, & cortina, 2018)page 531. data science harnesses the belief that data created by an individual using different applications or platforms, can be seamlessly combined then analyzed using sophisticated data analytics and ai. conversely, this belief has also fundamentally changed the way that all individuals view and interact with data and information in their daily lives. for instance, our trust in the google maps application on our phone to tell us exactly where we are at any given moment, extends to the belief that all information coming to us via our mobile phones and the applications we choose to use, must be some version of reality or the truth. we selfselect our filters (applications and services) for engagement with the wider world and our reliance on mobile technology and applications to navigate the world is now at an all-time high i.e. 3.5 billion or 45.04 % of the global population. 10 if we are a social media platform user, however, we can be bombarded with paid advertising or 'nudged' by recommender algorithms to make contact with other platform users, information sites and products and services that are deemed to be relevant to us and part of our 'shared reality' (echterhoff, higgins, & levine, 2009 ). nudging performs three functions : meeting platform user 1) epistemic; and 2) relational needs; and 3) adding to the platform owner's profitability'. for instance, the platform user is directed to people, products, information and communities of interest that help them to "achieve a valid and reliable understanding of the world" (levine, 2018) -pg 54; this then fulfills their "desire to affiliate with and feel connected to others" (levine, 2018) -pg 54; and ; platform owners and managers (and their influential users) then make lots of money selling targeted advertising by directing platform users in this way. this might be a desirable situation when sharing situational awareness within a social media platform community of interest where mental models align, but when combined with platform characteristics like user anonymity and lack of information assurance, then treating a social media platform as a trusted information source for shared situational awareness becomes problematic. for example, social media platform users can be a valuable source of eyewitness information for crisis management agencies to enhance the production of shared situational awareness for crisis decision making. social media information when generated in large volumes in a crisis, however, is difficult to process. the source of the information can take time to identify and authenticate and the information provided by them can be a problem to verify, validate, analyze and systematize. this produces a general lack of trust by crisis management agencies and other social media users, in the crisis information produced on social media platforms. this can have catastrophic consequences for shared situational awareness through failure to detect and use important and relevant information or through the belief in, and the propagation of, mis-information produced on these platforms (bui, 2019, ehnis and which can also impact and undermine social benefit and cultural cohesion in times of crisis (kopp, 2020) . we are currently living in an era of digital disruption which provides many economic and social benefits, but we must also be able to support crisis management based on shared situational awareness. post truth perspectives, fake news and the resulting infodemic has resulted in wide ranging digital destruction and the enablement and encouragement of mental model dissonance. how can we best address this problem? seppanen, makela, luokkala, and virrantaus (2013) have outlined the connection characteristics of shared situational awareness in an actor network. fig. 3 highlights the configuration of the connection which includes three requirements: 1) informationto bridge the information gap through the identification of key information elements; 2) communicationto understand the fluency of how actors communicate through describing this communication in detail; and 3) trustto analyse the role of trust on the quality and fluency of communication. they reason that "if trust could be increased the availability, reliability, and temporal accuracy of information could be improved". recent research conducted on the use of social media platforms for crisis communication purposes, so far concludes that: 1) trusted agencies have an early mover information advantage in crisis communication on social media platforms such as twitter (mirbabaie, bunker, stieglitz, marx, & ehnis, 2020) ; 2) information communicated by trusted agencies can be amplified and intensified by influential social media users and others to "communicate, self-organize, manage, and mitigate risks (crisis communications) but also to make sense of the event (commentary-related communications)", for example through retweets on twitter (stieglitz, bunker, mirbabaie, & ehnis, 2018); 3) trusted agencies and the information they supply is influential in shaping the human response to crisis situations (mirbabaie, bunker, stieglitz, & deubel, 2019) ; 4) trusted agencies find processing the high volumes of information communicated through social media platforms problematic due to the difficulty in authenticating the information source (user) and establishing the accuracy, timeliness and relevance of the information itself ; and 5) there are a number of tensions which emerge in the use of social media as a crisis communications channel between trusted agencies and the general public. these tensions occur in the areas of: information, generation and use i.e. managing the message; emergence and management of digital and spontaneous volunteers; management of community expectations; mental models which underpin prevention, preparation, recovery and response protocols (pprr); and management of the development of the large-scale adoption of social media technologies for crisis communications (elbanna, bunker, levine, & sleigh, 2019) . this knowledge points us to a number of areas of research focus in is for the future development of data analytics and artificial intelligence to more effectively align mental models for shared situational awareness. these should: • build on the trust in government and their crisis management agencies, as well as other influential actors in crisis management communications, to provide and amplify advice and information as early as possible in a crisis; • build frameworks that create algorithmic transparency, information governance and quality assurance for platform and service providers and data aggregators to create and reinforce trust in them as information sources i.e. so they become trusted actors in the communications network; • address how platform and service developers and government communication system developers can share concepts and build systems that address crisis communication requirements, including those used in iup, ds and ai; and • address government failures to provide robust is services, during the covid-19 pandemic, and the subsequent impacts this has had on trust in government and their systems for tracking and tracing infections (chakravorti, 2020) . these areas of focus are important given the negative impacts that are already emerging from the use of ai during the covid-19 pandemic i.e. varying levels of data quality and comprehensiveness, development of covid-19 treatments based on the use of this variable data, use of social control and surveillance methods to minimize virus spread (smith & rustagi, 2020 , naughton, 2020b . it is time to critically analyze and evaluate how centrally managed platforms, their data and systems algorithms are being used during the covid-19 pandemic (and other crises) by the companies who own and run them. how are they using the information they collect i.e. development of services, influencing users, creation of profits etc., (how) are they limiting the spread of post truth arguments and fake news/information and are they exacerbating or assisting with the management of crises? some platform owners (youtube, twitter, whatsapp) are currently making efforts to be more transparent in their platform operations, data governance and quality assurance (hern, 2020; naughton, 2020a) . there have also been growing calls from critics for regulation of these companies and their business practices (lewis, 2020) . there is a long way to go, however, to address the problems, issues and barriers caused by these companies for the production of shared situational awareness to support crisis management. for instance, the latvian government wanted to access the google/apple designed contact tracing framework (a bluetooth enabled api) which "can later be translated into covid-19 exposure notifications" and which are sent to contacts of a covid-19 positive person. google and apple set preconditions to accessing this framework, however, by only allowing the registration of one government/health authority approved contact tracing app per country and by not allowing government health agencies access to the personal details of contacts, due to their evaluation of potential privacy issues (ilves, 2020) . multi-jurisdictional legal definitions and treatment of privacy issues is also a complicating factor in this decision. this situation presents a problem to any country wishing the use the api, as contact tracers need to be able to: 1) assess the level of potential exposure to the virus of the contact; and then 2) provide advice to the contact as to what action they should take. this could be anything from "get a test and self-isolate for 14 days" through to "take no action at all, socially distance from others, but watch for symptoms". as covid-19 health advice can have critical health, economic and social consequences for an individual, the advice needs to be tailored for the individual and be as least impactful as possible. merely sending an exposure notification to a contact of a covid-19 infected person, does not guarantee any action, or the correct action being taken by that person. by prohibiting access to data and controlling their api in this way, google and apple are not sharing available data with not sharinggovernment health agencies that would allow them to tha perform effective contact tracing which could save many lives while preventing large scale economic hardship and vice versa. this presents us with a difficult legal and ethical situation to ponder i.e. does the individual requirement for data privacy outweigh the opportunity to save lives and livelihoods? we are now in the midst of a pandemic and the 'infodemic' that has followed in its wake and to counter the effects of this overload of inaccurate and misinformation, the who has collaborated with the providers of social media platforms (e.g. facebook, twitter, etc.) to mitigate the impact of false information on social media (who, 2020) in order to support shared situational awareness and effective crisis management. this is an unsustainable and unrealistic situation, however, due to the ongoing cost, level of resources and necessary skills required for such an intervention. while many countries have been unable to adequately deal with the pandemic, there are many success stories of shared situational awareness supporting health agency and public response for effective virus containment through day-to-day decisions and actions. australian governments (federal and state) have had mixed results in the containment and management of the covid-19 pandemic. there have been communications and is missteps along the way e.g. ruby princess cruise ship (mckinnell, 2020) and the melbourne quarantine hotels (kaine & josserand, 2020) where quarantine protocols were breached, as well as the current technical problems with the collection and use of the data from the australian federal government covidsafe tracking and tracing app (taylor, 2020) . we are also currently seeing the rapid development of a covid-19 outbreak in metropolitan melbourne (victoria), where previously there had been a successful pandemic response. this has necessitated the reinstatement of lockdowns, strict social distancing enforcement and the closure of the nsw/victorian border. this outbreak has been exacerbated by misinformation circulating on social media targeting specific cultural groups, which has caused general confusion (especially in non-english speaking communities) as well as the promotion of racist tropes and hate speech (bosley, 2020) . while managing a pandemic is a complex and complicated process with many stakeholders, to achieve a more effective level of crisis management there are benefits to be obtained by shared situational awareness through the alignment of mental models that represent more broadly acceptable situational reality and truth. this alignment would further support our trust in government as well as develop trust in other organizational and individual actors in the communications network. individual differences in political, social and cultural contexts also add a layer of complexity to the alignment of mental models for shared situational awareness. government agencies should refine their mental models of situational awareness to accommodate those variations in factors of significance which impact alignment e.g. cultural behavioral practices, housing conditions, working environments and practices, access to services, regard for community leadership, digital literacy, access to technology etc. or they risk the ongoing development and reinforcement of dissonant and alternative mental models and erosion of their trusted status. (mirbabaie et al., 2020) both government and platform providers have public interest and safety information communications requirements to satisfy in both the short and long-term, which directly impact our ability to manage pandemics and other types of crises and disasters effectively. there must be collaboration and cooperation (either legislated or voluntary) to build on the trust in government to provide information as early and as often as possible in a crisis (and enable the amplification of, and action taken from this advice) as well as ensure algorithmic transparency, information governance and quality assurance for robust and trusted communication and information services overall. to remain successful in managing the pandemic, however, requires long term vigilance and effort by both the pandemic managers and the international journal of information management xxx (xxxx) xxxx public alike. as we can see by the current covid-19 outbreak in victoria, mental model alignment (and realignment) during a crisis is a continual process which requires constant attention, effort and resources. "a critique of how science is produced is very different from the post-truth argument that there are alternative truths that you can choose from. post-truth is a defensive posture. if you have to defend yourself against climate change, economic change, coronavirus change, then you grab at any alternative. if those alternatives are fed to you by thousands of fake news farms in siberia, they are hard to resist, especially if they look vaguely empirical. if you have enough of them and they are contradictory enough, they allow you to stick to your old beliefs." bruno latourinterview (watts, 2020) . guest editor's introduction: toward an archaeogenealogy of posttruth reports melbourne coronavirus cluster originated at eid party could stoke islamophobia, muslim leaders saythe guardian (online) 25 social media, rumors, and hurricane warning systems in puerto rico a philosophy of information technology and systems (it&s) as tools: tool development context, associated skills and the global technology transfer (gtt) process repertoires of collaboration for common operating pictures of disasters and extreme events bright ict: social media analytics for society and crisis management digital contact tracing's mixed record abroad spells trouble for us efforts to rein in covid-19. the conversation (online) july shared reality: experiencing commonality with others' inner states about the world spring update: trust and the covid-19 pandemic fake news as a two-dimensional phenomenon: a framework and research agenda repertoires of collaboration: incorporation of social media help requests into the common operating picture emergency management in the changing world of social media: framing the research agenda with the stakeholders through engaged scholarship social media influencers in strategic communication: a conceptual framework for strategic social media influencer communication shared situational awareness in emergency management mitigation and response youtube bans david duke and other us far-right users. the guardian (online) classifying twitter topic-networks using social network analysis why are google and apple dictating how european democracies fight coronavirus? the guardian (online) 16 melbourne's hotel quarantine bungle is disappointing but not surprising. it was overseen by a flawed security industry. the conversation (online) 8 fake news: the other pandemic that can prove deadly strongly recommended" revisiting decisional privacy to judge hypernudging in self-tracking technologies going back to basics in design science: from the information technology artifact to the information systems artifact socially-shared cognition and consensus in small groups facebook and google must move away from the zero-sum game. the sydney morning herald -opinion (online) monetizing data: a practical roadmap for framing, pricing & selling your b2b digital offers queensland researchers analysing coronavirus conspiracy theories warn of social media danger ruby princess passengers disembarked before coronavirus test results to get flights, inquiry hears social media in times of crisis: learning from hurricane harvey for the coronavirus disease 2019 pandemic response who sets the tone? determining the impact of convergence behaviour archetypes in social media crisis communication twitter taking on trump's lies? about time too. the guardian (online) 31 silicon valley has admitted facial recognition technology is toxic -about time. the guardian (online) 14 algorithms of oppression: how search engines reinforce racism defining and measuring shared situational awareness a kuhnian analysis of revolutionary digital disruptions mental models: a robust definition. the learning organization the role of shared mental models in developing shared situational awareness developing shared situational awareness for emergency management editorial 'post-truth? the problem with covid-19 artificial intelligence solutions and how to fix them. stanford social innovation review sense-making in social media during extreme events australia's covidsafe coronavirus tracing app works as few as one in four times for some devices. the guardian (online) 17 big data methods: leveraging modern data analytic techniques to build organizational science this is a global catastrophe that has come from within' interview. bruno latour: the guardian (online) 7 novel coronavirus (2019-ncov) situation report the age of surveillance capitalism: the fight for a human future at the new frontier of power i would like to thank the communications and technology for society research group at the university of sydney business school,and the marie bashir institute for infectious diseases and biosecurity for their continued support for this work, and adjunct associate professor anthony sleigh and dr christian ehnis for their encouragement and invaluable feedback on this paper. key: cord-292774-k1zr9yrg authors: haldule, saloni; davalbhakta, samira; agarwal, vishwesh; gupta, latika; agarwal, vikas title: post-publication promotion in rheumatology: a survey focusing on social media date: 2020-09-13 journal: rheumatol int doi: 10.1007/s00296-020-04700-7 sha: doc_id: 292774 cord_uid: k1zr9yrg the use of social media platforms (smps) in the field of scientific literature is a new and evolving realm. the past few years have seen many novel strategies to promote engagement of readers with articles. the aim of this study was to gauge the acceptance, opinion, and willingness to partake in the creation of online social media educative material among authors. we conducted a validated and anonymized cross-sectional e-survey with purposive sampling among authors of the indian journal of rheumatology journal over a cloud-based platform (surveymonkey). descriptive statistics are used and values expressed as the number of respondents (n) against each answer. of 408 authors, 102 responded. we found that a large majority (74) supported promotions on smps. visual abstracts (81) were the most preferred means for promotion. a reasonable proportion (54) of the authors held the view that they could make these materials for themselves, with little guidance. however, currently only a few (47) were doing so. awareness on social media editors in rheumatology was dismal (4). citations were the preferred metric of article visibility (95), followed by altmetrics (21). these findings suggest that authors support article promotions on smps, although most do not promote their articles. graphical abstracts are the preferred means of promotions. further, the opinion on logistics is divided, calling for larger studies to understand the factors that need to be addressed to bridge the gap. social media is a broad term that encompasses the use of technology to participate in social networking. the use has extended in the twenty-first century beyond personal networking, to academia and telehealth [1] . the widespread lockdowns and public mandate for social distancing during the ongoing pandemic have further strengthened the case for using social media platforms (smps) for academic communication in this period [2] . several journals have picked up on this trend by sharing their work on smps [3] . smps are increasingly being used to share information from primary as well as secondary, tertiary, and grey literature [4, 5] . of these, original research (primary and secondary articles), comprises the most important updated information for doctors, researchers, and administrators alike [6] . in times when pre-prints are being archived to rapidly disseminate scientific research, articles published in scholarly journals after an extensive peer-review are of greater scientific credence [7, 8] . the rapidly rising number of research articles on an area of interest, such as covid-19, can make it challenging to assimilate the required information [9, 10] . the large volume of information available can be overwhelming and may sometimes hinder the process of learning. furthermore, retention of information may be hampered by the use of only one type of traditional learning cue, i.e., text [11] . the use of newer methods to present information, such as visual (or graphical, fig. 1) , voice, or video abstracts, can be helpful to attract and sustain the reader's attention. experts suggest that we retain 10% of what we read, 20% of what we hear, and 30% of what we see [12] . hence, using additional tools to promote literature on smps may bring a dynamicity to the process. moreover, mixed sensory cues may enhance the learning experience and overcome barriers to poor memory and recall [11] . infographics, video abstracts and voice abstracts (or podcasts) are potential strategies to enhance the scientific readership experience. since these strategies are novel, their implementation comes with challenges of its own, such as an evident lack of clarity as to who should prepare these promotional educative materials. while the authors may be willing to take responsibility themselves, developing such resources is a time-consuming skill, and they may need assistance from trained personnel. moreover, cost constraints may limit the use of professional editing agencies, more so in the developing countries. thus, we aimed at studying the acceptance, opinion, and willingness to participate in the creation of online social media educative material among authors of published self-articles in scholarly journals. the e-survey was designed on an online cloud-based website (survey monkey ® .com) with the intent to cover different aspects of social media editing, such as willingness for social media promotions of (2), means of promotion (4), ethics (3), logistics (3), preference for article metrics, publication models and pre-print archiving (2), current knowledge/use of social media for these purposes (4). the questionnaire featured 22 questions, most (12) of which were multiple choice questions needing a single answer option, while others (9) could have more than one answer option selected, and some (1) needed a single answer to be selected from a list. four items identified the respondent characteristics, and the rest (18) covered various domains listed above. choices were closed ended for most (11) , with an 'other (please specify)' option where deemed appropriate (11) . two rheumatologists and three undergraduate medical students reviewed the questions and confirmed them to be representative of the content and face validity. the survey underwent three rounds of dummy fill-ups to identify errors in wording, grammar, and syntax. the respondents could change the answers before submission but not after it. the survey was partly anonymised with internet protocol (ip) address and emails of respondents being the only linked identifiers. all questions were made mandatory, such that emails of corresponding authors of articles published from 2010 to 2020 in the indian journal of rheumatology (ijr, n = 408) were obtained from scopus. the ijr is a scopus and web of science indexed platinum open-access society journal of the indian rheumatology association with a wide readership in india. the questionnaire was circulated to the list hence obtained. the eligible participants were given a month's time to voluntarily complete the survey from 26 march to 26 april 2020. the survey link was open from the time the authors were first intimated about the study. the cover letter included details on the background and purpose of the study. informed consent was taken at the beginning of the survey and no incentives offered for survey completion. internet protocol (ip) address checks were done to avoid duplicated responses from a single respondent. data handling was completely anonymous, with the ip addresses and email lists remaining with the first and corresponding author. other authors had access to the synthesized data in tables without linked identifiers. an exemption from review was obtained from the institute ethics committee of sanjay gandhi post graduate institute of medical sciences, lucknow as per local guidelines. we adhered to the checklist for reporting results of internet e-surveys to report the data [13] . descriptive statistics were used, and figures designed using the surveymonkey website. data are expressed as median, percentage and inter-quartile range. numbers in brackets signify the number of respondents for the answer choices being discussed. of the 102 respondents, most (83) lived in india and were practicing rheumatology (77, table 1 ). nearly half (50) were in practice for 11 years or more. the average survey time was 5 min and 4 s. the response rate was 25%. over two-thirds (74) said they would like their publication promoted on social media, researchgate (70) being the most preferred platform, followed by twitter (40), facebook (37), whatsapp (35), academia.edu (27) , and linkedin (26) . only five said they would not prefer their publication being promoted. however, only 47 promoted their articles [on research-gate followed by whatsapp (32)] currently, and 26 did not do so. when asked who should promote articles, specially appointed social media editors were preferred by nearly half (46) while 24 felt all editors should do so, and 29 believed only the copyright holders can promote their publication on social media. most felt the use of appropriate hashtags (43) and appropriate timing (42) were crucial for successful promotion, and an equal proportion (46) advocated the use of artificial intelligence-based algorithms for the same. a dismal four people knew the correct number of rheumatology journals that have social media editors. nearly three-fourths (77) were unaware that the ijr had sme (s). visual (or graphical) abstracts were the most preferred (81) means for enhancing visibility among authors, while voice (47) and video (39) abstracts were preferred by fewer. while 54 felt they could prepare a visual abstract by guidance from the editorial team, another 25 felt the editorial team should do it (without charges). on the other hand, 34 felt they could do video abstracts themselves and another 37 said it should be outsourced to a third party. similar proportions (36) were willing to prepare voice abstracts after guidance, though outsourcing was less supported (11). preference for citations as metric (95) was almost unanimous though nearly one in five (21) also preferred altmetrics for visibility. the green open access was the most preferred model (45) followed closely by platinum open access (31) . pre-print archiving was preferred by a minority (15) . we noted good acceptance for social media promotions of published scholarly literature by over two-thirds of the authors, although less than half had actually done so. visual (or graphical) abstracts were the most preferred means for enhancing visibility among authors. however, the opinion on logistics of promotion and preparation was divided. the use of visual abstracts was popular amongst the respondents. however, video and voice abstracts were far less so. this could possibly be, in part due to the perception that making visual abstracts is simpler than the other options. this is supported by our finding that over half felt they could themselves make the visual abstracts with due guidance, as opposed to one-third who felt the same regarding video and voice abstracts. however, further studies should be done to determine the reasons for preferences within the various promotional tools, as well to understand who would be best suitable to prepare them. visual abstracts are a clear, concise format to expeditiously disseminate information, and are now increasingly being encouraged by various journals [14] . at times where healthcare workers are burdened with medical care of covid-19 patients, visual abstracts allow them to find the most relevant material quickly. a recent study showed that infographics summarized medical research literature and were associated with higher reader preference and lower cognitive load during summary review, although no difference was found in late information retention [15] . in the current fast-paced world, where technology governs most aspects of development, scientific literature must evolve to fit the needs of the hour. now more than ever, as we fight a global pandemic, information needs to travel faster, and beyond any man-made borders to be effective. smps are a fitting solution for many of these needs. it has been increasingly found that there exists a relationship between the traditional impact factor and activity on social media, with some sources having a near perfect correlation [16] . however, many researchers feel overwhelmed by the internet and social media due to a lack of scientific guidance [17] . moreover, over 90% professionals use social media for personal reasons, with merely 65% doing so for academics purposes [18] . while citations are the traditionally preferred metric of visibility, altmetrics are now increasingly being identified as an important metric for publication success [19] . altmetrics are non-traditional article-level bibliometrics that gather details of engagement of research work on a wide variety of online platforms, including but not limited to mentions in the news, blogs, and on twitter and other smps, article pageviews and downloads, etc. a drawback of using citations is the inevitable time lag in acquiring them, reducing utility for young scholars. moreover, citations reflect article use by researchers. but in this shrinking world with borderless communication, and there are many more stakeholders than there were before. it is just as important for hospital administrators, policy makers, clinicians, and educators to be informed of the latest developments, and to modify their practices accordingly. altmetrics may provide a more wholesome picture of the article visibility and utility from diverse areas. moreover, altmetric scores on researcher platforms, such as academia and mendeley, may translate into higher cite scores, due to the characteristics of the readership population [20] . a recent study found a high correlation (0.83) between the scimago journal rank scores and the number of followers on twitter, despite adjusting for time since creation of the account, further substantiating enhanced visibility of articles using smps and the potential to enhance journal (and consequently article) metrics with social media practices [16] . acceptance of social media promotions was good among our respondents, although understanding of its utility may be poor, translating to the admittedly low rates of active social media practice for academic promotions. the use of smps for promotions of own articles was inferred as practice. this may be improved by educating healthcare professionals about the various aspects of social media use [21] . notably, the preferred platforms for promotions may vary, with researchgate and whatsapp being popular in india and wechat in china [22] . a recent survey conducted among rheumatologists in the european network recorded facebook as the most commonly use platform, though only 46% used it to establish a professional online presence [23] . further research may provide a better understanding of individual differences. interestingly, the opinion regarding the responsibility of social media promotions was divided among authors. though nearly half felt social media editors (smes) should do so, a significant number felt only editors and copyright holders should take the responsibility. social media promotions require specific skills, time and dedication. it is also essential to be aware of standards for quality and content for effective promotions. smes are more likely to be aware of these, and the various tools to meet these requirements. a lack of awareness regarding availability of smes for rheumatology journals was evident in our respondent population, possibly a reflection of poor interest and interaction of researchers on smps. a shift in the culture from researchers being passive bystanders to active participants in this process may enhance academic engagement [24] . although smes may be proficient at promotions, every author and member of the scientific community can, and should, partake in the narrative themselves. the impressions of tweets are shown to improve with a wider retweeting network. the uses of hashtags and mentions are other effective ways to enhance engagement [25] . audio abstracts may feature as podcasts, which are popular in the west, although the trend may not have caught on so well in india yet. podcasts are increasingly being used for medical education, both within teaching institutions and on an international scale by major journals. [26] . nearly half of our respondents were open to audio abstracts, suggesting this merits exploration in india as well. copyright and plagiarism remain an important concern with social media promotions. when sharing images and infographics, it is essential to check copyright permissions, and provide the source information. some journals allow certain articles to be freely shared for promotions. articles shared on open-access media are known to have better visibility, and this was reflected in our respondents' opinion too. our findings show that pre-print archiving was preferred by less than one-third of the respondents. preprint servers like medrxiv are rapidly gaining popularity, especially since the covid-19 pandemic [27] . even though most of these submissions on archival platforms do not undergo the process of peer review, there has been a boom in literature available through medrxiv/bioarxiv. most journals too, now encourage pre-print submissions. however, resorting to such information for key decisions can lead to disastrous consequences. the authors agreed that the use of artificial intelligence algorithms to promote articles would be a beneficial tool. algorithms, such as the medfact, which was published in the canadian conference on artificial intelligence in 2018, aim at enabling recommendations of trusted medical information within health-related social media discussions [28] . medfact automatically extracts relevant keywords from online discussions and queries trusted medical literature with the aim of embedding related factual information into the discussion [28] . extrapolated to medical literature, this may be one of the solutions to the ethical concerns regarding social media and its lack of credible information. however, social media is a double-edged sword, and it is vital to educate professionals regarding ethical use to deliver credible scientific information and perspectives without engaging in misinformation, data ownership violation, breach of personal privacy, incivility, cyber bullying, and professional misconduct [29] . this is essential as the work of promoting articles on smps is a trinomial; an amalgamation of technological challenges with ethics in science and dealing with widely varying cultural diversity [30] . moreover, it is important to be mindful of the fact that use of smps has addictive potential, and although excessive preoccupation correlates with task-related and relationship-building behaviours, it contributes most strongly to negative social media-related deviant behaviour at the workplace. fortunately, individuals using smps for academic growth are aware of positive as well as negative effects [31] , and thus, reinforcement of this knowledge may potentially curb negative behaviours related to social media use. while our survey is limited by self-selection and recall biases, and unknown characteristics of the non-respondents, it highlights key issues regarding the role of social media in academia, while laying the groundwork for larger studies for understanding these further. the responses were limited in the current study by a short survey duration, coinciding with the onset of the covid-19 pandemic. our anonymized survey did not allow correlation of authors' responses with their publication activity. however, we hope that the primary insights offered by this exploratory study would pave the way for larger global study across non-indian rheumatology journals on the subject. to conclude, authors in rheumatology journal support the use of social media for promotions of published scholarly literature, although this does not translate into practice. the use of graphical abstracts is supported by a majority, with video and voice abstracts being less popular. the opinion on logistics is divided, calling for larger studies to understand the factors that need to be addressed to bridge the gap. medical journals in the age of ubiquitous social media social media and the new world of scientific communication during the covid19 pandemic future evolution of traditional journals and social media medical education searching and synthesising 'grey literature' and 'grey information' in public health: critical reflections on three case studies social media as a tool to increase the impact of public health research primary vs secondary literature in the biomedical sciences: primary vs secondary sources misinformation during the coronavirus disease 2019 outbreak: how knowledge emerges from noise information and misinformation on covid-19: a cross-sectional survey study social media in the times of covid-19 management of rheumatic diseases in the time of covid-19 pandemic: perspectives of rheumatology practitioners from india the impact of presentation style on the retention of online health information: a randomized-controlled experiment: health communication visual abstracts bring key message of scientific research improving the quality of web surveys: the checklist for reporting results of internet e-surveys (cherries) adoption of visual abstracts at circulation cqo: why and how we're doing it exploring the role of infographics for summarizing medical literature immunology and social networks: an approach towards impact assessment an introduction to social media for scientists social media and health care professionals: benefits, risks, and best practices evaluating altmetrics mendeley readership altmetrics for medical articles: an analysis of 45 fields-thelwall-2016-journal of the association for information science and technology-wiley online library social media for medical journals perception about social media use by rheumatology journals: survey among the attendees of iracon 2019 social media use among young rheumatologists and basic scientists: results of an international survey by the emerging eular network (emeu-net) social media for research, education and practice in rheumatology #eular2018: the annual european congress of rheumatology-a twitter hashtag analysis podcasting in medical education: a review of the literature coronavirus research moves faster than medical journals-bloomberg medfact: towards improving veracity of medical information in social media using applied machine learning letter to the editor: social media is a double-edged sword in the covid-19 pandemic challenges for social media editors in rheumatology journals: an outlook impact of social media on academic performance and interpersonal relation: a cross-sectional study among students at a tertiary medical center in east india the authors thank all respondents for filling the questionnaire and dr sakir ahmed for reviewing the survey questions. lg is the social media editor (sme) of the journal of clinical rheumatology and the indian journal of rheumatology. va is the editor in chief of the indian journal of rheumatology. the key: cord-279936-f0lh3g8u authors: heyes, cecilia title: culture date: 2020-10-19 journal: curr biol doi: 10.1016/j.cub.2020.08.086 sha: doc_id: 279936 cord_uid: f0lh3g8u if you are not sure what ‘culture’ means, you are not alone. in 1952, anthropologists kroeber and kluckhohn identified 164 definitions of culture and there has been growth rather than rationalisation in the ensuing 70 years. in everyday english, culture is the knowledge and behaviour that characterises a particular group of people. under this umbrella definition, culture was for many decades the exclusive province of the humanities and social sciences, where anthropologists, historians, linguists, sociologists and other scholars studied and compared the language, arts, cuisine, and social habits of particular human groups. of course, that important work continues, but since the 1980s culture has also been a major focus of enquiry in the natural sciences. if you are not sure what 'culture' means, you are not alone. in 1952, anthropologists kroeber and kluckhohn identifi ed 164 defi nitions of culture and there has been growth rather than rationalisation in the ensuing 70 years. in everyday english, culture is the knowledge and behaviour that characterises a particular group of people. under this umbrella defi nition, culture was for many decades the exclusive province of the humanities and social sciences, where anthropologists, historians, linguists, sociologists and other scholars studied and compared the language, arts, cuisine, and social habits of particular human groups. of course, that important work continues, but since the 1980s culture has also been a major focus of enquiry in the natural sciences. the founding of the cultural evolution society in 2015 revealed that there are now thousands of biologists worldwide investigating the evolutionary origins of culture and trying to explain cultural change using mathematical techniques from population genetics. these biologists are asking when and where in the animal kingdom culture has originated; exploring the behavioural, cognitive, ecological and social factors that make culture possible; and trying to understand how cultural change has interacted with genetic change to produce the rich diversity of human societies. cultural evolutionists do not always use the term 'culture' in a way that ordinary speakers of english would recognise, and, as we shall see, they have developed defi nitions of culture that relate to their explanatory projects in subtle and interesting ways. in contemporary research with an evolutionary fl avour, just three uses of 'culture' are common ( figure 1a) , and they all link it with social learninglearning assisted by observation of, or interaction with, another agent or its products. in order of increasing specifi city, the term 'culture' is used by evolutionists to refer to: fi rst, information construction -processes whereby organisms change their environments. within the niche construction framework, social learning can occur, not only when an animal observes another agent or its recent secretions, but whenever an animal encounters a feature of its environment that has been changed -deliberately or inadvertently, recently or long ago -by other animals. culture 1 is used when the purpose of enquiry is to fi nd out how social learning infl uences evolutionary dynamics across the animal kingdom; when asking how social learning contributes to behavioural adaptation, interacts with genetic processes, and semi-detaches animals from ecological constraints. culture 1 has very little to do with what most people, in science and on the street, think of as culture. the second defi nition is more restrictive and closer to what we mean when we talk about human culture in everyday life. to count as culture 2 , or a primer or behaviour acquired through social learning; second, one or more socially learned behaviours shared by the members of a group; or third, socially learned behaviours that are shared by members of a group and have improved over successive episodes of social learning. it is important not to confuse the fi rst of these defi nitions, culture 1 , with the second and third, culture 2 and culture 3 , because they represent very different explanatory projects ( figure 1b) . the fi rst defi nition suggests that culture is present in all the many vertebrate and invertebrate animals that are capable of social learning. grouse have culture 1 because the females prefer to mate with males with whom they have seen other females mating, and snails have culture 1 because they sometimes fi nd prey by following the slime trails of other snails. the scope of this minimal defi nition of culture is yet broader when it is used by those interested in niche the three commonly-used defi nitions of culture are nested; culture 1 is more inclusive than culture 2 , and culture 2 is more inclusive than culture 3 . (b) projects. the three defi nitions of culture are linked with different explanatory projects. the anthropocentric project, which seeks to understand what makes human lives distinctive, overlaps with the project examining interactions between social learning and evolution. the search for cultural selection (also known as the 'third-way project') is part of the effort to understand relations between social learning and evolution, and is sometimes (but not always) part of the anthropocentric project. (c) fields. people who study 'cultural evolution' come from many fi elds of science (the list here, from behavioural ecology to zoology, is not exhaustive). each study of cultural evolution relates to one or more of the three explanatory projects. the anthropocentric project is also a focus of evolutionary psychology. cultural evolutionary research is like evolutionary psychology to the extent that it explains distinctively human behaviour with reference to complex, genetically inherited cognitive processes. panels a, b and c represent conceptual relations, not volumes of research. for example, cultural evolution and evolutionary psychology are represented by ovals of equal size, but this does not indicate the two fi elds are yielding similar volumes of research. similarly, the degree of overlap between the two fi elds is not an estimate of how many studies of cultural evolution share assumptions with evolutionary psychology. 'tradition', a behaviour must be not only socially learned (suffi cient for culture 1 ), but group-typical. it must be present in all or many members of one or a few social groups, and absent or rare in other social groups of the same species. and, crucially, the group-typicality must be due to the social learning, rather than to ecological or genetic differences between groups. for example, some groups of rats living on the banks of the po river eat molluscs, and other groups in the same area of italy do not. mollusceating would be an example of culture 2 if the variation between groups arose because, in some groups but not others, lucky or inventive rats had discovered how to dive for molluscs, and passed on this handy trick to other members of their groups through social learning. in fact, bennett galef's research suggests that the group-typicality of mollusceating is due to ecological variation; the groups of rats that dive for molluscs live in areas where there are few alternative sources of food. therefore, it is likely that mollusc-eating in rats is driven by hunger, rather than enabled by social learning, and consequently that it does not amount to culture 2 . there is evidence of culture 2 in primates and other mammals (for example, dolphins, meerkats, mongoose, whales), fi sh and birds. some groups of chimpanzees use tools -to hunt invertebrates, crack nuts, or obtain water -which are not used by other groups of chimpanzees. coral reef fi sh socially learn where to mate, and local populations use distinct mating sites over generations. new caledonian crows show regional variation in the construction of leaf tools used to spear and hook grubs, and, in the most rigorous and extensive research on culture 2 , songbirds have been found to develop distinct regional dialects through social learning. in most species, there is evidence of culture 2 relating to just one behaviour -for example, mating site selection, leaf-tool making or song dialect -but fi eld studies, where there is limited potential to control for ecological variation, suggest that some groups of great apes have multiple traditions. for example, carel van schaik and colleagues have identifi ed more than 20 behaviours -including 'kiss-squeak' gestures and creative uses of leavesthat vary across groups of orangutans in borneo and sumatra. culture 2 tends to be used when the purpose of enquiry is to fi nd out about the origins of human culture. like users of culture 1 , researchers who defi ne culture as socially learned group-typical behaviour may have a broad interest in the evolutionary consequences of social learning. however, the primary function of culture 2 , as a scientifi c instrument, is to identify behaviour in nonhuman animals that may illuminate the phylogenetic and ecological, social and cognitive factors that have produced the rich potential for group-typical behaviour, belief and technology found in our species. i shall turn now to culture 3 . the terms 'cumulative culture' and 'cumulative cultural evolution', which are used interchangeably, have become increasingly prominent since the 1990s. these terms suggest that social learning can not only produce behavioural variation between groups (culture 2 ) but improve behaviour over generations. you learn a certain knot from me, you discover an even better way of tying that knot, and the agents who learn from you inherit your improved method. more formally, alex mesoudi and alex thornton recently listed four minimum requirements for cumulative culture or, as i am calling it, culture 3 : "(i) a change in behaviour (or product of behaviour, such as an artefact), typically due to asocial learning, followed by (ii) the transfer via social learning of that novel or modifi ed behaviour to other individuals or groups, where (iii) the learned behaviour causes an improvement in performance, which is a proxy of genetic and/or cultural fi tness, with (iv) the previous three steps repeated in a manner that generates sequential improvement over time" (mesoudi and thornton, 2018, p.2) . some cultural evolutionists, such as claudio tennie, believe that culture 3 is uniquely human, while others argue that the regional variation in tool-use behaviour of great apes and corvids (see above) meets mesoudi and thornton's criteria. some of the most striking experimental evidence of cumulative culture comes from work on pigeons. takao sasaki and dora biro found that homing pigeons can improve their skills by fl ying with a more experienced bird, and when they are put in transmission chains -where, after each novice has become an expert, it is paired with a new, naïve bird -homing performance improves over re-pairing generations (figure 2) . two subtly different explanatory projects motivate research on cumulative culture or culture 3 . one of them, the anthropocentric project, also inspires research using culture 2 . this project aims to explain notable human achievements -from the control of fi re and the construction of kayaks, through knowledge of quantum physics to exploration of mars -and to identify forerunners of the relevant capacities in other animals. some researchers pursuing this anthropocentric project, often identifi ed as evolutionary psychologists, ascribe impressive human achievements primarily to the brilliance of individual human minds ( figure 1c ). they acknowledge that we pool our skills and discoveries, but see the features of individual minds, rather than the interaction of minds, as the secret of our success. in contrast, many cultural evolutionists -those interested in culture 2 and culture 3 -believe that our achievements are fundamentally collective; we have been able to thrive in a wide range of environments, and to make radical changes to those environments, primarily because we work together, learning from one another. the other explanatory project, the cultural selection project, relates specifi cally to culture 3 , to cumulative culture. this project, also pursued by people who identify as cultural evolutionists, asks whether darwinian selection occurs in the cultural domain, whether 'cultural selection' occurs in any species. specifi cally, it asks whether behavioural adaptation at the population level can occur via a process in which variants are generated by mistake or trialand-error learning rather than mutation, and inherited through social interaction rather than genetic mechanisms, and where selection depends on the bearer's success in passing on their variant to biological offspring and to unrelated individuals via social learning -to 'babies' and to 'students'. the cultural selection project is also known as the 'third way project' because two routes to population-level behavioural adaptation are already wellknown. first, in human and nonhuman animals, the fi t between a population's r1248 current biology 30, r1233-r1255, october 19, 2020 ll behaviour and the environment in which it occurs can be enhanced by genetic evolution. for example, natural selection acting on genetic variants is the primary architect of web-spinning in spiders. second, at least in humans, the fi t can also be improved by what daniel dennett calls 'intelligent design' -by the foresight and planning of individuals and groups. intelligent design is what many evolutionary psychologists take to be of overriding importance. for example, confronted with the threat of covid-19, governments across the globe anticipated what its effects would be, planned methods of mitigating the effects using scientifi c evidence, and attempted to change people's behaviour by implementing those plans via a range of institutions. the cultural selection, or third way, project asks whether there is another way in which the behaviour of a population can become adapted: a process that, in contrast with genetic evolution (the fi rst way), selects among socially learned rather than genetically inherited variants, and, in contrast with intelligent design (the second way), where the adaptiveness of the selection does not depend on individuals or groups being smart enough to design novel solutions or to recognize what works and what does not. the anthropocentric and cultural selection projects can be diffi cult to tell apart. many cultural evolutionists are interested in both projects. some of these cultural evolutionists get their wires crossed, and others, in an entirely coherent way, see cultural selection as the answer to the anthropocentric question; as the thing that explains distinctively human achievements. but the differences between the anthropocentric and cultural selection projects, although rarely recognised, are important. specifi cally, the anthropocentric project is compatible with the assumption -widely held since the enlightenment and backed by evolutionary psychology -that humans are able to do remarkable things because each of us is smart. in contrast, the cultural selection project raises a radically new possibility. it suggests that many of our striking achievements, and those of other animals, depend on each of us being pretty dumb; that wisdom comes from the population-level process of cultural selection, rather than the workings of individual minds. to see how this counter-intuitive idea could be true, imagine a population of animals where two different twig types are used to extract edible grubs from tree trunks -fat and straight twigs (a) or thin and bent twigs (b) -and juveniles socially learn which type to use. the juveniles' social learning (mesoudi and thornton's second requirement for cumulative culture), and any subsequent improvement (third requirement), could be foresighted or short-sighted. in the foresighted case, each juvenile might decide whether to adopt a or b after careful comparison of the number of grubs procured by models using a and b, and any improvement might be based on deep thought about where the grubs tend to be located within the trees, and the causal powers of different twig types. the foresighted social learner is rodin's thinker. in the short-sighted case, whether a juvenile adopts a or b might be determined by who she happened to see just before she made her fi rst attempt to secure a grub. if she saw an a-user she selects an a-type twig, and if she saw a b-user she selects a b-type twig. whether her attention was caught by an a-user or b-user may, in turn, have depended on how many grubs each actor was securing. after all, hungry animals pay close attention to food and therefore see other objects and events in its vicinity. but in the short-sighted scenario, juveniles do not compare the number of grubs produced by a-users and b-users. their choice of models is determined by what or who grabs their attention rather than clever strategies. upper panel: in each chain of the experimental group, a single pigeon (red) was fi rst released from the same site 12 times, then partnered with a naïve bird (orange) and fl own as a pair a further 12 times. the fi rst bird was then replaced by a third bird (yellow) and this new pair (orange-yellow) was released 12 times. this procedure was repeated until the fi fth-generation naïve bird (purple) was added and fl own a fi nal 12 times. in the control groups, single pigeons (solo) and fi xed pairs (pair) were released the same number of times as the experimental group (60 fl ights). lower panel: linear mixed-effects model fi tted to the fi nal fl ights of each generation for all three treatment groups. over generations, route effi ciency continued to increase in the experimental group but quickly plateaued in the solo and pair groups. (data from sasaki and biro, 2017.) ll it depends on simple attentional mechanisms found throughout the animal kingdom, not on causal reasoning, planning or metacognition (thinking about thinking). similarly, in the short-sighted scenario, if a juvenile improves the socially-learned method -for example adopts b and then begins using twigs bent in, not one, but two places -she does it by trial-and-error. she does not have mental models of the location of the grubs in the tree trunk, or of the causal powers of twigs, she just has a go with a range of twigs that are similar to the b-type -the type she learned from her model -and settles on the variant that works best for her. if the foresighted learner is rodin's thinker, the short-sighted learner is wash 'n' go. now, for the anthropocentric project it does not matter much whether the requirements for cumulative culture are met through foresighted or short-sighted cognitive processes. in either case, the resulting improvement can be chalked up as an instance of the collective intelligence that makes humans special, or as an evolutionary precursor of that 'specialness'. if the processes are foresighted, the cultural evolutionists' view is similar to that of evolutionary psychologists -the intelligence of individuals is crucially important -but the cultural evolutionists' perspective is still distinguishable from a standard evolutionary psychological view to the extent that it emphasises the importance of social learning ( figure 1c ). in contrast, for the cultural selection project, the difference between foresighted and short-sighted processes is crucial. insofar as the requirements for cumulative culture are met by foresighted cognitive processes, they indicate not cultural selection (the third way) but intelligent design (the second way). if cumulative culture is critically dependent on foresight, a version of the enlightenment view of humanity is vindicated. the secret of our success lies in the intelligence of individuals, on each of us being rodin's thinker, even if that intelligence requires networks of minds, across time, to meet its full potential. the alternative -dependence of cumulative culture on shortsighted cognitive processes -would support a much more radical view. it would suggest that some of the most impressive achievements of humans, and other animals, depend on individuals being dumb rather than smart -willing to copy the behaviour of others in wash 'n' go style, with minimal assessment of the behaviour's utility. the cultural selection project raises the possibility that complex cognitive processes are fruits rather than seeds of culture. in the past it has been widely assumed that culture 2 and culture 3 require social learning based on fancy, foresighted cognitive processes -for example, a capacity to copy the fi ne details of body movements ('imitation'), to understand models' intentions ('theory of mind' or 'shared intentionality'), and to weigh up the pros and cons of copying one model rather than another ('social learning strategies'). in other words, it was assumed that complex cognitive processes are the seeds of culture; once they have evolved in a lineage, via genetic inheritance, there is the potential for signifi cant regional variation in behaviour (culture 2 ) and for improvement of socially learned traits over generations (culture 3 ). the cultural selection project makes clear that this need not be the case. cultural selection could produce culture 2 and culture 3 without complex cognition. adaptation via cultural selection, like adaptation via genetic selection, requires offspring to be similar to their parents, and a tendency for more effective variants to be copied more often than less effective variants, but it does not require these conditions to be met via complex forms of social learning. apart from their homing skills, pigeons do not seem to be especially smart. therefore, cumulative culture in pigeons ( figure 2 ) provides a proof of principle that culture 3 can get off the ground without the involvement of complex cognition such as imitation, theory of mind, and strategic thinking. further evidence comes from the dolphins of shark bay, western australia, where there are signs that a spongebased foraging technique, learned in a cognitively undemanding way by juveniles from their mothers, is evolving via cultural selection. so, if complex cognitive processes are not the seeds of culture, is it just a coincidence that humans are both smart and heaving with culture? do our capacities for imitation, theory of mind and other complex cognitive processes have nothing to do with our outstanding diversity (culture 2 ) and propensity to improve socially learned behaviour over generations (culture 3 )? that seems very unlikely, but an alternative solution to the puzzle is emerging: recent research on the childhood development of imitation, theory of mind, and other complex cognitive processes suggests that -like beliefs, preferences, technologies and social conventionsthese cognitive processes are products of culture; fruits rather than seeds of cultural selection. for example, recent studies have shown that newborn humans cannot imitate; imitation is not 'in our genes'. instead, the cognitive mechanism enabling imitation is built in the course of childhood through social interaction with parents and other expert imitators, and, at the population level, the imitation mechanism was shaped to do its job by cultural selection; it is a product of cultureculture coevolution. but if this is true of imitation and other distinctively human cognitive mechanisms, if they are fruits rather than seeds, then what are the seeds? what determines whether a lineage, capable of generic but not fancy social learning, develops group-typical behaviour (culture 2 ) or cumulative culture (culture 3 )? modelling of archaeological and anthropological data, and studies of nonhuman primates, suggest the answer is social factors. rather than cognitive factors, the social structure of a species (for example, how long juveniles spend in close proximity to their parents), and demographic variables (for example, the size of social groups and their spatial distribution) have a major infl uence on the probability that culture 2 and culture 3 will emerge. for example, it is possible that cultural selection of knowledge and skills can get started only in species where young learn almost exclusively from their parents and cultural fi tness depends on biological reproduction. similarly, it is possible that cultural selection of knowledge and skills can only take off -become so important that it supports the cultural selection of complex, specialised cognitive mechanisms -when populations are so large that there is minimal risk of experts being wiped out by epidemics, confl ict, and climatic events. ll r1250 current biology 30, r1233-r1255, october 19, 2020 © 2020 elsevier inc. culture has infl ated. in the time frame of kroeber and kluckhohn's work, 70 years ago, the idea that culture can be equated with social learning (culture 1 ) is relatively new, and socially learned grouptypical behaviours (culture 2 ) used to be called 'traditions' rather than culture. consequently, increasing use of the term 'cumulative culture' (culture 3 ), along with mesoudi and thornton's heroic efforts to defi ne it, are attempts to protect two signifi cant explanatory projects: to work out what makes human lives so unusual (the anthropocentric project), and to fi nd out whether darwinian evolution occurs in the cultural domain (the cultural selection project). recent research with these aims suggests that social rather than cognitive factors play a dominant role in the emergence of cumulative culture. we humans are smart because we are cultured, rather than cultured because we are smart. understanding the multiple factors governing social learning and the diffusion of innovations the cultural evolution of cultural evolution chimpanzee ethnography reveals unexpected cultural diversity what's social about social learning? who knows? metacognitive social learning strategies cognitive gadgets: the cultural evolution of thinking enquire within: cultural evolution and cognitive science cultural evolution: conceptual challenges what is cumulative cultural evolution? cumulative culture can emerge from collective intelligence in animal groups afterword: tough questions the reach of gene-culture coevolution in animals long-term decline in survival and reproduction of dolphins following a marine heatwave local motion in a visual scene allows the detection of prey or predator and predicts their future positions. relative motion segregates objects and reveals their 3d relationships. 'optic fl ow'the motion of texture across the fi eldguides locomotion and balance. given these several uses of visually perceived motion, it is unsurprising that many species have evolved hard-wired neural mechanisms to extract motion as a primitive feature of the visual world [1]. in the cortex (e.g. [2-4]), and even the retina [5], of primates, cells are found that respond selectively according to direction of motion. in visual areas v1 and mt, some directionally selective cells are also tuned for the second attribute of motion, speed [3] . it might be thought that the brain derives a single velocity signal from the activity in this population of neurons -since speed and direction must often be combined to predict an object's future position or to derive a 3d structure. however, we report here a striking difference in discrimination of the two attributes: thresholds for direction, but not those for speed, increase with the spatial separation of the stimuli.several previous fi ndings hint that direction and speed may be differently computed. for example, direction discrimination is poorer for oblique than for cardinal directions, but this is not the case for speed [6] . also, speed discrimination for arrays of random dots is of similar precision whether the two arrays move in the same, in opposite or in orthogonal directions [7] . and transcranial magnetic stimulation, applied medially, is reported to impair speed discrimination disproportionately relative to direction discrimination, under conditions where the physical stimuli and their discriminability were similar [8] . in the present experiment, we asked how the precision of discriminating speed or direction changed as the spatial separation of the discriminanda increased. the stimuli were pseudo-random arrays of moving dots, briefl y presented ( figure 1a ). they fell on an imaginary circle (radius: 5 degrees of visual angle) centred on the fi xation point [7] . the spatial separation of the two arrays varied between blocks and had a maximal value of 10 degrees of visual angle, while their eccentricity remained constant.in alternating runs, we measured the discrimination of the two attributes. in both cases, the participant's task was chosen to be the simplest possible: detection of the presence of a difference. in one of two intervals ( figure 1b) , the two arrays moved in the same direction and at the same speed; in the other, they differed in speed or in direction according to the condition tested. an adaptive procedure estimated the stimulus difference that supported 79.4% correct (see experimental procedures in supplemental information, published with this article online). the reference speed at which discrimination was measured was 5 deg.s -1 and the reference direction was 135° from vertical (4.30 o'clock).normalised average thresholds for 10 participants are shown in figure 1c as a function of the spatial separation of the two arrays of moving dots. a striking difference is seen between the results for discrimination of direction and for discrimination of speed. thresholds for detecting a difference in direction (open circles) increase systematically with the spatial separation of the two arrays (one-way repeated measures anova (after greenhouse-geisser correction): f(2.739,24.652) = 18.44, p < 0.001). in contrast, thresholds for speed (closed circles) vary little with separation, a result we previously found for discrimination of spatial frequency. in fact, a one-way repeated measures anova with greenhouse-geisser correction does show a marginally signifi cant effect of separation (f(3.181,28.628) = 3.414, p = 0.029), owing probably to the higher thresholds for abutting arrays. the latter effect correspondence key: cord-271853-wexe9gq0 authors: lu, quan; cai, zehao; chen, bin; liu, tao title: social policy responses to the covid-19 crisis in china in 2020 date: 2020-08-14 journal: int j environ res public health doi: 10.3390/ijerph17165896 sha: doc_id: 271853 cord_uid: wexe9gq0 the 2020 coronavirus pandemic has catapulted china into a serious social and political crisis. this article focuses upon how chinese social policy has responded to the covid-19 crisis. it reveals that the chinese welfare state has woven a comprehensive social safety net to mitigate the social suffering of chinese society in the midand post-crisis periods. different types of social policy programs have been combined and synthesized, including social insurance, social assistance, and social welfare arrangements. facing the challenges of the new risks caused by the pandemic, the collaboration of the chinese state and intermediary social welfare organizations has played a crucial role in providing both cash benefits and social services (benefits in kind). for the first time, social policy in china has acted as a major player for coping with the negative outcomes of a pandemic. this article concludes that the pandemic-related crisis has justified an interventionist approach and logic, driven by the state’s welfare system, which favors a model of “big government”. however, this model also requires justification and legitimation. the covid-19 pandemic represents the most serious public health crisis in china since the founding of the people's republic of china (prc), with the fastest spread and the widest infection range, challenging the country's socioeconomic development and people's daily life. facing these challenges, chinese governments have established strong command-and-control mechanisms, reminiscent of war times, to respond to this crisis and control the virus [1] . these measures appear to have worked sufficiently, and the pandemic in china seems to have been brought under control. the central government has played a proactive role by issuing a number of key policies in the field of social security, effectively relieving the anxiety of patients infected with covid-19 and their families from the financial burden of medical treatment, and also fully mobilizing social resources to effectively support the resumption of work and production. china has witnessed a rapid expansion of social security programs over the past decades, especially since 2000, and has established the world's largest comprehensive social protection network [2] . currently, the social security system in china consists mainly of three types of social programs: contributory social insurance, non-contributory social assistance, and tax-financed social welfare. employment injury insurance, and maternity insurance, and all of these programs are extended to urban employees. at the same time, it also includes basic pension insurance and basic medical insurance for urban and rural residents who do not fall under the category of urban employees. according to a report released by the ministry of human resources and social security, the total number of persons covered by pension insurance is 943 million (419 million are urban employees and 524 million are urban and rural residents). the total number covered by medical insurance is 1.344 billion (317 million are urban employees and 897 million are urban and rural residents). more than 95 percent of chinese citizens are covered through this program. medical expenses in conformity with the drug catalogue, diagnosis and treatment items and medical care service facility standards for medical insurance and medical expenses for emergency treatment or rescue are paid from this program. the current reimbursement rate is around 60 percent of the total expenses for insured urban employees and about 50 percent for insured urban and rural residents. further, at the end of 2018, 196 million employees had been covered by unemployment insurance, 239 million employees had been covered by work accident insurance and 204 million employees had been covered by maternity insurance. for china's social assistance system, the most important program is the minimum living standard scheme (mlss, known as dibao), which covers residents whose per capita income/annual net income falls under the threshold of the local minimum living standard in both urban and rural areas. according to the statistical report on the development of civil affairs issued by the ministry of civil affairs in 2019, 10 .07 and 35.02 million people received benefits from the mlss in urban and rural areas, respectively. in addition, medical assistance, educational assistance, housing support, legal assistance, and a relief system after natural disasters are also important ingredients of china's social assistance system. the country's social welfare program provides funds and social care services to ensure the livelihood of the elderly, children, and persons with disabilities who experience extraordinary difficulties [3] (see figure 1 ). however, interventions through social protection policy and questions that must be reconsidered in relation to disease-related crises have been largely neglected in academic research. therefore, this article will specifically analyze how different types of current social security programs have responded to the outbreak and the outcome of the pandemic-related crisis and highlight the however, interventions through social protection policy and questions that must be reconsidered in relation to disease-related crises have been largely neglected in academic research. therefore, this article will specifically analyze how different types of current social security programs have responded to the outbreak and the outcome of the pandemic-related crisis and highlight the shortcomings of these measures. the remainder of this article is organized as follows. section 2 constructs an analytical framework for the study. section 3 presents the research findings, including reflections on policies in areas such as unemployment insurance, welfare institutions, social insurance, and social assistance. section 4 offers a discussion and concludes the paper. within modern capitalist welfare systems, social policy is considered an institutional response to the negative effects of free-market competition and the rising and contingent risks that occur during market fluctuation [4] [5] [6] . in particular, state-organized social protection programs have corrected the primary distribution mechanism, mitigating social problems in the capitalist market economy. social policy dovetails with the long-term institutional policy intervention by welfare states in the field of production and reproduction [7] , having been established in the continuing transformation of the capitalist economy from a laissez-faire model to a market economy increasingly regulated by welfare states [8] . although the formation of modern state-organized social policy represents a long-range transitionary process, it is necessary to take another aspect of social policy into consideration-the social policy and social protection adopted and stimulated by short-term events and shocks. in particular, special attention should be paid to social crises and socially and economically anomic developments that deviate from the state of social normality, challenging and jeopardizing regular and consistent socioeconomic development within a short-term or medium-term period [9, 10] . social crises often alter the "normal" state of a society, creating a critical juncture posing an acute threat to the status quo of the current social and political system. the nexus between crises and social policy has not been investigated sufficiently in academia. commonly, crises have been regarded as negative events that can overshadow the regular functioning of welfare states, causing dysfunctionality and disruption of the existing social order. moreover, historically, social crises are closely related to welfare state retrenchment. for instance, the oil crisis in the 1970s and the subsequent stagflation in the western world had precipitated the end of the golden age of capitalism and the postwar economic boom, resulting in the reduction of social expenditures during the reagan and thatcher administrations [11, 12] . however, the intuitive assumptions concerning the nexus between crisis and welfare retrenchment have been upended by empirical developments in various welfare states and welfare regimes. usually, social crises have increased the suffering and the poverty gap in a society and precipitated social protests and social turmoil, challenging the current social political order and endangering the legitimacy of governments. against this backdrop, many state administrations have been inclined to expand public revenues and state social investments to circumvent social disorder and sharply increasing social and economic problems. in some cases, crises have fostered new opportunities for the extension of welfare state intervention and the expansion of social protection programs. conflict theories have generally verified that social conflicts such as social protests, social movements, and struggles among different social classes for resources have benefited and accelerated social policy expansion in welfare states [6, 13] . social crises represent a special type of social conflict. during the outbreak of crises, social conflicts usually intensify, social grievances are raised, and the battle among different social classes for subsistence and resources escalates. all this tremendously jeopardizes social cohesion; thus, social and political responses are urgent for the survival of governments. if governments do not act in time, social discontent may transform into destructive protest. for instance, the roosevelt-administration initiated welfare state arrangements in the united states in the 1930s after the shocking (after-) effects of the great depression began to unfold [14] . hort and kuhnle have verified empirically that after the asian financial crisis of 1997-1998, social expenditures in the region of east and southeast asia were not reduced as usually assumed; on the contrary, in nearly all of the 10 selected examples in this region, social protection programs remarkably expanded, during and even after the crisis [15] . these counterexamples demonstrate that crises do not always cause austerity and the state's retreat from public investment. under certain conditions, crises and the subsequent pressure imposed upon governments may unintentionally become driving forces for elite groups to change and respond to critical demands from society. in other words, the suffering during periods of crises can be transformed into positive assets for welfare state extension and expansion. this paradoxical development concerning welfare expansion during economic crises has also been traced in the developmental trajectory of the korean welfare state [16] . historical examples, along with the current pandemic crisis in 2020, have unveiled a trend in which state administrations from various countries are inclined to expand their capacities and intensify state intervention in society to lessen social tensions and calm the social discontent and public anger emerging from the outbreak of crises. in major global crises, such as the great depression, the global financial crisis of 2007-2008, as well as the covid-19 crisis, "big government" represents a model for coping with social problems and social conflicts [17] ; accordingly, the myths of market omnipotence and neoliberal ideology have been substantially diluted [18] . counter to assumptions concerning the retreat of welfare states, these substantial crises have strengthened the power of the state, disenchanting the "laissez-faire model". facing a crisis of acute existential survival, ordinary working populations and residents, as well as enterprises short on liquidity must seek assistance and bailouts from the state. in turn, the state must devote considerable resources to society to ensure a threshold of existence. otherwise, widespread malnutrition or famine, or the demise of many small-and medium-sized enterprises, would very likely endanger the state's basic functioning, causing enormous loss of human resources and financial drain, and leading to danger and risk for the survival of the state itself. crises have provided stimuli for governments to assume the role of the ultimate guarantor and provider of public goods for their citizens. thus, crises are somehow related to "big government" and an active interventionist state. in the chinese case, the pervasive model of "big government" may shift rapidly into a quasi-war state to respond to crisis. however, many emergency measures and acts need special justification and legitimation, since personal freedoms and right of free mobility may be constrained, as they have been during the pandemic-related lockdowns and curfews. the social security system has been designed and built to cope with risks. however, the covid-19 pandemic is a sudden public health event, which by itself is a risk of a new type. it therefore brings substantial challenges to the existing social security system. during the covid-19 pandemic, china's social security system has largely functioned well in many aspects, but some serious problems have also been exposed that call for further improvement. this study applies the method of event analysis with a special focus on social and political responses to this special crisis event. the trajectory and chronological development of covid-19 from february through june of 2020 has been intensively observed and consequently integrated into our analysis of the social policy responsiveness to this crisis-related event. the pandemic-related crisis has been divided into three primary stages-the pre-crisis, during crisis, and post-crisis periods. regular social policy arrangements before the outbreak of covid-19 have previously been introduced. some hallmark subevents in the arena of chinese social protection during the outbreak of the pandemic and in the post-crisis period have been identified and analytically discussed and reflected, including policy measures and strategies adopted in the areas of health insurance, unemployment insurance, social assistance, and social welfare, among others. to complement our event-centered policy analysis, we have collected different kinds of secondary data such as policy documents and data published by the state administration, including the ministry of human resources and social security (mhrss) and the ministry of civil affairs (mca), which characterize the coping strategies of the chinese state and society in relation to covid-19. secondary documents issued by different state administration and public media have uncovered the urgency and exigency created by pandemic and presented an assemblage of emergency measures, formal and institutional policies implemented during the crisis. through the process tracing crisis-related events, using various data sources, we reconstruct the panorama of social policy responses to the critical juncture that chinese society experienced amid the pandemic. the impact of the covid-19 pandemic on employment might be short-term, but it is more serious and complicated than the situation of sars in 2003 [19] . therefore, helping enterprises to overcome difficulties is still an important measure to stabilize employment and the economy. governmental departments have formulated various policies for different regions and different types of enterprises to reduce social insurance contributions. for example, in hubei province, where the pandemic has been most severe, the government has exempted certain employers (except for the public sectors) from paying social insurance fees for no more than five months. for other regions, the social insurance contributions of large enterprises may be halved for a period of no more than 3 months, not exceeding 5 months for small-and medium-sized enterprises. finally, enterprises with difficulties in production and operation may apply for deferred payment of social insurance premiums for no more than 6 months. (the above contributions refer to the portion paid by the employer; payments by individuals must be made on time. it is noteworthy that none of the above policy adjustments affect personal entitlements.) using unemployment insurance to help employers and reduce the unemployment rate is another important measure. specifically, for small-and medium-sized enterprises, if the unemployment rate is not higher than that in the national survey of the previous year, part of the unemployment insurance benefits may be refunded to stabilize employment. meanwhile, enterprises were encouraged to implement training programs for those affected by the pandemic, which could be subsidized if they organized employees to participate in offline or online vocational training during the shutdown period. according to a spokesperson from the ministry of human resources and social security, the pension insurance, unemployment insurance, and employment injury insurance contributions reduced in february reached 123.9 billion yuan ($17.5 billion). the total amount of deductions in contributions from february to june was estimated to be more than 500 billion yuan ($70.6 billion), effectively supporting the resumption of work and production. at the same time, 1.46 million enterprises received unemployment insurance refunds, amounting to 22.2 billion yuan ($3.1 billion), benefiting 49.51 million employees [20] . notwithstanding the achievements outlined above, some problems have also been exposed with regard to supporting enterprises by fully utilizing unemployment insurance policy. the functions of the unemployment insurance system are twofold: one is to maintain the basic livelihood of the unemployed and their families, and the other is to actively create conditions for their reemployment through professional training, job referrals, and other means. at present, the main function of this system in china is to maintain the livelihood of the unemployed; however, the promoting and preventing functions have not been fulfilled. it is mandated that employees shall participate in unemployment insurance, and the premiums should be jointly paid by employers and employees; however, statistics reveal that the number of people participating in this insurance program stands at 196 million, accounting for only 45 percent of urban workers. this is the lowest insured rate among all types of social insurance, because a large number of migrant workers and informal employees are not included in this program. at the same time, the cumulative balance of unemployment insurance funds reached 581.7 billion yuan ($82.1 billion), 6.4 times of its expenditure of 91.5 billion yuan ($12.9 billion) in 2018 [21] . in other words, even if unemployment insurance fees are no longer collected, the funds can still be used for more than 6 years, suggesting that the amount of cash benefits paid out is low, and other unemployment benefit programs should be added. it is worth noting that, in this pandemic, some companies in china have adopted innovative forms of employment such as "shared employees", with individuals working in multiple companies at the same time, to reduce their own expenditure burden by lowering wages and/or not paying social security fees; however, the government has also required these companies to reduce the layoff rate and pay basic wages. therefore, a responsibility-sharing mechanism should be established to finance the expenditures. in this sense, the unemployment insurance funds can shoulder the task by paying a portion of the wages for workers who have not returned to work, and thereby reducing the burden on the enterprise. these measures will better allow the enterprises to weather the storm. the practice of the unemployment insurance system has exposed another problem: according to current regulations, insured persons will not be qualified to receive unemployment insurance benefits after being laid off, unless they have contributed to the system for no less than one year. in the pandemic, a new special policy has been introduced to provide unemployment subsidies for laid-off employees who have contributed for less than one year. however, this subsidy is lower than the usual unemployment insurance benefits. we believe that the special policy should become part of the formal unemployment insurance system and be incorporated into the current regulations. welfare organizations, such as nursing houses for people in need, tend to be higher-risk areas in terms of emergency management, as these are places where elderly people, dependent children, people with disabilities, etc., live in close quarters. in the event of emergencies (including the covid-19 pandemic), high-density living spaces and collective actions cause a chain reaction of infection, making residents even more vulnerable [22] . indeed, specific demographic groups living in welfare organizations are susceptible to covid-19 because of their underlying health conditions, making special protection policies during the pandemic more significant and urgent than ever. in the early stages of the areas with high incidence of covid-19 in china, there were clustered cases within nursing homes. on 21 february 2020, according to the notice of the wuhan civil affairs bureau, as of february 19, social welfare agencies in wuhan had a total of 12 confirmed cases; 11 were elderly residents (including one deceased) and one employee [23] . in response to this, the relevant departments implemented three measures: (1) several anti-pandemic guidelines were issued for different types of welfare agencies based on the risk level of the region, followed by stricter closed management for these agencies to accommodate the elderly, persons with disabilities, and their service staff. (2) cross-regional caregivers were arranged to provide necessary support. there were more than 20,000 elderly residents in the old-age care agencies in wuhan, but only 3000 local care staff. in addition, some of these caregivers were infected or self-isolated, so there was a shortage of care staff in general. thus, the ministry of civil affairs of the central government coordinated cross-regional care and nursing staff to offer support to wuhan [24] . (3) care services for stay-at-home elderly residents whose families were isolated and/or sick were provided. daily life became more complicated for elderly residents living alone due to the pandemic, and their routine caregivers were not always available to serve in a timely manner. moreover, some caregivers were being treated or medically isolated because of the pandemic, which forced vulnerable groups to stay at home. to address this situation, welfare agencies would provide door-to-door services or arrange for these residents to be cared for in-house. however, the protection for some caregivers and volunteers in this case was, to some extent, less focused. in the process of prevention and control of the covid-19 pandemic, in addition to medical workers, some volunteers were infected or even passed away at work, but technically, volunteers cannot be identified as beneficiaries of work-related accident benefits; similar cases also applied to caregivers as informal workers without work-related accident insurance. therefore, establishing a social compensation system is necessary. social compensation refers to the compensation by the state and society for the loss of interests (physical disability or a sharp decrease in income, and so on) of relevant stakeholders, when is caused by uncontrollable risks (such as natural, societal, or policy-related events). germany and the taiwan region have built relatively complete social compensation legal systems, but mainland china has not yet established such a system. unlike the civil compensation caused by torts, the administrative compensation brought by wrong administrative acts and state compensation brought by judicial misconduct, social compensation is mainly to pay for losses caused by wars, natural disasters, and other uncontrollable social risks. this includes not only compensation for the direct victims of such disasters, but also praise for the staff and volunteers involved in disaster relief. in china, the social insurance system is primarily composed of five sub-programs: medical insurance, employment injury insurance, unemployment insurance, pension insurance, and maternity insurance. the first three in particular have played a major role in providing economic support for the insured during the covid-19 pandemic. 3.3.1. medical insurance and related policies: programs that bear the brunt as mentioned above, there are two kinds of medical insurance system in china: one for urban employees, and the other for urban and rural residents other than urban workers. the former is paid by employers and employees (6 percent and 2 percent of wages, respectively), and the latter is paid by residents and subsidized by the government (in 2020, the individual contributions are 280 yuan, and the central and local financial subsidies are not less than 270 yuan). the medical insurance fund is principally used for in-hospital and substantial medical expenses of the insured, and the current average reimbursement rate is more than 70 percent of the total expense for urban employees, and around 60 percent for urban and rural residents who participate in the scheme. effective medical security measures, mainly medical social insurance, were taken in a timely manner during the covid-19 crisis in china, so that patients and their families are relieved from worrying about treatment costs, specifically: (1) shortly after the outbreak, the state issued a policy to include drugs and medical services for the treatment of the new coronavirus as part of the payment range for the medical insurance fund. (2) furthermore, the personal medical burden is borne by fiscal resources of the government, thus achieving free treatment for patients with covid-19. the policy was initially limited to confirmed cases, but was later expanded to suspected ones. (3) simultaneously, when people seek medical treatment within one's coordinated areas of the social medical insurance fund, it is mandated that treatment must be provided first, with the fee to be settled later. (4) for medical institutions admitting a large number of patients, social medical insurance would prepay funds to ensure that the effectiveness of treatment from hospitals is not impaired due to payment policies. the above policies may be summarized as "two guarantees", first to ensure that no patient is rejected or treated in an untimely manner due to medical expenditure or cost problems, and, second, to guarantee that no designated medical institution is impaired from treating patients due to budget management regulations from the medical insurance fund. for foreign patients, if they have participated in china's basic medical insurance or any commercial insurance, their fee will be paid by the corresponding insurance funds; alternatively, they must bear the cost themselves. however, whether insured or not, medical institutions will treat first and charge later to ensure that everyone can receive medical treatment in time. the total cost of confirmed and suspected covid-19 cases in china was about 1.486 billion yuan ($0.21 billion) as of 6 april 2020. the per-capita medical cost of diagnosed inpatients reached 21,500 yuan ($3035), and of the severe ones, more than 150,000 yuan ($21,176). the medical insurance fund paid 990 million yuan ($139.8 million), accounting for 66.6 percent of the total medical cost. the total cost of diagnosed inpatients involved was 1.118 billion yuan ($0.16 billion), 746 million yuan ($105.3 million) of which was paid by the medical insurance fund, accounting for 66.7 percent. the total cost of the suspected patients was 368 million yuan ($52 million), with the medical insurance fund paying 66.6 percent of it (245 million yuan) [25] . overall, the medical insurance fund paid about two thirds of the total cost, and the remaining one third was borne by fiscal funds at various levels. however, these medical security measures were not without constraints. many of the medical security policies issued during the covid-19 pandemic were interim measures, which made them difficult for some local medical funds to implement in an orderly fashion [26] . one question yet to be clarified concerns the ultimate responsibility for payment: between public finance and the medical security fund, which one should eventually bear the medical expenses, or how they should be shared on the basis of specific principles? that is, in this pandemic, the medical security funds and fiscal funds work together to provide free medical care to patients. however, according to the social insurance law (the third paragraph of article 30), the basic medical insurance funds should not pay expenses that should be borne by public health funds. therefore, it is necessary to rethink the relationship between public finance and medical security funds in major pandemics like covid-19. to address this problem, the first step is to take the perspective of the comprehensive process of public health emergency management. according to china's emergency response law, the emergency management process includes four phases: prevention and preparation; monitoring and early warning; rescue and disposal; and rehabilitation and recovery. on the one hand, the beneficiaries of the public health funds include the entire population, so these funds should be mainly used in the prevention and preparation phase, for vaccination, tracking, and service provision for people who test with underlying health conditions. on the other hand, medical insurance helps diversify risks among insured persons, so it should mainly target the medical expenses of patients. furthermore, the impact of major public health events on different regions is often disproportional. according to the latest information, among 84,614 confirmed cases recorded nationwide, 68,135 were diagnosed in hubei province, accounting for more than 80 percent of the total cases. however, at present, the overall planning level of medical insurance funds in china is only at the municipal level, inevitably resulting in a larger burden of medical expenses in areas with severe pandemics, which cannot be shared on a larger scale. faced with such a contradiction, limited by the reality of the situation, medical insurance cannot achieve national pooling in a short period of time; it is still necessary to establish a sharing mechanism between the medical insurance and the public finance for medical expenses, especially in areas with severe pandemics. the responsibility-sharing mechanism between public finance and the medical insurance system also concerns the issue of due beneficiaries, or more specifically, foreigners in china and chinese students overseas. for foreigners in china, as long as they have participated in medical insurance, they are entitled to benefits; and if they also fulfill their tax obligations, they should also benefit from public financial subsidies. for overseas students, in the context of the global spread of the covid-19 pandemic, a large number of students want to return to china. in response, the chinese government has issued a policy stating that if they return, they will be responsible for their accommodation and boarding expenses during the period of quarantine. whether their medical expenses will be paid depends on whether they have participated in medical insurance. this practice is in line with the basic principles of medical insurance. however, if the medical expenses are mainly to be borne by public finance at the national level, these students should enjoy free treatment, regardless of whether they are insured or not, paying taxes or not. other insurance sub-programs have also contributed to the battle against the covid-19 crisis. as far as unemployment insurance and work-related injury insurance are concerned, although the contribution rates have continued to decline over the past five years, and the scope and level of expenditures have increased, the accumulated balances have continued to rise [27] . (there may be many factors contributing to the increasing accumulated balance. first, and likely foremost, more workers have participated in the social insurance system. according to the ministry of human resources and social security, the number of participants in the unemployment insurance system increased from 170.43 million in 2014 to 196.43 million in 2018. second, on the expenditure side, the total number of beneficiaries has remained stable, fluctuating around just above 2 million people during 2014-2018, despite the relatively higher level of benefits and larger scope of compensation projects for qualified insured persons. moreover, the level of overall planning in the unemployment insurance system has been low, reducing the efficiency of unemployment insurance funding, which also helps explain the situation. relatively developed regions usually enjoy more advantages in the labor market such as more local and immigrant workers, and thus more contributions to the unemployment insurance program, while unemployment rates are relatively low, in contrast to underdeveloped regions. these developed regions have contributed the most to the accumulated balance on a national scale, but this surplus cannot be properly shared by other regions if they are not in the same overall planning area.) this has provided a solid foundation for expanding expenditures related to the pandemic. employment injury insurance was adjusted in time to recognize and thus protect caregivers on the front line. to begin with, it was made clear that medical care staff and other related staff, who were infected with covid-19 or died from it in the course of their work to prevent and control the pandemic, would be recognized as work-related injuries cases, and their legitimate entitlements and interests would be protected. given that the covid-19 outbreak in china was mainly concentrated in wuhan, the central government mobilized medical care staff from other administrative areas to support wuhan city. from 24 january (a traditional chinese holiday, the eve of the spring festival) to 8 march, approximately 42,600 staff members from 346 medical teams across the country arrived in wuhan and hubei province to participate in medical treatment. however, as of 11 february, 1716 medical care staff, accounting for 3.8 percent of the national confirmed cases, had been confirmed as infected with covid-19 nationwide [28] . in addition, as of 8 march, 53 community workers perished in the line of duty during the epidemic prevention and control [24] . in order to ensure the basic entitlements for these employees, the relevant authorities opened a "green channel" to simplify the procedure for identifying work-related injuries. at the same time, if the requirements are met, deceased medical care staff and other pandemic prevention workers are eligible to be recognized as martyrs. according to the regulation on honoring martyrs, the state has established a reward system for martyrs. the reward standard is 30 times the per capita disposable income of urban residents in the previous year. meanwhile, the state grants preferential treatment to the survivors of martyrs to ensure that their quality of life is not lower than the average living standards of local residents, and the state will also provide support for their children's education and parents' pension. furthermore, the unemployment insurance system, by nature, works counter-cyclically in the sense of economics. as the pandemic caused a large number of enterprises to fail in resuming a timely production schedule, workers were thus unable to return to work, which adversely affected both the employers and employees. as a policy response, a series of regulations have been issued by various governmental departments to broaden the scope of beneficiaries. for insured persons who lost their jobs due to the pandemic in hubei and other pandemic-stricken areas, if they do not meet the basic requirements for receiving unemployment insurance (e.g., participating in and contributing to the insurance fund for no less than one year), they will be offered an unemployment subsidy. the standard is no higher than 80 percent of the local unemployment insurance premium, and it is only paid for six months. for those who had not contributed to unemployment insurance, the unemployment assistance benefit would be paid, in an amount equivalent to 120 to 150 percent of the social relief amount prescribed by the local civil affairs department, and the specific amount is determined by the provincial government. in most countries, social assistance acts as a bedrock and functions as a last resort of social protection, which aims to contribute to the prevention and alleviation of poverty. china issued the interim measures for social assistance (imsa) in 2014, which initially established a social assistance system consisting of the minimum subsistence security system and eight specific social assistance programs. (the eight specific social assistance programs include the minimum living standard scheme, the relief and support system for people living in dire poverty, medical assistance, educational assistance, housing support, legal assistance, a relief system after natural disasters and the temporary-assistance scheme.) with the target of "precise poverty alleviation" to be achieved in 2020, the goal of the social assistance system will shift from eliminating absolute poverty to alleviating relative poverty [29] . following the outbreak of the covid-19 pandemic, a range of social assistance measures were taken to guarantee a basic livelihood for the poor. during the period of epidemic prevention and control, vulnerable groups, such as families receiving subsistence allowances (i.e., the dibao households), low-income groups, vagrants, beggars, and workers who could not return to their workplace, encountered many difficulties as a result of regional closures, self-isolation, or quarantine. to address this situation, chinese civil affairs departments adopted a series of measures: (1) for the dibao households, the family means test could be carried out remotely, and the means test and dynamic adjustments could be suspended in areas with severe pandemics. (2) the amount of cash benefits for the impoverished increased. for instance, hubei province stipulated that 500 yuan ($70.6) should be added to the amount received by people in need in urban areas, and 300 yuan ($42.4) in rural areas. (3) temporary assistance would be given to those who have difficulty in life due to self-isolation, quarantine, or infection. (4) in principle, china's social assistance is mainly for people with local household registration (hukou). however, during the covid-19 outbreak, temporary accommodation, food, clothing, and other help was provided to non-local residents in need. despite the success in constraining the covid-19 pandemic, at present, one of the major problems with social assistance in china is that each specific sub-program is based on the minimum subsistence security system. in many regions, only those households with low-income are qualified to apply for benefits from other specific assistance programs. during the covid-19 pandemic, there were many laborers who could not return to their hometowns in time for the new year's holiday. urban residents' incomes dropped, and they experienced temporary difficulties due to their employers failing to resume work in time. these fragile groups are undergoing hardship and need temporary assistance. however, according to china's imsa, the objectives and standards of temporary assistance are not clear. in practice, it is mainly aimed at the homeless. but it should be also targeted at fragile groups whose lives have been severely constrained during major crisis events like the covid-19 pandemic. since china's social assistance is tied to local household registration, workers and residents from other administrative areas cannot apply, which may be reasonable under normal circumstances, but in the context of major emergencies, household registration restrictions should be softened. this scenario represents another problem in the existing social assistance system that has been exposed during the covid-19 pandemic. many people in need of social assistance benefits might not be living in their local household registration location, and thus cannot possibly apply in a timely manner. thus, it is crucial to reflect on the current social assistance system in china and extend social assistance benefits to all residents in the face of sudden public health events. furthermore, the current social assistance system operates mainly by providing cash benefits. however, in this pandemic, most communities have adopted the strategy of closed management, and cash benefits alone might not enable the beneficiaries to purchase goods or services in time. therefore, during the covid-19 pandemic, social assistance must provide in-kind benefits and services and ensure the basic livelihood of chinese residents. at the same time, special emphasis should be placed on employment assistance, as it helps people who have temporarily lost their jobs due to the pandemic become more employable as soon as possible and become self-reliant workers again. in modern society, social security systems represent an important institutional arrangement in responding to individual risks through collective organization. with the proper utilization of techniques and digitalization in public services, the efficiency and effectiveness of the social security can be substantially enhanced. first of all, a number of charitable organizations actively carry out various fundraising activities to make up for the shortage of public resources. during the pandemic prevention and control periods, charitable organizations fully utilized their advantages in terms of fundraising, social services, and mental health interventions. various foundations mobilized social donations and purchased pandemic materials for prevention, effectively making up for the lack of materials in some significant areas in the early stages of the crisis. as of 24:00 on 8 march, charitable organizations and the red cross system at all levels across the country had received about 29.29 billion yuan ($4.14 billion) in donations and donated about 522 million items [24] . among them, the wuhan red cross society (rcs) received more than 1.697 billion yuan ($0.24 billion) by 24:00 on 3 april, according to the announcement on its official website [30] . in addition, the closed management of residential areas in many regions brought great inconvenience into the daily lives of residents. many charitable organizations have launched services such as centralized purchase of daily necessities for residents and the provision of mental health counseling to help residents survive the pandemic period. in addition, efforts to promote and practice online activities not only improved the efficiency of the services, but also reduced the risk of pandemic spread. after the pandemic occurred, various social security agencies actively promoted online processing. business that previously was undertaken on a face-to-face basis could be moved online, thus reducing the crowding of people, the chances of infection for various fund-contributing companies, charitable organizations, etc. moreover, the efficiency and quality of such services were also improved. for example, the departments of human resources and social security announced an online application platform for claiming unemployment insurance benefits, notifying each recipient about their benefits online. it is believed that after the pandemic, more beneficiaries of social insurance will be accustomed to handling social security procedures or formalities online. nevertheless, looking back at the performance improvement of the social security system reveals some urgent and necessary adjustments. the larger and broader the impact of the public health emergency, the more actors are involved in the response, and more effective cooperation between different parties is required [31] . among them, the most important is the cooperation between the government and charitable organizations. as the third sector, charitable organizations can provide more precise, differentiated, and high-quality services. over the course of the pandemic prevention and control, charitable organizations not only demonstrated a strong capacity to draw resources, but also exposed problems such as insufficient credibility, untimely information disclosure, and unfair resource distribution. for example, the wuhan rcs did not distribute donated materials to hospitals in time, there was unfairness in the process of distribution, and the information about donated and distributed materials was not disclosed in time, all of which led to a wave of questioning by the public. charitable organizations in china are largely still immature; therefore, to strengthen their capacity, china should focus on the following three aspects: (1) strengthen the role of hub-type charitable organizations such as the charity federation, the rcs, etc., at all levels, and utilize them as a link between governments and charitable organizations to coordinate social resources in response to major public crises. (2) acknowledge the shift in charitable organizations' functions from financing to service provision. charitable organizations in china are currently divided into social groups, foundations, and private non-enterprise units. among them, foundations can both raise funds and provide social services; private non-enterprises can only provide social services and are unable to raise funds. in accordance with the principle of the social division of labor, it is recommended to establish a new pattern, with funds raised by foundations, professional services provided by social service agencies, and a connection between these two types of organizations through a bidding mechanism. (3) information disclosure should be well implemented. in the event of a major crisis, in particular, charitable organizations should promptly release information about fundraising and material distribution through various channels and accept public supervision. only in this way can public maintain confidence in charitable organizations. the unexpected and sudden outbreak of covid-19 in wuhan and its prompt spread nationwide have created a special situation and state of exigency and urgency, challenging the status quo of the socio-economic order within and outside hubei province. the crisis precipitated by the pandemic has quickly led to a critical juncture at which the chinese administration must quickly and effectively respond. the negative effects of the crisis have created strong pressure and an incentive for a quick administrative response and effective action in the part of the chinese state. the explosiveness and severity of the pandemic crisis and its unpredictable as well as astronomical social costs have strengthened the model of "big government" in the chinese case [32] , with massive state intervention in society and the economy. besides the usual intervention methods such as lockdowns, curfews, travel bans, the use of big data for tracing and breaking infection chains, the creation of health-related codes via smartphones, and nationwide mobilization of medical assistance for wuhan and hubei province, social policy intervention has also become especially relevant. in both the mid-crisis and post-crisis periods, we have observed an increase in social welfare and social protection programs. however, this topic has been largely neglected, both in academic research and public perception. social policy intervention is deeply connected with the social fact that modern society is a risk society [33] , and some social risks, such as environmental pollution and global warming, have evolved into global risks that challenge all nation states. social policy must circumvent new global risks like global pandemics, and the social protection programs of nation states must find an effective way to mitigate the social risks and hazards caused by newly emerging infectious diseases such as covid-19. these programs are not only targeted at national citizens, but also at international migrants such as tourists, foreign visitors, guest workers, etc. how modern social policy responds to pandemics has become a new and urgent research question for all nation states. the adopted social protection programs in china include a wide range of policy areas, such as health insurance, unemployment insurance, and accident insurance, among others. from the perspective of system types, we can differentiate social protection programs amid the covid-19 crisis into social insurance, social assistance, social welfare, and enterprise-related special subsidies and policy measures. existing social insurance programs, the mlss, and some special temporary policy arrangements have been combined to circumvent the sharp increase in social suffering. within the portfolio of different benefits, we have noted: (1) cash payments such as unemployment allowances and unemployment subsidies, benefits from the chinese social assistance program (mlss), ensuring the material security of millions of people and employees who have suffered from temporary layoffs, shortened work hours, or mandatory breaks imposed by employers; (2) benefits in kind, including service programs like testing, diagnosis, and therapy for covid-19 patients, free of charge, either financed by health insurance programs or subsidized by state revenues. also included are special social protection and social services for elderly people in nursing homes and social welfare units who constitute one of the highly vulnerable groups exposed to the virus; (3) favorable policy measures, such as the alleviation of income tax burdens and the granting of special loans for small-and medium-sized enterprises who face challenges in existential survival owing to a lack of liquidity because of the drastic freeze in economic and commercial activities. with regard to targeted welfare clients, we can also distinguish two types of program-individual-related and collective-related benefits. the first includes benefits that target individual demands, delivered to each citizen in case of need. the second is delivered to collective units such as households and enterprises. in sum, different interventionist forms, including monetary intervention, service-related intervention, policy-related intervention, and legal intervention have been combined and synthesized to help residents and social and economic units to traverse the "valley of tears" [34] amid the covid-19 crisis. the unprecedented covid-19 crisis has indeed stimulated rigorous state intervention in the areas of livelihood, welfare, and wellbeing for millions of people who have suffered directly and indirectly from its negative effects. as with various historical examples, the crisis derived from the coronavirus has stimulated public expenditures and a model of "big government". it has further legitimated hyper-normal and, in some cases, nationwide and large-scale extralegal intervention policy to lessen the intensity and severity of soaring social problems and escalating social conflicts. however, this kind of special intervention within and beyond the regular legal and institutional framework has also reached its limits, leaving many problems unresolved, such as the question of who should take responsibility for the medical treatment of residents that have dropped out from the regular health insurance system and who should finance diagnosis and therapy for overseas chinese and foreigners returning to chinese territory, and to what extent. the tacit problems of coverage loopholes in the chinese social security system have become explicit during the development of the crisis. even in cases of monetary compensation and intervention, impoverished residents or the unemployed who have received cash benefits, either from social assistance or from unemployment insurance, have been unable to purchase enough daily necessities and basic commodities due to the lockdown and curfew that has constrained the normal functioning of physical stores and brick-and-mortar businesses. charitable organizations have played a vital role in providing benefits in kind for individuals and families in need. ensuring material security and social safety encompasses more than one single area of social policy and requires much more coordinated policy intervention from different arenas, including economic policy, employment policy, fiscal policy, and social policy. coproducing responses to covid-19 with community-based organizations: lessons from zhejiang province the social protection system in ageing china china's social assistance: in need of closer coordination citizenship and social class and other essays vom armenhaus zum wohlfahrtsstaat: analysen zur entwicklung der sozialversicherung in westeuropa; campus: frankfurt am main the three worlds of welfare capitalism herausforderungen des sozialstaates; campus: frankfurt am main the political economy of the welfare state a grounded theory of construction crisis management fractal crises-a new path for crisis theory and management ending welfare as we know it (again): welfare state retrenchment dismantling the welfare state? reagan, thatcher and the politics of retrenchment toward a theory of social conflict america's welfare state: from roosevelt to reagan the coming of east and south-east asian welfare states the korean welfare state: a paradox of expansion in an era of globalisation and economic crisis global financial crisis and government intervention: a case for effective regulatory governance the financial and economic crisis of 2008: a systemic crisis of neoliberal capitalism impact of covid-19 on china's employment protection and social security system accelerate the implementation of periodic tax and fee reduction to stabilize employment how to revive 600 billion unemployment insurance funds with the benefit rate has been declining for ten years? available online evolution mechanism of safety accidents and rule of law path of risk management and control in old-age care institutions 12 confirmed covid-19 and 1 death in wuhan social welfare home. the beijing news epidemic prevention and control and livelihood security in civil affairs. china news the per-capita medical cost of patients with severe covid-19 exceeds 150000 yuan, being reimbursed in accordance with regulations reform and high-quality development of the medical security system with chinese characteristics social security fee reduction from the perspective of "tax wedge": fighting the epidemic and long-term reform national health commission. care for the health of medical staff and improve working conditions theoretical and policy focus of relative poverty: establishing a governance system for relative poverty in china innovation and development of national emergency management institution and mechanism in the new era bring back big government from industrial society to the risk society: questions of survival, social structure and ecological enlightenment crossing the valley of tears in east european reform . special thanks to two anonymous referees for their insightful, valuable, and very helpful comments, which contributed to improving the text significantly. the authors declare no conflict of interest. key: cord-102891-0z397ppn authors: wren, brandi; ray, ian s.; remis, melissa; gillespie, thomas r.; camp, joseph title: social contact behaviors are associated with infection status for whipworm (trichuris sp.) in wild vervet monkeys (chlorocebus pygerythrus) date: 2020-10-07 journal: biorxiv doi: 10.1101/2020.10.07.329409 sha: doc_id: 102891 cord_uid: 0z397ppn social grooming in the animal kingdom is common and serves several functions, from removing ectoparasites to maintaining social bonds between conspecifics. we examined whether time spent grooming with others in a highly social mammal species was associated with infection status for gastrointestinal parasites. of six parasites detected, one (trichuris sp.) was associated with social grooming behaviors, but more specifically with direct physical contact with others. individuals infected with trichuris sp. spent significantly less time grooming conspecifics than those not infected, and time in direct contact with others was the major predictor of infection status. one model correctly predicted infection status for trichuris sp. with a reliability of 95.17% overall when the variables used were time spent in direct contact and time spent grooming others. this decrease in time spent grooming and interacting with others is likely a sickness behavior displayed by individuals with less energy or motivation for non-essential behaviors. this study highlights the need for an understanding of a study population’s parasitic infections when attempting to interpret animal behavior. we chose chlorocebus pygerythrus as the study species because individuals 171 exhibit variation in grooming behaviors [56] , allowing us to examine differences in the 172 relationship between social behaviors and parasite infection status. groups of ch. 173 pygerythrus in ldnr -and much of the surrounding region -typically vary in size from 174 13-25 individuals [54, 55, 57] . six groups of ch. pygerythrus at ldnr are habituated, and 175 researchers have been conducting studies of these groups semi-regularly for more than a 176 decade [58-61]. we collected data from three of the six habituated groups at ldnr: 177 blesbok group, donga group, and bay group. at the commencement of the study there 178 were 14 individuals in the blesbok group, 16 in the donga group, and 17 in the bay 179 group; the total study population fluctuated due to births, migrations, and deaths, and was 180 54 at the conclusion of the study. here we present data on a total of 55 subjects as well as 181 a subset of 38 of those study subjects. information on group composition for each social 182 group can be found in wren [55] and wren et al. [36, 62] . we located groups using 183 known sleeping sites and home ranges. data were recorded for only the blesbok group 184 from july -october 2009 because other researchers were studying the donga and bay 185 groups during that time. data were collected from all three social groups for the 186 social group differences are presented in table 3 . these differences are likely due 302 to the different sampling efforts for each social group as noted in the methods section. (table 3) . however, because anova is robust with respect 326 to violations of homogeneity of variance analyses could still be performed. there were 327 statistically significant differences among groups for: total seconds observed (f (2, 52) = 328 22.79, p < 0.001); number of grooming partners (f (2, 52) = 15.70, p < 0.001); number of 329 grooming partners giving (f (2, 52) = 8.11, p = 0.001); number of total partners (f (2, 52) = 330 19.08, p < 0.001); time self-grooming (f (2, 52) = 3.54, p = 0.036) ( table 4) . planned contrasts revealed specific differences among groups and combinations 343 of groups (tables 5 & 6 ). there were statistically significant differences for all monkeys were lost from sight, but we kept data from all follows longer than 5 min. we 193 used continuous recording for all behavioral data we recorded data on the following variables for all bouts of social grooming: start 195 and stop times, whether grooming was given or received, and identity of grooming or more, the direction of grooming switched (i.e., the individual being groomed 199 began grooming its partner or vice versa) we also recorded data on start and stop times for direct physical contact with another 201 individual and identification of direct social contact partners we collected 332 fecal samples non-invasively from identified individuals 204 directly following defecation, and samples were immediately preserved in a 10% 205 buffered formalin solution. we recorded data on the following variables for we used three methods to detect parasite eggs and cysts in samples in order to 210 reduce the risk of false negatives: fecal flotation, fecal sedimentation, and 211 immunofluorescence microscopy. we isolated helminth eggs and protozoan cysts and 212 oocysts from fecal material using fecal flotation with double centrifugation (at 1800 rpm 213 for 10 min) in nano 3 solution and fecal sedimentation with dilute soapy water we 406 equation, based on a higher -2 log likelihood (37.68) and lower nagelkerke trichuris sp. and 86.11% of observed presence of trichuris sp infected individuals at ldnr spent 415 an average of 4% of their observed time grooming others, while those not infected with 416 this parasite spent an average of 14% of their observed time grooming others. however, 417 no differences existed in time spent being groomed by others. overall, for the entire 418 sample (n = 55), study subjects spent about 20% of their time in direct contact with 419 another individual. the subset used for parasitological analysis spent 6.5% (n = 38) of 420 their time in direct contact with another individual. this large difference is primarily 421 influenced by the inclusion of infants and mothers with infants in the entire sample of n = 422 55, but only mothers in the smaller subset of n = 38. these mother-infant dyads remain in 423 almost constant contact for the first weeks of a monkey's life and this inflates the overall 424 mean for the group. because there were not enough fecal samples from these infants, 425 their behavioral data was not included in hypothesis testing these results do not support the hypothesis that social grooming facilitates 429 transmission of this type of gastrointestinal parasite. one possible explanation for these 430 results is that individuals that are infected with trichuris sp. experience degraded health 431 and/or less motivation to groom others and interact with others. red colobus monkeys 432 (procolobus rufomitratus) in uganda that were infected with trichuris sp. decreased their 433 time spent performing a number of behaviors those 434 same individuals spent more time resting as well as ingesting plant species and/or parts 435 that suggest self-medicative behavior. whipworm is known to cause anemia, chronic 436 dysentery, rectal prolapse, and poor growth in humans with symptomatic infections [68], 437 so less energy, motivation, or interest for behaviors like social grooming should not be 438 surprising in other species another possible explanation is that trichuris sp. more directly alters host 440 behavior in vervet monkeys. gastrointestinal parasites are known to alter host behavior in 441 some host-parasite relationships, an idea referred to as the manipulation hypothesis for example, toxoplasma gondii causes intermediate rodent hosts to be more 443 attracted to the scent of felid predators dicrocoelium dendriticum causes infected ants to wait on the tips of blades of grass 445 where they can be ingested by sheep, the parasite's definitive host. because manipulation host to a definitive host, and vervet monkeys do not serve as intermediate 448 hosts for trichuris sp other studies have found multiple morphotypes of trichuris sp. in nonhuman 451 primate hosts in captivity in nigeria [74,75], suggesting that potentially multiple species 452 of trichuris sp. may infect nonhuman primates. the major implication of this has been 453 seen as relevant for public health because it may mean that the species of trichuris sp 76] noted that ill or infected animals display altered behavior, and argued 459 that these sickness behaviors can be adaptive. one study of chimpanzees (pan 460 troglodytes schweinfurthii) revealed that infected individuals exhibit altered behavior, 461 most fittingly described as lethargy the ghai et al. [67] study that revealed that trichuris sp. 464 was associated with a reduction in grooming and mating and also found that individuals 465 infected with this parasite took longer to switch behaviors than those individuals that 466 were not infected this study suggests that the gastrointestinal parasite trichuris sp. is associated 469 with behavioral differences, specifically decreased time spent grooming others and time 470 spent in direct contact with others, in vervet monkey hosts. these behavioral differences 471 are extreme enough to influence group means when assessing behavior. further, if an 472 individual is less likely to groom or interact with conspecifics, then they may also 473 experience lower social status and thus lower reproductive fitness we would like to thank the mpumalanga parks and tourism agency we are also grateful 481 to katie dean, claire detrich, ruby malzoni, liz sperling moses for assistance in the laboratory grooming systems of insects: structure, mechanics pollen transport and deposition by bumble bees in erythronium: 489 influences of floral nectar and bee grooming grooming patterns in the primitively eusocial wasp 491 polistes dominulus a video-tracking method to identify and understand circadian patterns in 493 drosophila grooming hoxb8 is required for normal grooming behaviour in 496 mice self-grooming by rodents in social and sexual 498 contexts costs and 500 constraints of anti-parasitic grooming in adult and juvenile 501 rodents neurobiology of rodent self-grooming and its value for translational 504 neuroscience relationship of bill morphology to grooming 506 behaviour in birds comparative analysis of time spent grooming by 508 birds in relation to parasite load of great tits and fleas: sleep baby 510 sleep do grooming behaviours affect 512 visual properties of feathers in male domestic canaries, serinus 513 canaria? grooming in primates: implications for its utilitarian 517 function the distribution of grooming and related behaviours among 519 adult female vervet monkeys intragroup cohesion and intergroup hostility: the relation between 521 grooming distributions and intergroup competition among female 522 primates grooming down the 524 hierarchy: allogrooming in captive brown capuchin monkeys the development of grooming and its expression in adult 527 animals elimination of external parasites (lice) is the primary 529 function of grooming in free-ranging japanese macaques insects groom their antennae to enhance olfactory acuity grooming behaviour as a 535 mechanism of insect disease defense beta-endorphin concentrations in 537 cerebrospinal fluid of monkeys are influenced by grooming relationships seyfarth rm. a model of social grooming among adult female monkeys functional significance of social grooming in primates silk jb. social components of fitness in primate groups grooming reciprocation among female primates: a meta-550 analysis infection strategies of 552 retroviruses and social grouping of domestic cats gorilla susceptibility to ebola virus: the cost of sociality dynamics of a multihost 558 pathogen in a carnivore community integrating contact network 560 structure into tuberculosis epidemiology in meerkats in south africa: 561 implications for control social network analysis of wild chimpanzees provides insights for predicting 564 infectious disease risk making connections: insights from 566 primate-parasite networks number of grooming partners 570 is associated with hookworm infection in wild vervet monkeys 571 (chlorocebus pygerythrus) social bonds between unrelated 577 females increase reproductive success in feral horses social bonds of female baboons enhance 580 infant survival fitness increases 582 with partner and neighbour allopreening heart rate responses to social interactions in 586 free-moving rhesus macaques (macaca mulatta): a pilot study grooming in barbary 589 macaques: better to give than to receive? the social 594 transmission of disease between adult male and female reproductives of the 595 dampwood termite zootermopsis angusticollis infectious diseases in primates: behavior, 598 ecology and evolution primate parasite ecology: the dynamics and 600 study of host-parasite relationships no effects of a feather mite on 602 body condition, survivorship, or grooming behaviour in the seychelles 603 warbler, acrocephalus sechellensis emerging 607 infectious disease and the challenges of social distancing in human and non-608 human animals who infects whom? social networks and tuberculosis transmission 611 in wild meerkats social transfer of pathogenic fungus promotes 614 active immunisation in ant colonies a vegetation classification and management plan for the a floristic description and 619 utilisation of two home ranges by vervet monkeys in loskop dam nature 620 wren bt. behavioural ecology of primate-parasite interactions social and ecological influences on activity budgets of 624 vervet monkeys, and their implications for group living when females trade 627 grooming for grooming: testing partner control and partner choice models of 628 cooperation in two primate species 632 59. van de waal e, renevey n, favre cm, bshary r. selective attention to 633 philopatric models causes directed social learning in wild vervet monkeys pansini r. induced cooperation to access a shareable reward increases the 636 hierarchical segregation of wild vervet monkeys helminths of vervet monkeys chlorocebus aethiops, from loskop dam nature reserve measuring behaviour: an introductory guide noninvasive assessment of gastrointestinal parasite infections in 646 free-ranging primates a legacy of low-impact logging does not elevate 649 prevalence of potentially pathogenic protozoa in free-ranging gorillas and 650 chimpanzees in the republic of congo: logging and parasitism in african 651 apes sickness 655 behaviour associated with non-lethal infections in wild primates the public health significance of 658 trichuris trichiura modification of intermediate host behaviour by 660 parasites host specificity parasites and the behaviour of animals parasite manipulation of host behaviour: an update and frequently 666 asked questions the effect of toxoplasma gondii on animal behaviour: playing 668 cat and mouse prevalence and 670 morphotype diversity of trichuris species and other soil-transmitted helminths 671 in captive non-human primates in northern nigeria gastrointestinal helminths of resident wildlife at the federal 675 university of agriculture zoological park biological basis of the behaviour of sick animals wrangham 680 rw. noninvasive monitoring of the health of pan troglodytes schweinfurthii 681 in the kibale national park, uganda key: cord-340101-n9zqc1gm authors: bzdok, danilo; dunbar, robin i.m. title: the neurobiology of social distance date: 2020-06-03 journal: trends cogn sci doi: 10.1016/j.tics.2020.05.016 sha: doc_id: 340101 cord_uid: n9zqc1gm abstract never before have we experienced social isolation on such a massive scale as we have in response to covid-19. yet we know that the social environment has a dramatic impact on our sense of life satisfaction and well-being. in times of distress, crisis, or disaster, human resilience depends on the richness and strength of social connections, as well as active engagement in groups and communities. over recent years, evidence emerging from various disciplines has made it abundantly clear: loneliness may be the most potent threat to survival and longevity. here, we highlight the benefits of social bonds, choreographies of bond creation and maintenance, as well as the neurocognitive basis of social isolation and its deep consequences for mental and physical health. j o u r n a l p r e -p r o o f 3 are conventionally most concerned about all had much less impact on survival rates. key factors included obesity, diet, alcohol consumption, how much exercise was taken, the drug treatments prescribed, and local air pollution. these authors conducted a follow-up analysis of 70 studies of longevity in older people, which followed ~3.5 million people over an average of ~7 years [16] : social isolation, living alone and feeling lonely increased the chances of dying by about 30%, even after accounting for age, sex and health status. many other studies have shown that social isolation (though not self-reported feelings of loneliness) was a significant predictor of the risk of death. for example, a longitudinal analysis of ~6,500 british men and women in their fifties [17] found that being socially isolated increases the risk that you will die in the next decade by about 25%. quantitative analysis of nearly ~400,000 married couples in the american medicare database revealed that, for men, the death of their spouse increased their own chances of dying in the immediate future by 18%. the death of the husband in turn increased the wife's risk of dying by 16% [18] . similar effects on morbidity rates have been found with respect to social support. a series of elegant prospective studies using data from the framingham heart study [19, 20] found that the chances of becoming happy, depressed or obese were all strongly mirrored by similar changes in the closest friend. there was a smaller significant effect due to the behaviour of the friends' friend. even a just detectable effect was present due to the friend of a friend's friend, but nothing beyond. this contagion phenomenon was especially strong if the friendship was reciprocal (i.e., both individuals listed each other as a friend). if the friendship was not mutual, the social contagion effect was negligible. the investigators also documented a strong effect of "geographical contagion". if you have a happy friend who lives within a mile radius, you are 25% more likely to become happy. and you are 34% more likely to be happy if your next-door neighbour is happy. people who belong to more groups are less likely to experience bouts of depression. such findings emerged from the uk longitudinal study of ageing (elsa) that repeatedly profiled around ~5,000 people from the age of 50 onwards. previous research showed [21] that depressed people reduced their risk of depression at a later time point by almost a quarter if they joined a social group such as a sports club, church, political party, hobby group or charity. indeed, joining three groups individuals were more immersed in their local community and trusted their neighbours more [22] [23] [24] . the causal directionality was difficult to pin down in these cases because of the cross-sectional nature of the data. nevertheless, path analysis provided some indication that intensity of social exchange was the candidate driver. the impetus to access social capital in the wider community [7] extends beyond humans. there is now a wealth of evidence from long-term field studies of wild baboons that socially wellconnected females experience less harassment by other monkeys [7, 23] , have lower levels of cortisol stress hormones [25, 26] , faster wound healing [27] , produce more offspring and live longer [28] [29] [30] [31] . such ramifications of social capital appear to hold up across a diversity of species, including chimpanzees [32] , macaques [33] [34] [35] , feral horses [36, 37] and dolphins [38] . a key underlying reason for these effects, at least in humans, is likely that loneliness directly impairs the immune system, making you less resistant to diseases and infections. research found [39] that freshmen students who reported feeling lonely had a reduced immune system response when they were given a flu vaccine compared to students who felt socially well engaged. moreover, those students with only 4-12 close friends had significantly poorer responses than those with 13-20 friends. these two effects seemed to interact with each other: having many friends (a large social group of nineteen or twenty friends) seems to buffer against a weakened immune response. yet, feeling lonely and having few friends results in a particularly poor immune defence. other investigators [40] used data from the framingham heart study to show that people with fewer contacts in their social network had elevated serum fibrinogen concentrations. in contrast, people enjoying many social contacts had low fibrinogen levels. fibrinogen plays an important role in blood clotting when a blood vessel has been ruptured, as well as facilitating wound healing and tissue repair more generally: high concentrations thus signal poor health. endorphins constitute a core component of the psychoendocrine mechanism underpinning friendship (see box 1). other research found [41] that social bonds stimulate the release of the body's natural killer cells, one of the white blood cells of the innate immune system whose core function is to destroy harmful bacteria and viruses. people who are more socially integrated have better adjusted biomarkers for physiological function, as indexed by lower systolic blood pressure, lower body mass index, and lower levels of creactive protein -the latter being another molecular response to inflammation. this insight was evident in each of four age groups (adolescents, young adults, middle age and old age) based on data from four large longitudinal american health databases [42] . the investigators found that, in j o u r n a l p r e -p r o o f adolescence, lack of social engagement had as big an effect on risk of inflammation as lack of physical activity. in old age, lack of friends had a bigger effect on risk of hypertension than the usually cited clinical causes like diabetes. even more worrying, the effects of social relationships on these physiological measures of good health during adolescence and young adulthood can persist into old age. in a longitudinal study of 267 males, for example, research found [43] that the more socially integrated a child was at six years of age, the lower their blood pressure and body mass index (a measure of fatness) two decades later in their early thirties. this result held up when they controlled for race, body mass index in childhood, parental socioeconomic status, childhood health and extraversion. social isolation may well have pervasive effects on brain connectivity. if rats are socially isolated when young (a condition that would give rise to feelings of loneliness in humans), neural function and plasticity are altered [44] [45] [46] [47] . in particular, episodes of social isolation can irretrievably alter the function of the prefrontal cortex (the part of the brain that is central to managing our social relationships [see below]), as well as its axon myelinisation (the laying down of the fatty sheaths around neurons that enable them to transmit signals faster and more efficiently) [44] . while short periods of loneliness in humans rarely have any long-term adverse outcomes, persistent loneliness escalates the risk of alzheimer's disease and depression [48, 49] . loneliness also leads to poor sleeping habits, with adverse psychological and physiological consequences [50] . the fact that friends can have such dramatic effects on our health and well-being may lead us to suppose that the more friends we have, the better. however, the number of friends and family relationships we can manage at any given time is limited by cognitive constraints to ~150 [51, 52] . there is, however, considerable individual variation, with social network sizes ranging between approximately 100-250. a number of fairly conventional factors are responsible for this variation: age (younger people typically have larger social networks than older people [53] ), sex (females usually have larger social networks than males [53, 54] ; though this does vary with age [55] ), personality (extraverts have larger social networks than introverts [56] ; women who score high on the neuroticism personality dimension have fewer acquaintances than those who score lower [57] ). friendships, however, require the investment of considerable time to create and maintain. the emotional quality of a friendship depends directly on the time invested in a given social link [57] [58] [59] . one prospective study estimated that it takes around 200 hours of face-to-face contact over a three-month period to turn a stranger into a good friend [60] . conversely, the emotional quality of a j o u r n a l p r e -p r o o f 6 relationship will decline rapidly ( figure 1 ) if contact rates drop below those appropriate to the relationship quality [61] . time resources, however, are naturally limited: we devote only around 20% of our day to direct social interaction (excluding business-related interactions), equivalent to about 3.5 hours per day [62] . given that our relationships are not all of equal value to us (friends serve a variety of different functions for us [63, 64] ), we allocate our valuable time across our social network in such a way as to maximise the different benefits that friends of different quality provide [65] . this dynamic results in a specific social fingerprint that is unique to each of us [66] . nonetheless, there are some broadly consistent patterns: a 40% share of our time is devoted to our five closest friends and family, and a further 20% to the ten next closest individuals. in other words, 60% of the 3.5 hours a day we spend in social interaction are devoted to just 15 people. social partners in the outermost layers of the social network each receive just 30 secs of our time a day on average. this gives rise to a very distinctive layering to our social networks, with layers that have a characteristic fractal pattern: the innermost layers of closest friends is very small (typically 5 people) but intense, the outermost ( ~150) very large but more casual [67, 68] . it is that inner circle of five closest friends and family that seems to matter most in terms of the buffering of both loneliness and disease. geographical distance also imposes strong constraints on the organization of friendship. the '30-min rule' provides an empirical reminder that people are less willing to visit friends and family who live more than 30 mins away -no matter whether that involves travel on foot, by bicycle or by car [69] . cutting across this effect is the influence of genetic relatedness: the kinship premium (i.e., the strong mutual benefits that kinship typically affords) incentivizes us to travel an extra mile to maintain contact with family than we are with friends [70] . while the role of close contacts, like friends, is pivotal, other regular contacts can also contribute to one's social capital. previous authors [71] famously claimed that weak -as opposed to strong, or close -ties provide important sources of external information. analyses of information flow in social networks suggest that sources outside the 50 closest friendships offer few benefits [72] . other benefits of interaction with more loose social ties can, of course, include heightened subjective well-being and sense of belonging to the local community [73] . however, as is often the case in such studies, it is crucial to precisely define the meaning of weak versus strong ties, since all weak ties belonged to the same community (a student class). regular interaction with different people at the periphery of social networks can give rise to heightened perceived social and emotional fulfillment in ways that act as psychological buffers [24] , although this might depend on personality or social style [74] . social-affective processes in the presence of others take a different form than during the others' physical absence. already in a nursery, if a baby starts crying, other nearby babies hear the distress signal and typically also start crying by mere emotional contagion. in addition to utterances and prosody, humans tend to align their communication towards each other by imitating vocabulary, grammar, mimics and gestures. for instance, humans tend to unconsciously synchronize their facial expressions even with people who are directing gaze at somebody else [75] . such subliminal motor and emotional resonance is typically found to be intrinsically rewarding [76] . on the positive side, contagion processes can uplift an individual's happiness through people within the close neighborhood, but also miles apart [19] . on the negative side, loneliness also spreads rapidly through an individual's social interaction partners, thus affecting even friends of friends of friends [77, 78] . reading others' faces -impossible during a conventional phone call -may be an evolutionarily conserved means for exchanging pivotal information, which coevolved with the corresponding decoding machinery in brain and behavior responses (see next section). faces offer a plethora of social information about an individuals' sex, age, ethnicity, emotional expression and potentially their intentions and mental state (all of which influence the strength of the bond between two individuals [59] ). throughout development, learning and maturing critically hinge on joint attention of two individuals on the same object [79, 80] . such mentalizing and eye gaze processes have been repeatedly linked to the higher associative and the striatal reward circuitry [79, [81] [82] [83] . some authors even argue that the importance of such facets of interpersonal exchange may explain why humans developed wide and white sclera in the eyes -more easily visible than in most animals [84] . what may lead to greater vulnerability to predators for some species (by making the individual and her intentions more visible and exploitable) may have boosted learning and cooperation in human primates [85] . such evolutionary adaptations facilitate how humans automatically represent the (visual) perspective of nearby others. making statements about objects channels [88] . compared to actual interpersonal encounters, a surprising number of psychological constants exist in how humans entertain and juggle with social relationships in digital environments. for example, the upper bound of ~150 contacts (cf. above), as well as the structure of these networks, appears to hold across both the real world and a variety of virtual online contexts [53, 68, 89, 90] , suggesting that group size in today's society is still orchestrated by the same principles as when we were hunter-gatherers. indeed, several neuroimaging studies [e.g., 51, 91] broadly confirm that our online social networks correlate with the volumes of the same core brain regions that resonate with the size of our offline networks [52, 92] . these constancies suggest that lively virtual social interaction may similarly entrain faculties like memory and concept generation. conversely, paucity of social interaction and loneliness may have deleterious effects on the cognitive and memory systems. it is conceivable that enhancement or decline of cognitive and neural reserve may be mediated by analogous pathways potentially involving dendritic arborization in the hippocampal and prefrontal regions [49] . the need for personalized interactions may already be reflected in the way that stock market traders sometimes add coded numbers to money transfers (e.g., 10,000,467 instead of 10,000,000 shares) as a potential replacement for the recognition of somebody's unique facial identity rather than remaining anonymous [93, 94] . this attractor for a full range of face-to-face cues during social interactions may explain why emojis have become so popular: they replace the important emotional signals in the absence of the ostensive facial cues that we use for the interpretation of utterances in the face-toface environment. these considerations raise the important question how the brain implements toggling between real-world social interactions and virtual or imagined social interaction in the absence of physical contact [79] . the right temporoparietal junction was proposed as a key switching relay between two antagonistic classes of neurocognitive processes: those more anchored in one's current external sensory environment and more stimulus-independent ones relying on internally generated information [95] . this idea was later substantiated by a multi-modal neuroimaging study in 10,000 humans [96] : the right and left temporoparietal junction explained most variation in functional coupling changes between all major brain networks. hence, these two association cortex regions may help mediate shifts of focus from the person in front of you to a person you are texting with on the phone, who is out of sight or touch. taken together, evidence of digital communication suggests that this new medium does not in fact change the general pattern of our social interactions or the numbers of people we contact [68, 89, 90, 97] . the sizes of the layers in our social networks are unchanged by using digital media or virtual communication. also, the frequencies with which we contact certain people in each social j o u r n a l p r e -p r o o f layer are strikingly similar in the online and offline worlds. some digital vehicles, however, lack the communicative richness of real face-to-face interactions: when asked to rate their satisfaction with interactions with their five closest friends each day, participants rated face-to-face and skype interactions as equally satisfying and both as significantly more satisfying than interactions with the same individual by phone, text messaging, sms messaging, email or text-based social media such as facebook [87] . human and non-human primates live in groups mainly to minimize external ecological threats, including predators, raiding by neighbors, and environmental risk. advanced forms of cooperation are rare in non-primate species [98, 99] and probably emerged in non-human primates several million years ago. today, the average humans spends up to 80% of waking hours in the presence of others [100, 101] . investing cognitive resources in keeping track of friends, family and colleagues is highly demanding -more costly than contemplating the physical facts [102, 103] . not only time limits (cf. above) but also neurocognitive limits [e.g., 104] effectively constrain how close one can be to how many individuals. but how is regular social stimulation reflected in neurobiology? in monkeys [105, 106] and in humans [51, 52, 107, 108] , various indices of sociality and measures of social network size are robustly associated with specific regions of the neocortex. these same regions are responsible for processing social information such as predicting others' intentions [109, 110] . at least some of these brain-behavior associations may be cross-culturally consistent in humans, as evidenced by a structural neuroimaging study in the usa and china [111] . whole-brain analyses have repeatedly highlighted a relationship between the ventromedial prefrontal cortex and measures of social network complexity and social competence [92, 105, 110, [112] [113] [114] [115] . the ventromedial prefrontal cortex and striatal nucleus accumbens have been found to play a key role in both social reward behaviors and the amount of social stimulation in humans [113] and other mammals [e.g., 44, 47] . functional neuroimaging has shown that these neural correlates are also implicated in tracking others' popularity status in real-world social networks [116] . similarly, positron emission tomography has shown that, in humans, the density of mu-receptors for betaendorphin, especially in the ventromedial prefrontal cortex, correlates with social attachment style, for which endorphins are more important than other neuropeptides [117] . other evidence, such as in a functional neuroimaging study on maintenance and manipulation of social working memory [104] , has also related the dorsomedial prefrontal cortex to social network properties. there are similar correlations for social cognitive skills like mentalizing that are crucial to maintaining functional social relationships [118] [119] [120] . analyses of social richness and brain morphology in humans tend to identify a neural network involving the prefrontal cortex with several parts of the so-called default mode network as being crucial for managing social networks (e.g., noonan et al., 2018) . this major brain network of the higher association cortex has probably recently expanded in primate evolution [121] . its constituent regions are often thought to support several of the most sophisticated neurocognitive processes [122, 123] . in monkeys, there is evidence that experimental manipulation of social group size results in adaptations in the volume of frontal brain regions, the posterior superior temporal sulcus or temporo-parietal junction, as well as the amygdala and other parts of the limbic system [105, 106] . in humans, there is evidence for structural coupling between social network size measured by number of online friends and parts of the default mode network, including the hippocampus [51] . from a clinical perspective, functional connectivity alterations in the default mode network have been demonstrated as a consequence of feelings of loneliness in younger adults [124] . moreover, the default mode network is especially subject to vulnerability in normal cognitive aging [125] , and is among the main brain circuits to be impacted by neuropathology in alzheimer's disease [126, 127] . complementing higher associative parts of the human social brain [128] , amygdala volume is larger in individuals with more extensive social networks in humans [52, 107] . amygdalar functional connectivity was also reported to increase with canonical brain networks implicated in face perception and approach-avoidance behaviour [107] . indeed, previous authors reported [129] that a patient with complete bilateral amygdala lesions lacked a sense of appropriate personal space vis-ã vis other people (figure 3 ). this patient exhibited no discomfort when at close distances from another person, even to the point of touching the other's nose -despite the fact that their conceptual understanding of people's private physical space was intact. in contrast, healthy individuals typically show amygdala activation in response to close personal proximity. in a similar vein, the grey-matter volume of the amygdala correlated negatively with social phobia [130] . the amygdala may hence be required to trigger the strong emotional reactions normally associated with personal space violations, thus regulating interpersonal distance in humans. such reports on the social brain often seemed to be in conflict about whether they highlight the prefrontal cortex or the amygdala of the limbic system. this apparent discrepancy was reconciled in a recent population neuroimaging study [131] : social traits such as daily exchange with family, friends, and work colleagues were associated with brain morphology in ~10,000 uk biobank participants. particularly prominent findings were reported in the limbic system, where volumes varied consistently with various indicators of social isolation. less socially stimulated participants showed volume effects in various parts of the social brain including the ventromedial prefrontal j o u r n a l p r e -p r o o f cortex and the amygdala, in addition to the nucleus accumbens of the reward circuitry. volume effects in these regions were reported for several markers of brittle social integration, such as living in a socially "emptier" household, knowing fewer individuals with whom to regularly share experiences and concerns, feeling unsatisfied with one's friendship circles, as well as having grown up without brothers or sisters and being unhappy with one's family situation [131] . this analysis also demonstrated wide-ranging sex differentiation in how traits of social isolation are linked to brain morphology. these findings underscore evidence from animals for a sex specific co-evolutionary relationship between the primate brain and social complexity [social brain hypothesis: 132, 133]. the perspective of brain network integration in loneliness was investigated in a seminal neuroimaging study of intrinsic functional connectivity in ~1,000 humans [124] . careful analysis showed that feelings of loneliness especially affect the neural communication strength between the limbic system and the default mode network as well as the communication strength inside of the default mode network. as a particularly discriminatory pattern for loneliness, impoverished functional modularity was found for the default mode network and its interacting brain networks. in contrast, a positive sense of one's meaning in life was linked to strengthened functional differentiation of the canonical network ensemble. the collective evidence led the investigators [124] to argue that the default mode network and its coupling partners represents a neural signature reflecting one's own purpose in life versus social disconnection to others. according to unicef estimates, ~140 million children worldwide live deprived of parents who could provide comfort and support. ~8 million of these children grow up in institutions without the socioemotional context of a regular family. in one of the earliest randomized clinical trials of its kind, orphans raised in institutions were systematically compared to orphans who were later welcomed into a foster home [134] . abandoned children were randomly assigned either to remain under the care of the institution or to transition to the care of foster-parents. their cognitive trajectories were monitored over several years. those children who remained in the institution showed significantly lower development indices and lower iqs [of around 70: 134] than the adopted orphans. being deprived of social bonds with caregivers also led to a pernicious reduction in grey-and white-matter tissue and lower fiber tract integrity as evidenced by brain mri [134] . institutional rearing was also shown to exacerbate the decay of the telomeres in cell nuclei [135, 136] . these protection caps normally prevent chromosome deterioration, which acts like a cellular sand clock of aging. their shortening has major consequences for various biological pathways and health outcomes. the younger the children were when adopted by a foster family, the better the cognitive performance later [137] . impoverished cognitive domains include memory and executive function: for orphans who transitioned to a foster home, some cognitive facets remained below-average throughout later life (e.g., short-term visual memory and attention allocation). other cognitive dimensions (e.g., visual-spatial memory and spatial working memory) caught up with a normal trajectory at age 16 [134] . such unique evidence underlines the fact that lack of socioemotional context in early life severely impedes brain development and maturation of the cognitive repertoire, which can be partially mitigated by developing social bonds to non-genetic parents (see box 2) . early psychosocial deprivation also shows inter-generational effects, which are probably mediated through maternal and epigenetic effects [138] . social isolation in childhood leads to molecular annotations of the genetic strand (such as methylation or phosphorylation of the histones that provide the structure for dna strands) that are passed on to influence how children cope with stress and in turn how they raise their own children. for instance, in rats, socioemotional experience as a pup has an impact on how the rat's own pups later deal with stress and high anxiety levels [139] . epigenetic regulation of gene transcription is involved in how maternal care promotes the rat pup's brain development and cognitive maturation. more licking and grooming by the mother increases protein expression of the grm1 gene in the pup's hippocampus. this up-regulated gene transcription leads to greater availability of glutamate receptor proteins in hippocampal cells for inter-neuronal signaling [140] . in humans, a longitudinal neuroimaging study indeed showed that social support from the mother promotes volume growth trajectories in the hippocampus, and predicts socioemotional development and emotion regulation in early adolescence [141] . in young rhesus monkeys, loss of social contact to the mother leads to behavioral aberrations that last right into adulthood. such social isolation was shown to entail down-regulated dendritic growth in the prefrontal cortex and reduction in gene expression in the amygdala [142] . social adversity undergone by children with institutional upbringing led to disturbed functional connectivity between the prefrontal cortex and the amygdala [143] . such perturbed brain maturation through social deprivation may be mediated by glucocorticoids, which are known to be inhibited by maternal care in primates [144] . hence, maternal care is a critical enrichment of the social environment that promotes maturation, expression of growth hormones, and synaptogenesis in various brain circuits. in contrast, social neglect leads to disturbed social attachment, as well as increased aggression and hyperactivity, often potentially lifelong [145, 146] . how vulnerable an individual is to parental deprivation is subject to complex nature-nurture interactions that are strongly conditioned on personality and overall genetic endowment [147, 148] . rats separated early from their mothers were impaired in adult life in emotion regulation and arousal management [149] . early socioemotional isolation of rat pups had impact on whether these rats later showed healthy responses to stress by mounting adequate cortisol levels [150] . hormones of the hypothalamic-pituitary-adrenocortical (hpa) axis are an important endocrine mechanism of stress neurobiology that plays a key role in social isolation. in baboon monkeys, infant survival is jeopardized for mothers who are more socially isolated and not well integrated in the local communities including ties to sisters, adult daughters, and other mothers [151] . monkey mothers with a thinner social network are less likely to have infants which themselves have high fitness [28] . female baboon monkeys with a larger close social circle of grooming partners have healthy cortisol levels and typically deal better with stressful situations [25, 26, 152] . when one of these strong social bonds is disrupted, such as when a close member of the social group is killed by predators, cortisol titres rise in the blood. such monkeys then tend to seek out new connections to "repair" the lost link in their social network [153] . a lower-than-usual cortisol level in the morning is indicative of extended stress periods in adults [154] . the same diurnal cortisol dynamic is frequently observed in disturbed child-caregiver relationships [155] . in rhesus monkeys, a low hormone response has been observed after repeated separations from the mother. the same observation has been reported for children who were moved between several caregivers. an intact child-caregiver relationship probably provides a stress reserve to adrenoreceptor responses so that children get over stressful episodes quicker [156, 157] . after undergoing adversity in early childhood, such as emotional or physical neglect, maltreatment, or maternal separation, enhancement of the child-caregiver relationship can mitigate the effect of previous hits to the hpa system. early disturbance in important social relationships is linked to dysfunctional cortisol hemostasis in adult life [158] . in some neglected children, ensuing problems and behavioral disruptions can even be exacerbated in adult life [159] . abnormal blood cortisol levels can potentially be prevented, mitigated or restored by family-based therapy and other interventions [160] . nonetheless, dysregulated diurnal cortisol levels are further linked to various mental disorders including major depression, substance abuse, and post-dramatic stress disorder [154] , in addition to stress-induced impact on the immune, cardiovascular, and metabolic systems [161, 162] . further insight into the neurobiology of social isolation has also been derived from rigorous experiments with adult primates (see also box 3). in one study, 20 monkeys were separated from others to live alone for 1.5 years [163] . subsequently, monkeys were re-integrated into social groups of four monkeys housed together. repeated positron emission tomography (pet) scanning revealed increased levels of d 2 receptors in the basal ganglia, which includes key nodes of the reward j o u r n a l p r e -p r o o f circuitry (see above), after being socially housed. this neurochemical adaptation in the monkeys' brain circuitry was apparent after as few as 3 months of social rehabilitation [163] . these authors also reported several differences in respect of social integration and social rank: monkeys of higher rank were groomed more by others. in contrast, subordinate monkeys spent more time by themselves. as a consequence at the behavioral level, the lower-rank monkeys were also significantly more willing to self-administer cocaine, which may also relate to heightened drug abuse in lonely humans [164] . such molecular imaging evidence shows that changing from social deprivation to an environment with constant social stimulation causes neural remodeling in the dopaminergic neurotransmitter pathways in non-human primates, which may be clinically relevant for substance abuse disorders in humans. we are social creatures. social interplay and cooperation have fuelled the rapid ascent of human culture and civilization. yet, social species struggle when forced to live in isolation. the expansion of loneliness has accelerated in the past decade. as one consequence, the united kingdom has launched the 'campaign to end loneliness' -a network of over 600 national, regional and local organizations to create the right conditions for reducing loneliness in later life. such efforts speak to the growing public recognition and political will to confront this evolving societal challenge. these prospects should encourage us to search for means to mitigate possible negative backlash. we offer some suggestions in box 4. additional insight into stress-responsive brain systems is imperative to tailor clinical decision making and therapeutic interventions to single individuals. there is also a dire need for additional longitudinal research on the hpa axis and the cortisol response to psychological stressors. we are grateful to guillaume dumas and tobias kalenscher for valuable comments on a previous version of the manuscript. db was supported by the healthy brains healthy lives initiative (canada first research excellence fund), and by the cifar artificial intelligence chairs program (canada institute for advanced research). primates service their relationships through social grooming. grooming triggers the endorphin system in the brain through a very specific neural system: the afferent ct fibres [165] . these axon bundles have receptors at the base of most hair follicles, have the unusual properties of being unmyelinated (and hence very slow, especially compared to the pain receptors in the skin), with no return motor loop (unlike pain and other proprioceptive neurons), respond to a very specific stimulus (light slow stroking at ~2.5cm per sec) and directly trigger the endorphin reward system [166] . although humans no longer have the full fur covering that encourages social grooming, we still have the receptors and instead use physical contact in the form of touching, stroking, caressing, and hugging as a means for strengthening social ties in our more intimate relationships [167, 168] . physical touch is intimate, and hence limited mainly to close family and friends ( figure 2 ). to bond our wider range of relationships as well as our more intimate ones, humans exploit a number of behaviours that turn out to trigger the endorphin system. these joint activities include laughing [169, 170] , singing [171, 172] , dancing [173, 174] , feasting [22] and emotional storytelling [175] . an important feature of all these behaviours is that behavioural synchrony seems to ramp up the level of endorphin release [174, 176] . in baby primates, close social interaction is not only beneficial, but critical for maturation and resilience. experiments in baby monkeys showed that upbringing in social isolation during the first years causes a variety of social deficits. when separated early from their mothers, baby monkeys showed strong symptoms of social withdrawal: self-hurting behaviour like biting, stereotypical and repetitive motor behaviour, excessive avoidance behavior towards others as well as poor social and maternal skills as adults. when separated later from their mothers, baby monkeys tended to indiscriminately approach unknown monkeys without fear [cf. 177] . reports of human children in some crowded russian and rumanian orphanages painted a strikingly similar picture: socially and emotionally abandoned children showed either forward-j o u r n a l p r e -p r o o f backward rocking tics and social escape or overly strong attachment style, analogous to neglected baby monkeys [cf. 178] . these cases invigorated the then-contested claim that mother-child bonds are indispensable for normal development, and that foster-care parents can compensate many of these needs [134, 160, 179, 180] . disruption of social interplay during critical development impacts negatively on cognitive, verbal, social and motor performance, and predisposes to mental health issues. in other words, early neglect remains measurable in brain and behaviour in later life. the socioemotional dialogue between caregiver and baby is mediated in several important ways. mothers speak to their offspring in "baby talk", which potentially evolved only recently in humans [181] . accompanied by direct face-to-face exchanges, these communication bouts with characteristic vocabulary and prosody promote infant development milestones. the interpersonal stimulation grabs the baby's attention, she gains weight faster, modulates her emotional state, and enhances various health outcomes. mother-infant communication is also delivered through direct skin-to-skin contact [166] . postnatal touching bolsters mother-infant bonding, alleviates anxiety, and provides intrinsic pleasure through endorphin release [182] [183] [184] . throughout life and quite independent of geography, primate societies are orchestrated by the creation, curation, and cultivation of social bonds though purposeful social closeness. among the many consequences of loneliness on body and mind, the scarcity of social contact encourages drug compensation behaviour, such as alcoholism, possibly via non-social rewards triggering dopaminergic neurotransmitter pathways [163] . at the genetic level, loneliness was shown to entail under-expression of anti-inflammatory genes involved in glucocorticoid response and over-expression of genes related to pro-inflammatory immune responses [185] . fortunately for future clinical intervention, loneliness may be a modifiable determinant in healthy aging [11] . as people grow older, the social network typically becomes smaller -naturally diminishing the cognitive stimulation through frequent and intense social interaction on a daily basis, thus potentially reducing the neural reserve. over the last century, the average human lifespan in developed nations has increased by nearly three decades. on the other hand, older people were also reported to show a decline in the capacity to take other people's point of view, as demonstrated in three separate mentalizing tasks [163] . these authors showed that social cognition j o u r n a l p r e -p r o o f deficits were related to decreased neural activity responses in the medial prefrontal default mode network [163] . this capacity is likely to be particularly important when introspecting other people's minds who are not physically present -where social cues like facial expression, mimics, and gestures are missing. both limited social stimulation and weakening social reflection capacities relate to the sense of loneliness in complicated and important ways [13] . once lonely, bias for negative information processing of cues from others hinders social rehabilitation in a downward cycle [4, 186] . many recent studies have corroborated the corpus of empirical evidence that the feelings of loneliness escalate the risk of certain neurological diseases and especially alzheimer's disease in later life [49] . social isolation at massive scale risks creating cohorts of individuals who are socially dysfunctional. it may therefore be important to identify ways of mitigating the worst of the effects so as to alleviate the consequences. the following possible countermeasures may be worth exploring: ï�· one promising intervention would involve creating opportunities where mutual social support relationships (friendships) could develop naturally. you cannot, however, force people to become friends: both parties need to be willing to devote resources to each other in a context where available time budget for social engagement is limited [187, 188] and there are competing friendship interests [66] . however, by providing more opportunities for people to meet in congenial environments, new friendships may blossom. ï�· social neuroscientists [189] undertook a longitudinal intervention study on 332 matched adults who underwent regular training sessions. several months of cognitive training improved empathy for others' affective state or perspective-taking of others' mental state, which resulted in structural remodeling in brain regions belonging to the social brain network, including the frontoinsular network and the default mode network. daily affective training resulted in thickening of the right anterior and mid-insula, with correspondingly enhanced compassion ratings. different training regimes correlated with different brain regions. further research is urgently needed to explore therapeutic interventions using training of social capacities in socially deprived humans. j o u r n a l p r e -p r o o f ï�· one important lesson is that joining clubs can have important benefits in reducing both a sense of loneliness and psychological or psychiatric conditions [21] . one obvious solution is to encourage vulnerable individuals to join social groups and communities that suit their interests and abilities. establishing a wide range of such clubs is likely to be much cheaper than paying for carehomes and prisons. ï�· singing is known to have a dramatic, immediate effect on creating a sense of social engagement and elevating psychological well-being [the "ice-breaker effect" : 171] . vulnerable individuals could be encouraged to join choirs and community singing groups. encouragement and funding may need to be invested in establishing a network of choirs. ï�· use of video-embedded digital communication is likely to gain in importance. this is especially true where family and friendship groups can meet in the same virtual space. the visual component of the interpersonal encounter appears to play a key role in creating a more satisfying experience of digital social media [87] . emotional closeness at the start of the study is set at 0 for both groups. redrawn from [61] . regions. in 1,368 people from several countries, this study investigated the permissibility of social touch [167] . the authors showed that human social touch is particularly dependent on the nature of the relationship. the topography of accepted social touching depends on many factors, including a) emotional relationship, b) type of interpersonal bond including kinship, c) sex, and d) power dynamics. close acquaintances and family members are touched for more different reasons. culture influence, measured in five countries, was small. female, rather than opposite-sex, touch was evaluated as more pleasant, and it was consequently allowed on larger bodily areas. reproduced from [167] . ï�· what further refinements of online digital media might improve people's function in creating and maintain friendships, especially for the housebound? it is insufficiently known which types of modern medium best mimic which neurocognitive facets of real social interaction. ï�· which neurobiological mechanisms explain how the default mode network and its connections to subordinate brain systems support higher social capacities, and their decline in social deprivation? this associative brain network needs to be more completely understood; especially regarding the congruencies and idiosyncrasies between healthy aging trajectories, the experience of social isolation, and vulnerability to neurodegenerative pathologies. in terms of progress towards causal understanding, putting a premium on 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hvujl36d the brick-and-mortar retail smes (small and medium enterprises) market is confronted with unprecedented challenges: digitization procurement in a company not prepared for a digitalized business model, and the actual digitalization process of the business model, which not only changes the business rules but disrupts them with new possibilities. despite industry 4.0 transforming manufacturing in terms of the way of producing and distributing goods by means of process digitization, the offline retail smes market is struggling to satisfy customers’ shopping expectations due to two direct constraints: existing offline competitors operating under a narrowing market share, and online retail competitors increasing market share due to their better positioned ecommerce it platforms. the purpose of this work is to study the potential effect of digitalization on smes, focusing on businesses operating in the offline retail market, by means of provisioning cloud solutions supporting the business digitization process. the study is based on data collected from a wide range of official sources in conjunction with extensive research work reviewing technologies applicable to these kinds of businesses. the validation is performed through the focus group methodology between the months of june to october 2019, with 20 participants from the henares corridor, madrid (spain) area, considering them as a relevant sample of offline retail smes in spain. the value proposition of this study can help offline retail smes understand the difference between digitization and digitalization, the necessity of digitalization in their businesses, the existence of accelerators such as e-receipt cloud solutions, and the disruptive potential of digitalization to their business models on long-term survival regarding competitors and raising the circular economy. the brick-and-mortar retail smes (small and medium enterprises) market is confronted with unprecedented challenges (minco-tur, 2020): digitization procurement in a company not prepared for a digitalized business model, and the actual digitalization process of the business model, which not only changes the business rules but disrupts them with new possibilities (fitzgerald et al., 2014; gartner 2020a) ; all within the background of a deep crisis triggered by online ecommerce competitors, which forces offline retail smes to digitalize or die due to the continuously changing market (safari et al., 2015) . however, recently an additional issue has gained popularity: the covid-19 pandemic which has taken all society, business and industry by surprise and will most probably lead to a major domestic and global economic recession (carlsson-szlezak et al., 2020; wren-lewis, 2020) ; unfortunately with the current available data it is still too soon to assess its entire economic impact. the investigation of the literature and secondary sources has been focused on the most tangible elements affecting the day-to-day aspects of smes regarding digitization (pricewaterhousecoopers, 2016) and the ability to create new added value for customers (chung et al., ecommerce online competitors and their technological barriers that stop them becoming digitalized, has been done, where the study explores the context of the industry 4.0 pressure on companies (minc-otur, 2020) , as well as analyzing the concepts applicable regarding digitization and digital transformation of offline retail smes within the ever-changing market trends and demands (gartner 2020a) , linking the market requirements to the growing challenges of multi-channel customer communication, such as sms (mccorke et al., 2013; guberti, 2015) , e-mail (hartemo, 2016; reimers et al., 2016) , instant messaging mobile applications (amirkhanpour et al., 2014) and social networks (brown, 2015) . at the same time, the research examines some of the reasons why social networks have increased in popularity (guberti, 2019) , as well as the reasons why they have transformed the business-customer interaction relationship (camarero izquierdo, gutiérrez cillán and san martín gutiérrez, 2005) , where customers have increased the demand to know exactly what is being delivered to them from the source of the raw materials up to the manufacturing process (oh and teo, 2010) . this demand is also taking on customization, where companies are expected to adapt to new market trends and ways of utilizing the product (palmer and ponsonby, 2002; charlesworth, 2014) , such as the shared economy or the collaborative economy, where clients are not only expecting but demanding a particular solution, while also requiring personalization in shape, color, or timing, which shifts the entire way companies deliver and do business challenging them from the manufacturing process to the intermediaries and shipping agents (haas et al., 2015) . retail smes are transforming into small value-added aggregators that are expected to respond to customer needs, all under the umbrella of unstoppable pressure for environmental protection and efforts to reduce waste management within daily operations (haanpää, 2007) . given the aforementioned scenario, the research inevitably addresses the comparison with regards online retail smes, which from a technological point of view are far better positioned as they can acquire more in-depth knowledge regarding their customers based on the way the ecommerce platform is developed (safari et al., 2015) . in contrast with offline retail smes, they obtain selling patterns and conversion paths (san-martín and jiménez, 2017) allowing them to take quick decisions based on real time data (devaraj et al., 2002) . on the other hand, offline retail smes lack that body of information and rely only on basic sales information from erp (enterprise resource planning), whereas the use of crm (customer relationship management) is missing (faedpyme, 2018) and the technological barriers prevent them from digitalizing (mincotur, 2020) . the methodology section describes how the study has been developed in a multi-step process relying on the initial identification of the sme gaps contrasting extensive literature research from derived studied and official data sources, summarizing the outcomes regarding the applications to smes. based on the identified gaps, an e-receipt conceptual model has been postulated regarding technological aspects that an e-receipt platform should envision as a digital enabler for the transformation of offline retail smes, trying to anticipate the possible issues and converging solutions, such as technological barriers (faed-pyme, 2018; ontsi, 2018) or delivery of the actual digital receipt functionality (berson et al., 2000; safari et al., 2015) . the hypothesis of the e-receipt as digital enabler has been contrasted on the basis of an empirical research of a focus group methodology, between the months of june to october 2019, involving the participation of 20 offline sme retailers from the henares corridor, madrid (spain) area, segregated into a first set of 11 participants following an evaluation questionnaire answered based on their hands-on business experience regarding the relevance of the e-receipt within the participating retail companies and about how the envisioned e-receipt solution could fit into their daily operations; together with a second set of nine participants while writing the article in order to fine-tune the first set focus group outcomes. extensive research was carried out in order to draw the e-receipt conceptual model guidelines used during the focus group activity, from the point of the components and the subsequent interactions between the companies which implement it and their customers. each module describes the necessary steps required for a successful iteration and the impact that could have on the smes if implemented (mijanur rahman and ripon, 2013) . the modules describe in great detail the customer perspective within the e-receipt ecosystem, as well as what tangible value is created and distributed among all involved actors. the implementation outlines the offline sme-related aspects from the point of view of the technological barriers, the tight integration of the e-receipt within business activity, the multi-channel distribution as well as all the new interactions generated with the client in a simple format easily exploitable and deployable (fundación telefónica and red.es, 2015; ontsi, 2019) . this involves customers within the daily business activity and obtains information regarding their preferences so that smes can create new sorts of products or services that satisfy both the requirements and personalization level demanded by them (devaraj et al., 2002) . the platform explores new forms of customer interaction through a multi-channel, dynamic advertising system based on shopping patterns. finally, it investigates how companies can gain new sources of information and knowledge about their customers throughout the analytical dashboard (faedpyme, 2018; ontsi, 2019) providing cross-selling and up-selling patterns so that they can create new engaging campaigns that meet customer interest and demands (chung et al., 2016) . the results section focuses on the outcomes of applying the e-receipt platform as a digitalization enabler to offline retail smes and how this could help them to accelerate towards digital transformation of their business model and new business opportunities -as far as the digital transformation of the paper receipt is concerned -reducing the technological barriers (ontsi, 2018) especially with regard the integration of software-as-a-service cloud services, the multi-channel communication with their clients, the possible analytics and insights provided by the e-receipt platform to assure customer satisfaction and loyalty (fundación telefónica and red.es, 2015; ontsi, 2019) . the other outstanding items addressed in this research are the environmental aspects demanded by both customers and companies to fight the generated waste due to business activity (mineco and corrales, 2011) , but also the issues most underestimated by companies, such as cybersecurity (incibe 2018b) that are becoming more relevant and impacting on society every day, as well as the regulations related to privacy that allow customers to take control and action regarding their personal data (incibe, 2017) . finally, the conclusions section synthesizes the offline retail sme market demand for digital enablers and the hypothesis of e-receipt as an accelerator could lead to a tangible impact on both businesses and society in terms of possible solutions to technological barriers and the requirements of multi-channel customer interactions, together with their corresponding practical and theoretical implications. as the research field focuses on only particular aspects, as described under the limitations section, the investigation offers many possible lines of future work, such as the internationalization of the research to other markets, their possible technological implications or further discussion regarding customers' behavior and patterns. what is known: offline retail smes struggle as the lack of digitalization creates a technological gap in data collection and analytics (fae-dpyme, 2018; ontsi, 2019) , leading to decisions based on intuition due to lack of supporting data, slow reaction time based on observed occurring trends, reactive business actions, under-utilized or non-existent customer behavior information or lack of customer behavior analysis tools (minc-otur, 2019). therefore, in order for offline retail smes to remain competitive, they have to make the appropriate investment in technology (mincotur, 2020), but this is not an easy task for all smes, as it implies procurement, training, hardware and software compatibility, maintenance or dedicated it staff (safari et al., 2015) . these aspects also affect the personalization and customization of the offered products and services, where customers are left only to the provided number of choices without the possibility of making additional changes. customers expect and demand a product or service that fits their needs and not the needs of the retailer or the manufacturer (oh and teo, 2010) , where shared economy and circular economy require the retailers to customize their products to the new consumer habits (haas et al., 2015) . therefore, the authors have established extensive bibliographic research covering both international and national references, organized in five main areas (table 1) considered as high potential impact on offline retail smes that could explain the contextual smes situation table 1 theoretical framework model and main contributions. own elaboration. source main contribution 1. industry 4.0 context, digitization and digitalization (arnold et al., 2016) research industry 4.0 digital enablers transform companies' business model and internal organization, together with the relationship between partners and customers, under a cost-efficient paradigm. (fitzgerald et al., 2014) research digital transformation success is strongly linked with the technological dissemination, organizational aspects and leadership qualities. (davenport and prusak, 1998; porter and heppelmann, 2015) research the transition from data to information and knowledge sets the baseline for the digital transformation; and information as a key asset that feeds the internal it systems to support business operations and continuity. (delgado et al., 2010; autio et al., 2018) research entrepreneurship and start-up success is connected to its technological foundation and its capacity to transform data into knowledge. (mccorke et al., 2013; guberti, 2015) research factors such as technological availability, ease of interaction, openness to advertisement, personalization and incentives aspects, have evolved the sms from a personal communication function to a key marketing tool. (hartemo, 2016; reimers et al., 2016) research equivalent to sms, permission-based e-mail marketing provides potential for greater customer involvement and engagement, while empowering their decisions (opt-in / opt-out). (church and de oliveira, 2013; modak and mambo, 2014) research mobile chatting applications provide companies with a cost effective (compared to sms) and more interactive (compared to e-mail) alternative channel. (al-suwaidi, 2013) research social networks have changed customer behavior and privacy concerns favoring a more connected and exposed personal life in terms of opinions, brands or product preferences. (dholakia et al., 2004) research social network community groups can bias customers' shopping preferences due to the group belonging and bonding feeling, as well as to social behavior pattern of "influencers and followers". (palmer and ponsonby, 2002) research "prosumers" (users that consume and generate their own social content) show a positive outcome regarding the effects of the social network to indirectly promote and advertise brands or products. (oh and teo, 2010) research hybrid online and offline selling channel approaches demonstrate positive effect on the overall personalized customer experience (integrated product and price information), as well as an increase in the perceived service quality. (haas et al., 2015) research the circular economy is considered an actionable way for companies (generating new business models and opportunities) and consumers (more conscious behavior and personalization) to reduce the waste generated and pollution. (chung et al., 2016) research social networks' pattern-based recommendation algorithms may provide customers with a more accurate product personalization than the actual self-customization approach. (safari et al., 2015) research companies relying on software-as-a-service or cloud-based solutions provide substantial opportunities for the business operations, such as cost reduction, agile decision making and scalability. (devaraj et al., 2002) research customers choose to buy from the online or offline channel based on platform familiarity, cost and service quality criteria. (kim et al., 2003) research the crm software success is linked to a customer-oriented model fed by continuous data sources, such as offline sales data, online sales data, online customer interactions, inventories and existing products. (berson et al., 2000) book general erp and crm software provides smes with cross-correlation of sales and customer data functionality to obtain information regarding smes' customer habits. (haanpää, 2007) research there is a global consumer pressure on smes for a circular economy and a greener business activity footprint. (herbig and milewicz, 1993; karaosmanoglu and melewar, 2006) research in addition to regulations, companies must adapt to the consumers' demands as they require to publicly express a waste reduction commitment through corporate social responsibility (csr) and actual facts. references specific to spanish environment (mincotur, 2020) website governments can have a strong positive impact on the local business ecosystem by providing companies with access to industry 4.0 information, technologies and financial credit facilities. (mincotur, 2019) report spanish government report pointing out that online commerce has been cannibalizing offline market share and that future investment in business digitization is essential. (ontsi, 2018 , ontsi, 2019 report spanish government report pointing to the barriers of smes towards digitalization and the related business issues derived from the lack of appropriate icts. (faedpyme, 2018) report report on spanish smes' digitalization achievement, corporate social responsibility (csr) and environmental management, as well as the investment situation in icts. (san-martín and jiménez, 2017) research the m-commerce-based strategy is found to provide spanish smes with a direct selling channel where the customer obtains a personalized value proposition, under a cost-efficient paradigm. (cid, 2012; casas, 2020) articles more restrictive regulations against mass texting and associated costs push spanish companies to explore new channels, such as mobile marketing or social networks. (incibe, 2017 (incibe, , 2018b report spanish government report regarding smes' cybersecurity threats, vulnerabilities and investments in icts. (incibe, 2018a) report spanish government report regarding smes' and customers' privacy adherence to gdpr regulation. from the point of view of digitalization, communication, customer habits, technological barriers and environmental constraints, which later on will act as a baseline for the e-receipt model validation. the novelty of this research is to validate the feasibility of the e-receipt conceptual model as an actual digitalization enabler along with its suitability aspects within the offline retail sme environment. retail smes. the industry 4.0 transformation provides more customer personalization options, as well as a streamlined production process, either for service or product, which all companies, regardless of whether they are a manufacturer or an intermediate (arnold et al., 2016) , can take advantage of to generate and create new business opportunities (fitzgerald et al., 2014) . the industry 4.0 model is of great interest as governments and international institutions pursue its implementation (mincotur, 2020) in society, both customers and businesses, by providing financial stimulus for smes to digitalize and improve their business models to be more competitive on national and international markets (autio et al., 2018) . digitization as digital procurement: according to gartner (gartner 2020b) , the digitization process can be considered as the internal process companies execute in order to purchase equipment, either new or refurbished, with digital capabilities such as sensors, connectivity or advanced information processing, which replaces existing obsolete or near end-of-lifecycle equipment. as the purchase of equipment is considered as a major investment, the companies are usually motivated to buy new hardware in two situations: (1) maintenance costs of existing equipment are higher than the cost of new equipment; or (2) to support the company strategy, such as creation of new products or increase of business capacity (porter and heppelmann, 2015) . despite the equipment upgrade, the digitization process does not necessarily imply a change of the business model (pricewaterhousecoopers, 2016) , it only increases the company's automation capacity and control over production. operations, interactions and activities involving customers or providers remain unaltered. digitalization as business model transformation: on the other hand, following gartner (gartner 2020a) , the digitalization process can be considered as the internal process that companies execute in order to transform their existing business model into a digitally-based business model where the ict (information and communications technology) is located at the core of the daily operations involving customers and providers into the business activity (pricewaterhousecoopers, 2016). the basis of the company's digitalization process is the actual digitization plan to acquire the necessary icts: on-premises equipment or equivalent cloud services subscriptions. without it, the digital transformation process cannot take place as the company lacks the necessary data inputs, processing capacity and data exchange mechanisms. as the digitalization process involves customers and providers, the company can take advantage of new business opportunities that were not previously explored due to their lack of feasibility (porter and heppelmann, 2015) : (1) interact with the customer, by means of social networks, websites, trends or direct communication channels to obtain data that can be further transformed into information (davenport and prusak, 1998) regarding habits and personalization preferences (chung et al., 2016) ; (2) apply this information to products or services to personalize or to create new ones that adapt to the customers' needs and formats (safari et al., 2015) , such as cloud paas (product-as-a-service) or saas (software-as-a-service) based; and (3) integrate with providers (delgado et al., 2010) to automate orders of goods, such as the drop-shipping model, or different shipping options, such as bikeriders or future drone-based methods. sms for business: sms remains an underexploited solution for business activities (mccorke et al., 2013; guberti, 2015) , especially due to the price (cid, 2012) and local regulations (casas, 2020) . offline retail smes: (1) normally do not send any confirmation messages, such as shipping delivery notices, pick-up confirmations; or (2) use them to interact with the customers, such as chat bots already being employed by other sectors; or (3) for marketing actions, such as periodic delivery of promotional brochures or coupon codes. unfortunately, sometimes sms is also used for unsolicited communication (spam) (casas, 2020) or illicit scams targeted to obtain an economic benefit. e-mail for commercial actions: with the extensive use of the internet, e-mail has become one of the most exploited business communication channels (hartemo, 2016; reimers et al., 2016) , and smes do at least one business activity by e-mail: invoices, quotations, support and helpdesk activities, advertisement, club membership, government paperwork, etc., at virtually no cost as compared to the sms or paperbased alternatives. as this is one of the most used communication channels around the world, it also becomes a target of unsolicited mass spam messages that the account owner never signed up to receive (karwal, 2015) , or even criminal actions such as targeted scams to obtain an economic benefit. e-mail service providers and government regulations try to fight and protect consumers from these kinds of actions. instant messaging mobile applications for business: instant messaging (im) applications can be considered as one of the most popular mobile applications categories and have completely surpassed sms in terms of exchanged messages figures (church and de oliveira, 2013) . some smes have adopted the im mobile channel with relative success (amirkhanpour et al., 2014) , but with some limitations as the actual applications are designed for personal communication rather than business purposes. nowadays, im applications try to replicate the same personal communication success story, but in a b2c (business to consumer) communication context (modak and mambo, 2014) , where the business owners can interact with their customers in an easy and convenient way by making use of existing im applications (jubin, 2015; katre, 2016) . these new ims' features for business are expected to include business information, business hours schedules, automated chat bots that reply to customers' requests or crm (customer relationship management) integration. social networks for business: the power of social networks has changed social habits (brown, 2015) . social networks connect millions of users together, which opens new marketing opportunities for any kind of business activity, including the social network itself, a major part of whose income comes from advertisement services (charlesworth, 2014) . the first social networks were merely closed groups of friends that shared specific content and were very concerned about privacy; as opposed to the new generation, the so-called digital natives, who have overcome the fear of privacy (al-suwaidi, 2013) and not only publish, but expose their personal life in the role of "influencers" of other users. this shift of habits affects marketing campaigns, as today's social network users demand experiences, want to know more about products or services and their added value (guberti, 2019) , care about the environment and demand a personalized service; whereas most smes do not even own a social network account (ontsi, 2019). however, customers also criticize errors and mistakes (charlesworth, 2014) , therefore, companies are forced to keep up with reputation indexes and develop comprehensive marketing strategies (camarero izquierdo, gutiérrez cillán and san martín gutiérrez, 2005) leading to new business models and new job titles, such as community manager. large companies have noticed that corporate website use has fallen in favor of social networks, therefore in order to preserve contact with their customers, some have developed chat bots that automatically reply to users' enquiries by means of direct messages chats. demanding experiences: the retail consumer's buying patterns have shifted from simple economic transactions to experiential transactions (dholakia et al., 2004) . the latest generations, from millennials onwards, changed their consumption habits, preferring to rent or pay per use; and they demand information regarding the production and origins of the raw materials. as social networks have a tremendous impact, companies now create special online customer experiences to enhance the brand or product awareness (aaker, 2011) , where top influencers evangelize how the customer experience should be, promoting the experience of shopping for that brand or the use of the product, instead of the traditional "buy this product" advertisements (palmer and ponsonby, 2002; charlesworth, 2014) . social network channels promote a differentiation strategy by creating a story behind the product or brand, making them unique (evans, 2010) ; and positive feedback, such as like or love buttons, as well as posting comments or retweets, increasing the customer interaction and impact of the product or brand (kerpen, 2011) . ecommerce websites provide automated product recommendations following customers preferences, using a clean and straightforward user interface with outstanding "buy" and "check-out" buttons, as well as a rating score, such as stars or similar shape, based on previous published customers' feedback (amirkhanpour et al., 2014) , delivering a very lean customer experience where the buying process is simplified and, together with virtual money wallets, reduces the stress of paying: customers obtain the product they were looking for and achieve the satisfaction of a good investment based on the positive reviews in a hassle-free transaction process. personalization and customization: customers expect and demand a product or service that fits their needs and not the retailer's or the manufacturer's needs (oh and teo, 2010) , where shared economy and circular economy require retailers to customize their products to the new consumer habits (haas et al., 2015) . many offline retailers complain and criticize how their customers stopped buying specific goods and tend to rent or to share them as a service: the tendency is that the shared-economy model is changing the whole society, including businesses. customers are not only expecting a personalized product or service according to their needs, but also customized in shape, color, format or delivery options (chung et al., 2016) ; companies must adapt themselves to the new business models of shared economy and circular economy, otherwise they will struggle to meet the market's needs and expectations (charlesworth, 2014) . despite industry 4.0 (mincotur, 2020) transforming goods production and distribution by means of process digitization (arnold et al., 2016) , the offline retail sme market is struggling to satisfy customers' shopping expectations due to two direct constraints: existing offline competitors operating under a narrowing market share; and online retail competitors increasing market share due to their better positioned ecommerce it platforms (safari et al., 2015) . technologically, all offline-based smes acknowledge the fact that online commerce has been cannibalizing offline market share and that future investments in business digitization are essential (mincotur, 2019). table 2 depicts the position of non-it platform-based offline retailers as compared to it platform-based online retailers. it platform-based online retail businesses, as opposed to non-it platform-based offline retail businesses, where business decisions are usually based on intuition due to lack of supporting data, have a deeper understanding of their customers regarding demand forecasting and shopping experience customization (san-martín and jiménez, 2017), as they continuously collect behavioral information across the whole shopping process (turban et al., 2009 ): (1) shopping patterns and conversion paths; (2) cross-sale information and trending sale information; (3) customer segmentation, micro-segmentation, conversion and retention rate; (4) customer targeted promotions based on historical transactions; and (5) cross-channel performance measured by inbound traffic on social networks. average offline sme retailers, with the exception of medium to large enterprises that allocate specific budget for business digitization to achieve digitalization (faedpyme, 2018; ontsi, 2018) , lack the appropriate instruments to collect customer behavior data or to elaborate adequate insights (ontsi, 2019): (1) existing software mainly focusing on accounting and erp (enterprise resource planning) aspects; (2) under-utilized or non-existent crm (customer relationship management) software; (3) non-existent customer or sales analytics tools as they are perceived as high complexity and time-consuming tasks to be done the business owners; (4) new software is normally not in the scope of the annual budget and bears an investment risk with an associated roi (return on investment) assumption; (5) new software is perceived as time consuming as it requires support, training and optionally new hardware installation; and (6) new software is perceived as providing too many features not required for the daily business activities or not completely fitting the business model. in general, offline sme retailers focus on sales figures and reports (faedpyme, 2018), but they do not correlate that data into a crm system, thus they cannot extract information regarding customer habits (berson et al., 2000) . one of the most valuable types of data a retailer possesses is sales data, as it provides traceability to each and every transaction executed in the business activity. but this data is not relevant in itself unless it is correlated with customers. some businesses implement this correlation by means of member club cards, where a customer provides the member card in order to get a benefit such as a discount or personalized promotion. the strategy behind this is to correlate the invoices to a specific member who previously provided some personal information in order to join the club; this way the company can compile statistics and extract patterns from invoices, and provide personalization based on consumers' habits and preferences. due to the nature of the ecommerce, where everything is digital, all transactions are conveniently stored in the erp database ready for crm analytics (devaraj et al., 2002) . in addition to the sales data, different aspects of user website behavior can be added, such as: (1) reference to how the user arrived on the webpage; (2) historically what products user has been looking for; (3) interest, in the number of times the product was displayed; (4) urgency, as the time duration buying the product. combining all this information, ecommerce can then adjust the 4 ps marketing theory: product reviews, placement and recommended products, price adjustments and promotion on the landing page. on the other hand, for an offline retailer this normally stays only at transactional level, without exploitation of the crm information (kim et al., 2003) , with the retail manager in charge of the 4ps: product review and quality check, placement on the shop floor, price adjustments based on intuition and promotion based on traditional advertising formats; relying on personal experience and empirical experiments. based on these facts, there seems to be an important gap between online and offline retail segments, where offline faces multiple difficulties in identifying and attending to customers' needs. there is global demand from consumers for a circular economy and waste management (haanpää, 2007) , as well as a number of regulations aiming to reduce the footprint of business activity on the environment (mincotur, 2019) . from the point of view of the environment, the society as a whole is increasing awareness regarding the human activities generating waste and how these actions negatively impact on nature (aaker, 2011) . business activities, by means of srb/scr (social responsibility of business/ social corporate responsibility) commitment (herbig and milewicz, 1993; faedpyme, 2018) regarding green initiatives and reducing waste as part of the daily activity, are expected to be as environmentally friendly as possible, at the same time lowering their environmental footprint (karaosmanoglu and melewar, 2006) . cybersecurity is one of the major concerns worldwide and stands as one of the most important topics within companies' digitization and digital transformation, as illicit hacking actions are expected to become more and more frequent (incibe 2018b; ontsi, 2019) . on the other hand, privacy is another top priority item as spanish lopd (organic law on data protection) and international gdpr (general data protection regulation) regulations are constantly evolving (incibe 2018a) while customers are becoming more conscious of their digital fingerprint, where failing to comply with the standards on data collection and data processing could lead to substantial fines for smes. the study is based on data collected from a wide range of official sources in conjunction with extensive international and spanish research specifically identifying and describing the sme offline retail market status in terms of multiple aspects, such as digitalization, communication channels, customer habits, technological barriers and environment, selected by the authors as fundamental to understand and place companies in their exact technological position with regards to the market status and their competitors from both offline retail and online retail-based companies, as well examining the applicable technologies for this sme segment. based on the identified literature and market gaps, a conceptual model regarding e-receipts as digital enablers covering its technological components, user interaction flow and analytics within the offline retail sme transformation context has been elaborated to be further validated within focus group activity, consisting of approximately 30 min (excluding wrap-up and clean-up steps) of semi-structured, faceto-face interview sessions with different offline retail sme management-related key personnel who agreed to participate in the research. the henares corridor, madrid (spain) area has been considered as highly relevant for this study as it overlaps offline and online retail smes as well as major e-commerce logistic centers, such as amazon. initially, a total of 95 local offline retail smes were contacted by e-mail during the months of june and july 2019, asking whether they were willing to participate anonymously in an economics research project involving a face-to-face, short discussion session (table 3) after or before the close of business hours with someone who had a role related to management functions. from the total number of contacted companies, only 11 replied to schedule a date for the interview, while an additional nine delayed replies were received between september and october 2019. therefore, the hypothesis of the e-receipt as a digital enabler has been contrasted on the basis of an empirical research study of a focus group methodology involving the participation of a total of 20 offline sme retailers who were presented with the e-receipt conceptual model, segregated into a first set of 11 participants following a semi-structured evaluation questionnaire answered based on their hands-on business experience regarding the relevance of the e-receipt within the participating retail companies and about how the envisioned e-receipt solution could fit into their daily operations; together with a second set of nine participants while writing the article in order to fine-tune the first set of focus group outcomes. retail companies could provide invoices using both paper support and digital support in order to accommodate each customer's preferences. by providing an electronic receipt or e-receipt, the companies could associate the invoice with a customer and could analyze that information (berson et al., 2000) in an anonymous way or in a personalized way, if the customers have previously provided their consent and personal information. the e-receipt solution (fig. 1) could be developed by third-party cloud-based technology companies and provided to companies following a saas (software-as-a-service) model (safari et al., 2015) , on a monthly subscription plan to mitigate the financial impact on the business activity. the next section describes one fig. 1 . e-receipt technological components example. own elaboration. gavrila and a. de lucas ancillo technological forecasting & social change 162 (2021) 120381 of the many possible e-receipt models, following a holistic analysis regarding the most relevant modules, expected functionalities and conceptual user interface. nevertheless, the authors must state that the hypothesis of the e-receipt has been formulated independently of any possible resemblance of existing patents or existing solutions. the e-receipt could be implemented as a third-party service on a cloud platform (fig. 1-1.1) , where retailers could integrate their pos (point-of-sale) software (mijanur rahman and ripon, 2013) by means of a dedicated desktop connector installed on the company's premises. this simple connector would act as an interface between the sales software database and the e-receipt database. each time a transaction is done, the connector would synchronize the database information and would generate a new digital receipt entry. every time a transaction is done, the cashier would ask the customer the preferred receipt format: paper-based or e-receipt. if the customer wants a digital receipt, the cashier would ask for the preferred communication channel and input that information, such as e-mail address, social network profile, via the connector's virtual keyboard or phone number using the numeric keypad, and finally would press the send button. any information is optional as the customer can easily provide it within the url access link. the e-receipt desktop connector would synchronize ( fig. 1-1.2) with the e-receipt cloud platform exchanging the sales information and associating the transaction with the provided customer identification data. after the information is uploaded on the cloud platform, it would be automatically processed, and the digital receipt would be sent to the customer phone through the appropriate communication channel. the e-receipt platform ( fig. 1-1.3) would not only be a cloud-based solution that would avoid the ownership of on-premises hardware, software licenses or associated costs of support and maintenance, but would also be deployed as a saas (software-as-a-service) distribution model where the e-receipt solution would be provided as a pay-per-use application service where companies would only pay for a monthly subscription fee including all associated hardware, software licenses, support and maintenance costs and would only need to subscribe the capacities required for their operations, eliminating any technological entry-barriers. from the financial point of view, the saas model would avoid companies making any kind of up-front investment in elements not considered part of the business core; and from the accounting point of view, companies would consider the monthly fee as part of the daily activity. the e-receipt cloud platform ( fig. 1-1. 3) would be in charge of: (1) permanently storing all the received transactions and crosschecking them with the customer identifier; (2) distribution of the e-receipt information according to the communication channel provided; (3) providing a permanent url database for e-receipt retrieval together with the e-receipt information upon retrieval request; (4) advertisement display management together with digital data treatment management (opt-out and opt-in of customers in compliance with privacy regulations); and (5) analytics services. upon receiving a transaction from the company's pos e-receipt plug-in connector, the e-receipt cloud platform would automatically distribute it (fig. 1-1.4) virtually on any kind of communication channel as preferred by the customer. from the technical point of view, the e-receipt could be implemented on any communication platform, potentiating the customer's communication relationship and multichannel presence such as sms, e-mail, social networks or even im mobile applications. companies could hold multiple communication strategies such as providing an sms-only option as a fallback for older people or for non-social network users, and an e-mail or social network channel for other interested customers. the customers would receive a notification message via their preferred communication channel containing brief information regarding the company, such as name and store location, sending the notification as well as an online short url (uniform resource locator) unique access code to retrieve the e-receipt. the customer could retrieve ( fig. 1-1.5 ) the e-receipt at any time by opening the provided url unique access code that would open a web browser to access the e-receipt responsive front-end ui regardless of the accessing device, such as computer, tablet or mobile. customer could share the url with any other person or third-party applications, such as house accounting or digital notebooks for their own record. the e-receipt responsive front-end ui elements could take into consideration the following minimum items (fig. 1): (2.1) advertisement banner, that could be based on the advertisement display system as part of the e-receipt platform analytics feature; (2.2) legal information area, mandatory as per paper-based receipt related regulations; (2.3) transactions information area, mandatory as it describes the transaction status; (2.4) barcode area, mandatory for barcode scanner; (2.5) qr code area, which could be used for sharing the e-receipt; (2.6) social network area, which could be used for sharing or storing the e-receipt within social networks accounts; and (2.7) an unsubscribe url, that could be used for adjusting the privacy configuration, such as how data is collected and processed, within the e-receipt platform. finally, the e-receipt platform would provide analytics ( fig. 1-1.6 ) to the retailers regarding their customers' activity, where the e-receipt dashboard could be considered as its core and would provide meaningful information regarding the most important aspects of the sales activities: (1) sales analytics insights: the sales dashboard could contain the daily, weekly and monthly sales reports to be compared for performance and to support the business decisions; and the products performance dashboard could provide insights of top selling products as well as top margin leading products; (2) advanced analytics module insights: the cross-sales dashboard could provide the most relevant product pairing that could fit other customers based on sales data; automatic reports could contain customized reports that could be triggered upon specific conditions, such as "lower than x amount sales" figures, and could be sent automatically to the specified e-mail addresses; periodic reports could contain customized reports that could be scheduled or sent periodically, such as "weekly average sales on x product category", to the specified e-mail addresses; and the multistores benchmark could be a specific feature for businesses that operate more than one store and might want to compare sales performances between them; and (3) customers performance insights: the visit counter could display how many times a customer is visiting the store and historical transactions record; the loyalty index could be an automated index rate based on the historical transaction record, including return rate of products and digital tickets number of visits; and targeted campaigns could propose advertisement actions based on the sales analytics data to engage the customers in a personalized shopping experience. by reviewing the extensive available international and domestic literature, by designing the e-receipt conceptual model and by validating it using a focus group methodology, as described under their corresponding sections, the potential of e-receipt as a digitalization enabler has been positively concluded, together with a relevant number of outcomes (table 4 ) regarding the applicability dimension of e-receipt within offline retail smes. local regulations require offline retail smes to provide a printed receipt to their customers upon the execution of any kind of commercial transaction; without any added value to customers or the company itself. on the other hand, thanks to companies' digitization (gartner 2020b) , such as the procurement of new software or cloud subscriptions, companies can take advantage of these digital enablers and take the opportunity to pivot the paper-based receipt towards a digital accelerator in the form of an electronic receipt or e-receipt. this approximation can be considered as an example of business digitalization (gartner 2020a) or "digital transformation", as the receipt is not only being digitized from paper format, but its final use and purpose is repositioned to generate new value propositions and business opportunities (faedpyme, 2018) in the offline retail market: where customers benefit from a digital e-receipt copy for permanent storage while reducing paper waste; and companies enhance customer fidelity based on sale analytics data never before exploited in the offline retail channel. smes' digitalization process is generating new market needs (fae-dpyme, 2018), where software providers take advantage of the potential gaps and develop cloud services based on the subscription model, such as saas (software-as-a-service) (safari et al., 2015) , allowing them to reach more companies than before, as due to the cloudbased architecture the platform is scalable in performance, accessible online from any place, and the subscription-based costs are no longer an entry barrier. consequently, smes are adapting to these market changes (fig. 2) : companies have stopped buying complete in-house software solutions and consider contracting them as an external service based on a monthly rate while reducing expenses and lowering the investment risk (ontsi, 2018) . therefore, the existing smes technological barriers disappear in favor of new business opportunities (ontsi, 2019): (1) upgrading to new features or web-based functionalities erp (seethamraju, 2015) ; (2) integration of simple and efficient sales analytics tools within the web erp plug-ins database; (3) deployment of simple and efficient webbased crm software (berson et al., 2000) ; (4) simple to calculate software ownership costs together with a clear monthly fee accounted for as a cost part of the daily activities rather than an investment; (5) reduced investment risk: if the software does not fit the purpose it can be simply canceled without any penalties or depreciation of the hardware or software, as the whole platform is external and located on the cloud platform; (6) saas reduces the required support needs as all the technical maintenance is done by the provider, while the company can focus on the training and how to get the most out of the product; (7) saas products provide subscription plans based on the requirements of each company so it can select the plan that fits best; and (8) providing the latest version and updates of the platform, therefore reducing the risk and need of buying additional software or periodic upgrades, that not only cost money, but can also break feature compatibility with older versions or other companies' software. as the e-receipt provides a deeper understanding of the customers based on the collected analytics, habits and preferences, companies can interact following the most adequate communication channel or mix of channels, as best considered (fundación telefónica and red.es, 2015; ontsi, 2019) : (1) sms channel: in addition to the integration with the e-receipt for url distribution, can be used for basic information such as confirmation messages, delivery notice, pick-up confirmation, interact with the customers by means of chat, or for marketing actions such as periodic delivery of promotional brochures or coupon codes with unique reference number for further analytics purposes. nevertheless, the cost of the sms will always limit the scope of action; (2) email channel: to be exploited as a cost-effective alternative to sms for e-receipt platform in combination with e-mail marketing campaigns regarding promotions and new products, as well as to act as a bridge towards social networks interaction; (3) instant messaging for business: companies can replicate the e-receipt interactions from sms and e-mail channels virtually at almost no cost, while including business information, business hours schedules, automated chat bots that reply to customer requests, and crm integration; and (4) social networks: can provide a private e-receipt interaction by means of direct messages features, or create shopping experiences as the customers want to know more about the product or services, their added value, their impact on the environment and what kind of personalization is provided. the e-receipt platform helps companies grow their business by transforming the traditional retail approach into a digitalized hybrid solution (faedpyme, 2018; ontsi, 2019) based on sales information not fully exploited before: (1) improved market response: by knowing the sales trend, the customer can anticipate to the next super-sale product or to the next sale-season demands; (2) improved customer reaction time: insights providing deep information regarding the customer lifecycle, empowering companies to take marketing actions that pursue everchanging customer preferences; (3) improved proactive actions: on the floor store operations, such as pricing and promotion, can be done based on real store metrics just when they occur; (4) improved data collection: providing additional sources of information, such as number of accesses to the platform, customer interest index, returning customers, return product rate, among others, that provide companies with new perspective regarding the customer segmentation; (5) templatefig. 2 . conceptual software-as-a-service lifecycle cycle in smes. own elaboration. based scenarios: intuitive and easy to use platforms facilitate companies in the creation of their own reports and access to meaningful insights without the need of expensive training or third-party applications; and (6) faster results and communication: the customers can target marketing campaigns in real time and establish direct communication faster than any other paper-based, radio or television channel. despite social network campaigns targeting the most demanded products or services, they should not be limited only to those, as the crm and e-receipt can provide cross-sales information (berson et al., 2000) , the companies can focus on the rest of the sales drivers, differentiating themselves from their competitors and engaging with their customers in a more personal approach providing not just a product (chung et al., 2016) , but a complete solution, such as a complete outfit for a target occasion. based on the information collected, they can adapt the tone and messages expected by their customers (devaraj et al., 2002) , and can segment based on the specific url reference used to access the publication, according to the origin of the actions, such as sms, social network or im. as an underlying conclusion, smes must improve their social network strategy as today there is a major gap between business activity and the customers (ontsi, 2019). when customers turn to the offline retail channel, they expect and demand a similar process, however there are different human aspects not taken into consideration that can negatively affect the customer experience: (1) the retailer might not have enough time, motivation or knowledge to assess the customer's questions. the customer is required to search online for the technical questions or comparison, and probably will end the transaction online on a competitor's website rather than in an offline store; (2) prejudice regarding the retailer, such as physical look or behavior, may encourage or discourage the transaction, as opposed to ecommerce where there is no human contact. the retailer may try to bias the customer, such as promoting a specific brand and may potentially hide information, such as available stock or quality issues. the retailer may lose the transaction if the customer discovers the shopping process is being manipulated. customers are not only expecting a personalized product or service according to their needs, but also customized in shape, color, format or delivery options, and companies need to integrate the customer analytics information from a crm and e-receipt platform in their business models, or they could struggle to satisfy the market needs (minco-tur, 2019). this process involves all the supply chain: (1) the producers need to be able to satisfy the market demand in terms of quality, price and characteristics; (2) shipping companies need to accelerate the delivery of the products; (3) intermediaries or aggregators need to add special values or disappear from the process; (4) retailers need to reduce stock and offer more personalization options, and diversify their providers or producers so they can create new and unique products according to their customers' needs. finally, they must collect and analyze the customers' trends to anticipate and provide a personalized catalog of products or services. the paper-based commercial advertisement is based on generic promotions to call customers' attention and pursue them to finalize an economical transaction. however, those promotions target many segments and they are required to run for a large amount of time, such as on a monthly or weekly basis. the e-receipt advertisement feature is highly appreciated by offline retail smes as it provides an additional mechanism to reach customers and engage them in the shopping process (fundación telefónica and red.es, 2015) . companies can make use of the self-service e-receipt platform to create their advertisement campaigns based on their own designs or on existing templates without the need of external help. the e-receipt platform by cross-referencing the sales patterns and customers' information has the potential to transform advertisements and discounts into a personalized shopping experience (camarero izquierdo, gutiérrez cillán and san martín gutiérrez, 2005) , while establishing a continuous communication channel with the digital subscriber customers (chung et al., 2016) where they receive promotions based on their real interests, which compared with the paper-based version would require a lot of resources, such as printing and distribution, and generate a lot of paper waste. those promotions could be accessed in real time by means of the multiple available channels such as sms, e-mail, im or social networks, and they could have a limited duration based on the retailer's needs. the deployment of an e-receipt solution is found to create a positive impact on the society by reducing the environmentally-generated paper waste in an actionable way (anderson and cunningham, 1972) . offline retail smes perceive it as a tangible and economical approach to reducing their waste footprint, especially when they are receiving a lot of pressure from the srb/scr (social responsibility of business/ social corporate responsibility) intentions that are more and more demanded by the society (faedpyme, 2018): (1) reduce paper waste: by means of using a digital copy, the paper version is not needed anymore. the impact can be then measured in economic terms such as cost of the paper rolls or in number of saved trees; (2) go green initiative: as the whole society is targeting being greener (mineco and corrales, 2011), both companies and customers can participate in this aim by choosing a digital copy instead of the paper versions. companies, despite their good will and good intentions of going green, need to evaluate the real cost involving this action (minco-tur, 2019), and here the e-receipt solution based on cloud and softwareas-a-service leverages the risks, which instead of requiring a big investment works seamlessly with the current platform at a very low monthly rate; and (3) stop losing tickets: from the customer point of view, a big advantage over the paper-based version is that the digital receipt does not deteriorate and is always available in a convenient format. consequently, customers only have to access the permanent url to access the full information and cross-check the transaction details. on the other hand, the business only needs the unique receipt reference to get access to the transaction elements for any modification. from customers' it security perspective, they seem more likely to use dedicated cloud-based e-receipt services rather than on-premises solutions that may not protect their privacy and data. similarly, companies are found to be keener on storing e-receipts on a cloud solution rather than storing them on site (incibe 2018b) . this is due to the fact the cloud solutions are perceived as more secure as the cloud datacenters have dedicated cybersecurity teams, more advanced than any other solution a retail sme could deploy; but also due to technical reasons such as maintenance, uptime or backups that are normally performed by cloud datacenters experts, more skilled and reliable than sme office-level it employees. the e-receipt solution is found to help improve customers' privacy, as they would be empowered to decide what commercial actions, such as analytics, advertisements, and third-party information sharing, are subject to the data they generate, by means of automated and confidential opt-in and opt-out selection built within the platform (incibe, 2017) . without technological automation, these processes would take very large amount of time and resources affecting both business activity and customers' privacy. as highlighted from the researched literature, offline retail smes are urged to position themselves and embrace the digitization and digital transformation of their processes in order to pivot their business model towards a customer-centric approach involving suppliers, providers, manufacturers, shipping companies, multi-channel communication, product or service customization and personalization; all within the context of the ever-growing circular and sharing economy. smes are forced to adapt to the everchanging market rules and trends in order to remain competitive, not only on the spanish market but also at the european and international level, where the offline retailers are expected to transform themselves into value-added aggregators to differentiate themselves from the better prepared online ecommerce platforms as well as other offline retailers, as opposed to being mere intermediaries. fortunately, the digital barriers due to the technological platforms' complexity are now leveraged due to the third-party software providers developing software-as-a-service cloud solutions, which bring smes affordable and customized solutions without the software and hardware maintenance inconveniences. more than ever, smes need these digital enablers to help them accelerate their business transformation: (1) to integrate with third-party partners participating in the delivery of the products or services; (2) to collect data during the whole transaction process; (3) to collect data regarding customers on all multi-channel dimensions; (4) to analyze and process that data to extract information regarding the next advertisement steps together with personalization and customization strategies; and (5) to comply with cybersecurity, customer privacy and environmental concerns. in an effort to assist and accelerate that digital transformation, the research has constructed a hypothetical e-receipt technological scenario, describing the platform components regarding possible cloud-based synchronization, multi-channel delivery, optimized user interface, advanced advertisement and analytics functionalities, among other aspects, which address the identified smes' shortcomings, such as industry 4.0 deployment, customers' ever-changing habits, technological barriers, narrowing market due to ecommerce and other offline competitors, as well as strong environmental pressure; and providing an achievable and easy-to-adopt digital enabler within the business activity while delivering tangible value for both customers and companies. practical implications: the research, the process of which has focused on offline retailers and has evaluated comprehensive literature material together with an extensive source of secondary information, envisioning an e-receipt conceptual model for offline retail smes while empirically contrasting and fine-tuning the outcomes within with a focus group of 20 spanish offline retailers, as described within the methodology section, points to the fact that the provision of certain cloud solutions associated with e-receipts, such as gdpr compliant electronic receipts sent to personal e-mail addresses or by sms to mobile phones, offered as a value-added service enabler to their customers, could facilitate spanish offline retail smes in both digitization and digitalization processes: • customers benefit from e-receipt for permanent storage while reducing paper waste to the environment; • smes benefit from a tangible srb/scr (social responsibility of business/ social corporate responsibility) commitment regarding go green initiatives and reducing paper waste as part of the business activity; • smes benefit from a proper instrument that collects shopping behavior data not exploited before and analyses that data to get internal insights aimed to personalize customers' shopping experience. training remains mandatory to properly operate the platform; • smes benefit from an automated cloud platform with no on-premises hardware, based on a periodic subscription model without any initial upfront investment needs; • smes' business model pivots from a generic and static approach to a hybrid online-offline and personalized customer experience approach; • smes' business model pivots from a product-centric to a solutioncentric model, driven by collected customer behavior information and product lifecycle information; and • smes' business model, as part of the customer product customization, can easily expand and integrate circular economy business model principles, such as collaborative sharing, product-as-a-service options, refurbishing or taking care of the end of the product lifecycle, to expand income sources as well as to cover unattended market segments. theoretical implications: however, the underlying objective of the e-receipt hypothesis as a digital enabler is to provide smes, independently from their market segment, with a comprehensive understanding regarding the challenges associated with the digital transformation process by starting from conceptualizing a mere theoretical model up to the actual integration of it as part of day-to-day business activities, supporting and extending the theoretical baseline of the research. • digitization: this can be considered as the procurement process by which companies purchase new equipment that converts analogic parts of the company's processes into digital (gartner 2020b) . despite the equipment upgrade, the digitization process does not necessarily imply a change of the business model; it only increases the company's capacity of production automation and control over it. the company operations, interactions and activities with customers or providers remain unaltered; • digitalization: this is considered as the internal process that companies execute in order to transform their existing business model into a digital-based business model where the ict (information and communications technology) is located at the core of the daily operations involving customers and providers to the business activity (gartner 2020a); • the necessity of digitalization in their businesses: as opposed to ecommerce, the offline retail smes market is struggling to satisfy customers' shopping expectations due to two direct constraints: the existing offline competitors operating under a narrowing market share, and the online retail competitors increasing market share due to their better positioned ecommerce it platforms (ontsi, 2018) . technologically, all offline-based smes acknowledge the fact that online commerce has been cannibalizing offline market share and that future investments in business digitization are essential (fae-dpyme, 2018); • multi-channel communication for customer experience and customization: based on the information collected companies can adapt the tone and messages expected by their customers (hartemo, 2016; reimers et al., 2016) . the e-receipt platform could provide multiple url reference numbers according to the origin of the actions, such as sms, social network or im (amirkhanpour et al., 2014); • the existence of accelerators such as e-receipts cloud solutions: this not only provides a digitized version, but its final use and purpose is repositioned to generate new value propositions and business opportunities in the offline retail market, where customers benefit from a digital e-receipt copy for permanent storage while reducing paper waste; and companies enhance the customer fidelity based on sale analytics data never before exploited in the offline retail channel; • saas delivery as a solution to technological barriers: software providers take advantage of the potential gaps and develop cloud services based on a subscription model, such as saas (safari et al., 2015) , allowing them to reach more companies than before, as due to cloud-based architecture the platform is scalable in performance, accessible online from anywhere and the subscription-based costs are no longer an entry barrier; • the disruptive potential of digitalization to their business models on long-term survival regarding competitors and raising the circular economy: undoubtedly the e-receipt has a disruptive potential of enabling smes' digital transformation by involving customers in the business activity while generating new value propositions and business opportunities in the offline retail market, where customers are not only expecting a personalized product or service according to their needs, but also customized in shape, color, format or delivery options (haanpää, 2007; mincotur, 2019) by strengthening this relationship, companies can differentiate themselves from their competitors and engage with their customers in a more personal approach by taking advantage of the multi-channel communication, providing not just a product, but a holistic solution involving the principles of the shared and circular economy, based on collected information regarding their new shopping behavior (ontsi, 2019); and • environmental involvement to create a positive impact on the society: by reducing the environmental generated paper waste in an actionable way, companies perceive e-receipt as a tangible and economical approach to reduce their waste footprint (herbig and milewicz, 1993; faedpyme, 2018) . as in any investigation, there aresome limitations of this study. despite the positive outcomes regarding the e-receipt as a digital enabler application to smes, the authors have identified some specific areas that should be taken into consideration regarding the interpretation of the results and future works related to this study. (1) market limitations: one limitation is the actual analyzed market segments, where the study was focused specifically on offline retail, leaving room for further analysis regarding additional segments where e-receipt could also be considered as fit for purpose; (2) geographical limitations: as the study was conducted in the spanish environment, there is an option that not all outcomes could be extrapolated to other international markets, hence the requirement of further investigation regarding the applicability of e-receipt to more widely international smes; (3) methodology limitation: as the focus group methodology could provide biased outcomes due to the discussion context and qualitative aspects, as compared to a survey-based approach which could provide quantitative comparable results; and (4) some theoretical framework-related limitations: despite multiple software patents available in the market, there is a lack of specialized literature regarding e-receipt applications and how smes could practically adopt these improvements, consequently limiting the overall applicability of the identified study outcomes. although the scope of the paper is limited to the above-mentioned conclusions, the following section outlines several possible lines of action to guide future investigations regarding this subject matter: (1) international market research: inevitably, research should be expanded to benchmark against other european or other international markets and how they might behave against similar technological circumstances. one possible example would be united states smes, which are showing a considerable propensity not only to embrace new technologies but also to lead in the creation of new business solutions through silicon valley and other start-up ecosystems; (2) e-receipt kpi and user behavior analysis: this line of research may focus on the identification of kpi and relevant user behavior analysis within the offline retail sme environment; together with the know-how to capture and extract such information in order to be able to take the appropriate decisions; (3) investigate other e-receipt solutions and implementations: another area of opportunity is to research the technological components and platform solutions that could improve the application of e-receipt in smes. this line could describe the interaction between the modules and the ict requirements regarding the cloud platform, delivery, synchronization and retrieval of receipts; and (4) how e-receipt empowers customers' privacy: this approach could evaluate the psychological and social consequences regarding customers' privacy in a digital context where all the information is publicly exposed, and how the e-receipt platform could empower customers privacy in providing opt-in and opt-out features regarding the treatment of their data. finally, this paper tries to envision the future of the offline smes but does not intend to limit itself only to the aspects described herein and invites future researchers to take the initiative on the results of this research and further develop them, extracting new knowledge regarding smes' digital transformation. table 2 . position of non-it platform-based offline retailers as compared to it platform-based online retailers. own elaboration. non-it platform-based offline retail it platform-based online retail decisions based on intuition due to lack of supporting data. data-driven decisions supported by business data. slow reaction time based on observed occurring trends. fast reaction time based on early detection of trend patterns. reactive business actions. proactive business actions. under-utilized or non-existent customer behavior information. continuous customer behavior information collection. lack of customer behavior analysis tools. dashboards providing historical patterns and behavior analytics. semi-structured questionnaire used during the face-to-face focus group activity. own elaboration. focus area e-receipt discussion aspects discussion area e-receipt as digitalization enabler due to the use of software-as-a-service (saas) and cloud technologies-based e-receipt model, leading to new business opportunities, upgrades to new features, integration of sales analytics tools with less hardware and software maintenance. due to a deeper understanding of the customers based on the e-receipt collected analytics, habits and preferences, the companies can develop the most adequate communication channel or a mix of multiple channels, as best considered, creating shopping experiences regarding products or services, their added value, their impact on the environment and what kind of personalization is provided. as the e-receipt could provide an overall improvement of the market response, customer reaction time, stimulating proactive decision-making, within an improved data collection and detailed reporting process. due to the integration of customer analytics information from crm and the e-receipt platform in their business models, customers could obtain a more personalized product or service according to their needs, together with customized shape, color, format or delivery options. due to the creation of an additional mechanism to reach customers and engage them into the shopping process, such as e-receipt advertisement features where customers could receive promotions based on their real interests, which compared with the paper-based version would require a lot of resources, such as printing and distribution, and generate a lot of paper waste. as a tangible and economical approach to reduce business-activity-generated waste footprint, by means of using e-receipt digital copy the paper version is no longer needed, where the impact can be measured in economic terms using the cost of the paper as a reference index. cybersecurity stands as one of the most important topics within companies' digitization and digital transformation, where e-receipt cloud-based solutions are perceived as secure due to the datacenters' advanced cybersecurity resilience. on the other hand, the e-receipt solution is found to help improve customers' privacy, as they would be empowered to decide what commercial actions, such as analytics, advertisements, third-party information sharing, are subject to the data they generate, by means of automated and confidential opt-in and opt-out selection built within the platform. eight characteristics of successful retail concepts from tribe to facebook: the transformational role of social media mobile marketing: a contemporary strategic perspective the socially conscious consumer how the industrial internet of things changes business models in different manufacturing industries digital affordances, spatial affordances, and the genesis of entrepreneurial ecosystems social media marketing: how to build and execute your own social media strategy the impact of customer relationship marketing on the firm performance: a spanish case what 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marketing, social media marketing how to use whatsapp for business -5 tips with examples likeable social media a model for evaluating the effectiveness of crm using the balanced scorecard the antecedent effects of sms marketing on consumer intentions elicitation and modeling non-functional requirements -a pos case study marco estratégico en política de pyme 2030 la responsabilidad social empresarial en la pequeña y mediana empresa dancing with whatsapp: small business pirouetting with social media consumer value co-creation in a hybrid commerce servicedelivery system the social construction of new marketing paradigms: the influence of personal perspective how smart, connected products are transforming companies capital projects and infrastructure (cpi): pwc. available at permission email marketing and its influence on online shopping the adoption of software-as-a-service (saas): ranking the determinants a typology of firms regarding m-commerce adoption. mobile commerce 550-565 adoption of software as a service (saas) enterprise resource planning (erp) systems in small and medium sized enterprises (smes) introduction to electronic commerce the economic effects of a pandemic since september 2017 has been working on multiple international research and development projects regarding virtual reality, data analytics, cybersecurity, air traffic management and unmanned/ drones traffic management within industrial applications at indra company his-academic experience includes: schools of tourism and economics, faculty of economics & business and polytechnic. he published 7 books, coordinated 28 studies on the information society and icts. elected president of the it sectorial area of ametic during 2016-2018. more than twenty-five years of experience, working in consulting, services, industry and public administration (indra, tecnocom, everis and ibm, cemex and dod) key: cord-282194-0sjmf1yn authors: cherak, stephana j.; rosgen, brianna k.; amarbayan, mungunzul; plotnikoff, kara; wollny, krista; stelfox, henry t.; fiest, kirsten m. title: impact of social media interventions and tools among informal caregivers of critically ill patients after patient admission to the intensive care unit: a scoping review date: 2020-09-11 journal: plos one doi: 10.1371/journal.pone.0238803 sha: doc_id: 282194 cord_uid: 0sjmf1yn background: the use of social media in healthcare continues to evolve. the purpose of this scoping review was to summarize existing research on the impact of social media interventions and tools among informal caregivers of critically ill patients after patient admission to the intensive care unit (icu). methods: this review followed established scoping review methods, including an extensive a priori-defined search strategy implemented in the medline, embase, psycinfo, cinahl, and the cochrane central register of controlled trials databases to july 10, 2020. primary research studies reporting on the use of social media by informal caregivers for critically ill patients were included. results: we identified 400 unique citations and thirty-one studies met the inclusion criteria. nine were interventional trials–four randomized controlled trials (rcts)–and a majority (n = 14) were conducted (i.e., data collected) between 2013 to 2015. communication platforms (e.g., text messaging, web camera) were the most commonly used social media tool (n = 17), followed by social networking sites (e.g., facebook, instagram) (n = 6), and content communities (e.g., youtube, slideshare) (n = 5). nine studies’ primary objective was caregiver satisfaction, followed by self-care (n = 6), and health literacy (n = 5). nearly every study reported an outcome on usage feasibility (e.g., user attitudes, preferences, demographics) (n = 30), and twenty-three studies reported an outcome related to patient and caregiver satisfaction. among the studies that assessed statistical significance (n = 18), 12 reported statistically significant positive effects of social media use. overall, 16 of the 31 studies reported positive conclusions (e.g., increased knowledge, satisfaction, involvement) regarding the use of social media among informal caregivers for critically ill patients. conclusions: social media has potential benefits for caregivers of the critically ill. more robust and clinically relevant studies are required to identify effective social media strategies used among caregivers for the critically ill. introduction social media is defined as "websites and applications that enable users to create and share content or to participate in social networking" [1] . social media tools are platforms and communities, such as facebook or skype, that facilitate quick communication and enable interaction among several users at any given time [2] . social media participation in older age groups is steadily increasing [3] , contributing to over 3.2 billion active users worldwide [4] . in considering the various user-generated content and social networking platforms, the role of social media conveys different meanings between users and non-users, age groups (e.g., millennials), and demographic populations. since technological change is associated with linguistic and cultural changes, the role of social media is constantly in flux [5] . the use of social media in healthcare for increasing speed of communication, distributing accurate information, and promoting knowledge of support, treatments and self-care options is becoming more widespread [6, 7] . patient-and family-centered healthcare, which acknowledges that patients and their informal caregivers are central figures in decision-making and delivery of care [8] , recognizes that patients and caregivers exist within an online social structure and network of relationships [9] . social media tools, such as real-time communication platforms, educational material, and self-management guides, are now more commonly incorporated in the decision-making process to aid caregivers with making informed decisions regarding their loved one's care [10] . critically ill patients are often unable to communicate their care preferences (e.g., due to mechanical ventilation, coma, etc.) including those that are in line with their individual values and goals [11] . in these situations, critically ill patients rely on their informal caregivers to learn about their diagnosis and treatment options, and to make important decisions on their behalf [12] -these situations can be stressful and distressing for an informal caregiver [13] . family-centered interventions may improve caregiver's comprehension, satisfaction, and long-term psychological outcomes during and after a family member's critical illness [13, 14] . social media tools as family-centered interventions might allow for personalization, presentation, and participation of informal caregivers in their loved one's care, engaging them in the decision-making process and promoting better patient and informal caregiver outcomes [2, 15] . despite their potential value, it is unclear whether social media tools can be meaningfully and systematically deployed in critical care medicine [16] . we therefore asked the question: what is the extent, range, and nature of research evidence on the impact of social media interventions and tools among informal caregivers of critically ill patients? this scoping review was conducted and reported as per the arksey-o'malley 5-stage scoping review method [17] . the approach for this review followed the scoping review methods manual by the joanna briggs institute [18] . the preferred reporting items for systematic reviews and meta-analysis protocols (prisma-p) guideline was used to develop the protocol [19] (s1 table) . we adhered to the prisma-scr extension for scoping reviews [20] to report findings. inclusion criteria were as follows: (1) primary quantitative or qualitative research; (2) reporting on social media use with at least one informal caregiver as an end-user; (3) conducted with informal caregivers of critically ill patients of any age group; and (4) in any language or publication year. studies were excluded if they were not primary research (e.g., reviews or editorials), did not report on caregiver use of social media, or were not conducted in a critical care population. for the purposes of this review, we defined: (1) a caregiver as any informal (i.e., non-clinical) person who regularly provides support to the patient and is in some way directly implicated in the patient's care or directly affected by the patient's health problem (e.g., family, friend); (2) social media as any form of electronic communication that allow users to share information and other content and create online communities; and (3) critically ill patients as any persons who are currently admitted to an intensive care unit (icu) or had previously been admitted to an icu. studies were excluded if only abstracts were available. comprehensive literature searches were conducted in medline, embase, psycinfo, cinahl, and the cochrane central register of controlled trials. the search strategies for each database were developed with a medical librarian (dll) and were revised after reviewing preliminary search results. the search strategies combined synonyms and subject headings from three concepts: 1) caregivers; 2) critical care; and 3) social media. a search of the cochrane database of systematic reviews was undertaken to identify review articles related to the research question and their reference lists were screened to identify potential studies missed in the search. all databases were searched from inception to july 10, 2020. reference lists of included papers were reviewed to identify potential studies missed in the search. no language or date limits were applied. the complete medline search strategy is shown in s2 table. after a subset of the team (sc, ma) achieved 100% agreement on a pilot-test of 50 random studies, all titles and abstracts were reviewed independently in duplicate by two reviewers (sc, ma). any study selected by either reviewer at this stage progressed to the next stage. the fulltext of all articles was reviewed independently in duplicate by two reviewers (sc, ma); articles selected by both reviewers at this stage were included in the final review. disagreements were resolved by discussion or the involvement of a third reviewer (br) when necessary. references were managed in endnote x9 (clarivate analytics, philadelphia, pa, usa). two reviewers (sc, kp) abstracted data independently and in duplicate for each included study using a data collection sheet developed and piloted by the review team. discrepancies were resolved through discussion with a third reviewer (ma). information on document characteristics (e.g., year of publication, geographic location), study characteristics (e.g., setting), caregiver group (e.g., spouses, parents, family caregivers), social media tool used (e.g., communication platform, content community, social networking site, blog or microblog), objectives and outcome measures of social media use, statistical significance, and authors' conclusions were collected. studies that examined social media as one component of a complex intervention were noted as such. findings were synthesized descriptively to map different areas of the literature as outlined in the research question. using a social media framework described in previous research [6] , we categorized social media tools into five categories: collaborative projects (e.g., endnote, slack), blogs or microblogs (e.g., wordpress, twitter), content communities (e.g., youtube, slide-share), social networking sites (e.g., facebook, instagram), and real-time communication platforms (e.g., text messaging, web camera, facetime) (s3 table) . study objectives and outcomes were classified according to an adaptation from those outlined in coulter and ellins [21] proposed framework for strategies to inform, educate and involve patients (s4 table) . the main objective from each study was categorized into one of five categories: to improve health literacy, clinical decision making, self-care, patient safety or other. outcomes reported in each study were classified as patient and caregiver knowledge, patient and caregiver experience, use of services and cost, health behaviors and health status, and usage feasibility. studies that reported statistically significant outcomes determined by p<0.05 related to the main objective of the study were classified as "statistically significant." studies that reported outcomes that were not statistically significant were classified as "not statistically significant," and if a study did not assess significance through statistical equations that study was classified as "not assessed." descriptive statistics were calculated using stata ic 15 (statacorp. stata statistical software: release 15. college station, tx: statacorp llc). we screened 400 unique abstracts and reviewed 72 full-text articles; 41 full-text articles were excluded, the most common reasons being that the study did not report original research (n = 15/41) or that the study did not report on social media use (n = 12/41) (fig 1) . hand searching resulted in the inclusion of seven additional studies. there was 85% agreement on title and abstract screening and 89% agreement on full-text screening. the 31 included studies were published between 2000 and 2020 and primarily conducted in north america (n = 20, 65%) or europe (n = 9, 29%), and with neonatal or pediatric critical care populations (n = 23, 74%) ( table 1 ). fig 2a depicts the different icu types from the included studies. the median start date was 2015 (range: 1997-2016) and the median duration was 19 months (range: 3-95 months). many studies (n = 9, 33%) were interventional studies [22, 23, 27, 29, 30, 32, 33, 39, 48] of which most were conducted in neonatal icus (6/9). we included six qualitative studies and most (4/6) were conducted with neonatal or pediatric critical care populations. caregivers were most commonly parents (n = 19, 61%) [30, 31, 33, 35-38, 41-44, 47-49, 51 , 52] and unspecified family caregivers more broadly-which could include parents, but the term was more broadly defined (n = 7, 23%) [23, 24, 26, 27, 32, 39, 50] . one study was specific to mothers [40] and one study was specific to fathers [45] . few studies reported additional perspectives from members of the clinical care team (e.g., nurses, primary care physicians) (n = 3, 10%) [29, 34, 50] or critical care patients (n = 3, 10%) [22, 28, 49] . more than half of the studies examined real-time communication platforms (e.g., face-time, skype) (n = 17, 55%) [23, 24, 28, 30-40, 47, 51, 52] , which accounted for many of the studies conducted with adult populations (3/7, 43%) and most of the studies conducted with neonatal or pediatric populations (14/22, 64%). included studies were categorized by the type of social media tool used (s3 table) . fig 2b depicts the different specific social media tools from the included studies. real-time communication platforms, that allowed user communication with messages, voice, and/or video, were the most common social media tool used (n = 15, 56%), followed by social networking sites (n = 6, 19%) and content communities (n = 5, 16%). few studies (n = 2, 7%) assessed the use of blog or microblogs and only two studies examined social media use in general. overall, most social media tools included functions that operated like communication platforms, such that they provided the option for users to post and share experiences. many studies (n = 8, 30%) included a social media tool as part of a complex intervention, and most of these studies (n = 6/8) used mobile phones to facilitate the social media component. all of these studies (n = 6/6) reported that the ubiquitous nature and technical capacity of mobile phones were strong motivating factors. several of these studies (n = 5/6) addressed potential misuse of information and privacy concerns over text messaging by an established mobile phone dedicated to the study, and provided recommendations to the clinical care team (i.e., nurses, physicians) for text messaging with informal caregivers. the most common intended use of social media was for caregiver satisfaction (n = 9, 29%). most studies that examined caregiver satisfaction used communication platforms (n = 8/9). social networking sites were often used to improve self-care (n = 2/6, 30%), and content communities were mainly intended to improve patient safety (n = 2/4, 50%). there were few studies that addressed clinical decision making (n = 4, 13%) and half (n = 2/4) used content communities. five studies (16%) did not fit the framework, and were classified as "other"; three of these studies reported the prevalence of social networking use (n = 1) or of internet use more broadly (n = 2), and two compared mothers and fathers use of information and communication technology (n = 1) or frequency and length of webcam viewing (n = 1). usage feasibility and patient and caregiver experience outcomes were most commonly reported (n = 30 and n = 23, respectively) ( table 2 ). patient and caregiver knowledge outcomes were reported in 16 studies (52%), and use of services and cost outcomes, and health behaviors and health status outcomes were reported in eight studies each. among outcomes related to usage feasibility (n = 30), measures of usage and demographics were most common (n = 22, 73%) and were often accompanied by measures of users' attitudes and preferences (n = 20, 67%). measures of patient or caregiver satisfaction or of clinician-patient/caregiver communication were most commonly reported for outcomes related to patient and caregiver experience (n = 13 and n = 12, respectively). fig 3a provides a summary of outcomes as they relate to the study objectives. there were no defining trends between outcomes with regard to objectives for social media use, but measures related to the use of services and cost, or to health behaviors and health status, were generally least reported among any objective. one study reported outcomes related to potential for unintended consequences or harm from social media tools [50]. 2 reported at least one outcome related to social media use by an informal (i.e., non-clinical) caregiver; adult patient defined as >15 years. 3 reporting prevalence of internet use among critically ill septic patients and caregivers. 4 comparing mothers' and fathers' use of information and communication technology. 5 comparing mothers' and fathers' frequency and length of viewing their hospitalized neonate via webcam. 6 reporting prevalence of social networking site use among parents of preterm infants. 7 determining parents perception and preferences for information sharing in the neonatal intensive care unit. https://doi.org/10.1371/journal.pone.0238803.t001 social media use among caregivers of critically ill patients: a scoping review 4a). studies that collected data during and/or after 2016 reported only positive, negative or indeterminate effects of social media use. majority of studies with a sample size >300 reported a negative effect, and majority of studies with a sample size 100-300 or <100 reported a positive effect (fig 4b) . prospective observational studies commonly reported a neutral effect and the majority of prospective intervention studies reported a positive effect (fig 4c) . among the studies that assessed statistical significance, the majority determined that social media use had a positive effect (fig 4d) . the most common type of study design was interventional (n = 9, 29%)-of which 4 were controlled by randomization (i.e., rcts)-followed by prospective cohort (n = 8, 26%) and qualitative (n = 6, 19%). of the quantitative studies (n = 25, 68%), majority assessed statistical significance (n = 20/25) and majority determined there was a significantly positive effect of social media use (n = 12/20). among the randomized interventions (n = 4), two found a significantly positive effect, one found a significantly negative effect and one did not assess statistical significance. fig 3b provides a summary of authors' conclusions of social media use with regard to study objectives. the majority of studies with the objectives of improving health literacy, self-care, patient safety or caregiver satisfaction, reported a statistically significant positive effect. among the four studies that aimed to improve clinical decision making, one study social media use among caregivers of critically ill patients: a scoping review reported a positive effect but did not assess statistical significance, and three studies reported a negative effect but only two assessed significance. we used scoping review methodology to synthesize the literature on the extent, range, and nature of research evidence on the impact of social media interventions and tools among informal caregivers of critically ill patients. there is a growing body of literature, primarily from neonatal or pediatric populations, suggesting that real-time communication platforms are now social media use among caregivers of critically ill patients: a scoping review commonly used social media tools among informal caregivers of critically ill patients. in contrast, there is very little literature regarding caregiver use of social networking sites, blogs, or content communities. the most common intended use for social media was to improve caregiver satisfaction with the experience and role of an informal caregiver of a critically ill patient. outcomes related to usage feasibility, such as measures of user's attitudes, preferences, and demographics, were nearly always reported. few studies assessed cost-effectiveness of using social media tools with informal caregivers, and outcomes related to health behaviors and health status of either the patient or caregiver were reported infrequently. although most studies concluded that the use of social media among informal caregivers is beneficial and meaningful, the potential for unintended consequences or harm specific to informal caregivers were not adequately explored. the low reliability and high variability of content shared on social media highlights the importance of control from medical personnel to avoid the spread of "fake news" [53] . the emerging utilization of social media tools among informal caregivers for critically ill patients have practical implications for critical care medicine. modern mobile phones are powerful computational devices. the technical capacity of mobile phones to facilitate phone-based health interventions was a motivating factor for several included studies. mobile phones are also omnipresent and nearly always at hand [54] , which makes it possible to increase the number of points of care to virtually any place and time [55] . the combination of the technical capacity, personal nature, and convenient proximity of mobile phones has reduced barriers to adoption and increased acceptance of phonebased health interventions in numerous healthcare settings [56] . the immediacy of access of conclusions on social media use with regard to patient and caregiver focused objectives 1,2,4 . 1 adapted from coulter and ellins, 2007; only the main study objective was recorded from a single study; 3 more than one outcome category could be recorded from a single study; 4 only one overall conclusion was recorded from each study. frequency indicated by color: red, very frequent; yellow, moderately frequent; green, infrequent. n, number of studies. https://doi.org/10.1371/journal.pone.0238803.g003 mobile phones might also be useful to informal caregivers after patient discharge by providing prompt advice and support, which may reduce healthcare costs by preventing hospital or icu readmission. mobile phones in healthcare settings also have disadvantages. with regard to nursing, disruption of workflow, interruption of practice, and improper usage have been reported [57] . for example, in the study conducted by piscotty and colleagues [58] , 67% of nurses checked their mobile phone more than 2 times per shift and 22% checked their mobile phone more than 10 times per shift. further, possibility of misuse of information that may violate patient privacy remains an unresolved problem [59] . nursing organizations have responded with guidelines on professional social media use in the workplace [60] [61] [62] . many included studies addressed potential privacy issues by an established mobile phone dedicated to the study, and recommended to refrain from using patient last names and conditions, to keep communications brief, and to destroy caregiver phone numbers after patient discharge [63] . that mobile phones may be useful to facilitate social media interventions in critical care medicine is a noteworthy finding of this review, but further research is needed on how social media strategies can be implemented into practice without violating privacy or ethical considerations. support and encouragement can contribute to caregiver confidence, which can promote better understanding of a stressful illness-related situation and enable the caregiver to provide better care [64] . many included studies found that caregivers reported a more satisfactory critical care experience and increased knowledge of a patient's condition and long-term treatment options when provided with links to online resources with credible information. in the last decade, several members of the united states critical care societies collaborative have started using social media [65] . the society of critical care medicine is one member, which uses web-based education initiatives to provide accurate and reliable information to educate their members and the public [15] . as well, the world federation of societies of intensive and critical care medicine also recognized that social media plays a large role in achieving more and better involvement with other member societies, and actively uses social media to liaise with important groups, such as young clinicians [66] . considering the differences in how critical care societies use diverse approaches to deliver overlapping educational content can provide a rich opportunity to inform development of future web-based education initiatives, targeted specifically at informal caregivers. real-time communication platforms have been studied and implemented in many healthcare settings [67, 68] . several included studies found that in neonatal icu populations, parents who were communicating with the clinical care team using videoconferencing instruments (e.g., facetime, skype) felt significantly more satisfied with their infants' care when they were unable to be physically present. no study conducted in adult icu populations used a social media tool dedicated entirely to videoconferencing, although most social media tools included functions which operated similar to communication platforms. further, no included study from any icu reported the use of communication platforms to engage non-local family members or young children who may benefit from remote communication with their loved one. since many communication platforms are free to download on most electronic devices and allow for multiple users at once, an important area for future research is the use of communication platforms by entire support groups of both adult and non-adult critical care patients. this type of research is warranted to determine if positive outcomes of communication platforms depend on whether the caregivers' relationship to the patient is parent-child (i.e., parent providing support to children) versus child-parent (i.e., children providing support to parents). it is important to recognize that social media tools are exactly that-tools-rather than a substitute for personal interaction with healthcare providers. recent studies in other healthcare settings have found that patients' value in-person interaction with healthcare providers more than social media communication, and that healthcare providers are regarded as the most important source of information [69] . knowledge on the values and preferences of the clinical care team, however, is lacking, and a common concern of many clinicians is that information shared on social media may not always be accurate. more understanding on physician preferences and social media accuracy is important as physicians often rely on patients' informal caregivers to make decisions regarding the patient's care, which frequently contributes to caregiver psychological morbidity [70] . individualized social media interventions adapted to caregiver preferences may improve caregiver's satisfaction and psychological morbidity [13] . more research on accurate, proper and potential use of social media in critical care medicine is required before implementation into daily practice. our review indicates there is untapped potential for social media interventions and tools to provide personalized support to informal caregivers of the critically ill. we recommend future inquiry on this topic examine mental health interventions using social media to determine the effect of social media mental health interventions on psychological outcomes of informal caregivers of the critically ill. this information is particularly relevant to challenges related to restricted visitation and social isolation associated with the covid-19 pandemic [71] . the large numbers of patients experiencing critical illness and visiting restrictions enacted to prevent the spread of covid-19 complicate participation of informal caregivers in patient care and recovery [72] . these factors are likely to make mental health consequences of critical illness on informal caregivers more prevalent and severe [73, 74] . social media interventions and tools may be an effective mode of mental health support for informal caregivers of critically ill patients. this scoping review has several strengths. we conducted an extensive literature search and screened reference lists of included studies in order to identify the full breadth of available literature on social media use in critical care populations. the search was executed in five bibliographic databases and was not restricted by language or dates. it was intentionally broad to ensure that social media use across all critical care populations were included. we followed rigorous methodology defined by adherence to recommended protocols and reporting criteria for scoping reviews. further, the interdisciplinary team of a critical care physician, a critical care nurse, and a psychiatric epidemiologist, offered complementary expertise and knowledge. in spite of these strengths, there are limitations to note. we did not search the grey literature nor did we search social media itself, and could have missed studies, though our search strategy was comprehensive and full-text hand searching was completed. as well, the lack of a universal definition for social media, since social media is a relatively new concept that is continually transforming, added complexity to the process of study selection. however, our broad inclusion of study design allowed us to produce a comprehensive summary of the state of the literature on social media use by informal caregivers in critical care medicine. ultimately, the relatively rapid evolution of social media means studies on usage will nearly exclusively reflect social media use of the past. though such studies are valuable, it is important to note that the medium of social media is evolving faster than it is being studied. there is a growing evidence base to support the use of social media among informal caregivers of critically ill patients. there is untapped potential for social media tools to provide personalized support to informal caregivers. social media tools might enable informal caregivers to gain the knowledge that they need in order to feel empowered, involved, and satisfied. social media users should exercise caution on applications and networking sites so as not to compromise patient privacy. in sum, social media represents a flexible medium to deliver health information, and the individualized support that caregivers can obtain through using social media may promote an invaluable collaborative relationship when caring for critically ill patients. supporting information s1 social media.: oxford dictionary social media in critical care social media-statistics & facts ranked by numbers of active users (in millions). statista social media usage: 2005-2015. pew research ceter users of the world, unite! the challenges and opportunities of social media neurology and the internet: a review patient and family members' perceptions of family participation in care on acute care wards a new dimension of health care: systematic review of the uses, benefits, and limitations of social media for health communication social media and health care professionals: benefits, risks, and best practices a comparison of the opinions of intensive care unit staff and family members of the treatment intensity received by patients admitted to an intensive care unit: a multicentre survey a randomized trial of a family-support intervention in intensive care units association of surrogate decision-making interventions for critically ill adults with patient, family, and resource use outcomes: a systematic review and meta-analysis translating evidence to patient care through caregivers: a systematic review of caregiver-mediated interventions social media engagement and the critical care medicine community evaluation of mobile apps targeted to parents of infants in the neonatal intensive care unit: systematic app review. jmir mhealth and uhealth scoping the field: services for carers of people with mental health problems the joanna briggs institute best practice 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involvement with patient care in the icu: survey of critical care nurses a family information brochure and dedicated website to improve the icu experience for patients' relatives: an italian multicenter before-and-after study. intensive care medicine american journal of critical care: an official publication, american association of critical-care nurses effects of a social media website on primary care givers' awareness of music therapy services in a neonatal intensive care unit. the arts in psychotherapy testing the feasibility of skype and facetime updates with parents in the neonatal intensive care unit. american journal of critical care: an official publication, american association of critical-care nurses smartphones and text messaging are associated with higher parent quality of life scores and enrollment in early intervention after nicu discharge a randomized controlled study about the use of ehealth in the home health care of premature infants the use of short message services (sms) to provide medical updating to parents in the nicu web camera use in the neonatal intensive care unit: impact on nursing workflow diabetes self-management care via cell phone: a systematic review patient adherence and accuracy using electronic diaries during remote patient monitoring in type 1 and type 2 diabetes can the ubiquitous power of mobile phones be used to improve health outcomes in developing countries? global health to tweet or not to tweet? nurses, social media, and patient care impact of healthcare information technology on nursing practice mobile phone messaging reminders for attendance at healthcare appointments social media guidelines for nurses registered nurses' association of ontario available from: categorization of objectives and outcomes master's programs in advanced nursing practice: new strategies to enhance course design for subspecialty training in neonatology and pediatrics guidelines for using electronic and social media: the regulatory perspective the effectiveness of mi smart: a nurse practitioner led technology intervention for multiple chronic conditions in primary care patient safety and quality: an evidence-based handbook for nurses. advances in patient safety lessons learned from web-and social media-based educational initiatives by pulmonary the world federation of societies of intensive and critical care medicine newsletter online, social media and mobile technologies for psychosis treatment: a systematic review on novel user-led interventions methods of using real-time social media technologies for detection and remote monitoring of hiv outcomes social media use in healthcare: a systematic review of effects on patients and on their relationship with healthcare professionals retiring the term futility in value-laden decisions regarding potentially inappropriate medical treatment ethical dilemmas due to the covid-19 pandemic bereavement support on the frontline of covid-19: recommendations for hospital clinicians rehabilitation after critical illness in people with covid-19 infection intensive care management of coronavirus disease 2019 (covid-19): challenges and recommendations we thank dr. diane lorenzetti (university of calgary) for the development of the search strategies. key: cord-273601-icituitn authors: liu, m.; thomadsen, r.; yao, s. title: forecasting the spread of covid-19 under different reopening strategies date: 2020-05-29 journal: nan doi: 10.1101/2020.05.26.20113993 sha: doc_id: 273601 cord_uid: icituitn we combine covid-19 case data with demographic and mobility data to estimate a modified susceptible-infected-recovered (sir) model for the spread of this disease in the united states. we find that the incidence of infectious covid-19 individuals has a concave effect on contagion, as would be expected if people have inter-related social networks. we also demonstrate that social distancing and population density have large effects on the rate of contagion. the social distancing in late march and april substantially reduced the number of covid-19 cases. however, the concave contagion pattern means that when social distancing measures are lifted, the growth rate is considerable but will not be exponential as predicted by standard sir models. furthermore, counties with the lowest population density could likely avoid high levels of contagion even with no social distancing. we forecast rates of new cases for covid-19 under different social distancing norms and find that if social distancing is eliminated there will be a massive increase in the cases of covid-19, about double what would occur if the us only restored to 50% of the way to normalcy. as covid-19 spreads across the world and the united states, governments and individuals have worked to slow the growth of the disease by reducing the extent to which people leave their homes. in the united states, these actions have largely been acted on by households who have voluntarily stayed home unless they needed to travel, but they have also been bolstered by orders of local and state governments. these orders have occurred over different time periods, and have taken many different forms, but they have had a similar flavor of limiting gathering sizes, closing schools, and shutting down non-essential businesses or shifting their operations to a contact-free experience. that said, many areas of the country never had any form of stay-at-home orders. ultimately, the purpose of the stay-at-home orders is to reduce the amount of contact between people in order to slow the growth of covid-19, which is thought to be spread primarily through droplets that require being within a relatively small distance of an infected person. in this paper, we first measure the extent to which social distancing reduces the speed at which covid-19 spreads. we then run simulations of how covid-19 will spread over time under different policy regimes. we find that covid-19 spreads less than proportionately with the number of contagious individuals. we also observe that social distancing during late march and april significantly reduced the spread of the disease. higher population density also leads to an increased spread of covid-19. our model gives good out-of-sample forecasts of the disease for the two and half weeks after the end of our mobility data, assuming that the country continues the nearly 50% return to normalcy observed at the end of april (as compared to the observed peak social distancing levels). we forecast that completely opening up the country to 100% of the pre-shutdown levels of social interaction will lead to 4 million additional covid-19 cases (officially diagnosed) by the end of september 2020, corresponding to a doubling of the cases than we would expect if the country continued with the path of 50% return to normalcy we observe at the end of april. however, there is a great heterogeneity among counties, and according to our simulations 44% of the counties could open up while still experiencing a low infection rate of less than 0.1% over a 3-month period. these counties all have low population densities. the model we estimate is a simplified version of a susceptible-infected-recovered (sir) model. we assume that where y i,t is the number of individuals who are infected in county i on day t, r i,t is the rate at which infectious individuals in the county transmit the disease, s i,t is the percentage of the county population that is susceptible to covid-19 (i.e., the share of people who have not yet had , and y i,t is the number of cumulative individuals who have been infected by day t. the y i,t−2 −y i,t−8 term reflects our assumption that infected individuals are contagious from the second day after they catch the virus through the seventh day, leading to a serial interval of 4.5 days 1 . this treatment of the infectious population is an approximation to the standard sir models, where the infectious population is typically modeled as a stock that has an outflow at a constant rate. this assumption makes the estimation much easier with the large number of fixed effects we include in our model, and as a practical matter this assumption only has a minimal impact on our estimates of the contagion of covid-19. in the supplemental appendix we show that we get extremely similar results if we take the time of contagiousness to be 14 days the main difference between this model and a standard sir model is that a standard sir model constrains ω = 1. we show in the supplemental appendix that the estimated model with this constraint does not perform well out of sample. we instead find that ω < 1. this shows that the marginal impact of one more sick person diminishes as more and more people are sick. there are several reasons why this may be expected, with the greatest reason being that contagious individuals may end up endangering many of the same group of unexposed individuals. one might expect this to be the case if people often have the same or overlapping groups of friends or acquaintances. we see some of this directly when, for example, cases are clustered within households, nursing homes, or places of work. in the accompanying supplemental appendix we present a networking model and show that we would get ω < 1 if people have interconnected networks of contact. in order to better understand the variation of the rate of contagion, we allow r i,t to vary according to a number of factors instead of treating it as a constant parameter. thus, we model this specification implies that transmission rates can differ across counties (the county fixed effects α i reflect different population densities and also different demographic compositions), time periods (date fixed effects β t are included mostly to accommodate different rates of testing and also the different rates of reporting that happen on weekdays vs weekends), levels of social distancing d i,t , and different temperatures, h i,t , the impact of which has been debated 2 , 3 , 4 . the social distancing measure, d i,t , is based on cellphone gps location data that are provided by safegraph, and are available for free to researchers studying covid-19. we measure social distancing as the fraction of phones that stay exclusively at home during a given day. the ε i,t term is our statistical error term. equation (1) is estimated by taking the logarithm of both sides, with the details in the appendix. note that the social distancing level by individuals, as well as social distancing regulations, are not determined in a vacuum. rather, we observe that people social distance more in areas that are harder hit by covid-19. thus, the ε i,t term may be correlated with the social distancing measures, causing a biased, underestimated impact of social distancing on slowing the spread of the disease. we control for this endogeneity bias by estimating the model using an instrumental variables (iv) technique, where we use the amount of rain as an instrument for social distancing. specifically, we assume that rain directly shifts the level of social distancing, but is not correlated with ε i,t . to estimate the model parameters, we use county-level officially confirmed covid-19 daily case data of 2,704 us counties or county-equivalents from february 3 to april 28. we omit the data from new york, new jersey and connecticut, as explained in the technical appendix. we append the data with daily county-level weather data as well as cellphone mobility data provided by safegraph. the results are presented in table 1 . we find that social distancing indeed decreases the growth rate of covid-19: moving from the observed mean pre-covid level of social distancing (0.25) to the post-covid peak level (0.40), the magnitude of r is reduced by 56%. we also find that the exponent on the number of contagious people, ω, is 0.47. it is significantly lower than 1, the exponent assumed in a standard sir model. this shows that there is a strongly concave relationship between the number of infected people and the rate at which the disease spreads. this level of concavity also implies that while initial outbreaks of covid-19 will expand exponentially, they will quickly turn to a slower rate of growth. the growth looks linear or even plateauing when plotted cumulatively, although the disease will persist for a long period of time and continue building a substantial number of cases. this may explain why the recent growth rate of covid-19 cases has slowed considerably after a quick take-off, and yet this growth has persisted. we also find that higher temperatures may slow the spread of the virus, but with a much smaller impact. most of the variation of the contagion rates r i,t is captured by our county-level fixed effects, α i , in equation (2) . in order to understand the drivers of the contagion rates, we run a regression of the county fixed effects α i against county-level demographics. it has been shown in 5 that when the number of fixed effects is large, these coefficients can be treated as data for the purpose of statistical inference. the results are reported in table 2 . we find that population density is a crucial factor influencing the spread of the disease. in fact, covid-19 would be expected to never flare up beyond a very small base level in 2/5 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may 29, 2020. some areas with sufficiently low population densities, as we discuss below. we also observe that greater concentrations of black and hispanic residents and public transit commuters are associated with higher contagion rates. interestingly, higher median incomes are related to greater contagion. we are uncertain what drives this result: one possibility is that people with higher incomes may interact more with nearby cities that have more outbreaks. we also include the share of seniors (age 70+) and children (below age 18) in the population. seniors are marginally more likely to spread the disease, but children show no sign of having a lower rate of infecting people, confirming the finding in 6 . using our model, we simulate future cases beyond our sample period. first, to examine how our model performs, we predict the out-of-sample case numbers from the end of our data period up to may 16, 2020, under different social distancing assumptions. we start by forecasting the cumulative covid-19 cases if each county continued the social distancing at the levels observed at the end of april. assuming the observed february level as normalcy, the end-of-april level is at the 50% between the peak lock-down level and normalcy (so we say that such a level is at 50% of normalcy). we also implement the same exercise under 3/5 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 29, 2020. . several other social distancing benchmarks. these benchmarks are defined specifically in the supplemental appendix. the results appear in figure 1 . we observe that our model forecasts the pattern of disease contagion well if the level of social distancing in early may remained at the level seen at the end of april (50% return to normalcy). finally, we forecast how the disease will evolve up to september 30, 2020 under different reopening strategies. the cumulative and daily cases appear in figures 2 and 3 , respectively. the cyclicality observed in figure 3 reflects the variation we observe in the weekly data, which may reflect different reporting delays or different social-distancing behavior due to the day-of-the-week effect. the forecast shows that social distancing matters, but that the impact of increased mobility becomes higher as we move closer to normalcy. if social distancing is eliminated, we observe that the largest effects will be felt in the first two months. this occurs because of the shrinkage of the uninfected population in each county. note that cases will be elevated to almost double the daily rate that we would observe under a 50%-return-to-normalcy even into the september of 2020, when cases are likely to reach an almost steady weekly level. our estimates suggest that it will be difficult to return to school and normalcy in the fall of 2020 without sparking a large outburst of covid-19. ultimately, moving from the 50%-return-to-normalcy to a full return to normalcy will lead to 4 million additional confirmed cases. if we assume that confirmed cases are only 10% of actual cases, and that covid-19 has an 0.75% infection-fatality rate (ifr), as we justify in the supplemental appendix, we would expect 300,000 to 600,000 deaths by the end of september 2020 if the social distancing occurs at 50% to 100% levels of normalcy, respectively. we note, however, based on our forecast that 44% of the counties in the sample (1, 196) could completely reopen and still experience a confirmed case rate lower than 0.1% from june to august, 2020. these counties are less populated and account for less than 15% of the population in our sample. we also note that our analyses do not consider the positive effects of alternative preventive protocols such as wearing facial masks and better hand washing. such protocols may help slow the contagion process. taken together, we demonstrate that the rate of spread of covid-19 in the united states is concave in the number of contagious individuals. this explains why the growth rate of covid-19 cases has been slower than expected given the initial exponential growth, above and beyond the effect from social distancing. we empirically identify the substantial impact of social-distancing on combating the pandemic. we also forecast how covid-19 will evolve in the future, and the timing over which different parts of the country will reach their peaks and how the patterns may affect our reopening strategies. 16may2020 01jun2020 01jul2020 01aug2020 01sep2020 30sep2020 date 16may2020 01jun2020 01jul2020 01aug2020 01sep2020 30sep2020 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 29, 2020. . https://doi.org/10.1101/2020.05.26.20113993 doi: medrxiv preprint in this online appendix, we first present our data. we then discuss our model and assumptions. finally, we present our assumptions for the simulations. our data come from a multitude of sources. we lay out the sources for each of these in turn. data of positive cases are based on the covid-19 data published by the new york times (https://github.c om/nytimes/covid-19-data, accessed on may 17, 2020). the data contain the daily confirmed case counts in the u.s. at the county or county-equivalents level. we exclude cases in the states of new york, new jersey, and connecticut due to the large outbreak there and the complicated relationship between new york city (which is the seat of 5 counties) and the surrounding counties. we drop 3 of the remaining counties because we do not have social distancing data for 2 of them, and we cannot match the demographic data for a third (oglala lakota county, sd). this reduces the number of counties to 2,778. in addition, we remove 74 counties that had no confirmed cases in the entire sample period. the remaining 2,704 counties and county-equivalents constitute our main sample. these counties account for 89.6% of the total u.s. population and 55.2% of the total u.s. confirmed cases as of april 23, 2020. there are a few days where there are negative cases that are reported. these are generally corrections to previous over-reporting. thus, we clean the negative numbers of cases by subtracting the absolute value of the negative cases from the proceeding day. in the event that that leads to a negative number of the proceeding day, we iterate again. covid-19 also has an incubation period of approximately 5 days 1 , 2 . because of this lag between when a person gets sick and when they are diagnosed with covid-19, we assume that the cases reported on a particular date actually measure the covid-19 infections from 5 days earlier. we also assume that the true number of cases is approximately 10 times the number of diagnosed cases. we get this number by assuming that the infection fatality rate (ifr) is 0.75% 3 . we also assume that any deaths that occur happen 14 days after the confirmed test result. on may 16, 2020, the last day of our confirmed case data, there were 88,660 deaths in the us. on may 2, 2020, there were 1,138,961 officially diagnosed cases. we hence obtain the factor as (88,660/0.0075)/1,138,961 = 10.4. we round this number to 10. our estimates are not sensitive to the specific factor we use. we use social distancing data from the company safegraph, which collects cellphone gps data from u.s. residents, and has made them available for free to academics studying covid-19. these data are collected through a series of pings that the company receives for all users who have installed a number of smartphone apps. the list of apps that collect this information is kept as a trade secret. for each county, we use the fraction of cellphones that stayed near home for the whole day as our measure of social distancing. the safegraph data are published at the census block group level. to accommodate other data sources which are available at a less granular level, we aggregate the this . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 29, 2020. . variable to the county level by taking the weighted median, using the number of cellphones in each census block group as the weight. we obtain the demographic data from the census bureau's 2014-2018 american community survey (acs), which contains information of each county's profile of population, ethnicity, age, median income, and commuting pattern. the acs, however, does not report population densities. safegraph, the company who provides us with the social distancing data, also maintains a dataset of the land area of each census block group in the us. we aggregate the land areas to the county level. together with the county population information from the census bureau, we are able to construct the population density data of each county. we gathered historical daily rain and temperature data from national oceanic and atmospheric administration (noaa) (source: https://www.ncei.noaa.gov/metadata/geoportal/rest/metadata/item/ gov.noaa.ncdc:c00861/html, accessed on may 21, 2020). the raw weather data is at the weather station level and we match weather stations to the counties they are in. we use the average values across weather stations within the same county to construct the weather variables for that county. for a small number of counties where there are no associated weather stations, we use the daily state averages as proxies. we obtained county-level voting data from https://public.opendatasoft.com/explore/dataset/ usa-2016-presidential-election-by-county/table/?disjunctive.state (accessed may 20, 2020). this data is explained at https://github.com/deleetdk/usa.county.data (accessed may 20, 2020), and the election vote totals originally came from the new york times. shelter-in-place orders (sip) data are compiled by keystone, a strategy and economics consulting firm. the company collects and distributes the sip data (https://www.keystonestrategy.com/coronavirus-covid19 -intervention-dataset-model/, accessed on may 21, 2020.) for free to researchers studying covid-19. our sample is an unbalanced panel because counties start to have positive number of confirmed cases on different dates. the earliest date we observe in the sample is jan 29, 2020, and the last day is april 23, 2020. note that we construct actual cases using reported cases 5 days later, and thus the corresponding sample period based on reported cases is feb 3, 2020 to april 28, 2020. summary statistics of all of the variables we use in the estimation are presented in table a1 . note that our case data proceed past the dates used for estimating the model and are up to may 16, 2020. we use those data for validating the model. those data are publicly available, but we are happy to supply summary statistics for this hold-out sample upon request. in this subsection, we detail the assumptions we make and the estimation procedure. as noted in the main paper, the model we estimate is a modified version of the standard susceptible-infected-recovered (sir) model: where y i,t is the number of individuals who are infected in county i on day t, r i,t is the rate at which infectious individuals in the county transmit the disease, s i,t is the percentage of the population that has not yet had covid-19 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 29, 2020. . and is thus susceptible to it, and y i,t is the number of cumulative individuals who have been infected up until day t. this model differs from the standard sir in two key ways. first, the standard sir model constrains ω = 1. we discuss in the paper that there are theoretical reasons to believe that the correct model of transmission involves ω < 1. as an example, we present a network model below that demonstrates that ω < 1 is possible even using the conventional transmission mechanism. second, the standard sir model does not specify a discrete time frame over which the infected individuals are contagious, but rather builds a stock of infected individuals and assumes that these individuals exit their infected period at a fixed rate. we view our model as an approximation of this process, which greatly eases our estimation and allows us to easily add important variables to explain the contagion process in our analysis. we use a 6-day infectious window and an assumed latent period of 2 days (y i,t−2 −y i,t−8 ). this gives a mean serial interval of 4.5 days, which is close to several estimates 4 . in this appendix, we also present the results where we use a 14-day window (y i,t−2 −y i,t−16 ), and show that results are similar. we assume that the rate of transmission, r i,t varies by a set of factors, which we model as r i,t = exp x i,t β + ε i,t . x i,t includes county-level fixed effects, date fixed effects, the measure of social distancing, and daily average temperature. the county fixed effects account for differences in demographics across counties, such as the demographics shown in table 2 of the main paper as well as other unobservable county-specific factors. the date fixed effects account for both day-of-the-week differences in the patterns of travel for people (e.g., the time away from the house to go to work or to go to the park, which may lead to different exposures to the disease) as well as differences in the rate of testing and reporting that occur across time. we assume that the errors ε i,t are uncorrelated across counties. we further assume that ε i,t is uncorrelated across time, although we cluster the standard errors by county. we estimate the model by taking logarithm of both sides. after rearranging we get: note that sometimes y i.t , the diagnosed case number, is 0 for some counties on some dates. therefore, we adjust this formula slightly by adding 1 to y i,t so the logarithmic values are always well-defined: in some counties, y i,t−2 −y i,t−8 is 0 for some periods. we do not use those observations for estimation. note that because this is a lagged variable, this is a selection based on independent variables and not based on dependent variables, and hence it does not bias our estimation. one concern that can arise in estimating this model is that the amount of social distancing is likely to be correlated with the error terms, ε i,t in the regression. we address this concern using an instrumental variable (iv) approach, which requires that we find a variable that affects social distancing but is not correlated with ε i,t . we use the amount of rain (measured in mm) as a shifter of social distancing that does not directly cause covid-19 to spread. we run a first stage regression of social distancing to test whether this instrument has much power. the f-statistic for this test is 435.43, indicating that this is a strong instrument. the main estimation results are presented in table 1 of the paper and replicated in column 1 of table a2 in this appendix. research on covid-19 is nascent, and there are different views of how long infected individuals stay contagious. suppose that such individuals are contagious for 14 days instead of 6 days. then the model becomes: we present the estimation results of this model in column 2 of table a2 . note that this regression has more observations because there are fewer instances where we observe no cases in a county for a 14-day window than for a 6-day window. the results are largely unchanged. the coefficient on social distancing levels are slightly lower, but well within one standard error of the corresponding coefficient in column 1. the exponent on the infectious individuals is 0.435. that is somewhat smaller (but statistically different) than the 0.470 we observe with the shorter 6-day window, but overall the curvature shape is similar to what we have observed with the 6-day window. the effect . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 29, 2020. . of temperature is slightly smaller but similar. as we will discussion below in section simulation, both specifications give similar long-run forecasting results. all county-level demographic factors remain constant over time in our analysis. while our main regression gives many insights, impacts of these demographic factors on the spread of the virus are captured by the county fixed effects. in order to better understand how these factors affect the contagion rate, we next regress the county fixed effects on several demographic variables. the coefficients from this regression should be thought of as the impact of these demographics on the rate of contagion. the results from the model are reported in column 1 of table a3 (replication of table 2 in the paper). in column 2 we present the results we would obtain if we instead modeled the contagious period to be 14 days. similar to table a2 , the results are again very similar under this alternative specification. the only statistically significant difference is that the coefficient on log(population density) is slightly smaller, although the effect is of a very similar magnitude. we also observe that the r 2 of the 14-day contagious period model is slightly lower than the r 2 of the 6-day contagious period model. while the focus of this paper is on measuring the contagion effect, we consider an exploratory regression to see what is correlated with the rate at which individuals choose to social distance. the results are shown in table a4 . the results indicate that the levels of social distancing are driven much more by the number of national cases than the number of local cases. the results also indicate that the fraction of voters who voted for trump in the 2016 presidential election explains much of the observed levels of social distancing. going from a solidly clinton-voting to a solidly trump-voting county (i.e., going from the minimum to the maximum of trump vote shares) represents a swing of almost 9 percentage-points of social distancing. to put the change into prospective, the social distance measures range from 11% to 65%, a 54 percentage-point variation. demographically, higher population densities lead to lower social distancing, but increased compliance with sheltering-in-place orders. more affluent counties have less social distancing. counties with a higher fraction of black population are less likely to social distance, perhaps due to work demands. a greater hispanic population and a greater public transportation population are both associated with more social distancing. supporting the idea that much of the traveling is for work, we see that people are less likely to practice social distancing on weekdays than on weekends. in terms of policy, the closing of schools is the policy that is most-indicative of how much social distancing will occur. we observe that closing public venues is correlated with reduced social distancing, and that limiting gatherings (we treat all gathering size limits of 500-people or less the same, but most of these limits are for far smaller groups than 500 people) has a statistically significant effect on the amount of social distancing. after estimating our model, we forecast the number of cases that would emerge under different social distancing regimes. for this exercise, we first divide our model's predicted numbers of "true" cases by 10, which gives us the prediction of diagnosed cases (as described in section positive cases). next, because the 2,704 counties in our sample are a subset of the whole nation, on a given date the predicted diagnosed case number is a fraction of the total cases in the us. while this fraction changes on a daily basis, we use an approximation by taking the median of the daily ratios between diagnosed cases observed in our sample and in the whole nation during our sample period. the median of the daily ratios is 0.63. accordingly, we divide our predicted diagnosed cases by 0.63 to obtain the national number of diagnosed cases. the first step of our simulation involves validating the model: we predict how many cases would emerge in the weeks after our data (dates: april 29 to may 16, 2020) in order to validate our model. the results are shown in figure 1 in the original paper. we observe that we are well able to predict the number of observed cases if the social distancing in early may represented a 50% return to normalcy, which is defined as stayed home in county i in february, and fractionstayathome i,t represents the fraction of devices staying home in county i on date t. we compute the different levels of social distancing accordingly: for example, a 25% towards normalcy represents social distancing at the level of 0.75×(minimum social distancing) + 0.25×(maximum social distancing). we find that the levels of social distancing at the end of april were approximately at the 50% return to normalcy levels. overall, our model predicts the national cases well. we next forecast the cumulative and daily cases of covid-19 through the end of september at different levels of social distancing. those forecasts appear in figures 2 and 3 in the original paper. in figure a1 below, we replicate figure 2 in the paper but further add the confidence intervals. to avoid cluttering, we only depict 50% and 100% return-to-normalcy levels in a1. as a robustness check regarding the 6-day contagion window specification, we also consider forecasting us daily cases under the specification where the contagion window is 14 days. figure a2 shows the evolutions of daily cases till september 30, 2020 under 50% and 100% return-to-normalcy regimes. we overlay the forecasts of both 14-day and 6-day specifications for easy comparison. from the figure, we may see the forecasts of 14-day and 6-day contagion window specifications are fairly close under the 50% return-to-normalcy level. for the 100% normalcy level, the two specifications differ at the beginning but converge quickly. in the long run, the two specifications give similar forecasts for daily cases. one unique feature of our model is that we estimate an exponent on the number of contagious cases. we include this flexibility because such a model fits the data much better, and also leads to forecasts that have more limited growth after an initial take-off of covid-19 cases, as is commonly observed. to demonstrate our model's better fit, we compare the prediction of our model against an alternative model with the exponent fixed at 1 as the standard sir model in figure a3 . at the 50%-return-to-normalcy level that is observed at the end of april, the standard sir model would predict much higher cumulative case numbers than the actual numbers. in contrast, our model's prediction fits much better. we next illustrate that the concave relationship we estimate for the number of contagious individuals on the number of new cases can come from social networks between people. we seek to demonstrate the theoretical feasibility of our results rather than the necessary or sufficient conditions under which the nonlinearity will arise. thus, we simulate a very simplified model of networks and disease process. to do this, we simulate a network with the following process: we take 10,000 individuals. we create a network by first randomly assigning that any two individuals will be joined with a common node with probability 0.001999 (corresponding to each person getting almost 20 friends on average). call these connection "round-1 friends." we then expand this network by assigning each node to have an edge with each of the round-1 friends of their friends with a probability of 0.6. we assume that the disease spreads with the following process. we seed 4 individuals to have the disease in period 0. then in each period we assume that any connected individual will get sick with probability 7/(number of connections), where the number of connections is specific to the individual, and varies due to the random assignment of the people who are connected (this probability is capped at 1 in case someone is randomly assigned fewer than 7 connections, which is very unlikely). after simulating this process, we then regress (ln (y t ) − ln (s t )) = c + ω ln (y t−1 ) + ε t . we run this simulation 10 times. the mean value forω = 0.51, with a range of (0.44, 0.62). this shows the plausibility of network effects leading to an estimate in the range that we have estimated in our main model. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 29, 2020. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may 29, 2020. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may 29, 2020. . https://doi.org/10.1101/2020.05.26.20113993 doi: medrxiv preprint 16may2020 01jun2020 01jul2020 01aug2020 01sep2020 30sep2020 date actual cum. cases 50% return-to-norm. 50% return-to-norm. cis 100% return-to-norm. 16may2020 01jun2020 01jul2020 01aug2020 01sep2020 30sep2020 date . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may 29, 2020. . https://doi.org/10.1101/2020.05.26.20113993 doi: medrxiv preprint serial interval of novel coronavirus (covid-19 ) infections high temperature and high humidity reduce the transmission of covid-19 role of temperature and humidity in the modulation of the doubling time of covid-19 cases temperature significant change covid-19 transmission in 429 cities generalized least squares inference in panel and multilevel models with serial correlation and fixed effects cluster of coronavirus disease 2019 (covid-19) in the french alps the incubation period of coronavirus disease 2019 (covid-19) from publicly reported confirmed cases: estimation and application early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia. the new engl a systematic review and meta-analysis of published research data on covid-19 infection-fatality rates serial interval of novel coronavirus (covid-19 ) infections key: cord-299833-f2q6di3t authors: pietrabissa, giada; simpson, susan g. title: psychological consequences of social isolation during covid-19 outbreak date: 2020-09-09 journal: front psychol doi: 10.3389/fpsyg.2020.02201 sha: doc_id: 299833 cord_uid: f2q6di3t perceived social isolation during the covid-19 pandemic significantly has had an extraordinary global impact, with significant psychological consequences. changes in our daily lives, feeling of loneliness, job losses, financial difficulty, and grief over the death of loved ones have the potential to affect the mental health of many. in an atmosphere of uncertainty, it is essential that clear and precise information is offered about the problem and how to manage it. in this contribution, a rationale is provided for an urgent call for a rapid response to the mental health impacts of covid-19. moreover, suggestions for individuals to regulate their emotions effectively and appropriately are provided. the mental health consequences of covid-19 are already visible and even by conservative estimates they are yet to reach their peak and likely to considerably outlive the current pandemic. the most common psychological disorders emerging are anxiety and panic, obsessive-compulsive symptoms, insomnia, digestive problems, as well as depressive symptoms and post-traumatic stress (rogers et al., 2020) . these are not only a direct consequence of the pandemic but also largely driven by the effects of prolonged social isolation -that is the objective lack of interactions with others (leigh-hunt et al., 2017) . the medical journal the lancet recently published an article from which a clear and alarming picture emerges: periods of isolation, even less than 10 days, can have long-term effects, with the presence -up to 3 years later -of psychiatric symptoms (brooks et al., 2020) . although necessary to limit the spread of the epidemic, in fact, human beings are not "designed" to manage segregation for a long time. as the greek philosopher aristotle reminds us, man is a "social animal, " unable to live isolated from others, since the absence of relationships removes essential conditions for the development of personal identity and the exercise of reason. although our first instincts may be to react angrily at (and with) people who pour out onto the streets, there is a need for a more universal compassionate stance -and recognition that the very nature of the human being is in stark contrast with the situation we are experiencing. moreover, research shows that nourishment and movement -besides being important therapeutic expedients -are a fundamental vehicle for communicating with ourselves, others, and the world, and have an enormous influence on our biopsychological balance. prolonged isolation can adversely affect physical and emotional health, altering sleep and nutritional rhythms, as well as reducing opportunities for movement (cacioppo and hawkley, 2003) . as a result, the natural channels of human expression and pleasure become depressed, with attendant impacts on mood and subjective well-being (nardone and speciani, 2015) . furthermore, in accordance with current regulations, we have begun to behave "as if " other people are potentially dangerous for our health and for the health of our loved ones. this turn of events has cultivated a new universal belief based on vulnerability-to-harm, whereby proximity to fellow humanbeings poses a direct threat (nardone and portelli, 2005) . to date, more and more people are avoiding social relations, no longer by imposition, but as a choice. a decision initially moved by the fear of an invisible enemy and by the total uncertainty about what is right to do/not to do, to say/not to say, to think/not to think, derived from the informationambiguous and conflicting -that we have received. in turn, this determines behavior that will gradually replace our old worldview and interpersonal relationships. while the levels of environmental stress continue to rise, we are witnessing the deterioration of relationships. rather than connecting people, restrictive measures are creating rivalries and arousing discord between people. as conveyed by the latin phrase "divide et impera" (literally divide and conquer), an authority that exerts high levels of control and division in governing a population, tends to fragment them. the magnitude and impact of fragmentation can be influenced substantially by leadership style. grandiose leadership, for example, may create the seductive illusion of safety, with claims of invincibility and omnipotence, while providing an outlet for a range of grievances associated with inequalities and poverty through paranoia and blame of perceived "enemies. " these processes provide fuel for xenophobia and deeper divisions within society (case and maner, 2014; o'reilly and hall, 2020) . anger and nervousness, unspoken and lasting, come back to haunt us with psychological problems. likewise, spending an unusual amount of time together in confined spaces -often unsuitable for the purpose itselfincreases the risk of conflicts and domestic violence. china has experienced a significant rise in separations and divorces, particularly stressful events, which can act as a triggerespecially among the most sensitive -for the development of mental health problems, primarily depression. on the other hand, prolonged social isolation characterized by reduced social connections and contact, generates deep disconnection among those who live alone or cannot rely on an adequate social network, thus increasing the likelihood that depressive symptoms will emerge. social isolation has been linked to cognitive impairment, reduced immunity, increased risk of cardiovascular disease, and ultimately, mortality (cohen et al., 1997; bassuk et al., 1999; barth et al., 2010; heffner et al., 2011) . the association between physical frailty and social isolation has been linked to heightened inflammatory activity, as indicated by increased levels of c-reactive protein and fibrinogen (loucks et al., 2006) . social isolation and loneliness are related concepts and often coexist -loneliness can lead to isolation, and vice versa (shankar et al., 2011) . loneliness has been an emerging issue in society in recent years, and has been linked to depression, irritability, and preoccupation with negative self-related thoughts, alongside a 26% increase in risk of premature death. research suggests that this has been a growing problem in industrialized countries, with approximately one-third of the population affected, and one in 12 people affected at a severe level. further, it appears that income and socioeconomic status are no barrier to loneliness -everyone is equally at risk holt-lunstad and smith, 2016) . loneliness is increasingly recognized as a public health issue, especially due to the detrimental effects on health and potential for premature mortality (grant et al., 2009; cole et al., 2015; murthy, 2017; yanguas et al., 2018; bzdok and dunbar, 2020) . loneliness is associated with feelings of emptiness, sadness, and shame, alongside the subjective perception that one is disconnected from others. it not only can occur in the context of social isolation but can also persist beyond this and can be experienced even when others are physically present. like social isolation, loneliness has been linked to depression (cacioppo et al., 2006; han and richardson, 2010) , increased cortisol levels (edwards et al., 2010; miller, 2011) , lowered immunity (cole et al., 2011) , and clinical disease, with attendant increases in length and frequency of hospital stays (thurston and kubzansky, 2009; hawker and romero-ortuno, 2016) . further, social isolation and loneliness may be stronger predictors of suicidality than other well-known risk factors, such as anxiety and hopelessness (hom et al., 2017) . in spite of the clear risks associated with loneliness, treatments to date based on cognitive-behavioral principles have shown poor outcomes (masi et al., 2011) . with the onset of covid-19, enforced social isolation is likely to be exacerbating what is already a significant issue in our society (hughes et al., 2004) . added to this is the devastating and understandable impact of concerns related to economic problems and the loss of a loved one. during the coronavirus epidemic, we are forced to deal with death in ways unrelated to human civilization: from the thought of not being able to be with the deceased in his/her last moments of life, to the sense of guilt for the idea of having inadvertently infected the person, to the distress of not being able to properly honor him/her with a funeral ceremony, fundamental to the process of mourning -these are all factors that amplify the pain of death, increase the rates of depression, the consumption of alcohol, drugs and risky behaviors and, in the more extreme cases of suicide. unlike the common and ineliminable moments of crisis that characterize the existence of each of us -which, although destabilizing, represent a unique and fundamental opportunity to review personal strategies for problem management -in this period, people are experiencing impotence, vulnerability, and a feeling of loss of control over one's life as a response to something indeterminate in time and space. this generates anguish for an uncertain future and, once again, favors the appearance of depressive symptoms -especially in those most frontiers in psychology | www.frontiersin.org vulnerable, including those who already suffered from mental health problems and in health workers. those who have been placed in quarantine and those working on the front lines to deal with the epidemic are also at risk of being stigmatized: as possible "plague-spreaders, " they are viewed with fear and suspicion. certainly, some will prove to be more resilient than others and will be able to count on the presence of greater personal, social, and economic resources, but we all will be affectedto varying degrees -by the impact of this revolution on our way of living and relating to each other and on our physical and psychological health. the environmental stressors that characterize this particular historical moment clearly suggest the risk of a new epidemic, and this time there are signs it could be our mental health; but the national health system, once again, may not be ready to stem the effects of the epidemic. as the reality of social isolation persists throughout and beyond the pandemic, loneliness and interpersonal disconnection will emerge, particularly for those most socially vulnerable. psychophysical exhaustion, anxiety, fear and pain, anguish, trauma, and anger -these emotions alternate, mix, and grow in intensity to the point of overwhelm, leading to clinically significant psychological disorders, such as "reactive depression. " while the covid-19 crisis increases the risk of depression, depression affects the individual's ability to solve problems, set and achieve goals, and function effectively, at work and in relationships, making recovery from the crisis even more difficult. in fact, even if it manifests in different ways, at the basis of depression there is always an attitude of renouncement. people gradually lose any form of active reactivity in the face of life's difficulties: there is an increasing tendency to complain, let off steam, and rely completely on others in the management of themselves, all actions of delegation, therefore of renunciation. and, as described by emile cioran, the renunciation is nothing more than "a small daily suicide. " feeling safe and protected is a fundamental primary need of the human being to be able to move freely in the surrounding world, as well as the feeling of having control over the events of our own life. when all this fails, when the belief that whatever we do will not improve things begins to develop, a sense of "learned helplessness" takes hold, blocking any possibility of liberation or change. the anguish we experience is a normal human response to a serious crisis. recognizing and accepting these feelings prevents them from turning into disorder. giving up, delegating, and complaining are all attitudes that at the beginning of a crisis can help us, but after several months can become entrenched, self-perpetuating, and end up complicating the situation, evolving as a slow drift into a depressive mindset. recognizing these patterns immediately in one's thought processes and behavior is the best way to move in the opposite direction and to break the vicious circle that leads to global renunciation -and that characterizes the most severe depressive forms. this pandemic will inevitably lead to redefining our relationship styles, which will no longer be based on proximity but on distance. physical contact will be replaced by negotiated sharing, while the digitalization of lives, already started with the advent of social media, technology, and virtual reality, will be further emphasized, thanks to medical-scientific legitimacy. abandoning the idea that "things will go back to normal" and facing the changes taking place with flexibility mitigates the onset of psychopathology. the human being -by nature -is extremely flexible -facilitating adjustment to the reality that change will become the new normality (rossi et al., 2020) . in lao tzu's words, "water is fluid, soft, and yielding. but water will wear away rock, which is rigid and cannot yield. as a rule, whatever is fluid, soft, and yielding will overcome whatever is rigid and hard. this is another paradox: what is soft is strong. " but it takes time. specific treatment options are available for the most problematic situations, and more available than before the advent of the coronavirus, as mental health professionals -even the most resistant -are -flexibly -offering online support and advice. first, however, there is a need for higher level changes: state economic support measures are crucial responses to both the economic recession and the psychological depression. institutions must ensure that this experience is as tolerable as possible for people. alarmist messages, such as the emphasis on the negative aspects of the pandemic (number of seriously ill people or deaths) rather than on the positive ones (number of recovered), the abuse of alarmist expressions ("death even among young people"), and stories rich in personal details about the victims, are as counterproductive as excessive references to positivity and optimism, which, on the other hand, produce a paradoxical effect: the unrealistic nature of the messages may lead to greater mistrust and perhaps dismay ("they do not tell it as it is"). even vague or ambiguous messages ("if we are united, everything will be fine, " "be responsible, " "stay alert, control the virus") dilute the desired effects. human resilience is closely linked to the depth and strength of our interpersonal connections, including our involvement in groups and communities. in contrast, loneliness appears to be one of the greatest threats to our health, survival, and well-being. in an atmosphere of uncertainty and fear, it is essential that clear and precise information is provided on the problem and on the management of the emergency. greater cultural and economic investments will therefore have to emerge to support better and more timely prevention, treatment, and rehabilitation programs in the field of mental health, because "there is no health without mental health. " frontiers in psychology | www.frontiersin.org 4 september 2020 | volume 11 | article 2201 the original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author. lack of social support in the etiology and the prognosis of coronary heart disease: a systematic review and meta-analysis social disengagement and incident cognitive decline in community-dwelling elderly persons the psychological impact of quarantine and how to reduce it: rapid review of the evidence the neurobiology of social distance the neuroendocrinology of social isolation social isolation and health, with an emphasis on underlying mechanisms loneliness as a specific risk factor for depressive symptoms: cross-sectional and longitudinal analyses divide and conquer: when and why leaders undermine the cohesive fabric of their group social ties and susceptibility to the common cold myeloid differentiation architecture of leukocyte transcriptome dynamics in perceived social isolation transcript origin analysis identifies antigen-presenting cells as primary targets of socially regulated gene expression in leukocytes elevated macrophage migration inhibitory factor (mif) is associated with depressive symptoms, blunted cortisol reactivity to acute stress, and lowered morning cortisol social isolation and stress-related cardiovascular, lipid, and cortisol responses the relationship between depression and loneliness among homebound older persons: does spirituality moderate this relationship? social determinants of discharge outcomes in older people admitted to a geriatric medicine ward social isolation, c-reactive protein, and coronary heart disease mortality among community-dwelling adults loneliness and social isolation as risk factors for cvd: implications for evidence-based patient care and scientific inquiry a systematic review of help-seeking and mental health service utilization among military service members a short scale for measuring loneliness in large surveys: results from two population-based studies an overview of systematic reviews on the public health consequences of social isolation and loneliness relation of social integration to inflammatory marker concentrations in men and women 70 to 79 years a meta-analysis of interventions to reduce loneliness social neuroscience. why loneliness is hazardous to your health work and the loneliness epidemic knowing through changing: the evolution of brief strategic therapy mangia, muoviti, ama. firenze: ponte alle grazie grandiose narcissists and decision making: impulsive, overconfident, and skeptical of experts-but seldom in doubt psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the covid-19 pandemic the anxiety-buffer hypothesis in the time of covid-19: when self-esteem protects from loneliness and fear for anxiety and depression loneliness, social isolation, and behavioral and biological health indicators in older adults women, loneliness, and incident coronary heart disease the complexity of loneliness gp drafted and edited the manuscript. ss critically revised the manuscript. all authors contributed to the article and approved the submitted version. key: cord-253576-bsu6j1q7 authors: ammar, a.; chtourou, h.; boukhris, o.; trabelsi, k.; masmoudi, l.; brach, m.; bouaziz, b.; bentlage, e.; how, d.; ahmed, m.; mueller, p.; mueller, n.; aloui, a.; hammouda, o.; paineiras-domingos, l. l.; braakman-jansen, a.; wrede, c.; bastoni, s.; pernambuco, c. s.; mataruna, l.; taheri, m.; irandoust, k.; khacharem, a.; bragazzi, n. l.; chamari, k.; bailey, s. j.; bott, n. t.; gargouri, f.; chaari, l.; batatia, h.; mohamed ali, g.; abdelkarim, o.; jarraya, m.; el abed, k.; souissi, n.; gemert-pijnen, l. v.; riemann, b. l.; riemann, l.; moalla, w.; gomez-raja, j.; epstein, m.; sanderman, r. title: social participation and life satisfaction of peoples during the covid-19 home confinement: the eclb-covid19 multicenter study date: 2020-05-09 journal: nan doi: 10.1101/2020.05.05.20091066 sha: doc_id: 253576 cord_uid: bsu6j1q7 abstract background public health recommendations and governmental measures during the covid-19 pandemic have enforced numerous restrictions on daily living including social distancing, isolation and home confinement. while these measures are imperative to mitigate spreading of covid-19, the impact of these restrictions on psychosocial health is undefined. therefore, an international online survey was launched in april 2020 in seven languages to elucidate the behavioral and lifestyle consequences of covid-19 restrictions. this report presents the preliminary results from the first thousand responders on social participation and life satisfaction. methods thirty-five research organisations from europe, north-africa, western asia and the americas promoted the survey through their networks to the general society, in english, german, french, arabic, spanish, portuguese, and slovenian languages. questions were presented in a differential format with questions related to responses before and during confinement conditions. results 1047 replies (54% women) from asia (36%), africa (40%), europe (21%) and other (3%) were included in the analysis. preliminary findings revealed psychosocial strain during the enforced covid-19 home confinement. in particular, large decreases in the amount of social activity through family (58%), friends/neighbors (44.9%) or entertainment (46.7%) were triggered by the enforced confinement. these negative effects on social participation were also associated with lower satisfaction (-30.5%) during the confinement period. conversely, social contact score through digital technologies has significantly increased (p<0.001) during the confinement period with more individuals (24.8%) being socially connected through digital technology. conclusion these preliminary findings elucidate the risk of psychosocial strain during the current home confinement period. therefore, in order to mitigate the negative psychosocial effects of home confinement, implementation of national strategies focused on promoting social inclusion through technology-based solution is urgently needed. public health recommendations and governmental measures during the covid-19 pandemic have enforced numerous restrictions on daily living including social distancing, isolation and home confinement. while these measures are imperative to mitigate spreading of covid-19, the impact of these restrictions on psychosocial health is undefined. therefore, an international online survey was launched in april 2020 in seven languages to elucidate the behavioral and lifestyle consequences of covid-19 restrictions. this report presents the preliminary results from the first thousand responders on social participation and life satisfaction. thirty-five research organisations from europe, north-africa, western asia and the americas promoted the survey through their networks to the general society, in english, german, french, arabic, spanish, portuguese, and slovenian languages. questions were presented in a differential format with questions related to responses "before" and "during" confinement conditions. results 1047 replies (54% women) from asia (36%), africa (40%), europe (21%) and other (3%) were included in the analysis. preliminary findings revealed psychosocial strain during the enforced covid-19 home confinement. in particular, large decreases in the amount of social activity through family (58%), friends/neighbors (44.9%) or entertainment (46.7%) were triggered by the enforced confinement. these negative effects on social participation were also associated with lower satisfaction (-30 .5%) during the confinement period. conversely, social contact score . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) social participation and engagement requires the maintenance of a variety of social connections and relationships, as well as involvement in social and community activities. 1, 2 examples of these activities include visiting and having contact with family and friends, 3 belonging to religious groups, 4 participating in occupational or social roles (e.g., volunteering for association or nonprofit organization; 5 ), voting 6 engagement in cultural and sports activities, 7 and attending meetings. 8 a good social participation boosts feeling of attachment, provides a consistent and coherent sense of identity, and enhances the sense of value, belonging and attachment to the individual's community. 5 in this context, prilleltensky et al. 9 reported that integration into community life and participation in social activities actively increases psychological and social wellbeing as well as an individual's sense of belonging. in the same way, smetana et al. 10 showed social participation enhances self-efficacy and personal self-control in adolescents. termed "social health," the enhancement of social participation is one of the important targets for health professionals. 11 as indicated by levasseur et al. 12 , social participation is related to mortality, morbidity, and life quality. the world health organization' (who) recommends that particular attention should be given to social participation, especially for elderly as they spend less time in structured employment. 13 also, social participation plays an important positive role in personal wellbeing (e.g., life satisfaction) 14 and social wellbeing 5 for adolescents and adults. on the other hand, participating in personal leisure activities (a form of social participation) is of high importance for physical health, mental health, and improved quality of life. 15 social participation and life satisfaction are strongly related. 5 life satisfaction is defined as the estimation of life quality based on an individual's preferences and satisfaction in these domains. 16 for social wellbeing, life satisfaction is of crucial importance. indeed, it has been reported that . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may 9, 2020. . life satisfaction is associated with psychiatric disorders (e.g., depressive disorders) and suicidal ideation. 16 a novel coronavirus, named sars-cov-2 or covid-19, was detected in hubei, china in december 2019. as of this publication (april 11,2020), covid-19 was reported in more than 200 countries, affecting more than 2,350,000 peoples and resulting in more than 160,000 deaths. the covid-19, which was declared a global pandemic on march 11 th , 2020, is a serious challenge, facing all societies. to decelerate its rapid transmission, social confinement remains the best non-pharmacological solution and as a result, many countries have imposed stringent social distancing measures. while quarantine has been utilised previously to combat infectious diseases (e.g., cholera, sars, ebola), the level of confinement applied to the global population is the most severe in history. although it is the most effective solution to slow the spread of infectious disease, home confinement can also have negative effects on social participation and life satisfaction. this crisis (i.e., covid-19 spread and the associated confinement) may also be associated with sensations of loneliness, grief, and loss of life satisfaction. possible relationship changes with family and friends, as well as mitigated participation in community life are expected. the purpose of this investigation is to examine the effects of home confinement on social participation and life satisfaction. results of this study could provide conclusions about confinement related social participation and life satisfaction changes; the ultimate goal being to highlight the importance of setting up programs to support individuals as they go through this crisis. we report findings on the first 1047 replies to an international online-survey on mental health and multi-dimension lifestyle behaviors during home confinement (eclb-covid19). eclb-. cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may 9, 2020. . covid19 was opened on april 1, 2020, tested by the project's steering group for a period of 1 week, before starting to spread it worldwide on april 6, 2020. forty-one research organizations from europe, north-africa, western asia and the americas promoted dissemination and administration of the survey. eclb-covid19 was administered in english, german, french, arabic, spanish, portuguese, and slovenian languages. the survey included sixty-four questions on health, mental wellbeing, mood, life satisfaction and multidimension lifestyle behaviors (physical activity, diet, social participation, sleep, technology-use, need of psychosocial support). all questions were presented in a differential format, to be answered directly in sequence regarding "before" and "during" confinement conditions. the study was conducted according to the declaration of helsinki. the protocol and the consent form were fully approved (identification code: 62/20) by the otto von guericke university ethics committee. the eclb-covid19 electronic survey was designed by a steering group of multidisciplinary scientists and academics (i.e., human science, sport science, neuropsychology, computer science) at the university of magdeburg (principal investigator), the university of sfax, the university of münster, and the university of paris-nanterre; development followed an initial structured review of the literature. the survey was then reviewed and edited by over 50 colleagues and experts worldwide. the survey was uploaded and shared online via the google platform. a link to the electronic survey was distributed worldwide by consortium colleagues via a range of methods: invitation via e-mails, shared in consortium's faculties official pages, researchgate™, linkedin™ and other social media platforms such as facebook™, whatsapp™ and twitter™. public were also involved in the dissemination plans of our research through the promotion of the eclb-covid19 survey in their networks. the survey included an introductory page . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may 9, 2020. . describing the background and the aims of the survey, the consortium, ethics information for participants and the option to choose one of seven available languages (english, german, french, arabic, spanish, portuguese, and slovenian). the present study focusses on the first thousand responses (i.e., 1047 participants), which were reached on april 11, 2020, approximately oneweek after the survey began. this survey was open for all people worldwide aged 18 years or older. people with cognitive decline were excluded. during the informed consent process, survey participants were assured all data would be used only for research purposes. participants' answers are anonymous and confidential according to google's privacy policy (https://policies.google.com/privacy?hl=en). participants don't have to mention their names or contact information. in addition, participant can stop participating in the study and can leave the questionnaire at any stage before the submission process and their responses will not be saved. response will be saved only by clicking on "submit" button. by completing the survey, participants are acknowledging the above approval form and are consenting to voluntarily participate in this anonymous study. participants have been requested to be honest in their responses. the eclb-covid19 is a multi-country electronic survey designed to assess change in multiple lifestyle behaviors during the covid-19 outbreak. therefore, a collection of validated and/or crisis-oriented briefs questionnaires were included. these questionnaires assess mental wellbeing (short warwick-edinburgh mental well-being scale (swemwbs) 17 ), mood and feeling (short mood and feelings questionnaire (smfq) 18 questionnaire for lockdowns (slsql), social participation (short social participation . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 9, 2020. . questionnaire short form (ipaq-sf) 19, 20 ) , diet behaviors (short diet behaviors questionnaire for lockdowns (sdbql)), sleep quality (pittsburgh sleep quality index (psqi) 21 ) and some key questions assessing the technology-use behaviors (short technology-use behaviors questionnaire for lockdowns (stbql)), demographic information and the need of psychosocial support. reliability of the shortened and/or newly adopted questionnaires was tested by the project steering group through piloting, prior to survey administration. these brief crisis-oriented questionnaires showed good to excellent test-retest reliability coefficients (r = 0.84-0.96). a multi-language validated version already existed for the majority of these questionnaires and/or questions. however, for questionnaires that did not already exist in multi-language versions, we followed the procedure of translation and backtranslation, with an additional review for all language versions from the international scientists of our consortium. as a result, a total number of sixty-for items were included in the eclb-covid19 online survey in a differential format; that is, each item or question requested two answers, one regarding the period before and the other regarding the period during confinement. thus, the participants were guided to compare the situations. given the large number of questions included, the present paper focuses on newly developed slsql and sspql as brief crisis-oriented tools. the present short social participation questionnaire-lockdowns (sspq-l) is a crisis-oriented short modified questionnaire to assess diet behavior before and during a lockdown period. the sdbq-l is based on the eighteen items of the spq. the original spq items aim to ask respondents to indicate how regularly they had undertaken each activity in the last 12 months. from questions 1 to 12, participant could choose one of the six response categories: ''never'', . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 9, 2020. . ''rarely'', ''a few times a year'', ''monthly'', ''a few times a month'', and ''once a week or more''. the remaining four items requested a binary ''yes'' or ''no'' response regarding participation in community groups in the last 12 months. 22 given that we are assessing social participation before and during the home confinement, which is a short period (days to months), we adapted the response categories and shortened the number of questionnaires by combining similar questions (e.g., q1 and 2; q2 and q3; q12 and q14), while adding one more question about the use of phone calls for communication. accordingly, the final sspq-l includes 14 items with five response categories (i.e., "never"=1 point; "rarely"=2 points; "sometimes"=3 points; "often"=4 points and "all times"=5 points) for the 10 first items and "yes"=5 points / "no"=1 point response categories for the four remaining items. total scores of this questionnaire correspond to the sum of the scored points in the 14 questions. the total score for the sspq-l is from "14" to "70", where "14" indicate that participant has "never" being socially active; a score between "15" and "28" indicate that participant has "rarely" being socially active, a score between "29" and "42" indicate that participant is "sometimes" socially active, a score between "43" and "56" indicate that participant is "often" socially active, and a score between "57" and "70" indicate that participant is at "all times" socially active. the present short life satisfaction questionnaire-lockdowns (slsql) is a crisis-oriented short modified questionnaire to assess satisfaction with the respondent's life as a whole before and during the confinement period. the slsql is the short version of the satisfaction with life scale (swls)'s five items. 23 three questions from the swls questionnaire, that showed to be related to emotional well-being, were included to allow an individuals' conscious evaluative judgment of participant life by using the person's own criteria. using the 1 -7 scale below, . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 9, 2020. . participants indicate their agreement with each of the three included items (strongly agree=7; agree=6; slightly agree=5; neither agree nor disagree=4; slightly disagree=3; disagree=2; strongly disagree=1). total score of this questionnaire, correspond to the sum of the scored points in the 3 questions. the total score for the slsq-l is from "3" to "21", where "3" indicate that participant is "extremely dissatisfied", "4-6" indicate that participant is "dissatisfied", "7-9" indicate that participant is "slightly dissatisfied", "10-12" indicate that participant is "neutral", "13-15" indicate that participant is "slightly satisfied", "16-18" indicate that participant is "satisfied", and "19-21" indicate that participant is "extremely satisfied". descriptive statistics were used to define the proportion of responses for each question and the total distribution of the total score of each questionnaire. all statistical analyses were performed using the commercial statistical software statistica (statsoft, paris, france, version 10.0). normality of the data distribution was confirmed using the shapiro-wilks-w-test. values were computed and reported as mean ± sd (standard deviation). paired samples t-tests were used to assess significant difference in total scored responses between "before" and "during" confinement period. effect size (cohen's d) was calculated to determine the magnitude of the change score and interpreted using the following criteria: 0.2 (small), 0.5 (moderate), and 0.8 (large). 24 pearson product-moment correlation tests were used to assess possible relationships between the "before-after" δ of the assessed multidimension total scores. statistical significance was identified at p<0.05. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 9, 2020. . 1047 participants were included in the preliminary sample. overall, 54% of the sample were women and 46% were men. geographical breakdowns were from asian (36%, mostly from western asia), african (40%, mostly from north africa), european (21%) and other (3%) countries. age, health status, employment status, level of education, and marital status are presented in table 1 . change in social participation score from "before" to "during" confinement period in response to sspql assessment tool are presented in table 2. statistical analysis showed the total score of sspql decreased significantly by 42% "during" compared to "before" home confinement (t=69.19 p<0.001, d=2.14). this significant decrease was observed in the score recorded by each question (1 to 14) . particularly, the recorded score in social participation through family, neighbors, friend or church or religious activities (q1-q3) were lower at "during" compared to "before" confinement with |δ%| ranged from 56% to 59% (34.9 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 9, 2020. . change in life satisfaction score from "before" to "during" confinement period in response to slsql are presented in table 3. statistical analysis showed that the total score of slsql decreased significantly by 16% "during" compared to "before" home confinement (t=21.05, p<0.001, d=0.65). this significant decrease was observed in the score recorded by the three included questions (q1-q3). particularly, in response to the direct (q3) and indirect (q1-q2) questions related to life satisfaction lower scores were recorded at "during" compared to "before" confinement with |δ%| ranged from 14% to 18% (17.6 to contain covid-19 transmission, policymakers in many countries have considered implementing restrictive measures. understanding the psychosocial implications of these measures will allow for better-informed decisions. the present study aims to provide insight into the effect of home-confinement on life satisfaction and social participation, based on data extracted from the first thousand multi-country responses. preliminary results from 1047 participants (54% female; 36%, from western asia, 40% from north africa, 21% from european and 3% from other countries) showed covid-19 home confinement has a negative effect on social participation and life satisfaction. total score in the social participation questionnaire decreased by 42% with more socially (+71.15%, never-rarely socially active) inactive individuals "during" compared to "before" the confinement period. similarly, total score in life satisfaction questionnaires decreased by 16% with more people feeling dissatisfied (extremelyslightly) (+16.5%) "during" compared to "before" the confinement period. cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 9, 2020. . highlighting the fact that people in quarantine report a greater symptom of psychological distress; furthermore, some of these symptoms appear to stay long after the quarantine period ends. 27 similarly, results from chinese studies indicate the covid-19's resultant social distancing measures engendered less life satisfaction and more distress. 28 with significant negative effects of the current covid-19 pandemic on social participation and life satisfaction scores, the present findings support these previous reports, elucidating the risk of psychosocial strain during the current home confinement period. particularly, the recorded total score during the home confinement was about 26pts (vs. 44pts before confinement), meaning that participants are rarely engaging in social activities, with a higher risk of social exclusion. this could be explained by social restrictions and reduced mobility imposed by governmental entities to contain the spread of the virus. 29 present findings indicate the 71.15% reduction in total social participation score was largely due to the decrease in social participation through family-visit activity (58%), with less individuals reporting regular (often/all times) visits to their family during compared to before the confinement period (7.2% vs. 65.2%). social participation through entertainment activities or neighbors/friend visits recorded the second large decrease (44.9% to 46.7%), with the proportion of people declaring to regularly visit their neighbors/friends or regularly go to coffee shops/restaurants/parties decreased from more than 47% at before confinement to between 1% and 3% during confinement period. of note is that younger populations showed a very large decrease in social participation through class participation, gym, or exercise activities (40% to 53%). the present widespread social isolation imposed by covid-19 could induce a detrimental effect on mental health. indeed, according to one study evaluating 1006 italians under covid-19 quarantine, longitudinal forced isolation increased depression, unworthiness, alienation, and helplessness. 29 in addition, worse health conditions, as well as distress, were reported by adults who were not working in china. 28 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 9, 2020. . the present findings confirm the causal relationship between social participation and psychological health, showing a significant positive correlation between the total score recorded for social participation and life satisfaction (p<0.001 and r=0.23). additionally, it was revealed that social distancing during home confinement was associated with less satisfied persons (-30.5%). indeed, before the confinement more than 60 % agreed to being satisfied with their life, while during the confinement only 30% reported agreeing to this statement. similarly, total scores of life satisfaction moved from "slightly satisfied" (i.e., before home confinement) to "neutral" (i.e., during home confinement). this close relationship between social distancing and life dissatisfaction may be due to the fact that socially distancing yourself from someone to which you are emotionally attached is difficult and can result in life dissatisfaction. therefore, to keep an acceptable level of life satisfaction, it is important to stay connected while staying away. as our study indicates, social participation through family, friends and neighbors was most negatively affected by confinement, revealing the importance of staying in touch with friends and family to keep an acceptable level of life satisfaction. the present findings also showed that social participation through internet, social media, phone calls etc. has increased from before to during home confinement with more individuals (24.8%) declaring the use of digital-facilities to stay socially connected during the home confinement period (61.5% vs. 36.7%). as participants demonstrated a greater use of technology during the confinement period, this medium may provide an avenue to foster social communication, thereby mitigating life dissatisfaction. information and communications technology (ict) such as video chat, social media, social platform, gamification, mhealth, interactive coach etc. can be therefore suggested to stay connected while staying away. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 9, 2020. . the results from the first 1047 replies to the eclb-covid19 survey reveal a psychosocial strain during home confinement. in particular, a large decrease in social participation, triggered by enforced home confinement, was associated with lower satisfaction levels. conversely, social contact through digital technology has increased during the confinement period. therefore, in order to mitigate the negative psychosocial effects of home confinement, implementation of national strategies to promote social inclusion through ict-based solutions are urgently needed. additionally, given that present findings are based on data from heterogenic populations with no criteria-based subsamples analysis, further research is warranted to identify subpopulations that might be more affected by covid-19 confinement measures. identification of such populations would allow for better informed and more targeted mitigation strategies. we thank our consortium's colleagues who provided insight and expertise that greatly assisted the research. we thank all colleagues and peoples who believed on this initiative and helped to distribute the anonymous survey worldwide. we are also immensely grateful to all participants who #stayhome & #boostresearch by voluntarily taken the #eclb-covid19 survey. research are urgently needed to help understand the impacts of the covid-19 pandemic on peoples' lifestyle. however, normal funding mechanism to support scientific research are too slow. the authors received no specific funding for this work. the authors declare no conflict of interest. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 9, 2020. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 9, 2020. . is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 9, 2020. is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 9, 2020. social disengagement and incident cognitive decline in community-dwelling elderly persons gender, older people and social exclusion. a gendered review and secondary analysis of the data social engagement and its relationship to service provision in residential care and assisted living social networks and selfrated health in two french-speaking canadian community dwelling populations over 65 from social integration to health: durkheim in the new millennium mental 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sciortino, rosalia; saini, fabio title: towards a comprehensive narrative and response to covid-19 in southeast asia date: 2020-09-01 journal: nan doi: 10.1016/j.ssaho.2020.100058 sha: doc_id: 269090 cord_uid: o93gxlzx the dominant narrative of the covid-19 pandemic in southeast asia barely gives attention to the many social and cultural dimensions of the crisis, and humanities and social science experts remain at the margins of containment decisions. this short commentary highlight our potential contribution based on our disciplinary core principles and what has been learned from other epidemics, foremost hiv. it argues that we can help broaden the current epidemiological approach to understand and impact on the social drivers of vulnerability and risk for diverse populations in specific contexts, while promoting transformative change. we can achieve this through paradigmatic adjustments as well as a more daring and engaged role on our part. three months into the covid-19 pandemic, a dominant narrative has developed, which is focused on tallying numbers of cases and deaths, forecasting economic impacts and hoping for better treatment and a vaccine. in the region where we live, southeast asia, the many social and cultural dimensions of the crisis have become obfuscated and the voices of humanities and social science experts and even public health specialists seems subdued. measures have been implemented top-down without much discussion on their contextual suitability, implications and impacts. yet, as stated by jürgen renn explaining germany's unique choice to form a multidisciplinary advisory working groups on covid-19 of which he is a member, this crisis is complex and systemic, and needs to be dissected from every angle [1] . clearly this pandemic is caused by a virus, but understanding it, controlling it and reducing its human costs depends also on social knowledge and interventions. the fact that in the current global covid-19 discourse such interventions are often called 'non-pharmaceutical' [2] shows once more the very limited space that our disciplines have been able to gain (or claim) in the health domain in the past and now. this compels us to more openly articulate the urgency of a comprehensive narrative and response to this pandemic. our short commentary aims to highlight the contributions that social scientists and practitioners can make to responses to covid-19. based on our disciplinary core principles and what has been learned from other epidemics, foremost hiv, we can help shift a purely epidemiological approach to addressing the social drivers of vulnerability and risk for diverse populations in specific social contexts, and build agency of these groups while promoting social transformative change. we can achieve this through paradigmatic adjustments as well as a more daring and engaged role on our part. to make our case, we will move from knowledge to interventionrelated issues and mostly refer to countries in southeast asia (sea), but some of the statements and comparisons may have a global resonance. for about two decades, east and southeast asia have seen the emergence of new zoonotic infectious diseases starting in southern china, spreading to its surroundings, until eventually selfexhausting. in particular, the sars outbreak in the late 2002 and the avian influenza (h5n1) outbreak in 2003 have had significant transnational health and economic impacts, disproportionately affecting the region and its most vulnerable populations. since then, it has been recognized that this geo-economic space is a hotspot for major zoonotic outbreaks because of the rapid market integration and the increasing density and mobility of the human and animal populations. the latter, because of environmental encroachment, wildlife trade and expansion and commercialization of livestock production. past studies of pathogens' transmission pathways from animals to humans showed how people's behavior and the way they interact with the animals and their habitats is conducive to health threats and biodiversity decline. in the case of sars, the horseshow bat and the civets were identified as the virus reservoir and intermediate host respectively, with the spillover made possible by the hunting, farming, sale, consumption and export of wild animals across southern china and mainland southeast asia. cultural habits, economic profit and livelihoods' necessities drive these practices with wild animals being used for food but also for traditional medicine, clothing, decorations or to be raised as pets [3] . to understand and tackle the complexity of intersecting health, biodiversity and socio-economic factors, in the past decade transdisciplinary initiatives were launched that promoted a new holistic approach, such as the ecohealth and the one health paradigms. the first, draws from the humanities and the natural, social and health sciences to examine the dependence of human well-being on the interplay of ecological and socio-economic systems. the second brought together veterinary and human medicine to study human-animal disease transmission, and later broadened its scope to include varied agricultural and environmental challenges [4] . these promising initiatives were still evolving and being operationalized when the sars-cov-2 virus that caused covid-19 hit. although research is ongoing to establish the exact origin of this virus and its transmission to humans, there appears to be consensus of its being zoonotic and its spread presumably related to the farming and trading of wildlife in southern china [5] . these contextual similarities with previous outbreaks raise questions about the lack of preparedness for a virus that, in spite of the many conspiracy theories, could have been expected [6] . at the same time, they do encourage us to persevere in the path undertaken and strive harder to improve and systematically implement and institutionalize the nascent transdisciplinary paradigms in the recognition that covid-19 like previous crises "[does not] lie comfortably within the domain of a single discipline" [7] . increased humanistic and social insights in ecohealth and one health -or an integrated version of the two -would broaden the collaborative inquiry and the derived interventions emphasizing the systemic socio-cultural, economic and political dynamics of emerging infectious diseases. these insights are critical to address the root causes of this pandemic and its cascading systemic effects by questioning current development models. they can also contribute to shorter-term decisions such as whether and how to ban wildlife trade and markets in a culturally sensitive and eco-socially responsible manner, and enhance disease-risk prediction for successive outbreaks. if the transdisciplinary approach has to function, however, there needs to be new integrated research models that benefit from disciplinary strengths, but deconstruct the disciplinary silos. going beyond the rhetorical level is arduous and greater investments ought to be made to change sectoral institutional structures and specialisms, hierarchical value systems and resource allocation as well as to establish clear mechanisms for knowledge-sharing and collaboration [8] . the paradigms should also be improved by embedding transformative processes and actors. as we learned from hiv, this is necessary not only to successfully address health threats, but to ensure that covid-19 is an opportunity to revisit current structures and, paraphrasing writer arudhati roy, 'the portal' to a more just and sustainable society [9] , as we argue in the last section. outside of epistemological initiatives, social scientists and practitioners ought to engage more in ensuring that the specific contextual drivers and risk factors of any epidemic are taken into account in the development and tailoring of a package of available interventions -both at policy and programmatic levels -especially when these entail changes to established social expectations, norms, and practices and affect different groups in different ways. in the case of covid-19, we have a number of tools at our disposal ranging from testing and identification of carriers and their contacts to washing hands and social distancing, isolation and quarantine -just to name a few. except for disagreement on when (and what types, and for which populations) masks are needed -by some media not too convincingly explained in terms of cultural attitudes [11] -these measures are meant for the entire global community. however, there is no universal guideline on their right mix and no consensus on the degree of enforcement required to ensure people's adherence. this is where understanding of what is feasible and effective (or not) in a specific context becomes of strategic importance. achieving a successful mix of interventions both in the midst of the covid19 pandemic and for exit strategies is contextually defined. what can be recommended for a slum or overcrowded area where social distancing is difficult, if not impossible, and hand washing with clean water is a challenge? or for areas, such as most provinces in thailand, which have already been declared as drought-affected areas with national dams and reservoirs only at an average of 49% capacity of which only 26% is usable water [12] ? what is the alternative to 'work from home' for the many who have low-wage jobs or work in the informal economy? how can prevention and risk reduction campaigns be framed to be meaningful to various population segments who have diverse cultural idioms and differential access to resources and capacities? similarly, recognizing that lockdown can never be 100 percent and that at some point even the stricter ones will have to open up in a "second phase", socio-cultural insights should feed into the discussion of what is essential and should be left functioning to provide people comfort and keep society going amid the necessary disruption -and all this weighted against epidemiological risks. policy formulation would benefit from a more inclusive debate and from the realization that 'essential' is not only medically or economically defined and that a top-down cookie cutter approach may not fit diverse realities even within the boundaries of one country. the definition of epidemiological risk itself is not immune from socio-cultural biases. in singapore, national spatial modeling exercises [13] and containment measures missed to include the large migrant population. the government was taken aghast by the growing spread of the infection to migrants' dormitories and finally recognized migrants' substandard living conditions, although the 'stay-at-home' order forces them to remain at risk. other southeast asia countries have still to learn from this experience and are overlooking migrant and refugee populations in their regional and national health security plans or even persecuting them like in malaysia [14] . here is where ethical discussion and human-rights-based approaches could raise key questions on our collective responsibility to protect the most vulnerable in our midst and address their marginalization. contextual knowledge is also crucial to comprehend the many global and regional graphics filling the infosphere and print media. looking like a grim competition on which country has the highest number of cases and deaths, they leave the readers with fear rather than compassion for those hardest-hit. what do these numbers really mean? does it make sense for southeast asia to compare in absolute instead of relative terms the number of cases in the large populations of indonesia and the philippines with those of tiny countries such as brunei or even the somewhat larger singapore? similarly, does it make sense to compare fatality rates without taking into account the number of swabs and the procedures applied in collecting them? in explaining differences in prevalence, incidence and fatality rates within and across countries, we should be weary of simplistic discussions and engage on social media to encourage the public to be statistically literate "i.e. to think critically about the information being presented; to understand the context; and to be able to tell the story in the data" [15] . among the explanations to be given, we ought to stress that geographical differences in outcomes can only be partially explained bio-medically as they are the product of the interplay of epidemiological and social, political, cultural and historical factors. as global health expert and anthropologist paul farmer puts it "any kind of essentialism about the host or the pathogen" nor specific preventives or therapies would be sufficient to explain the wide variation observed in this pandemic [16] . unless we understand in more detail the contextual determinants of covid-19, statistics will not tell us what has led to the numbers and comparative differences we are seeing. innovative research is needed that combines disciplines and methodologies and provides disaggregated data and analysis, with risk broken down according to age, gender, class, occupation and other social variables this evidence serves to identify and characterize the (combination of) factors that accelerate or slow down transmission in different populations and settings. it would also allow us to find out which groups may be more vulnerable and, for example, to check how far diverse groups have access to information, testing or care -all elements that are essential to determine if any intervention is effective [17] . among others, we know that age matters and elderly people are at greater risk, especially if they have co-existing medical conditions, but we still have to investigate more their living and family arrangements from live-in care facilities to habiting in extended families to autonomous housing. we know that gender has an impact: men fall to the coronavirus much more than women; but we do not know whether this is because of genetic or social factors or both. we also do not fully appreciate yet the role of population density, socio-economic conditions, quality of health care, pollution and environmental degradation. thailand official data are detailing transmission settings [18] , but for other countries in the region, more advocacy is needed to ensure focus is not only on the basic clinical characteristics. there is also much left to be known about human to human transmission and behavior that facilitate spreading more extensively. large covid-19 infection clusters or super-spreading events (sses) have barely been studied. besides transmission within households, hospitals are j o u r n a l p r e -p r o o f proving spawning ground for transmission also among health workers in countries like indonesia and the philippines. from news reporting, massive religious gathering of various faiths in indonesia and malaysia and cultural and entertainment events (like thai boxing and discotheque hopping in thailand) have resulted in significant infection clusters and spreading of the disease, in some cases even to neighboring countries in the region. we are also seeing a shift from infections in socio-economically privileged communities connected through global travel towards people in more vulnerable settings, such as singapore's migrants living in dormitories and workers in a tobacco factory in indonesia. but besides these general trends we lack elements to carefully map and analyze transmission to help policy decisions concerning, for instance, which venues to reopen after lockdown [19] . as of now, those seem more dictated by interests of different forces in society than by evidence. the humanities have a major role to play in helping people come to term with the existential aspects of this crisis. the visual imaginary in the media, mostly consisting of death and intensive care scenes, and the escalating numbers of cases and fatalities, have augmented our fear, sensationalizing fatality rates and dehumanizing human sufferings. whether this narrative has been fostered, intentionally or not, to imprint the urgency of our taking protective measures and "stay at home", it remains one-sided and may have unwanted consequences, including on mental health. it is well established that "scaring the already scared" only changes behavior in the short term, is ineffective especially with high levels of anxiety [20] and it may cause traumas and prejudices that make more difficult to learn to live with the virus. in yoong's words "it makes us myopic, it helps us focus only on the short term. it reduces our ability to empathize with each other. and it leads us to behavior like panic-buying, which we know when we are our better selves is not the right thing to do" [21] . out of fear, people scapegoat the 'other' as the 'transmitter', triggering unnecessary stigma and discrimination that hampers the efforts to control the epidemic and build solidarity. we seem to have forgotten that it is the virus, and not the carriers that should be battled, and that epidemics are not only a matter of individual responsibility, but also of political and economic accountability. all over the region, health workers have been ousted by their landlords, people fingered for their perceived not complying with containment measures, patients accused of lying to avoid quarantine or hospital admission. the dread for 'silent carriers' is stopping the public from appreciating that their gaining some level of immunity to the virus eventually, as it is expected, will become the barrier to the spread [22] . yet, fear can be overcome by better understanding and taking preventing measures so that one reduces risk for oneself and others, irrespective of what others do. besides more accurate reporting of the clinical realities of covid19, a new narrative needs to be formulated that show that the pandemic is also a tale of survival, resilience and solidarity. this begins with the recognition that human perception of risk and related behavior are embedded in specific socio-cultural structures and therefore rather than blaming individuals, efforts should be directed at intervening on the environments that put them at risk. when, during the aids epidemic, the low bargaining power of sex workers with their customers was understood adequately, thailand successfully introduced the '100 percent condom policy', making responsible the owners of the entertainment establishments for enforcing condom use, lessening the blame on the sex workers [23] . for those who seem not to comply with isolation measures, assessments should be made on whether they have internalized (not only understood) why measures are necessary and whether they are in a position to practice those measures. if not, our responsibility is to devise strategies to change their behavior, beyond financial disincentives and even "shooting" at them as recently ordered by the leader of the philippines [24] . polio eradication programs have also highlighted the importance of building communitywide social support for behavior change, using a whole-community approach, and building community capacity and cohesion for long-term ownership and sustainability [25] this should include strategies to enable and empower people to adopt and maintain prevention and riskreduction practices, especially when these have to be in place for the foreseeable future and may disrupt relationships and networks. cultural and artistic practices can contribute to enhancing communities' resilience in facing the crises, coping with the disruption and recovering. across the region, grassroots groups and community organizations are harnessing their cultural idioms and social capital to come to terms with the unprecedented limits covid-19 has placed on their daily lives and rituals and to foster a collective safety culture in often constrained settings with little, if none, government attention. how to strengthen such organic efforts without falling in the trap of seeing communities as homogenous or reducing culture to a tool for "enabling negative aspects to be managed and controlled, and positive ones to be harnessed in instrumental solutions to reduce risk and dispel 'ignorant' beliefs" [26] ? also, how to avert misuse of cultural resilience to justify inaction in tackling structural dynamics that place communities in conditions of marginalization and vulnerability in the first place? moving forward, it is fundamental to produce engaged work and strategize on how to compel governments, media, academia and other key stakeholders to acknowledge, integrate, and act upon socio-cultural concerns in the current response to the pandemic, recovery plans and in mitigating its long-term consequences. as many have pointed out, covid 19 is much more than a health crisis. it has amplified the inability of most systems around the world to socially, economically, and medically protect the most vulnerable in societies [27] . covid19 has shaken the global order and exposed the fragility of a model based on the cannibalization of the planet and the reduction of people to consumers. it has shown the limits of private health care and commercialization of public goods and exposed the entrenched wealth and welfare inequities in the ways people have been differentially affected by the pandemic. this precarious architecture of unbalanced systemsunconcerned with sustainable development, resilience, and equity -appears to be tumbling down in a cascade that researchers call "synchronous failure" [28] . it is urgent to challenge the current response to covid19 that ignores these complex implications and remains largely informed by the politics of security -or securitization -that j o u r n a l p r e -p r o o f justifies extraordinary measures in the face of an existential threat. in a region already prone to authoritarianism, fear of the pandemic is being manipulated to further concentrate power, curtail freedom of assembly and speech, and justify inaction on structural changes [29] . surveillance measures are being implemented with scant public discussion on the use of intrusive technologies and personal information and data, and no guarantee of their being rolled back once the epidemic is over. what happened in the aftermath of the attacks of 11 september 2001 showed us that surveillance measures introduced at times of emergencies may easily become a permanent fixture especially in countries where democratic guarantees are not in place or are already weak [30] , like in southeast asia. the growing use of criminal law and repressive measures to enforce compliance needs to be opposed. as stated by the hiv justice worldwide steering committee "communicable diseases are public health issues, not criminal issues" and their generally biased application persecute the most vulnerable in society, including homeless and poor people and members of already stigmatized groups, while failing to provide them the economic and social support to enable them to protect themselves and others [31] . the failure to provide a comprehensive response is causing great suffering and desperation. in thailand, this has led to a growing number of suicides. civil society organizations have mobilized to provide personal protective equipments (ppes) and food aid, but they are overwhelmed by so many people queuing and standing (at a distance) for hours under the sun. moreover, relief cannot substitute the much-needed strengthening of social protection mechanisms-e.g. through paid sick leave and investments in health [32] and for redistribution measures to reduce the income and wealth inequities that the covid-19 outbreak will only deepen [33] . this bring us to take responsibility for contributing to the imagining and pursuing of alternative futures [34] . as social scientists and practitioners, let us reject the ideological platform of the socalled 'new normal' that predicates change only in terms of continued exertion of control and induced epidemiological mores after lockdowns. instead, we should inform and design transformative reforms for equitable and sustainable development. the time is now to tackle the inequities that this pandemic has exposed, and restructure our relations in society and with the environment [35] . 22 april) german humanities scholars enlisted to end coronavirus lockdown. times higher education impact of non-pharmaceutical interventions (npis) to reduce covid-19 mortality and healthcare demand china has made eating wild animals illegal after the coronavirus outbreak ecohealth and one health: a theory-focused review in response to calls for convergence germany's covid-19 expert: 'for many, i'm the evil guy crippling the economy'. the guardian a new threat from an old enemy: re-emergence of coronavirus computational models that matter during a global pandemic outbreak: a call to action implementing a one health approach to emerging infectious disease: reflections on the socio-political, ethical and legal dimensions the pandemic is a portal insight: covid-19 response ignores social context at our peril. the jakarta post 12 march) why wearing a face mask is encouraged in asia thailand facing double whammy -covid-19 and worsening seasonal drought interventions to mitigate early spread of sars-cov-2 in singapore: a modelling study. the lancet migrant worker cluster: a singapore nightmare. the asean post home page covid-19 context clues corona virus disease (covid-19) 23 april) covid-19 superspreader events in 28 countries: critical patterns and lessons scaring the already scared: some problems with hiv/aids fear appeals in namibia what have epidemiologists learned about the coronavirus? the new yorker covid-19: lessons learned? what comes next? the 100 per cent condom use policy: a success story shoot them dead community engagement, routine immunization, and the polio legacy in northern nigeria 22 january) pandemics -social sciences are vital, but we must take the next steps. institute for development studies (ids) rethinking social transformations: inequalities in the arab region in light of covid-19 coronavirus spell the end of the neoliberal era. what's next? explaining successful (and unsuccessful) covid-19 responses in southeast asia covid-19, surveillance and the threat to your rights hiv justice worldwide steering committee statement on covid-19 covid-19 pandemic will erase gains, may see 11 million driven into poverty in east asia and pacific: world bank 3 may) coronavirus is a wake-up call for thailand's inequality. khaosad english covid-19, discipline and blame from italy with a call for alternative futures 1 may) new normal? how about making a better one? the bangkok key: cord-298184-4o5ffk7y authors: veleva, vesela title: the role of entrepreneurs in advancing sustainable lifestyles: challenges, impacts, and future opportunities date: 2020-10-14 journal: j clean prod doi: 10.1016/j.jclepro.2020.124658 sha: doc_id: 298184 cord_uid: 4o5ffk7y this paper examines the role of entrepreneurs in advancing sustainable lifestyles (sls) to address climate change and social inequity. it is based on empirical study of eight u.s.-based sustainable entrepreneurs, focused on reducing material consumption. while business has a key role to play, many large companies are unwilling to promote sls as this is contrary to their current business models which are focused on growing consumption and sales. this presents an opportunity for entrepreneurial companies with innovative business models who are passionate about sustainability and social impact, and better positioned to take risks and innovate. the research examined emerging business models for advancing sls, key success factors and challenges reported by the entrepreneurs, the social and environmental impacts of their actions, and the future opportunities for scaling up such practices. the study found that entrepreneurs are well positioned to address simultaneously environmental and social issues, however, they lack resources to effectively measure these impacts to demonstrate an overall positive benefit and strengthen their value proposition. promoting green attributes alone is not enough to change the behavior of most consumers. it is critically important to emphasize other benefits such as a product/service quality, time or cost savings, or social impact. social media, formal and informal sustainability networks, it, sustainability policies, and consumer awareness are key to developing viable business models and competitive strategies that are difficult to replicate. the study found that sustainable entrepreneurs often face “costly” sustainability actions and lack the power to change „the rules of the game“; for this they need to collaborate with other key stakeholders, including ngos, policy makers, and progressive companies. based on the research findings the author proposes a new framework for the role of sustainable entrepreneurs as civic and political actors who not only offer innovative products and services, but help educate and influence key stakeholders, develop informal sustainability ecosystem, and thus create momentum for policy changes. following the paris agreement in 2015, many cities and nations globally have taken steps to achieve substantial cuts to their greenhouse gas (ghg) emissions by focusing on major sources of emissions: electricity, housing, and transportation. yet, global carbon emissions have continued to rise reaching a record of 36.8 billion tons in 2019 (mooney & dennis, 2019) , before sharply declining due to the covid-19 pandemic (le quere, 2020). one reason is that policymakers' ambitious plans do not account for indirect emissions closely aligned with lifestyles, such as the energy embodied in producing the food, buildings, or consumer goods and services made outside a city or a state's boundaries (so-called consumption-based emissions) (mont et. al. 2014; brown & cohen, 2019; southerton & welch, 2019) . a recent study in oregon, united states, showed that while sector-based ghg emissions in the state increased 10% between 1990 and 2016, consumption-based emissions were up 42% over the same period (brown and cohen, 2019) . such outsourcing of emissions is not just creating the illusion of making progress, but it is also an issue of equity and justice, as more affluent households have greater carbon footprints. fifty percent of the world's ghg emissions have been attributed to the richest 10% (southerton & welch, 2019) . decarbonization and dematerialization of existing lifestyles and services, however, do not go fast and deep enough. research has shown that technological innovation alone cannot help addressing climate change (alfredsson et. al., 2018; cohen et. al. 2017) . there is an urgent need to lower the consumption of material goods, such as living in smaller homes, buying fewer disposable goods, consuming less read meat, and driving and flying less. to reach an 80% reduction of a city's ghg emissions or a carbon neutrality (such as the city of boston's goal for year 2050) will require more structural changes in the way people live and work. changing consumer lifestyles, however, is challenging as it requires to examine systemically the entire value chain and overcome a range of economic, institutional, cultural, and social barriers. business model innovation 1 is increasingly seen as essential for advancing sustainable lifestyles (sls) such as using public transportation, renewable energy, adopting plant-based diets, reducing material consumption, and housing footprint (bocken and short, 2016) . such a transition will require a fundamental shift in the purpose of business and how value is defined by companies and society. it will require new innovative actors who can work with other key stakeholders to help solve environmental and social challenges (mont et. al. 2014; ghisellini et. al., 2016; murray et. al., 2017) . while business has a key role to play, many large companies are unwilling to promote sls as this is contrary to their current business models that are focused on growing consumption and sales (windsor, 2018) . further, logistical hurdles and risks associated with revamping of global supply chains, often prevent companies from adopting new strategies (york & venkataram, 2010) . these factors present an opportunity for entrepreneurial companies with innovative business models who are passionate about sustainability and social impact, and better positioned to take risks. entrepreneurs' niche experiments can provide valuable insights and social learning about the challenges and opportunities in advancing sls, as well as help build momentum towards enacting government policies that "change the rules of the game" to reward sustainable businesses mont et. al. 2014; windsor, 2018) . however, researchers have reported that majority of business model innovations fail and there is a need to better understand the challenges that entrepreneurs face (geissdoerfer et. al. 2018) , the impacts they create (horisch, 2015) and the role of sustainability networks in entrepreneurial success (davies & chambers, 2018) . more empirical research is needed to examine the different pathways towards sustainability transformation and how to translate customers aspirations into purchasing activities (schaltegger et. al. 2016) . this paper aims to address some of these research gaps and examine the role of sustainable entrepreneurs in advancing sustainable lifestyles by explore the following questions: what are some emerging business models for advancing sls and the role of value chain partners and social networks in ensuring success? what are the social and environmental impacts created by sustainable entrepreneurs and how do they measure and communicate these? what are the main challenges faced by sustainable entrepreneurs presently and how do they work to overcome these? what is the role of sustainable entrepreneurs in advancing sustainability transition? the paper is structured as follows: it begins with a literature review, illustrating the impact of personal consumption on climate change, current strategies to promote low carbon lifestyles and the role of sustainable entrepreneurs in such a transition. it then introduces the research method utilized and presents key findings from the cross-case analysis. the author then proposes a new framework for the role of sustainable entrepreneurs in advancing sls and concludes with discussion of the main lessons learned, research contribution, and implications for future policy, practice and research. despite the 2015 paris agreement to address climate change, signed by 197 countries, global carbon emissions have continued to rise reaching a record of 36.8 billion tons in 2019 (mooney & dennis, 2019) . nineteen of the 20 warmest years globally have been registered since 2001, demonstrating a clear trend towards warming (nasa, 2020) . governments around the world have enacted a range of policies to address major sources of emissions: electricity, housing, and transportation. yet, such efforts will be insufficient to stop global climate change unless we address personal consumption and lifestyles (mont et. al. 2014; alfredsson et. al. 2018; brown & cohen, 2019; southerton & welch, 2019) . according to the u.s. environmental protection agency (epa) 42% of u.s. greenhouse gas (ghg) emissions are associated with the energy used to produce, process, transport, and dispose of products (99% of which are thrown away in 6 months) (u.s. epa, 2016) . a recent analysis of 79 major cities worldwide revealed a 60% increase of those cities' carbon footprints when using consumption as opposed to production-based accounting (c40, 2020). while much of the world still needs further development and consumption to reduce poverty and hunger, developed countries must reduce their consumption to address climate change and social inequity. wealthier countries such as finland and japan, for example, have three to five times higher lifestyle carbon footprints compared to poorer countries like brazil and india (lettenmeier et. al., 2018) . in the european union, total material consumption is estimated at 40-50 tons per year, compared to a sustainable level of 8 tons per capita per year (mont et. al. 2014) . the need to address individual consumption and unsustainable lifestyles was first recognized in 1992 in agenda 21 but has received limited attention by policy makers and other stakeholders until recently (mont et. al. 2014) . sustainable lifestyles (sls) are seen as an alternative to the current consumption-centered lifestyles and defined as "a cluster of habits and patterns of behavior embedded in a society and facilitated by institutions, norms and infrastructures that frame individual choice, in order to minimize the use of natural resources and generation of wastes, while supporting fairness and prosperity for all" (unep, 2016) . a recent unep framework for sustainable living defined five core areas for taking actions at the consumer level: housing, mobility, food, consumer goods, and leisure (unep, 2016) . a shift toward more sls has the potential to drive greater economic equality, open new business opportunities, and improve quality of life. for instance, telework helps improve employees' wellbeing and engagement; plant-based diets improve health outcomes; preventing waste (from surplus food or consumer goods) is associated with financial and time savings; smaller houses are more affordable. three main types of strategies have been used to address personal consumption and advance sls: a) education and awareness about the impacts of individual actions on climate change; b) policies to reduce consumption and change consumer behavior, and c) innovative business models to reduce or modify consumption. while environmental awareness and concerns about climate change are growing , few people understand their personal contribution or what actions they can take. a recent study found that 45% of americans are willing to change their behavior to reduce environmental impacts (nielsen 2018 ) but 85% of people do not know their carbon footprint or how to lower it (grinstein et. al., 2018) . in a recent study cordero et. al. (2020) measured the impact of a year-long university course about climate change and found that participants reduced their individual carbon footprint by 2.86 tons of co 2 per year five years later. the authors argue that if applied at scale such education programs "would be of similar magnitude to other large-scale mitigation strategies, such as rooftop solar or electric vehicles." other studies have found that education is necessary but not sufficient to change consumer behavior due to the gap between individuals' aspirations and actions. even in countries with strong culture for environmentalism, a small share of consumers buy sustainable products (vringer et. al. 2017) . often it is believed that consumers are "free" to make a choice, but research has identified a range of barriers, from simple (e.g., price, availability and quality) to more complex (social, institutional, and economic). for instance, public transportation may not always be available, or it could be inconvenient. while biking has been promoted as healthier alternative to driving, ensuring bike safety remains a challenge in many communities. telework can help reduce individuals' carbon footprint and is linked to increased well-being and productivity (gimenez-nadal et. al. 2018 ) but it requires adoption at an organizational level. consumers also face a range of social and moral dilemmas ; vringer et. al. (2017) found that people are often reluctant to impose constraints on others. addressing such economic, institutional, and moral barriers requires government interventions such as new taxes, subsidies, disclosure mandates, or bans. most research on sls to date has focused on policy initiatives. southerton and welch (2019) analyze different policy approaches for changing individual behavior -from pricing, to information (education), use of social marketing campaigns, and infrastructure development (e.g., for mobility). they argue that while there are many successful examples of effective policies, more must be done to address the social, cultural, economic, and material barriers for reducing consumption. they call for "radical policy experimentation" and an "open debate and dialogue at local, regional, national and international levels that directly tackle consumption and visions of future ways of life." such radical approaches include j o u r n a l p r e -p r o o f promoting "time affluence" (as alternative to material affluence) and reducing the working week. such an approach, however, is problematic for many working-class employees, who need overtime hours to meet their basic needs (lautsch and scully, 2007) . the literature on sustainability clusters has identified the importance of supporting infrastructure and other local factors in promoting productivity, innovation, and competitiveness (maskell and malmberg 1995; martin and mayer 2008; porter and kramer 2011) . resilient clusters include not only the local businesses but also institutions such as schools, universities, trade associations, and non-profit organizations. local governments can play an important role in promoting cluster development and firm competitiveness by setting clear and measurable social goals and enacting relevant policies to promote social development and business sustainability (deutz and gibbs, 2008; veleva et. al. 2015) . in their "shared value" framework porter and kramer (2011) emphasize the "profound effect" of a business location on a firm productivity and innovation, which remain understudied by researchers. they argue that "shared value helps uncover new needs to meet, new products to offer, new customers to serve and new ways to configure the value chain, where the resulting competitive advantage will often be more sustainable than conventional cost and quality improvements". other researchers have examined shifting to sustainable consumption through the lens of the social change theory (cohen et. al. 2017) . sustainable consumption is defined as "the use of goods and services that respond to basic needs and bring a better quality of life, while minimizing the use of natural resources, toxic materials and emissions of waste and pollutants over the life cycle, so as not to jeopardize the needs of future generations" (norwegian ministry of environment, 1994) . in the current capitalist economy where consumption is seen as key to economic success, changing the dominant "regime" is challenging and more likely to happen gradually through incremental changes "in the fractures of the dominant system, in niches where they do not seem to pose any immediate threat to dominant classes and institutions" (cohen et. al., 2017) . more generally, the literature on sustainability transitions, degrowth, and steady state economy, has called for national-level policies to overhaul our current economic system to ensure more sustainable production and consumption (jackson, 2009; cosme et. al. 2017; cohen et. al. 2017) . this approach, however, is outside the scope of the current study. new business models a business model is about how an organization creates, delivers, and captures value (or in simple words, how it makes money). in this paper, we define "business model" using three main elements: the value proposition, value creation and value capture. sustainable business models are distinct in their focus on analyzing and communicating a sustainable value proposition to customers, in how they create and deliver value, and how they capture value while also maintaining or regenerating natural, social and economic capital (schaltegger et. al. 2016) . business model innovation, on the other hand, is more challenging to define. it typically does not require inventing new products, technologies, or markets, but instead involves changing the revenue stream, synchronizing the time horizons, or integrating the incentives (girotra & netessine, 2014) . for instance, leasing instead of selling solar panels was a major business model innovation which enabled overcoming the upfront costs for customers and thus led to expansion of the market for solar energy. developing long-term relationships with suppliers, customers and other partners along the value chain, can help companies co-create value, and thus generate competitive advantage. recent empirical study of 15 centers for urban remanufacture in europe found that majority of examined initiatives were dependent on external support, and were not financially viable (ordonez et.al., 2019) . the researchers concluded that entrepreneurial innovation was needed to make the business j o u r n a l p r e -p r o o f case, and recommended launching business incubators in the area of reuse and remanufacturing. companies are increasingly seen as playing an important role in changing consumer behavior "through marketing and branding, new business models and choice editing" (bocken, 2017) . bocken et. al. (2014) introduced eight sustainable business model archetypes, described as businesses that a) maximize material and energy efficiency, b) create value from waste, c) substitute with renewables and natural processes, d) deliver functionality rather than ownership e) adopt a stewardship role, f) encourage sufficiency, g) re-purpose the business for society/environment, and h) develop scale-up solutions. bocken and short (2016) introduce the concept of "sufficiency-based business models" where companies deliver sustainability by "reducing absolute material throughput and energy consumption associated with provision of goods and services by moderating end-user consumption and encouraging consumers to make do with less." key enablers for companies' success with such business models include: strong focus on customers, commitment to go against the business-as-usual trends, performance and incentive systems aligned with sustainability objectives of the firm, strong focus on quality and durability, and radically different marketing campaigns. freudenreich and schaltegger (2020) examine sufficiency-oriented business models in the clothing industry and report that innovations such as service-and sharing-oriented businesses can be successful and help address both social and environmental problems in the clothing sector. however, legislation and policy intervention are often needed to bring such niche practices to the mainstream (bocken & short, 2016) . this confirms previous findings by that besides b corporation and social entrepreneurs, most profit-oriented corporations "cannot be expected to solve climate change and other environmental problems without changes in government incentives for business. " geissdoerfer et. al. (2018) further report the designimplementation gap in sustainable business model innovation which leads to market failure. the role of sustainability entrepreneurs in advancing sls there is a growing body of research on the role of entrepreneurs in addressing sustainability challenges. thompson et. al. (2011) provide one of the most comprehensive analysis of the similarities and differences between social, environmental and sustainable entrepreneurs. while all three are similar in their mission-driven business strategies, they also differ. social entrepreneurs are primarily focused on their social mission related to helping people. environmental entrepreneurs focus "on environmentally-relevant market failures" and seek to deliver both economic and ecological benefits. sustainable entrepreneurs aim to deliver longterm benefits across a "triple bottom line" or create simultaneously environmental, social and economic benefits (thompson et. al. 2011) . for the purposes of this study we will focus on sustainable entrepreneurs with the recognition that there is an overlap between the three types and environmental entrepreneurs are a sub-category of sustainability entrepreneurs (thompson et. al. 2011) . according to york and venkataraman (2010) entrepreneurs are best positioned to solve complex problems and turn uncertainty into business opportunity with social and environmental benefits as they are willing to take risks and innovate. bocken and short (2016) demonstrate that while startup businesses may not be economically viable initially, this can change over time because of regulatory action or changes in the market. even though entrepreneurs have limited resources and reach, their ability to foster strategic partnerships with large players can stimulate disruptive innovation, leading to industry transformations in sustainable development. 2 pacheco et. al. (2010) demonstrate how sustainable entrepreneurs are able to change the "rules of the game" or the competitive landscape, by "proactively devising and influencing the establishment of new industry norms, property rights, and government legislation that transform the payoffs of their competitive games". examples of such industry transformations include the fair-trade movement, leadership in environment and energy design (leed) for buildings, and benefits corporation (b-corp) certification. according to entrepreneurs are able to "escape the green prison" or the disadvantages they face when pursuing costly sustainable actions, by either identifying opportunities within the current market system or "creating new opportunities through institutional changes that improve the competitiveness of sustainable behavior. " schaltegger et. al. (2016) take a co-evolutionary view of sustainability transformation by examining how pioneering business models can be scaled or replicated by startups and large companies (incumbents), leading to sustainable mass markets. haigh and hoffman (2014) report how hybrid organizations, defined as organizations at the interface between for-profit and nonprofit sectors that address social and ecological issues, are able to successfully challenge "the notion of trade-offs between economic, ecological, and social systems and instead create business models that develop synergies between them." the result is creating opportunities for "for-profit activities to be undertaken in ways that address sustainability issues." the authors demonstrate how hybrids challenge a) the existing beliefs about the social, ecological and economic system, b) the competitive practices, and c) how sustainability is enacted. firms focused on new business models for sustainability, however, face many challenges. geissdoerfer et. al. (2018) report that numerous new business model innovations fail due to the inability to implement their ideas in practice. based on comprehensive literature review they identify seven categories of challenges: a) balancing a triple bottom line, b) mind-set challenges, c) lack of resources, d) difficulty integrating technology with business model innovation, e) engaging in external relations, and f) lack of effective sustainability-focused business modelling methods and tools. the authors call for additional research on the challenges that business model innovation faces and the reasons for the low success rates. future studies should help understand: a) the implementation of the business model innovation process, b) its tools, and c) its challenges (geissdoerfer et. al. 2018) . veleva and bodkin (2018) report that top challenges for both entrepreneurs and large companies focused on waste reduction and circular business models include the lack of regulation and incentives, the lack of data and indicators to measure and communicate impacts, and the cost of product or waste take-back. entrepreneurs face additional challenges such as lack of brand awareness and market demand, access to financing, mentorship, networks, and the complex product or packaging design that prevents proper repair or recycling. the economic viability of secondary supply chains (focused on product reuse or remanufacturing) can be a key challenge due to the cost of recovering products and materials (freudenreich & schaltegger, 2020) . entrepreneurs also face the challenge of effectively communicating their sustainability impacts (horisch, 2018; holt & littlewood, 2015) . more broadly, entrepreneurs focused on creating new opportunities "may be limited by the opposition of other interested parties' with powerful political influence who may "impair entrepreneurs' ability to promote new institutions" . overcoming these challenges often requires that entrepreneurs look beyond their industry peers to form relationships with environmental, economic development or other civil organizations . policy makers, are key for supporting the growth of start-ups by providing subsidized loans and other legal infrastructure to internalize existing externalities (horisch, 2018). being able to achieve positive environmental and social impacts is at the core of the business model for sustainability for entrepreneurs and how they differentiate from competitors. at the same time, holt & littlewood (2015) find that most entrepreneurs are not effectively measuring and capturing such impacts. to address this challenge, they offer a framework for identifying, mapping and building indicators of impact for hybrid organizations. the authors further acknowledge that both positive and negative impacts may arise from entrepreneurs' activities and these must be clearly identified and addressed. often there are trade-offs between the environmental and social impacts. measuring and reporting impacts is challenging due to its complexity and lack of resources, even though it is critically important for "fostering stronger relationships between hybrids and external stakeholders including customers, beneficiaries and communities, international donors and supporters, and managers in traditional businesses" (holt & littlewood, 2015, p. 122) . horisch (2018) also reports that "sustainable start-ups face the challenge to communicate the sustainability effect connected to their products and services." without communicating both the direct and indirect impacts, they are unable to put pressure on established competitors or standard-setting organizations in order to change consumer expectations and prevailing norms (horisch, 2018). more broadly, however, the assessment of social and environmental impacts is challenging because it is based on personal values, beliefs and priorities. in his analysis of the socio-technical transitions to sustainability, geels (2010) raises the question of who should choose between multiple "green" pathways and establish the criteria for the choice? one option is for government to do so with the assistance of technical experts; the second one includes a more inclusive group of stakeholders, society groups and the public. in both cases it is important for entrepreneurs to be part of this process to gain legitimacy and public support, since these are key for securing financial investments and supportive policies (geels 2010) . similarly, costa & pesci (2016) find that effective metrics must be defined and constructed in an open dialogue with all relevant stakeholders; that there is "no single "gold standard" of measurement but instead a variety of metrics which reflect local goals, needs and stakeholder demands. using social network theory, neumeyer et. al. (2018) demonstrate that entrepreneurs' degree of connectivity with key stakeholders and access to different types of networks is key for their success. oskam et. al. (2018) introduce the concept of "value shaping" which refers to the "mutually constitutive process in which on the one hand networking helps to refine and improve the overall business model and on the other hand an improved business model spurs expansion of the network." the authors identify five micro-level processes through which value shaping happens: ideation, conception, business start-up, early growth and continued growth. they report that redirecting value and extending value are influenced by network interaction and are a critically important step in creating value for multiple stakeholders. other researchers have also demonstrated that "transformation to sustainable practices is an incremental and co-evolutionary process requiring collective action among actors, including but not limited to sustainable entrepreneurs" (divito & bohnsack 2017; schaltegger et. al. 2016) . horisch (2015) uses the multi-level perspective (mlp) as theoretical framework to examine the role of entrepreneurs in sustainability transitions. according to the framework developed originally by geel (2002), societal transitions "result from interaction processes between three different socioeconomic levels, which build a nested hierarchy: micro level niches, meso-level regimes and macro-level landscape" (horisch, 2018). start-ups are important actors primarily at the niche level, although they can play a role at the mesolevel. their role, however is currently underexplored. based on literature review horisch (2018) identified two ways in which entrepreneurs can advance sustainability transitions: j o u r n a l p r e -p r o o f through their market impact and through their sustainability effect. sustainability entrepreneurs must first create products and services with positive societal impacts and then distribute these "as widely as possible to develop a large overall sustainability effect and a significant contribution to sustainability transitions." this, however is challenging as start-ups either have limited resources to expand or are restricting their growth to stay true to their mission. regardless, start-ups can influence other important actors at the meso-level, such as large companies (schaltegger et. al., 2016) , public authorities and standardizing bodies (e.g., the international organization for standardization) which are critically important for changing regimes and advancing a societal transition. our understanding of the sustainable entrepreneurial ecosystems and how it leads to change, however, is still limited, according to neumeyer et. al. (2018) , who call for further research into four areas: a) how environmental, social and economic value is created in a community or a region, and the role of key stakeholders; b) what are the formal and informal rules for being part of a sustainable entrepreneurial ecosystem; c) how can success be defined and measured, and d) what is the role of emerging online social networks in advancing sustainable business models. schaltegger et. al. (2016) call for more empirical research on the different pathways taken by sustainable niche pioneers and other market actors, and the challenges and opportunities they face. ludeke-freund (2020) integrates two major perspectives about the role of entrepreneurs -agency perspective and systems perspectiveand calls for more empirical research to examine "if and how sustainable entrepreneurs can unfold agency within given systems such as industries and markets" and "if and how sustainable entrepreneurs actually use their business models to benefit from public policies." this study aims to address some of these research gaps, by examining sustainable entrepreneurs' business models, created impacts, current challenges and how they work with key stakeholders to overcome these and advance a shift to more sls. this study is based on interviews with eight u.s.-based entrepreneurial companies focused on reducing material consumption and promoting sls. the sustainable entrepreneurs in the study included box save, fixit clinic newton, food for free, irn surplus, joro, preserve, project repat, and semi-new computers. they represent both for-profit and non-profit organizations from diverse sectors in different stages of development. data for each company was collected between december 2018 and may 2019 using two main sources: a) publicly available information from websites, case studies, and other publications, and b) in-depth, semistructured interviews with founders and senior managers. the interview protocol was developed based on a literature review. all interviews were audio-recorded and transcribed for accuracy. the empirical data was managed through cross-case analyses using methodology described in eisenhardt (1989) and eisenhardt & graebner (2007) . all collected data and information were aggregated and summarized in a table format to enable further analysis (see appendices a and b). to ensure validity and reliability of the qualitative analysis, as well as protect confidential information, each participating company was invited to review and provide feedback to the transcribed interviews and data analysis. the primary goal of the study design was to select a diverse group of companies in terms of maturity (measured by years in operation), type of business (for-profit or non-profit), and business model (selling products or services). all participating entrepreneurs were committed to delivering benefits across a "triple bottom line." the study focused primarily on business to consumer (b2c) companies to gain insights about how participating entrepreneurs work to change consumer behavior and the key challenges they face in this process. the interview questions and case research explored the following: • what are some emerging business models for advancing sls and the role of value chain partners and social networks in ensuring success? • what are the social and environmental impacts created by sustainable entrepreneurs and how do they measure and communicate these? • what are the main challenges faced by the entrepreneurs and how do they work to overcome these? what is their role in the transition to sls? detailed descriptions of the cases are provided in appendix a and include each company story and current activities. appendix b summarizes the key findings for each participating company in four areas: a) business model and value proposition, b) social and environmental impacts, c) key challenges, and d) future opportunities for scaling up sustainable business models. study participants reported a range of factors behind their business success such as increasing awareness about climate change and other environmental and social problems, strategic partnerships along the supply chain, sustainability policies, it, and quality customer service, confirming previous findings (dean & mcmullen, 2007; bocken & short, 2016; veleva & bodkin, 2018) . growing consumer awareness and willingness to take action were reported as important enabler by food for free, joro, preserve, semi-new computers, and irn surplus, confirming findings by cordero et. al. (2020) . "people are paying more attention to sustainability. i see the momentum, especially in the last few years. some of it is related to culture, some to regulation," according to sasha purpura, executive director of food for free (veleva & smith, 2020) . sustainability-focused public policies directly or indirectly support their business models. for instance, the massachusetts organics ban in 2014 and the higher waste disposal fees have benefitted food for free, preserve and irn surplus. the city of newton's policies to reduce waste and increase reuse are key for the launch of fixit clinic newton. analysis of the eight cases revealed that strategic long-term partnerships along the value chain are a key part of each entrepreneur's business model (see table 1 ). for instance, semi-new computers' partnership with harvard university and large corporations provides continuous source of surplus computers for refurbishing and resale/donation. joro's partnership with a carbon offset organization provides opportunities for revenue generation. for recycling company preserve, partnerships with materials processors ensure a continuous supply of raw material (post-consumer polypropylene), where its partnerships with retailers such as whole foods and target ensure a sales channel. food for free's partnerships with grocery stores and universities ensure access to fresh, healthy food, while its partnership with cities provides funding and access to people in need. furthermore, all participating entrepreneurs are part of an informal ecosystem of sustainable businesses and other stakeholders who act as suppliers, customers, or strategic partners (e.g., food for free and the town of cambridge, box save and monoflo, fixit clinic and green newton, preserve and stonyfield farm, plum organics and ocean plastics initiative). such networks, while informal and underdeveloped, provide competitive advantage and ensure entrepreneurs stay true to their sustainability mission. this finding is in line with neumeyer & santos' (2018) research about the importance of social capital and access to different types of network actors for launching a sustainable business model. the geographic location (massachusetts, usa) was also reported as key factor for entrepreneurial success, confirming previous research on the importance of a specific location for providing supportive culture, capital and other resources, as well as allowing to quickly respond to customer needs and gain trust and legitimacy (neumeyer et. al. 2018; porter & kramer, 2011) . in all cases technology enables companies to optimize logistics, reduce the costs of storing and shipping (e.g., box save, irn surplus), leverage low cost marketing (e.g., preserve, joro, box save, and project repat) and educate customers (joro, food for free). with exception of semi-new computers, all entrepreneurs use online social networks such as facebook, twitter, instagram, linkedin, you tube, and others (see table 1 ), which they see as critical for their business success. this finding confirms previous research by correia et. al. (2014) on the role of social networks and mobile technologies in building competitive advantage by providing a new way to expand business, adapt to new consumers, turn fans into customers, and develop tacit organizational knowledge about virtual communities which is hard to replicate (correira et. al., 2014) . the research also confirmed previous findings about the importance of having a strong focus on customers, building long-term relationships, providing some incentives, and making it easy for consumers to act (bocken & short, 2016; bocken 2017 (2014) that entrepreneurs (and sustainability entrepreneurs in particular) are best positioned to solve complex problems and deliver social and environmental benefits. in addition to addressing waste and ghg emissions, participating entrepreneurs create positive social impacts such as developing new skills (fixit clinic, semi-new computers), reducing food insecurity (food for free), saving time (box save, irn surplus), and improving health (joro, food for free), in addition to creating local jobs. moreover, several participating entrepreneurs reported their social impacts as key for differentiating from competitors. while for companies like joro educating and empowering consumers to address climate change is at the core of their business model, other study participants emphasize cost or time savings, revenue generation, social impacts, and/or outstanding customer service. as one of the interviewees summed it up, "green attributes do not always lead to sales," confirming previous findings by esty & winston (2009) . all study participants reported lack of resources to more effectively measure the environmental and social impacts of their products and services. while some included specific indicators such as amount of products/waste repurposed or people served, these typically measured outcomes and not overall impacts such as greenhouse gas emissions prevented, skills developed, or time and dollar saved. for instance, irn surplus provides its customers with individualized reports which describe the outcomes and some impacts, but the latter are often qualitative or measure outputs, versus impacts. for example, for one of its customers -kent place school in summer, new jersey -irn surplus leveraged its network and partnership with steelcase to locate a nearby recipient -habitat for humanity restore in bucks county, pa, about 70 miles away. the company reported several key impacts from the project: a) the school's ability to uphold its commitment to sustainability and reuse or recycle more than 5.5 tons of furniture without paying more than for disposal; b) steelcase's ability to uphold its commitment "to providing environmentally sustainable products and services throughout the lifecycle of steelcase products," and c) dozens of families who benefitted from obtaining "high-quality, low-cost furnishings through the habitat restore, or living in the habitat homes that restore revenues help to build." (irn surplus, 2020) . food for free measures the amount of surplus food repurposed (in pounds) and the number of meals distributed. in 2019 it helped rescue 2 million pounds of food and feed over 30,000 people (veleva & smith, 2020) . the company, however, is unable to estimate the ghg gas emissions prevented from food rescue compared to composting or disposal, or the dollar savings and improved health outcomes for people having access to fresh, healthy food. similarly, fixit clinic newton measures the number of participants and products repaired but is unable to track and report the environmental and social impacts such as increased awareness of environmental problems, reduced ghg emissions and waste, new skills development, time to repair a product, or dollars saved. for many people the lack of time often leads to buying new products instead of repairing an old one, a sustainability challenge reported previously in the literature (southerton & welch, 2019) . better measurement would not only help strengthen entrepreneurs' value proposition among early adopters as reported by veleva & bodkin (2018) but is also crucial for evaluating potential trade-offs and demonstrating an overall positive impact. for instance, box save estimates that when comparing cardboard boxes to reusable crates for 400 users, manufacturing of the former generates 27,000% more co 2 (not including shipping for landfill or recycling) (donovan, 2020) . this estimate, however, does not reflect the fact that cardboard is made of renewable resource, while polypropylene is derived from fossil fuel. preserve's move to compostable single use products could help reduce the ghg emissions from collecting and recycling post-consumer polypropylene. however, recent studies have warned about potential presence of highly toxic per-and polyfluoroalkyl substances (pfas) in compostable products, a class of over 3,000 fluorinated chemicals that persist in the environment for a long time, and are associated with cancer, developmental toxicity, immunotoxicity, and other health effects (cpa, 2018). furthermore, compostable containers require special facilities for handling (e.g., anaerobic digesters), which may not be available locally, potentially leading to landfill disposal or incineration, both associated with release of ghg emissions (veleva & smith, 2020) . while semi-new computers is committed to prevent waste and ghg emissions while closing the digital divide by sending refurbished computers to nigeria, ghana and sierra leone, they have been criticized for potentially contributing to the growing e-waste crisis in africa (clark & clark, 2019) . in addition, shipping computers to such far destinations contributes to climate change and air pollution. without proper life-cycle analysis and measurement of the overall social and environmental impacts of their business, it is not possible to confirm the overall positive impact. these findings illustrate the importance of developing and using effective indicators to measure and evaluate the social and environmental impacts at a company or product/service levels. previous research has found that even large companies within the same sector using standardized indicators, report inconsistent and vastly different measures focused on outputs rather than impacts (veleva et. al. 2017) . aggregating different measures to identify an overall impact is challenging as it reflects a variety of assumptions, local issues, and personal values, therefore must include other stakeholders affected by such practices. this confirms research by costa & pesci (2016) that effective metrics must be defined and constructed in an open dialogue with all relevant stakeholders; that there is "no single "gold standard" of measurement but instead a variety of metrics which reflect local goals, needs and stakeholder demands (costa & pesci, 2016; matzembacher et. al. 2019 ). deven's eco-industrial park provides one example of how a multi-stakeholder process can be leveraged to develop locallyrelevant sustainability indicators, which can serve as a valuable tool to raise awareness, promote transparency and accountability and guide local policies towards established goals and targets (veleva et. al. 2015) . despite their success to date, study participants reported numerous challenges in scaling up operations (see appendices a and b). while all of them offer competitive pricing, they often cannot compete with inexpensive imports from china based on cost alone (e.g., preserve, semi-new computers, project repat). to stay true to their mission, many face costly sustainable actions, such as using sustainable packaging, eco-friendly materials, or recycling waste instead of sending to landfill (e.g., project repat, food for free, box save, preserve, semi-new computers). this confirms previous findings that entrepreneurs are often at competitive disadvantage when pursuing new sustainable business models ludeke-freund, 2020) . all entrepreneurs report insufficient funding and other resources (space, transportation, storage, volunteers) as a key challenge. non-profit organizations such as food for free and fixit clinic rely on grants and volunteers to support their work; others such as box save, semi-new computers, project repat, joro, and preserve, capture value based on customers' willingness to pay for a product or service that is high quality, good value or socially and environmentally responsible. all entrepreneurs in the study reported not having the capacity to effectively measure and communicate the social and environmental impacts of their products and services which could strengthen their value proposition. these findings confirm previous research on the barriers faced by companies advancing new business models to reduce consumption bocken & short 2016; veleva & bodkin, 2018) . the lack of brand awareness was another challenge faced by most entrepreneurs, especially the "younger ventures" such as box save, joro, project repat and fixit clinic. some reported lack of consumer awareness about how to act to address sustainability challenges (joro, fixit clinic, box save), while others reported a gap between consumer aspirations and actions (preserve, semi-new computers). this confirms previous findings that consumer education is necessary (grinstein et. al. 2018) but not enough to change behavior (vringer et. al. 2017) . social media could be leveraged further to help consumers overcome some of the social and moral dilemmas reported in the literature (vringler et. al. 2017) . study participants also reported the need to raise awareness about the environmental and social impacts of reuse versus recycling and disposal in order to change the evaluation criteria used by customers, confirming previous research by veleva & bodkin (2019) . customers' lack of time was reported as a barrier by some participants (e.g., fixit clinic newton, preserve, joro) but was leveraged as opportunity by others (e.g., box save, food for free, irn surplus). the heightened awareness and interest by young people to take sustainability action and increasing local sourcing and zero waste commitments by cities and companies are expected to support future sustainable entrepreneurs. in addition, as reported by windsor (2018) "businesses, consumers and institutions (government and others) "are likely to face increasingly volatile, uncertain, complex, and ambiguous conditions in the future". the 2020 covid-19 pandemic, for instance, is expected to accelerate the shift towards more local and regional production and consumption, leading to reduced ghg emissions from transportation and new opportunities for sustainable entrepreneurs (mckinsey, 2020) . all sustainable entrepreneurs in the study see the lack of government policies such as carbon tax, bans on disposal of certain products, mandating design for repair, or a full-cost accounting, as the greatest barrier for scaling up their businesses but also the greatest opportunity in the future which confirms previous research (caldera et. al. 2019; veleva & bodkin, 2019) . for instance, a carbon tax (or a tax on raw materials) would make preserve products and box save services more price competitive. bans on landfill disposal of furniture and other products, would help create markets for reuse and recycling and support entrepreneurs such as irn surplus. the 2014 massachusetts organic waste ban for example, has led to significant growth in entrepreneurial companies focused on food rescue and composting, and measurable economic and social benefits (icf, 2016) . adopting laws mandating design for disassembly and repair, could help expand the secondary markets for many products and support entrepreneurs such as semi-new computers and fixit clinic. introducing reporting requirements for waste similar to the city of boston building energy and disclosure ordinance (city of boston, 2017) can increase transparency about the amount of waste generated and create incentives for large organizations to seek alternatives to landfill or incineration. although entrepreneurial players in the study have been able to identify opportunities within the current consumption-based economic system, scaling up such niche experiments requires involvement of other stakeholders and policy action (dean & mcmullen, 2007; bocken & short 2016; southerton and welch, 2019; cohen et. al. 2017; horisch, 2015; ludeke-freund, 2020) . for instance, the proliferation of fixit clinics in the u.s. has attracted the support of politically-active public advocacy groups which are working with citizens and progressive policy makers to adopt new "right to repair" mandates at state levels (u.s. pirg, 2019). as of december 2019, at least 20 u.s. states had put forward digital right to repair bills; these however, were opposed by the $2.5 billion electronic industry, demonstrating the push back by powerful incumbents and the challenges in changing current regimes (allendorf, 2018) . transitioning to more sustainable consumption systems requires creation and reinforcement of a new path, as well as "destabilization of the existing path," according to heiskanen et al. (2011) . path dependence is defined as the self-sustaining characteristics of existing systems, while path creation relates to creating new paths by engaging various stakeholders and generating momentum and respectively, change (heiskanen et al. 2011) . environmental entrepreneurs are often seen as "agents of change" and "a major force in the overall transition towards a more sustainable business paradigm" (schaper 2002) . while they are more likely to pursue path creation in sustainable consumption systems, the latter requires significant resources, including financial and political power, which they often lack, as demonstrated in the current study. what entrepreneurs are able to do, however, is to educate and influence other stakeholders, advance informal and formal sustainability networks and thus create momentum towards new policies, norms, and institutions. for instance, food for free is able to influence both policy makers and large companies to secure resources, reduce food waste and advance new policies to change food expiration labels. preserve's business model has attracted the attention of some large companies such as berry and vdl: "there's something about what preserve has been doing that makes the larger companies interested in us. one example is with berry, a $4 billion sales and $9 billion in market cap. they work with the gimme 5 program every year and they make that preserve to go container. our partner in europe is vdl [they make the mini cooper]. they are an ecofriendly/socially responsible business and they are huge." 3 transition to more sustainable lifestyles requires collective action and collaborations among various stakeholders, including users, ngos, progressive large companies and policy makers. a truly sustainable future "requires system-based thinking that involves in equal measure, society, environment and economics" (murray et. al., 2017) and calls for new policies that reward sustainable behavior. based on the study findings and analysis, the author proposes a new framework for the role of sustainable entrepreneurs in advancing sustainable lifestyles (see figure 1 ), which demonstrates that they are not only innovators but also civic actors supporting this transition. in collaboration with a range of stakeholders such as other sustainable entrepreneurs, large companies, ngos and policy makers, sustainable entrepreneurs launch innovative business models to advance sls. most of their business model innovations include social rather than technical experiments which provide valuable insights and social learning about the challenges and opportunities in changing consumer behavior. to succeed, sustainable entrepreneurs leverage strategic partnerships, social media, it, the growing sustainability awareness, and public policies, which help them identify opportunities within the current economic system. their main value proposition for consumers is based on offering cost or time savings, social benefits, education and empowerment to act; they also provide strong customer focus and quality service. with their business model experiments, sustainable entrepreneurs help create informal and formal sustainability network and influence key stakeholders such as large companies, ngos and policy makers. thus, they act not just as innovators but also as civic actors helping create momentum towards enacting government policies that "change the rules of the game" to reward sustainable businesses that help address climate change and social inequity. the current study confirmed many findings from prior research about sustainable entrepreneurs' ability to launch innovative business models to address complex issues such as climate change and social inequity. it also identified some key lessons learned by first movers. first, entrepreneurs are well positioned to address simultaneously environmental and social issues. however, they lack the resources to effectively measure related impacts to strengthen their value proposition and demonstrate an overall positive impact. such measures require working with other stakeholders and developing locally-relevant indicators reflecting existing challenges, needs and goals. second, environmental awareness has significantly increased in recent years and a growing number of people are willing to take actions to reduce their carbon footprint. educating and empowering such early adopters could not only support new innovative business models, but also help change prevailing social norms, if effectively leveraging social networks and strategic partnerships. third, promoting green attributes alone is not enough to change the behavior of most consumers. it is critically important to emphasize other benefits such as a product/service quality, social impacts, time or cost savings. this confirms previous findings by esty & winston (2009) that sale of green goods is difficult and "green" should be promoted as the "third button" after quality and cost savings. fourth, formal and informal sustainability networks, social media, and sustainability policies, are key to developing viable business models and competitive strategies that are difficult to replicate. finally, to avoid "costly" sustainability actions and change the competitive landscape, entrepreneurs need to reach out and collaborate with other key stakeholders such as policy makers, ngos, and citizens coalitions, in order to change "the rules of the game," such as the laws, institutions and social norms. without such actions their market and sustainability impacts will be limited. the study demonstrates that policymakers have a key role to play in advancing sls by a) adopting consumption-based ghg emission inventory and raising awareness about the impact of individual lifestyles on climate change; b) enacting effective regulations or eliminating regulatory hurdles to sls; c) providing incentives to companies engaged in such practices through taxes, subsidies, disclosure mandates, or bans on certain products or practices in order to "level the playing field"; d) providing financial support, networking and mentorship opportunities for sustainable entrepreneurs, and e) supporting development of enabling infrastructure, new institutions and norms that promote sls. local zero waste goals or waste bans, for example, can increase demand for alternatives to landfill disposal and incineration and thus act as powerful drivers for entrepreneurial innovation. improved city planning could advance the use of public transportation, bicycling, and walking, supporting entrepreneurs focused on mobility solutions such as bike and shooter sharing. enacting regulations that ban toxic chemicals from products and packaging, and mandating design for disassembly and repair, are crucial for enabling reuse of products and materials. policy makers can utilize tax incentives or subsidies to reward companies advancing more durable, low-carbon choices such as the swedish tax break for repaired products (orange, 2016) and the european union "right to repair" laws (right to repair, 2020). providing financial support to entrepreneurs and other organizations in the form of grants, low interest loans, or business incubators, is critical for supporting smaller companies as previously reported in the literature (lowitt, 2008; rizos et. al., 2015; ludeke-freund, 2020 ). in addition, government agencies could partner with non-profit organizations to help raise awareness about the importance of waste prevention and reuse versus recycling, by launching carbon footprint labels, awards, benchmarking studies or networks promoting sls. such networks should include a variety of stakeholders, such as entrepreneurs, progressive corporations, non-profit organizations, academics, policy makers, and citizens' organizations. they could work to develop a locallyrelevant vision for sustainable living, indicators to measure progress, and actions to drive change. the present study demonstrates that a growing number of sustainability entrepreneurs are experimenting with new business models to promote sustainable lifestyles. they are able to overcome existing challenges by leveraging the growing consumer awareness, value chain partnerships, it, social networks and sustainability-focused policies, to launch innovative products or services which offer time or cost savings, quality service, and a range of social and environmental benefits. in this process they help educate and influence other important actors such as ngos, large companies, and policy makers, confirming previous research by geels (2010) and ludeke-freund (2020) . sustainability entrepreneurs, however, are unable to achieve a market effect and a shift to sls on their own, which requires political support and new regulations. their role is to experiment with innovative business models, help create sustainability networks, educate and influence key stakeholders, and empower them to act. in this process entrepreneurs provide valuable insights and social learning which has largely been missing in the sustainability transitions literature primarily focused on technological innovations and solutions. scaling up entrepreneurs' experiments to achieve a market impact (horisch, 2018) , however, requires the collaboration of various stakeholders in order to advance better measurement, bold policy interventions, enabling infrastructure, and new social norms to promote sustainable living. policy makers in particular have a key role to play to internalize existing externalities and ensure sustainable entrepreneurs are not at competitive disadvantage, which confirms previous findings by ludeke-freund (2020) . the study has several limitations. first, it only included eight entrepreneurial companies. a future study should consider including a larger number of entrepreneurs within each of the five domains of sls to examine emerging drivers, challenges and future opportunities as seen by the participants. research can also focus on a specific sector to explore in greater detail emerging business models and how entrepreneurs work with policy makers and other stakeholders to define key sustainability goals, indicators, and strategies to change existing norms and institutions. another limitation was that participating companies were based in massachusetts, a state with high public awareness and support for environmental and social initiatives. a future study could consider comparing two different regions to examine the impact of environmental awareness and culture on entrepreneurial success. in addition, future research could include a multi-stakeholder study for a specific region to examine the role of social and cultural norms and institutions on consumer behavior. the main contribution of this research is that it demonstrates that sustainable entrepreneurs act as civic and political actors who not only offer innovative products and services, but help educate and influence key stakeholders, develop informal sustainability ecosystem, and thus create momentum for civil and political changes. the study examines the main challenges faced by sustainable entrepreneurs presently and provides key lessons learned about how to overcome these. it illustrates the need for implementing effective indicators to measure the social and environmental impacts of sustainable products/services, in order to evaluate potential trade-offs and ensure overall positive impact. the research confirmed previous findings about the ability of entrepreneurs to identify opportunities within the current market system. however, it demonstrates that sustainable entrepreneurs cannot change "the rules of the game" on their own. scaling up their business models to achieve market and sustainability impacts requires collaborations among various stakeholders and bold policy actions to change the incentives for consumers and companies. company story and business model box save: promoting reusable moving boxes box save was founded in 2016 by two entrepreneurs, paul benoit and doran donovan, who worked for years in the finance and software industry, respectively. they launched box save after exploring many ideas such as used book shops and used sporting goods' shops (they also visited a company renting reusable moving boxes in washington d.c. to learn about their experience). the firm's core business is to rent reusable moving boxes to households, businesses, nonprofits and government agencies in the greater boston area. the co-founders run their business with minimal expenses; they have eight part-time employees and one part-time driver (they also deliver boxes themselves). the employees work mostly on cleaning the boxes which are sanitized with ecofriendly cleaner after each use. according to co-founder donovan there are about 40 firms in united states with similar business, but they do not compete as each operates in a specific geographic area; instead they connect via facebook to share ideas. box save initially struggled to get exposure, but in 2019 emerged on the top of the search results for greater boston. for every $1 invested in marketing they get $4 in revenue (they use facebook, yelp, google, and real estate firms). in their first year of operations box save saw 130% growth; in 2018 their sales were up 35% compared to the prior year 4 . the company's reusable boxes are made of polypropylene and can be used up to 500 times (or 25 years) and then recycled. they are also manufactured in the u.s. by monoflo, thus reducing transportation impacts. cardboard boxes on the other hand are used once or twice and even when recycled use 75% of the energy required to make a new box (box save, 2020) . despite these environmental benefits, the company's main messaging and value proposition for customers focuses on time and money savings (they offer drop off and pick up of the boxes, flexible schedules) and the outstanding customer service. fixit clinic-newton: helping people repair products fixit clinic is a non-profit organization launched in 2009 in the u.s. by entrepreneur peter mui with the main goal to help people repair broken products and thus extend their useful life and prevent waste. the company was modelled after the repair cafe movement in europe with one main difference -fixit clinic uses volunteers and teaches people about doing the repairs themselves (repair cafes, on the other hand, use specialists to repair consumer products). it aims to help people develop critical thinking and repair skills while saving them money and teaching them about sustainable consumption. the concept has grown quickly, and hundreds of events have been held recently across united states hosted by municipalities, local governments, ngos, colleges, and public libraries (gulf coast makercon, 2018) . since design constraints can make it challenging to repair many products, supporters of the idea have advanced new right to repair legislative proposals in numerous states in the u.s. (repair.org, 2019). following the steps of other massachusetts communities such as cambridge and belmont, the city of newton held its first fixit clinic in june 2019 at the newton free library. organized by the newton recycling committee, the event brought in volunteers who helped attendees repair a variety of products such as jewelry, textiles, lamps, and vacuum cleaners, among others. the success of the event led to scheduling two more events and discussions about making the fixit clinic a more regular event for residents. at the same time, organizers admitted that the lack of time, volunteers and ability to repair many products limit fixit clinic's impact. food for free: turning food waste into healthy meals food waste is a major problem around the world and especially in the united states where 31% of food is lost at the retail and consumer levels (contributing to waste generation and climate change), while 11.8% of u.s. citizens face food insecurity (usda, 2018) . to address these two problems, food for free, a small nonprofit company in cambridge, massachusetts, began taking surplus food from grocery stores and other organizations (which would otherwise be thrown out), and creating healthy meals for people in need. the idea for the company emerged in 1981 when a group of friends realized that local meal programs were struggling to provide fresh food for people in need, while supermarkets were throwing away large amounts of food they could not sell. this led to launching an organization which can "bridge the gap between waste and want" (food for free, 2020). food for free's most innovative program is the family meals, which began in 2014 as a partnership with harvard university after the company leadership realized that it was legal to donate cooked food. in 2020 food for free had 14 full-time equivalent employees and about 300 volunteers helping to prepare the meals, which are sent to schools and community colleges. food for free takes all food for free and gives it out for free, therefore it relies on funding from individuals and small businesses, foundation grants, and state and city contributions to support its work (e.g., their backpack program) (veleva & smith, 2020) . irn surplus: promoting reuse instead of recycling irn was launched as recycling company in 1999. in 2014 it decided to shift its core business to focus only on reuse. this led to the change in its name to irn surplus. the idea about reuse emerged in 2002 when co-founder mark lennon began getting calls from colleges unable to donate all of their surplus products locally (irn, 2018). as a result, "irn ended up with thousands of pieces of furniture that the local environment couldn't absorb," shared lennon. to address this problem, the co-founders developed a national and international network of recipients. presently irn surplus is a privately held, for-profit firm with 12 employees, which works with companies and universities interested in donating surplus products. the transition to reuse was a result of "evaluating the business environment and deciding that it doesn't make sense to compete with the big names such as casella, waste management and el harvey, but instead focus on their niche market of repurposing, where there is very little competition," explains lennon 5 . irn surplus has three core commitments: a) to handle everything, b) to make reuse simple, and c) to make reuse cost effective (irn, 2019) . to be competitive, the company charges 10%-30% less than the cost of waste disposal. they operate in a very efficient way; the generators and recipients split the cost of transportation and all companies they work with use their own labor to move the products. irn surplus does not use warehouse which helps reduce overhead, although for some clients they keep a few storage trailers. while the company is operating only as b2b business, it sees great opportunities in the b2c space and is interested in working with apartment complexes. joro: educating consumers to reduce their carbon footprint joro was launched in 2018 by sanchali pal and cressica brazier who sought to apply massachusetts institute of technology (mit) research to help address the complex problem of climate change. the company's main business model leverages an app which helps people measure and reduce their carbon footprint. on its website and app joro states: " if everyone improved their footprint by 7.6% each year for the next 10 years, we'd achieve the global paris climate targets to keep average temperature rise below 1.5c. together, we can cut our emissions in half by 2030 " (joro, 2020). joro provides simple suggestions on how to achieve such reduction, from walking and biking less than 2 miles, to taking public transit for distances less than 10 miles, to limiting meat to one meal per day, or turning the thermostat down by 3 ℉. in addition, consumers can buy carbon offsets. in 2019 joro conducted a beta pilot with 1,903 app users and reported that participants reduced their carbon footprint by 6% on average (39% of this reduction was result of behavior change and 61% a result of carbon offset). the top five behavior changes reported by 570 joro active users included reducing meat consumption, cold water washing, walking and biking more, unplugging devices when not in use, and avoiding red meat (joro, 2020). preserve: upcycling plastics and offering plantbased products preserve is a privately-held company which is also certified as b-corp (benefit corporation), focusing not just on profits but also on delivering value for all stakeholders. it was founded in 1996 by entrepreneur eric hudson, who in the early 1990s saw the waste problem and tried to solve it by focusing on recycling (preserve, 2020). in 2020 preserve had 18 employees and some sales representatives. its core business involves taking post-consumer/post-industrial polypropylene (#5) plastic and upcycling it in a variety of reusable products -toothbrushes, cutlery, and containers. in 2019 it launched the preserve ocean plastic initiative (popi) with the goal to utilize high-density polyethylene (hdpe) plastic that was "headed for the ocean." recently it also began offering compostable single use cutlery in response to growing demand. its partnerships with retailers, companies, and materials suppliers ensure low cost, continuous supply of post-consumer/postindustrial polypropylene. preserve uses digital marketing to reach customers. while the company offers competitive pricing, mr. hudson shares "we don't offer premium price, but our price is higher. we seek to be parity priced with everything we do. our reusable plates are a little higher price than something that you'd find from china, and certainly more expensive than the disposable alternatives." 6 preserve's business has grown over the years driven by increasing awareness of environmental problems and demand for reusable and compostable products. as of january 2020, preserve's products sold in 28 countries (an increase from 18 just two years earlier). project repat: upcycling old t-shirts into blankets nathan rothstein and ross lohr started the company in 2012 with the goal to solve the problem of excess clothing via upcycling. "people do not realize that majority of donated cloths do not get reused or recycled", explained erin kizer, project repat chief operating officer. customers send their old t-shirts and project repat makes blankets from them and sends them back. the company has robust system for tracking orders and three local partners to make the blankets -precision sportswear in fall river, massachusetts, opportunity threads in north carolina, and open arms studio in texas (project repat, 2020). to reduce costs, they only sell online and use various social media platforms. a few years ago, they opened a store in newton, massachusetts, but found that e-commerce was a more effective platform for their type of business. as of 2020 project repat had four employees and operations in massachusetts, north carolina, and texas. to reduce the environmental impacts of shipping they use low carbon footprint bags to send the blankets and recycle all cardboard boxes from customers. they are committed to be zero waste company and send all their waste for recycling, which presently is costly and one of their big challenges. finding supply chain partners in the u.s. is another challenge as most of this work has been outsourced to asia. while the company's products provide social and environmental benefits (jobs, local manufacturing and waste prevention), in their messaging they do not focus on these but instead on the intrinsic value of the products. "we pitch it as a way to preserve value as people have emotional connection to old t-shirts. promoting environmental friendly choices doesn't translate to sales," explained kizer. 7 semi-new computers: extending computers' useful lives via charlie thompson and marlene archer spent many years working in the computer industry before starting semi-new computers. in the 1990s ms. archer was at boston computer society where members would match donations to non-profit organizations. often such donations included refurbished computers. when she began working at harvard university ten years later, she met the university sustainability director which led to the discussion about surplus computers. she found repair & refurbishing that harvard business school, for example, replaces all its computers every three years even though 80% of them are in excellent condition. 8 the conversation led to launching a program to repair and donate surplus computers, which became known as semi-new computers (semi-new computers, 2019). over the years the two co-founders launched some innovative initiatives and partnerships. for instance, they developed a partnership with autistic students in lexington, massachusetts (part of a job readiness training), where the students helped clean and prepare the computers. funding for the training was provided by the native towns of the students (23 towns participated) and harvard university provided the old computers. another innovative initiative was the bridge program, where semi-new computers trained harvard university employees who may not speak english well (e.g., janitors). the goal of the program was to teach such people basic computer skills and provide them with refurbished computers for use at home. according to mr. thompson, "this was very labor-intensive process; people didn't have internet access at home, they didn't know how to set up a computer. we had to send someone to help them." over the years the business has faced numerous challenges. initially they used to sell new and used computers (which they received from other large organizations in the boston area), but there was no significant difference in price and functionality (e.g., if 3-years old computer costs $300 and a 5-years old is $100, people would just buy the new one). as a result, semi-new computers began sending refurbished computers to nigeria, ghana and sierra leone. software presents another major challenge with computer refurbishing, due to the constant upgrades and the cost of new software. as mr. thompson summed it up, "we had a vision to make boston a refurbished hub. right now it doesn't make sense to scale up as the economics doesn't work." as of 2020 the two co-founders were considered consultants to harvard university and their company was based at the harvard recycling center, although they continued to work with other universities and major corporations (semi-new computers, 2019). they were also actively volunteering at the cambridge fixit clinic to help people repair their computers and develop such skills among young people. the economics doesn't work (new computers are inexpensive); technological challenges (e.g., software does not work); lack of skilled people to repair electronics; lack of more space. policies to address planned obsolescence and tax waste generation and resource use (e.g., mandate design for disassembly; carbon and waste taxes) why achieving the paris agreement requires reduced overall consumption and production how big tech stopped right to repair in new york towards a sufficiency-driven business model: experiences and opportunities business-led sustainable consumption initiatives: impacts and lessons learned business model innovation climate-governance entrepreneurship, higher-order learning, and sustainable consumption: the case of the state of oregon evaluating the enablers and barriers for successful implementation of sustainable business practices in 'lean' smes building energy reporting and disclosure ordinance global e-waste: unintended consequences of marketing strategies necessitates a plan for change purchasing safer compostable food ware social change and the coming of post-consumer society: theoretical advances and policy implications integrating hybridity and business model theory in sustainable entrepreneurship americans increasingly see climate change as a crisis, poll shows the role of climate change education on individual lifetime carbon emissions social impact measurement: why do stakeholders matter assessing the degrowth discourse: a review and analysis of academic degrowth policy proposals what is disruptive innovation? toward a theory of sustainable entrepreneurship: reducing environmental degradation through entrepreneurial action entrepreneurial orientation and its effect on sustainability decision tradeoffs: the case of sustainable fashion firms sustainable lifestyles: addressing climate change and social inequity building theories from case study research theories building from cases: opportunities and challenges green to gold: how smart companies use environmental strategy to innovate, create value, and build competitive advantage developing sufficiency-oriented offerings for clothing users: business approaches to support consumption reduction ontologies, socio-technical transitions (to sustainability), and multi-level perspective a review on circular economy: the expected transition to a balanced interplay of environmental and economic systems telework, the timing of work, and instantaneous well-being: evidence from time use data fourth paths to business model innovation meet the repair maker: peter mui of fixit clinic the new heretics: hybrid organizations and the challenges they present to corporate sustainability path creation for sustainable consumption: promoting alternative heating systems in finland identifying, mapping, and monitoring the impact of hybrid firms massachusetts commercial food waste ban economic impact analysis prosperity without growth: economics for a finite planet degrowth in business: an oxymoron or a viable business model for sustainability? restructuring time: implications of work-hours reductions for the working class temporary reduction in daily global co 2 emissions during the covid-19 forced confinement key findings from the study on lifestyle carbon footprints: long-term targets and case studies of the carbon footprints of household consumption sustainable entrepreneurship, innovation, and business models: integrative framework and propositions for future research social and sustainable entrepreneurship (advances in entrepreneurship, firm emergence and growth the emergence of a successful eco-industrial park in the united states sustainable entrepreneurial process: from idea generation to impact measurement covid-19: implications for business the impact of social norms on entrepreneurial action: evidence from the environmental entrepreneurship context sustainable lifestyles 2050: stakeholder visions, emerging practices and future research global greenhouse gas emissions will hit yet another record high this year, experts project the circular economy: an interdisciplinary exploration of the concept and application in a global context global climate change: vital signs of the planet unpacking the sustainability landscape sustainable business models, venture typologies, and entrepreneurial ecosystems: a social network perspective waste not want not: sweden to give tax breaks for repairs designing away waste: a comparative analysis of urban reuse and remanufacture initiatives the interaction between network ties and business modeling: case studies of sustainability-oriented innovations escaping the green prison: entrepreneurship and the creation of opportunities for sustainable development right to repair wraps up a big year europe, let's reuse, refurbish, repair the circular economy: barriers and opportunities for smes semi-new computers welcomes you business models for sustainability: a co-evolutionary analysis of sustainable entrepreneurship, innovation, and transformation transitions for sustainable consumption after the paris agreement. sustainability: science, practice and policy distinctions not dichotomies: exploring social, sustainable, and environmental entrepreneurship unep. 2016. fostering and communicating sustainable lifestyles food security status of u.s climate change and waste corporate-entrepreneur collaborations to advance a circular economy entrepreneurs in sustainable consumption: the furniture trust case the need for better measurement and employee engagement to advance a circular economy: lessons from biogen zero waste journey understanding and addressing business needs and sustainability challenges: lessons from devens eco-industrial park food for free: from food waste to healthy meals sustainable consumption dilemmas environmental dystopia versus sustainable development utopia: roles of businesses, consumers, institutions, and technologies the entrepreneur-environment nexus: uncertainty, innovation and allocation highlights • entrepreneurs as civic and political actors who help create momentum for political changes • their value proposition based on time & cost savings, social & env. impact, and quality service • it, sustainability networks, and social media -key to developing viable business models • key challenges: costly sustainable actions, impact measurement, resources, brand awareness • shifting to sls requires stakeholder collaborations and bold policy action the role of entrepreneurs in advancing sustainable lifestyles: challenges, impacts, and future opportunities vesela veleva: conceptualization, methodology, data collection and analysis, writing-original draft preparation the authors would like to thank all participating companies and the university of massachusetts boston for funding this research through the umass boston public service grant, project: p20190000041791. higher cost of product compared to imports from china; lack of interest from consumers; lack of resources (funding and time) to do good measurement (e.g., policies to tax raw materials (so recycled materials will be price competitive); investment in better recycling technology j o u r n a l p r e -p r o o f ☒ the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☐the authors declare the following financial interests/personal relationships which may be considered as potential competing interests: vesela veleva sept. 7, 2020 j o u r n a l p r e -p r o o f key: cord-308271-zzepl3on authors: calderón-larrañaga, amaia; dekhtyar, serhiy; vetrano, davide l.; bellander, tom; fratiglioni, laura title: covid-19: risk accumulation among biologically and socially vulnerable older populations date: 2020-08-17 journal: ageing res rev doi: 10.1016/j.arr.2020.101149 sha: doc_id: 308271 cord_uid: zzepl3on emerging data show that the health and economic impacts of covid-19 are being disproportionately borne by individuals who are not only biologically, but also socially vulnerable. based on preliminary data from sweden and other reports, in this paper we propose a conceptual framework whereby different factors related to biological and social vulnerability may explain the specific covid-19 burden among older people. there is already some evidence showing large social disparities in the prevention, treatment, prognosis and/or long-term consequences of covid-19. the remaining question is to what extent these affect older adults specifically. we provide the rationale to address this question with scientific methods and proper study designs, where the interplay between individuals’ biomedical status and their social environment is the focus. only through interdisciplinary research integrating biological, clinical and social data will we be able to provide new insights into the sars-cov-2 pandemic and inform actions aimed at reducing older adults’ vulnerability to covid-19 or other similar pandemics in the future. covid-19 has a clear predilection for aged people. up to one quarter of the deaths due covid-19 have been in older people aged 70-79 years and up to two thirds in those over 80 years, regardless of the incidence of the disease or the completeness in the ascertainment of deaths across countries ( table 1) . however, we know that "age" is a summary measure of life-long biological, physiological and functional changes partly determined by and in strong interplay with external social, physical, cultural and economic forces. in fact, emerging data show that the health and economic impacts of the virus are being disproportionately borne by people with a poor socioeconomic background. insert table 1 here j o u r n a l p r e -p r o o f recent statistics from health authorities in e.g. new york 1 , barcelona 2 and even stockholm 3 reveal how the coronavirus outbreak appears to affect immigrant communities and lower-income neighbourhoods the hardest. death records currently show that african americans account for more than half of those who have died from the novel coronavirus in cities like philadelphia or chicago, far in excess of their representation in the general population. in the uk, early research has shown that the proportion of nonwhite patients in intensive care units was 2.3 times greater than their share in the general population 4 , and that people living in more deprived areas have experienced covid-19 mortality rates more than double those in less deprived areas 5 . most of the information on social differences in covid-19 pandemic comes from media reports based on anecdotal or other ad hoc data ( table 2) . moreover, the real magnitude of the inequalities is likely to be underestimated due to the inexistence of accurate socioeconomic and ethnicity data across many local authorities and care services 6 . fortunately, scientific inquiries into these questions have already begun. for instance, a range of social indicators such as population density, ethnic makeup diversity, urban/rural setting, level of education, lifestyle and living conditions that can be inferred from people's area of residence are now starting to be linked to different health and well-being outcomes. early findings from geographic modelling performed in the us indicate that income inequality was an influential factor in explaining covid-19 incidence rates across counties 7 . insert table 2 here similarly, preliminary analyses based on publicly available data from stockholm region (sweden) show differences in excess mortality for covid-19 across community measures of country of birth, median income and education one month after the outbreak (figure 1 ). j o u r n a l p r e -p r o o f some preliminary data show that social disparities related to covid-19 take place at different time windows of the disease process. social differences have been reported in the prevention of the contagion, in the care of the disease and related comorbidities, and in the prognosis and long-term consequences of the infection ( table 3 ). this could be especially relevant for those individuals who experience both a social and biological vulnerability as the older adults. disparities in the prevention of contagion. social disparities in awareness of the risks and in adoption of preventive measures, such as hand hygiene and physical distancing, can be attributed to the shortage of information adapted for minority languages and the unequal access to internet. these barriers are exacerbated in the communities of older adults, frequently characterized by lower health-and technological literacy. in a survey of more than 600 socio-demographically diverse adults living in chicago, those who were black, were living below the poverty level, or had low health literacy were less likely to believe that they might become infected; black respondents also felt less prepared for an outbreak than white adults 8 . people in worse socioeconomic circumstances are more likely to experience overcrowding in the household, and it is also more common that different generations cohabit together. the type of jobs that lower-income people tend to have (e.g. care services, transportation, food and restaurant businesses) also put them, and their often cohabiting parents, at an increased risk of contagion, since they are difficult to perform from home and often require proximity with the client. following quarantine orders could be particularly challenging for those living in smaller, shared, or cramped accommodations. in certain cultures, socially isolating older family members may be viewed as abandonment and will therefore be difficult to adhere to. coronavirus testing seems to be socially patterned, too. for example, in philadelphia (us), individuals living in higher-income communities are reported to have been tested for covid-19 six times more often than those in lower-income neighbourhoods 9 . this is mainly because, for most testing sites, testing is performed from a car and with a referral from the primary care physician to get tested. many in philadelphia's lower-income black neighbourhoods do not have primary care physicians, let alone a car. care disparities for covid-19 and comorbidities. general access to healthcare has been shown to vary widely across socioeconomic groups. this will be especially relevant in countries without universal health care systems and where large numbers of under-or uninsured people are concentrated in certain areas. in the us, many uninsured patients have been faced with substantial medical billings 10 or even denied healthcare 11 for covid-19 treatment. besides the ease of access to health services, care outcomes may have been influenced by different healthcare systems models, and their level of development of primary care, public health, and community medicine, all of which closely interact with individual biological and social factors. in the context of a shortage of hospital beds, intensive care unit beds, and ventilators, implicit involuntary bias on the part of the healthcare system as well as individual providers, could affect the care people receive. much criticism has been voiced against the formulation and implementation of "ageist" policy, whereby resources are prioritized based exclusively on patients' chronological age 12 . older people from minority or disadvantaged groups may thus face double discrimination, placing them in an extremely vulnerable situation. the lack of community capacity and mobilization in deprived areas may be a key bottleneck to providing timely assistance to older patients and their affected families 13 . moreover, the use of telemedicine for in-person clinical evaluation poses special challenges for older adults, particularly those with sensory or cognitive impairments or who are unfamiliar with new technologies. despite being the unique form of connection with healthcare services for some, these technology platforms lack rigorous assessment in older adults 14 . disparities in prognosis and long-term consequences. because older people from lower-income backgrounds are more likely to suffer from chronic conditions (e.g. obesity, diabetes mellitus, chronic lung disease, and cardiovascular disease) 15 , multimorbidity 16 or even frailty 17 , they are also at a higher risk of covid-19-associated complications and mortality 18, 19 . moreover, older and socially vulnerable persons affected by covid-19 could be less likely to be recruited for respiratory rehabilitation and monitoring 20 , especially in those countries with no universal health coverage. indeed, the pulmonary function tests used to follow-up and stratify these patients (e.g. lung plethysmography, carbon monoxide diffusing capacity) are expensive and/or not easily available through telemedicine. those with lower household incomes have been shown to experience significantly greater mental strain as a result of prolonged quarantine, most likely due to over-crowded accommodation as well as to increased risk of losing income 21 . self-isolated older adults are more likely to experience loneliness, poor food availability and unbalanced diet, lack of exercise, and lower cognitive stimulation, which will considerably decrease their levels of resilience, leading to a cascade of physical and mental health problems. such risk will be exacerbated among poor older people, who rely most on social care and community support. in addition, people's ability to maintain remote contact with family and friends, which seems essential for long-term mental health, also depends on their access to smart phones, computers and internet, and above all, their internet literacy, which is especially low among the oldest old. the pandemic's toll will reach dramatic levels in those contexts where all above-mentioned vulnerability factors cluster together, as is the case of conflict zones, prisons, and refugee camps. not to speak about those places where people lack the very access to clean water with which to wash their hands to prevent infections, an intolerable reality for more than 840 million people around the world. the care home sector is another example where several of these factors cluster together, which has led to the highest death rates worldwide 22 . aspects related to their congregate nature, the populations served (i.e. older adults with high burden of morbidity and cognitive and functional impairment), the dominance of private for-profit providers, decreasing quality standards in terms of health promotion and prevention, the often precarious working conditions of the staff, and residents' limited networks of psychosocial support, have placed nursing homes in the eye of the storm. the covid-19 pandemic is far from being the "great equalizer" that affects all social groups alike, as it has been portrayed. it expresses a disproportionate preference for individuals who are not only biologically, but also socially vulnerable. in fact, it is further amplifying the large social inequalities already existing in the older populations. yet, this is nothing new. the 1918 flu pandemic also showed j o u r n a l p r e -p r o o f a significant geographic variation in mortality driven by socioeconomic factors 23 . similarly, during the 2009 h1n1 influenza pandemic, the death rate was found to be three times higher in the poorest compared to the wealthiest quintile of the british population 24 . while the european commission has earmarked €140 million to support research on the diagnoses, treatment, and vaccine development, and another €87 million to produce medical devices and help overburdened healthcare systems and businesses 25 , no funds seem to be specifically allocated to carry out the "social autopsy" of the covid-19 outbreak. there is an urgent need to address these questions with scientific methods and proper study designs, where the interplay between individuals' biomedical status and their social environment is the focus. we propose a conceptual framework addressing biological and social differences in covid-19 burden developed specifically for older people, considering potential disparities in its prevention, treatment, prognosis and/or long-term consequences (figure 2 ). what is currently missing is research focusing on the interplay between the biological and social backgrounds, which is relevant for all, but especially for older adults' health, when challenged by an acute severe disease as covid-19. thus, integrated biological, clinical and social data are urgently needed worldwide to guide actions aimed at reducing older adults' vulnerability to covid-19. in the long run, it is societies' deep-rooted structural inequities as well as the disciplinary fragmentation of research fieldsthat now seem to have intensified due to this new diseasethat we will need to address. combating this and future pandemics will inevitably mean combating outdated research practices and assuring efficient and egalitarian public healthcare systems within each country and worldwide. this research did not receive any specific grant from funding agencies in the public, commercial, or notfor-profit sectors. note: excess mortality calculated comparing the mortality rate between 1-10 april 2020 with the average mortality rate recorded for the corresponding 10-day period during the two previous years. income refers to employment (acquisition) income. source: own elaboration based on publicly available data from statistics sweden (https://www.scb.se/). the new york times. a month of coronavirus in new york city: see the hardest-hit areas desigualtats socials i covid-19 a barcelona how are sweden's foreign residents reacting to the country's coronavirus approach? uk government urged to investigate coronavirus deaths of bame doctors covid-19: deprived areas have the highest death rates in england and wales black doctors blast "woefully anemic" data on minority coronavirus cases gis-based spatial modeling of covid-19 incidence rate in the continental united states attitudes, and actions related among adults with chronic conditions at the onset of the u.s. outbreak high-income philadelphians getting tested for coronavirus at far higher rates than low-income residents the commonwealth fund. update on federal surprise billing legislation: new bills contain key differences teenage boy whose death was linked to covid-19 "turned away from urgent care for not having insurance aging in times of the covid-19 pandemic: avoiding ageism and fostering intergenerational solidarity the social determinants of health and pandemic h1n1 2009 influenza severity telemedicine and telecare for older patients--a systematic review preliminary estimates of the prevalence of selected underlying health conditions among patients with coronavirus disease 2019 -united states epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. supplementary appendix sociodemographic determinants of worsening in frailty among community-dwelling older people in 11 european countries case-fatality rate and characteristics of patients dying in relation to covid-19 in italy the effect of frailty on survival in patients with covid-19 (cope): a multicentre, european, observational cohort study. lancet public heal respiratory rehabilitation in elderly patients with covid-19: a randomized controlled study the psychological impact of quarantine and how to reduce it: rapid review of the evidence european centre for disease prevention and control. surveillance of covid-19 in long-term care facilities in the eu/eea a socially neutral disease? individual social class, household wealth and mortality from spanish influenza in two socially contrasting parishes in kristiania 1918-19 socio-economic disparities in mortality due to pandemic influenza in england the color of coronavirus: covid-19 deaths by race and ethnicity in the u covid-19: data deaths involving covid-19 by local area and socioeconomic deprivation: deaths occurring between 1 coronavirus (covid-19) related deaths by occupation, england and wales: deaths registered up to and including conclusiones de la territorialización de la pandemia de covid-19 en el área metropolitana de madrid source: own elaboration based on publicly available data from the french institute for demographic studies key: cord-288024-1mw0k5yu authors: wang, wei; liang, qiaozhuan; mahto, raj v.; deng, wei; zhang, stephen x. title: entrepreneurial entry: the role of social media date: 2020-09-29 journal: technol forecast soc change doi: 10.1016/j.techfore.2020.120337 sha: doc_id: 288024 cord_uid: 1mw0k5yu despite the exponential growth of social media use, whether and how social media use may affect entrepreneurial entry remains a key research gap. in this study we examine whether individuals’ social media use influences their entrepreneurial entry. drawing on social network theory, we argue that social media use allows individuals to obtain valuable social capital, as indicated by their offline social network, which increases their entrepreneurial entry. we further posit the relationship between social media use and entrepreneurial entry depends on individuals’ trust propensity based on the nature of social media as weak ties. our model was supported by a nationally representative survey of 18,873 adults in china over two years. as the first paper on the role of social media on entrepreneurial entry, we hope our research highlights and puts forward research intersecting social media and entrepreneurship. social media, defined as online social networking platforms for individuals to connect and communicate with others (e.g., facebook), has attracted billions of users. an emerging body of literature suggests that social media enables entrepreneurs to obtain knowledge about customers or opportunities, mobilize resources to progress their ventures, and manage customer relationships after venture launch (cheng & shiu, 2019; de zubielqui & jones, 2020; drummond et al., 2018) . further, social media allows entrepreneurs to efficiently manage their online relationships and reinforce their offline relationships (smith et al., 2017; thomas et al., 2020; wang et al., 2019) . despite much research on the impact of social media on the launch and post-launch stages of the entrepreneurial process (bird & schjoedt, 2009; gruber, 2002; ratinho et al., 2015) , there is little research on the impact of social media on the pre-launch stage, the first of the three stages of the entrepreneurial process (gruber, 2002) . despite the popularity of social media, it remains unclear whether and how social media affects individuals at the prelaunch stage of the entrepreneurial process, given social media consists of weak ties and substantial noise from false, inaccurate or even fake information, which may or may not benefit its users. in this study, we aim to contribute to the literature by investigating whether individuals' social media use affects their entrepreneurial entry based on social network theory. we argue that a higher social media use will allow an individual to develop a larger online social network and accumulate a greater amount of social capital, which facilitates entrepreneurial entry. a larger social network may facilitate individuals' information and knowledge seeking activities (grossman et al., 2012; miller et al., 2006) , which have a significant impact on their ability to generate and implement entrepreneurial ideas in the pre-launch stage (bhimani et al., 2019; cheng & shiu, 2019; orlandi et al., 2020) . social media, unlike offline face-to-face social networks, allows a user to develop a large social network beyond their geographical area without incurring significant effort and monetary cost (pang, 2018; smith et al., 2017) . the large social network arising from social media further enables social media users to build larger offline networks beyond their geographical proximity. hence, we argue that individuals' social media use has a positive impact on their offline network, which facilitates their entrepreneurial entry. however, social media is dominated by weak ties, and individuals with low trust propensity may not trust other online users easily so they are cautious about online information and knowledge. thus, we propose that trust propensity, an individual's tendency to believe in others (choi, 2019; gefen et al., 2003) , moderates the relationship between social media use and entrepreneurial entry. fig. 1 displays the proposed model. we assessed the proposed model on a publicly available dataset of china family panel studies (cfps), which consists of a sample of nationally representative adults. our findings reveal that social media use https://doi.org/10.1016/j.techfore.2020.120337 received 8 august 2020; accepted 21 september 2020 has a positive impact on entrepreneurial entry with individuals' offline network serving as a partial mediator. further, the findings confirm that individuals' trust propensity moderates the relationship between their social media use and entrepreneurial entry, with the relationship becoming weaker for individuals with high trust propensity. our study makes several important contributions to the literature. first, we contribute to the emerging entrepreneurship literature on an individual's transition to entrepreneurship by identifying factors contributing to the actual transition (mahto & mcdowell, 2018) . the identification of social media use addresses mahto and mcdowell's (2018) call for more research on novel antecedents of individuals' actual transition to starting entrepreneurship. to the best of our knowledge, this is the first study on the role of social media on individuals' entrepreneurial entry using social network theory. the research on social media in entrepreneurship area has focused on post-launch phases of entrepreneurship (cheng & shiu, 2019; drummond et al., 2018; mumi et al., 2019) , while research on individuals at the pre-launch stage of the entrepreneurial process is lacking. second, our study specified a mechanism for the impact of individuals' social media use on entrepreneurial entry via their offline network and used instrumental variables to help infer the causality. yu et al. (2018 yu et al. ( , p. 2313 noted that "specifying mediation models is essential to the advancement and maturation of particular research domains. as noted, mathieu et al. (2008: 203) write, 'developing an understanding of the underlying mechanisms or mediators (i.e., m), through which x predicts y, or x → m → y relationships, is what moves organizational research beyond dust-bowl empiricism and toward a true science.'" third, we contribute to the limited stream of research in the entrepreneurship literature on the networking of individuals in the prelaunch phase which has focused on networking offline (dimitratos et al., 2014; johannisson, 2009; klyver & foley, 2012) . instead, we offer a clearer picture of networking for entrepreneurship by connecting the literature on online social media use (fischer & reuber, 2011; smith et al., 2017) with offline social networks and entrepreneurial entry. the paper is organized as follows. the next section, section 2, provides an overview of the social capital theory and associated literature used to construct arguments for hypothesis development. section 3, data and methods, reports the context, method, and the variables. section 4 reports the results of the statistical analysis, instrumental variable analysis to address endogeneity concerns, and an assessment of robustness checks. section 5 discusses the study findings, outlines key study limitations, and provides guidance for future research and section 6 concludes. social capital theory (rutten & boekema, 2007 ) is a popular theoretical framework among management scholars. more recently, the theory has been increasingly used by entrepreneurship scholars to explain behaviors at the levels of both the individual (e.g., entrepreneurs) and firm (e.g., new ventures) (dimitratos et al., 2014; klyver & foley, 2012; mcadam et al., 2019) . according to the theory, the network of an individual has a significant influence on an individual's behavior (e.g., seeking a specific job) and outcomes (e.g., getting the desired job). in the theory, the network represents important capital, referred to as social capital, that produces outcomes valued by individuals (mariotti & delbridge, 2012) . social capital allows an individual to obtain benefits by virtue of their membership in the social network. the underlying assumption of social capital is, "it's not what you know, it's who you know" (woolcock and narayan (2000) , p. 255). for example, people with higher social capital are more likely to find a job (granovetter, 1995) or progress in their career (gabby & zuckerman, 1998) . for firms, social capital offers the ability to overcome the liability of newness or resource scarcity (mariotti & delbridge, 2012) . in entrepreneurship literature, scholars have used social capital to explain resource mobilization and pursuit of an opportunity by both entrepreneurs and small firms (dubini & aldrich, 1991; stuart & sorenson, 2007) . at the individual level, entrepreneurs embedded in a network are more likely to overcome challenges of resource scarcity and act promptly to launch a venture to capitalize on an opportunity (klyver & hindle, 2006) . for example, high social competence entrepreneurs establish strategic networks to obtain information, resources and more strategic business contacts (baron & markman, 2003) . mahto, ahluwalia and walsh (2018) supported the role of social capital by arguing that entrepreneurs with high social capital are more likely to succeed in obtaining venture capital funding. further, entrepreneurship scholars have argued that social networks influence entrepreneurs' decisions and the probability of executing a plan (davidsson & honig, 2003; jack & anderson, 2002; ratinho et al., 2015) . in women entrepreneurs, the presence of a robust social network is a key determinant of success (mcadam et al., 2019) . research suggests that the extent of a social network determines which resources entrepreneurs can obtain (jenssen & koenig, 2002; witt, 2004) . in the entrepreneurial context, scholars have also examined the influence of social networking at the firm level. for example, new and small firms often use a strong social network to overcome the liability of newness or smallness to pursue growth opportunities (galkina & chetty, 2015; mariotti & delbridge, 2012) . entrepreneurial ventures with limited resources often rely on their networks to obtain information and knowledge about consumers, competitors and networks in a foreign market (lu & beamish, 2001; wright & dana, 2003; yeung, 2002) . in the internationalization context, it is almost impossible for entrepreneurial firms to enter a foreign market without a robust social network (galkina & chetty, 2015) . it is well documented that new firms commonly use strategic networking for resources and capabilities (e.g., research and development) unavailable within the firm. the research on social networks in the entrepreneurship area is robust, but is focused almost exclusively on traditional offline social wang, et al. technological forecasting & social change 161 (2020) 120337 networks with limited attention to the dominant online social media. as offline social networks and online social networks differ significantly in terms of strength of ties (i.e., weak ties vs. strong ties) between network associates (filiposka et al., 2017; rosen et al., 2010; subrahmanyam et al., 2008) , empirical findings from traditional offline social networks may not be applicable to online social networks because offline social networks are dominated by strong ties while online social media are dominated by weak ties (filiposka et al., 2017) , and strong ties are based on a high degree of trust and reciprocity while weak ties have low trust and reciprocity. this significantly limits our understanding of entrepreneurial phenomena in the context of online social media. further, the research on social networks has also paid limited attention to the pre-launch phase of the entrepreneurial process, focusing mostly on entrepreneurs and established entrepreneurial ventures. finally, as offline social networks, which have strong ties, are the main context of the literature, the role of individual trust propensity remains unexplored as well. this offers a unique opportunity to investigate the role of social media and individuals' trust propensity in the pre-launch phase of the entrepreneurial process. the widespread adoption of the internet has led to an exponential growth in social media around the world. we refer to social media as "online services that support social interactions among users through greatly accessible and scalable web-or mobile-based publishing techniques" (cheng & shiu, 2019, p. 38) . social media, using advanced information and communication technologies, offers its users the ability to connect, communicate, and engage with others on the platform (bhimani et al., 2019; kavota et al., 2020; orlandi et al., 2020) . some of the most popular social media companies in the world are facebook, twitter, qq, and wechat. the large number of users coupled with other benefits of social media platforms, such as marketing, engagement, and customer relationship management, have attracted firms and organizations to these platforms. for example, firms have used social media to build an effective business relationship with their customers (steinhoff et al., 2019) , create brand loyalty (helme-guizon & magnoni, 2019), and engage in knowledge acquisition activities (muninger et al., 2019) . firms have also started adopting social media to enhance their internal operations by strengthening communication and collaboration in teams (raghuram et al., 2019) . thus, social media and its impact on firms and their environment has intrigued business and management scholars driving growth of the literature. recently, entrepreneurship scholars have begun exploring the impact of social media on entrepreneurial phenomena. limited research on social media in entrepreneurship suggests that social media allows entrepreneurial firms to enhance exposure (mumi et al., 2019) , mobilize resources (drummond et al., 2018) , and improve innovation performance (de zubielqui & jones, 2020) . this limited research, while enlightening, is devoted almost entirely to the post-launch stage of the entrepreneurial process, where a start-up is already in existence. the impact of social media on other stages of the entrepreneurial process, especially the launch stage (i.e., entrepreneurial entry), remains unexplored and is worthy of further scholarly exploration. for example, even though we know that social media can offer new effectual pathways for individuals by augmenting their social network, whether social media influences entrepreneurial entry or offline social networks remains unexplored. thus, our goal in this study is to address the gap in our understanding of the impact of social media on entrepreneurial entry. a social network refers to a network of friends and acquaintances tied with formal and informal connections (barnett et al., 2019) , that can exist both online and offline. social media is useful for creating, expanding and managing networks. research suggests social media can be used to initiate weak ties (e.g., to start a new connection) and manage strong ties (i.e., to reinforce an existing connection) (smith et al., 2017) . similar to social interactions in a physical setting, people can interact with others and build connections in the virtual world of social media, which eliminates the need for a physical presence in the geographical proximity of the connection target. the lack of requirement for geographical proximity with the in-built relationship management tools in social media allows a user to connect with a significantly larger number of other users regardless of their physical location. the strength of relationships among connected users in social media is reflected by the level of interaction among them; users in a strong connection have a higher level of interaction and vice versa. however, given the probability of a much larger number of connections in social media, dominance of weak ties is accepted. when connected users, either online or offline, in a network reinforce their connection by enhancing their level of interaction in both mediums (i.e., offline and online), they strengthen ties. for example, when two connected users in social media engage in offline activities, they may enhance their offline social tie through the joint experience . research also informs that social media use helps reinforce or maintain the strength of relationships among offline friends (thomas et al., 2020) . social media allows people to communicate with their offline friends instantly and conveniently without the need to be in geographical proximity (barnett et al., 2019) . the opportunity to have a higher level of interaction at any time regardless of physical location offers social media users the ability to manage and enlarge their offline social network. further, social media can also be used to initiate offline ties directly. in the digital age, users can connect their friends and acquaintances to other friends and acquaintances on social media. social media platforms also recommend connections to users based on their user profile, preferences, and online activities to generate higher user engagement. for example, in china, when a user intends to connect with a person known to their friends or connections, they can ask their friends for a wechat name card recommendation. once connected online, users can extend their connection to their offline networks as well. as a result, higher social media use may enhance a user's offline social network. thus, we hypothesize: h1. social media use of a user is positively associated with their offline social network. entrepreneurship, a context-dependent social process, is the exploitation of a market opportunity through a combination of available resources by entrepreneurs (shane & venkataraman, 2000) . the multistage process consists of: (a) the pre-launch stage, involving opportunity identification and evaluation, (b) the launch stage, involving business planning, resource acquisition, and entrepreneurial entry, and (c) the post-launch stage, involving venture development and growth (gruber, 2002) . our focus in this study is on entrepreneurial entry, which is the bridge between the pre-launch and launch stages of the entrepreneurial process, representing the transition from an individual to an entrepreneur (mahto & mcdowell, 2018; yeganegi et al., 2019) . entrepreneurial entry requires a viable entrepreneurial idea (i.e., opportunity) and resources (ratinho et al., 2015; ucbasaran et al., 2008) . individuals' social networks are important for researching and assessing entrepreneurial ideas (fiet et al., 2013) and accumulating valuable resources for entrepreneurial entry (grossman et al., 2012) . research suggests that networks play a crucial role in the success of entrepreneurs and their ventures (galkina & chetty, 2015; holm et al., 1996) . social networks allow individuals to access information and resources (chell & baines, 2000) . a larger social network allows entrepreneurs and smes to overcome resource scarcity for performance enhancement and expansion, especially international expansion (dimitratos et al., 2014; johannisson, 2009 ). although enlightening, the prior research on social networks in entrepreneurship has focused only on the traditional offline networks. in the digital age, social media has emerged as the key networking tool and enhanced individuals' ability to significantly enlarge their network and draw a higher social capital. these platforms allow entrepreneurs to efficiently manage both their online and offline networks and relationships . social media has significantly expanded the ability of individuals to network by removing geographical, cultural and professional boundaries. it allows people, separated by physical distance, to overcome the distance barrier to network and manage relations effectively (alarcóndel-amo et al., 2018; borst et al., 2018) . this is especially beneficial for an individual searching for entrepreneurial ideas that may be based on practices, trends, or business models emerging in the geographical locations of their network associates. as an example, jack ma of alibaba did not have to travel to the us to stumble upon the idea of an online commerce platform. social media allowed him to observe and obtain that information through network associates. while social media enlarges the social network of an individual with associates located beyond their geographical location, critics of the platform argue that such networks are mostly made up of weak ties lacking the strong ties of an offline network. however, individuals can still obtain useful and valuable information from abundant weak ties in such social networks (granovetter, 1973) . when accessing the network, the individuals have access to knowledge and information from various domains to inform their entrepreneurial ideas. further, the efficiency of social media allows for more effective and easy communications with distant individuals (alarcón-del-amo et al., 2018) . the improved communication with distant network associates allows individuals to strengthen their ties and obtain richer and reliable information. individuals may also obtain valuable access to new resources or new associates, who may support the formation of their new entrepreneurial venture. the distant network associates could also offer individuals additional resources in the form of entrepreneurial connections to new partners, buyers, suppliers, or talent, which all improve the chance of launching new ventures. it is well known that people, especially venture capitalists and investors, tend to minimize their risk by investing in known entrepreneurs rather than unknown entrepreneurs . thus, we believe social media use is beneficial for entrepreneurial entry. h2. social media use is positively associated with entrepreneurial entry. social media significantly enhances individuals' capability to expand their networks by removing cultural, geographical, and professional boundaries, to manage and strengthen offline social relationships. according to prior research, offline networks can provide the spatially proximate information and resources relevant to entrepreneurial entry (levinthal & march, 1993; miller et al., 2006) . social media enhances the efficiency and reduces the transaction cost of communication with offline network associates, allowing individuals to use them for information, knowledge and resource search. a recombination of information and knowledge is key to generating and then evaluating entrepreneurial ideas for entrepreneurial entry. in an offline social network, an individual has a stronger relationship with network associates because of their face-to-face interactions and collective experience in geographical proximity. further, geographical proximity in an offline social network facilitates relationships in real life by augmenting face-to-face interactions via virtual means (kim et al., 2019) . the additional channel of communication via virtual social media allows individuals to obtain timely and richer information, which may help them benefit from the collective wisdom and capability of their higher social capital (orlikowski, 2002) to develop entrepreneurial opportunities. the richer information and better access to knowledge and resources all benefit their entrepreneurial entry. thus, with higher social media use, individuals will have an expanded offline social network, which provides them the resources needed for successful entrepreneurial entry. therefore, we propose: h3. the offline social network mediates the relationship between social media use and entrepreneurial entry. trust propensity refers to an individual's tendency to trust others (choi, 2019; gefen et al., 2003) . trust propensity is a stable personality trait formed early in life through socialization and life experience (baer et al., 2018; warren et al., 2014) . like other ingrained personality traits, it affects an individual's behaviour, especially trust, in many situations (baer et al., 2018; friend et al., 2018) . for example, a customer with a high trust propensity is more likely to trust a salesperson without doubting their integrity (friend et al., 2018) . while trust propensity enables trust, it may leave individuals vulnerable due to reduced monitoring and reduced flow of new ideas (molina-morales et al., 2011) . furthermore, an individual with a high trust propensity may be inclined to obtain information from others indiscriminately and be locked into relationships. this may influence the individual's information processing capability. in the literature, trust propensity has attracted the attention of scholars seeking to explain not only the offline behavior of individuals, but also online behavior in social media platforms and virtual communities (lu et al., 2010; warren et al., 2014) . in social media, network associates are mostly connected through weak ties representing lack of trust and reciprocity. the existence of significant weak ties in social media makes the role of individual trust propensity critical. we believe trust propensity in social media moderates the impact of individuals' social media use on entrepreneurial entry by influencing their ability to network with strangers and known associates. further, prior findings in the literature suggest that trust influences entrepreneurial information searching and processing (keszey, 2018; molina-morales et al., 2011; wang et al., 2017) . this supports the possibility of trust propensity as the moderator of the link between social media use and entrepreneurial entry. in social media, the trust propensity of an individual influences their interaction and behavior (lu et al., 2010) . accordingly, an individual with a high trust propensity is more inclined to trust others. however, the trust in the relationship may not be mutual as the transacting party may lack the same trust propensity. as a result, the individual may fail to generate identical trust from the other individual thereby limiting the benefits of the relationship. with the aid of social media, an individual has the ability to access a large network of weak ties with remote individuals. this may allow the individual to obtain and validate information crucial to formalizing and finalizing an entrepreneurial idea. however, the advantage of higher social capital from access to a large network on social media may be eroded when individuals have a high trust propensity due to multiple factors. first, the network associates of individuals on social media vary significantly in terms of their trust propensity. the variations in the trust propensity of associates may result in them providing information via social media that may not always be reliable. in particular, network associates with low trust propensity may be reluctant to share valuable information. individuals with high trust propensity will treat a network associate and the information they provide with trust and without suspicion (peralta & saldanha, 2014; wang et al., 2017) . as a result, social media users may be exposed to both true and false information from associates. thus, such individuals are more likely to experience greater obstacles in distinguishing reliable information from unreliable noise, thereby incurring significantly higher information and resource search costs. the higher cost may hinder formation and finalization of an entrepreneurial idea and may hamper entrepreneurial entry. alternatively, individuals with low trust propensity are more likely to be more cautious (choi, 2019) . such individuals, due to their cautious attitude, are less likely to experience noise in their information and resource search, and thus may find it easier to distinguish reliable information from w. wang, et al. technological forecasting & social change 161 (2020) 120337 unreliable information. as a result, the cost (i.e., monetary, labor, and time) of obtaining information and resources for such individuals is lower, which may significantly enhance the probability of entrepreneurial entry. second, in social interactions and transactions trust may trigger a lock-in effect (molina-morales et al., 2011) . the lock-in effect refers to a scenario where high trust propensity individuals interact only with a few trusted associates on social media. the lock-in effect prevents the individuals from benefiting from a higher social capital on social media. thus, a lock-in effect may significantly limit individuals' information and resource search to a limited number of associates, which may significantly impair development and formation of their entrepreneurial idea, and ultimately entrepreneurial entry. however, individuals with low trust propensity are less likely to suffer from the lock-in effect thereby increasing their probability of entrepreneurial entry. thus, we hypothesize: h4. trust propensity moderates the relationship between social media use and entrepreneurial entry. we tested our proposed model on a sample of adults in china, a country with the world's largest population and the second highest total gross domestic product. china provides a rich setting for examining the link between social media and entrepreneurial entry for multiple reasons. first, china has experienced exponential growth in entrepreneurship and private enterprise development unleashed by economic transition (he et al., 2019) . the resulting entrepreneurial intensity provides a suitable context for investigating entrepreneurial phenomena including entrepreneurial entry. second, in china the adoption and use of social media is widespread with the world's largest number of users of internet (li et al., 2020) . the major american-based social media platforms, such as facebook, twitter, and instagram, were inaccessible in china at the time of the study (makri & schlegelmilch, 2017) , and people in china use other social media, such as wechat, qq, and sina weibo, which mirror or are similar to the american social media platforms (li et al., 2020) . our data is from the surveys of china family panel studies (cfps). cfps is a nationally representative longitudinal survey conducted every two years since 2010 by the institute of social science survey at peking university (xie & hu, 2014) . the cfps covers 95% of the chinese population in 25 provinces, providing extensive individual-and familylevel economic and social life information. the data from cfps has been validated and used for research in entrepreneurship (barnett et al., 2019) and other fields (hou et al., 2020; sun et al., 2020) . the survey, first conducted in 2010, had three follow-up waves in 2012, 2014, and 2016. our study used data from the 2014 and 2016 waves, which started including variables on internet activities. the 2014 survey contains 37,147 observations from 13,946 families. we matched the samples in 2014 and 2016 through a unique identifier of the respondents. as our study focuses on the transition of an individual to an entrepreneur, we excluded respondents who had entrepreneurial entry, and our final study sample had 18,873 observations. entrepreneurial entry. the cpfs survey followed existing literature to operationalize entrepreneurial entry, an individual's entry into entrepreneurship, by whether (s)he started a business or became selfemployed (barnett et al., 2019; eesley & wang, 2017) . accordingly, in the study, entrepreneurial entry refers to whether the respondents became entrepreneurs within the two years between the 2014 and 2016 surveys. specifically, the cpfs surveys had a multiple choice question on employment information, where participants chose their current employment status among: (a) agricultural work for your family, (b) agricultural work for other families, (c) employed, (d) individual/private business/other self-employment, and (e) non-agricultural casual workers. we used option d to operationalize entrepreneurial entry, following barnett et al. (2019) . if the respondent did not choose option d in year 2014 but chose option d in year 2016, (s)he transitioned to self-employment in those two years, and we dummy coded this individual 1 on entrepreneurial entry. social media use. a primary use of social media on the internet is socializing (bhimani et al., 2019; hu et al., 2018) . social media is the main online platform where people connect to each other and share information (bahri et al., 2018) . the 2014 cpfs survey measured social media use by asking, "in general, how frequently do you use the internet to socialize?". the respondents selected an option from the following: (1) everyday, (2) 3-4 times per week, (3) 1-2 times per week, (4) 2-3 times per month, (5) once per month, (6) once per a few months, and (7) never. as the scale was inverted, we reverse recoded it as 8 minus the selected option to obtain the measure of social media use. offline social network. offline social network refers to an individual's network of associates in the real world. scholars have used a variety of measures to assess the social network of an individual, including the cost of maintaining the relationship (du et al., 2015; lei et al., 2015) . in china, the context of our study, a social network is composed primarily of family, friends, and close acquaintances (barnett et al., 2019) . an important means of maintaining such relationships is through exchanging gifts during important festivals, wedding and funeral ceremonies, and other occasions. thus, scholars have used gift expenses and receipts in the previous year to assess social networks in china (barnett et al., 2019; lei et al., 2015) . we focused only on expenses incurred on gifts as the cost of maintaining an offline social network. hence, we operationalized offline social networks by the question on "expenditure on gifts for social relations in the past 12 months" from the 2014 cpfs survey. given that the expenditure is an amount, we transformed it using its natural log (ln (expenditure + 1)) (lei et al., 2015) . trust propensity. following the guidance of previous studies (chen et al., 2015; volland, 2017) , the cpfs survey assessed trust propensity by a single item scale that asked the extent to which a respondent trusts others. the respondents indicated their preference on a 0-10 scale. the data for trust propensity is from the 2014 survey. controls. in statistical analysis, we controlled for respondent demographics such as gender, age, and education. as age can correlate to people's resource availability, experience, and willingness to assume risk in a nonlinear fashion, we followed prior research to include the squared term of age as a control variable (belda & cabrer-borrás, 2018) . given the possibility of personal and family income influencing an individual's ability to finance a start-up (cetindamar et al., 2012; edelman & yli-renko, 2010) , we included it as a control variable in the analysis. all control variables are from the 2014 survey. we report descriptive statistics along with correlations among the study variables in table 1 . table 1 shows there is significant correlation among study variables, with most of the correlation coefficients below 0.40. the negative correlation between age and social media use, at 0.58, is the only exception. given the reported correlation among study variables, we rule out the possibility of multicollinearity in the sample. we further confirmed our inference by calculating variance inflation factors (vif), which were well below the threshold level of 10 with the highest vif being 1.94. w. wang, et al. technological forecasting & social change 161 (2020) 120337 we used stata and spss to test our hypotheses. in the regression models, we used ordinary least squares regression to predict offline social network and logit regression to predict entrepreneurial entry. we report the results of hypothesis testing in table 2 . in the table, model 1 shows the impact of social media use on offline social network. the regression coefficient suggests that social media use has a positive and significant (β=0.039, p<0.01) influence on the offline social network consistent with hypothesis h1. thus, it provides support for h1. in table 2 , models 2 and 3 provide support for hypotheses h2 and h3. the results of model 2 show the main effect of social media use on entrepreneurial entry is significant (β=0.050, p<0.05), thus providing support for h2. in model 3, when we add offline social network, the coefficient of social media use decreases (β=0.047, p<0.05) and the coefficient of offline social network becomes significant (β=0.084, p<0.05). meanwhile, the chi-squared statistics suggest that the model improved significantly (δχ 2 =6.04, p<0.05). the results offer preliminary support for hypothesis h3 (baron & kenny, 1986) . we further confirm h3 by using the bootstrapping method due to its inherent advantages (hayes, 2013; kenny & judd, 2014; preacher & hayes, 2008) over the technique of baron and kenny (1986) . we apply bootstrapping with model 4 in spss process (hayes, 2013) . with 5000 bootstrapping samples, the results show that social media use has an indirect effect on entrepreneurial entry (β=0.0033, 95% confidence interval: 0.0008-0.0065) while the direct effect is also significant (β=0.0465, 95% confidence interval: 0.0066-0.0864). thus, the results support hypothesis h3. the moderating effect of trust propensity is also reported in model 5 of table 2 . in the table, the interaction of social media use and trust propensity is significant and negative (β=-0.017, p<0.05) along with a significant change from model 4 to model 5 (δχ 2 =4.66, p<0.05). this notes: n refers to the sample size. ⁎ p < 0.10; ⁎⁎ p < 0.05; ⁎⁎⁎ p < 0.01. notes: n refers to the sample size. standard errors in parentheses. ⁎ p < 0.10, ⁎⁎ p < 0.05, ⁎⁎⁎ p < 0.01 w. wang, et al. technological forecasting & social change 161 (2020) 120337 provides support for hypothesis h4. in fig. 2 , we depict the moderating effects, where social media use of high trust propensity individuals has a weaker impact on entrepreneurial entry. additionally, model 6 displays the results for all study variables, suggesting it is robust. we performed additional robustness checks by using alternative measurements for social media use and trust propensity. first, as social media is a communication channel on the internet, we used an item measuring the degree of importance of the internet as a communication channel as an alternative measure of social media use. the results of the analysis with alternative measures are in table 3 and are largely consistent with our original analysis except for the moderating effect of trust propensity. second, because a high trust propensity individual is more likely to trust others, and vice-versa for a low trust propensity individual, we used an alternative dichotomous measure of whether people are mostly trustworthy or cautious when getting along with others for trust propensity. the results of the analysis with the alternative measure of trust propensity are reported in table 4 and offer support for the moderating effect of trust propensity. we assessed endogeneity issues using the two-stage least squares instrumental variables (2sls-iv) approach. there is a possibility that social media use may not be fully exogenous and could be under the influence of certain unobservable characteristics that also influence offline social network. following prior literature (semadeni et al., notes: standard errors in parentheses. the sample size n varies because less missing values on the alternative measurement. social media use is measured with the item "how important is the internet as a communication path?" the answer is scored on a 1-5 scale from "very unimportant" to "very important". ⁎ p < 0.10, ⁎⁎ p < 0.05, ⁎⁎⁎ p < 0.01 w. wang, et al. technological forecasting & social change 161 (2020) 120337 2014), we treated social media use as an endogenous variable and reassessed our results on offline social network. in our model, we identified two instruments to investigate potential endogeneity issues. to investigate endogeneity, we used two instrumental variables (iv): (1) online work and (2) online entertainment. we operationalized the two ivs through the frequency of using the internet to work and the frequency of using the internet to entertain, respectively. first, as people can work or entertain on social media, we suggest that these two ivs are correlated with social media use and satisfy the correlation with the endogenous variable. second, the ivs should not be directly correlated with the error terms of estimations on offline social network because learning and entertainment are not the direct social activity but instead the users aim to learn and to entertain. hence, online learning and entertainment should not directly impact offline social network in a strong manner. empirically, in the first stage result in model 1, the results of the instruments on the potentially endogenous variable are, by and large, significant, suggesting the relevance of the instruments. also, the results of cragg-donald f-statistics show that the instruments are strong (f=9342.66). moreover, the results of overidentification estimations suggest that the instruments are exogenous (sargan statistics p=0.55) (semadeni et al., 2014) . thus, the results statistically suggest that both ivs satisfy the conditions of qualifications as ivs. last but not least, both durbin (p<0.01) and wu-hausman (p<0.01) tests confirm the endogeneity. the results of the iv estimation, reported in table 5 , are similar to the previous result. the outcomes of the two-stage estimations are consistent with the regression outcomes in the previous analysis. these outcomes empirically confirm that social media use positively affects offline social network, even after considering the endogeneity issues. despite social media being dominated by weak ties and the substantial noise of false, inaccurate or even fake information, our findings reveal that individuals with higher social media use tend to conduct entrepreneurial entry. it is consistent with the positive benefits of higher social capital or a larger social network (galkina & chetty, 2015; johanson & vahlne, 2009 ). our results suggest that higher social media use indicates a higher probability of a larger social media (online) network, which provides higher social capital that benefits entrepreneurial entry. our findings that the positive influence of offline social network on entrepreneurial entry is also due to the network effect extends the research on the offline social networks of entrepreneurs (chell & baines, 2000; dubini & aldrich, 1991; klyver & foley, 2012) . the literature suggests that social networks influence entrepreneurs' decision making and actions, and entrepreneurs require a strong social network to succeed in the entrepreneurial process (jenssen & koenig, 2002; witt, 2004) . our findings, using instrumental variable analysis, suggest that higher social media use enhances individuals' offline social networks. this finding is consistent with past evidence that users often used social networking sites to connect with family and friends (subrahmanyam et al., 2008) . unlike past studies that simply indicate an overlap between social media and offline network associates (mcmillan and morrison (2006) ), our instrumental variable analysis helps to establish the impact of online networks on offline networks, suggesting social media enhances offline networks and subsequently entrepreneurial entry. specifying mediation models is essential to the advancement of research domains and hence this study helps research on social media in entrepreneurship to further develop beyond its nascent stage (yu et al., 2018) . finally, our finding that trust propensity moderates the influence of social media use on individuals' entrepreneurial entry suggests that social media, which is dominated by weak ties and substantial noise from false, inaccurate or even fake information, is in fact beneficial to entrepreneurial entry. such benefit may be smaller for people who are notes: standard errors in parentheses. the sample size n varies because less missing values on the alternative measurement. trust propensity is measured with the item "in general, do you think that most people are trustworthy, or it is better to take greater caution when getting along with other people?". we code 1 for the answer "most people are trustworthy" and 0 for "the greater caution, the better". ⁎ p < 0.10, ⁎⁎ p < 0.05, ⁎⁎⁎ p < 0.01 table 5 the results of instrumental variable analysis (n = 18,873). more trusting. specifically, our findings indicate that an individual's trust propensity plays a critical role in their use of social media and the outcome they experience. our results have important implications for practice. first, as social media can help individuals build networks that help with business resources and information both locally and remotely, people can target social media to help refine and validate entrepreneurial ideas and secure much needed resources for entrepreneurial launch. second, as individuals' trust propensity enhances or hinders the positive role of social media on entrepreneurial entry, potential entrepreneurs may specifically aim to apply more caution to their online contacts to obtain higher benefit from social media use for entrepreneurial entry. finally, given the role of social media in entrepreneurship, social media platforms may more specifically promote and facilitate networking of individuals to increase the level of entrepreneurial activity that can be enhanced via social media. our study has limitations and offers opportunity for further inquiry. first, theoretically, we used social network theory, and another theoretical framework may identify other possible mechanisms. for instance, an identification based theory may argue that social media use's influence on entrepreneurial entry could also be attributed to identity change in individuals due to network associates as theorized by mahto and mcdowell (2018) . however, given the lack of information about network associates on social media, identity change may be a remote probability. empirically, we operationalized offline social networks using gift expenses that serve as a proxy for the offline social network. the large nationally representative survey we used contained only expenditure on family relationships, yet individuals also need to expend similarly on gifts, eating out, etc. to maintain relationships with work acquaintances, partners, clients, former school mates, distant relatives, etc. hence, the expenditure on other relationships may mirror the expenditure on family relationships captured by this survey. we acknowledge these limitations and call for future research to search for alternative measures of social networks in other datasets. third, we caution readers in generalizing the findings of our study outside of china due to the study sample. china is different from other countries in terms of its cultural, legal, and social environment, which may affect respondent behavior on social media and entrepreneurial launch. thus, we suggest scholars empirically examine our model in other cultures. our study addresses the effect of social media on the entrepreneurship process, especially the pre-launch phase, by assessing the link between social media use and entrepreneurial entry. we use social capital theory to explain the link between social media use and entrepreneurial entry. we further argue that this relationship is contingent on individuals' trust propensity. thus, individuals with low trust propensity are more likely to benefit from social media use for entrepreneurial entry compared to individuals with high trust propensity. we also find that social media use strengthens individuals' offline social networks, which further aids their entrepreneurial entry. in conclusion, a key message is that social media can help individuals' transition to entrepreneurship. and practice, journal of applied psychology, journal of small business management, and family business review, etc. raj serves on editorial review boards of family business review and international entrepreneurship and management journal. he is also an associate editor of the journal of small business strategy and journal of small business management. wei deng is a phd candidate major in organization management at school of management, xi'an jiaotong university. his research interests include social entrepreneurship, entrepreneurial bricolage, and female entrepreneurship. his research has been published in journal of business research, asia pacific journal of management, and others. stephen x. zhang is an associate professor of entrepreneurship and innovation at the university of adelaide. he 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(who), concludes that child maltreatment is a global concern calling for a multi sectoral interdisciplinary approach. school professionals, such as social workers, teachers, and health care professionals are in positions to discover and report maltreatment enabling social workers to intervene. however, a variety of reports reveal an evident gap between incidences and frequency of number of cases reported. a review of relevant research indicates that the problem of “not reporting” suggests that moral conflicts are activated in the process of decision-making. the aim was to gain a deeper understanding of school professionals’ experiences of reporting suspected neglect and abuse to the social welfare board. in a mixed method approach 32 school professionals, such as teachers, social workers, nurses and psychologists participated in interviews and responded to questionnaires. findings from the qualitative content analysis were compared to the quantitative analysis in a meta-analysis. moral conflicts occur when faced with making decisions about how to best deal with a child’s situation. thoughts about the child’s best interest and relationship with his/her parents as well as the informants´ own safety, were central. the comparative metaanalysis of both data sets revealed these conflicts commence with a moral sensitivity of possible negative consequences for the child. moral sensitivity can be viewed as a “good” personal attribute, it paradoxically might lead to moral stress despite an open ethical climate. based on the results of this study, further research on the interpersonal aspects of dealing with moral conflicts involved in reporting suspected child abuse is indicated. protection services to intervene in cases of maltreatment a "multi sectoral approach" is required. there are many official sectors of professionals who are by law entrusted to observe and report any suspected childhood abuse and neglect. school is the primary sector where professionals have daily contact with pupils, enabling early detection. however, a discrepancy between the number of children exposed to neglect and abuse and the number of officially reported cases has been detected. the question why professionals who are by law delegated to report suspected child abuse and neglect fail to do this needs to be explored. if the professionals in a school system have an accumulated knowledge to be able to identify child maltreatment and competence there must be a dimension that has yet to be explored. in this study, a focus is placed on the ethical nature of reporting suspected child abuse. from a relational ethical perspective, moral conflicts occur in situations in which one person has the authority to make decisions for another; for example, persons who are by legislation judged not to be competent or have the capacity to understand the nature and consequences of decisions that are made on their behalf. although a country may have routines that clearly regulates the responsibility and directions in responding to suspected child maltreatment, it appears that the "human" factor has not adequately been attended to in relevant research of child maltreatment. a personal awareness of how decisions and consequences of actions taken can be conceptualized as moral sensitivity; that one's decision may lead to actions that may have negative outcomes for another person (lützén, 2006) . in this current study we explore school professionals' experiences and deliberations in situation when they suspected child abuse and neglect from an ethical perspective. a mixed method approach included combining qualitative and quantitative data-collection methods, which will be further developed in following sections. the united nations convention on the rights of the child (un, 1989) was developed in recognition of the claim that "the child, for the full and harmonious development of his or her personality, should grow up in a family environment, in an atmosphere of happiness, love and understanding". however, this is not always the case. according to who (2016) a quarter of all adults have been physically abused as children. moreover, worldwide inequality in children's circumstances results in child maltreatment (gilbert et al., 2012) including all forms of physical and emotional ill-treatment (who, 2016) . even national inequality plays a vital role for the risk of maltreatment (bywaters, 2015) . lundén (2011) identifies four areas of maltreatment, namely, "emotional unavailability in the parent-child relation, emotional neglect, physical neglect, and abuse" (pp. 33-34) . according to the annual report for 2016 from united nations children's fund (unicef) child protection systems existed in 139 countries according (unicef, 2017) and national mandatory legislature for reporting child maltreatment exists in many countries. this was also the case in the usa (steen & duran, 2014) , australia, and canada (mathews & kenny, 2008) as well as most european countries according to the european union agency for fundamental rights (fra, 2016) . wiklund (2006) observed that neglect and physical abuse was less frequently reported in sweden in comparison anglo-saxon countries. the swedish national board of health (snbh) estimated reports about maltreatment in 154/1000 children up to 17 years old during 2018. of these 73% were 6-17 years old and approximately 75% were mandatory reports. the reports often concerned the same child (mean 1.9 reports per child) (snbh, 2019). however, according to cocozza, gustafsson, and sydsjo (2007) notifications in sweden represent the tip of the iceberg, which is also recognized in other studies conducted in sweden (svensson, andershed, & janson, 2015; talsma et al., 2015) as well as in other countries (feng, huang, & wang, 2010; goebbels, nicholson, walsh, & de vries, 2008; toros & tiirik, 2016) . these documented facts indicate that children's well-being may also be seriously affected leading to lifelong consequences. research and international publications clearly address the health, social and, judicial aspects of child abuse and the need for early detection and interventions. what seems to be lacking is a discourse, grounded in empirical research, on the ethical aspects of reporting suspected child abuses. in many related studies, other concepts analogous to an ethical framework were used. meyers and cornille (2002) for example, found that "emotional distress" and "compassion fatigue" were commonly experienced by professionals engaged in child protection. similarly conrad and kellar-guenther (2006) , found that approximately half of child-protection staff suffered from compassion fatigue. megan-jane johnstone, a scholar well-known for her work on bio-ethics, pointed out two decades ago, that the ethical aspect of child abuse has to date not received appropriate attention. according to johnstone, "child abuse constitutes a significant moral problem and as such, demands a substantial moral response" (1999, p. 192) . in a publication (20 years later), johnstone maintained that despite legislation, reporting suspected child abuse to a relevant authority is inconsistent in many countries (johnstone, 2019, pp. 352-355) . she states that "reliable data is needed" in order to produce reliable interventions (p. 354), in agreement with johnstone's standpoint that obstructions to mandatory reporting of child abuse has not given attention to the ethical aspects, supports the need for a research design that focuses on how school professionals describe their personal involvement-feelings and actions taken-in cases of suspected maltreatment-and how they have dealt with their duty to report. the purpose of this present study was to investigate school professionals' experiences of dealing with suspected child abuse and neglect-and how they think, reason and act. consequently, the following overarching research questions guided the study design: 1. what concrete incidents of reporting suspected child abuse stand out as particularly difficult for school professionals? 2. what are school professionals' thoughts and reasoning when they decide to report or not to report suspected child abuse? 3. how can their concerns and actions taken be described as morally challenging? the concept of moral sensitivity, comprising, feeling, benevolence and genuineness, as described by one of the co-authors of this study, provided a theoretical framework for the study (lützén et al., 1995) . briefly, the concept of moral sensitivity can historically be traced to the idea of "moral sense" introduced by the philosophers hutcheson and shaftesbury in the eighteenth century. moral sense was viewed as an intuitive faculty that was aroused by a person-s perception of a situation as opposed to rationalist theory of ethics, that objectivity, rational and principled thinking were the only valid ways of knowing what actions to take. hume (1990) , in contrast, upheld the idea that feelings are required in being able to distinguish between "virtuous" and "vicious" actions. in other words, subjectivity, and a feeling for humanity was the main components of moral sense as opposed to rational and principlebased judgment. more current, the interpersonal approach to understanding morality, as a subjective awareness of a person's vulnerability can be linked to a phenomenological approach to ethics. for example, tymeiniecka (1986), introduced the moral sense in her work on morality from the standpoint of benevolence, intersubjectivity and context. these dimensions were also identified using the grounded theory research method in a psychiatric health care context in which patients had limited freedom in their own care (lützén, nordin & brolin, 1994) . timans, wouters and heilbron (2019) recommend the use of a mixed-method research approach in social science. in agreement with these authors, the intention of this study design was to contribute to an understanding of the moral dimension of how a selected group of participants think and act when they suspected child abuse and neglect. the mixed method design also gave a dynamic option to expand the scope and thereby improved the analytic power of the study (levitt et al., 2018; timans et al., 2019) . the design consisted of three components: (1) purposeful selections of participants. (2) qualitative and quantitative data are collected simultaneously and analyzed, while the former data's focus is on individual experience and the latter on group's focus on means of responses relative to report child abuse and neglect. (3) comparative analysis of both research approaches intended to validate the result of the study. narrative interviews can capture emotional elements of significance, whereas, quantitative data, such as the scales that were used in this study could be compared with the qualitative analysis and lead to a meta-analysis. thus, the mixed method design required researchers who could contribute to the analysis of data with their knowledge namely ethics, nursing, social work and psychology. the swedish social services act (sfs, 2001:453) legislates that municipalities are responsible for ensuring a good and secure childhood and obliged to intervene in cases of child abuse and neglect. the municipalities through social workers, have the responsibility to intervene in cases of child abuse and neglect. mandatory reporting to social welfare board about children at risk concerns everyone working with children, including preschool, primary and secondary school. according to the swedish education act (sfs, 2010:800) school attendance is mandatory for children from age 6 to 16 years. child corporal punishment is prohibited by swedish parental code (sfs, 1949:381) . in january 2020 the united nations convention on the rights of the child was incorporated as swedish law (2018, p. 1197). the study was performed within the primary school system in sweden. all schools in sweden follow government legislation as to infrastructure, level of competence of professional staff and curriculum. the swedish education act (sfs, 2010:800) advocates a holistic view on educational goals as well as promotes social development and health for all pupils. consequently, all schools are obliged to provide access to inter-professional schoolhealth teams consisting of the school principal, nurse and doctor as well as social workers employed as counsellors. also psychologists, and teachers with pedagogical competence in guiding children with learning difficulties are a part of the school-health team. the purposeful sampling was aimed at including participants with various occupations as well as a broad variation of schools within a geographic area. six primary schools in the middle of sweden, in rural area (n = 1), small town (n = 2) and big city (n = 3) were included, representing both public and private regime. the principal from each of the six included schools approved and distributed information about this study to all personnel. thirty-two persons: 27 women and five men volunteered, one of them did not answer the questionnaire (table 1 ). the school health team (n = 18) was represented by principals, nurses, counsellors and psychologists. the teaching staff (n = 16) was represented by teachers and auxiliary staff. face-to-face interviews were performed by combining two interview techniques, the narrative interview (riessman, 2008) and the "think-aloud" method (drennan, 2003) . the purpose of the narrative interviews was to gain knowledge of the participants' experience of concrete situations when they suspected abuse and neglect of a pupil. the "think aloud" interview technique was chosen to generate new perspectives, while responding to the three questionnaires. the interviews were conducted by the first and second author. an interview guide was used to promote stability in data collected (graneheim & lundman, 2004) . first, some background questions were asked about their professional role and experiences, followed by an open request: "please tell about a situation in which you considered to report child abuse or neglect to social services". the understanding of the decision-making process was deepened using follow-up questions such as "what happened then?" "how did you react on that?" to clarify details in the narratives. during the course of the data collection, follow up questions were supported by insights from earlier interviews. when the narrative part was exhausted the questionnaires described below were introduced with the request: "please think aloud when you respond to the questions in the questionnaires". the interviews lasted approximately 1 h and were recorded and thereafter transcribed verbatim. in order to place a focus on the moral dimension of reporting child abuse and neglect, questionnaires about moral sensitivity, moral stress and ethical climate, were chosen. all three instruments have been extensively used in international studies separately or together: the moral sensitivity questionnaire (msq) moral sensitivity in this study is conceptualized as a genuine concern for the welfare of others who are in vulnerable situations along with an awareness of the consequences of one's actions (lützén, 1993) . moral sensitivity is stimulated by observations and thoughts that are of moral relevance. consequently, moral sensitivity produces feelings that have an evaluative function as to the consequence of one's actions. the original moral sensitivity questionnaire consisted of 30 items was developed by lützén (1993) and later modified by reducing the number of items to nine (lutzen, dahlqvist, eriksson, & norberg, 2006) . work related moral stress questionnaire (wrms), was developed by lützén et al., and is based on the supposition that a conflict between two or more alternative actions to take, causes moral stress. for instance, in situations where one person has a commitment to do what is best for the well-being of another, can lead to moral stress. an example is when a person perceives that the morally "right" thing to do is circumscribed by practical realities (lutzen, blom, ewalds-kvist, & winch, 2010) . the questionnaire contained nine statements regarding stress the participants may have experienced when concerned about the welfare of a pupil. the ethical climate survey (ecs) was originally developed by olson (1998) to measure how nurses perceive the ethical climate of their workplace and translated into swedish by lutzen et al. (2010) . the questionnaire consists of 26 items. for our study, the questionnaires were all adapted to the school environment, i.e. mostly by changing the word "patient" to "school pupil", leading to msq-s, wrms-s, ecs-s. when responding to the questionnaires the participants were asked to think out loud, as shown in one response to a question in the moral stress questionnaire: my ability to perceive pupils' needs …"yes, that can be the case, so i'll put a 5 there". in addition, the participants completed requests for information about their occupation, age and education. the think-aloud interviews provided information about how the questions were interpreted. the transcriptions were analyzed using the respond problem matrix considering five types of problems that respondents often experience when answering questions in a survey: lexical, temporal, logical, omission/exclusion, and/or computational problem (conrad & blair, 1996) . none of these problems were identified. on the contrary the participants expressed the questions as relevant and easy to understand. the transcribed narrative parts of the interviews were subjected to qualitative content analysis inspired by graneheim and lundman (2004) , to show the logic in how content is abstracted, interpreted, and connected to the aim. at first, the transcriptions were read as a whole and then divided into meaning units i.e. parts in the text relating to the same central meaning. these meaning units were condensed i.e. shortened while still maintaining the core meaning. these units were coded and analyzed according to similarities and differences resulting into categories. the analysis was performed by first author in collaboration with second author. the first author was experienced in this specific method of qualitative content analysis (forsner, nilsson, finnstrom, & morelius, 2016) . to strengthen trustworthiness, the analysis was discussed between authors. furthermore, to provide transparency in the analytical process and credibility of the results, quotations from the transcribed text are provided. the transcribed interview citations were translated into english, which means that we did not correct any grammatical errors. the results were computed with ibm, spss software, versions 24. the participants' responses to the questionnaires were subjected to descriptive statistics, principal component analysis with several high communalities (above .80) and all loading markers were set to be above .40. the occurrence of several high loading markers above .80 compensate for a smaller sample size. in agreement, a thumb rule of a ratio of 10 cases to 1 independent variable was employed in our research (maccallum, widaman, zhang, & hong, 1999) . to assure the strength of the components, each component was reliability-tested by cronbach alpha (nunnally, 1994) . for linear regression analysis this ratio is also appropriate (tabachnik & fidell, 1989, p. 129 ; table 2 , f2 = .61). by the latter method we answered the questions which predictors are valid for the moral dimensions. spearman correlations and one-sample t-test were likewise applied when considered correct. the methods were chosen to explore relationships among variables in one sample, while keeping the confidentiality principle intact for the participants. to fulfill the mixed-method design, both data sets was subjected to comparative meta-analysis. the narrative analysis was interpreted in light of the statistic findings in a comparative analysis. the emotional elements of significance were captured in narrative data whereas, quantitative data, such as the scales could be compared with the qualitative analysis and lead to a meta-analysis. the benefits of the study were considered to outweigh any possible risk for the participants. in line with the declaration of helsinki, participants were assured of their rights of voluntary participation and confidentiality. participants were assured that they could talk about their experiences without revealing identity of the persons mentioned, and that all data was going to be handle with caution to protect from identification. the participants were offered counselling if reflections on situations caused bad memories. the study was approved by the regional ethical board in uppsala, sweden (2014/439). the participants described situations in which they had considered whether to report or not when they encountered pupils who they suspected were exposed to abuse and/or neglect. most of them recalled more than one example of abuse and neglect, which resulted in a total of 63 cases. the participants went through three phases when facing child maltreatment: (a) awareness (b) deliberation and (c) aftermath. their experiences during the phases are described in seven categories (a) feeling concerned and worrying about the child, (b) to report or not; the best for the child; maintaining the relationship with the child as well as with the parents; (c) negative consequences from actions; and longstanding concerns. awareness appeared as feeling concerned and worrying about the child. signs of neglect, psychological or physical, or of physical or sexual abuse raised concerns. neglect was detected when the participants observed parental shortcomings such as lack of bonding, inability to provide adequate clothing, nutrition and security as one of the participants told: "and he had to cook his own food". alcohol and other drugs came up as problems among the older children. also unauthorized school absences were recurring problems and made the participants feel concerned about the child as exemplified in this quote. "we had no idea about their home situation, but it was through the younger girl, aged 11 years, that /…/ she cried and cried and just wanted to go home and the older girl, aged 15 years, also stayed at home. but she showed no other signs". these signs made the participants aware of possible abuse and/or neglect. awareness also was demonstrated in experiences when worrying about the child's wellbeing. sensing that something wasn't all right with the child was 'exemplified in this quote: "so everything he said was worrying me". these kinds of episodes made the participants aware of possible maltreatment. when deliberating whether to report or not and what was the best for the child appeared to conflict with the conviction of the importance of maintaining the relationship with the child as well as with the parents. difficulties in determining what was best for the child were reported: "but this is really hard, how to think what is best for the child". sometimes, worries about the child were vague and reporting seemed too intrusive: "we were not sure if it was a child who was a mythomaniac or if it was true". some said that a negative experience from a previous situation had given them doubts that reporting would be beneficial to the child. also, the participants felt that helping the child themselves rather than reporting was the best thing to do as one of the participants recalled: "his mother was not to count on /…/ she wants him all well but she doesn't have the ability/…/ but there we have always tried to compensate". in this as well as other cases, the participants said that they were against reporting and didn't trust that the child would benefit from notifying the social service. also, participants expressed a feeling that reporting could further aggravate the situation for the child as reflected in the following comments: "then unfortunately it's like this, we report and report. no, there's no intervention. everything has to be voluntary and then we see the children feeling bad and maltreated but no change in spite of the report from us. i can give several examples. and you lose, you lose motivation maybe; yes, you know, you think twice before you report". however, others had no hesitations, but to act and report promptly as told by one of the participants "but if someone is maltreated and is abused for different reasons then you have to intervene no matter what". the latter was often the case when abuse was evident. the participant wanted to maintain a relationship with the child and/or the child's family and feared that notification might disrupt the relationship. the relationships with parents were emphasized as important in terms of being able to help the child. the interviews uncovered the risk of damaging parents' trust when reporting maltreatment. the participants gave examples when parents had expressed disappointment and/or anger when they had reported child abuse and neglect to authorities. sometimes the relationship with the parents even became hostile as told by one teacher: "that mom, she still hates me more than anything". by contrast, some participants described the opposite, talking about a deepened relationship with the family as well as the child. also deliberating as to whether to report or not report, the participants told about sharing their doubts and seeking support from colleagues, school health team and the principal. sometimes these discussions had led to reports and other times to a decision to not report to the social services. both situations were experienced as strenuous. in the interviews the aftermath of negative consequences from actions and longstanding concerns appeared to strongly influence the participants' experience. reporting to authorities could mean the loss of the child's trust. others told about being confronted by children who were disappointed and angry when contacted by the social services. still others told about children being forbidden to have any further contact. not attending the lessons with the teacher responsible for notification or as told by this school nurse: "the girl was forbidden to come to me and then when her sibling started at school the sibling was also not allowed to visit me". threats and aggressive confrontations from the parents were frequently narrated, exemplified by this participant who received a threatening telephone call from a dad: "do you know what kind of weapons i've got here?" even examples of threats to the participants' children were reported. also being questioned by their colleagues was described "i got a lot of crap" and that colleagues expressed conflicting opinions without being familiar with the facts. frustration about dysfunctional collaboration with the social services were frequently expressed as exemplified in this quote: "i was called to the social welfare office /…/ and this, it was about that the dad could argue and blast me down /…/ and the principal gave me support but i got no support from the social workers". the fact that the participants' experiences led to longstanding concerns were obvious. some of stories originated far back, one as far as twenty years ago. "but for sure it's still with me /…/ i think a lot about how it is for the boy /…/ if he has any contact with his dad, whether it ended, whether it, like, got better". examples of this came up both when their concerns for a child had led to a report to the social services and in cases without notification or when the participant did not know whether someone else had reported the case. these longstanding concerns seemed to affect the participants both emotionally and morally. the number of questions in each employed instrument pertaining to work-related moral stress, the ethical climate and moral sensitivity, are described in table 1 . also, the questionnaire's internal reliability is denoted in forms of cronbach's alpha in table 1 . the work-related moral stress was explained by means of a significant linear regression model (f[2.29] = 8.906, p = .001). it showed that 38% of the total variance in the work-related moral stress variable was explained by the ethical climate and professionals' moral sensitivity. when analyzing an individual explanatory factor's significance, it was found that the ethical climate was not a significant explanatory variable to work-related moral stress. in contrast, moral sensitivity contributed to the model uniquely and significantly by explaining 38% of the variance in workrelated moral stress according to the squared part correlation ( table 2) . the participants' responses about the school's ethical climate were reduced to four reliability-tested clusters to find out whether different clusters of the three questionnaires complemented each other. the participants' opinions along with descriptive data as well as correlations between the clusters within the school's ethical climate as well as with school professionals' experience of work-related moral stress are depicted (table 3) . the participants' work-related moral stress was reduced by pca and yielded two components. the components' correlations with moral sensitivity in the school environment are depicted in table 4 . the participants' moral sensitivity is depicted in table 5 . also correlations with work-related moral stress in school are denoted (table 5) . to furthermore understand the moral challenges when suspecting child abuse and neglect, the narrative data was interpreted in light of the statistic findings. thus, expressions such as "felt concern for the child" and "to do what is best" builds on a cognitive awareness and moral motivation to do what one feels is right. the participants in our study said that their hesitation to report was in concern of the negative consequences a report may have for the child. the participants assessed their ability to perceive the needs, and to identify pupils who are in distress, as satisfactory. their awareness of the conflict between the obligation to act and the moral awareness of the possibility of doing harm, appears to be the main conflict in this study. the interpretation of the participants' experiences can be viewed as a decision-making process, not necessarily linear, that is initiated by feelings of concern for the welfare of the child (see fig. 1 ). these feelings initiated a cognitive awareness of the consequences of decisions that will have an immediate or future impact on the child. the participants, in this study, expressed a sense of personal vulnerability; being exposed to threats and being questioned by colleagues and social service as to their observations of suspected child abuse. in some cases, the participants' concern for the welfare of the child and lack of parental care seemed to lead to a change in their professional role, substituting their professional role for a proxy parental role. the aim of this study was to gain a deeper understanding of school professionals experience when they suspect child abuse and neglect and how they think, reason and act. the findings of this study cast light on the moral complexity involved in the course of decision-making process whether to report-or not to report-child abuse and neglect to social services. an awareness of the child's dependency on each decision that is made, places a pressure on the professional to make the right decision. the situations that were described by the participants clearly substantiates johnstone's claim that child abuse is a significant moral issue. the words used by the participants in their narratives highlight the feeling dimension of moral sensitivity that helps a person in "knowing" what is at stake in the decision-making process (lützén, 1993) . the participants were worried that reporting to social services would damage their relationship with the child, by betraying the child's confidence and thus affecting the possibility to help the child. similar findings came up in focus groups with swedish school nurses (kraft & eriksson, 2015) . the school professional's awareness of a child's vulnerability and of how their decision, to report or not report, can impact on the relationship to his or her parents can be interpreted as the cognitive dimension of moral sensitivity (lutzen et al., 2010) . lundén (2011) found that the relationship to parents as well as support from social services influence the tendency to report suspected abuse. it is possible that this was also the case in the current study. collaboration with social services, as well as support from colleagues, were perceived as important for the motivation to report suspected child abuse. also, contrary negative experiences from collaboration with social services made school professionals disinclined to report long afterwards. the findings of feng, chen, fetzer, feng, and lin (2012) also indicate that once teachers know about child abuse, their intention to report is most influenced by factors in their employing school. social workers need to be aware of the importance of trusting collaboration with school professionals to facilitate their intention to report, without hesitation, every noticed sign of maltreatment and abuse. the participants' responses to the questionnaires show that work-related moral stress was explained by moral sensitivity and not by the ethical climate as the result of earlier research (lutzen et al., 2010) . the participant's satisfaction with ethical climate may have contributed to the fact that thoughts of leaving their employment were not prominent. available support and resources for ethical concerns influence the ability to endure higher levels of moral stress and still be satisfied with the job situation (ulrich et al., 2007) . moreover, high "compassion satisfaction", i.e., a good feeling related to the ability to help others, correlated with fewer burnout symptoms (conrad & kellar-guenther, 2006) . it is possible that this was also the case in the current study because the participants described engagement in teaching as well as in the pupils' well-being. kraft and eriksson (2015) found that school nurses' primary intention was to support maltreated children. this intention was also revealed in the narratives in the current study and may to some extent conflict with the intent to report. alvarez, kenny, donohue, and carpin (2004) argue that failure to report child maltreatment leaves hundreds of thousands of children and their families without the needed interventions and, furthermore, increases the risk of further maltreatment. furthermore, they say that the reason why professionals ignore the legal mandate to report abuse is their inability to recognize the signs, along with misunderstanding of the law and worries of negative consequences. yet, the findings of the current study, however, suggest that the interviewed school professionals were competent to identify signs of maltreatment in their pupils and that they understood the request of the law. apprehension of negative consequences to themselves, seemed to prohibit reporting, but most prominent barrier to reporting was fear of negative consequences for the child. from a quantitative standpoint the sample size, although normally distributed, is a limitation for generalization or external validity, however fulfilling the rule of thumb of 10 cases for each independent variable. as regards generalization or external validity to other groups, we suggest that future researchers seek a larger group, when realistic. presently, our methods were tailored for one undivided group to avoid compromising confidentiality by putting the participants at risk of identification. namely, maccallum et al. (1999) suggest that the minimum sample size depends upon the nature of the data itself, most remarkably on its 'strength'. strong data is data in which item communalities are consistently high, that components exhibit high loadings on a substantial number of items (at least three or four) and the number of factors is small. these criteria were satisfied. from a qualitative research standpoint the sample size and purposeful sampling is satisfactory (sandelowski, 1995; levitt et al., 2018) . however, one limitation might be that persons who volunteer to be interviewed might have had more negative experiences than those not participating, thus, biasing the findings. however, since the study aimed to specifically shed light on the participants' situations and particularly the ethical dimensions experience, the purposeful sampling was appropriate. the mixed-method design strengthened both data sampling as well as analyses (timans et al., 2019; levitt et al., 2018) . the study did shed light on the phenomenon from a variety of perspectives by inviting both teachers and school-team members including principals, nurses, counsellors and psychologists to participate in. another limitation with the study is that it is not possible to guarantee the principle of anonymity. thus, we have adopted the principle of confidentiality by not revealing details that make it possible to identify neither the participants nor the persons mentioned in the interviews. furthermore, face to face interviews might make the participants reluctant to share experiences casting an unkind light on their role in the situation. however we interpreted the fact that the participants disclosed situations when they didn't decide to report as an indication that the participants were honest when narrating about their experiences. in order for social workers to be able to utilize intervention methods, early detection of suspected child abuse and neglect to child protection services is essential. the purpose of this study was to investigate school professionals' experiences with perspectives from teachers, nurses and psychologists as well as social workers. we think that the findings also appear to be of importance for social workers responsible to investigate the situation and intervene in the child's best interest. foremost, they need insight into the situation for teachers and others who have daily contact with children and adolescents and have the professional knowledge to able detect early signs of abuse and/or neglect. moreover, a closer collaboration with school professionals may help to increase social workers' understanding of moral challenges when deliberating what is best for the child may result in the low frequency of reporting. since there is a proven gap between current maltreatment and reported cases social workers are not informed and are then unable to help, leaving the abused and neglected child without early appropriate interventions. our study revealed a chain of moral conflicts beginning with the school professionals' moral awareness of the negative consequences of reporting suspected child abuse and neglect would bring about. problematic interactions with social services, colleagues and parents seemed to serve as obstacles rather than as openings for collaboration. although moral sensitivity can be viewed as a good characteristic, it paradoxically leads to moral stress if the prime and dominant problem is not re-solved. an unexpected finding was that some of the participants, in their struggle to decide what to do, seemed to have a closer relationship with the child, hence on the brink of leaving their professional role. whether our interpretation of this finding is correct or not should be an imperative focus for further research. notwithstanding that this is a small study, further research on the relational and interactive aspects of dealing with moral aspects involved in reporting suspected child abuse is required. open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. why are professionals failing to initiate mandated reports of child maltreatment, and are there any empirically based training programs to assist professionals in the 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(reports about child maltreatment. national survey entryway into the child protection system: the impacts of child maltreatment reporting policies and reporting system structures föräldrabalken (swedish parental code) kap 6, 1 § socialtjänstlagen (swedish social act) skollag (swedish educational act) lag om förenta nationernas konvention om barnets rättigheter (law conserning convention on the rights of the child) a survey of swedish teachers' concerns for preschool children at risk of maltreatment using multivariate statistics facing suspected child abuse-what keeps swedish general practitioners from reporting to child protective services? scandinavian journal of primary health care mixed methods research: what it is and what it could be preschool teachers' perceptions about and experience with child abuse and neglect analecta husserliana yearbook of phenomenological research ethical climate, ethics stress, and the job satisfaction of nurses and social workers in the united states convention on the rights of the child. retrieved december 9 united nations children´s fund child maltreatment signs of child maltreatment. the extentand nature of referrals to swedish child welfare agencies acknowledgements open access funding provided by umea university. we would like to thank the participants of the study who generously shared their time and experiences. we express our gratitude to karin lundén for sharing her expertise about child maltreatment. grants from the afa insurance supported this research project. key: cord-034973-1yucjgp5 authors: burgason, kyle a. title: using loseke to examine the influence of laws, myths, and claims making on sex offenders’ socially constructed realities date: 2020-11-09 journal: sn soc sci doi: 10.1007/s43545-020-00005-5 sha: doc_id: 34973 cord_uid: 1yucjgp5 the realities surrounding sex offenders in the united states can often times be inundated with preconceived and even false certainties. a consequence of such misleading beliefs for sex offenders can be the creation of urban legends and myths that motivated individuals can use to back an agenda and that can bring unintended collateral damage creating false realities for offenders, their families, law enforcement, and the community. this study utilizes loseke’s lens to examine the socially constructed realities in which sex offenders in the united states are forced to live. the history of the treatment of sex offenders is detailed from colonial america through child sexual abuse panic of the 1980s and into the current cyber age. we review laws passed in the 1990s, through the first part of the new millennium, which fueled individuals’ fear of sex offenders. additionally, we explore how claims-makers use myths and socially constructed realities to create social problems for sex offenders, generate public fear and resentment, and pressure policy makers and legislatures to pass laws that promise false hope and false security to communities. finally, myths associated with cyber sexual offenders are explored. solutions to combat myths are offered to legitimize the true reality surrounding sex offenders. the laws concerning sex offenders seek to achieve protection for citizens of a community, incapacitation of offenders, and possible rehabilitation and a return to society of a productive citizen. the realities surrounding sex offenders can often times be false (griffin and miller 2008; social and harris 2016) , perpetrated by countless to have a socially constructed reality, one must start with identifying a social problem, and having the problem gain enough support and backing to be deemed legitimate. whether the social problem is real or not is often of little consequence, it simply must be believed. shotter (1993) notes in our arguments about the nature of things we must realize, our statements, whether true or false, are not always about real things, sometimes what they refer to is imaginary. as such, one first must understand what a social problem is, and how individuals go about constructing them. spector and kitsuse (1977) define social problems as the activities of individuals or groups making assertions of grievances and claims with respect to some conditions (75). they agree with loseke (2003) in that the conditions that lead to the creation of a social problem must meet a certain criterion. the term social problem as defined by loseke (2003, p. 6 ) is used to indicate that something is wrong; it refers to conditions evaluated as wrong because they create harm. the second part of the definition is, the condition must be widespread, which means it must hurt more than a few people. the third part of the definition is, the social problem must be able to be changed by humans. the final part of the loseke definition is, the social problem and conditions should be changed (loseke 2003) . the two basic conditions that make up a social problem are objective and subjective. objective conditions are conditions that we can see; they are about measurable and widespread conditions in the environment and they are about the living, breathing people who are hurt by these conditions, or who create these conditions (loseke 2003) . the objective condition is seen as having an intrinsically or malignant nature standing in contrast to a normal society, this makeup of the social problem is usually accompanied by an identification of the conditions that cause the problem and by proposals as to how the problem might be handled (blumer 1971) . the subjective conditions are those that cannot be observed. peoples' ideas about risks matter more than the actual risk measured by objective indicators (loseke 2003) , as noted by zatz (1987) chicano youth gangs and crime the creation of a moral panic (kraska 2004) . in actuality, most social problems exist in terms of how they are defined and conceived in a society instead of being an objective condition with a specific objective make up. a social problem does not exist for a society unless it is recognized by the society to exist. in not being aware of a social problem, a society does not perceive it, address it, discuss it, or do anything about it; the problem is just not there (bulmer 1971) . the societal definition gives the social problem its nature, lays out how it is going to be approached, and shapes what is done to correct it (bulmer 1971) . therefore, whatever people perceive to be a social problem, can in fact become one if they can convince enough individuals in society the problems exist. this can be accomplished by constructing realities where the conditions meet or appear to meet the four-part definition for a social problem. these realities are the result of an intricate process of learning and constructing meanings and definitions of situations through language, symbols, and interactions with other people (kraska 2004) . the social problems and realities are not constructed on their own, they need people to create them, accept them, and allow them to gain power and legitimacy. these people are often referred to as the actors (kraska 2004; loseke 2003) in the social problem construction game. social constructionism focuses on the process by which a social problem is constructed (kraska 2004; spector and kitsuse 1977) . the focus by the criminal justice system on sex offenders did not happen overnight. criminal justice is a social construction that shifts with intellectual perspective, political influence, social sentiment, cultural values, and the interests of powerful groups in society (kraska 2004) . some authors describe social constructionism as a dramaturgy, where the actors work hard to construct and maintain an effective impression of themselves through the orchestration of appearances (kraska 2004) . as with any social problem, there are certain actors, known as claims-makers, pushing for the problem and another group of actors, known as the audience, for which the claims are targeted. before establishing who can be a claims-makers and an audience member for the sex offender constructed realities, one must clearly understand what a claim is and who claims-makers and audiences are, and what they do. a claim is any verbal, visual, or behavioral statement that seeks to persuade audience members to define a condition as a social problem, or a demand one party makes on another (loseke 2003; spector and kitsuse 1977) . notice no mention of a factual or true statement is contained within the definition. this is what makes the process of constructing social problems and realities different from other problems, objective and empirical evidence need not exist as myths alone can serve as the basis for claims, and is often the case when it comes to sex offenders. we learn about myths from our parents, people in church, socializing with friends, and from teachers. myths are conceptual schemes that help us interpret reality and organize our thoughts and beliefs about reality. they organize how we see reality; they allow us to adhere to our particular belief system even when contradicted by reality. thus, myths tell us where society's problems reside, where we should look for solutions, and what solutions are acceptable (kappeler 2004 power of myths comes not from their ability to reflect reality accurately but from the power and legitimacy they gain over time, and eventually become truths for many people. myths can be restricted to specific criminal justice events, always presented as occurring regularly or with increasing frequency (kappeler 2004 ) just as the sex offender scare was through the 1980s and into the 1990s by means of claims making. claims making is the process of trying to convince the public a particular issue or situation which should be defined as a social problem (macionis 2005; spector and kitsuse 1977) . the process begins with the belief that people create meaning because meaning is not inherent in objects; individuals who create this meaning are the claims-makers, or put another way, the people who pitch the claims or myths to the audience (loseke 2003) . the other groups of actors in a social construction drama are the audience members. a social constructionism audience is those people who evaluate the believability and importance of what claims-makers say (loseke 2003; spector and kitsuse 1977) . they are critical because a social problem is created only when audience members evaluate claims as being believable and important. how and where the claims and myths are pitched to the audience are important in addressing whether or not the conditions are significant enough to be considered worth the audiences' time. it is important to remember there are multiple claimsmakers pitching multiple claims to audiences at the same time. it is up to the claimsmakers to use the correct pitching techniques and myths to make their particular problem seem like the one warranting the most time and resources. audiences have a limited caring capacity and only have time to address the most important claims (loseke 2003) . a social problem must gain social endorsement if it is to gain respectability in public discussion. if the social problem does not obtain audience support, it is doomed. just because a social condition is recognized as crucial by some people in a society does not mean the problem will break through into the area of public consideration. if the social problem fails to obtain legitimacy, it struggles and deteriorates outside of the arena of public action (blumer 1971) . loseke (2003) suggests using particular motivational frames to make one's claim more enticing. for those fearing sex offenders, a motivational frame could be for the parents and children of the community to appeal to emotion with stories of sexually abused children; however, there is also a chance to appeal to cultural themes. two possible themes used to construct a motivational frame in the case of parents of children and victims would be through family, and fair play. fair play, because members of the victims' groups would claim it is unfair their children, as well as themselves, must live in fear because a sexual predator lives in the neighborhood, and is not banned from commuting to libraries, schools, playgrounds, and other places where innocent children convene. the theme of family, because strong families are one of the backbones of our nation, and if a member suffers from a sexual assault, be it an elderly person or a young child, that family's world comes crashing down around them. they lose faith in moral goodness, local law enforcement, and possibly their faith in a higher power. their motivational frame might be effective if it includes the fact that having someone being violated by a sexual offender affects the entire family negatively. whether one is a claims-maker for or against sex offenders' rights, it comes down to which side makes the more compelling argument to the policymakers. one need only look to the victims of sex offenders and their families to see the sn soc sci (2021) claims-makers in this drama, and two of the most popular audiences would have to be communities where sex offenders live and lawmakers. innocent children as victims in their home communities are one of the main groups examined when talking about sex offenders. the possible claims-makers in this drama would be parents of children who had been victims of sexual assault by registered sex offenders, or couples with young children that have a registered offender living in their neighborhood. the claims these groups could use would be the emotion-filled story of their own child's, or another child's, experience with a sex offender. such as the story of 10-year-old jetseta gage, a mentally challenged girl who was kidnapped, raped, and murdered at the hands of convicted sex offender roger bentley, only to be stuffed into the cabinet below a sink in his trailer (amw 2006) . as kraska (2004) notes one of the largest, most powerful, and widely accepted claims-makers for criminal justice issues such as sex offenders is the media. the media plays and has played a powerful role in educating the public and influencing public policy in everyday ventures as well as with criminal justice issues. they have a vested interest in the promotion of criminal justice myths because their public is fascinated with sensationalized crime, and crime has become a media product which sells better than any other media commodity (kappeler 2004) . zatz (1987) notes at the most visible level, social problems and the responses to them are created in part by the media. the media confirm, distort, and structure the conflict between the claims-makers and the deviant group (kraska 2004) , in this case sex offenders. the media are important because they offer claims-makers the largest possible audiences, and because they can reach many different people, as our world gets larger and more mobile we must rely on the media to tell us about it. it is logical to argue claims presented through the media will influence more audience members' understanding of social problems (loseke 2003) . loseke (2003) notes television becomes particularly important when claims are presented as factual news or based on facts, because these programs encourage viewers to evaluate claims as truthful. on any given day, there are numerous events that are potentially important, but only some become the topic of news shows, producers and editors decide what is and what is not news. they decide how to package the stories in ways that will captivate audience members. on a day-to-day basis, there are predictable biases in how those stories are presented (loseke 2003) . the history of the influence of media on sexual abuse started in the late 1970s with women recalling repressed memories of being raped when they were children (jones 1999) . media attention surged through the 1980s particularly after allegations of sexual abuse at mcmartin preschool in california in 1984, the day school scandal in fells acres, massachusetts in 1984, and the case of new jersey nursery school worker kelly michaels who was absurdly accused of 280 counts of sexual assault in 1987 (rabinowitz 2003) . during these years, the media's focus was on the hidden problem of child sexual abuse, the pain the survivors of such abuse endured, and the need to raise the country's attention to the prevalence of the problem (beckett 1996) . later in the eighties it was found the aforementioned cases were all hoaxes that were conjured up in the minds of the young children and drawn out by the corrupt tactics used by investigators. the media's focus on sexual abuse ranging from awareness of the problem to false allegations of abuse influenced therapy practice and research sn soc sci (2021) 1:6 6 page 6 of 21 on the topic (jones 1999 ). jones states research and publications about the problem of sexual abuse went from none in the early 1980s to 14 articles by 1989. publications about sexual abuse leapt to almost 1500 articles from 1995 to 1998 mirroring the emphasis placed on sexual abuse by the media during those years. in terms of therapy, the media's attention on false memories, which were blamed on therapists, had an impact on therapist treatment. the once accepted belief of repressed memories became controversial, causing therapists to become wary of the subject for fear of lawsuits (jones 1999) . the other audience in which sex offender claims-makers would most likely be pitching to would be lawmakers. the parents of victims and young children as claims-makers would use the aforementioned emotion-filled stories of heartbreak and evil and sensationalized media reports to convince lawmakers the rules regarding sex offenders should be strengthened. along with legislatures, these emotionfilled stories would likely attract more followers to the movement for the claimsmakers, the more americans who support a social problem; the more policymakers must be attentive (loseke 2003) . it is strength in numbers form of claims making. another vital strategy is making the claim at the right time, if one can produce a large number of people during election time all fighting for the same conditions to be recognized, the claims-makers might come to a certain understanding with a particular candidate. such promises might be, "if this issue is brought before the legislature and gets the laws changed, i can promise you all of these votes" (loseke 2003, p. 60) . you have the offenders arguing the requirements of the laws such as notification and proximity laws are too harsh, and need to be lessened, and in dealing with the same social problem you have the groups of parents, victims, and other supporters trying to persuade the laws are too lax, and need to be strengthened. the actors try to show sex offenders are inherently evil and pose a significant threat to the children of the community. make the audience members see that the presence of offenders in the community means increased worry to parents, and that having these people live in communities with regular people and children causes an increased threat to the safety and innocence of the children. the aforementioned strategies are the grounds that claims-makers use to pitch the claim. punishments for most crimes throughout the early years of america had religious overtones, and sexual offenses were no exception. sex crimes were considered sins, and public shaming, flogging, and other degradation ceremonies were common (friedman 1993; roth 2005; shelden 2008) . each region of the country had different degrees of punishment; in the chesapeake, hard flogging was common, as was being pulled behind a boat until nearly drowning (roth 2005). in the late eighteenth century and early nineteenth century, the criminal justice system paid less attention to sex crimes as catching and punishing offenders required very precise social conditions, both cultural and structural. cultural because enough people within the community had to find the act offensive, and structural as laws against sex crimes were difficult to enforce except in small communities (freidman 1993) . in larger sn soc sci (2021) 1:6 page 7 of 21 6 environments such as new york and philadelphia, it would be next to impossible to be aware of all sexual crimes taking place, especially those perpetrated in poor working-class communities. between 1750 and 1796 in the superior court of massachusetts, just 4.3% of the indictments were for moral and sexual crimes (freidman 1993) . following the progressive era and beginning in 1937 in michigan, were the sexual psychopath laws. by the mid-1970s, more than half of the states had mentally disordered sex offender laws (masters et al. 2011) . these laws allowed the state to confine sex offenders with a mental disease for indefinite periods in a psychiatric hospital instead of corrections facilities. such laws were abandoned when determinate sentencing came to be popular; however, many called for a return to indeterminate sentencing for violent sex offenders. many violent sex offenders with fixed sentences were released back into society to reoffend. current sex offender statutes in most states allow the incarceration period to be extended beyond the original courtmandated because of fear that sex offenders, once released, will reoffend (masters et al. 2011). as such, offenders are confined for what they are believed likely to do in the future, not for the crime they committed. even during the early years of the unites stated, loseke's propositions were applicable to sex crimes. there was a wrong, as sexual crimes were viewed as a sin. it was widespread, as each region of the country had its own sanctions. finally, we can infer that communities tried to change the problem via the punishments described in an attempt to repent or get right with god for the sins committed. having violent sex offenders released after serving a determinate sentence led the state of washington to create the sexually violent predator law (svp). under the svp act, recidivists may be declared sexually violent predators, confined to a mental health system, and required to stay until considered cured (masters et al. 2011) . masters et al. states even though preventive detention laws are popular with the general public, their future is uncertain. under existing law, sexual predators can be freed only after they have been effectively "cured." however, most psychiatrists consider sexual predation to be an anti-social behavior rather than a mental illness and argue it cannot be cured. the washington state psychiatric association called for the repeal of the state's sexual predator law going on record to assert sexual predation is not a mental illness, but falls under criminal conduct (masters et al. 2011 ). these doctors declared sexually violent predator laws give offenders what is equivalent to a sentence of life imprisonment. this could lead to slippery-slope mentality in that if recidivism is going to be the basis for determining mental illness and confining offenders in mental institutions, people could call for indeterminate sentences for other repeat felony offenders as well. loseke's (2003) tenants are prime display over the course of the next few cases discussed. the wrong is the sexual assault and/or death of jacob wetterling, megan kanka, adam walsh, and pam lyncher. loseke's second proposition is also present as the conditions were most assuredly widespread as these attacks were celebrated cases that made national and international headlines as many others go unreported to national media. in addition, these cases were spread across the entire country. tenant three is supported in that all of these cases lead to the laws and legislation sought by individual wanting justice for the victims and to prevent such atrocities sn soc sci (2021) 1:6 6 page 8 of 21 from happening again. loseke's fourth proposition is a natural progression from her third as it would be rare event to find someone in favor of allowing sexual assaults on innocent victims. as such, this social problem (violent sexual assaults) should be changed to protect potential victims of sexual predators. the reader should keep these tenants in mind as they read through the following cases and visualize the techniques and methods detailed in the previous section that are utilized by claimsmakers to achieve their desired result. then, one must ask if those ends (socially constructed realities in which many offenders are forced to live) justify the means (the myths perpetuated by some claims-makers). prior to 1994, few states required convicted sex offenders to register their addresses with local law enforcement. major federal statutes dealing with crimes by sexual offenders were named after victims in the cases. the high-profile cases began with the story of young jacob wetterling, leading to one of the most important pieces of legislation written to date on laws governing convicted sex offenders, the jacob wetterling act. the jacob wetterling crimes against children and sexually violent offender act was enacted on september 13, 1994 (reno 1998 national center missing kids) . this requires state implementation of a sex offender registration program for persons convicted of a criminal offense against a minor, or a sexually violent offense (42 u.s.c. 14071; sex offender sentencing; reno 1998). the act requires offenders to be registered for at least ten years as well as update address information when they move and verify the registered address periodically (reno 1998). the registration alone was not enough, as was revealed just a month and half before the jacob wetterling act was enacted by the murder of 7-year-old megan kanka by a released sex offender. the public backlash called for programs to provide the public with information regarding released sex offenders. megan kanka was a 7-year-old girl from hamilton township, new jersey whose family unknowingly lived across the street from jessie timmendequas, a twice-convicted sex offender. on july 29, 1994, timmendequas used the promise of seeing his new puppy to lure young megan into his home where he proceeded to rape, strangle, and eventually murdered megan (masters et al. 2011; national center missing kids; walker 2006) . in 1996, president clinton signed a federal law that mandated states develop a registry of known sex offenders (national center missing kids). the law requires law enforcement personnel to make information on registered sex offenders available to the public (reno 1998; masters et al. 2011; national center missing kids; sex offender sentencing; walker 2006) . while the jacob wetterling act and megan's laws were linked directly with keeping children safe from sexual predators, the case of pam lychner shows adults also can be the victims of sex offenders. pam lychner was a 36-year-old real-estate agent from spring valley village, texas who was assaulted by william david kelley, while selling her home in 1990 (sex offender sentencing). following the attack lychner founded "justice for all," a victims' rights advocacy group that lobbies for tougher sentences for violent criminals (sex offender sentencing). lychner is also credited with helping to formulate the language for the bill that created a national database that helps track offenders and bears her name. the pam lychner sex offender tracking and identification act of 1996 requires perpetrators of particularly serious offenses and recidivists be subject to lifetime registration (reno 1998). despite the implementation and improvements made in the above-mentioned acts, and because mobility has increased significantly in our society (friedman 1993) , many sex offenders continued to offend. the national center for missing and exploited children reports that numerous offenders failed to comply with registration duties and remain undetected due to the inconsistencies among state laws. lawmakers recognized this problem along with the burden faced by law enforcement to keep track of the increasing number of offenders and took action. their solution was based on another high-profile case, adam walsh. adam walsh was a 6-year-old boy from hollywood, florida who was kidnapped from a store and murdered (child search 2003) . consequently, the adam walsh child protection and safety act mandates specific registration requirements for sex offenders in all states (pub. l. 109-248 2006; national center missing kids). additionally, the adam walsh act contained details concerning internet sexual abuse, which was quickly becoming widespread in the latter part of the 1990s and into the early part of the new century. it imposed criminal penalties for participation in a child exploitation enterprise, increased penalties for registered sex offenders who committed a felony sex offense against a minor, and prohibited the embedding of deceptive words or images in a website to deceive individuals into viewing obscene material. when the adam walsh act passed, online sexual predators were by no means new, but had become the new norm in soliciting young victims. loseke's (2003) arguments are even more salient in the cyber age as computers help to expand the social problem as outline in tenant two. with the advent of the internet and smart-phones, the problem of sexual assault and exploitation is even more widespread and ubiquitous. while computers and the internet open a world of possibilities for children, they can be exposed to dangers. computer telecommunications have become one of the most prevalent techniques used by pedophiles to share illegal photographic images of minors and to lure children into illicit sexual relationships and attempt to sexually exploit children through such online services. as the reader will see going forward, with the greater reach of the internet, loseke's third proposition is satisfied as claims-makers and legislatures alike moved feverishly to create and implement more laws and legislation in hopes of changing the national issue. similar to before, nearly all would agree that this particular problem should be changed as the use of the internet for sexual exploitation often inclines to put one of the most vulnerable segments of our population as the main targets for predators, children. some of the techniques used by these individuals to gain trust include attention, affection, kindness, and even sending gifts. these offenders listen to and empathize with children, and use ample time, money, and energy in selecting a victim with the ultimate goal of lowering the child's inhibitions and slowly introducing sexual content into their communications (fbi). young people are often the victims of a variety of internet crimes, including solicitations to engage in sexual acts for commercial gain through production and distribution of child pornography or for personal sn soc sci (2021) five percent received sexual solicitations that made them upset or afraid; of these victims, 37% were between the ages 10 and 13. another 3% were asked to allow contact or a meeting offline. the anonymity that the internet affords offenders makes it difficult to get accurate information about them; the true identity, age, and gender of the perpetrators may be different from what they state. victims believed nearly all the perpetrators were strangers. two-thirds of all solicitations came from self-described males. approximately two-thirds of solicitations occurred in chat rooms; 24% were instant messages. one-quarter of respondents received unwanted sexual material, more boys 57% compared to girls 42% (connelly 2001; finkelhor et al. 2000) . nearly half of the victims did not tell anyone about the solicitation; of those who did, about a quarter informed a parent. as access to internet technologies expands via increased use of wireless and handheld technologies, monitoring internet communications has become increasingly challenging. with the emergence of the internet and other communications innovations creating more opportunity for criminals to solicit victims (roth 2005), lawmakers and law enforcement were pressured to pass legislation and enforce new laws to help ensure the safety of children online. the child pornography prevention act of 1996 and the federal bureau of investigation's innocent images national initiative were the results of citizens' requests. the investigation of a missing juvenile from prince george's county, maryland in 1993 by the fbi lead to the discovery of two suspects who had sexually exploited numerous juveniles over the past 25 years and the creation of the innocent images national initiative (iini). further investigation into these activities determined adults were routinely utilizing computers to send sexually explicit images to minors and, in some instances, to lure minors into engaging in illicit sexual activity. in 1995, based on information developed during this investigation, the iini addressed the illegal activities conducted by users of commercial and private online services and the internet. the child pornography prevention act of 1996 followed the cases of megan kanka and jacob wetterling and expanded the federal prohibition on child pornography to include not only pornographic images made using actual children, but also any visual depiction, which is or appears to be of a minor engaging in sexually explicit conduct. as well as any image that is advertised, promoted, presented, described, or distributed in such a manner that conveys the impression or depicts a minor engaging in sexually explicit conduct (u.s. code. vol. 18 2256 1996), making online pornographic images and words of children or to children a strict liability crime. this means all intent has been removed from the criminal act, one either possessed child pornography or did not, as it takes one's intentions completely out of the circumstances and the accused's mental state is irrelevant to guilt or innocence and the chief evidentiary proof rests in the act alone (nemeth 2004) . myths that create the realities as loseke's (2003) propositions have been met, the wrong identified (sexual assault), having widespread effect (numerous victims), changes can be made by people and should be made (laws enacted by claims-makers such as the media, coupled with the resulting legislation). boundless myths often associated with such offenders, have also been generated, leaving many sex offenders as well as citizens living in socially constructed realities. the current study selected seven myths commonly associated with sex offenders. these myths were , as well from an informal write-in poll asking undergraduate students taking an introduction to criminal justice class at a midsized southern university, to provide two statements they believed true of the master statuses of sex offenders. the myths examined in the current study is by no means an exhaustive list as there exists a wealth of myths surrounding sex offenders and the literature on the topic is overwhelming, as no one article can do full justice to all research on sex offenders. what we have attempted to do is use loseke's (2003) formulations to demonstrate how each of these myths could be easily create and perpetuate a socially constructed reality in the hands of a motivated claims-maker. one of the most popular myths is sex offenders have high recidivism rates social and harris 2016) , which is not supported by empirical research (harris and hanson 2004; helmus et al. 2012; langan and levin 2002; langan et al. 2003; nieto and jung 2006; prentky et al. 1997; sample and bray 2003, 2006; tewksbury et al. 2012) . some studies of treated sex offenders show great variability in recidivism with rates ranging from 0 to 50% for any offense. offenders who participated in cognitive-behavioral treatments, which include monitoring in the community by probation or parole personnel suggest increased positive outcomes with recidivism rates ranging from 0 to 18% (jones 1999) . in a meta-analysis of recidivism studies, hanson and bussiere (1998) similarly found that recidivism rates for sex offenders varied considerably, with an average across all studies was 13.4%. a 2003 study by the u.s. department of justice found that within three years of prison release, 5.3% of sex offenders were arrested for another sex crime. according to the study, sex offenders were less likely than non-sex offenders to be rearrested for any offense: 43% of sex offenders verses 68% of non-sex offenders (beck and brien 2004) . beck and brien (2004) note another study conducted in canada found of 4,724 sex offenders, nearly 75% had not been charged with another sexual offense after 15 years. according to the available research, the average recidivism rate for sex offenders is low when compared to rates for other crimes. a plausible explanation for such variation might be dependent on the offender and offense characteristics, such as whether or not the perpetrator is a chronic sex offender or someone who was caught on their first offense. another prevalent myth concerning sex offenders is that strangers are more likely to sexually abuse children than family members (abc news 2006; craun sn soc sci (2021) levenson and d'amora 2007; meloy et al. 2008; snyder 2000; vanzile-tamsen et al. 2005) . the reality is of the 500,000 children who are molested each year (macionis 2005, p. 173) , only 10% of the offenders were strangers, 90% are family, friends, and people known to the child (masters et al. 2011) . most of the legislation aimed at controlling sex offenders is focused on the perpetrators being strangers. children are actually at greater risk of sexual abuse from family members. this myth feeds the fear of parents and communities about strangers within their neighborhoods and their childrens' lives. many schools are teaching young children the difference between a "good touch" and a "bad touch" and emphasizing the need to tell an adult if a person acts toward them in a manner they feel is wrong (macionis 2005). on the surface, this seems like a fine idea, but if as the research suggests, the offender is someone the child knows, possibly even a family member or parent, it seems doubtful a child will inform on a family member or parent to another adult. a third myth surrounding sex offenders is sex offender registries reduce sexual assaults (agan 2011; drake and aos 2009; letourneau et al. 2010; meloy et al. 2007; prescott and rockoff 2011; sandler et al. 2008; schram and milloy 1995; tewksbury and jennings 2010; vasquez et al. 2008; veysey and zgoba 2010; zevitz and farkas 2000; zgoba et al. 2008 ) and proximity laws reduce sexual assaults (barnes et al. 2008; davey 2006; loney 2008; meloy et al. 2008; nieto and jung 2006; tregilgas 2010; zandbergen et al. 2010) . in reality, there is little evidence these registries and proximity laws provide effective protection from or act as a deterrent to repeat sex offenders. a sex offender study dealing with 10 states found the passage of sex offender registration and notification laws demonstrated no systematic influence on the number of rapes committed in the states. most of the states in the sample showed no significant differences in the average number of rapes committed before and after the sex offender laws (vasquez et al. 2008) . the majority of proximity laws require offenders not live within a thousand or several thousand feet of a place where children congregate. this can cause serious problems in some suburban neighborhoods where most of the community has several schools and parks. with offenders being forced from urban areas, they are settling in masses in the suburbs of larger cities where many families live. polk county iowa chief deputy of police bill vaughn stated since october 10 of 2005, a month after the 2000-foot law was put into action, the number of sexual offenders living in rural polk county jumped from 76 to 114 as offenders have had to relocate (dobbs 2005) . offenders are being forced into these clumps similar to "hoovervilles" pushing them away from their work, families, and homes. some registered offenders are not abiding by the proximity laws. a study by tewksbury and mustaine (2006) found nearly 22% of a 96-person sex offender sample in seminole county, florida was found living within 1000 feet of a playground or park, 14.6% near an elementary school or day care center. the authors added together the child congregation locations to gauge how many of these locations sex offenders lived near. data indicated that 31.3% live near at least one-child congregation location, 14.6 near two locations, and 3.1% near three locations. they also found out that 12 out of 21 sexual offenders of minors were actually breaking florida law by living sn soc sci (2021) near places children congregate. a similar study by walker et al. (2001) found 48% of registered sex offenders with child victims lived within 1000 feet of day cares, parks, and schools. it is not just real-world sex offenders that deal with socially constructed realities as the new millennium brought a hyper focus on the internet and social media, the world of online sexual offenders is not without its own myths that have been constructed through claims-makers such as the media and community fear. a number of the following myths examined in the current study were identified by college students and centered on predators on the internet. one such myth is about internet sex offenders using deception and trickery to lure small children on the internet into violent sexual meetings. in reality, the majority of internet-originated sex crimes involve adult men who use the internet to meet and seduce underage adolescents into sexual encounters. the offenders use internet communications such as instant messages, e-mail, and chartrooms to meet and develop intimate relationships with victims. in most cases, victims are aware they are conversing online with adults (wolak et al. 2008) . wolak et al. (2008) note media stories and much of the internet crime prevention information available and suggest it is naïve and inexperienced young children who are vulnerable to online child molesters and it is this that makes them vulnerable. the research indicates, however, by the preteen years, child internet users comprehend the social complexities that exist online at similar levels compared to adults (wolak et al. 2008; yan 2006) . as children grow older and become more experienced online, they participate with more advanced and interactive internet users, which puts them at greater risk than younger, less experienced children who use the internet in simpler, less interactive ways (wolak et al. 2008) . another myth surrounding online sexual victimization identified by students is social networking sites have increased the risk of sexual victimization by online predators. in reality, a study conducted between june and october 2007, consisting of over 400 interviews with police about online sex crimes showed no cases of sex offenders stalking and abducting minors based on information posted on social networking sites (wolak et al. 2008) . the study suggested online predators do not stalk their victims, but actively seek out those victims susceptible to seduction. the study also showed children with profiles on social networking sites, even those trying to meet new people, were no more likely than other children to have uncomfortable or inappropriate contacts with online users. an additional myth identified by students associated with online sex offenders is online predators are violent pedophiles. the reality is online predators primarily target adolescents as opposed to young children (wolak et al. 2004 ). most online predators do not fit the clinical definition of a pedophile, which is, an individual who is involved in sexually arousing fantasies, urges, or behaviors involving sexual activity with a prepubescent child (apa 2000) . young children were found to be less accessible online compared to teenagers, as young children are more supervised and less likely to respond to the advances of predators because children are less interested in relationships and romance (wolak et al. 2008) . teenagers with certain characteristics identified as more vulnerable such as those with poor relationships with their parents, who experience loneliness and depression, and who are gay or questioning boys (wolak et al. 2004) . violence is a rare occurrence in online sex sn soc sci (2021) crimes. evidence from wolak et al. (2008) study suggests online predators are not among the sex offenders who abduct or assault victims. most online child predators are patient enough to develop relationships with victims and shrewd enough to move those relationships offline (wolak et al. 2008) . it would seem offenders are aware of how to speak to teens to gain and keep their trust through the face-to-face meeting if one was to occur. the final myth examined here is violent sex crimes against children have increased because of the internet. the reality is several sex crimes and abuse indicators have shown declines during the same period in which the use of the internet has been expanding (freeman-longo 2000) . from 1990 to 2005, the number of sexual assault cases validated by authorities declined 51 percent (finkelhor and jones 2006) . for example, the rate of sexual assaults reported by teenagers to the national crime victimization survey declined by 52% between 1993 and 2005. additionally, a statewide survey of students in minnesota also showed declines in sexual abuse during this period (wolak et al. 2008) . having examined the many myths that have been used to construct the realities of sex offenders, both in real life and online, it is not difficult for one to infer these realities carry with them consequences for the offenders and communities alike. the construction of social realities based on myths hides contradictions in logic, reality, and carries consequences. myths may seem harmless, but when associated with the criminal justice system they can have dire consequences for individuals and society (kraska 2004 ). one of the major effects of these realities is the laws that establish where sex offenders can live. using information gathered from census tracts for several counties in florida, mustaine et al. (2005) investigated to see if registered sex offenders are more likely to be found in areas with greater social disorganization due to choice or because of stigmatization. the study found negative location characteristics were higher in the census tracts of sex offenders as compared to the rest of the county and the nation. these tracts had higher levels of unemployment, more families living below the poverty line, and the educational level tended to be lower, fewer homes were lived in by owners, housing values were lower, and household income was lower in these census tracts. the study also found that tracts with higher concentrations of sex offenders are more disorganized and less desirable than tracts with lower concentrations of offenders, as these high concentration tracts also had locational, household, and housing characteristics which signified they were more disorganized and disadvantaged places to live (mustaine et al. 2005 ). the conclusion reached by this study was communities with characteristics of social disorganization are likely to be the homes of registered sex offenders as offenders live in these areas because they are relegated to such a location. a similar study conducted by mustaine et al. (2006) investigated if registered sex offenders currently reside in different locations than they did when arrested, and if offenders did change locations, are their current residences located in more or less socially disorganized locations than their residences at the time of arrest. the study found residential location typically changes after being arrested for a sex offense, and of those who changed locations, half moved to less disorganized areas, and half moved to more socially disorganized areas. those offenders that lived in less socially disorganized areas originally were more likely to move downward after registration, while sn soc sci (2021) those who already lived in highly socially disorganized areas were more likely to stay the same or have minimal movement . these studies suggest convicted sex offenders are living in the more socially disorganized areas where quality work and community support tend to be the lowest. the research implies it is not the choice of offenders to live in these areas, but rather many are forced to comply with residency restrictions. another problem myth-based realty can bring on sex offenders is aggravation and isolation within a community. this can lead to increased rates of negative consequences for offenders including amplified stress, shame, harassment, job loss, loss of friends, and community harassment or vigilantism (ackerman and sacks 2012; lasher and mcgrath 2012) . notably, all of these consequences can be counterproductive insofar as they can lead to reoffending (freeman and sandler 2010; hanson et al. 2009 ). some libertarians believe the residency and notification laws are unfair and are an additional punishment beyond the offender serving his or her time. many offenders are released back into hostile, rejecting communities that have been influenced by media and have few support systems; here the offenders are expected to lead a functional crime-free life while facing difficulty finding housing and employment, threats or harassment, vigilantism, and ostracism from the community (walker 2006) . these constructed realities can take a toll on offenders' families economically, socially, psychologically, and even physically (levenson and tewksbury 2009) as well as bring about increased community fear. an evaluation in wisconsin of community notification laws where people were informed via public meetings resulted in citizens leaving feeling more worried about being victimized than they did when they were unaware of the offender being in neighborhood. research has also shown the collateral effect of such realities including a decline in home values for homes close to registered sex offenders (linden and rockoff 2008; pope 2008) . they have led to extensive financial and resource allocation costs for law enforcement to implement and impose community notification programs (zgoba et al. 2008) . likewise, probation and parole agencies have had to invest significantly more time to aiding offenders in finding housing and jobs (zevitz and farkas 2000) . a group often overlooked are the families of offenders. these realities can take a significant toll on them economically, socially, psychologically, and even physically (levenson and tewksbury 2009) . a final issue worth noting with these realities may well encompass sex offenders who are not violent predators, pedophiles, or rapists, yet still are required to register. this includes individuals who "moon" people, people arrested for urinating in public, and gay and bisexual men convicted of cruising parking lots for sexual partners in public places (jones 1999) . being aware of the socially constructed realities that sex offenders are living, and examining the history of the laws that the myths and realities help to create, might provide people with a more accurate perspective of the daily obstacles faced by convicted sex offenders. the current study demonstrated the usefulness of using loseke's (2003) tenants to examine and understand how a motivated group of individuals (claims-makers) can take a true social problem (sexual assaults) and use fear and false narratives to sn soc sci (2021) establish and perpetuate myths associated with sex offenders, which in turn can lead to the needless fear and suffering of both offenders and citizens. a possible solution to the problems currently affecting these offenders could be a different type of monitoring. as described above, certain members of society only become more fearful or more likely to be vengeful when they are aware of the sex offenders in their neighborhoods. only notifying law enforcement of the offender's presence in the neighborhood could possibly reduce both fear and chances of vigilantism. the members of the community would not have to know the identity of the offenders and could continue living their lives without concern. the actions and location of the offenders would be the responsibility of law enforcement and the use of full gps tracking for all offenders could be employed. the gps tracking ankle bracelet, which allows law enforcement to track the offender continuously throughout the day, is the most expensive of all tracking bracelets costing around $7.25 per offender per day (roos 2005) . although more expensive, this method of tracking would allow officers to know the exact location of offenders throughout the day including when approaching or loitering in a restricted area. however, recent studies have shown no discernible difference in recidivism between gps-tracked offenders and those that were not tracked via gps (levenson and d'amora 2007; tennessee board of probation and parole 2007; turner et al. 2007) . some conceivable solutions to the online sex offender problems lie not with posting personal information, as millions of children use facebook, instagram, and snap chat safely. rather the preventative focus needs to be on controlling and monitoring interactions as online-initiated sexual assaults come about through direct communication between predators and victims (wolak et al. 2008 ). this could include talking to children about what types of behavior or signals predators will be looking for, as well as what topics to avoid speaking about online such as loneliness, dislike of one's parents, and sex. additionally, better investigation and monitoring techniques on the part of computer forensic investigators could serve to quell this problem. as burgason and walker (2013) outline as forensic investigators may be able to build a case based on a few encase searches and a dump of images, videos, and communication, other cases are more complicated and require a more in-depth investigation (5). as such, the study details the benefits of utilizing optimal foraging theory as a blueprint to track how offenders use the internet for illicit purposes as "being able to follow an offender from one website to another can aid in establishing timelines of events and in developing profiles, motives, and establishing behavior of the offender. this can aid greatly in complex investigations and prosecutions" (burgason and walker 2013) . laws regarding sex offenders have enticed myths, and these myths have driven the creation of constructed realities that are teeming with problem for offenders, their families, and citizens alike. the claims-makers throughout the past two decades have been successful in getting support from proper audiences, from the media circus surrounding child sex offenses in the 1980s and early 90s, to the passing of the internet pornography and stalking laws. many social problems tend to lose their appeal after a certain number of years. sexual assaults are in the minority in that they show no signs of stopping or even slowing down since obsession started in the mid-1990s. in fact, as recently as the summer of 2020 as the sn soc sci (2021) covid 19 pandemic was in full swing across the nation, a moral panic concerning sex offenders gripped the upper west side of manhattan. to quell the spread of the pandemic, new york city officials started filling boutique hotels with homeless individuals including more than a dozen sex offenders. this did not sit well with some of the "well to do" members of the community and their elected representative who quickly began perpetuating a number of the myths outlined above. one particular city official addressed mounting concerns to her constituents stating, "all level 3 sex offenders have been moved out" and that she was "demanding that all remaining offenders be moved out as well." it was not until days after the offenders had been removed that the official softened her stance contending "i initially took an extreme position and stated that 'no registered sex offenders should be allowed on the upper west side'-but that's not realistic. there are around 1,600 registered offenders across manhattan, and neighborhoods cannot wall themselves off" (mckay 2020). as this incident shows, even today, loseke's (2003) tenants hold true as the homeless sex offenders were viewed as the social problem that was widespread across the upper west side of manhattan. a number of citizens and official thought the problem should be changed and could be changed by taking action. the claims-makers organized, utilized myths to elicit fear from the community, and were able to have the offenders removed from the area. sexualized crime, particularly crimes involving a protected class of citizens such as children, will always garner attention from powerful audiences such as politicians and lawmakers. furthermore, as long as the media, police, and other claims-makers are willing to use myths to construct realities against sex offenders, they have little chance of convincing enough people they are not as dangerous as perceived. this study identified many of the myths that accompany online sexual predators as well and demonstrated the vitality of loeske's (2003) from early colonial american clear through to the present-day nyc. from the internet being full of violent pedophiles, to social networking sites being a hot spot for predators to solicit victims, empirical evidence has busted these myths. solutions have been offered to help to rectify the problem of sex offenders causing fear and stress within society, as well as suggestions in educating individuals, especially children, of the dangers involved in becoming interactive with strangers online. to change policy, one needs to identify a social problem and gather enough support to bring the said social problem to a public arena. the issue many sex offenders face is finding support for their side of this social problem. while this study alone may not be able to change the minds of enough people, it could serve as a starting point toward a reform of the laws working against sex offenders and many communities. it might also help to quell some of the myths that serve as the building blocks to the socially constructed realities which many sex offenders and their families suffer through on a daily basis. it the authors hope that the current study can be utilized to properly inform the public as to the true nature of sex offenders' lives, as we now have the aid of empirical evidence in support of our argument, while cynics can only cling to their myths. myths about sex offenders can general strain theory be used to explain recidivism among registered sex offenders sex offender registries: fear without function? analyzing the impact of a statewide residence restriction law on south carolina sex offenders trends in the us correctional populations: recent findings from the bureau of justice statistics culture and the politics of signification: the case of child sexual abuse social problems as a collective behavior optimal foraging theory's application to internet sex offender search behavior: a theoretical model for computer forensic investigations the adam walsh story internet crimes against children. office for victims of 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(2007) monitoring tennessee's sex offenders using global positioning systems: a project evaluation where to find sex offenders: an examination of residential locations and neighborhood conditions assessing the impact of sex offender registration and community notification on sex-offending trajectories a longitudinal examination of sex offender recidivism prior to and following the implementation of sorn sex offender treatment in the united states: the current climate and an unexpected opportunity for change implementation and early outcomes for the san diego high risk sex offender (hrso) gps pilot program. university of california, irvine, center for evidence-based corrections the impact of sexual assault history and relationship context on appraisal and responses to acquaintance sexual assault risk the influence of sex offender registration and notification laws in the united states: a time-series analysis sex offenses and offenders reconsidered: an investigation of characteristics and correlates over time the geographic link between sex offenders and potential victims: a routine activities approach internet-initiated sex crimes against minors: implications for prevention based on findings from a national study online predators and their victims: myths, realities and implications for prevention and treatment what influences children's and adolescents' understanding of the complexity of the internet? ed) theorizing criminal justice: eight essential orientations residential proximity to schools and daycares: an empirical analysis of sex offense recidivism the impact of sex-offender community notification on probation/parole in wisconsin megan's law: assessing the practical and monetary efficacy key: cord-019065-u07gnlv5 authors: voßschmidt, stefan title: sicherheitspolitische bedrohungen und risiken und das „geltende“ recht in der 2. hälfte des 2. jahrzehnts des 21. jahrhunderts unter besonderer berücksichtigung der sicherstellungsund vorsorgegesetze. sicherheitspolitik in zeiten der uneindeutigkeit date: 2018-06-02 journal: politisches krisenmanagement doi: 10.1007/978-3-658-20811-0_6 sha: doc_id: 19065 cord_uid: u07gnlv5 das grundgesetz (gg) kennt klare regelungen zum spannungsund verteidigungsfall, vgl. nur art. 80a, 115a abs. 1 gg. diese bestimmungen wurden unter den bedrohungslagen des kalten krieges und seiner gefährlichsten tage in der kubakrise in einer notstandsverfassung zusammengefasst, bei einer großen wintex-übung im ausweichsitz der verfassungsorgane in mariental erprobt und von der ersten großen koalition „verabschiedet“ (1966–1969, kabinett kiesinger/brandt). veränderungen folgten. daher dürfte die auf den ersten blick provokativ erscheinenden aussage von eric schmidt und jared cohen zutreffen: "all future wars will begin as cyberwars. cyberattacs and online desinformation campaigns will define the next generation of conflict, and they will unfold silently, invisibly and relatively inexpensivly." (time 2016). kurzum "unscheinbar" werden diese konflikte beginnen. politik und wirtschaft müssen folgende ziele umsetzen: "keep our information secure and our infrastructure safe". künftig werden auch nichtstaatliche akteure cyberattacken stemmen können. die dazu notwendigen "tools" bietet das darknet an. sie werden darüber hinaus ihre attacken so aussehen lassen (können) als ob sie von einem anderen z. b. einem staat ausgehen. um dem vorzubeugen sind auch neue regeln und normen notwendig (vgl. ebd.) . als eine neue regelung ist das "gesetz zum besseren informationsaustausch bei der bekämpfung des internationalen terrorismus" vom 26. juli 2016 2 zu nennen. aufgrund dieses gesetzes kann das bundesamt für verfassungsschutz mit ausländischen nachrichtendiensten gemeinsame dateien errichten. die befugnisse der bundespolizei zum einsatz von verdeckten ermittlern werden 1 das weißbuch der bundeswehr ist ein durch das bundesministerium der verteidigung erarbeitetes und durch die bundesregierung verabschiedetes grundlagendokument, das die sicherheitspolitische lage der bundesrepublik deutschland und der verbündeten für die kommenden jahre aus sicht der regierung darstellt (vgl. wikipedia 2017a), und als leitfaden für sicherheitspolitische entscheidungen und handlungen in deutschland dienen soll. 2 bundesgesetzblatt i (2016, s. 1818). erweitert (gnüchtel 2016 (gnüchtel , s. 1113 (gnüchtel -1119 . inwieweit hat nun diese bedrohungslage auswirkungen auf die notstandsgesetzgebung im grundgesetz bzw. auf den bevölkerungsschutz. rechtspositivistisch könnte hier vermerkt werden: es gibt wenig entsprechende neue gesetze(svorhaben). das bekannteste ist das it-sicherheitsgesetz. der begriff des bevölkerungsschutzes findet sich nicht im grundgesetz. es handelt sich auch nicht primär um einen rechtlichen, sondern um einen politischen begriff, der seit ca. dreißig jahren als oberbegriff für zivilschutz, polizeiliche gefahrenabwehr. bei polizeilichem handeln ist zu prüfen, ob eine ermächtigungsgrundlage einschlägig ist und ob die voraussetzungen dieser norm erfüllt sind. wieweit die generalklausel neben standardmaßnahmen oder spezialermächtigungen als "auffangtatbestand" einschlägig ist, hängt vom einzelfall ab. in der regel ist die anwendung der generalklausel ausgeschlossen, wenn sich aus dem konkreten einzelfall ergibt, dass standardmaßnahme oder spezialermächtigung einen problemkreis abschließend regeln sollen. ist dies nicht der fall, kann m. e. in allen bereichen des gefahrenabwehrrechtes auf die generalklausel zurückgegriffen werden. unter dem begriff hilfeleistungsrecht werden feuerwehr-, rettungsdienst-, katastrophen-und zivilschutzrecht zusammengefasst. auch diese aufgaben gehören (wie das polizeirecht) als nichtpolizeiliches gefahrenabwehrrecht zum besonderen verwaltungsrecht. daraus folgt, dass feuerwehr und rettungsdienst auf das allgemeine ordnungsrecht und seine ermächtigungsgrundlagen -vor allem die generalklausel und die bestimmungen über störer/nichtstörer zurückgreifen können, soweit sie nicht selbst eine dem § 14 absatz 1 des preußischen polizeiverwaltungsgesetzes (prpvg) nachgebildete generalklausel zur verfügung haben. eine entsprechende generalklausel kennt das polizei-und das ordnungsrecht in den ländern. diese generalklauseln (da sie alle derselben vorschrift nachgebildet sind) greifen immer in der gleichen situation, nämlich dann, wenn gefahr für die öffentliche sicherheit und ordnung besteht. sie ziehen allesamt dieselbe rechtsfolge nach sich: es können die notwendigen maßnahmen getroffen werden. notwendig bedeutet "geeignet" und "erforderlich". unter "erforderlich" versteht man, dass es kein milderes, gleich zweckgeeignetes mittel geben darf. da die generalklausel als ermächtigungsgrundlage in die rechte der bürger eingreift, ist immer auch die verhältnismäßigkeit des eingriffes zu prüfen. der grundsatz der verhältnismäßigkeit, dem verfassungsrang zukommt, begrenzt jede maßnahme. der katastrophenschutz umfasst alle maßnahmen des landes zum aufbau eines einheitlichen hilfeleistungssystems bei großschadensereignissen als ergänzung der normalen gefahrenabwehr (brandschutz-und rettungsdienst). kreisfreie städte und kreise unterstützen durch vorsorgliche planungen (gefahrenabwehrpläne, maßnahmekalender, etc.) und einrichtungen. die bezeichnungen, der regelungsumfang und der zuschnitt der gesetze sind in den ländern zum teil sehr unterschiedlich, die kernaufgaben aber im wesentlichen gleich. länder, kreise und gemeinden haben aufgrund dieser vorschriften jeweils zuständigkeiten und aufgaben innerhalb der allgemeinen gefahrenabwehr. der rettungsdienst ist z. b. in der regel den kreisen zugewiesen, der feuerschutz den gemeinden. der "staat" im sinne des grundgesetzes sind bund, länder und gemeinden. die grundsätzlichen zuständigkeiten in der nichtpolizeilichen, auf den bevölkerungsschutz bezogenen gefahrenabwehr sind auf diese drei ebenen aufgeteilt. den kommunen (städte und gemeinden, kreise und kreisfreie städte), obliegt die zuständigkeit in der gefahrenabwehr, für den brandschutz-und rettungsdienst (alltägliche gefahrenabwehr). die städte und gemeinden handeln ggf. im rahmen der bundes-bzw. landesauftragsverwaltung. die übertragenen tätigkeiten sind pflichtaufgaben und müssen umgesetzt werden. somit ergeben sich konkret folgende zuständigkeiten: das land für den katastrophenschutz auf landesebene und überörtliche gefahrenabwehr in planerischer und finanzieller hinsicht, der bund für ergänzung und erweiterung in bezug auf konzeption und finanzierung, sowie bei ergänzungsteilausstattung für einsatz und überwachung, die kommunen/städte (gemeinden) und kreise: brandschutz-und rettungsdienst (tägl. gefahrenabwehr). die kommunen sind in bundesauftragsverwaltung für einsatz, überwachung und verwaltung der vom bund gestellten ressourcen, in landesauftragsverwaltung für überwachung und einsatz der vom land aufgestellten einheiten zuständig. das katastrophenabwehrrecht ist vom recht der allgemeinen und besonderen gefahrenabwehr (ordnungsbehördenrecht, polizeirecht) abzugrenzen. die zivile gefahrenvorsorge ist, was den katastrophenschutz betrifft, grundsätzlich ländersache. die gesetzlichen regelungen in den ländern unterscheiden sich oftmals. dennoch bleibt das grundsystem in seinen strukturen erhalten und die länderspezifischen systeme sind kompatibel, wenn z. b. vor einem großschadensfall gemeinsam überlegt wird, wie zusammengearbeitet werden kann. im katastrophenfall arbeiten alle staatlichen ebenen ungeachtet der grundsätzlichen trennung eng zusammen. rechtsgrundlage bildet die amtshilfe, art. 35 abs. 1 gg. dies gilt in den grenznahen regionen auch grenzüberschreitend. trotz der brexit-entscheidung und der übergabe des austrittsgesuches durch premierministerin may -europa wächst zusammen. die deutsch-niederländische grenze ist für den unkundigen an manchen stellen nicht zu erkennen. konzeption "zivile verteidigung" in der konzeption "zivile verteidigung" (kzv) ist u. a. festgelegt, dass die funktionsfähigkeit der lebens-und verteidigungswichtigen einrichtungen und anlagen zu den strategischen zielen des zivilschutzes in deutschland gehört. das bbk wird in einer rechtsverordnung zum sicherheitsüberprüfungsgesetz (süg) konkret als lebenswichtige einrichtung im öffentlichen bereich definiert. diese feststellung bedeutet, dass die tätigkeit in bestimmten bereichen des bbk als sicherheitsempfindlich gilt. das führt dazu, dass es zur ausübung solcher tätigkeiten einer vorherigen sicherheitsüberprüfung bedarf. anders als im bereich geheimschutz, wo es um den zugang zu oder den umgang mit verschlusssachen geht, erfordert hier schon die beschäftigung an einer sicherheitsempfindlichen stelle innerhalb einer lebenswichtigen einrichtung eine sicherheitsüberprüfung. diese personellen maßnahmen werden als "vorbeugender personeller sabotageschutz" bezeichnet. ziel ist es, empfindliche bei derartigen risiken, gefahren und katastrophen ist die kommunikation zwischen den handelnden fachleuten (katastrophenschutzbehörden, thw, hilfsorganisationen etc.) und der bevölkerung schon immer bedeutsam gewesen. die bedeutung dieser auf konkrete gefahren bezogenen kommunikation die gemeinhin in risikokommunikation (kommunikation über risiken vor der krise) und krisenkommunikation (kommunikation während der krise) differenziert wird, hat aber mit der nutzung der social media und des web. 2.0 eine neue dimension und zusätzliche bedeutung erhalten. hier kann in echtzeit interagiert werden. gleichzeitig wird anhand der social-media-fakten ein gemeinsames situationsbewusstsein der interagierenden möglich, das die veränderungen zwischen dem risiko (eventuell modellierbar, möglichkeit etwas hilfreich-vorbereitendes zu tun) und der konkret gewordenen gefahr in der krise anschaulich macht. anhand der zeitgleichen transparenz objektiver gesichtspunkte und subjektiver wahrnehmungen werden entscheidungen überall transparent und können auch hinsichtlich ihres sinns und zwecks nachvollzogen werden. aus "umsetzen" und "dulden" den grundprinzipien der preußischen verwaltung wird mitwirkung. damit eine risiko-und krisenkommunikation erfolgreich sein kann, ist nicht nur ein informations-und wissensstand der zuständigen behörden über die gefahr erforderlich, sodass je nach sachlage informationen und warnungen erfolgen können. darüber hinaus muss die behörde auch wissen, welche information und welche kommunikation die bevölkerung wünscht bzw. benötigt. denn kommunikation ist interaktion, d. h. sie beruht aus einem informationellen austausch. austausch im zeitalter des web 2.0 heißt austausch "just in time". dies ist über social media möglich, über herkömmliche kommunikationskanäle (presse-mitteilungen, radio, fernsehen) nicht. um das informationsbedürfnis nachvollziehen und vorausberechnen zu können sind social-media-analysen der social media communities denkbar, z. b. "zeitgeist" für google oder "memology" für facebook (vgl. opinioiuris 2013; wikipedia 2015 wikipedia , 2017b . informationserhebung, -analyse und -verarbeitung, z. b. um ein aktuelles lagebild zu erstellen war schon immer eine zentrale teilaufgabe der gefahrenabwehr. auch das ziel: vollständigkeit, validität und aktualität der daten hat sich nicht geändert (vgl. gusy 2011, s. 187 f.) . deshalb könnte der eindruck entstehen, bei der social-media-analyse handele es sich lediglich um eine qualitative verbesserung einer ansonsten prinzipiell gleichwertigen verfahrensweise, eine besondere form der informationsgewinnung (vgl. walus 2013, s. 2). als maßnahme bei der daten und informationen erhoben werden, könnten personenbezogene und spezifische social media analysen das grundrecht auf informationelle selbstbestimmung (artikel 1 in verbindung mit artikel 2 gg) bzw. den schutzbereich des fernmeldegeheimnisses (artikel 10 absatz 1) tangieren, bei der allgemein gefahrenaufklärenden analyse ist dies aber nicht der fall (vgl. opinioiuris 2013). grundsätzlich obliegen social-media-analysen den für die gefahrenabwehr zuständigen behörden, in der regel auf landes-, kreis-, oder gemeindeebene, denen der katastrophenschutz und die katastrophenvorsorge übertragen sind. die verwaltungskompetenz auf dem gebiet der gefahrenabwehr liegt in der regel bei den ländern. dessen ungeachtet haben bundesverfassungsgericht und bundesverwaltungsgericht entschieden, dass die regelungen der artikel 63 ff., gg insbesondere die aufgabe der staatsleitung auch die informationstätigkeit der bundesregierung mit umfassen. die an der selbstverantwortung der bürger ausgerichtete politische ordnung deutschlands gebietet es, den bürger durch ausreichende information auch in die lage zu versetzen, dieser selbstverantwortung gerecht zu werden. dies gilt im besonderen in krisensituationen 8 . sogar im zivilschutz ergänzen behördliche maßnahmen nur die selbsthilfe der bevölkerung (vgl. o. v. 2009 ). diese aufgabe der informationellen krisenbewältigung entspricht dem heutigen begriff der risiko-und krisenkommunikation. die wahrnehmung dieser aufgabe erfordert eine nutzung der social-media. der umfang wäre im einzelnen festzulegen. die nutzung der social-media ermöglicht mithin die partizipative beteiligung der bürger. sie ermöglicht zudem eine situationsanalyse, die ein schnelles "vor die lage kommen" erlaubt. über risiken und krisen-/katastrophensituationen wird kommuniziert, zwischen den bürgern untereinander, zwischen staaten, zwischen staat und bürger. dabei ist der staat im sinne des artikel 28 grundgesetz umfassend als bund, länder und gemeinden und die zuständigen behörden (i. b. den gefahrenabwehrbehörden) zu verstehen. damit eine erfolgreiche krisenkommunikation später funktionieren kann, müssen bereits in der risikokommunikation die grundlagen gelegt werden. dabei ist die lebenswirklichkeit der bürger bestimmend. risikokommunikation ist der zielgerichtete austausch oder das teilen von informationen über risiken, deren potenzielle folgen sowie deren bewältigungsstrategien zwischen politischen, behördlichen (staatlichen) und anderen interessenvertretern sowie der öffentlichkeit, z. b. den medien und der bevölkerung. bei dem prozess der risikokommunikation handelt es sich um einen zielgerichteten, grundsätzlich partizipativ angelegten kommunikationsprozess, den austausch von informationen. in diesem prozess kommunizieren staat und bürger gleichberechtigt miteinander. dieser prozess vollzieht sich im gespräch (in der normalen face to face kommunikation) gleichzeitig. ein gegenseitiges aufeinander eingehen ist nicht nur möglich, sondern normal. diese gleichzeitigkeit war bis vor wenigen jahren in der risikokommunikation nur sehr eingeschränkt möglich, in der krisenkommunikation waren die einschränkungen noch viel größer. daher wurden eher "verlautbarungen" der behörden, anweisungen und verhaltensmaximen erwartet. heutzutage ist weltweit (auch in deutschland) die lebenswirklichkeit von immer mehr menschen durch die jederzeitige nutzung der social-media bestimmt. das mobiltelefon ist zum leicht transportablen computer geworden, mit dem eine kommunikation (mit wem ich will) jederzeit, sieben tage die woche, 24 h am tag möglich ist. diese selbstverständlich gewordene kommunikationsverfügbarkeit und -nutzung gilt für alle themen, das internet bietet hier nahezu unbegrenzte möglichkeiten. das hat vielfältige gründe, einer der wichtigsten ist die schnelligkeit und zielgenauigkeit des informationsflusses. ich bekomme genau die information genau dann, wann ich sie will. das informationsbedürfnis wird unmittelbar gestillt. unterrichtung durch die bundesregierung antwort der bundesregierung das gesetz zum besseren informationsaustausch bei der bekämpfung des internationalen terrorismus. neue zeitschrift für verwaltungsrecht polizei-und ordnungsrecht (8. aufl., s. 187 f.) rechtshandbuch zivile sicherheit innerer staatsnotstand handbuch des katastrophenrechts, schriften zum katastrophenrecht (bd. 9 bundeswehr und polizei werden in den nächsten tagen gemeinsam den ernstfall eines terroraktes proben gesetz über den zivilschutz und die katastrophenhilfe informationserhebungen durch social-media-analysen im rahmen der staatlichen risiko-und krisenkommunikation bundeskompetenzen im bevölkerungsschutz das katastrophenschutzrecht der europäischen union handbuch krisenmanagement (2. aufl.). wiesbaden: springer vs resilienz und recht im bevölkerungsschutz informationserhebungen durch social-media-analysen im rahmen der staatlichen risiko-und krisenkommunikation social media key: cord-338332-msjtncek authors: sharifian, neika; sol, ketlyne; zahodne, laura b.; antonucci, toni c. title: social relationships and adaptation in later life date: 2020-09-18 journal: reference module in neuroscience and biobehavioral psychology doi: 10.1016/b978-0-12-818697-8.00016-9 sha: doc_id: 338332 cord_uid: msjtncek social relations encompass a complex and dynamic set of characteristics that have been shown to distinctly affect health and quality of life across the lifespan and especially in older adulthood. in this chapter we begin with a brief review of several prominent theories of social relations. next, we consider how social relations can be understood based on the resource they provide (e.g., contact frequency, social support), the relationship they stem from (e.g., friends, family), the strength of the tie (e.g., strong, weak) as well as the means of communication (e.g., offline, online). we briefly summarize how these characteristics have been shown to uniquely influence health and quality of life in older adulthood. finally, we contemplate potential clinical applications, provide recommendations for the future and offer final concluding comments. social relations have been increasingly recognized as fundamentally important to the health and well-being of individuals in every part of the world and may be especially relevant in later life. older adults may be more susceptible to the risks of social isolation due to age-related changes such as retirement, changes in health, and loss of network members (e.g., widowhood). indeed, survey research conducted in the united states reports that american adults aged 60 years and older report spending over half their waking hours alone (livingston, 2019) . about 28%, estimated to be roughly 13.8 million individuals, of all non-institutionalized american older adults reported living alone in 2017 (administration for community living & administration on aging, 2018). although higher proportions of older adults living alone are seen in north american and nordic countries (reher and requena, 2018) , similar trends are emerging globally. for instance, in singapore, the number of older singaporeans (65 years and older) living alone is estimated to increase by 42% from 2012 (35,000) to 2030 (83,000) (ministry of health, 2016). further, the proportion of older adults world-wide is also increasing (i.e., population aging). as of 2015, an estimated 8.5% of the world's population was aged 65 and older. by 2030, this is projected to increase to 12%, and by 2050, 16.7% of the world's population will be 65 years or older (he et al., 2016) . this increase in the older adult population is paired with the proportion of youth (under 20 years old) remaining flat over the same time period (he et al., 2016) . a rapidly aging population will face several socioeconomic and health-related changes such as increased chronic disease burden, increased healthcare costs, and reduced labor supply (bloom et al., 2015) , this despite the fact that people are remaining healthier longer. as social relations are a modifiable factor that has been linked to a variety of health-related outcomes (cacioppo and cacioppo, 2004; cornwell and waite, 2009; coyle and dugan, 2012; steptoe et al., 2013) , coupled with increases in population aging, the need to understand the implications of social relations or lack thereof (i.e., social isolation) is becoming more relevant and more urgent. in past decades, the field has made great progress in developing increasingly sophisticated evidence to document the who, what, why, and how of social relations. as the field moved forward, social relations was identified as an umbrella term that refers to structural characteristics of the social network (e.g., age, gender, education of network members), social support (e.g., aid, affect or affirmation that is exchanged) and support adequacy or satisfaction (e.g., the evaluation of the support network and social support available to the individual). all of these aspects of social relations, in turn, affect the individual's health and well-being both contemporaneously and longitudinally. while empirical evidence has accumulated in support of positive effects of social relations on health and well-being, there has also been recognition that not all social relations are positive or have a positive effect on people. it is clear that some people are disadvantaged by negative or ambivalent relations which, in turn, have the potential to negatively influence health and well-being. this greater specificity has framed and advanced the scientific study of social relations. in this chapter we begin with a consideration of several prominent theories of social relations, highlighting important characteristics of social relations as well as potential age-related changes in social relations. next, we move to a summary of extant knowledge about how social relations are associated with health and quality of life by examining the hierarchical breakdown of social relations (see fig. 1 ). to exemplify this, we can use contact frequency, one specific dimension of social relations, as an example. contact frequency is one unique social resource stemming from social relations and can be viewed as distinct from other social resources (i.e., social support, social strain, etc.). this resource can further be broken down by examining the source of this social contact. is the individual interacting with friends, family, children, their spouse, a neighbor, etc.? even further, an examination of the strength of that specific relationship tie can also highlight the unique contributions to health. is the individual interacting with a close or more casual friend? or a combination of close family and casual friends? finally, as technology is increasingly facilitating social interactions, we examine how individuals are in contact with their social ties. is the individual interacting with a close friend inperson or simply calling a friend to chat? each of these dimensions may have unique implications for how social relations influence health and quality of life. in this chapter, in line with this breakdown of the complexities of social relations depicted in fig. 1 , we discuss the different dimensions of social relations, including positive and negative aspects of relations. further, we will consider different relationship types from parents and peers in early life to family and friends in later life, noting the critical role of each. we also examine the interesting and evolving research recognizing the strength of weak ties. finally, with recognition of the rapidly changing world and influence of technology, the means of communication are reviewed and discussed. individuals engage in social relationships across the life course and it is important to note that age-related changes in the structure, function and quality of social relations occur in later life. prior theoretical and empirical evidence has documented the structure of older adults' social networks as well as mechanisms that may explain shifts in social relations such as partner selection and how older adults deal with interpersonal conflict. the following section highlights three prominent theories commonly used in the aging literature that focus on social relations: (1) the convoy model of social relations, (2) socioemotional selectivity theory, and (3) the strength and vulnerability integration model. we acknowledge that these are not the only theories regarding aging and social relations. our discussion here is simply meant to be illustrative of prominent theories often cited in prior literature. the convoy model of social relations (antonucci, 2001; kahn and antonucci, 1980) was designed to include the individual as part of a dynamic network across the lifespan and over the life course. this model is less culture laden and allows the individual to project their own convoy as they experience it without being driven by external norms or expectations. under optimal conditions, the convoy surrounds and supports individuals throughout their life-time. personal characteristics, such as age, gender, and personality, as well as situational characteristics, such as role expectations, resources, and demands, shape the individual's current and evolving convoy. ideally, the people who form an individual's convoy provide a reassuring foundation that helps an individual grow, develop and cope with their life experiences. at the same time, situational factors provide the context within which these social relations evolve. context is important because it situates the individual's expectations as well as the demand characteristics of organizations, roles, and/or norms. both are critical in the development of social relations. in 1987, antonucci & akiyama published one of the first empirical examinations of the convoy model using data from a national study of adults 50 years of age and older collected in 1980. they documented the structure and function of respondents' convoys and examined separately the influence of spouse, children, family and friends. in 2019, antonucci, ajrouch and webster replicated that study with data collected in 2005 from a regionally representative sample and showed remarkable similarities in structure. both cohorts had convoys of similar size, gender composition, years known and sources of support, suggesting that these characteristics are fairly consistent over time. network size in both samples included approximately 7 people, included more women than men, and individuals knew their network members, on average, 38 years. there have also been changes in convoys over the 25 years and not always in the direction that might have been predicted. more recent cohorts were older, lived closer to and had more frequent contact with their network members than the earlier 1980 cohort. on the other hand, there was one notable difference in network composition. proportion of family that composed a convoy was significantly smaller in 2005. reports of emotional closeness were largely the same in the two cohorts, assessed as the number of people defined as closest (3-4), closer (2-3) and close (1-2). composition of convoys were also fairly similar. convoys consisted, in both samples, of spouse, children, siblings and other family and friends. only the percentage of family decreased over the two samples. all others were substantially the same. the authors conclude not only that these are critical characteristics of a convoy but also that despite many demographic and social changes, these appear to be basic and critical elements of the convoy. empirical studies of the effect of social relations on health using the convoy model permit a detailed examination of these associations, often resulting in more nuanced findings or greater specificity with respect to long held or traditional findings. we provide three such examples with respect to mortality, socioeconomic status and network member education. a classic and very important finding in the literature indicates that people with more positive social relations live longer. this is a finding we do not mean to contest. however, antonucci and colleagues found that under conditions of serious or life-threatening illness, people with more negative relations live longer. they interpret the finding as indicating that under some situations negative relations may be experienced as negative but prolong life by encouraging life-saving behavior change such as diet, exercise or adherence to a medical regimen. another classic finding is that people of lower socioeconomic status have poorer health than people of higher socioeconomic status. this, too, is generally true. yet, in another study by antonucci and colleagues (antonucci et al., 2003) , middle aged men of lower socioeconomic status with key support from their children were as healthy as men of higher socioeconomic status. and finally, webster and colleagues (webster et al., 2013) found that the education level of network members was significantly associated with an individual's self-rated health, above and beyond their own educational attainment and also controlling for that individual's age, gender, race, and marital status. while it is a long standing finding that higher education is associated with health, this finding indicates the importance of the education level of the people closest to you for your own health. in summary, these findings suggest that careful assessment of personal, situational and social relations characteristics can provide a more nuanced understanding of how social relations influence health and well-being of the individual in later life. socioemotional selectivity theory (sst; carstensen, 1995; carstensen et al., 1999) is based on and derived from baltes' selection, optimization and compensation model (soc: baltes, 1997; baltes et al., 2006) . according to sst, people make active choices about the number and closeness of relationships in which they would like to invest, and older adults become more selective in choosing their social network members due to shifts in motivation (english and carstensen, 2014) . these shifts in social relations are driven, in part, by perceptions of time rather than age per se. sst is fundamentally a lifespan theory which takes into account different life goals at different points in the lifespan (carstensen et al., 1999) . younger people are motivated to reach out and explore the world, in part, due to having more expansive time horizons (i.e., open-ended). thus, younger adults strive for more knowledge-focused goals (i.e., achievement, accumulating information, etc.) to gain more independence from their family of origin and seek new connections as they seek to discover their place in the world. as individuals get older, sst argues people perceive their time left to live as more limited. with age, people become less interested in exploring new relationships but rather focus on relationships they already have that are more emotionally meaningful. with this goal dominating the basis of their social relationships, people begin to reduce the number of relationships in which they are invested in order to devote more of their remaining time to their close relationships, which become increasingly significant to them. in an early empirical examination of sst, three cohorts of nationally representative samples were examined. across all three cohorts, younger people reported wanting to increase the number of social relations (e.g., friends) while older people felt they had enough friends and were quite satisfied with the current size of their social networks (lansford et al., 1998) . experimental data are also supportive. for example, in a cross-sectional study (fredrickson and carstensen, 1990) investigating social partner selection, individuals were asked who they would spend half an hour of free time with: a member of their immediate family (familiar social partner), a recent acquaintance they have a lot in common with (novel social partner) or an author of a book they read (novel social partner). when asked in the unspecified condition, older adults showed greater preference for familiar social partners compared with younger adults. in contrast, in a condition in which participants were told to imagine they were moving across the country by themselves (i.e., a salient ending condition), younger adults showed similar social preferences to older adults (study 2; fredrickson and carstensen, 1990) . in another study, using the same paradigm as the previous study (fredrickson and carstensen, 1990) , researchers examined social partner selection in hong kong before, right after and 4 months after the september 11th terrorist attacks (study 1; fung and carstensen, 2006) . before september 11th, younger people were less likely to select familiar social partners than older people. right after 9/11, however, age differences were no longer present such that both younger and older individuals showed a preference towards familiar social partners. four months after 9/11, age differences reemerged, showing a greater preference of familiar social partners at older ages (study 1; fung and carstensen, 2006) . further, in a longitudinal study, social partner selection was examined in hong kong during the peak of the sars epidemic and right after it subsided. during the sars epidemic, no age differences in social partner selection emerged, however, after the sars epidemic, younger ages were less likely to select familiar social partners compared with older ages (study 2; fung and carstensen, 2006) . overall, sst highlights the role of motivation, life goals, and context (i.e., perceptions of time left and/or the finitude of life) which influence social relationship preferences. that is, older individuals tend to be more likely to prefer familiar social partners, which may reflect a shift from knowledge-focused goals to emotion-focused goals due to changing perceptions of time horizons. prior research has shown that age is a good predictor of time perception such that older adults show more limited future time perspectives than younger adults (lang and carstensen, 2002) . however, life events and experimental manipulations can also reduce time horizons (e.g., fredrickson and carstensen, 1990; fung and carstensen, 2006) and thus, shifts in motivation and social preferences may occur at any life stage. overall, sst argues that close social relationships become more, not less, important as people age, which may be driven by motivational changes in goals. at the same time and perhaps because of this, people become more selective about their relationships. they prefer to invest what they perceive to be their limited remaining time in relationships that are most important to them. the strength and vulnerability integration (savi; charles, 2010) model, building on the tenets of sst (carstensen et al., 1999) , describes age-related gains and losses that influence the process of emotion regulation in older adulthood. in particular, consistent with sst, the savi model addresses the frequent finding that older adults express higher levels of well-being than younger adults. this finding is somewhat counterintuitive in that older adults are known to experience increased susceptibility to the negative consequences of high emotional arousal, such as from conflict and misunderstandings stemming from social relations. to protect themselves from this vulnerability, older adults are theorized to use strategies that allow them to avoid and/or disengage from emotionally laden situations and do so to a much greater extent than younger adults. indeed, prior research has shown that older adults tend to endorse more passive emotion regulation strategies compared with younger adults (blanchard-fields, 2007) which may have more benefits for health and well-being in later life. for example, in a daily diary study of u.s. adults, older age was associated with less affect reactivity to interpersonal stressors when individuals avoided an argument whereas older age was unrelated to affect reactivity when individuals engagement in arguments (charles et al., 2009) . this strategy, of avoiding negative social situations, serves to protect the older individual from their known heightened sensitivity to stress and may explain, at least in part, the observed age-related benefits in well-being achieved by avoiding negative social situations. this interpretation was further supported in a cross-sectional study in which younger and older adults were presented with audiotapes of two actors insulting another person in which they were instructed to imagine that the negative comments were directed at them (charles and carstensen, 2008) . in response to these imagined insults, older adults made fewer cognitive appraisals about the speakers, expressed less negativity and less anger, but equivalent levels of sadness compared with younger adults in response to the overheard insults (charles and carstensen, 2008) . these findings may indicate that older adults protect themselves by shifting attention away from and disengaging from averse social situations, thus dampening negative responses. in another form of self protection from vulnerabilities and consistent with sst, savi theorizes that older adults maintain social relationships with close others while pruning more peripheral social partners (english and carstensen, 2014) . this occurs in order to help maintain important, emotionally meaningful relationships and helps to maximize emotional well-being (see review, rook and charles, 2017) . these changes in social partner selection are another form of self protection, driven not only by perceptions of time left (i.e., sst), but also by accrued knowledge and experience (charles, 2010) . the amount of time lived may be an important indicator of social expertise (luong et al., 2011) such that older adults may have more experience dealing with everyday life which allows them to be selective and increase efficiency at dealing with and avoiding potential stressors (charles, 2010) . savi further expands on sst by highlighting not only age-related gains (i.e., strengths), but also age-related losses (i.e., vulnerabilities). specifically, older adults experience decreases in the body's ability to downregulate strong negative emotional responses that may have consequences for emotional and physical health outcomes (charles, 2010) . increased difficulty at downregulating sustained emotional arousal and reactivity in older adulthood may, in turn, attenuate age-related improvements in emotion regulation when faced with unavoidable stressors (charles, 2010) . while many long-term social ties are positive, some are not. negative close social relations often cannot be avoided and may be a source of strain and ambivalence. thus, when older adults are unable to avoid situations that cause high levels of distress, such as conflicts or misunderstandings in social relationships, they are likely to experience arousal that may challenge their health and quality of life (rook and charles, 2017) . for example, in a classic finding rook (1984) found that negative relations had a more powerful effect on well-being than positive relations. in a related longitudinal study of british adults aged 40 to 77, negative social interactions were more strongly associated with physical health with older age (hakulinen et al., 2016) . overall, the savi model builds on the foundation of sst, further highlighting the age-related gains and losses associated with maintaining emotional well-being. notably, the savi model posits that older adults actively down regulate emotional stress, avoid high arousal circumstances and/or limit their reaction to those circumstances whenever possible. this approach offsets the increased vulnerability of older people to stress and its negative effects on health and well-being. these strengths and vulnerabilities, in turn, may influence the selection of social network members (i.e., social pruning) as well as how individuals choose to interact during social contexts (i.e., avoiding interpersonal stressors/conflicts). each of these theories are lifespan in nature and offer accumulating evidence concerning individual and specific important insights concerning the who, what, why, and how of social relations. the convoy model of social relations offers an overarching, inclusive theory meant to identify specific aspects of social relations (i.e., structure, support and satisfaction) while also detailing what and how personal and situational characteristics influence the individual's needs for specific aspects of social relations. all antecedent elements of the model influence consequences for the individual in terms of health and well-being outcomes. on the other hand, socioemotional selectivity theory focuses on what motivates individuals to seek and invest in relationships, and specifically what influences exactly the types of relationships in which people will invest (e.g., new vs. old, close vs. distant). sst argues that people are motivated by goals which are affected by circumstances (e.g., time, place and context). this, in turn, influences the choices people make about with whom they choose to spend their time. finally, the strength and vulnerability integration model drills down even further the how and why of social relationships. specifically, savi examines the strategies people, especially older adults, use to avoid extremes of emotions and maintain emotional regulation. this is accomplished by maximizing the positive and minimizing the negative in their relationships (i.e., how) thus avoiding emotion regulation problems often caused by and associated with the stress and strain of difficult relationships and/or circumstances (i.e., why). each theory offers guidance about specific aspects of social relations. some theories motivate specific research questions whereas others guide the interpretation of research findings. while the convoy model provides a heuristic framework within which to understand the causes and consequences of social relations over the life course, sst focuses on the individual's time perspective and what motivates social interactions while the savi model specifies a common strategy among older adults used to maintain high levels of well-being through emotion regulation and avoidance of conflict. in the paragraphs below we use these theories to interpret findings that address common dimensions of social relations, relationship types, and means of communication. finally, we end with a consideration of clinical applications and future recommendations. the extent to which people engage with, and receive benefits from, their social relations is influenced by structural, functional, and qualitative aspects of their relationships (holt-lundstad, 2018) . structural aspects refer to the objective components of the network that are directly observable, such as total network size, age of, gender, relationship to and frequency of contact with network members. supportive or functional aspects of social relations refer to the exchange of aid (e.g., tangible goods, instrumental support), affect (e.g., emotional support, affection), and affirmation (e.g., confirmation of values; informational support). on a more evaluative level, qualitative aspects of social relations are those pertaining to one's subjective experiences of interactions with others in their social networks such as satisfaction, enjoyment, strain or conflict with their relationships. one example of the distinction between structural and qualitative aspects of social relations can be found in the growing literature on social isolation versus loneliness (cacioppo and hawkley, 2009) . social isolation refers to the lack of network members and the lack of support exchanges and corresponds to the objective, structural and functional aspects of not receiving support. in contrast, loneliness refers to the distress experienced or the individual's personal assessment that they are not sufficiently supported by others. that evaluation of a lack of support results in low levels of satisfaction which corresponds to a low evaluation of the quality of their relationships. it should be noted that quality of relationship is a subjective evaluation in that two people with the same support exchanges might evaluate those support exchanges differently, which would then have different effects on health outcomes (van tilburg et al., 1998) . greater specificity of structural, functional, and qualitative aspects of social relations has significantly contributed to a better understanding of how social relations influence health in older adulthood. the following sections explicates specific ways in which structural, functional, and qualitative aspects of social relations distinctly contribute to health-related outcomes. in this section, we frequently highlight cognitive health as illustrative both because of its overall importance and link to alzheimer's disease and because significant advances have recently been made demonstrating the association between social relations and cognitive functioning in numerous populations around the world. social network size is a commonly used indicator of network structure which has been shown to be related to physical (i.e., mortality; berkman and syme, 1979; kauppi et al., 2018) and cognitive health (barnes et al., 2004; bennett et al., 2006) outcomes in older adulthood. for instance, in a clinicopathologic study examining social network size, cognitive functioning and brain pathology at autopsy, individuals with a larger social network showed attenuated associations between brain pathology and cognitive functioning. in other words, even when individuals had more severe levels of brain pathology, cognitive function remained high for participants with larger social networks whereas individuals with a smaller social network showed lower cognitive function at higher levels of brain pathology (bennett et al., 2006) . these findings suggest that social network size may be a source of cognitive reserve and may contribute to the maintenance of cognition, in spite of neuropathology. additionally, a cross-sectional investigation of the role of network size on cognition using a cohort of u.s. older adults by katz and colleagues (katz et al., 2020) found that social network size was significantly related to executive functioning but this association varied by race and ethnicity. they reported that the strongest associations existed between executive functioning and quadratic estimates of the number of close children of non-hispanic black participants, and number of close family members for hispanic participants. on the other hand, among black participants, a curvilinear relationship indicated that less than or more than two close children was associated with lower executive functioning. this was not the case for hispanic participants, among whom higher executive functioning was associated with fewer (0-1) and greater (4-5ã¾) numbers of family member contacts. prior research has also shown the potential benefits of contact frequency for health and quality of life. a recent study by grant and colleagues (grant et al., 2009 ) who followed a sample of middle aged adults in britain, showed that people reporting less contact with network members had higher salivary cortisol upon waking and throughout the day, compared with those in more frequent contact with their network members. these findings suggest that less frequent contact with network members, which could be an indication of social isolation, negatively affects the stress response of the body. as is perhaps evident, this has important implications for other health outcomes. indeed, less contact frequency has been associated with higher mortality (berkman and syme, 1979) . as reviewed in more detail later, this biochemical response to social isolation may be one way by which contact frequency contributes to physical health. in a related longitudinal study of american adults by seeman and colleagues, higher frequency of contact was associated with better executive functioning and better memory while decreases in contact frequency over two time points was associated with worse memory (seeman et al., 2011) . this study was unique in that it began to specify exactly what dimensions of cognitive functioning are influenced by contact frequency. similarly, zahodne and colleagues (zahodne et al., 2019a) , using longitudinal data from a u.s. nationally representative sample of older adults, found that more contact was associated with better memory at baseline and slower memory decline over 6 years. on the other hand, social network size was not associated with memory trajectories (zahodne et al., 2019a) . these findings suggest that it is the stimulation of social contact rather than the number of social ties which positively affects cognitive functioning among older people. these authors also examined the reverse, to see whether memory was associated with changes in social contact over the same span of time. it is noteworthy that they report no association between memory and change in contact frequency (zahodne et al., 2019a) , indicating that it is the loss of social relations that is detrimental to cognitive health, rather than declines in cognitive health leading to more isolation. another important structural characteristic of social relations can be measured by the number of social activities in which an individual engages. number of social activities and/or groups represent a form of structural ties. these appear to be beneficial to cognitive health as they help increase the number of weak ties (i.e., peripheral social ties such as neighbors, acquaintances, etc.) in the social network. these activities seem to promote health through the requirement of active contingent interaction and allocation of resources through the exchange of support (i.e., see in-depth discussion regarding the strength of weak ties in the next section). social activities are those that involve actively interacting with others, such as playing cards, going to church, or playing a competitive sport, and these activities may have implications for health in older age. prior research has found that social activity was associated with less disability at baseline and slower decline in function over 9 years (mendes de leon et al., 2003) . similarly, in another study, barnes and colleagues (barnes et al., 2004) reported that more frequent social activity was associated with baseline global cognitive function and slower decline in global cognition over time, independent of network size. furthermore, the number of different types of social groups with which one engages may also be beneficial for health given that number of social groups is associated with increased network size (hawkley et al., 2008) . the above examples and prior research have shown promising links between structural aspects of social relations and health outcomes. it is important to note, however, that these various structural aspects of social relations work in tandem with other aspects of social relations. just as there are structural aspects of social relations, functional support or the exchange of support as well as qualitative aspects of social relations are important components of social relations that merit further discussion. these functional and qualitative aspects of support may also be independently associated with health. functional or social support refers to the actual support that is exchanged and can be subcategorized by whether the support provided included practical aid (e.g., instrumental/tangible support), affect (e.g., emotional/affectional needs) and/or affirmation (e.g., verification of values) (kahn and antonucci, 1980; krause, 1987) . social support has been shown to be associated with a wide variety of physical and mental health outcomes. for example, an irish longitudinal study of older adults found a negative association between social support and depressive symptoms. of note, this pattern of findings varied across men and women, with higher levels of spousal support and less strain from one's spouse as well as better social network integration being protective against depressive symptoms only in men (santini et al., 2016) . further, there were no associations between support and anxiety for either men or women, suggesting that functional aspects are more impactful for mood compared to anxiety (santini et al., 2016) . another longitudinal study similarly found that baseline social support and change in social support over 3 years were both related to depressive symptoms in that more support was related to fewer depressive symptoms, but loss of support was related to more depressive symptoms (oxman et al., 1992) . in regards to cognitive health, in a longitudinal study of american older adults, no associations between baseline social support and change in cognitive function was found; however, the authors did find an association between satisfaction with social support (i.e., quality) and global cognitive function and processing speed/attention at baseline . social support may also facilitate increased physical activity in older adults, which may be another way of promoting health and well-being over time. for instance, in a study of south korean older adults, social support was related to increased physical activity (kang et al., 2018) . this increase may be due to the increased accountability and companionship that comes with joint physical activity, which can help older adults be more motivated to adhere to fitness regimens and other healthy behaviors to promote overall quality of life. examining an outcome such as physical activity engagement may be an area where the type of support given and received can be further disentangled as the reciprocal benefits of support given and support received may have mutually beneficial health outcomes. it is important to note, however, that individuals can both receive and provide social support to network members and these may have distinct effects on health in later life. for example, in a study by thomas (2010) , when simultaneously modeling support received, support given, and other aspects of social relations, the authors found that psychological well-being was positively associated with support given, while support received was not associated with psychological well-being. these findings suggest that when considering indicators of psychological health, it may be more important to consider the effects of support, both given and received, in order to identify more salient effects of social relations on mental health outcomes. to this point, a study by lafleur and salthouse (2017) found that providing both informational and emotional support were beneficial for memory. a similar pattern of findings has also been demonstrated internationally. specifically, in a longitudinal study examining older adults in southwestern france, independent of other indicators of social relations such as network size, receiving more support than giving support was associated with lower odds of dementia incidence (amieva et al., 2010) . of note, another longitudinal study of american older adults found that emotional support received was independently associated with change in overall, better cognitive performance after accounting for other indicators of social relations, including perceptions of support given by the participant (seeman et al., 2001) . in this same study, authors found that the effect of support given as indicated by a measure asking about frequency of instrumental and emotional support given, was not associated with cognition at baseline or change in cognition over two times points. combined, these studies highlight the importance of the type of functional support exchange to improve health, and that the effect of giving support may not be equally associated with positive health outcomes as support received in similar types of support exchanges. the quality of one's social relations may have a unique effect on later life health outcomes. social strain, a distinct negative qualitative aspect of social relations, can be described as the degree of interpersonal conflict and/or obligatory interactions (i.e., family obligations), that results in the person perceiving increased dissatisfaction and distress from these interactions (yang et al., 2014) . prior research has linked social strain in older adulthood to health-related outcomes. for example, in the study mentioned above by antonucci and colleagues investigating the links between social strain and health, under conditions of serious illness, the strength of positive and negative interactions with network members was associated with mortality in a somewhat counterintuitive manner. stronger negative interactions were related to lower mortality as were weaker positive interactions. on the other hand, a study of danish middle aged adults, always or often experiencing social strain had higher risk of mortality compared with those who reported seldom experiencing these strains (lund et al., 2014) . in a longitudinal study, seeman and colleagues (seeman et al., 2011) investigated a cohort of american older adults and found that more social strain was independently associated with worse executive function while accounting for other social relations. of note, these authors did not find measures of quality of social relations to be related to change in cognitive function over time (seeman et al., 2011) . recall that in the longitudinal study of irish older adults mentioned above examining associations of social strain with depressive and anxiety symptoms, a positive association between social strain and depressive symptoms but no association between strain and anxiety was found (santini et al., 2016) . together these studies suggest that while strain may have overtly negative health consequences, there may be aspects of interacting with others that may be protective, indicating that further study into the mechanisms underlying the association between social strain and health is warranted. because of the ways that social strain affects mental health, physical health, and cognitive health, studies have also found that qualitative aspects of social relations are associated with increases in similar biochemical processes in the body. in a study examining social strain and risk of elevated inflammation using a composite of five indicators of inflammation (c-reactive protein, fibrinogen, interleukin-6, e-selectin, intracellular adhesion molecule 1), social strain was independently associated with increased risk for elevated inflammation (yang et al., 2014) . further, the effect of social strain was stronger than the effect of social support, confirming rook's (1984) finding and suggesting that the presence of social strain may be more detrimental to health than the absence of social support (yang et al., 2014) . these findings provide some insight by which social strain can affect physical and mental health outcomes. as the convoy model suggests, both personal and situational characteristics influence the structure, function and quality of life. one manifestation of the situation is culture, which can fundamentally influence expectations and evaluations of social relations. what may be seen as social support in some cultures, may be perceived as social strain or conflict in others. their detrimental effects may then depend on the cultural norms as well as how closely individuals identify with a particular culture and adhere to its norms. as an example, collectivistic cultures may view responsibility of family members, particularly responsibility to older adults, to be important in family relations. a qualitative study by willis (2012) explored this topic in a study on caregiving of older adults in britain around ethnic identity and duty to elders in examining the effects of collectivistic cultures. those who identified with their ethnic group membership, and whose ethnic group valued service and support of elders as one behavioral indicator of collectivistic culture, were more likely to indicate agreement that younger generations should take care of their elders. in this study of largely ethnic minorities, minorities of south asian descent and white irish immigrants endorsed beliefs consistent with collectivistic ideals of taking care of elders, while white british older adults did not endorse these beliefs (willis, 2012 ). an international comparison of perceived filial piety (i.e., responsibility for elders) in five european countries, germany, israel, norway, spain, the united kingdom and the united states similarly found that sense of filial piety depended on the collectivist versus individualist orientation of the european country and, in the case of the united states, the ethnic/racial background of the respondents (jackson et al., 2008) . although perception of obligation regarding elder care may be either individually or culturally based, an elder who perceives a younger person as not adhering to those elder care norms may experience their relationship as strained when these expectations are not met. quality of relationship, as noted above, refers to the individual's evaluation of their social relationships. thus, people with the exact same amount of exchanges (functional support) and number of relationships (structure of social network) can feel differently about the quality of their relationships. one might feel their relationships are perfectly adequate, another might feel dissatisfied with the same relations and, instead of being content with them, feel quite lonely. thus, loneliness is differentiated from structural network characteristics, such as social isolation, and functional characteristics such as support received, in that it is the individual's evaluation of satisfaction with their social relations that affects health and emphasizes the person's negative emotional reaction to their dissatisfaction with the quality of their social relations. loneliness, in particular, may be a salient example of the importance of investigating quality of social relations. increased loneliness in older age has been linked to a number of mental health, physical health, and cognitive outcomes. for example, more loneliness is associated with increased depressive symptoms over time . loneliness has also been associated with poorer physical health, as indicated by increased physical disability (shankar et al., 2017) , hypertension , and increased mortality (patterson and veenstra, 2010) . furthermore, individuals who reported often feeling lonely had a higher risk of mortality due to non-ischemic cardiovascular diseases, compared with those who reported never feeling lonely, when accounting for other aspects of social relations (patterson and veenstra, 2010) . the odds of non-ischemic cardiovascular mortality were higher than all-cause mortality, suggesting that loneliness's impact on cardiovascular health may be a leading cause of death (patterson and veenstra, 2010) . indeed, other studies have examined loneliness and cardiometabolic disease and demonstrated that increased risk of metabolic syndrome (e.g., waist circumference, triglycerides, high density lipoprotein cholesterol, blood pressure, and fasting glucose; whisman, 2010) is associated with higher amounts of loneliness. loneliness may also impact cognitive health in older adulthood. while one cross-sectional study with an american sample of racially and ethnically diverse older adults did not find an association between a comprehensive measure of loneliness and episodic memory when accounting for structural aspects of social relations and other psychosocial factors (sol et al. under revision) , another cross-sectional study with an irish sample did find an independent association between loneliness and global cognition, processing speed, and visual memory when accounting for social network integration (o'luanaigh et al., 2012) . in a recent longitudinal study of social activities among chinese older adults, an independent association emerged between loneliness and global cognitive decline over 9 years, among those engaging in more frequent social activities (zhong et al., 2017) . loneliness has also been associated with increased inflammation, important as inflammation is often associated with all of the aforementioned health outcomes (kiecolt-glaser et al., 2010) , including cognitive function (zahodne et al., 2019b) . increased inflammation is one of the mechanisms proposed by hawkley and capitanio (2015) , as to how loneliness affects health. thus, further study of the biochemical mechanisms between loneliness and various health outcomes may also provide insight into ways to reduce its detrimental effects in older age. additional specification is suggested in a recent study by kang and colleagues (kang et al., 2018) who found that while physical activity did not mediate the relationship between social support and quality of life, the positive relationship between social support and quality of life was mediated through a negative relationship with loneliness. these findings show how other aspects of social relations (i.e., functional exchanges/ support) can affect health outcomes through qualitative factors (i.e., loneliness). furthermore, when modeling both social isolation and loneliness concurrently, their relative impact may depend on the outcome studied, as social isolation may be related to increased likelihood of poorer self reported health, while increased loneliness may be related to increased likelihood of poorer mental health (coyle and dugan, 2012) . taken together, these studies highlight the complexity of various aspects of social relations and loneliness and how they each contribute to overall health. as loneliness may be a potential risk factor for health and quality of life in older adulthood, understanding the antecedents of loneliness may be an important area for future intervention. several factors may contribute to the experience of loneliness. previous experiences of loneliness may be one predictor which leads to a cyclical pattern of behaviors which results in additional feelings of loneliness over time (cacioppo and hawkley, 2009) . personality influences social relationships and these relatively fixed characteristics may contribute to the cycle of loneliness, particularly characteristics indicating neuroticism (buecker et al., 2020) . nonetheless, other research has found that levels of neuroticism decrease over the life course (ormel et al., 2012) , which is promising as older adults who experience elevated levels of neuroticism earlier in the life course may be able to seek and maintain the relationships they desire in order to reduce loneliness. taken together, these concepts and the related studies show the importance of examining not only the structural aspects of social relations but also the exchange of support and the subjective or evaluative aspects of social relations. consistent with the tenets of the social convoy model, this evidence helps identify why structural aspects of social relations are important given its emphasis on the observable aspects of social networks and the ways in which these observable aspects influence health over the life course. in addition, this evidence helps identify why structural characteristics such as network size and frequency of contact contribute to health because the presence of others and contact with them is essential to developing the relationships critical to health. further, an examination of the distinct dimensions of social relations helps identify ways in which the qualitative aspects of relationships helps to motivate reasons for maintaining contact in older age in order to better invest limited time with more meaningful relationships, as proposed by and consistent with socioemotional selectivity theory. similarly, the links between higher quality social relations and health outcomes supports the tenets proposed by the savi model, which suggest that maintaining contact with desired others and pruning unwanted relationships reinforce positive emotional experiences with desired others. these motivations to protect limited time (i.e., sst) and to increase positive emotional experiences (i.e., savi) can be in the form of both support/functional exchanges as well as perceived relationship quality. given that none of these aspects of social relations exists in isolation nor are easily separable, future work can further refine understanding on the ways in which structural, functional, and evaluative aspects of social support may improve overall health. understanding the nuances underlying social relations may also help improve interventions that target improving structural, functional support exchanges, and qualitative aspects of social relations in order to better meet and resolve older adults' specific needs in social relations. further, structural and functional aspects of social relations such as social isolation and support exchanges, as well as qualitative aspects such as loneliness, are specific ways in which social relations affect health. examining these various components of social relations together may help improve future study into ways to increase the beneficial aspects of social relations while reducing those characteristics of social relations that negatively affect health in older adulthood. as we seek to understand the association between social relations and health, it has become clear that specific social relationships may provide unique forms of interaction and support. in the following sections, we highlight the characteristics and importance of several types of social relations and their unique impact on later life health. we highlight (1) the importance of early-life social relationships with parents and peers, (2) the importance and distinctions between friends and family, and (3) the role of weaker social ties such as fellow church members and neighbors in older adulthood. prior research focusing on social relationships in later life as well as a majority of the research covered in this chapter predominantly focus on the associations between current social relationships and health outcomes in older adulthood. it should be acknowledged, however, that social relationships grow and develop across the lifespan. specifically, social relationships in childhood play a critical role in developmental processes that have been shown to have far reaching effects on social, mental, physical and cognitive health in adulthood. as theorized in attachment theory and the social convoy model, social relationships build from previous social experiences (antonucci et al., 2014; bowlby, 1980) . specifically, attachment theory argues that children develop internal working models of attachment (i.e., a representation of one's self and of relationships in general) that will guide expectations and behaviors exhibited in future social relationships (see chapter, siegler et al., 2011) . indeed, prior research examining attachment of white middle-class infants at 12 months old showed that a majority of the infants (72%) received the same secure/insecure attachment classification in early adulthood (waters et al., 2000) . therefore, early life relationships with parents and important others may have far reaching effects on health and quality of life through late life current social relationships. further, prior research also suggests that early life social relationships may influence health more directly through the development of physiological stress response (luecken and lemery, 2004) . that is, children who have poorer quality relationships with parents may be hypervigilant to threat cues in their environments, may exhibit poor self-regulatory responses (i.e., maladaptive coping strategies) and elevated physiological stress responses (see reviews; luecken et al., 2006; luecken and lemery, 2004) . in line with this notion, prior research has linked parental social relationships to a variety of health outcomes later in life. for example, in a cross-sectional study of u.s. adults examining the associations between retrospective childhood social support and allostatic load measured by a sum of risk scores across 7 physiological systems, higher social support in childhood (emotional and instrumental) was associated with less biological dysregulation in midlife (slopen et al., 2016) . consistent with these crosssectional findings, a longitudinal study of harvard undergraduate men found that lower ratings of parental caring in young adulthood was associated with greater risk of illnesses such as coronary artery disease, hypertension, duodenal ulcer, and alcoholism 35 years later (russek and schwartz, 1997 ). an examination of the influence of early parental relationship quality on cognitive health outcomes by sharifian and colleagues revealed that respondents from a nationally representative u.s. sample of older adults who reported higher retrospective maternal relationship quality showed less decline in episodic memory over time through reduced loneliness and depressive symptoms. similarly, in a population-based longitudinal study of non-hispanic african american and white adults, greater retrospective childhood social support was associated with better initial memory through educational attainment and mental (stress) and physical (bmi) health pathways (zahodne et al., 2019c) . these findings highlight the enduring effects of early life social relationships on health-related outcomes directly and indirectly through multiple biopsychosocial pathways. in addition to parental relationships, peer relationships in childhood and adolescence may also have long-term implications for health. peer relationships become especially salient as individuals begin to spend more time with age peers in adolescence and begin to value expectations of peers more highly (see chapter, brown and larson, 2009) . social acceptance by peers has previously been identified as a reliable indicator of socioemotional and behavior adjustment outcomes and are thought to have long-term ramifications for developmental processes over the life course. for example, in a 27-year prospective swedish cohort study, peer problems at age 16, defined by perceived degree of unpopularity and social isolation at school, were linked to greater risk of metabolic syndrome at age 43 (gustafsson et al., 2012) . this finding was robust after accounting for health behaviors, school adjustment and family circumstances in adolescence as well as psychological distress, health behaviors and social circumstances in adulthood (gustafsson et al., 2012) . peer bullying specifically has also been associated with a variety of health-related later outcomes. for example, in a longitudinal study following american children into young adulthood, being a victim of bullying as well as being a bully-victim (i.e., someone who is bullied and is also a bully) was associated with increased risk of poorer health, socioeconomic and social-relationship outcomes in adulthood (wolke et al., 2013) . consistent with the previous study, in a 50-year prospective follow-up of a british birth cohort, bullying victimization in childhood (ages 7 and 11) was associated with worse mental, physical, and cognitive health outcomes in midlife (takizawa et al., 2014) . findings specific to adult social relationships indicate that bullying in childhood was associated with weaker social relationships in adulthood (takizawa et al., 2014) and support the hypothesis that later-life social relationships are based on and develop from earlier relationships such as interactions with adolescent peers. these findings are consistent with the social convoy model and attachment theory, suggesting that parental relationships in childhood and peer relationships in adolescence may act as building blocks for developmental processes in later life. specifically, early life social relationships may influence current and later life health outcomes (i.e., mental, physical, cognitive) through the early development of internal working models of attachment. these early life social relationships may also influence health outcomes through their impact on threat appraisal, self-regulatory and physiological responses to stress (luecken et al., 2006; luecken and lemery, 2004) . additionally, although not discussed in detail in the current chapter, early life social relationships with parents have been linked to self-regulatory behaviors in childhood (eisenberg et al., 1999) and in early adulthood (baker and hoerger, 2012) . thus, children and adolescents who develop appropriate self-regulatory skills in childhood are likely to show better regulation skills later on in life. this may be an important individual difference that influences emotion regulation strategy selection and efficiency in order to avoid age-related vulnerabilities to high arousal situations (i.e., conflicts, misunderstanding) as conceptualized within the savi model. in light of the above summarized findings, we conclude that it is important to consider not only current characteristics of social relations in older adulthood, but also significant social relationships at pivotal developmental periods. an ongoing issue in the field of social relations is the relative importance of family and friends as well as their association with health and well-being, especially in later life. when prior research has compared the distinct effect of friends and family, friendships are often shown to more strongly benefit later life health and quality of life. for example, in a cross-sectional study across 97 countries, valuing both family and friendship relationships was associated with better health and higher happiness, however, valuing friends became a stronger predictor of health and happiness at older ages (study 1, chopik, 2017) . in a longitudinal follow-up study of u.s. older adults, friendship strain was associated with more chronic illness over time. at the same time, support and strain from spouse, children and friends predicted subjective well-being whereas other family relationships (i.e., relatives other than spouse and children) were not associated with health or well-being (study 2, chopik, 2017) . similar patterns were also evidenced in studies examining cognitive health outcomes. for example, in a cross-sectional study of chinese nonagenarians and centenarians, the number of friends and being married, but not the number of children or ties with neighbors, were associated with better cognitive health (wang et al., 2015) . finally, in a recent longitudinal nationally representative study of u.s. older adults, more frequent contact with friends, but not family, was associated with less decline in memory over time (zahodne et al., 2019a) . these converging findings may reflect the distinct features of friendships versus familial ties. friendships can be seen as more voluntary in nature. as individuals actively select their friends, friendships may provide different resources compared with family ties that help to promote health and quality of life. for instance, friendships are often reported as a greater source of companionship in later life, especially in comparison to family ties (crohan and antonucci, 1989; quan-haase et al., 2017) . they may, therefore, influence later life health through shared activities and mutual interests. indeed, prior empirical research has shown activity engagement to mediate the association between friendships and health. for example, in a cross-sectional study of swiss older adults, higher engagement in leisure activities mediated the association between a higher number of close friends and higher cognitive functioning (ihle et al., 2018) . similarly, evidence from a longitudinal study of u.s. adults showed that higher contact frequency with friends, but not family, was associated with higher engagement in cognitive and physical activities, both of which were associated with higher episodic memory and executive functioning . this pattern of findings has also been demonstrated when examining socioemotional outcomes. for example, in a nationally representative longitudinal study of germans, informal social activities with friends were associated with better subjective well-being (i.e., higher positive affect, lower negative affect, and higher life satisfaction) in older adults. in contrast, informal social activities with family were only associated with an increase in positive affect and an increase in negative affect in older adults (huxhold et al., 2014) . using experience sampling, a study of older canadian adults found that when older adults reported being in the company of friends, they also reported more positive subjective well-being compared with when they were with family (larson et al., 1986) . this finding may be partly attributable to the types of activities individuals engage in with friends versus family. specifically, when with family members, older adults reported higher engagement in maintenance activities (i.e., housework) and passive leisure activities (i.e., watching television). in contrast, when with friends, older adults reported higher engagement in more active leisure activities such as hobbies, religious/cultural engagement, and sports (larson et al., 1986) . these findings are also consistent with the notion that friendships bolster activity engagement. family ties, in contrast to friendships, may be viewed as more obligatory in nature. family ties are more permanent relationships with less autonomy at selection (dono et al., 1979) and are sometimes seen as a burden (crohan and antonucci, 1989; quan-haase et al., 2017) . despite friendships often being viewed as a better source of companionship, family ties may be a better source of longterm social support which is critical to maintaining one's quality of life in older adulthood. illustratively, a cross-sectional study of older adults found that family members were identified as greater sources of social support (instrumental and emotional) and social control (i.e., efforts to promote healthy and deter risky health behaviors), whereas friends were identified as greater sources of companionship (rook and ituarte, 1999) . in another cross-sectional study, older adults' expectations for assistance (i.e., services and resources) from family exceed expectations from both close and casual friends. older adults were more likely to endorse expectations that family should help with tasks such as providing shelter, money, unsolicited advice or put themselves at risk for the older adult (mancini and simon, 1984) . of note, reported expectations of family and close friends for intimacy (i.e., feelings and emotions) and social integration (i.e., shared experiences, companionship) were similar (mancini and simon, 1984) . examining a group of older women hospitalized for congestive heart failure in the past year, friedman (1993) found that women who reported emotional support from family and women who reported emotional support from both family and nonfamily (i.e., friends/neighbors) had higher positive affect than those who reported support only from nonfamily (friedman, 1993) . similarly, women who reported tangible support from family and women who reported tangible support from both family and nonfamily had greater life satisfaction than those who reported only tangible support from nonfamily (friedman, 1993) . consistent with cantor's (1979) hierarchy of support, friedman suggested that older women who are ill may feel more satisfied with tangible assistance that comes from family, as it aligns with their expectations and norms (i.e., more appropriate to receive this type of help from family rather than nonfamily). family ties may provide more long-term assistance and support to help older adults that may not be seen as appropriate for non-family ties to provide. antonucci (2001) suggested that people develop a support bank, an informal accounting of what is given and what is received over time from individuals specifically and more generally. it may be that the long-term nature of family relationships means that older people feel that they are more entitled to support from family members as they are more likely to have provided support to these same or related individuals in the past. this is consistent with findings indicating that older adults report that major support services such as caretaking are more commonly expected of family relationships relative to other types of social relationships (quan-haase et al., 2017) , and family members represent more appropriate social ties to help with more long-term issues (cantor, 1979) . in sum, the importance of both family and friends relationships across the lifespan for health and quality of life is clear. less clear, however, is the relative importance of friends versus family (i.e., which is more important?). from a developmental and clinical scientist perspective, it seems most likely that both are important and play different roles, especially in late life. much as motherinfant attachment provides the secure base from which infants discover and explore the world, it appears that close family relations provide a secure base for adults as indicated by the fact that they are known to be a comforting source of instrumental as well as emotional support. with regard to peer relations, it appears that older people are more likely to turn to friends for companionship and leisure activities. both types of relationships contribute in important and significant ways to health and quality of life. with age and a more limited future time perspective, sst would predict that people spend more time with close family and begin to limit interactions with friends. the nature of families and the availability of friendships are idiosyncratic and thus likely to vary depending on specific circumstances. overall, family relationships and friendships occur in very different contexts (i.e., friends outside the home, family within the home, etc.) and situations (i.e., for leisure, during health crises, etc.) and may therefore influence later life health through different pathways. although close social relationships with friends and family are important for successful aging, other more peripheral social ties, such as those with fellow church members, neighbors and acquaintances, may also provide beneficial resources in later life. the strength of weak ties as proposed by granovetter (1973) posits that weak ties may provide unique forms of support in times of need. specifically, weak ties can link individuals to resources to which they might not normally have access and may also provide contrasting views and information not available from strong ties (granovetter, 1983) . weak ties may also provide unique types of support that only geographic proximity and shared communities can, such as a neighbor having a spare set of house keys (dono et al., 1979) . indeed, in a longitudinal study following u.s. adults over a 23-year period, although close and weaker ties were both associated with a reduction in depressed affect, the number of weaker social ties was more strongly associated with maintaining a low level of depressed affect over time than the number of close social ties. weaker ties were also more strongly associated with maintaining positive affect over time compared with close ties (huxhold et al., 2020) . although prior research suggests that older adults reduce the number of peripheral social ties (sst & savi), the convoy model outlines different personal and situational characteristics predicting the types of social ties an individual needs. weak ties are likely useful under those personal and situational circumstances that indicate needs not readily met by stronger social ties. while other forms of weak-ties exist, we specifically highlight two that may be particularly relevant for older adults as illustrative examples: church-related ties and neighbors. religious involvement may be an avenue by which the strength of weak ties has a powerful impact on the individual. prior research has linked religious attendance to physical (ferraro and kim, 2014; krause, 2002) and cognitive health outcomes (hill et al., 2006; kraal et al., 2019) . for example, in a longitudinal study investigating religious involvement and c-reactive protein (a biomarker for cardiovascular disease risk and progression), higher religious attendance was associated with less increase in c-reactive protein in black, but not white, older adults (ferraro and kim, 2014) . similarly, in a cross-sectional study of white and black american older adults, individuals who received more church-based social support also reported better health, and these associations were stronger in black older adult participants (krause, 2002) . an investigation of a third us minority group, mexican american older adults, found that those who attended church monthly, weekly and more than weekly showed slower rates of global cognitive decline (mmse) than those who did not attend church (hill et al., 2006) . similarly, kraal et al. (2019) found in another longitudinal study of american older adults that higher religious attendance and more private prayer were associated with better concurrent memory functioning, even after accounting for nonreligious social participation. further, higher religious attendance and private prayer among black and hispanic older adults partially reduced the magnitude of racial and ethnic inequalities in memory, which suggests that religious involvement may be an important protective resource for racial and ethnic minorities . overall, individuals who are part of a church community may reap health benefits through feelings of belongingness or social support from these community members. further, church members may benefit health outcomes through social control, such that church members encourage healthy behaviors and discourage risky health behaviors. for example, in a cross-sectional study examining older samoan women who attended churches in los angeles county, informal, church-based ties increased the likelihood of utilizing preventive health services, including having a recent mammogram and planning to have a future mammogram (levy-storms and wallace, 2003) . consistently, in a study of malawi congregations, unmarried adolescents who were frequently exposed to messages about hiv/aids prevention within their congregations had higher odds of abstinence (trinitapoli, 2009 ). additionally, married individuals were more likely to be faithful in congregations in which leaders monitored sexual behaviors, and individuals were more likely to use a condom in congregations where leaders privately advised members to do so (trinitapoli, 2009) . in summary, fellow-church members and congregational leaders in one's network may be a distinct source of support and increase feelings of community and may, in turn, influence health-related behaviors that have a beneficial effect on health and quality of life. neighborhoods, specifically social relationships with neighbors, may be especially important in later life as older adults spend more time within their homes and communities (horgas et al., 1998; spalt et al., 2016) due to social role shifts (i.e., retirement) and changes in health and mobility. neighborhood social cohesion is often defined as feelings of mutual trust and solidarity among neighbors and the perception that neighbors are willing to do the right thing. prior research has indeed shown that in a nationally representative sample of american older adults, higher perceived social cohesion was linked to better physical health outcomes (i.e., stroke; kim et al., 2013) , and better cognitive outcomes (i.e., verbal fluency; zaheed et al., 2019) . these findings have been replicated in other populations, including among racial and ethnic minorities. for instance, in a cross-sectional study of south asian (india, pakistan, bangladesh, nepal, sri lanka) adults living in the united states, higher social cohesion was associated with lower prevalence of hypertension in women, but not men (lagisetty et al., 2016) . in another cross-sectional investigation, higher perceived social cohesion was associated with better global cognition, better episodic memory, and better executive functioning in chinese older adults living in the united states (zhang et al., 2019) . neighbors may be a unique source of informal support that helps to facilitate aging in place and the maintenance of life quality due to their close physical proximity. it has been argued that neighbors may help with short-term instrumental tasks particularly in times of emergency or as health and safety monitors (i.e., signs of an intruder or accident; dono et al., 1979) . illustratively, older residents of new york city identified neighbors as potential sources of informal social support when family was not available. a majority of the sample reported knowing one or more neighbors well and that these individuals would help each other out for specific tasks. neighbors tend to help out with short-term and/or emergency related tasks such as assistance with shopping when ill or in inclement weather and are readily available to sit or chat, whereas other more long-term tasks were often left up to family (cantor, 1979) . similarly, in a qualitative study examining older adults living in a naturally-occurring retirement community (norc), neighbors were described as being helpful for particular types of tasks, such as cooking, shopping, or transportation, but were thought of as inappropriate for other tasks like financial or personal issues (greenfield, 2016) . overall, neighbors, although often viewed as weak social ties, provide immediate help and compensate for non-available family members. in addition to providing small, short-term instrumental assistance for older adults they may also provide the opportunity for older adults to reciprocate, thus contributing to a feeling of community belongingness. available evidence indicates that different relationship types offer distinct benefits for health and quality of life and, as shown in fig. 2 , may operate through several distinct pathways. specifically, social relations in general may influence health and quality of life by promoting healthy behaviors (i.e., exercise, going to a doctor, etc.), increasing engagement in stimulating activities (i.e., leisure activities, hobbies, etc.), helping to alleviate stress (i.e., emotional and tangible social support), and providing access to novel information and resources. when examining which pathways each relationship type might operate through, prior research suggests that friends may be a greater source of companionship whereas family may be a greater source of long-term social support and care. further, more peripheral network members also bring about health benefits, for example when neighbors and fellow-church members provide short-term support or access to diverse informational resources. early-life social relationships, such as those with parents and peers, may influence emotional, physical, and cognitive health outcomes through social functioning. that is, consistent with attachment theory and the convoy model, early-life social relationships may be foundational and influence the development of subsequent social relationships in adulthood (i.e., romantic relationships, friendships, etc.) but may also directly impact health and quality of life through the development of physiological stress response patterns. still, despite prior research examining the complexities of social relationships and their implications for health and quality of life, further investigation is necessary to fully disentangle these unique associations of each relationship type. first, future research would benefit from greater attention to life course processes. informed by the convoy model, social relationships occur across the lifespan, and early life relationships may be foundational for the development of future social relationships. although retrospective data regarding early life social relationships have been linked to later life outcomes, scarce prospective research has utilized observed mother-child or peer interactions to alleviate concerns about recall bias. second, future research should focus on the underlying pathways in which social relationships may confer health benefits, specifically with regard to distinctions between friends versus family, in order to clarify intervention targets. finally, given differences found in specific ethnic and racial minority groups, the need for more representative samples is necessary to assess whether the same pattern of findings is consistently found across sociodemographic groups and cultural contexts. the structure of families and the expectations of friends versus family may differ depending on cultural norms. the distinct pathways that explain the link between relationship type and health outcomes may, therefore, not be universal. the role that technology plays in facilitating and shaping social relationships has been steadily increasing. technologies, such as emailing, texting and social media, are being used to a greater extent to connect with others and seem to be fundamentally changing how we interact. consistent with this notion, in a u.s. sample of young adults, 3-in-4 individuals reported that mobile devices were either greatly or moderately altering the way they were conducting interpersonal communication with their friends, and a vast majority of the sample reported almost constantly having their devices with them (pettegrew and day, 2015) . further, some evidence suggests that younger individuals may prefer to use technology-mediated communication over in-person social interactions (chung, 2013; pinchot et al., 2011) . although studies examining shifts in the ways in which individuals prefer to communicate have been conducted in predominantly younger adult populations, evidence suggests that older generations are increasingly engaging with these technologies as well. survey research conducted in the united states has shown that the rates of smartphone, internet and social media adoption steadily increased in older adult populations between 2013 and 2017 (duggan et al., 2015; pew research center, 2017) . the pew research center (2017) reported that around 4-in-10 adults aged 65 and older had a smartphone in 2017, which is more than double that of older adults who reported owning a smartphone in 2013. in a qualitative study of older adults in the toronto (canada) locality of east york, a majority of participants owned a smartphone, and over half reported engaging with digital media to connect with friends and family. further, once older adults began using digital media, it became a part of their routine to promote pre-existing relationships, foster companionship, and receive social support (quan-haase et al., 2017) . overall, technology-mediated communication is not only being used by younger generations, but also being adopted by older generations as well. as the impact of offline social relationships on health-related outcomes in later life may vary depending on multiple factors (i.e., relationships source, type of resource, etc.), it is also essential to understand how these shifts in means of communication may influence health and quality of life as individuals age. research examining social technology in older adult populations is still in its infancy, with scarce research examining its impact on health-related outcomes (antonucci et al., 2017) . further, evidence regarding the effects of social technology use are mixed, with some studies showing health benefits (chopik, 2016; dodge et al., 2015; myhre et al., 2017; quinn, 2018) whereas other studies show costs (frein et al., 2013; meshi et al., 2020; soares and storms, 2018) . as several intervention studies have focused on social technology and cognition, we highlight cognition as our illustrative health example in the subsequent sections to discuss the distinct bodies of research that have found cognitive benefits and cognitive costs of engaging with social technology. offline social relationships and interactions have been consistently linked to better cognitive functioning (e.g., cacioppo and cacioppo, 2004; seeman et al., 2011; , however, less is known regarding whether social resources facilitated through technology confer the same benefits. some evidence suggests that social technologies may provide a unique resource for older adults to connect with others and remain socially active and cognitively stimulated. although research is limited, some intervention research has indicated that engaging with social technology may be associated with improvements in cognitive functioning (dodge et al., 2015; myhre et al., 2017; quinn, 2018) . for example, in a 4-week randomized control trial examining social media use and executive functioning, social media novice older adults received instructional sessions about social media use (i.e., setting up accounts, privacy, etiquette, posting, etc.) and were compared with a wait-list control group (quinn, 2018) . the results revealed that instruction in social media use was associated with improvements in inhibitory control (i.e., ability to ignore irrelevant information) after the 4-week period and 4-months later (quinn, 2018) . in another intervention study examining the cognitive effects of learning how to use facebook, older adults received 1 week of instructional classes on how to use facebook and were instructed to subsequently post/comment daily for 7 weeks (myhre et al., 2017) . results revealed that older adults who learned how to use facebook showed significant improvements in updating, a component of executive functioning, compared with wait-list controls and those who were trained to use a private blog as an online diary (myhre et al., 2017) . finally, in a 6-week randomized controlled trial, older adults received daily 30 min face-to-face online communication, relative to the control group that received a weekly telephone interview. results demonstrated that cognitively-intact older adults who received the intervention showed improvements in semantic fluency immediately after the intervention and improvements in phonemic fluency at an 18-week follow-up assessment, relative to the control group (dodge et al., 2015) . these intervention studies indicate that learning how to use social media or engaging in frequent online communication in later life may help to improve some domains of cognitive functioning, such as executive functioning. that is, it may be that engaging in social media is cognitively stimulating in and of itself. it may also be that social media and online communication bolsters social stimulation, which has been linked to better cognitive outcomes. indeed, prior cross-sectional research in a nationally representative sample of american older adults has shown that the use of social technologies in later life was associated with better psychological and physical health outcomes, and these associations were mediated by lower levels of loneliness (chopik, 2016) . in the same cohort of u.s. older adults, internet use has been linked to lower levels of depressive symptoms in older adults (cotten et al., 2012) . of note, an australian study of older adults' internet use hints at the complicated associations between socioemotional outcomes and technology use. in this study, although time spent on the internet was associated with more social loneliness, using the internet as a communication tool was associated with less social loneliness (sum et al., 2008) . additionally, in the same study, internet use to identify new social ties was associated with higher levels of family loneliness, highlighting the complexities of researching social technology and the implications of how individuals use these tools (sum et al., 2008) . although some intervention research suggests there are cognitive benefits to social technology use in older adulthood, other evidence suggests that there may also be negative consequences for cognitive health. for example, in a cross-sectional study of college-aged adults, individuals who were classified as high facebook users (engaging with facebook more than 1 h per day) scored worse on a memory recall task compared with individuals classified as low facebook users (frein et al., 2013) . in an experimental study, college-aged adults were assigned to either passively view a series of paintings, take photographs of the paintings, or use snapchat (a photo-sharing based social media platform) to document their experience of the paintings. individuals who used snapchat during the experiment had lower recall for the visual details of the paintings than those who simply observed or used a camera to take pictures (experiment 1; soares and storm, 2018) . in another experimental study, college-aged adults were instructed to place their silenced smartphones either in another room, their pocket/bag, or on the desk where subsequent tests of cognitive capacity (working memory, fluid intelligence) were administered. the more salient the individual's smartphone (i.e., the closer it was), the more their cognitive capacity was impaired (ward et al., 2017) . further, in another experiment, these same researchers report that whether the phone was silenced or completely powered down did not alter this effect (ward et al., 2017) . much less observational or experimental research has examined the links between social technology and cognition in older adulthood. however, a daily diary study of u.s. adults aged 25 to 75, found that on days when social media use was high, individuals also reported more memory failures that same day and the subsequent day. these findings were not moderated by age, which suggests that social media use was associated with more memory failures regardless of the age of the user . the negative consequences of engaging with social technologies for cognitive functioning may operate through attentional and/ or cognitive offloading pathways. that is, individuals who are using social technologies may have reduced attentional capacity for other stimuli in their environment (soares and storm, 2018) . individuals may also use these technologies to offload information onto external memory sources (risko and gilbert, 2016) such that individuals are relying more on technology to store information that was once previously remembered (i.e., phone numbers, birthdays, etc.). finally, some evidence also suggests that the use of these tools may alter how we process and store information. for instance, in a series of experiments, individuals who believed they would have access to saved information for a recall task tended to have greater memory for where to find the information needed (i.e., the saved folder names) than for the content of the information itself (sparrow et al., 2011) . overall, some evidence suggests that engaging with social technology, such as social media or smartphones in general, can impair cognitive functioning, at least in younger adulthood. less is known regarding whether these same consequences extend into older adulthood, as prior intervention research has found beneficial effects. an important consideration regarding these mixed findings is how older adults are engaging with social technology in intervention studies. specifically, older adults who are novices (i.e., little to no previous experience) are recruited and subsequently instructed to actively use social media over an extended period of time (myhre et al., 2017; quinn, 2018) . prior research has suggested that more active use of social media (i.e., direct messaging, commenting, etc.) is associated with more beneficial outcomes, whereas passive use (i.e., lurking, mostly browsing, etc.) is associated with more detrimental outcomes, at least in regards to socioemotional health (escobar-viera et al., 2018; thorisdottir et al., 2019) . when measuring the ways in which older adults engage with social technologies such as social media, it is important to note that older adults tend to use these resources more passively in everyday life to keep in touch with family and close friends. for example, older adults tend to engage in more family activities, such as viewing relatives' photos (mcandrew and jeong, 2012) , and view these activities as an effective tool for keeping up with the lives of family and friends (i.e., social surveillance; jung et al., 2017) rather than as a platform to post photos and status updates. in a qualitative study, older adults who used social media tended to report being "lurkers" to keep watch over what their friends and family members posted online (yuan et al., 2016) . older adults report privacy concerns as a major issue when using these technologies (jung et al., 2017; xie et al., 2012) , which may impact how actively they use social media. in addition, the costs and/or benefits of social technology use for cognition may be domain-specific, which could help to explain some contrasting findings. for example, prior intervention research has shown stronger positive associations between social technology and executive functioning (e.g., dodge et al., 2015; myhre et al., 2017; quinn, 2018) , whereas other research has shown costs for memory functioning (e.g., frein et al., 2013; soares and storm, 2018) . in summary, evidence regarding whether the use of social technology affects health outcomes in later life is mixed. further investigation is necessary to understand the potential impact of online social interactions for health and quality of life in older adulthood. in particular, future research should first investigate when, why and how older adults engage with these technologies as their preferred means of communication. in line with the social convoy model, personal and situational characteristics of the individual are likely to influence what means of communication are most likely to be used. additionally, an individual's goals and motivation for contact, such as future time perspective, influence the preferred means of communication as may be predicted by socioemotional selectivity theory while the savi model would argue that the goal of regulating emotions and avoiding conflict might predict one means of contact (e.g., distal versus proximal, virtual versus in-person). future research is necessary to understand not only the implications of social technology on health and quality of life in older adulthood, but also how age-related changes in social relations and socioemotional goals may impact the selection and use of these same technologies. how an individual uses social technology may, in turn, have implications for health and quality of life. in line with this notion, whether an older adult uses technology actively versus passively or to facilitate pre-existing offline relationships versus develop new social connections appears to influence the effects of using social technology. another important consideration is that these technologies have only recently become more prevalent in older adult populations, and therefore, current research can only examine short-term implications of social technology use in later life. it is necessary to recognize and understand the long-term implications of use. for instance, it is important to disentangle the effects of growing up technologically embedded on younger generations' socioemotional and cognitive outcomes over the lifespan as well as long-term use of social technologies in older adults after adoption. further, it is important to understand the historical and contextual contexts that may further influence these associations, such as the greater prevalence of using social technology to interact with friends and family in daily life among younger generations. historical events, such as the experience of a pandemic that encourages physical distancing and self-isolation (e.g., covid-19 pandemic), may shift the relative importance of online social interactions. during such periods, online social interactions may thus have a more prominent role in health and quality of life as they become one of the limited ways in which individuals are allowed to interact and communicate with others. additionally, technology is rapidly changing as researchers try to understand the implications of these tools and therefore, the effects of these technologies for health may also change in tandem. technologies such as virtual and augmented reality technologies are becoming commercially available and these tools may have implications for health as well. for instance, in a recent study in which adults 50 and older played an exergame (i.e., physical activity using video games) in an immersive virtual environment (ive) over the course of 4-weeks, the ive group showed better executive functioning compared with the control group (i.e., non-immersive game) (huang, 2020) . thus, it is essential to continually assess whether changes in these technologies influence their effects on health and quality of life. finally, future research should clarify the potential domain-specific pathways that may explain the mixed findings regarding the costs or benefits of social technology in later life. it may be that gains are seen in one domain (i.e., executive functioning) but costs are seen in another (i.e., memory). the literature reviewed above reveals the powerful influences social relations can have on the physical, mental, and cognitive health of older adults. our increasing understanding of the complexities and nuances of social relations and their health impacts have important implications for multiple aspects of clinical practice. these specific insights may be harnessed to improve the clinical assessment and treatment of older adults. with regard to clinical assessment, the growing literature on social relations highlights the value of considering not only individual factors (e.g., age, educational attainment, comorbid health conditions), but also contextual factors, including characteristics of the social network(s) in which an individual is embedded, when assessing risk of mental and cognitive disorders. collecting more detailed information on the structure, function and the quality of an individual's social network can improve clinicians' understanding of risk and resilience. for example, characterizing objective social isolation without also querying the subjective experience of loneliness could result in an over-or under-identification of risk. similarly, cataloging an individual's social ties without also assessing the frequency and quality of interactions is likely to yield an incomplete picture of social resources that can be considered as promising intervention targets. thus, a comprehensive assessment of contextual factors can improve the development of clinical recommendations and treatment planning. with regard to clinical intervention, a more detailed understanding of links between social relations and health can help to reveal the "active ingredients" of social relations, allowing for more targeted interventions. for example, a recent longitudinal study that considered multiple structural aspects of social relations as predictors of cognitive aging found that contact frequency, but not social network size, was associated with slower declines in episodic memory (zahodne et al., 2019a,b,c) . findings such as these may be used to guide the development of interventions by suggesting that increasing the frequency of interaction with existing social network members may be more effective than introducing new network members, especially if contact with those new network members will be limited. similarly, seminal studies on older adults' physical and mental health (antonucci, 2001 ) and more recent studies on cognitive aging have drawn attention to the unique value of diverse social networks containing not only close family members but also more peripheral family members and friends (see review ; fingerman, 2009; zahodne et al., 2019a,b,c; ying et al., in press) . as another example, a more nuanced understanding of the costs and benefits of social strain within particularly salient relationships (e.g., the spousal relationship; birditt and antonucci, 2008) may help clinicians working with individuals and couples modify behaviors and/or interpretations to optimize the emotional and instrumental support derived from a key relationship. additionally, understanding the unique pathways in which different social relationships benefit health may help to clarify intervention targets. for instance, an understanding that friends may promote health through increased shared activities may inform future interventions to bolster friendships through activity/shared interest groups (i.e., art, bird watching, etc.). in line with a changing technological landscape, rapidly evolving research on the mode(s) by which individuals interact with social network members is also highly relevant to the design and implementation of interventions targeting social relations. the benefits of social interaction may differ when it occurs in-person, over the phone, or online. in particular, the role that newer social technologies (e.g., texting, video chats, social media) can play in shaping health outcomes is an active area of research. for example, research on younger adults suggests that active social media use (e.g., posting, commenting) is associated with better mental health, whereas passive social media use (e.g., scrolling, lurking) is associated with worse mental health (escobar-viera et al., 2018) . if findings such as these are extended to older adults, then interventions involving social media should focus on promoting active use rather than just getting older adults online. importantly, reducing the digital divide is necessary to ensure that efficacious interventions involving social technologies are also effective and that all older adults who would benefit from online social interaction have access. indeed, a recent systematic review concluded that various technologies have the potential to reduce social isolation in older adults, but more systematic trials are needed (khosravi et al., 2016) . in conclusion, the examination of social relations and health has made significant advances from early, small, qualitative studies to large quantitative studies. social relations encompass a complex and dynamic set of characteristics that may have distinct effects on health and quality of life in older adulthood. informed by the social convoy model, identifying the specific aspects of social relations (i.e., structure, function, quality) as well as detailing personal and situational characteristics (i.e., age, race, ethnicity, gender, etc.) may help to clarify how social relations specifically influence the individual. further, taking a life course perspective, it is important to understand the role of age-related gains and losses that may influence changes in social relationships in later life. socioemotional selectivity theory highlights the importance of motivational goals on social partner selection such that perceptions of time left may influence changes in social network size and composition. the strength and vulnerability integration model further exemplifies these points by highlighting that age-related vulnerabilities may impact social partner selection as well as how older adults cope with potential social stressors (i.e., avoidance or disengagement from negative social interactions). an understanding of the who, what, why and how of social relations helps to clarify the potential protective and/or harmful effects of each dimension of social relations on later life outcomes. specific social resources (i.e., social network size vs. loneliness), relationship types (i.e., friends vs. family), and means of communication (i.e., online vs. 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biopsychosocial effects of retrospective childhood social support and later-life cognition neighborhood social cohesion and cognitive function in u.s. chinese older adults: findings from the pine study loneliness and cognitive function in older adults: findings from the chinese longitudinal healthy longevity survey key: cord-272989-14exeaud authors: dawoud, dalia; chen, aleda m.h.; rossing, charlotte verner; garcia-cardenas, victoria; law, anandi v.; aslani, parisa; bates, ian; babar, zaheer-ud-din; desselle, shane title: pharmacy practice research priorities during the covid-19 pandemic: recommendations of a panel of experts convened by fip pharmacy practice research special interest group date: 2020-08-26 journal: res social adm pharm doi: 10.1016/j.sapharm.2020.08.020 sha: doc_id: 272989 cord_uid: 14exeaud across the globe, pharmacists on the frontline continue to fight covid-19 and its continuously evolving physical, mental, and economic consequences armed by their knowledge, professionalism, and dedication. their need for credible scientific evidence to inform their practice has never been more urgent. despite the exponentially increasing number of publications since the start of the pandemic, questions remain unanswered, and more are created, than have been resolved by the increasing number of publications. a panel of leading journal editors was convened by the international pharmaceutical federation (fip) pharmacy practice research special interest group to discuss the current status of covid-19 related research, provide their recommendations, and identify focal points for pharmacy practice, social pharmacy, and education research moving forward. key priorities identified spanned a wide range of topics, reflecting the need for good quality research to inform practice and education. the panel insisted that a foundation in theory and use of rigorous methods should continue forming the basis of inquiry and its resultant papers, regardless of topic area. from assessing the clinical and cost effectiveness of covid-19 therapies and vaccines to assessing different models of pharmaceutical services and education delivery, these priorities will ensure that our practice is informed by the best quality scientific evidence at this very challenging time. information overload might be as problematic as ever during the current pandemic. since the beginning of 2020, there has been an exponential growth in the volume of covid-19 related publications, from clinical trials to research papers to commentaries and opinion pieces. 1 the rate at which articles are being published has made it an insurmountable task to keep abreast of the new information. 2 yet, it is debatable as to whether or not this rapid increase in publications has been borne from quality research. 3 in fact, a recent analysis by girolamo and reynders (2020) indicated that much of the research has not led to new knowledge. 3 pharmacists desire and need evidence to inform practice, and without credible and scientifically sound research studies, partly due to the rush to publish, there is not only a pandemic but an "infodemic". 3, 4 hence, there is an urgent need to focus our research efforts to provide pharmacists and other healthcare providers with trusted information and evidence to inform patient care, pharmacy practice, and policy changes in the midst of covid-19. to address this challenge, methodologically robust, practitioner-led research is needed. it has been argued that "research" is not just for academics but is about authentic issues affecting the public, patients and pharmacists. 5 in many cases, professional organizations are collating information and providing resources for pharmacists in a variety of settings, with some that are more country-or apandemic. the difference is the ability to adapt research and test new models in light of the rapidly changing conditions in which we might be working. thus, the "best" research continues to be that which is grounded in solid theory, rigorous methods and execution, with a well-constructed plan for streams of research that are cogent and complementary to one another. a well-planned research agenda based in theory and rooted in the literature is not "interrupted" by a sudden pandemic. rather, the well-planned research agenda can be adapted toward and help meet the needs of an unexpected health crisis. most researchers in pharmacy practice were not conducting research on covid-19, itself, until after it took a hold on an unsuspecting world populace. however, a glance at some of the initial, wellregarded, and highly cited papers published in research in social and administrative pharmacy (rsap) and elsewhere reveals carefully executed research strategies and highly instructive commentary by researchers employing strong backbone and adaptation of their existing line of inquiry. for example, carico et al. provide insight into how pharmacists can apply the health belief model toward risk mitigation communication with patients. 15 they describe how communication grounded in a well-tested model can assist patients come to their own realization of the benefits of certain behaviors in addition to improving their knowledge of their susceptibility to, and danger posed by, covid-19 not through paternalistic communication but through guiding the patient in self-discovery. research by park et al. evinced that persons believing they were at less risk of contracting the disease were less likely to take part in risk mitigation strategies. 16 lam discussed the quick mobilization of pharmacists in macau in assisting other health professionals and serving on the proverbial front lines of care not only to treat patients but also to bolster mitigation strategies among a public with close geographic and familial ties with those at the original epicenter of the outbreak in wuhan, china. 17 j o u r n a l p r e -p r o o f this was made possible due to protocols and interdisciplinary mitigation strategies for various type of emergencies that had already been in place and had been constructed through scientific evidence and best practice. zheng et al. prepared recommendations for pharmacists' practice in light of the pandemic, again, coming from near its origins in china. 18 while emphasizing the need for flexibility and adaptability in the face of the pandemic, the recommendations were rooted in evidence-based practice from solid research accounting for evolutions in pharmacy practice prior to the pandemic. this group of researchers have long been involved in research proffering roles for pharmacists to ensure patient safety and to advance the roles of clinical pharmacists even prior to the pandemic. 19 cadogan and hughes wrote of pharmacists' priorities and shifts in practice during the covid-19 pandemic, but likewise, basing these on prior research on pharmacists' roles during unexpected emergencies, in a broader sense. 20 to that end, research in pharmacy practice, while grounded in solid frameworks, must be multifaceted. it takes myriad system factors and people to optimize pharmacists' roles and patient outcomes. thus, research must examine communication, operations, the interaction of health systems and economic factors, social support, patient and pharmacist/student education, and pharmacological and non-pharmacological aspects of therapy. basheti et al. evaluated pharmacists' readiness to engage in these various aspects of practice, including management of actual and potential medicinesshortages and weaknesses in the supply chain. 22 karasneh evaluated the effect of media coverage of the pandemic on pharmacists' awareness and practice activities finding perhaps an undue influence by lay media, as opposed to relying solely on medical and professional resources. 23 bahlol and dewey found pharmacists' preparedness to practice amidst the pandemic to be adequate, but lacking in reporting frequency, mechanisms, and structure. 24 indeed, if pharmacists are to be more integrated into public health systems, they must participate avidly in reporting of adverse events, triaging of patients, and informing health authorities of suspected health trends. dawoud described these and other activities that must be carried out by pharmacists, including adapting to technology, serving as vaccination hubs, and continuously gaining the public trust as critical means in which pharmacists can help society move forward post-lockdown and past the eventual ebb of the pandemic. 25 in a study employing the transtheoretical model of change, hoti et al. found pharmacists to outweigh pros versus cons and be in high levels of readiness to engage in risk mitigation strategies related to covid-19. 26 austin and gregory studied resilience of pharmacists during the pandemic and found significant themes in ability to adapt to new technology, provision of personal protective equipment by the organization, and dedicated support staff. 27 as such, future research can leverage these findings to assume that pharmacists want to and are prepared to evolve practice, but might need to adapt to and advocate for change in systems that make this more a reality. doing so must be placed within the j o u r n a l p r e -p r o o f context of improving patient outcomes, rather than improving pharmacists' "lot in life" for the sake of doing so. koster et al. demonstrated that emerging patient-centric pharmacist services have been deleteriously impacted by the pandemic and urged leaders to embrace tele-pharmacy even post-pandemic in a changed world, with all that new models of delivery entail. 28 amariles et al. worked with researchers outside of pharmacy to project future numbers of cases, morbidity, and hospitalizations not merely to project numbers but for anticipation of their country's needs for pharmacists to continue delivering the necessary care to patients with and without covid-19 and help ensure adequate supply chain of pharmacological therapies for weeks and even months into the future. 29 forecasting can and should become an even greater priority for pharmacy practice researchers, and asia, europe, the americas, and africa during the pandemic. 37 the services provided by pharmacists ranged from essential and extended services, services developed to ensure continuity of care, and supply of essential medicines as well as the responsibilities in emergency care. in another paper, elbeddini et al emphasized mental health issues impacting pharmacists during covid-19, highlighting increasing workloads as well as workplace harassment. 38 the pandemic also has pharmacy educators contemplating adaptations and transitions to be made in educating future pharmacists, both in the content of the education and in the logistics, or manner in which it is to be provided. covid-19 has brought a plethora of challenges, as well as opportunities for pharmacists to contribute. the community pharmacy sector is seeing increasing numbers of patients and the public.the current crisis has also seen an impact on medicines supply lines and health systems throughout the globe. this has been seen in high-, middle-and low-income countries. access to and availability of essential medicines have been impacted, medicinesshortages were noted and there were reports on the use of substandard and falsified medicines. 39, 40 the quality and safety of pharmaceuticals are increasingly important when a large number of people are relying on them. • as has always been the case, research conducted will be grounded in proven theory and rigorous methods. undergraduate transition and how we can better support students and early career practitioners, who seem particularly anxious about learning environments and career development support in early years. despite the local to global havoc caused by covid-19, pharmacy practice researchers have made a considerable effort to respond to this global emergency and their research output is starting to inform practice across the world.reflecting on this output, we should plan carefully for the coming stage to ensure that the impact and value of this research are maximised. the recommendations made by this panel of experts goes some way towards informing pharmacy practice researchers' and research funders'priorities in the next phase of this battle against the most disruptive pandemic that we have witnessed for decades. scientists are drowning in covid-19 papers. can new tools keep them afloat? characteristics of scientific articles on covid-19 published during the initial 3 months of the pandemic the need for an evidence-based encyclopaedia in health services research in pharmacy the pharmaceutical journal american society for health systems pharmacists (ashp)'s covid-19 resource center international pharmaceutical federation (fip)covid-19 information hub covid-19: clinical information and treatment guidelines covid-19: frequently asked questions and myth busting fip's response to the covid-19 pandemic: global pharmacy rises to the challenge responding to the pandemic together community pharmacists and communication in the time of covid-19: applying the health belief model. res social adm pharm optimistic bias and preventive behavioral engagement in the context of covid-19. res social adm pharm community pharmacist in public health emergencies: quick to action against the coronavirus 2019-ncov outbreak. res social adm pharm recommendations and guidance for providing pharmaceutical care services during covid-19 pandemic: a china perspective fighting against covid-19: innovative strategies for clinical pharmacists. res social adm pharm on the frontline against covid-19: community pharmacists' contribution during a public health crisis. res social adm pharm pharmacy emergency preparedness and response (pepr): a proposed framework for expanding pharmacy professionals' roles and contributions to emergency preparedness and response during the covid-19 pandemic and beyond pharmacists' readiness to deal with the coronovirus pandemic: assessing awareness and perception of roles. res social adm pharm media's effect on shaping knowledge, awareness risk perceptions and communication practices of pandemic covid-19 among pharmacists. res social adm pharm pandemic preparedness of community pharmacists for covid-19 key measures for a successful covid-19 lockdown exit strategy and the potential contribution of pharmacists provision of community pharmacy services during covid-19 pandemic: a cross sectional study of community pharmacists' experiences with preventative measures and sources of information resilience in the time of the pandemic: the experience of community pharmacists during covid-19. res social adm pharm impact of the covid-19 epidemic on the provision of pharmaceutical care in community pharmacies covid-19 in columbia endpoints: are we different, like europe? res social adm pharm department of health & human services. hhs expands access to childhood vaccines during covid-19 pandemic an evaluation of co-use of chloroquine or hydroxychloroquine plus azithromycin on cardiac outcomes: a pharmacoepidemiological study to inform use during the covid19 pandemic. res social adm pharm safety signals for qt prolongation or torsades de pointes associated with azithromycin with or without chloroquine or hydroxychlorquine. res social adm pharm the concern about ace/arb and covid-19: time to hold your horses! j am pharm assoc cannabidiol as prophylaxis for sars-cov-2 and covid-19: unfounded claims versus potential risks of medications during the pandemic. res social adm pharm pharmacists and the covid-19 pandemic pharmacists at the frontline beating the covid-19 pandemic pharmacists reinventing their roles to effectively respond to covid-19: a global report from the international pharmacists for anticoagulation care taskforce (ipact) mental health issues impacting pharmacists during covid-19 covid-19 and risks to the supply and quality of tests, drugs, and vaccines. the lancet global health drive-thru pharmacy services: a way forward to combat covid-19 pandemic key: cord-280840-t7zuhsnc authors: meinzen-dick, ruth title: collective action and “social distancing” in covid-19 responses date: 2020-05-31 journal: agric human values doi: 10.1007/s10460-020-10100-1 sha: doc_id: 280840 cord_uid: t7zuhsnc nan much of my research has been on the need for collective action in managing natural resources, and the value of groups to facilitate collective agency for women's empowerment. extensive research has shown that coordination among resource users is necessary to distribute rights and responsibilities for both appropriation and provision of common pool resources, such as for water withdrawals and maintenance of irrigation systems (anderies and janssen 2013) . and we are learning about the mechanisms through which women's groups contribute to empowerment, whether through collective enterprises (such as through self-help groups in india), access to finance, acquiring social services, or improving women's bargaining power in their households (brody et al. 2017) . what happens, then, when people cannot come together in person because of lockdowns to prevent transmission of covid-19? what happens to the irrigation systems in nepal and india that need collective labor to repair them? what happens to the women who rely on weekly savings group meetings to build their financial and social capital? the results can be isolation and depression, as well as economic losses. but as "absence makes the heart grow fonder", the requirements for physical distancing are also increasing appreciation for the value of coming together, strengthening the impetus to reach out to others. in this sense "social distancing" is a misnomer-physical distancing does not necessarily increase social distance. use of icts (information communication technologies) can provide some substitute for physical proximity. irrigation systems in nepal and india were already using mobile phones for communication, reducing the need for face to face meetings. we are seeing a lot of innovation in how people are using icts to connect with colleagues, friends, and family, such as the self employed women's association (sewa) groups using whatsapp to stay in touch when they cannot hold meetings in rural india. while much of the emphasis in the development literature has been on the use of icts for health or economic benefits, their value in maintaining social ties, to break isolation and maintain social capital, is harder to measure, but may be just as great in the long run. what about those without icts? this is another example of how covid-19 is increasing inequality, not only between rich and poor, but even between men and women. in pakistan, 81% of men, but only 50% of women, own a mobile phone and use it at least once a month; 37% of men and only 19% of women use mobile internet. overall in low and middle-income countries, women are 8% less likely to own a mobile phone (gsma 2020). in many ways we need collective action more now than ever, such as to promote behavioral changes to reduce transmission of covid-19, or sharing food and necessities with those suffering most (e.g. rathore 2020). for years, researchers have considered the "transaction costs" of meetings as a problem of the commons, while others have noted that there are values of the commons that go beyond the economic value of the resources, which derive from the social solidarity fostered by working together, and holding rights together. in that sense, meetings are an investment in building social capital and the cement for long term cooperation. having to go without the chance to come together may give us all a greater appreciation of these face to face interactions, especially those involving eating and drinking together. and while icts and other mechanisms show that social solidarity can transcend physical proximity, the imposition of physical distancing orders-and their eventual lifting-provides an important opportunity for examining the value of different types of interaction for creating social solidarity. this article is part of the topical collection: agriculture, food & covid-19. sustaining the commons can self-help group programs improve women's empowerment? a systematic review gsma. 2020. connected women: the mobile gender gap report 2020 combating covid: villages in andhra pradesh and rajasthan show the way. the bastion. https ://theba stion .co.in/polit ics-and/comba ting-covid -villa ges-in-andhr a-prade sh-and-rajas than-show-the-way/?fbcli d=iwar2 bhnrd xknev -qf0e5 vp acknowledgements this work was undertaken as part of the cgiar research program on institutions, and markets (pim) led by the international food policy research institute (ifpri). key: cord-207242-hb1r2aw7 authors: ghader, sepehr; zhao, jun; lee, minha; zhou, weiyi; zhao, guangchen; zhang, lei title: observed mobility behavior data reveal social distancing inertia date: 2020-04-30 journal: nan doi: nan sha: doc_id: 207242 cord_uid: hb1r2aw7 the research team has utilized an integrated dataset, consisting of anonymized location data, covid-19 case data, and census population information, to study the impact of covid-19 on human mobility. the study revealed that statistics related to social distancing, namely trip rate, miles traveled per person, and percentage of population staying at home have all showed an unexpected trend, which we named social distancing inertia. the trends showed that as soon as covid-19 cases were observed, the statistics started improving, regardless of government actions. this suggests that a portion of population who could and were willing to practice social distancing voluntarily and naturally reacted to the emergence of covid-19 cases. however, after about two weeks, the statistics saturated and stopped improving, despite the continuous rise in covid-19 cases. the study suggests that there is a natural behavior inertia toward social distancing, which puts a limit on the extent of improvement in the social-distancing-related statistics. the national data showed that the inertia phenomenon is universal, happening in all the u.s. states and for all the studied statistics. the u.s. states showed a synchronized trend, regardless of the timeline of their statewide covid-19 case spreads or government orders. covid-19 pandemic caused various societies to deviate from their normal. many societies faced an unprecedented situation, for which they were not prepared. this event was the first to cause such a large-scale halt on people's normal behavior. decision makers were not fully aware about people's reaction to new stay-at-home or social distancing orders, as there was no sufficient previous evidence. now, many weeks into the pandemic, we have learned a lot, not just about the virus, but also about societies' reaction to such events. we need to learn from this experience, so that we can be better prepared as individuals, communities, or societies, the next time such a disastrous event happens. there are a lot to learn on the subject of human behavior amid a pandemic. in this paper, we focus on american's reaction to social distancing. for the first time in history, large scale national evidence is available on this subject. reaction to social distancing can be studied in-depth through detailed surveys. however, such surveys are costly, and timeconsuming to design, collect, and analyze. furthermore, respondents may have reservations against reporting discord with social distancing orders. thanks to the technology, a massive amount of data has been passively collected from mobile devices, which can provide observed evidence on how people reacted to social distancing. we used daily feeds of mobile device location data, representing movements of more than 100 million anonymized devices, integrated with covid-19 case data from john hopkins university and census population data to monitor the mobility trends in united states and study social distancing behavior 1 . mobile device location data are becoming popular for studying human behavior, specially mobility behavior. earlier studies with mobile device location data were mainly using gps technology, which is capable of recording accurate information including, location, time, speed, and possibly a measure of data quality 2 . later, mobile phones and smartphones gained popularity, as they could enable researchers to sudy individual-level mobility patterns [3] [4] [5] . other emerging mobile device location data sources such as call detail record (cdr) 6-8 , cellular network data 9 , and social media location-based services [10] [11] [12] [13] [14] have also been used by the researchers to study mobility behavior. mobile device location data has proved to be a great asset for decision-makers amid the current covid-19 pandemic. many companies such as google, apple, or cuebiq have already utilized location data to produce valuable information about mobility and economic trends [15] [16] [17] . researchers have also utilized mobile device location data for studying covid-19-related behavior 18, 19 . our paper utilizes mobile device location data to study social distancing behavior. non-pharmaceutical interventions such as social distancing are important and effective tools for preventing virus spread. researchers have highlighted the importance of social distancing in disease prevention through modeling and simulation [20] [21] [22] [23] . the simulation models assume a level of compliance, which can now be validated through observed data. one of the most recent studies projected that the recurrent outbreaks might be observed this winter based on pharmaceutical estimates on covid-19 and other coronaviruses, so prolonged or intermittent social distancing may be required until 2022 without any interventions 24 , highlighting the importance of improving our understanding about individual's reaction to social distancing. in order to study the impact of covid-19, we have processed a set of national mobile device location data and created an online platform 25 . the next section describes the platform. section 3 briefly describes the methodology for processing location data and producing the statistics of interest. the analysis of the results from the platform showed an interesting trend, which we named "social distancing inertia". section 4 introduces this phenomenon. section 5 discusses the universality of the observed phenomena. the last section is dedicated to discussion and conclusion. the covid-19 impact analysis platform, available at data.covid.umd.edu provides comprehensive data and insights on covid-19's impact on mobility, economy, and society with daily data updates. researchers at the university of maryland (umd) are exploring how social distancing and stay-at-home orders are affecting travel behavior, spread of the coronavirus, and local economies. we are also studying the multifaceted impact of covid-19 on our lives, health, economy, and society. through this interactive analytics platform, we are making our data and research findings available to other researchers, agencies, non-profits, media, and the general public. the platform will evolve and expand over time as new data and impact metrics are computed and additional visualizations are developed. table 1 shows the current metrics available in the platform at the national, state, and county levels in the united states with daily updates. an integer from 0~100 that represents the extent residents and visitors are practicing social distancing. "0" indicates no social distancing is observed in the community, while "100" indicates all residents are staying at home and no visitors are entering the county. % staying home percentage of residents staying at home #trips/person average number of trips taken per person. the percent of all trips taken that travel out of a county. additional information on the origins and destinations of these trips at the county-to-county level is available, but not currently shown on the platform. the research team first integrated and cleaned location data from multiple sources representing person and vehicle movements in order to improve the quality of our mobile device location data panel. we then clustered the location points into activity locations and identified home and work locations at the census block group (cbg) level to protect privacy. we examined both temporal and spatial features for the entire activity location list to identify home cbgs and work cbgs for workers with a fixed work location. next, we applied previously developed and validated algorithms 26 to identify all trips from the cleaned data panel, including trip origin, destination, departure time, and arrival time. if an anonymized individual in the sample did not make any trip longer than one-mile in distance, this anonymized individual was considered as staying at home. a multi-level weighting procedure expanded the sample to the entire population, using devicelevel and trip-level weights, so the results are representative of the entire population in a nation, state, or county. the data sources and computational algorithms have been validated based on a variety of independent datasets such as the national household travel survey and american community survey, and peer reviewed by an external expert panel in a u.s. department of transportation federal highway administration's exploratory advanced research program project, titled "data analytics and modeling methods for tracking and predicting origin-destination travel trends based on mobile device data" 26 . mobility metrics were then integrated with covid-19 case data, population data, and other data sources. figure 1 shows a summary of the methodology. additional details can be found in a separate paper by the authors. the analysis of data from the covid-19 impact analysis platform showed a notable trend. we could observe that as soon as covid-19 cases first began to appear in significant numbers (i.e., early to mid-march), measures related to social distancing (index, %staying home, #trips per person, trip distance, out-of-town trips, etc.) began to improve quickly, with or without government social distancing orders, suggesting that those who wanted and were able to limit their interactions with others quickly and naturally responded to the emergence of new cases and adopted social distancing practices. however, after about two weeks into the pandemic (mid to late-march), measures related to social distancing stopped improving despite continuously increasing covid-19 case numbers and government stay-at-home orders. the trends showed that all measures related to social distancing saturated and stopped improving, revealing a phenomenon we name "social distancing inertia." for instance, as observed in figure 2 the percentage of people staying home nationwide rapidly increased from 20% to 35% at the onset of covid-19 and then has stagnated at 35% for three weeks as of april 10. digging deeper, we observed that the same trend is also observable in the states with the highest number of cumulative cases ( figure 2) . here, we focus on three selected statistics of interest related to social distancing. the first is percentage of people staying home, which shows the proportion of population that did not make any trips longer than one mile on a given day (figure 2) . the second is number of trips per person, which shows on average how many trips are observed per person on a given day (figure 3) . the third is miles traveled per person, which shows on average how many miles is taken per person on a given day (figure 4) . in the three figures below, the red curve shows the normalized trend of new confirmed covid-19 cases, based on the john hopkin's covid-19 database 1 . the other curve in each graph shows one of the statistics of interest. the left axis shows the values for the statistics of interest. we have removed weekends to have a consistent comparison. we have also used three day moving averages to remove the day-to-day noises. we can see that in all three figures, in both national and state level results, the static of interest has started increasing around the same time and reached a plateau after about two weeks. it is also worthwhile to see the effect of government stay-at-home orders. the date of government stay-at-home orders are identified with a black line in the figures. no significant improvement can be observed in any of the statistics after government orders. in fact, the trends have stopped increasing after the orders. government advisories and stay-at-home orders have not accomplished expected changes in mobility behavior according to our data analysis. the analysis suggests that those who were able to adopt social distancing practices had already done so before government intervention. those who could not or did not want to stay home showed significant behavior inertia and rendered government stay-at-home orders less effective than expected. the average increase of percentage of people staying at home one week after the order compared to one week before the order is 4.3 percentage points. another interesting observation was the universality of social distancing inertia. despite the fact that covid-19 case emergence had a different timeline in each state and government advisory orders were issued in different dates, all states were synchronized in their trends. figure 5 shows the percentage of people staying at home. the curves for all states are plotted together to show the universality of the phenomenon, and highlight how synchronized the curves are. figure 6 and figure 7 are plotted similarly for number of trips per person and miles traveled per person respectively. in these figures, the scales vary between the states, as the mobility behavior is generally different between states that have more urban regions and those that are mainly suburban and rural, but the trends are similar. the figures suggest that the phenomenon is nationwide. the synchrony suggests that people reacted to national emergence of cases or the national emergency declaration on march 13 th , not the trend of cases in their own region. the results showed that the improvements in statistics related to social distancing were smaller than expected. they also showed that the trends reached a plateau after about two weeks. even though all aspects of our results are suggesting the inertia, they cannot prove that people are not conforming with social distancing orders. one can still argue that the remaining trips are essential trips; or people that are not staying home are essential workers or are people traveling for their essential needs. however, digging deeper can provide further evidence suggesting inertia. the drop in the number of work trips per person was about 50%, which shows that even amid the pandemic, about 50% of people are going to their routine work place. the drop in number of nonwork trip was limited to 22%, suggesting that people have not significantly decreased their nonwork trip rate. one may argue that the nature of the non-work trips happening amid pandemic may be different from the non-work trips happening before, and the trips amid pandemic may be short walks in the neighborhood. however, looking into the drop in average miles traveled per person, the national drop is limited to 40%. we can see that people are still traveling significant miles. a recent analysis of placeiq data during pandemic showed that foot traffic to groceries has only decreased 27% 27 . altogether, the result suggest that a significant part of the nation is showing inertia toward social distancing. social distancing is very important to slow down the spread of covid-19. however, performing social distancing is quite different from peoples' habitual behavior. social distancing policy clashes with the deep-seated human instinct to connect with others in order to regulate emotions, cope with stress, and remain resilient during difficult times 28, 29 . therefore, without enforcement, incentives, or proper knowledge about the risks involved, people have an inertia to keep their habitual behavior. even though staying home may help prevent disease spread, people tend to repeat previous behaviors 30 . the inertia is common in other aspects of human behavior. in stock market, investors who missed an opportunity to leave a 'bear market' are less likely to sell their stocks at a later opportunity 31 . in consumer purchase decisions, customers showing inertia refrain from making new purchase 32 . in travel behavior, travelers are more likely to stick to their habitual mode, routes and departure time [33] [34] [35] . the inertia is also observed in the studies of disease spread and prevention. the influence of inertia is even considered in some sir models 36 . in a pandemic study focused on the spanish flu, the cognitive inertia has been shown as a main reason for the lack of preparation among unaffected areas (dicke, 2015). the study suggested that cognitive inertia grew from the traditional view that seasonal flu would run for a brief period, and has no threat on healthy group. a recent paper by an infectious disease research team showed the existence of inherent inertia toward social distancing through a game theory model, and stated the important role of national public statements in overcoming the social distancing inertia 37 . our study provided evidence from observed data on this phenomenon. answering why such inertia exists is outside the scope of this paper. a future paper can dig deeper and study device-level results to further investigate inertia and learn more about possible causes. such analysis needs to conform with privacy rules and regulations. we would like to thank and acknowledge our partners and data sources in this effort: (1) amazon web service and its senior solutions architect, jianjun xu, for providing cloud computing and technical support; (2) an interactive web-based dashboard to track covid-19 in real time deducing mode and purpose from gps data inferring dynamic origin-destination flows by transport mode using mobile phone data modeling real-time human mobility based on mobile phone and transportation data fusion. transportation research part c: emerging technologies 96 forecasting current and next trip purpose with social media data and google places returners and explorers dichotomy in human mobility modelling the scaling properties of human mobility 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states: simulations based on air traffic directly from wuhan projecting the transmission dynamics of sars-cov-2 through the post-pandemic period an interactive covid-19 mobility impact and social distancing analysis platform data analytics and modeling methods for tracking and predicting origin-destination travel trends based on mobile device data. (federal highway administration exploratory advanced research program advancing the social identity approach to health and well-being: progressing the social cure research agenda interpersonal emotion regulation: implications for affiliation, perceived support, relationships, and well-being inertia and decision making inaction inertia in the stock market 1 handbook of pricing research in marketing modeling inertia and compliance mechanisms in route choice behavior under real-time information travel choice inertia: the joint role of risk aversion and learning modeling route choice inertia in network equilibrium with heterogeneous prevailing choice sets beginning of the end of the pandemic? a comparison between italy and romania coordination and social distancing: inertia in the aggregate response to covid-19 key: cord-024385-peakgsyp authors: walsh, james p title: social media and moral panics: assessing the effects of technological change on societal reaction date: 2020-03-28 journal: nan doi: 10.1177/1367877920912257 sha: doc_id: 24385 cord_uid: peakgsyp answering calls for deeper consideration of the relationship between moral panics and emergent media systems, this exploratory article assesses the effects of social media – web-based venues that enable and encourage the production and exchange of user-generated content. contra claims of their empowering and deflationary consequences, it finds that, on balance, recent technological transformations unleash and intensify collective alarm. whether generating fear about social change, sharpening social distance, or offering new opportunities for vilifying outsiders, distorting communications, manipulating public opinion, and mobilizing embittered individuals, digital platforms and communications constitute significant targets, facilitators, and instruments of panic production. the conceptual implications of these findings are considered. technologies (for example, see flores-yeffal et al., 2019; hier, 2018; marwick, 2008; wright, 2017) . despite their insight and contributions, knowledge of social media's diverse effects remains scattered and fragmentary. thus, while some of this article's propositions can be gleaned from existing studies, it offers a systematic elaboration that aims to promote analytic balance and encourage productive exchanges that can orient future scholarship. after revisiting the media-moral panic relationship, this article assesses how social media escalate the frequency and intensity of overwrought reactions. while addressing several concrete examples, particularly the role of digital communications in promoting extremist agendas, as recent events concerning trumpism, brexit, the alt-right, and 'fake news' have shattered myths regarding their positive and empowering qualities, the focus of this article is more on general claims than particular findings. accordingly, rather than a final, definitive statement, it presents developmental suggestions and a heuristic that can, and should, be subjected to further scrutiny and debate. in the end, such preliminary efforts are significant as 'before we can pose questions of explanation, we must be aware of the character of the phenomenon we wish to explain' (smelser, 1963: 5) . while the identification and policing of deviance are perennial features of human groups, moral panics are 'unthinkable without the media' and are distinctive to modern, mass societies (critcher, 2003: 131) . in many respects, cohen and his contemporaries (cohen and young, 1973; hall et al., 1978; pearson, 1983) were the first to articulate the essential role of news-making in constructing social problems. beyond generating surplus visibility and making otherwise marginal behaviours appear pernicious and pervasive, the media represent an independent voice . by delineating moral boundaries and circulating dire predictions about monstrous others, the histrionic tenor of reporting sensitizes audiences, culminating in hardened sentiment and unbridled punitiveness (wright, 2015) . moreover, coverage translates 'stereotypes into actuality', elevating the actual and perceived severity of deviance (young, 1971: 11) . here, identifying affronts to moral order triggers virulent hostility, further marginalizing folk devils and amplifying their deviant attachments and identities. as a control culture is institutionalized, surveillance and intervention intensify, exposing additional deviance, confirming popular stereotypes and justifying further crackdowns (garland, 2008) . since cohen's research nearly a half-century ago, media systems have undergone sweeping transformation, leading many to question the continued relevance of his work. a particularly influential critique in these regards comes from mcrobbie and thornton (1995) . for them (1995: 560), cohen's emphasis on mass-broadcasting and its social and institutional correlates -a univocal press, hierarchical information flows, monolithic audiences -is untenable in the context of 'multi-mediated social worlds'. 1 specifically, it is held that the proliferation of media sources encourages exposure to alternative, if not dissenting, claims and reactions, ensuring that 'hard and fast boundaries between 'normal' and 'deviant' are less common' (mcrobbie and thornton, 1995; 572-3; cf. tiffen, 2019) . moreover, expanded access to media technologies -portable camcorders, personal computers, editing software and so one -broadens the remit of expression, giving rise to media sources inflected with the interests of marginalized groups (coleman and ross, 2010) . able to 'produce their own media' and defended by 'niche and micromedia' (mcrobbie and thornton, 1995: 568) , folk devils are no longer powerless victims and can 'fight back' (mcrobbie, 1994; cf. deyoung, 2013; thornton, 1995) . consequently, deviant outsiders and their supporters display greater capacity to contest and short-circuit panicked reactions, outcomes that render the success of moral crusades 'much less certain' (mcrobbie and thornton, 1995: 573) . focused on the diversification of conventional media space, mcrobbie and thornton conducted their stock-taking precisely as media systems were being further destabilized. with the onset of the 21st century, digital platforms not only underpin but also constitute social life in affluent societies, with individuals' identities and relations at least partly cultivated through computing infrastructures (lupton, 2018) . among the most significant manifestations of 'digital societies' are social media. whether as social networking (facebook), micro-blogging (twitter), or photo -(instagram) and video-sharing (youtube) sites, social media have profoundly reconfigured the production and exchange of information. as 'many-to-many' systems of communication, they promote vernacular discourse and creativity, permitting ordinary users to produce and distribute staggering quantities of 'user-generated content' (keane, 2013; yar, 2014) . 2 digital platforms are also displacing the mass media as an information source. 3 finally, as loosely coupled networks of users, their structure not only promotes virality -the rapid and unpredictable diffusion of content -but also fosters an expansive virtual sociality (baym, 2015; . here, various attributes -'likes', 'retweets', hashtags (#), mentions (@) and so on -index and anchor communications, promoting awareness of others and uniting spatially dispersed users into communities of shared interest and identity (murthy, 2013) . while mcrobbie and thornton could not have anticipated these momentous shifts, contemporary scholarship assumes, either overtly or implicitly, that their corrective remains as, if not more, relevant today (for example, see carlson, 2015; carrabine, 2008; fischel, 2016; marres, 2017) . with information control representing a critical axis of power, social media are frequently depicted as an elite-challenging 'microphone for the masses' (murthy, 2011; cf. gerbaudo, 2018; jenkins, 2006 . here, the accessibility and sophistication of digital platforms is believed to empower ordinary citizens to make their own news, name issues as public concerns, and shape collective sentiment (coleman and ross, 2010; turner, 2010) . with knowledge production and image-making increasingly steered by non-experts, many perceive citizen journalism as breeding accounts of reality rooted in public-mindedness rather than sensationalism or commercial considerations (goode, 2009) . in light of such developments, noted panic scholars claim digital media are shifting 'the locus of definitional power', ensuring 'more voices are heard' (critcher, 2017) and generating 'new possibilities for resistance' (lindgren, 2013 (lindgren, : 1243 . thus, the increasingly nodal configuration of media space has attenuated moral guardians' influence, ensuring that panics are 'more likely to be blunted and scattered among competing narratives' (goode and ben-yehuda, 2010: 99; cf. le grand, 2016) . while mcrobbie and thornton's claims remain influential, their ability to convincingly order the evidence is considerably more limited than recent analysis suggests. in accentuating social media's progressive consequences -information pluralism and robust opportunities for citizens to access the public sphere and defuse frenzied reactionsexisting scholarship neglects how digital platforms are 'underdetermined' and doubleedged (monahan, 2010) . informed by such issues, the following offers a counterpoint, detailing how social media's affordances intensify the proclivity to panic. whether as objects of unease, sources of acrimonious division, or venues for staging moral contests, on balance, contemporary media systems promote febrile anxiety. changing communicative and informational conditions frequently incite moral restiveness. as cohen himself intimates (2002 cohen himself intimates ( [1972 : xvii), societies are regularly gripped by fears that, if improperly governed, new media will have deleterious effects on younger generations. the latest iteration of so-called 'media' (drotner, 1999) or 'techno-panics' (marwick, 2008) , reactions to social media encapsulate deep-seated anxieties about social change and the types of people it begets. like prior episodes involving 'dangerous' media, including 'penny dreadfuls', pinball machines, comic books and 'video nasties', youth are ambivalently constructed as threatened and threatening (springhall, 1998) . while anxieties have surfaced around vulnerability stemming from, inter alia, online predators, sexting, cyber-bullying, and exposure to violent and pornographic content (barak, 2005; gabriel, 2014; lynch, 2002; milosevic, 2015) , youth are also positioned as undisciplined and pathological, with social media branded a leading culprit. alongside being blamed for moral failings -obesity, addiction, disengagement, cultural vacuity, solipsism (baym, 2015; thurlow, 2006; szablewicz, 2010 ) -multi-media platforms have been linked to violent criminality. whether in relation to video game violence, the possibility of obtaining information about weaponry and prior incidents, or the promise of celebrity immortality offered through documenting their grievances and attacks, digital media have been maligned for encouraging school shootings and associated massacres (ruddock, 2013; sternheimer, 2014) . 4 further, during the 2011 england riots, journalists and politicians referenced blackberry and twitter 'mobs', claiming teenage gangs employed digital communications to evade authorities, publicize lawlessness and coordinate anti-social behaviour (crump, 2011; fuchs, 2013) . such fears have frequently culminated in attempts by adult society to intensify surveillance, censorship, and control over online platforms. for such crusaders, who often utilize the very technologies they condemn to whip up outrage, techno-panics provide an alibi for manning the 'moral barricades' and reasserting the hegemony of their values (sternheimer, 2014) . thus, while they may empower grassroots actors and disturb social hierarchies, technological changes equally engender moral backlash and nostalgia. social media also reconfigure the external environment wherein panics occur. frequently valorized for encouraging connectedness and encounters with diverse others, upon closer inspection digital platforms exert centripetal force, producing 'filter bubbles' (pariser, 2011) and 'information silos' (mcintyre, 2018) which narrow social horizons and increase the likelihood of engaging with affective, and often acerbic, content. as news is increasingly digitally mediated, such dynamics reveal, pace mcrobbie and thornton (1995) , there is no one-to-one correspondence between media and message pluralism. able to curate content at the expense of professional gatekeepers, social media allow users to construct information ecologies that are personalized and restricted (sunstein, 2018) . such outcomes are exacerbated by social media's 'aggregative functionalities' (gerbaudo, 2018) : the use of promotional algorithms to deliver tailored content (rogers, 2013) . for example, by assessing the volume of 'clicks' (likes, shares, mentions, etc.) communications receive, facebook's customized news feed determines what is worthy of users' attention, filtering out stories deviating from extrapolations of their interests and preferences (mcintyre, 2018) . as this and related examples suggest, by amplifying users' biases and aversions, social media encourage confirmation bias and isomorphic social relations (powers, 2017) . social media also favour content likely to generate significant emotion and outrage. by promoting communications based on predicted popularity, they prioritize and reward virality and the intensity of reaction rather than veracity or the public interest (van dijck, 2013; yardi and boyd, 2010) . the result is the proliferation of 'click-bait', deliberately sensationalized content that captivates through affective arousal (vaidhyanathan, 2018) . more significantly, new media systems privilege incendiary communications. research suggests that, even for the most staid users, the frisson of disgust is too alluring as content unleashing fear and anger about out-groups is considerably more likely to garner attention and 'trend' (berger and milkman, 2012; vosoughi et al., 2018) . 5 these dynamics ultimately appear contagious as messages' emotional valence 'infects' other users, influencing their subsequent interactions and escalating bitterness and antipathy within online environments (kramer et al., 2014; stark, 2018) . together such conditions promote anxious alarm. by allowing users to remain cloistered within their preferred tribes and visions of reality, digital platforms encourage misrecognition and distort understanding of social issues, making the acceptance of bloated rhetoric more likely (albright, 2017) . accordingly, they obstruct heterogeneous interactions and exposure to opposing perspectives, dynamics long identified as precluding the root causes of panics -intolerance and hostility (murthy, 2013) . finally, by inflating the visibility of inflammatory content, social media mobilize animosity towards common enemies and transform uneasy concern into full-blown panic. alongside breeding fissiparous societies, multi-media platforms can be wielded to engineer crises. historically, panics require the mass media to generate sufficient concern and indignation. social media expand the pathways of panic production. as detailed below, walsh 7 by allowing ordinary netizens to identify and sanction transgression, they unleash participatory, crowd-sourced panics. additionally, as architectures of amplification, their structural features can be commandeered to promote moral contests that are surreptitious, automated, and finely calibrated in their transmission and targeting. conventional wisdom suggests that panics are spearheaded by seasoned and advantageously positioned activists and elites. by expanding capacities of media production and distribution, digital communications permit citizens to directly publicize issues and promote collective action. typically this has been associated with amateur news-making and attempts to document injustice and promote transparency and accountability (coleman and ross, 2010; walsh, 2019a; yar, 2014) , but scholars have recently documented opposing trends, where social media are appropriated to define and enforce public morality. as lay actors increasingly participate in the exposure and sanctioning of deviance, distinctions between the media, the public and moral entrepreneurs are blurring, ensuring that panics stem from unorthodox sources and display new discursive and interactional contours. on the one hand, social media enable micro-crusades that, while lacking broad public appeal and support, are sustained by dispersed groups of devoted and technologically equipped citizens. whether employed to advance claims that harry potter promotes satanism and the occult to impressionable youth (sternheimer, 2014) or discredit public officials and assert a link between vaccinations and autism (erbschloe, 2018) , digital environments offer optimal arenas for uniting the conspiratorial. given their accessibility and ease-of-use, they obviate the need for elite participation, promoting patterns of mobilization around issues where all citizens potentially emerge as crusaders (hier, 2018) . moreover, social media's 'mob-ocratic' tendencies can activate collective effervescence (gerbaudo, 2018) , producing panics driven by mass collaboration. falling into this category are online 'firestorms' (johnen et al., 2018) , spontaneous and electric outbursts where the documentation and exposure of moral breaches -petty theft, public outbursts, drug use, sexual promiscuity, etc. -are rapidly disseminated, igniting interactive cascades of denigration (trottier, 2018; wright, 2017) . such episodes often culminate in digital vigilantism: forms of extra-judicial punitiveness -ostracism, doxing, harassment, job loss, physical attacks, death threats -that emerge from below (powell et al., 2018; trottier, 2017) . 6 consequently, alongside increasing the frequency and velocity of panics, online environments appear to promote heightened virulence and excoriation. while underpinned by emergent technologies, forms of digitally mediated opprobrium are inseparable from late-modern social conditions as they offer a palliative for ontological precarity and allow otherwise atomized individuals to police social boundaries (ingraham and reeves, 2016; cf. bauman, 2013) . beyond expanding the profile of moral entrepreneurs, the networked and digital configuration of social media can also be marshalled to distort information flows, promote 8 international journal of cultural studies 00 (0) incendiary content, and channel user experience and engagement. in such instances, digital platforms constitute architectures of amplification that allow interested parties to punch well above their weight. 'attention hacking' and media manipulation. on the one hand, digital platforms permit highly energized and sustained groups to sculpt public sentiment by maximizing the visibility of 'information pollution' and 'fake news' -arresting, sensational and morally tinged content designed to distort and agitate (kalsnes, 2018) . whether by steering communications, creating fake accounts, or exploiting digital interactions, techniques of 'attention hacking' can strategically influence engagement patterns and produce wildly disproportionate effects (marwick and lewis, 2017) . ultimately, by allowing users to eliminate ambiguity and delineate moral boundaries in publicly visible ways, sites like twitter and facebook generate new types of agency that can rapidly propel the ideas and identities of various outsiders into prominence (joosse, 2018). 7 with their cacophonous character making it difficult to vet the integrity of content, digital platforms have been inundated with captivating, tendentious and skewed, if not entirely spurious, communications (news stories, videos, memes, blog posts, hashtags, etc.) to distort online conversations and mobilize receptive users. an exemplary case of digitally mediated crusades appeared during the 2016 american election as dedicated members of the 'alt-right', as well as digital mercenaries employed by the internet research agency (ira), a russia-backed 'troll farm', devoted considerable energy and resources to shaping political communication and behaviour. central to their efforts was the creation, sharing, liking and promotion of misinformation and provocative discourse about contentious sociocultural issues, including race relations, gun control, abortion, islamophobia and men's rights (bradshaw and howard, 2017; nagle, 2017; singer and brooking, 2018) . 8 armed with an appreciation of digital platforms' value in shifting the parameters of public discourse, such actors succeeded in generating virality, obtaining mainstream press coverage, and inciting considerable outcry and anxiety (phillips, 2018) . more recently, the role of digital communication in spreading fake news and inciting panic was on full display in initial reactions to the novel coronavirus (covid-19), an infectious respiratory disease of zoonotic origin. following its emergence in wuhan, china in january 2020, widespread scapegoating and fear-mongering erupted across social media. in relation to the former, the virus was racialized, with numerous messages linking it to the ostensibly exotic dietary practices and unsanitary behaviour of chinese populations, with representations depicting them as folk devils and dangerous, impure others (yang, 2020) . 9 reflecting a 'politics of substitution' (jenkins, 1992) , such claims-making diverted attention from considerably more deadly (and preventable) diseases (e.g. malaria), as well as, the structural conditions -media censorship, political corruption, weakly enforced health and safety standards -underlying the emergence and rapid spread of the disease. digital platforms were also used to circulate misinformation and dire, if not apocalyptic, predictions with various rumours -whether false reports of positive cases and contaminated chinese imports, stories of individuals absconding from quarantine zones, or claims that the virus was a bioweapon developed by the chinese or american governments -outpacing official information during the early stages of the outbreak (bogle, 2020) . by contributing to a broader climate of suspicion, such communications appear to be reactivating fears of a 'yellow peril', as well as producing emergency measures (enhanced surveillance, quarantines, travel bans etc.) and everyday expressions of racism and anti-chinese sentiment (dingwall, 2020; palmer, 2020; yang, 2020) . as this example reveals, like prior epidemics (sars, aids, etc.) where media coverage promoted fear and opprobrium about various outsiders (gay men, drug users, foreigners; see muzzatti, 2005; ungar, 2013; watney, 1997) , digital communications also play a significant role in distorting understanding and encouraging over-reaction. the episode equally suggests, however, that social media's anonymous, horizontal structure ensures that messages travel exponentially faster, lack clear origins and feature palpable vitriol, outcomes that escalate the impetus and excess of alarm (miller, 2020) . the spread of information pollution frequently hinges on perceptions of social media as the embodiment of the vox populi (gerbaudo, 2018) . here, fake accounts are utilized to raise awareness and bolster the credibility of favoured content. on the one hand, advances in artificial intelligence allow bots -machine-led communications tools that mimic human users and perform simple, structurally repetitive, tasks -to spread 'computational propaganda' (bradshaw and howard, 2017; ferrara et al., 2016) . as social machines and artificial voices, bots automate and accelerate diffusion and engagement, creating, liking, sharing, and following content at rates vastly surpassing human capabilities. thus, they facilitate viral engineering; expanding the momentum of certain messages and, in the process, altering information flows. to exude authority and authenticity, content is also circulated by bogus, 'sockpuppet' accounts posing as those of accredited experts (scientists, journalists, etc.) or ordinary citizens belonging to various groups (women, blue-collar workers, police officers, urban youth, etc.) and appearing to possess folk wisdom (bastos and mercea, 2017; marwick and lewis, 2017) . whether manual or automated, techniques of media manipulation also control narratives by reducing the visibility of unwanted and objectionable content. here, keywords and hashtags affiliated with opposing perspectives can be 'hijacked' as platforms are flooded with nonsense or negative messages to disrupt and drown out specific communications, denuding them of their salience and influence (woolley and howard, 2016) . a recent example of such efforts is found in twitter communications concerning the intensity of the 2019-20 australian bushfires, an outcome widely linked to the longer fire seasons produced by climate change. the preliminary results of research conducted by graham and keller (2020) suggests that, at the height of the crisis, a coordinated misinformation campaign was waged by a sprawling network of troll and bot accounts to advance broader narratives of climate denial. by flooding social media with hashtags like #arsonemergency (in place of #climateemergency) and co-opting those already trending (e.g. #australiafire, #bushfireaustralia), such actors sought to publicize conspiracies that criminal elements -whether arsonists, radical environmentalists, or isis fighters -were responsible for the blazes and that climate change is an elite-engineered hoax and form of population control (knaus, 2020) . finally, the propagation of misinformation involves attempts to harness social interaction and collective sense-making. studies suggest that distorted, emotionally charged content is considerably more likely to be shared by ordinary users who unwittingly enlarge its sphere of influence (albright, 2017; tanz, 2017) . 10 by bearing the imprimatur international journal of cultural studies 00 (0) of whomever shared it, whether a relative, colleague, neighbour, or opinion leader, the substance of messages is validated and appears authentic as it spreads laterally across users' networks (van der linden, 2017) . for instance, on several occasions, accounts linked to the alt-right and russian operatives have successfully 'seeded' content, goading journalists, bloggers, activists, and politicians (including president trump) into endorsing particular communications and providing broader platforms (phillips, 2018) . since messages distributed through formal channels and hierarchical apparatuses are frequently perceived as self-serving and inauthentic, media manipulation provides a powerful vehicle of promotion. by engineering popularity and relevance, the discursive swarms unleashed by bots and fake accounts can generate an impression of credibility, unanimity and common sense, an outcome essential to normalizing particular modes of thought (chen, 2015) . ultimately, by concealing the authors and agendas behind communications, such practices facilitate shadow crusades and astroturfing (rubin, 2017) . while applicable to numerous topics, digitally mediated crusades are distinctly prominent in relation to issues -migration, crime and policing, or terrorism -identified as leading and recurrent sources of panic (hall et al., 1978; kidd-hewitt and osborne, 1995; odartey-wellington, 2009; walsh, 2017 walsh, , 2019c welch and schuster, 2005) , as well as, central topics in online conversations during critical political moments (benkler et al., 2018; evolvi, 2019) . for instance, in their recent study of anti-immigrant crusades, flores-yeffal et al. (2019) observed how the indexing of social media communications through hashtags like #illegalsarecriminals and #wakeupamerica fostered networked discourses and connectedness, helping to construct scapegoats, circulate calls for action, and ensure that xenophobic rhetoric echoed throughout cyber-space (see also morgan and shaffer, 2017) . 11 additionally, preceding the brexit referendum, supporters of the far-right uk independence party utilized digital platforms to trigger and inflate fears about foreigners, circulating contentious claims about workforce competition, cultural displacement, crime and terrorist infiltration (vaidhyanathan, 2018) . computational crusades. finally, social media unleash crusades that are data-driven, granular, and highly dynamic in their transmission and targeting. here, the digital surveillance and marketing infrastructures that underpin social media's profitability permit computational modelling of user data, promising greater awareness of audiences and encouraging claims-making practices involving extensive narrowcasting; behavioural and psychometric profiling; and the production of predictive knowledge. while empowering users as participants and agents of communication, digital platforms also render them legible as vast tranches of information about their attributes (e.g. gender, race, income), activities (e.g. hobbies, movements, browsing habits), and associations (e.g. relational ties, organizational memberships) are continuously scrutinized for commercial, legal and political purposes (nissenbaum, 2009) . once harvested, user data undergoes deep profiling, producing digital dossiers which sort individuals based on dozens, and potentially hundreds, of variables. consequently, audiences are less collectivities to be influenced en masse, than individually calculable units, arrangements that permit those possessing the necessary resources and technological literacy to target users with highly customized messages (zuboff, 2015) . accompanying geodemographic criteria, algorithms can identify and calculate expressive energies and subjective orientations -moods, sensibilities, and emotions. with advances in machine learning and sentiment analysis, digital communications can be analysed to map meaning structures, and discern personality traits on scales previously unimaginable (andrejevic, 2013; stark, 2018) . for example, cambridge analytica, a consulting firm hired to assist the trump campaign's online messaging, harvested data concerning online engagement for over 230 million facebook users, pooling it with other information to develop a sprawling collection of psychographic profiles on potential voters and gauge their receptiveness to various messaging strategies (vaidhyanathan, 2018) . heralding the rise of communications that, while reaching immense audiences, are highly differentiated, it is estimated that, with the assistance of big data analytics, trump's campaign disseminated over 6 million distinct online ads, with variations of individual messages, at times, surpassing 200,000 (singer and brooking, 2018) . big data also yields inferential and predictive knowledge, with computer models unearthing correlations, extrapolating information about users, and forecasting reactions. here, digital enclosures are mined to identify regularities against which users are continuously compared, outcomes that allow claims makers to anticipate content's likely resonance and develop flexible outreach strategies (baym, 2013) . 12 practices of dataveillance are also recursive, as feedback in the form of engagement patterns is reflexively monitored to elaborate correlations and deepen knowledge of users (neuman et al., 2014) . accordingly, digital communications double as iterative experiments where multiple messages can be distributed simultaneously to survey reactions and refine techniques of persuasion (andrejevic, 2013) . in relation to panics, profiling user data liberates crusaders from 'monolithic massappeal, broadcast approach[es]' to issue mobilization (tufekci, 2014) . rather than attracting support through unifying, 'big tent' issues, dataveillance facilitates agile micro-targeted crusades. able to cleave populations into demographic and affective types, moral guardians can precisely 'hail' subjectivities, allowing them to combine mass transmission with individual connection and overcome what has traditionally been a hobson's choice between maximal exposure and intimate resonance. consequently, moral contests promise to become exponentially more sophisticated, ensuring overwrought discourse reaches, motivates and energizes its intended targets. moreover, given the expressive contours of panics, and the importance of emotions -anxiety, hostility, even hysteria -as levers of action (walby and spencer, 2012) , the mining, measurement and classification of affective states allows crusaders to viscerally connect with audiences and strengthen their messaging. as a distinct species of collective behaviour, moral panics represent contentious and intensely affective campaigns to police the parameters of public knowledge and morality. as such, they are necessarily dependent upon and constituted by claims-making, with interested parties historically seeking to actuate alarm by influencing the imagery and representations of the mainstream press, arrangements disrupted by recent upheavals in media space. to illuminate the complex relationship between panics and the broader socio-technical context in which they unfold, this article has surveyed the impact of digital communications, presenting a taxonomy of social media's effects on the issues, conditions and practices that incite collective alarm. while displaying elite-challenging potential, social media are ultimately janus-faced and contradictory. alongside providing emergent sources of unease, they cultivate facilitating conditions and offer ideal venues for constructing social problems. specifically, by elevating agitational discourse and promoting homophily, social media generate social friction and hostility. moreover, as instruments of panic production, new technologies reshape the identification and construction of deviance, both permitting lay participation and allowing various parties to manipulate public communications in ways that produce outsized, imperceptible and highly efficient influence. while gauging the precise effects of social media requires more rigorous scrutiny than can be provided here, the available evidence indicates that, all things considered, they inflate the incidence and severity of panics. on the one hand, various studies suggest that, as architectures of amplification, digital platforms reduce transaction costs and transform peripheral (as well as automated and artificial) voices into conspicuous claimants (vaidhyanathan, 2018) . 13 they also appear to enhance the spread of information pollution, with scholarship revealing that, whether transmitted by algorithms or human agents, 'misinformation, polarizing, and conspiratorial content' (howard et al., 2018: 1) not only 'diffuse[s] significantly further, faster, [and] deeper' on social media (vosoughi et al., 2018 (vosoughi et al., : 1146 albright, 2017) but also, during the final days of the 2016 election, represented the most popular informational content on facebook, leading many to speculate that it played a decisive role in trump's victory (waisbord, 2018) . finally, evidence surrounding the extent to which gross distortions, extremist views and readily falsifiable conspiracies (such as the views that: climate change is a manufactured crisis, violent crime is at historic highs, undocumented migrants are overwhelmingly violent criminals, etc.) are being normalized as public idiom gives considerable cause for concern (mcintyre, 2018; scheufele and krause, 2019). 14 beyond advancing understanding of the media-moral panic relationship, an important task in its own right, by initiating dialogue between theoretical expectations and empirical instances, the preceding analysis promotes conceptual refinement and renewal. specifically, accounting for social media's effects on panic production illuminates significant mutations surrounding the interactants, functions and communicative patterns that define contemporary crusades. first, as many-to-many systems of communication, social media promote novel patterns of participation, offering ordinary persons a greater role, facilitating spontaneous outbursts driven by multitudes and introducing automated, machine-led campaigns. additionally, in enabling new techniques of media manipulation, digital platforms contribute to the weaponization of panics. while conventional wisdom suggests that panics represent domestic affairs, oriented towards mobilizing support, acquiring power and status or manufacturing consent, the case of russia and information warfare suggests that normative conflict may be exogenously engineered to provoke significant social and psychological disruption. finally, in place of uniform messages and mass appeal, the combination of data-mining and behavioural profiling unleashes claims-making techniques that are inhabited and hyper-targeted. drawing attention to these features exposes significant transformations and bolsters the versatility and explanatory capacity of cohen's paradigm. thus, mirroring other recent interventions (falkof, 2018; joosse, 2018; wright, 2017) , by accounting for emergent social conditions, this article advances a nuanced, flexible framework rather than a fixed, uniform model. ultimately, exposing anomalous findings that push the limits of existing perspectives extends the concept's range of applicability, promoting a more robust framework capable of accommodating pivotal shifts in media space and the social relations they engender. alongside laying the foundation for further empirical applications, given the depth and rapidity of social change, such conceptual dexterity is an asset rather than a liability jewkes, 2015) . as an account of reaction and social problems construction, moral panic theory has traditionally emphasized the mass media's role in sculpting collective knowledge, arbitrating between the real and represented, and generating significant discrepancy between risk and response. this article suggests that, while the legacy press continues to play a significant role, with the ubiquity of digital platforms and technologies, the emergence and spread of panics is being reconstituted. in particular, scholars can further refine and expand the concept's range and impact by engaging with social media's diverse and far-reaching effects on the contours of collective alarm. while it is admittedly premature to predict what new attributes media systems will assume, and there is too much contingency to suggest that future developments will follow an inexorable path, it is hoped that, by taking technological change into account, the idea of moral panic will continue to influence understandings of how fear and transgression are mobilized for varied purposes. the author received no financial support for the research, authorship, and/or publication of this article. notes 6. in a striking example of online shaming and digitally mediated outrage, moral entrepreneurs associated with anti-paedophile activism in canada, the uk, and russia have all employed digital platforms to investigate, identify, expose and censure suspected sex offenders (favarel-garrigues, 2019; trottier, 2017) . 7. citing donald trump's rise as a charismatic political maverick, joosse (2018) argues that non-traditional media are ideally suited for producing and reiterating simplistic and highly resonant moral categories, outcomes that can endow otherwise peripheral parties with significant power and influence. 8. while a full discussion exceeds the scope of this article, the alt-right encompasses an illdefined amalgam of actors (white nationalists, men's rights activists, palaeo-conservatives, nativists, etc.) united by opposition to 'identity politics', multiculturalism, and perceived 'political correctness' (hawley, 2017; nagle, 2017) . 9. for instance, videos of chinese citizens eating bats, rodents, snakes and other 'dirty' or 'exotic' wildlife were quickly posted and widely distributed across various social networking sites (palmer, 2020) . 10. surveys from the usa reveal one-quarter of respondents have knowingly shared misinformation on social media (barthel et al., 2016) . 11. russian operatives also contributed to such efforts, distributing content and even organizing protests through fake twitter and facebook accounts (singer and brooking, 2018) . 12. research reveals, for instance, that various attributes -sexuality, religiosity, education, etc. -can be reliably predicted from patterns involving the single data point, facebook 'likes' (markovikj et al., 2013) . 13. for example, during the 2016 election, content from just six russian-backed facebook accounts garnered 340 million shares and nearly 20 million interactions on the platform (matsakis, 2018) . additionally, whether deployed by foreign agents or domestic extremists, bots produced one-third of posts concerning the 2016 brexit vote, despite representing just 1% of active twitter accounts (narayanan et al., 2017) . 14. for instance, over two-thirds of americans claim that fake news has left them disoriented and confused about basic facts (barthel et al., 2016) , while another survey revealed 75% of americans familiar with a fake news headline thought it was accurate (roozenbeek and van der linden, 2019). mcrobbie and thornton's (1995) critique continues to be cited as a core 'dimension of dispute facebook's 2.38 billion active users leave roughly 300,000 comments per minute and share over 5 billion posts per day two-thirds of american adults obtained some of their news from social media (shearer and gottfried, 2017), while, for british and north american youth, it represents their primary news source an exemplary case is pekka-eric auvinen a finnish shooter deemed the 'youtube gunman' after using the video-sharing site to publicize his actions, espouse nihilistic views, and share a final message immediately before killing eight people one study of facebook found the 'click-through' rate for socially divisive content exceeded typical ads by tenfold welcome to the era of fake news infoglut: how too much information is changing the way we think and know sexual harassment on the internet liquid fear many americans believe fake news is sowing confusion the brexit botnet and user-generated hyperpartisan news data not seen: the uses and shortcomings of social media metrics personal connections in the digital age network propaganda: manipulation, disinformation, and radicalization in american politics what makes online content viral coronavirus misinformation is running rampant on social media. abc science social network sites as networked publics: affordances, dynamics, and implications troops, trolls and troublemakers: a global inventory of organized social media manipulation. the computational propaganda project moral panic, moral breach: bernhard goetz, george zimmerman, and racialized news reporting in contested cases of self-defense crime, culture and the media digital objects, digital subjects the agency. new york times magazine folk devils and moral panics the manufacture of news: a reader the media and the public moral panics what are the police doing on twitter? social media, the police and the public the idea of moral panic: ten dimensions of dispute considering the agency of folk devils we should deescalate the war on the coronavirus. wired dangerous media? panic discourses and dilemmas of modernity extremist propaganda in social media #islamexit: inter-group antagonism on twitter. information on moral panic: some directions for further development digital vigilantism and anti-paedophile activism in russia. global crime, epub ahead of print 21 october the rise of social bots sex and harm in the age of consent #wakeupamerica #illegalsarecriminals: the role of the cyber public sphere in the perpetuation of the latino cyber-moral panic in the us social media: a critical introduction sexting, selfies and self-harm: young people, social media and the performance of self-development on the concept of moral panic crime social media and populism: an elective affinity? media social news, citizen journalism and democracy bushfires, bots and arson claims: australia flung in the global disinformation spotlight. the conversation making sense of the alt-right interview with stuart hall. communication and critical/cultural studies moral panics and digital-media logic: notes on a changing research agenda. crime, media, culture, epub ahead of print 6 social media, news and political information during the us election arxiv, epub ahead of print new media, new panics fans, bloggers, and gamers: exploring participatory culture intimate enemies media and crime the digital outcry: what incites participation behaviour in an online firestorm? new media & society expanding moral panic theory to include the agency of charismatic entrepreneurs fake news democracy and media decadence bots and trolls spread false arson claims in australian fires 'disinformation campaign'. the guardian experimental evidence of massive-scale emotional contagion through social networks the ashgate research companion to moral panics. farnham: ashgate moralising discourse and the dialectical formation of class identities youtube gunmen? mapping participatory media discourse on school shooting videos. media pirate panics: comparing news and blog discourse on illegal file sharing in sweden. information pedophiles and cyber-predators as contaminating forces association for the advancement of artificial intelligence digital sociology: the reinvention of social research to catch a predator? the myspace moral panic media manipulation and disinformation online the ftc is officially investigating facebook's data practices crime, media and moral panic in an expanding european union folk devils fight back rethinking 'moral panic' for multi-mediated social worlds it plays to our worst fears': coronavirus misinformation fuelled by social media. cbc cyberbullying in us mainstream media surveillance in the time of insecurity sockpuppets, secessionists, and breitbart. medium, 31 march twitter: microphone for the masses? media bits of falling sky and global pandemics: moral panic and severe acute respiratory syndrome (sars). illness kill all normies: online culture wars from 4chan and tumblr to trump and the alt-right russian involvement and junk news during brexit. the computational propaganda project (comprop) data memo the dynamics of public attention: agenda-setting theory meets big data privacy in context racial profiling and moral panic: operation thread and the al-qaeda sleeper cell that never was don't blame bat soup for the wuhan virus the filter bubble hooligan: a history of respectable fears the oxygen of amplification not everyone in advanced economies is using social media digital criminology: crime and justice in digital society my news feed is filtered? awareness of news personalization among college students on microtargeting socially divisive ads: a case study of russia-linked ad campaigns on facebook the fake news game: actively inoculating against the risk of misinformation deception detection and rumor debunking for social media youth and media science audiences, misinformation, and fake news news use across social media platforms 2017 likewar: the weaponization of social media theory of collective behavior youth, popular culture and moral panics algorithmic psychometrics and the scalable subject pop culture panics #republic: divided democracy in the age of social media the ill effects of 'opium for the spirit': a critical cultural analysis of china's internet addiction moral panic journalism fights for survival in the post-truth era club cultures from statistical panic to moral panic: the metadiscursive construction and popular exaggeration of new media language in the print media moral panics digital vigilantism as weaponisation of visibility coming to terms with shame: exploring mediated visibility against transgressions engineering the public: big data, surveillance and computational politics ordinary people and the media: the demotic turn is this one it? viral moral panics beating the hell out of fake news the culture of connectivity the spread of true and false news online truth is what happens to news: on journalism, fake news, and post-truth social media 'outstrips tv' as news source for young people how emotions matter to moral panics moral panics by design: the case of terrorism the handbook of social control desired panic: the folk devil as provocateur. deviant behavior social media and border security: twitter use by migration policing agencies. policing and society social media and policing: a review of recent research policing desire detention of asylum seekers in the uk and usa: deciphering noisy and quiet constructions automation, algorithms, and politics| political communication, computational propaganda, and autonomous agents: introduction moral panics as enacted melodramas making sense of moral panics a new virus stirs up ancient hatred. cnn the cultural imaginary of the internet dynamic debates: an analysis of group polarization over time on twitter the drugtakers. london: macgibbon and kee big other: surveillance capitalism and the prospects of an information civilization international journal of cultural studies 00(0) james p walsh is an assistant professor of criminology at the university of ontario institute of technology. in addition to moral panics, his research focuses on crime and media; surveillance; and border security and migration policing. key: cord-278022-sc02fyqs authors: ogundiran, akin title: on covid-19 and matters arising date: 2020-06-05 journal: afr archaeol rev doi: 10.1007/s10437-020-09390-x sha: doc_id: 278022 cord_uid: sc02fyqs nan the final phase of the editorial process that culminated in this issue of african archaeological review (volume 36, 2) took place in the atmosphere of panic and uncertainties unleashed by the coronavirus (covid-19) pandemic. i must first thank our authors, reviewers, editorial team, and the springer staff for keeping the clock of production moving despite the strains imposed by the pandemic on our working environment and mindset. five of the pervasive concepts in archaeology (and anthropology broadly) during the past 20 years are vulnerability, collapse, resilience, regeneration, and sustainability (e.g., chase and scarborough 2014; lane 2010; logan et al. 2019; mcanany and yoffee 2009; redman 2005) . these concepts-for which i will use the acronym, vcrrs-are often invoked in discussions about how past societies have coped with (or failed to manage) climate change, natural disaster, conflict, ecological degradation, resource scarcity, and social inequality and the implications for the present and future. infectious diseases are always in the background of our archaeological thinking, but these are not usually given as prominent a space as these other sources of perturbations. unlike epidemical outbreaks, those other perturbations are easier to observe in the archaeological record. for example, natural disasters such as tsunami, earthquakes, hurricanes, and tornadoes are similar to contagions in terms of their sudden and unpredictable occurrences. however, natural disasters often leave much more detectable signs than epidemics, although the latter can last much longer. in some instances, we can receive forewarnings of impending natural disasters and therefore be proactive (e.g., through evacuation). it is not so with microbes. they do not give warnings of their arrival, and they cannot be seen with the naked eye. as a result, we are limited to a gradualist reactive approach to pathogens as they wreak havoc on our corporeal and social fabric. as it has been with covid-19, past societies had to rely more on their political institutions and social systems than their medical know-how in breaking the chains of pathogenic spread. the coronavirus pandemic is relevant to the vcrrs concepts that have animated our scientific inquiry about social and cultural formation for several years. this ongoing pandemic is a stark reminder, on a grand scale, of human vulnerability. it is also a great test of societal resilience, and it presents us with the question of what to let go and what to keep. although, in some instances, the virus has not given us the choice. in the long run, the covid-19 crisis might force on us new ways of being, especially as we develop strategies of recovery and regeneration. but one thing is clear: epidemics will always be part of the human journey. exactly a hundred years ago, the world was just recovering from the influenza pandemic of 1918-1919 that took about 50 million lives worldwide. as many as two million people in sub-saharan africa possibly died from the pandemic (patterson 1983, p. 501) . since then, we have developed the most connected, urbanized, and scientifically advanced global system in human history. alas, we may not have been as well-prepared and efficient as one would expect in dealing with the covid-19 outbreak. this first truly global pandemic in a century has not only halted business as usual but has also overwhelmed the resources of many countries around the world. according to the johns hopkins university coronavirus dashboard, the total confirmed number of infections globally is nearing six million, and over 350,000 people have died at the press time for this issue (1). the african union's center for disease control and prevention has reported over 119,000 covid-19 cases and more than 3,500 deaths in africa. about 50,000 have recovered as of mid-may. overall, africa's covid-19 cases account for 2.1% of the global number and less than 1% of the worldwide covid-19-related deaths (2) . several conjectures have been offered as to why africa's numbers are low, considering the poor state of its healthcare compared with the global north (moore 2020) . although this pattern may change as this situation evolves, we must also confront two realities. first, the advanced healthcare system of north america and europe does not translate into healthy living for some segments of their population and access to good healthcare is uneven. second, the aggressive efforts of most african governments helped to significantly slow the spread of covid-19, as i witnessed in late february during my trip to the continent. the world health organization regional director for africa, dr. matshidiso moeti, has said that the covid-19 spread is unlikely to be as exponential in africa as it has been elsewhere. however, she also warned that without proactive testing, tracing, isolating, and treating, covid-19 could smolder in transmission hotspots across the continent for many years to come (3) . coronavirus, like all zoonotics in history, is a product of ecological perturbations, an outcome of the interdependence between humans and fellow organisms (vidal 2020; vijaykrishna et al. 2007) . and epidemics are no respecter of the visible and invisible walls that people and societies build to separate themselves into classes, ethnicities, genders, races, tribes, and other hierarchies of power and social difference. hence, coronavirus has sneaked into spaces of power, from the white house to 10 downing street, and it has penetrated the cramped working-class tenements from cape town to new york. covid-19 may defy social boundaries. however, social inequality-one of the staples of archaeological inquiry-has nevertheless mediated the brutal impacts of the virus. not surprisingly, the poor and the working class have higher chances to be exposed to and die from coronavirus because they have fewer opportunities for social distancing and must also work outside the home. not only do they have higher chances of contracting and spreading the virus to family members, but they often also have the underlying medical conditions and historically poor access to healthcare that make them more susceptible to death from covid-19 than the well-off. in the western world, where class and race tightly overlap, infected black people and other minorities in the usa are dying at a higher rate than their white counterparts (kendi 2020) . the class and age patterns of contraction and death from covid-19 are not yet clear in africa, but there is no doubt that the first wave of the infected were those who had recently visited europe, north america, and asia. as a result, according to a british broadcasting corporation report, covid-19 was initially perceived as the disease of the elite in many parts of africa (4). these elite are still being blamed on the street for bringing the disease to their respective countries, a reflection of the sharp socioeconomic divides on the continent. it is noteworthy that as early as february 2020, many african countries were at the forefront of proactive actions to stem the spread of the pandemic at the very time that many countries in the global north were in denial and foot-dragging about the disease. many scientists on the continent are also working to be part of the solution rather than waiting for what the global north can do for them. senegal, for example, is developing a $1 covid-19 testing kit as part of the strategy to help flatten the curve of infection. amadou sall, the director of the pasteur institute in dakar where the test kit is being developed, reportedly said that his laboratory could analyze 500-1000 tests a day and produce 4 million test kits a year (yeung 2020) . currently, each coronavirus test costs hundreds of dollars, and analyzing one test would take several hours. in nigeria, a group of scientists at the university of ibadan is investigating the efficacy of a local herb, euphorbia hirta, for treating the respiratory conditions associated with covid-19 (5) . many other examples abound in different parts of the continent. these efforts call attention to the need to support capacity building in africa rather than the usual benefactor gestures that merely reinforce the dependency syndrome in the continent. we are reminded that the most effective and lasting solutions to some of the contemporary medical problems in the world may originate in africa, as they did in the past. african herbal medicine and healing knowledge, for example, have made significant contributions to the advances in western science, from treating malaria to eradicating smallpox. the race by western scientists and drug companies to appropriate african knowledge of herbal plants for developing patented drugs has been ongoing for more than a century (e.g., osseo-asare 2014). all of these reinforce the need to expand the archaeological framework for heritage studies in africa beyond the valorization of places and monuments. of course, the agenda for archaeological heritage will always include the preservation of archaeological sites and landscapes, conservation of artifacts, and the use of these artifacts and sites for public education (volume 28, 1 of the journal was devoted to this topic almost a decade ago; sulas et al. 2011) . but these cannot be the stopping point. heritage studies must take advantage of the interdisciplinary approaches of archaeology so that it can be relevant to the needs of african peoples, especially by supporting the quest to liberate africa from economic and intellectual dependency rather than perpetuating that dependency. therefore, one would hope that the documentation, analysis, and application of indigenous knowledge and epistemology will be an integral part of the burgeoning archaeological heritage studies on the continent (also see mire 2011). as i have advocated in a recent editorial, those archaeological programs invested in heritage studies need to collaborate with experts in other fields so that the body of heritage-related knowledge they are collecting can inform scientific and policy efforts to improve human conditions in africa and elsewhere (ogundiran 2019 ). this echoes david phillipson's much earlier observation of the purpose that african archaeology must serve in generating bodies of knowledge that would contribute to the appropriate "policies for. .. health, food, sustainable exploitation of natural resources, and. .. fostering a sense of pride and self-reliance" on the continent (phillipson 2003) . covid-19 is challenging us to rethink how we do business and engage in archaeological inquiry. if history is a useful guide in this instance, we know that epidemics never traveled alone. they were always accompanied by other ecological, economic, and sociopolitical upheavals that have altogether changed or shaped the course of human history (e.g., mcneill 1998; oldstone 2009). the shortand long-term impacts of coronavirus on global politics and power relations are still not clear. nevertheless, almost every economist is predicting recessions, and the unemployment rate has exponentially risen in many countries, while the trains of global supply chains have also been derailed significantly. drastic budget cuts by national and subcontinent governments in the next fiscal year are all certain. for most african countries, the reliance on single commodity export and importation of almost all essential infrastructure, including medical supplies, portend significant economic and social trouble. but these also present opportunities for african countries and regional blocs to think creatively about local production and innovations. how might these knowns and unknowns affect human lives, archaeology, and heritage issues in africa? a forum has been convened for future publication in the african archaeological review that will explore some aspects of this question while also providing a platform to discuss what we are learning in african archaeology and heritage studies from the social, political, economic, and ecological dimensions of the covid-19 pandemic. the forum participants have been tasked to explore how the pandemic is affecting the way they conceptualize and think about the african past with reference to their scholarly interests in social formations and social emergents. the participants will also reflect on the insights that archaeology can provide to inform the ways current pandemic is being managed on the continent. we hope to publish 6-8 short essays on these and related topics in the coming months. covid-19 has disrupted most archaeological plans for the summer and early fall of 2020, especially fieldwork travels. most important, the much-anticipated biennial conference of the society of africanist archaeologists (safa) scheduled for september 21-24, 2020 in oxford (uk), has been postponed till next year-august 15-20, 2021, and this will still take place in oxford university. one must commend the sagacity and consultative approach of the safa executive and the conference organizing committee, led by elisabeth hildebrand and peter mitchell respectively, in the way the decision to postpone the 2020 conference unfolded. it is a template for future crisis management by the association, and the sequence of events deserves to be summarized here (6) . & april 24: the safa president, elisabeth hildebrand, announced the inauguration of a sixmember "covid matters committee" (cmc), in consultation with peter mitchell, "to gather perspectives and, in the next few weeks, decide whether or not we should postpone" the 2020 safa conference. the cmc members include two representatives from each of africa, europe, and north america: alemseged beldados, munyaradzi manyanga, timothy clack, paul lane, catherine d'andrea, and brian clark. & april 27: the safa members were given the opportunity to contact the cmc with ideas and suggestions on what should be done with the scheduled 2020 safa conference. hildebrand specifically charged cmc to determine the timing(s) and mechanism(s) for the 25th biennial conference and consider the maximum health, safety, and opportunities for participation across the safa membership. & april 29: events were moving very fast, and the alarming rate of new covid-19 cases and death in north america and europe, coupled with other factors, made it necessary for peter mitchell to announce, on behalf of the conference organizing committee, the postponement of the conference until mid-august 2021. & may 1: the co-chairs of cmc, paul lane and catherine d'andrea, reported the committee's first meeting to safa members. the committee made two important decisions. first, the cmc did not recommend holding the 2020 conference in september in "an entirely online format" because of unequal access of safa members to the internet. second, the committee plans to explore the viability of holding limited and small-scale online sessions in september 2020 "as a 'test drive' for incorporating more online access to full safa meetings in the future." & may 12: the cmc co-chairs contacted safa members again to report the outcome of the committee's may 7 meeting. they announced that the committee had reviewed and approved a google-based survey "to gather opinions from our membership on online options for september 2020 and future safa meetings" (the survey was released on may 22). the cochairs also informed members that "a series of online events will be hosted by the safa oxford organizing committee in september 2020, not as a replacement of the 2020 conference but to provide students and early career researchers with workshops on grant preparation and publications development. and, these junior scholars will also have the opportunity "to present aspects of their research in a poster format." the safa executive, the safa 2020 organizing committee, and the cmc members are to be commended for their hard work in leading the association through this uncharted path, although there are still several emerging questions yet to be answered. covid-19 no doubt challenges many of the ways in which we engage our sociality as scholars and professionals. the digital technology is playing a significant role in the ways we cope with these challenges. it is too early to understand the long-term effects of this technologyenhanced coping strategy on our future communication, interaction, knowledge sharing, and social networks, not to talk of global health, economics, and politics. covid-19 and its uncertain future notwithstanding, cameron gokee and i had the great pleasure of working with the authors whose articles appear in this issue of the journal. the lead article is the conversation that two senior african archaeologists, chap kusimba and innocent pikirayi, had with peter schmidt about his 50-year career (and still counting!). the interview covered a lot of ground, and we are pleased to feature peter schmidt's experience, accomplishments, and challenges in the following pages. his story is a significant part of the history of african archaeology. it offers many takeaways. also, this issue includes an article on new advances in archaeometallurgical study in senegal, with emphasis on the transformations in iron technology in the falã©mã© river valley region between the fourth century bc and seventh century ad. the next article focuses on schroda, a tenth-to eleventh-century farming settlement in the middle limpopo valley (south africa), where a functional analysis of ceramic vessels was undertaken to answer questions of site use and social organization. two articles are based in tanzania. one is a synthesis of the archaeological profile of the iringa region, from the early stone age to the colonial period, a product of 14 years of fieldwork. the other article explores the development of cognitive thoughts, planning depth, and cultural innovations by anatomically modern humans during the late msa and early lsa transitions in the famous mumba site. paul lane sent in a reflective commentary on the roles that the shanghai archaeological forum has been playing in world archaeology since 2013 and the implications of china's belt and road initiative for africa's archaeological heritage. this issue also features three book reviews. the reviewers noted the significant contributions of each book to africa's cultural history. the first book revisits the epistemology and methodology of sources in the study of west africa's history. the second provides the first booklength assessment of the state of middle stone age studies in nigeria. and the third examines mortuary culture, patterns of migration, and dynamics of identity in the ancient sahara region. on behalf of the editorial team of the african archaeological review, i wish you safety and well-being in this uncertain time. diversity, resiliency, and ihope-maya: using the past to inform the present what the racial data show: the pandemic seems to be hitting people of color the hardest developing landscape historical ecologies in eastern africa: an outline of current research and potential future directions usable pasts forum: critically engaging food security questioning collapse: human resilience, ecological vulnerability, and the aftermath of empire plagues and peoples the knowledge-centred approach to the somali cultural emergency and heritage development assistance in somaliland what african nations are teaching the west about fighting the coronavirus. the new yorker food security, food sovereignty, and indigenous knowledge viruses, plagues, and history: past, present and future bitter roots: the search for healing plants in africa the influenza epidemic of 1918-19 in the gold coast archaeology in africa and its museums: an inaugural lecture given at the university of cambridge resilience theory in archaeology africa's fragile heritages: introduction destroyed habitat creates the perfect conditions for coronavirus to emerge evolutionary insights into the ecology of coronaviruses cheap and easy $1 coronavirus test to undergo trials in senegal additional online sources for this essay african union's centres for disease control and prevention dashboard cause many deaths, says who. the new york times coronavirus: why some nigerians are gloating about covid-19. bbc news covid-19: ui scientists recommend euphorbia hirta linn. for relief key: cord-212813-yrca1hij authors: winkelmann, ricarda; donges, jonathan f.; smith, e. keith; milkoreit, manjana; eder, christina; heitzig, jobst; katsanidou, alexia; wiedermann, marc; wunderling, nico; lenton, timothy m. title: social tipping processes for sustainability: an analytical framework date: 2020-10-09 journal: nan doi: nan sha: doc_id: 212813 cord_uid: yrca1hij societal transformations are necessary to address critical global challenges, such as mitigation of anthropogenic climate change and reaching un sustainable development goals. recently, social tipping processes have received increased attention, as they present a form of social change whereby a small change can shift a sensitive social system into a qualitatively different state due to strongly self-amplifying (mathematically positive) feedback mechanisms. social tipping processes have been suggested as key drivers of sustainability transitions emerging in the fields of technological and energy systems, political mobilization, financial markets and sociocultural norms and behaviors. drawing from expert elicitation and comprehensive literature review, we develop a framework to identify and characterize social tipping processes critical to facilitating rapid social transformations. we find that social tipping processes are distinguishable from those of already more widely studied climate and ecological tipping dynamics. in particular, we identify human agency, social-institutional network structures, different spatial and temporal scales and increased complexity as key distinctive features underlying social tipping processes. building on these characteristics, we propose a formal definition for social tipping processes and filtering criteria for those processes that could be decisive for future trajectories to global sustainability in the anthropocene. we illustrate this definition with the european political system as an example of potential social tipping processes, highlighting the potential role of the fridaysforfuture movement. accordingly, this analytical framework for social tipping processes can be utilized to illuminate mechanisms for necessary transformative climate change mitigation policies and actions. there is growing concern that global climate change is reaching a point where parts of the earth system are starting to pass damaging climate tipping points (1): in particular, part of the west antarctic ice sheet (wais) appears to already be collapsing because of irreversible retreat of grounding lines (2, 3) which in turn is expected to trigger loss of the rest of the wais (4) . other tipping points may be close: a recent systematic scan of earth system model projections has detected a cluster of abrupt shifts between 1.5 and 2.0°c of global warming (5) , including a collapse of labrador sea convection with far-reaching impacts on human societies. the abrupt degradation of tropical coral reefs is projected to be almost complete if warming reaches 2.0°c (6, 7) . the possibility of the global climate tipping to a 'hothouse earth' state has even been posited (8) . against this backdrop, there is a growing consensus that avoiding crossing undesired climate tipping points requires rapid transformational social change, which may be propelled (intentionally or unintentionally) by triggering social tipping processes (9, 10) or "sensitive intervention points" (11, 12) . examples for such proposed social tipping dynamics include divestment from fossil fuels in financial markets, political mobilization and social norm change, socio-technical innovation (911, 13, 14) . equally, if human societies do not act collectively and decisively, climate change could conceivably trigger undesirable social tipping processes, such as international migration bursts, food system collapse or political revolutions (15) . social tipping processes have received recent attention, as they encompass this sort of rapid, transformational system change (9, 10, 13, 15) . here we develop an analytical framework for social tipping processes. drawing upon expert elicitation and a comprehensive literature review, we find that the mechanisms underlying social tipping processes are categorically different from other forms of tipping, as they uniquely have the capacity for agency, they operate on networked social structures, have different spatial and temporal scales, and a higher degree of complexity. following these distinctions, we present a definitional framework for identifying social tipping processes for sustainability, where under critical conditions, a small perturbation can induce non-linear systemic change, driven by positive feedback mechanisms and cascading network effects. we adopt this framework to understand potential social tipping dynamics in the european political system, where the fridaysforfuture movement (16) pushes the system towards criticality, generating the conditions for shifting climate policy regimes into a qualitatively different state. the proposed framework aims to establish a common terminology to avoid misconceptions, including the notions of agency, criticality as well as the manifestation and intervention time horizons in the context of social tipping. in this way, the framework can serve to connect literatures and science communities working on social tipping, social change, complex contagion dynamics and evidence from behavioral experiments (e.g. 14, 17). we start by reviewing the characterization of tipping points across the natural and social sciences. over the last 150 years, a suite of concepts and theories describing small changes with large systemic effects has been developed at the intersection of natural and social sciences. more recently, the concepts of tipping points and tipping elements have been broadly adopted by both natural and social scientists working within the field of climate change. while the concept of 'tipping' originated in the natural sciences (18, 19) , social scientists made extensive use of the idea in the 20th century, often without using the terminology of tipping. famously, schelling (20) , following grodzins (21) , developed a theory of tipping processes to explain racial segregation in us neighbourhoods. granovetter (22) modeled collective behavior as a tipping process that depends on passing individual thresholds for participation in riots or strikes. kuran (23) described political revolution in terms of tipping dynamics, while gould and eldridge (24) distinguish phases of policy change and stability in terms of 'punctuated equilibrium'. gladwell (25) popularised the concept of 'tipping points', exploring contagion effects ("fads and fashions"), sometimes triggered by specific events. several recent studies have examined tipping processes within contemporary social systems. homer-dixon (26) and battison (27) explored the 2008 financial crisis as a tipping phenomenon. nyborg (14, 28) discussed shifts in norms and attitudes, for example regarding smoking behaviors. centola (17) associated tipping points with the "critical mass phenomenon", wherein 20-30% of a population becoming engaged in an activity can be sufficient to tip the whole society. similarly, rockström et al. (29) highlighted this so-called pareto effect in the context of decarbonization transitions. kopp et al. (15) distinguished different social tipping elements within the realm of policy, new technologies, migration and civil conflict that are sensitive to "climate-economic shocks". here, a tipping element is a system or subsystem that may undergo a tipping process. since the mid 1990s, ecologists and social-ecological systems (ses) researchers have also developed an extensive body of research on tipping processes using the terminology of 'regime shifts' and 'critical transitions' (e.g. [30] [31] [32] . recognizing the impacts of human development on various ecosystems, this body of work often models ecological regime shifts as a consequence of social drivers. less attention, however, has been paid to sudden changes in social systems triggered by ecosystem changes. there is a rich literature on the collapse of past civilizations (e.g. 33, 34) and the potential role of tipping points in that (35) . recently, cumming and peterson (36) brought this together with work on ecological regime shifts, proposing a "unifying social-ecological framework" for understanding resilience and collapse. further, rocha et al. (37) noted that tipping dynamics can be produced by the interactions between climatic, ecological and social regime shifts. the concept of climate tipping elements introduced by lenton et al. (1) and schellnhuber (38) , has been increasingly adopted within earth and climate sciences. climate tipping elements are defined as at least sub-continental-scale components of the climate system that can undergo a qualitative change once a critical threshold in a control variable, e.g., global mean temperature, is crossed. positive feedback mechanisms at the critical threshold drive the system's transition from a previously stable to a qualitatively different state (1). other scholars, e.g., levermann et al. (39) , suggest a somewhat narrower definition of climate tipping elements by introducing additional characteristics, such as (limited) reversibility or abruptness. the tipping elements identified so far include biosphere components such as the amazon rainforest (40) (41) (42) and coral reefs (6, 7) , cryosphere components such as the ice-sheets on greenland and antarctica (43) , and large-scale atmospheric or oceanic circulation systems including the atlantic meridional overturning circulation (44, 45) . their tipping would have far-reaching impacts on the global climate, ecosystems and human societies (e.g. 8, 46). in response to the concept of climate tipping points, social scientists are re-engaging with this concept yet again, creating an additional layer of tipping scholarship with an emphasis on the need for and possibility of deliberate tipping of social systems onto novel development pathways towards sustainability (e.g. 11, 47) . scholars argue in particular that the rapid, non-linear change of social tipping dynamics might be necessary to speed up societies' responses to climate change, and to achieve the goals of the paris agreement. it is this element of acceleration, propelled by positive feedbacks, that makes the concept of tipping particularly interesting. for example, otto and donges et al. (9) reported expert elicitations identifying social tipping elements relevant for driving rapid decarbonization by 2050. rapid-paced changes are a distinctive feature potentially differentiating tipping dynamics from many other forms of social change, including incremental (policy or institutional) changes, or more radical (socio-technical) transitions or societal transformations. over the last decade, the literature on deliberate transitions and transformations towards sustainability has expanded significantly, exploring the dynamics that lead to the reorganization of social, economic or political systems (e.g. 48, 49) . in many ways, this literature and the emerging work on social tipping are interested in very similar phenomena: fundamental shifts in the organization of social or social-ecological systems -a movement from one stable state to anotherincluding a change in power relations, resource flows, as well as actor identities, norms and other meanings (48) . transformations can be fast, but speed is generally not one of their defining characteristics. this temporal feature of social tipping points -rapidity of change compared to the system's normal background rate of change -combined with the fact that tipping processes can be triggered by a relatively small disturbance of the system is motivating scholarship on leverage or 'sensitive intervention points', e.g. farmer et al. (12) , who identified such potentially high-impact intervention opportunities, e.g., financial disclosure, choosing investments in technology and political mobilization that may be key for triggering decarbonization transitions. based on a bibliometric and qualitative review of these various bodies of literature across the natural and social sciences, milkoreit et al. (10) proposed the following general definition of (social) tipping: "the point or threshold at which small quantitative changes in the system trigger a nonlinear change process that is driven by system-internal feedback mechanisms and inevitably leads to a qualitatively different state of the system, which is often irreversible." milkoreit et al. (10) further noted there is a need to recognize and identify potential differences between climatic (or ecological) and social tipping processes to gain a deeper understanding of these phenomena. given this diverse and nascent field, there is a clear need for consensus as to what defines social tipping processes, as well as an understanding of how these processes are similar and diverge from dynamics in other non-social systems. further, there are currently limited examples of social tipping elements in the context of sustainability transitions presented within the broader literature (9, 12, 13, 15) . here we explore the characterization of tipping processes within the natural and social sciences, examining how social and climate tipping processes are differently conceptualized. we draw upon a mixed qualitative methodological approach to illuminate these differences and key distinctions. initially, core differences were identified and discussed via expert elicitation (50) . a selected group of 25 experts from across the climate and social sciences were invited to take part in an expert elicitation workshop, that focused on identifying a common definition for social tipping processes, as well as the characterization of their dynamics. this workshop was convened in june 2018 in cologne, germany. the workshop participants were split into cross-disciplinary breakout groups, to independently identify the dynamics of social tipping processes. then, each of these groups reported their findings to the broader plenary, for discussion, consolidation, reconciliation and clarification. the process was then repeated for further clarification within the breakout groups. through this iterative inductive and deductive process, several unique themes and characteristics were identified from the broader set of codes, resulting in the key differences in and definition of social tipping processes presented below. drawing upon the differences identified in the expert elicitation workshop, we then review and synthesize the emerging field of social tipping processes, particularly in comparison to the related climate and ecological tipping dynamics. we then draw upon these unique characteristics to develop a common definition for social tipping processes, which we explore using the example of the fridaysforfuture student movement. social and climate systems' tipping processes exhibit several broad, fundamental differences in their structure and underlying mechanisms: (i) agency is a main causal driver of social tipping processes, (ii) the quality of social networks and associated information exchange provides for specific social change mechanisms not available in non-human systems, (iii) climate and social tipping processes occur at different spatial and temporal scales, and (iv) social tipping dynamics exhibit significantly more complexity than climatic ones. the most important characteristic differentiating social from climate tipping processes is the presence of agency. while a significant body of work (e.g. 51), including latour's actor-network theory (52) , addresses different forms and effects of non-human or more-than-human agency, here, we focus on a more narrow understanding of agency that is based on consciousness and cognitive processes such as foresight, planning, normative-principled and strategic thinking, that allow human beings to purposefully affect their environment on multiple temporal and spatial scales. while humans have a generally poor track record of utilizing their agentic capacities especially with regard to shaping the future (e.g. [53] [54] [55] , they appear unique in their capacity to transcend current realities with their decisions. agency in this more narrow sense can be understood as the human capacity to exercise free will, to make decisions and consciously chart a path of action (individually or collectively) that shapes future life events and the environment (56) . the notion of intentionality inherent in the idea of agency implies that human actors are not only able to adapt to changes in their environment, but also deliberately create such changes. non-human life forms can also be engaged in deliberate changes of their environment (e.g., beavers building dams), but the cognitive quality of these actions differs from those of humans, which can be based on different forms of knowledge and meaning about the world, moral norms and principles, or ideas about desirable futures. agency allows individuals and societies to be proactive rather than merely responsive in their relationships with other humans or the environment through planning, goal setting and strategic decision-making, which links decisions and behaviors in the present with consequences and realities in the (distant) future (57) . governance scholars address this social-cognitive capacity for forethought and goal-pursuit in terms of anticipation (58) and imagination (10) , which can be tied to a set of futuring methods (59, 60) . the ability to anticipate and imagine futures enables humans and their societies (53, 54) -as opposed to animal communities or ecosystems -to transcend the present and shape the future according to our values and goals (61), possibly increasing the prospects for human survival in times of fast and significant environmental change (56, 62) . although this ability has been underutilized in the past, especially in the context of responding to climate change (63), it is a crucial dimension of the human repertoire of tools to create change and to ensure its long-term well-being. agency interacts with many of the additional differentiating characteristics we identify below in important ways. for example, agency plays a role in the creation of social networks, institutions and meaning, i.e., the production of the structures of social systems. these network structures in turn enable and constrain agency (e.g. 64, 65) . physical climate tipping elements, such as ice sheets or ocean circulations, lack that ability to intentionally act and adapt. however, the adaptive capacity of ecosystems can be interpreted as a form of non-human agency and learning mechanism (66), see also supplementary information s2. while scholarship on non-human agency, including that of animals, inanimate objects, landscape features or ecosystems (e.g. 67, 68) might expand our understanding of agency, the cognitive abilities that characterize human agency, especially long-term and strategic thinking, do not exist in the non-human or inanimate worlds. understanding the nature of social networks is crucial for studying social tipping. while both natural (including physical and ecological) and social systems can be structurally characterized as networks and studied using a network science approach (69), social systems differ from natural systems in the quality of the networks' nodes and interconnections and the processes and dynamics facilitated and impacted by these particular network characteristics. social systems feature additional network levels of information transmission (cultural and symbolic) that are largely restricted to human societies compared to natural systems (70) . network qualities unique to social systems: networks in social and natural systems share various commonalities such as the existence of fundamental nodes and links (69) . in contrast to most natural systems, however, social networks have the capacity to intentionally generate new nodes, which include socially constructed entities such as organizations and movements (71) . new nodes can be created through cultural, political or legal means, as can the rules for their interactions with other existing nodes. social system nodes are unique in that they have richer cognitive realities, particularly agency and forethought. these nodes often have conflicting vested interests, which may be more short-sighted than future oriented. relationships in social networks can consist of shared meanings -especially norms, identities and other ideas -and a vast variety of cultural, economic and political relationships (e.g., employment, citizenship), all of which are not as pronounced or non-existent in less complex human societies and nature. hence, social network links are more diverse than links in natural systems and enable different kinds of network processes. for example, links between nodes in social networks are not necessarily dependent on physical co-presence, due to technologically enabled connections or the presence of more abstract interrelations such as shared norms, values or interpersonal relationships. social network dynamics can be of a purely ideational nature (e.g., the subject of the study of opinion and belief dynamics), but also involve material changes (e.g., resource extraction, movement and transformation for economic purpose). markets are unique social networks, involving both ideational and material network processes. in the anthropocene, the intensity and speed of socially networked interaction has increased dramatically, largely due to new media, digitalization, more efficient means of transportation, lower travel costs, and overall increased mobility, which is likely to increase spreading rates, while at the same time affecting the stability of the network itself (72) (73) (74) . generally, social tipping can either occur on a given network (e.g., through spreading dynamics changing the state of nodes (75) or change the network structure itself (see figure 1 ). the structural network changes generated by social tipping processes include transitions from centralistic or hierarchical to more polycentric (neuromorphic) structures in urban systems, energy distribution and generation networks (76, 77) . structural changes can manifest on large and small-scale spatial networks across multiple social structure levels. in order to capture these network tipping processes, quantifiers from complex network theory such as modularity, degree distribution, centrality or clustering can be used (69) . 3, 1975 to january 3, 1977) . node colors indicate different party membership and links between nodes are drawn if the corresponding members agree on 66% of all votes in the considered two-year period. the lower network shows the same for the 110th united states congress (january 3, 2007, to january 3, 2009 ). the transition from a closely entangled to an almost fragmented topology indicates a polarisation between democratic and republican party members over time (16) . temporal and spatial scales: scales can differ greatly between social tipping and climate tipping processes and are more ephemeral for social tipping than for climate tipping. temporally, tipping in social systems manifests more commonly on the scale of months to decades, while for the climate tipping elements range from years to millennia. human actors tend to focus on more short-term consequences or outcomes, as complex issues (such as climate change) with longer timeframes are often harder to assess (79) . within social systems, fund manager performance is evaluated quarterly, politicians often think in electoral cycles, business operates with annual or five-year forecasts, while individual practices and dispositions are constantly evaluated and reevaluated (80) (81) (82) . in natural systems, however, it might take decades, centuries or even millennia for outcomes of change processes to become detectable (see figure 2 ). both social and climate tipping elements can be ordered spatially (1, 39, 83) , although social tipping elements cannot always be precisely located geographically. social scientists and economists have long grouped systems and processes as existing on the macro-, meso-and micro-levels (or some variation thereof), whereby some social systems (e.g., financial markets, political systems, technologies) consist of interdependent subsystems existing on multiple spatial levels. social tipping processes can also display spatial-temporal ephemerality. while climate tipping elements have a known spatial extent and dimensionality (with often a comparable extent in latitude and longitude and a generally much smaller extent in altitude) and have persisted in their current stable state for thousands (if not millions) of years, social tipping processes do not have a spatial extent or effective dimensionality that is known ex-ante and they can emerge (move into a critical state) and disappear (move out of a critical state) over time. (84) , tabara (11) and lenton (13) . complexity: social tipping processes occur in complex adaptive systems (85-87) as opposed to the complex but non-adaptive physical climate system. as such they can exhibit comparatively greater complexity in the (i) drivers, (ii) mechanisms and (iii) resulting pathways of social tipping processes, as well as the aforementioned ephemerality in their spatial-temporal manifestations, including a potentially fractal and varying dimensionality and a more complex interaction topology (88, 89) . social tipping processes can rarely be linked to a single common control parameter, such as is the case with global mean temperature in climate tipping dynamics. for most of the climate tipping elements like the ice sheets or the atlantic meridional overturning circulation, the control variables such as local air temperature, precipitation or ocean heat transport, can often be translated or downscaled into changes in global mean temperature as one common driver (1, 38). however, for social tipping processes, multiple, interrelated factors are often identified as forcing the critical transition. for example, shifts in social norms regarding smoking (14) can be linked to several, entwined factors, such as policies, taxation, advertising and communication, social feedbacks (e.g., via normative conformity), or individual preference changes. centola et al. (17) show that tipping in social convention is possibly explained by a single parameter: the size of the committed minority). at larger scales, the collapse of complex civilizations has been linked to multiple interacting causes, and whilst disagreement abounds over the balance of causes in particular cases, there is general agreement that multiple factors were at play (33) . this kind of causality -multiple interacting, distributed causes across varying scales -are a key characteristic of complex systems (90) , contrasting starkly with conventional notions of causality involving bivariate relationships (one cause and one effect). further, due to their potential for agency and adaptive plasticity, social systems are open to a larger number of mechanisms that could cause a tipping process and various pathways of change that a tipping process could follow towards a greater number of potentially stable post-tipping states (91) . climate tipping processes are often modeled as bi-or multistable, where the directional outcomes of forcing are to some extent known or knowable, e.g., based on paleoclimatic data and processbased earth system modelling. given a specific forcing change, one can predict in what state the element will restabilize as well as the "net" effects of the tipping process on larger earth systems. based on this understanding, the tipping of climate system elements is generally perceived as undesirable and often as part of pushing the earth system out of the "safe operating space for humanity" (92, 93) . in contrast, for social systems, it is often unclear what a final stable state of the system will look like, or even whether the changes resulting from a tipping process will be normatively considered "positive" or "negative". as clark and harley (94) point out, the characteristics of complexadaptive social systems, including the diversity of actors and elements and the different outcomes generated by local and global interactions, imply that the development pathways of these systems are less predictable. further, a social tipping process can generate new and destroy existing actor types (e.g., identities, institutions) and their behaviors. cross-scale dynamics and local differences are important to understand the emergent system structure and change dynamics, but predictive capacities, e.g., regarding the timing of a social tipping point or the boundaries between different stable states, do not yet exist (94) . hence, the term 'managing transitions' is less useful than the idea of navigating a transformation pathway. the political nature of social change processes (95) -different actors within a social community pursuing different, sometimes opposing, interests and visions for a reorganization of a social system while bringing to bear different resources and strategies -further exacerbate this situation. actors can deliberately generate new feedback dynamics that support or slow change, even after a tipping point has been passed, and they can actively work to adjust the direction of change. from the discussion above, it follows that a definition of social tipping process should take a microperspective and incorporate network effects and agency in addition to common tipping characteristics already explored in the review by milkoreit if a tipping element is already in a critical condition, where the stability of its current state is low, there may be a time window during which an agential intervention might prevent an unwanted tipping process by moving the system into an uncritical condition (see also si text s1). alternatively, if a tipping element is not already in a critical condition, there may be a time window during which some intervention might move it into a critical condition in order to bring about a desired tipping process. the small change triggering the tipping process could be either (i) a localized modification of the network structure (e.g., a change on the level of single nodes, small groups of nodes or links) or of the state of agents or subsystems, (ii) small changes of macroscopic parameters or properties, or (iii) small external perturbations or shocks. we deliberately do not require the trigger to be a single driving parameter. this is because we expect that a social tipping process could be triggered by a combination of causes rather than a single cause. furthermore, a social tipping element may be tipped by several different combinations of causes. consequently, for social tipping elements we cannot always expect at this point to identify a common aggregate indicator (such as global mean temperature in the case of climatic tipping elements) and a well-defined 'threshold' for this indicator at which the system will tip (see also the discussion on complexity above). note that social tipping as defined here is a unique form of social change, e.g., distinct from climate economic shocks (15) and more specific than socio-technical transitions (96, 97) . further, social tipping also denotes a shift to a qualitatively different state, and such, is different from standard business cycles or causes of seasonality. as such, social tipping presents a particular process of social change, where a system undergoes a transformation from one qualitatively different state to another, after being in a more critical state and affected by a potentially small triggering event. we propose several filtering criteria to focus on social tipping processes (i) that have the potential to be relevant to global sustainability in future earth system tractories and (ii) where human interventions can occur within a pertinent intervention time horizon on the order of decades and will have consequences within a political/ethical time horizon on the order of hundreds of years. (i) relevance of social tipping for global sustainability the social tipping process can impact a wide array of social systems, such as technological or energy systems, political mobilization, financial markets and sociocultural norms. we consider social tipping processes to be relevant here that have an impact on the biophysical earth system or on macro-scale social systems. the qualitative change in a 'relevant' social tipping process significantly affects the future state of the earth system in the anthropocene directly or indirectly through interactions with other social tipping processes. relevance can hence be defined in terms of impacts on biophysical earth system properties such as global mean temperature, biosphere integrity or other planetary boundary dimensions. for example, tipping dynamics to a political system could result in policy regime changes, affecting substantial reductions in greenhouse gas emissions (9, 12). furthermore, we consider social tipping processes that have relevant impacts on macro-social systems and can be triggered by changes in the same biophysical earth systems, for example, mass migration due to climate impacts (84, 98) . we are interested in potential social tipping processes in which humans have the agency to substantively intervene. for example, such interventions could be via technological or physical capacities of agential or structural actors. this therefore places emphasis on human intervention, such as decreasing the likelihood of extreme weather events via mitigation efforts, or triggering socio-technological changes towards decarbonization. we define intervention and ethical time horizons as follows: intervention time horizon human agency interferes with a social tipping element, such that decisions and actions taken between now and an 'intervention time horizon' could influence whether (or not) the system tips. we suggest to consider only social tipping processes with an intervention time on the order of 10 years (9), which arguably presents a practical limit of human forethought (99) and of future-oriented political agency. for example, international governance efforts for global sustainability challenges, such as the ozone regime or the sustainable development goals, tend to work with similar time horizons. similarly, social tipping processes for rapid decarbonization to meet the paris climate agreement would have to be triggered within the next few years (9), with ambitious emissions reduction roadmaps aiming for peak greenhouse gas emissions in 2020 (29, 100) . the intervention time horizon is analogous to the 'political time horizon' defined for climate tipping elements in lenton et al. (1). the time to observe these relevant consequences should lie within an 'ethical time horizon'. this recognizes that consequences manifesting too far in the future are not relevant to the current discourse on how contemporary societies impact earth systems. such an ethical time horizon could consider only social tipping processes which can have relevant consequences within the next centuries at most, corresponding to an upper life expectancy of the next generations of children born. currently, international climate policies, including those of the european union (eu) are insufficient to meet the +1.5°c or +2°c goals of the paris agreement (101) . while european policy makers presume to lead global mitigation efforts and characterize their actions as ambitious (102, 103) , actual policy measures and proposals have been lagging behind this aspiration (104) . eu countries emit about a tenth of the world's emissions, and a policy change towards more rapid decarbonization would not only have significant direct impacts on the climate system, but likely have indirect effects on the policies of other major emitters. but what kinds of sociopolitical processes can lead to these necessary changes? could such changes result from social tipping dynamics? public opinion is a crucial factor in policy formation, where the public can be understood as a "thermostat" signalling what is politically feasible (105, 106) . shifts in public opinion can punctuate previously stable and 'sticky' institutions, leading to policy change (107) . increased activism and public concern regarding climate change can generate new coalitions, or shift the priorities of existing ones (108, 109) . here we examine the european political system as an example of and how social tipping processes could be triggered as a result of large-scale public activism and social movements. the european political system is composed of networks of agents (i.e., activists, decision-makers and organizations) with a range of social and political ties and is structured in nested and overlapping subsystems (i.e., national group, transnational political coalitions). viewed through the lens of social tipping, european political dynamics present a 'social system', embedded within the broader international political and climate change governance community 'environment'. driven by the fridaysforfuture movement (16) (among other things), a groundswell of bottom-up support for more proactive climate policies has recently developed among european citizens, resulting in routine mass demonstrations and historical wins for green parties in the 2019 european parliamentary elections, as well as in federal elections in austria, belgium and switzerland. the european political system could be moving towards a critical 'state', creating the conditions for a tipping process towards radical policy change, bringing european climate policy in line with the paris agreement. accordingly, the european political system could constitute a potential 'social tipping element', where as it nears critical conditions, a small change to the system or its broader environment could lead to large-scale macroscopic changes, affected by cascading network dynamics and positive feedback mechanisms. such transformations could involve establishing more aggressive mitigation strategies that connect goals (such as remaining below +2°c, 50% emissions reductions by 2030, zero carbon emissions by 2050) with measures and pathways that have a reasonable chance to achieve them (i.e., investment in negative emission technologies, increased carbon taxation policies etc.). the fridaysforfuture movement has been pushing the european political system towards criticality, where it becomes more likely that the system will be propelled into a qualitatively different state. the movement was set off and inspired by a single swedish high school student choosing to protest on the steps of the riksdag for meaningful climate action. greta thunberg's protest quickly spread through the european social-political networks until more than a million students have been participating in weekly protests. this growing bottom-up pressure on the european climate policy-makers (16, 110) has created an opening for significant policy change. the european political system consists of embedded subsystems at multiple scales. at the national scale, for example, the german socio-political system responded strongly to the activities of the similarly, several national western european green parties received historically strong electoral support in the may 2019 european parliamentary elections (such as in belgium, germany, finland, france and luxembourg). this increased support is also reflected in polling data in germany, where the green party has been effectively equal with the conservative party as the preferred political party of german voters in the latter half of 2019 ( figure 3 , panels c and d). subsequently, germany introduced its first ever federal climate change laws, mandating that the country meet its 2030 goals (a ~55% reduction in ghg emissions) and establishing pathways to carbon neutrality by 2050. currently, only a limited set of countries have enacted national climate change laws, and germany is one of the largest and most diverse economies to propose such actions. this presents the possibility for policy diffusion and transfer to other states (111) , particularly considering the influential role germany plays within the european union. climate policy entrepreneurs could build upon momentum to further capitalize on windows of opportunity, pushing climate change proposals prominently into national and supra-national governmental agendas before the ephemeral moment passes (112) . the 2020 covid-19 pandemic has placed new priorities on the policy agenda, also reflected in issue salience of climate change (see also fig. s1 in supplementary materials). as political and behavioral responses to covid-19 have led already to a significant temporary reduction in greenhouse gas emissions (113) , this shock could be further leveraged to reinforce climate action -future economic recovery packages should set european economies on a pathway towards carbonneutrality, rather than return to the old normal (114, 115) . drawing from this social tipping framework, the european political system may remain near a critical state. it remains unclear whether the covid-19 shock has supplanted climate change, or whether both remain on the political agenda. for example, discussions of a "green new deal" remain at the core of covid-19 economic recovery plans within the european union. the sociopolitical dynamics have likely moved the germany political subsystem further towards criticality, but it remains largely unknown whether this will result in tipping towards a qualitatively different state, in germany or in the broader european political system. rather, these judgements can likely only be made in hindsight, observing whether the system remained stable, moved towards criticality or experienced tipping dynamics. such an analysis in line with the proposed framework requires specific process tracing, identifying the key moments, actors, networks, mechanisms affecting criticality, the triggering event (threshold), and the positive feedback dynamics propelling the system towards qualitative changes. much attention is often paid to the specific triggering event, but it is rarely one single actor or action which accounts for the entirety of the tipping process. rather a full account needs to be made of all of the previous and related processes that have further placed the system towards criticality, allowing for such changes to become more likely. accordingly, for a tipping process to occur at the scale of the entire european political system, moving it into a state of decarbonization that is aligned with the paris agreement, a series of additional social movements and protests, or other shifts within the system or the environment, may be required. while we identify the role of fridaysforfuture in creating critical conditions, or potentially triggering the social transformations required for global sustainability, recent literature has identified further tipping candidates which could have generally "positive" effects on global sustainability. for example, divestment and reinvestment present candidates for rapid decarbonization and processes to achieve climate targets (9, 12). in this case, intervention times range from years to decades, depending on the social structure level (9). previous studies note that the adoption of technologies and behaviors such as rapid uptake of autonomously driven electric vehicles (if socially licensed), rapid change in dietary preferences reducing meat consumption and associated land-use and climate impacts can follow an epidemic-type model of diffusing across social networks (13, 15) . alternatively, social tipping processes can lead to states of criticality with less desirable outcomes: recently it has been shown that climate change has contributed to the emergence of infections carried by mosquitoes, like dengue fever or zika, which could be accelerated further by increased mobility, e.g., through denser air traffic networks (75) . the thermal minimum for transmission of the zika virus could in fact give rise to a threshold behaviour (116) . changes to the local environment may enact "push" factors, resulting in large scale migrations (117, 118) . further, increased global mean temperature has been suggested to increase the likelihood of civil conflicts (84) . these social tipping processes are of great interest to policy makers, as it is desirable to potentially trigger or facilitate "positive" tipping (11, 13) , while at the same time, mitigating the effects of potential "negative" outcomes. social tipping processes have been recently recognized as potentially key pathways for generating the necessary shifts for sustainability. drawing upon this emerging field, this paper develops a framework for characterizing social tipping processes. we find that mechanisms underlying social tipping processes are more likely to exhibit the unique characteristics of agency, social-institutional and cultural network structures, they occur across different spatial and temporal scales to climate tipping, and the nature of tipping can be more complex. social tipping processes thus present qualitatively different characteristics to those shared by climate tipping processes. accordingly, this paper develops a common framework for the unique characteristics of social tipping processes. we identify social tipping as a process, resultant of a complex system of drivers, resulting in shifting a system into a more (or less) critical state. it can thus serve to structure and inform future data analysis and process-based modelling exercises (118, 119) . even so, while there is an emerging focus on social tipping dynamics (9-13), there remains great difficulty in pinpointing tipping events and generalizing the emerging dynamics. drawing from natural tipping dynamics, previous work on social tipping has often focused on identifying specific trigger events or critical thresholds in macroscopic system variables in analogy to identifying for instance critical temperature thresholds in the context of climate tipping (10) . in natural systems the underlying dynamics are more deterministic and often can be directly observed, allowing for the identification of specific thresholds and events. while social systems comprise a much more open and complex system, one that is constantly adapting and where dynamics are often incredibly complex, interrelated and cannot be directly observed. accordingly, one could observe the same event across ten similar social systems, and could potentially observe ten unique outcomes. as such, anticipating a specific trigger, making causal inferences, or having generalizability in expected effects are all greatly limited within social systems. further, social tipping points are sometimes also understood as a point in time, rather than a point in a complex parameter space. such an approach makes it difficult to identify social tipping processes, as they often do not contain easily observable macroscopic thresholds nor temporal markers for change. rather, a complex adaptive systems viewpoint is required, understanding the multitude of interrelated processes and social structures driving change, and not focusing on a single trigger or threshold. accordingly, our framework proposed here focuses on identifying the processes and mechanisms of such change, and not a single triggering event, where the interplay of micro-level changes embedded within adaptive structural conditions can affect systemic changes. the notion of a critical state is central within our framework. changing conditions to the system's environment can cause it to enter more (or less) critical states, such that a single, or multiplicative action, can effect a systemic change. it is these changing conditions, and specifically the processes and dynamics underlying them, that are of analytical importance. drawing upon the analogy of a tipping coal wagon (15), it is not the single, specific piece of coal that caused the wagon to tip, but rather the processes by which the wagon was filled with enough coal that any single piece (placed at a number of different locales) could cause such tipping. accordingly, the specific triggering event of a social tipping process could be somewhat random or arbitrary, as the conditions are critical enough such that any event with enough magnitude could have triggered these dynamics. it is therefore key to focus on the processes and mechanisms underlying the nature of such critical states which allow some trigger event to cause contagion dynamics. from social network models, we can deduce which kind of structural features make a system less resilient and thus more prone to social tipping (119). one example is polarization, where social network models and social mediabased data analyses have shown that in polarized states with nearly disconnected network communities which in themselves are highly connected, contagion processes are more likely to occur (120) (121) (122) . behavioral experiments and corresponding conceptual modelling approaches suggest that minority groups can initiate social change dynamics in the emergence of new social conventions (17, 119) . furthermore, a rich social science literature has noted an array of factors (i.e. political institutions, technological or behavioral adaptation, environmental, normative and attitudinal) effective in shifting the social conditions surrounding climate change (14) . a better understanding of critical states as demanded by our framework may help to identify early warning signals that could possibly indicate that a social-ecological system is close to a critical state in specific situations (30, 123) . social tipping processes present a specific type of social change -characteristized by non-linear shifting states driving by positive feedbacks -which is similar to, but conceptually distinct from, other forms of social change. similar to how we explore the differences between natural and social tipping processes, further research should engage with social tipping in comparison to other forms of social change (such as historical institutionalist perspectives, social movements, policy feedbacks, complex systems). one of the greatest challenges lies in dealing with multiple, entangled drivers of tipping processes on different scales -temporal, spatial or social structural levels -and different levels of agency and heterogeneous agents and subsystems. in order to further understand the dynamics arising from these various levels of agency, it is crucial to identify examples from different subfields (economics, political science, demographics). a key current limitation in applying our framework is finding and operationalizing empirical data describing actual spreading processes on networks across these different levels, particularly compared to macro-economic data and public opinion polls (124) , even though first steps in this direction are being made (125, 126) . particularly data on the social structures and networks is notoriously difficult to access. while there have been advances in developing modeling frameworks (119, 127) to simulate social tipping dynamics, linking these theoretical modelling to empirical data and behavioral experiments requires more attention. even if predictive modeling (i.e., the kind of deterministic, time-forward modeling we know from earth system models for instance) of such social dynamics in the sense of inferring time trajectories is very difficult or even conceptually unfeasible, such process-based modelling of social tipping dynamics can be very crucial to understand the nature of critical states also in realworld social situations. lastly, we focus here specifically on social tipping processes relevant for mitigating climate change, or sustainability more broadly, fitting within the previous literature. but, such a framework for social tipping dynamics is generalizable to other areas of study and social phenomena (such as the 2020 rapid social movements and public opinion dynamics surrounding racial inequality in the united states). while we explore one example of social tipping in detail, further inquiry is required to test the distinctiveness of social tipping processes, as well as the utility of the proposed definition to other social tipping processes. systematizing the types of social tipping processes, and exemplary case studies, would help to further illustrate these forms of change. research is also warranted into establishing typical timescales of social tipping; understanding how network structures affect social tipping dynamics; identifying typical network structures of systems entering critical states; discerning the temporal aspects of how effects travel through different social network structures; and gaining a better understanding of the origin of spreading processes. data acquisition, analysis and process-based modelling could all play a role in this research agenda. a wealth of social media data is available to study potential social tipping processes. however, this kind of data has mostly yet to be adopted within the context of earth system analysis and tipping dynamics. social tipping processes could be decisive for the future of the earth system in the anthropocene: some rapid shifts in social systems are, in fact, necessary to meet the targets of the paris agreement and the sustainable development goals (8) . while we focus here on processes relevant for future trajectories of the earth system, we suggest that further analysis could use or adapt our definition to characterize other types of general social tipping processes (i.e. revolutions or rapid transformations). we also recognize that tipping processes within ecosystems present an interesting intermediary case between social and physical climate tipping as they typically incorporate characteristics from both realms. they are also crucial in determining future trajectories of the earth system (see preliminary discussion in the si). understanding, identifying and potentially instigating some social tipping processes is highly relevant for the future of the anthropocene, particularly with regard to the potential role in triggering rapid transformative change needed for effective earth system stewardship (9, [11] [12] [13] . resulting trajectory would still move at some time ″ > ′ into some state ″ (which will usually depend on the influence exerted) that is qualitatively different from * . similarly, an uncritical condition, ( ∘ , ∘ ), is tippable by a decision maker if there is a possible trajectory ( ( ), ( )) %2%3 , starting in ( ∘ , ∘ ) at some time ′, that the decision maker can force and to follow, and this trajectory would move into some state ″ at some time ″ > ′ that is qualitatively different from ∘ (a tippable uncritical state roughly corresponds to what others call a 'sensitive intervention point' ). at any time at which the system is not in an unmanageable critical state, the prevention time is the time interval it takes before some quasi-inertial trajectory has moved it into an unmanageable critical state. in other words, at time zero it is the largest time interval so that, when no intervention takes place until time , for all > 0 with < , the system would not be in an unmanageable critical state at time . similarly, at any time at which the system is in a tippable uncritical state, the triggering time is the time interval it takes before some quasi-inertial trajectory has moved it into an uncritical state that is no longer tippable. in other words, at time zero it is the largest time interval so that, when no intervention takes place until time , for all > 0 with < , the system would not be in a tippable uncritical state at time . we only consider social tipping processes for which the prevention or triggering time is smaller than some intervention time horizon. ecosystem tipping processes share properties of physical climate tipping dynamics in atmosphere, ocean and cryosphere in that they can often be described by a common driver, as well as that of deliberative social tipping elements in that they have adaptive capacity, and can therefore be regarded as intermediate. but, as previously noted, human agential capacity is far greater than those of other species. similarly to human social systems, ecosystems are comprised of interacting living organisms, they can be viewed as networks with components that can adapt (e.g., food webs). this is different from physical tipping elements such as the cryosphere elements (e.g., melting of permafrost) which do not typically exhibit the same networked structures. within the nominally 'climate' tipping elements are some major biomes -notably boreal forests, the amazon rainforest, and coral reefs -that are composed of living organisms and exhibit ecological network structures. indeed changing interactions between the living elements of these systems may be key to tipping dynamics -for example epidemic bark beetle infestation of boreal forests triggered by climate warming allowing the beetles to complete two life cycles rather than one within a season (128) . thus these biotic tipping elements lie towards smaller scale ecosystems in the continuum, and tend to be more closely related to social systems in spatial and temporal scales compared to the typically much larger and more slowly changing physical climate tipping elements. these differences give rise to a proposed ordering of tipping elements, ranging from (1) the physical climate tipping elements via (2) ecosystem tipping elements to (3) social tipping elements (table s1 ). 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misinformation: modeling fake news as complex contagion consensus and polarization in competing complex contagion processes early warning signals of regime shifts in coupled humanenvironment systems futurict: participatory computing to understand and manage our complex world in a more sustainable and resilient way fundamental structures of dynamic social networks interaction data from the copenhagen networks study earth system modeling with endogenous and dynamic human societies: the copan:core open world-earth modeling framework a first assessment of the impact of the extreme 2018 summer drought on central european forests general: we are very grateful to william c. clark, anne-sophie crépin, niklas harring, matthew ives, j. doyne farmer, wolfgang lucht, and john schellnhuber, for providing helpful insights and comments. we thank the participants of two dominoes workshops on social tipping dynamics held at gesis leibniz institute for social science, cologne, in summer 2018 and 2019 for foundational and framing discussions. the authors declare no competing interests. in this section, we give a more formal version of the definition of 'social tipping process' given in the main text, as a reference for mathematically inclined readers.after defining what we mean by a social system and its environment, we first classify their possible states into critical, unmanageable, uncritical, and tippable conditions, and then finally define the notions of prevention time and triggering time. by a social system, , we mean a set of agents together with a network-like social structure, that interacts in some form with the rest of the world, called the environment, , of the system, such that, if no "perturbation" or deliberate "influence" by some decision-maker occurs, and together can only follow certain "quasi-inertial" (or "default") trajectories restricted by the agency of the system's agents. let (%) and (%) denote the states that and are actually in at time .a critical condition for the system is a pair of possible system and environment states, ( * , * ), such that there exists another possible pair of states, ( ′, ′), with the following properties:1. the state pair ( ′, ′) is no further away in state space from ( * , * ) than a certain "small" distance, , that represents the possible magnitude of "local" perturbations in (affecting only few agents or network links directly) or small changes in that are considered sufficiently "likely" to care about, with respect to some suitable distance function . in other words, (( ′, ′), ( * , * )) < . 2. if and were in state ( ′, ′) at any time ′, there is a quasi-inertial trajectory that would move at some later time ″ > ′ into some state ″ that is "qualitatively" different from * . this move represents a "global" (i.e., affecting a very large fraction of the agents) and "significant" change in the system (but not necessarily in its environment).if such a change actually happens, the time point ′ (not the state!) at which it starts may be called the tipping point or less ambiguously the triggering time point, and the system behavior within the time interval from ' to ″ is called the corresponding tipping process. an uncritical condition for and then is any pair of states that is not critical.a critical condition is unmanageable for an actor that may influence or in some way if there exists a possible pair of states, ( ′, ′), with (( ′, ′), ( * , * )) < and the following property:• assume that and were in state ( ′, ′) at any time ' and afterwards the state of and would follow any trajectory ( ( ), ( )) %2%3 that the actor can force it to follow. then the key: cord-253212-ygmkul62 authors: khrennikov, andrei title: social laser model for the bandwagon effect: generation of coherent information waves date: 2020-05-17 journal: entropy (basel) doi: 10.3390/e22050559 sha: doc_id: 253212 cord_uid: ygmkul62 during recent years our society has often been exposed to coherent information waves of high amplitudes. these are waves of huge social energy. often they are of destructive character, a kind of information tsunami. however, they can also carry positive improvements in human society, as waves of decision-making matching rational recommendations of societal institutes. the main distinguishing features of these waves are their high amplitude, coherence (homogeneous character of social actions generated by them), and short time needed for their generation and relaxation. such waves can be treated as large-scale exhibitions of the bandwagon effect. we show that this socio-psychic phenomenon can be modeled based on the recently developed social laser theory. this theory can be used to model stimulated amplification of coherent social actions. “actions” are treated very generally, from mass protests to votes and other collective decisions, such as, e.g., acceptance (often unconscious) of some societal recommendations. in this paper, we concentrate on the theory of laser resonators, physical vs. social. for the latter, we analyze in detail the functioning of internet-based echo chambers. their main purpose is increasing of the power of the quantum information field as well as its coherence. of course, the bandwagon effect is well known and well studied in social psychology. however, social laser theory gives the possibility to model it by using general formalism of quantum field theory. the paper contains the minimum of mathematics and it can be read by researchers working in psychological, cognitive, social, and political sciences; it might also be interesting for experts in information theory and artificial intelligence. during recent years, the grounds of the modern world have been shocked by coherent information waves of very high amplitude. the basic distinguishing property of such waves is that they carry huge amounts of social energy. thus, they are not just the waves widely distributing some special information content throughout human society. instead, their information content is very restricted. typically, the content carried by a wave is reduced to one (or a few) labels, or "colors": one wave is "green", another is "yellow". at the same time, information waves carry very big emotional charge, a lot of social energy. therefore, they can have strong destructive as well as constructive impact on human society. in this paper, we present a model of the generation of very powerful and coherent information waves; a model based on the recently developed theory of social laser [1] [2] [3] [4] [5] [6] . we stress that social laser theory is part of the extended project on applications of formalism of quantum theory outside of physics, quantum-like modeling (see, e.g., monographs [7] [8] [9] [10] [11] and some selection of papers [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] ). this terminology was invented by the author to distinguish this modeling from attempts to reduce human consciousness, cognition, and consequently behavior to genuine quantum physical processes in the brain (see, e.g., penrose [32] or hameroff [33] ). we do not criticize • indistinguishability of people. the human gain medium, population exposed to the information radiation, should be composed of social atoms, "creatures without tribe": the role of national, cultural, religious, and even gender differences should be reduced as much as possible. content ignorance. social atoms should process information communications without deep analyzing of their contents; they extract only the basic labels ("colors") encoding the communications. of course, humans are still humans, not social atoms; thus, in contrast to quantum physics, it is impossible to create human gain mediums composed of completely indistinguishable creatures. people still have names, gender, nationality, but such their characteristics are ignored in the regime of social lasing. one of the basic components of lasers, both physical and social, is a resonator [4] . it plays the double role: • amplification of the beam (of physical vs. information) radiation; • improving coherence of this beam. social laser resonators play a crucial role in generation of coherent information waves of high amplitude. they are established via internet-based echo chambers associated with social networks, blogs, and youtube channels. their functioning is based on the feedback process of posting and commenting, the process that exponentially amplifies the information waves that are initially induced by mass media. echo chambers improve the coherence of the information flow through the statistical elimination of communications that do not match the main stream. this statistical elimination is a consequence of the bosonic nature of the quantum information field (sections 2. 9 and 4.4) . although this quantum process of coherence generation dominates in echo chambers, we should not ignore other technicalities increasing coherence (sections 6.2 and 6.3), such as censorship of moderators and the dynamical evaluation system of search engines of, e.g., google, youtube, or yandex. the latter system elevates approachability of posts, comments, and videos depending on the history of their reading (seeing) and reactions to them say in the form of new comments. this is a good place to recall that the quantum-like hilbert space formalism if widely used for the modeling of information processing by internet search engines, and, in particular, for information retrieval [54] [55] [56] [57] [58] [59] . we compare functioning of optical and information mirrors (section 4.2). the latter represents the feedback process in internet systems such as, e.g., youtube. in contrast to the optical mirror, the information mirror not only reflects excitations of the quantum information field, but also multiplies them. thus, this is a kind of reflector-multiplier (section 4.3). as the result of this multiplication effect, social resonators are more effective than physical ones. however, as in physics, resonator efficiency depends on a variety of parameters. one of such parameters is the coefficient of reflection-multiplication (section 6.1). we analyze the multilayer structure of an information mirror and dependence of this coefficient on the layer (section 6.1). the main output of this paper is presented in section 5 describing the quantum-like mechanism of the generation of big waves of coherent information excitations. we start the paper with compact recollection of the basics of social laser theory distilled from technical details and mathematical formulas. we present the basic notions of this theory such as social energy (section 2.2)) and social atom, human gain medium (section 2.3), information field (section 2.4), the energy levels structure of social atoms (section 2.6), and spontaneous and stimulated emission of information excitations (section 2.8). finally, we conclude the introduction by the schematic presentation of the functioning of social laser theory (section 3). the role of information overload in approaching indistinguishability of information communications, up to their basic labels, quasi-colors, is discussed in section 2.5. this is a good place to mention studies on coupling indistinguishability and contextuality [60] . finally, we point to coupling of the social laser project with foundations of quantum theory (appendix b). the basic component of a physical laser is a gain medium, an ensemble of atoms. energy is pumped into this medium aimed to approach the state of population inversion, i.e., the state where more than 50% of atoms are excited [47] . then, a coherent bunch of photons is injected into the gain medium and this bunch stimulates the cascade process of emission of the coherent photon beam. if the power of pumping is very high, i.e., it is higher than the so-called lasing threshold, all energy of pumping is transferred into the output beam of coherent radiation. to make this beam essentially stronger, the laser is equipped by an additional component, the laser resonator (typically in the form of an optical cavity). the laser resonator also improves the coherence of the output beam, by eliminating from the beam photons that were generated via spontaneous emission in the gain medium [47] . typically, in physics, coherence is formulated in physical waves terms, as electromagnetic waves going in phase with the same direction of propagation and frequency. for us it is convenient to reformulate this notion by excluding any reference to waves in the physical space, since we want to move to the information space. instead of the wave picture we can use the photon picture, so a propagating wave is represented as a cloud of energy quanta. (this is the fock representation in quantum field theory.) coherence means that they have the same energy (frequency) and the direction of propagation-photon's wave vector. we remark that a photon also has additional characteristics such as polarization, the quantum version of the ordinary polarization of light. for convenience of further considerations, let us call all characteristics of a photon additional to its energy quasi-color. we recall that the usual light's color is determined by photon energy (frequency). therefore, a photon has its color and quasi-color. the notion of social energy is the main novel component of our quantum-like modeling. to justify the use of a social analog of the physical energy, we use the quantum-mechanical interpretation of energy, not as an internal feature of a system, but as an observable quantity. thus, like in the case of an electron, we cannot assign to a human the concrete value of the social energy. there are mental states in the superposition of a few different values of the social energy. however, by designing proper measurement procedures we can measure human energy; see [1, 4] for details. social energy is a special form of the psychic energy. we recall that at the end of 19th/beginning of 20th century psychology was strongly influenced by physics, classical statistical physics and thermodynamics (in works of james and freud), later by quantum physics (in works of jung). in particular, the leading psychologists of that time have actively operated with the notion of psychic energy [61] [62] [63] [64] . later psychologists essentially lost interest in the construction of general theories and, in particular, operating with the notion of the social energy. recently, the notion of social energy attracted a lot interest in economics and finance, multi-agent modeling, evolution theory and industrial dynamics [65] [66] [67] . of course, these novel as well as old (freud-jung) studies support our model. however, we emphasize that the application of the quantum (copenhagen) methodology simplifies and clarifies essentially the issue of the social energy. we treat it operationally as an observable on a system, a human being. in contrast to, say, freud, we are not interested in psychic and neurophysiological processes of generation of psychic energy (see appendix a for a brief discussion). the basic component of social laser is a gain medium, an ensemble of people. as already mentioned, to initiate lasing, such a gain medium should consist of indistinguishable people, i.e., without tribe, without cultural, national, religious, and ideally sex differences. such beings are called social atoms. (it is not clear whether they still can be called humans). of course, people still have aforementioned characteristics, in some contexts they remember that they are men or women, or even christian, or swedish. we discuss contexts in which people behave as indistinguishable, as social atoms. creation of such behavioral contexts is the first step towards initiation of social lasing. we recall that in quantum physics the electromagnetic field is treated as a carrier of interactions. in the quantum framework, interaction cannot be represented as it was done classically, by force-functions. quantum interaction is of the information nature. in quantum information theory, excitations of the quantum electromagnetic field, photons, are carriers of information. at the same time, each excitation also carries a quantum of energy. this quantum picture is very useful for general modeling of information fields generated by mass media and the internet. communications emitted by newspapers, journals, tv, social networks, and blogs are modeled as excitations of a quantum information field, as quanta of information and social energy. as we know, the quantum description is operational; this is only the mathematical symbolism used for prediction of probabilities. even the quantum electromagnetic field cannot be imagined as a "real wave" propagating in spacetime. (in the formalism, this is a distribution, generalized function, with operator values. hence, this is a very abstract mathematical structure. it is useful for accounting for the numbers of energy quanta and description of the processes of their emission and absorption.) on one hand, this impossibility of visualization is a disadvantage of the quantum description compared to the classical one (we remark that the visualization of the classical electromagnetic field is also not as straightforward as might be imagined. the electromagnetic waves were invented as the waves propagating in the special media, the aether, similarly to acoustic wave propagating in air. later, einstein removed aether from physics. the picture of a vibrating medium became inapplicable. therefore, electromagnetic waves are vibrations of a vacuum. this is not so natural picture for the visualization of this process.). on the other hand, this is a great advantage, since it provides the possibility for generalizations having no connection with physical spacetime. thus, we model the information field as a quantum field with communications (generated, e.g., by mass media) as quanta carrying social energy and some additional characteristics related to communication content. as was already emphasized, quantum description is applicable to fields with indistinguishable excitations, where indistinguishability is considered to observable characteristics. in addition, "observable" means those characteristics that people assign to communications. these are labels of communications, say "terrorism", "war in syria", "coronavirus" and so on. such labels we shall call quasi-colors of information excitations, these are analogs of photon wave vector and polarization. thus, each communication is endowed with a quasi-color. it also carries a quantum of energy; its value we consider as communication color. thus, allegorically we can speak about red, blue, or violet information. content ignorance (up to communication quasi-color and color) is the crucial feature of the applicability of the quantum formalism. why do social atoms compress contents of communications to quasi-colors? the most important is information overload. the information flows generated by mass media and the internet are so powerful that people are not able to analyze communication content deeply, they just scan its quasi-color and absorb a quantum of the social energy carried by this communication. they simply do not have computational and time resources for such an analysis. it is also crucial that people lose their identity, so they become social atoms. for a social atom, there are no reasons, say cultural or religious, to analyze news; he is fine with just absorption of labels (quasi-color) and social energy (color) assigned to them. consider for simplicity social atoms with just two energy levels, excited and relaxed, e 1 and e 0 . the difference between these levels, is the basic parameter of a social atom, its color. a social atom reacts only to a communication carrying energy e c matching his color: if a communication carries too high-energy charge, e c larger than e a ("a social atom is yellow, but a communication is blue"), then an atom would not be able to absorb it. say a communication carrying social energy e c is a call for an uprising against the government. in addition, an atom is a bank clerk in moscow, who has liberal views and hates the regime, but the energy of his excited state is too small to react to this call. if e c is less than e a ("an atom is blue, but a communication is yellow"), then an atom would not be excited by this communication. the communication would be simply ignored. as well as a physical atom, a social atom cannot collect social energy continuously from communications carrying small portions of energy (compared to e a = e 1 − e 0 ), it either absorbs communication (if the colors of an atom and communication match each other) or it does not pay attention to it. in the same way, a social atom cannot "eat" just a portion of energy carried by too highly charged communication. in physics textbooks, the condition of absorption of energy quantum by atom is written as the precise equality: however, precise equalities are only mathematical idealizations of the real situation. the photon-absorption condition (3) is satisfied only approximately: the spectral line broadening is always present. the difference between the energies of atom levels is the mean value (average) of the gaussian distribution, a bell centered at this point of the energy axis. the dispersion of the gaussian distribution depends on an ensemble of atoms. ensembles with small dispersion are better as gain mediums for lasing, but deviations from exact law (3) are possible. it is natural to assume gaussian distribution realization of exact laws even for social systems; in particular, absorption of of excitations of the quantum information field by social atoms. thus, deviations from (1) are possible. however, a good human gain medium should be energetic homogeneous. therefore, the corresponding gaussian distribution should have very small dispersion. shock news, say a catastrophe, war, killed people, epidemic, terror attack, is very good for energy pumping to a social gain medium. the modern west is characterized by the high degree of excitation, the energy e 1 of the excited level is sufficiently high-otherwise one would not be able to survive: life in the megalopolis, long distances, high intensity of the working day, and so on. on the other hand, the energy e 0 of the relaxation level is very low-one who is living on state support, say, in sweden, has practically zero excitement, often his state is depressive. hence, e a = e 1 − e 0 is high and a social atom would absorb only communications carrying very high energy: as in aforementioned shock news or say in tv shows, people should cry loudly, express highly emotional psychic states. since e a is high (blue), people would not pay attention to plain news (say red colored). even scientific news attracts attention only if it is very energetic, carries big emotional charge (blue or, even better, violet). however, shock news is very good for energy pumping not only because it carries a high charge of social energy, but also because it is very good at peeling communications from content. labels (quasi-colors) such as "coronavirus is a bio-weapon" leads to immediate absorption of communications, and social atoms react immediately to the instinctive feeling of danger. in our quantum-like model (similarly to physical atoms), social atoms can both absorb and emit quanta of the social energy. as in physics, there are two types of emission-spontaneous and stimulated. the spontaneous emission happens without external interaction, a social atom spontaneously emits a quantum of social energy, in the form of some social action. such spontaneous actions are not coherent, different atoms do different things, quasi-colors of social energy quanta emitted spontaneously can be totally different. such emissions generate a social noise in a human media, noise that is unwanted in social lasing. in particular, spontaneous emission noise disturbs functioning of internet echo chambers. on the other hand, the emission of quanta of social energy can be stimulated by excitations of the information field. in the very simplified picture, it looks like this. an excited social atom by interacting with an information excitation emits (with some probability) quantum of social energy. the most important feature of this process is that the quasi-color of the emitted quantum coincides with the quasi-color of stimulating communication. this is the root of the coherence in output beam of lasers, both social and physical. (the colors also coincide; see section 2.6). in reality, the process of stimulated emission is more complicated. it is important that the information field (similarly to the quantum electromagnetic field) satisfies bose-einstein statistics. this is a thermodynamic consequence [1] of indistinguishability of excitations: two excitations with the same social energy and quasi-color are indistinguishable. as was shown in [1] , by using the gibbs' approach based on consideration of virtual ensembles of indistinguishable systems (or any origin) we obtain the standard quantum classification of possible statistics, bose-einstein, fermi-dirac, and parastatistics. indistinguishability is up to energy (for the fixed quasi-color). hence, by taking into account that the number of communications carrying the same charge of social energy can be arbitrary, we derive the bose-einstein statistics for the quantum information field (see [1] for derivation's details). interaction of atomic-like structures with bosonic fields are characterized by the following property: probability of stimulated emission from an atom increases very quickly with increasing of the power of a bosonic field. an excited social atom reacts rather weakly to the presence of a few information excitations. however, if they are many, then it cannot stay indifferent. in fact, this is just a socio-physical expression of the well-known bandwagon effect in humans' behavior [68] . in contrast to psychology, we can provide the mathematical field-theoretical model for such an effect. we consider the fixed energy (frequency) mode of the quantum electromagnetic field. for fixed quasi-color mode α, n-photon state |n, α , can be represented in the form of the action of the photon creation operator a α corresponding to this mode on the vacuum state |0 : this representation gives the possibility to find that the transition probability amplitude from the state |n, α to the state |n + 1, α equals to (n + 1). on the other hand, it is well known that the reverse process of absorption characterized by the transition probability amplitude from the state |n, α to the state |(n − 1), α equals to √ n . generally, for a quantum bosonic field increasing the number of its quanta leads to increasing the probability of generation of one more quantum in the same state. this constitutes one of the basic quantum advantages of laser-stimulated emission showing that the emission of a coherent photon is more probable than the absorption. since, as shown in [1] , indistinguishability, up to energy (color) and quasi-color, of information excitations leads to the bose-einstein statistics, we can use the quantum operational calculus for bosonic fields even for the quantum information field and formalize in this way the bandwagon effect in psychology [5] . this is the good place to recall that in our considerations the notion "social action" is treated very widely, from a purely information action, as posting a communication at facebook or commenting one of already posted communications, to a real physical action, as participating in a demonstration against putin or trump, or supporting government's policy on "self-isolation". the previous works on social laser [1] [2] [3] [4] emphasized external representation of social actions, say in the well-known color revolutions. in this paper, we are more interested in their representation in information spaces, e.g., spaces of social networks. however, we are even more interested in internal representation of some social actions as decision makings. in addition, a decision can have different forms, not only "to do"-decisions, but also "not to do"-decisions. the decisions of the latter type also consume energy and social atoms transit from the excited state to the relaxed one. it is also important to point to the unconscious character of many (or may be majority) of our decisions. for example, people can support (or not support) societal policies totally unconsciously. to make such decisions, they consume social energy. mass media and internet pump social energy into a gain medium composed of social atoms to approach the population inversion-to transfer most atoms into excited states. then a bunch of communications of the same quasi-color and energy (color) matching with the resonant energy of social atoms is injected in the gain medium. in the simplified picture, each communication stimulates a social atom to emit a quantum of social energy with the same quasi-color as its stimulator. resulting two excitations stimulate two social atoms to emit two quanta, the latter two quanta generate four and so on, after say 20 steps there are 2 20 , approximately one million of information excitations of the same (quasi-)color. in reality, the process is probabilistic: an atom reacts to stimulating information excitation only with some probability. the later increases rapidly with increasing of the density of the quantum information field. now, we discuss the basic counterparts of social lasing in more detail: • each information communication carries a quantum of social energy. the corresponding mathematical model is of the quantum field type, the information field. quanta of social energy are its excitations. each social atom is characterized by the social energy spectrum; in the simplest case of two levels, this is the difference between the energies of the excitation and relaxation states, besides of social energy, the excitations of the information field are characterized by other labels, quasi-colors. coherence corresponds to social color sharpness; ideal social laser emits a single mode of quasi-color, denoted say by the symbol α. humans in the excited state interacting with α-colored excitations of the information field also emit α-colored excitations. the amount of the social energy carried by communications stimulating lasing should match with resonance energy e a of social atoms in the human gain medium. to approach the population inversion, the social energy is pumped into the gain medium. this energy pumping is generated by the mass media and the internet sources. the gain medium should be homogeneous with respect to the social energy spectrum. in the ideal case, all social atoms in the gain medium should have the same spectrum, e a . however, in reality, it is impossible to create such a human gain medium. as in physics, the spectral line broadening must be taken into account. for example, a gain medium consisting of humans in the excited state and stimulated by the anti-corruption colored information field would "radiate" a wave of anti-corruption protests. the same gain medium stimulated by an information field carrying another social color would generate the wave of actions corresponding this last color. the general theory of resonators for social lasers is presented in [4] . here we shall consider in more detail special, but at the same very important type of social resonators, namely internet-based echo chambers. we recall that an echo chamber is a system in that some ideas and behavioral patterns are amplified and sharped through their feedback propagation inside this system. in parallel to such amplification, communications carrying (as quasi-color) ideas and behavioral patterns different from those determined by the concrete echo chamber are suppressed. in our terms, an echo chamber is a device for transmission and reflection of excitations of the quantum information field. its main purpose is amplification of this field and increasing its coherence via distilling from "social noise". the latter function will be discussed later in more detail. the echo chamber is also characterized by the resonance social energy e a of its social atoms. for simplicity, it is assumed that all social atoms have the same resonance energy e a . (in reality, resonance energy of social atoms is a gaussian random variable with mean value e a .) we underline that in this paper an echo chamber is considered to be a component of the social laser, its resonator. compared to physics we can say that this is an analog of an optical cavity of the physical laser, not optical cavity by itself. the coherent output of an echo chamber, the quasi-color of this output, is determined not only by the internal characteristics of the echo chamber, but also by the quasi-color of stimulating emission. let us consider functioning of some internet-based echo chamber; for example, one that is based on some social group in facebook (or its russian version "vkontakte") and composed of social atoms. the degree of their indistinguishability can vary depending on the concrete echo chamber. say, names are still present in facebook, but they have some meaning only for the restricted circle of friends; in instagram or snapchat, even names disappear and social atoms operate just with nicknames. by a social group we understand some sub-network of say facebook, for example, social group "quantum physics". the main feature of a social group is that all posts and comments are visible for all members of this social group. thus, if one from the group puts a post, then it would be visible for all members of this social group, and they would be able to put their own comments or posts related to my initiation post. this is simplification of the general structure of posting in facebook, with constraints that are set by clustering into "friends" and "followers". we assume that the ensemble of social atoms of this echo chamber approached population inversion, so most of them are already excited. a bunch of communications of the same quasi-color α and carrying quanta of social energy e c = e a is injected in the echo chamber. excited social atoms interact with the stimulating communications and emit (with some probability) information excitations of the same quasi-color as the injected stimulators. these emitted quanta of social energy are represented in the form of new posts in echo chamber's social group. each post plays the role of a mirror, it reflects the information excitation that has generated this post. however, the analogy with the optics is not straightforward. in classical optics, each light ray is reflected by a mirror again as one ray. in quantum optics, each photon reflected by a mirror is again just one photon. an ideal mirror reflects all photons (the real one absorbs some of them). in contrast, "the mirror of an echo chamber", the information mirror, is a multiplier. a physical analog of such a multiplier mirror would work in the following way. each light ray is reflected as a bunch of rays or in the quantum picture (matching better the situation), each photon by interacting with such a mirror generates a bunch of photons. of course, the usual physical mirror cannot reflect more photons than the number of incoming ones, due to the energy conservation law. hence, the discussed device is hypothetical. this is a good place to remark that as mentioned, a photon should not be imagined as a metal ball reflecting from mirror's surface. a photon interacts with the macro-system, the mirror, and the latter emits a new photon that is identical to the incoming one, up to the direction of spatial propagation. it seems to be possible to create a kind of a mirror with the complex internal structure (composed of special materials) such that it would generate emission of a bunch of photons. of course, such a multiplier mirror cannot function without the energy supply. the internet-based system of posting news and communications works as a multiplier mirror. each posted news or communication emits a bunch of "information rays" directed to all possible receivers-the social atoms of echo chamber's social group. in the quantum model, each post works as an information analog of photon's emitter. it emits quanta of social energy; the power of the information field increases. consequently, excited social atoms emit their own posts and comments with higher probability. we repeat that new posts have the same quasi-color as the initiating information excitations that were injected in the echo chamber. it is also important to remind that the process of stimulated emission is probabilistic. members of the social group would react to newly posted message only with some probability. in addition, resulting from the bosonic nature of the quantum information field, this probability increases rapidly with increasing of field's power. by reaction we understood emission of a new message, say a comment. if a social atom simply reads a posted communication, but does not emit its own information excitation, then we do not consider such reading as a reaction. for the moment, we consider only the process of stimulated emission. later we shall consider absorption as well. in the latter, reaction means transition from the ground state to the excited state; so, not simply reading. (in principle, a relaxed atom can read a post or a comment without absorbing a quantum of social energy sufficient for approaching the state of excitement.) the crucial difference from physics is an apparent violation of the energy conservation law (see appendix a for the discussion on this question). each post in a social group works as a social energy multiplier. thus, information excitations in the echo chamber generated by posted communications not only increase the probability of emission of new information excitations by excited atoms, but they also perform the function of additional energy pumping into the gain medium (social group). relaxed social atoms can absorb social energy not only from externally pumped messages from mass media, tv and other social networks, but even from their own echo chamber. then they also emit new posts and so on. the main distinguishing feature of the quantum information field is its bosonic nature. we now emphasize the impact of the bosonic structure to coherence of the information field inside of an echo chamber. as was already noted (section 2.9), the interaction of a social atom with the surrounding bosonic field depends crucially on the power of this field, the probability of emission of energy quantum by an excited social atom increases very quickly with increasing of field's power. now, we stress again that a social atom (as well as a physical atom) distinguishes the modes of the field corresponding to different quasi-colors. the probability of emission of a quantum of the fixed quasi-color α depends on the power of the field's mode colored by α. thus, if the power of the α-mode essentially higher than the power of the mode colored by β, then with very high probability social atoms would emit α-colored energy quanta (in the form of posts, comments, and videos). social atoms would ignore the β-colored energy quanta, the probability of emission of such quantum (and hence the increase of the power of the β-mode) is practically zero. if a social atom emits a communication, colored by β, then this information excitation would not attract attention of social atoms who are busy with communications colored by α. as was already emphasized, the crucial role is played by indistinguishability, up to the quasi-colors, of the excitations of the information field. social atoms should process information in the regime of label scanning, without analyzing its content. as was discussed, the easiest way to establish the indistinguishability regime of information processing is to generate an information overload in the gain medium composed of social atoms. of course, the loss of individuality by social atoms is also very important, people "without tribe" are better accommodated to perceive information in the label-scanning regime. in this regime, one would never absorb the main information of the β-labeled communication, say statistical data. in this section, we considered the quantum-like nature of coherence of the information waves generated in echo chambers. this indistinguishability of information excitations, the label-scanning regime. the information overload and the loss of individuality by social atoms are the main socio-psychological factors leading to this regime. in following sections 6.2 and 6.3, we consider supplementary factors increasing information field's coherence. now, we connect a social resonator, e.g., in the form of an internet-based echo chamber, to the social laser device described in section 3. as the result of the feedback processing of information in the echo chamber, the power and coherence of the information field increases enormously. one of the ways to consume the huge energy of this information field is to realize it in the form of physical social actions, mass protests, e.g., demonstrations or even a wave of violence. this is the main mechanism of color revolutions and other social tsunamis [1] [2] [3] [4] . however, in this paper we are more interested in the purely information consumption of the social energy of the coherent information field prepared in an echo chamber, namely for internal decision-making. decision-making on a question that important for society is also a social action; in particular, it consumes social energy. now, suppose that say a government needs some coherent and rational (from its viewpoint) decision on some question. it can use a powerful social laser. this is a good place to remark that an ensemble of echo chambers can be used coherently with stimulation by the same quasi-color α corresponding to the desired decision. by emitting the information excitation, a social atom confirms his-her support of the α-decision. such social action is realized in the mental space of social atoms, but, of course, it has consequences even for associated actions in the physical space. if the wave in the information space generated by a powerful social laser can approach the steady state, then social atoms live in the regime of the repeated confirmation of the internal α-decision: an atom emits and relaxes, then he/she again absorbs another α-excitation and moves to the state of excitement and so on. in this situation of surrounding by the information field of huge power concentrated on the same α-mode, the colors of the energy pumping and stimulated emission coincide. such repeating of the same α-decision is similar to concentration on the idea-fix and can lead to the state of psychosis and panic (see freud [62] ). as in physical lasing, the above ideal scheme is complicated by a few factors related to losses of social energy in the echo chamber. as is known, not all photons are reflected by mirrors of the optical cavity, a part of them is absorbed by the mirrors. the coefficient of reflection plays the fundamental role. the same problem arises in social lasing. an essential part of posts is absorbed by the information mirror of the echo chamber: for some posts, the probability that they would be read by members of the social group is practically zero. additional (essential) loss of social energy is resulted from getting rid of communications carrying quasi-colors different from the quasi-color α of the bunch of the communications initiating the feedback dynamics in the echo chamber. such communications are generated by spontaneous emission of atoms in the social group. the real model is even more complex. the information mirror is not homogeneous, "areas of its surface" differ by the degree of readability and reaction. the areas can be either rigidly incorporated in the structure of the social group or be formed in the process of its functioning. for example, "quantum physics" group has a few layers that are rigidly incorporated in its structure. one of them is "foundations and interpretations". this sublayer of the information mirror "quantum physics" has rather low visibility, due to a variety of reasons. once, i posted in "quantum physics" a discussion on quantum information and quantum nonlocality. in addition, i discovered that the social group moderators control rigidly the layer structure. the message that my post should be immediately moved to this very special area of the information mirror, "foundations and interpretations", approached me in a few minutes. it looks that even in such a politically neutral social group moderators work in the online regime. as an example of functionally created information layers, we can point to ones which are coupled to the names of some members of the social group, say "area" related to the posts of a nobel prize laureate has a high degree of readability and reaction. however, of course, one need not be such a big name to approach a high level of readability and reaction. for example, even in science the strategy of active following to the main stream speculations can have a very good effect. top bloggers and youtubers create areas of the information mirror with high coefficients of reflection-multiplication (see below (7)) through collecting subscriptions to their blogs and youtube channels. it is clear that the probability of readability and reaction to a post depends heavily on the area of its location in the information space of a social group or generally facebook, youtube, or instagram. the reflection-multiplication coefficient of the information mirror varies essentially. consider first the physical mirror and photons reflected by it. from the very beginning, it is convenient to consider an inhomogeneous mirror with the reflection coefficient depending on mirror's layers. suppose that k-photons are emitted to area x and n of them were reflected, i.e., (k − n) were absorbed. then the probability of reflection by this area p(x) ≈ n/k, for large k. now, for the information mirror, consider a sequence of posts, j = 1, 2, ..., k, that were put in its area x. let n j denotes the number of group's members who reacts to post j. each n j varies between 0 and n, where n is the total number of group's members. then coefficient of reflection-multiplication p(x) ≈ ( k ∑ j n j )/kn, for large k, n. if practically all posts generate reactions of practically all members of the group, then n j ≈ n and p(x) ≈ 1. we have already discussed in detail the multilayer structure of the information mirror of an echo chamber. this is one of the basic information structures giving the possibility to generate inside it the information field of the very high degree of coherence: a very big wave of information excitations of the same quasi-color, the quasi-color of stimulating communications. it is sufficient to stimulate atoms with the potential of posting in the areas of the information surface with the high coefficients of reflection-multiplication. these areas would generate a huge information wave directed to the rest of the social group. spontaneously emitted communications would be directed to areas with the low coefficients of reflection-multiplication. how is this process directed by the internet engines? it is described by the model of the dynamical evaluation of the readability history of a post. we shall turn to this model in section 6.3. although the dynamical evaluation plays the crucial role in generating the coherent information waves, one has not to ignore the impact of straightforward filtering. we again use the analogy with physics. in the process of lasing, the dynamical feedback process in the cavity excludes the excitation of the electromagnetic field propagating in the wrong directions. in this way, laser generates the sharply directed beam of light. however, one may want some additional specification for excitations in the light beam. for example, one wants that all photons would be of the same polarization. it can be easily done by putting the additional filter, the polarization filter that eliminates from the beam all photons with "wrong polarization". of course, the use of an additional filter would weaker the power of the output beam. the latter is the price for coherence increasing. in social lasing, the role of such polarization filters is played by say google, facebook, instagram, or yandex control filtering, e.g., with respect to the political correctness constraints. besides numerous moderators, this filtering system uses the keywords search engines as well as the rigid system of "self-control". in the latter, users report on "wrongly colored posts and comments" of each other; the reports are directed both to the provider and to social groups-to attract the attention to such posts and comments. the dynamical evaluation system used, e.g., by youtube, increases post's visibility based on its reading history, more readings imply higher visibility (at least theoretically). however, the multilayer structure of the information mirror of youtube should also be taken into account. the main internet platforms assign high visibility to biggest actors of the mass media, say bbc, euronews, rt, that started to use actively these platforms. then, and this is may be even more important, these internet platforms assigns high visibility to the most popular topics, say presently the coronavirus epidemic, videos, posts, and comments carrying this quasi-color are elevated automatically in the information mirrors of google, youtube, or yandex. of course, the real evaluation system of the main internet actors is more complicated and the aforementioned dynamical evaluation system is only one of its components, may be very important. we would never get the answer to the question so widely discussed in communities of bloggers and youtubers: how are the claims on unfair policy of internet platforms justified? by unfair policy they understand assigning additional readings and likes to some internet communications or withdraw some of them from other communications. (i can only appeal to my own rather unusual experience from the science field. once, i was a guest editor of a special issue (so a collection of papers about some topic). in particular, my own paper was published in the same issue. this is the open-access journal of v top ranking, a part of nature publishing group. presently, all open-access journals qualify papers by the number of downloads and readings. (therefore, this is a kind of youtubing of science.) my paper was rather highly estimated in these numbers. however, suddenly i got email from the editors that since i put so much efforts to prepare this issue, i shall get as a gift an additional 1200 downloads. of course, i was surprised, but i did not act in any way and really received this virtual gift... after this event, i am very suspicious of numbers of downloads and readings that i can see in the various internet systems. if such unfair behavior is possible even in science, then one can suspect that it is really not unusual.) starting with presentation of the basics of social lasing, we concentrated on functioning of one of the most important kinds of social resonators, namely internet-based echo chambers. we analyzed similarities and dissimilarities of optical and information mirrors. the main distinguishing feature of the latter is its ability not only reflect excitations of the quantum information field, but also multiply them in number. the coefficient of reflection-multiplication is the basic characteristic of the information mirror. we point to the layer structure of the information mirror of an echo chamber; the coefficient of reflection-multiplication varies depending on mirror's layer. we emphasized the bosonic nature of the quantum information field. this is a straightforward thermodynamic consequence [1] of indistinguishability of information excitations, up their quasi-colors. being bosonic, the information field increases tremendously the speed and coherence of stimulated emission of information excitations by excited social atoms. social atoms, "creatures without tribe", form the gain medium of a social laser. in contrast to quantum physics, we cannot treat real humans as totally indistinguishable. this is a good place to remind once again that our social lasing as well as generally decision-making modeling is quantum-like. quantum features are satisfied only approximately. this point is often missed in the presentation of "quantum models" for cognition and decision-making. in sections 6.2 and 6.3, we discuss some technicalities related to functioning of internet-based social groups and generally google and youtube. this discussion plays only a supplementary role for this paper. it would be fruitful to continue it and especially to discuss exploring of the quantum-like features of users and information supplied to them by the internet (cf., for example, with studies on quantum-like modeling of information retrieval [54] [55] [56] [57] [58] [59] ). in appendix a, we discussed very briefly interrelation between the psychic energy and the physical energy of cells' metabolism. it is very important to continue this study in cooperation with psychologists and neurophysiologists. the main output of this paper is description of the mechanism of generation of big waves of coherent information carrying huge social energy, a kind of information tsunamis. we especially emphasize listing of the basic conditions on human gain media and the information field generated by mass media and amplified in echo chambers leading to successful generation of such waves. the author recognizes very well that this study is still one of the first steps toward well elaborated theory. motion) interpretation of quantum mechanics [69] , whereas quite different from other interpretations, such as the many-world interpretation [70, 71] and the wise (wave function is the system entity) interpretation [72] . it should be also pointed out that in recent years, some physics-based social or network models have been studied [73, 74] . some new intersection of quantum and operational research are emerging, such as quantum machine learning [75, 76] . towards information lasers social laser: action amplification by stimulated emission of social energy social laser model: from color revolutions to brexit and election of donald trump on interpretational questions for quantum-like modeling of social lasing concept of information laser: from quantum theory to behavioural dynamics phase transitions, collective emotions and decision-making problem in heterogeneous social systems information dynamics in cognitive, psychological, social, and anomalous phenomena; series: fundamental theories of physics ubiquitous quantum structure: from psychology to finances quantum models of cognition and decision quantum concepts in the social classical and quantum mechanics on information spaces with applications to cognitive, psychological, social and anomalous phenomena. found. phys on quantum-like probabilistic structure of mental information pilot-wave theory and financial option pricing quantum dynamics of human decision making a quantum probability explanation for violations of 'rational' decision theory a quantum theoretical explanation for probability judgment errors decision theory with prospect interference and entanglement mathematical structure of quantum decision theory quantum-like model of behavioral response computation using neural oscillators a quantum probability explanation in fock space for borderline contradictions an operator-like description of love affairs can quantum probability provide a new direction for cognitive modeling? context effects produced by question orders reveal quantum nature of human judgments are quantum-mechanical-like models possible, or necessary, outside quantum physics? the visualizable, the representable and the inconceivable: realist and non-realist mathematical models in physics and beyond the role of information in a two-traders market conjunction and negation of natural concepts: a quantum-theoretic modeling a generalized probability framework to model economic agents' decisions under uncertainty quantum dynamics applied to cognition: a consideration of available options new fundamental evidence of non-classical structure in the combination of natural concepts the emperor's new mind quantum coherence in microtubules. a neural basis for emergent consciousness? brain and physics of many-body problems dissipation and memory capacity in the quantum brain model my double unveiled: the dissipative quantum model of brain enough! electoral fraud, collective action problems, and post-communist coloured revolutions why it's kicking off everywhere: the new global revolutions the color revolutions mistrust we trust: can democracy survive when we don't trust our leaders? the new digital age: reshaping the future of people why did people vote for brexit? deep-seated grievances lie behind this vote why did people vote for donald trump? voters explain; the guardian the science of structure: synergetics synergetics: an introduction-nonequilibrium phase transitions and self-organisation in physics laser light dynamics lasers and synergetics. a colloquium on coherence and self-organization in nature subjective probability: a judgment of representativeness prospect theory: an analysis of decision under risk critique des postulats et axiomes de l' cole amricaine risk, ambiguity, and the savage axioms ambiguity, and the dark-dependence axioms the geometry of information retrieval what is quantum information retrieval? how quantum theory is developing the field of information retrieval? supporting polyrepresentation in a quantum-inspired geometrical retrieval framework introduction to information retrieval and quantum mechanics deriving a quantum information retrieval basis the principles of psychology the standard edition of complete psychological works of sigmund freud on the nature of the psyche atom and archetype: the pauli/jung letters 1932-1958 competition between collective and individual dynamics from the financial crisis to sustainability? potsdam, european climate forum. available online: www.europeanclimate-forum.net/index.php?id=ecfreports interaction ritual chains oxford dictionary of psychology interpreting quantum mechanics in terms of random discontinuous motion of particles relative state" formulation of quantum mechanics many-worlds interpretation of quantum mechanics general quantum interference principle and duality computer modeling viral diffusion using quantum computational network simulation mechanics-an endless frontier quantum machine learning recent advances in quantum machine learning. quant. eng. 2020, 2, e34. [crossref] c 2020 by the author funding: this research received no external funding. the authors declare no conflict of interest. above we wrote about an "apparent violation" of the law of conservation of the social energy. we briefly discuss this point. the social energy is the special form of the psychic energy. hence, by discussing the conservation law we cannot restrict consideration solely to the social energy. the detailed analysis of transformation of different forms of the psychic energy and its origin in neurophysiological processes and finally the physical energy generated by cells' metabolism was presented by freud [62] . we do not plan to discuss here the freud's hydrodynamical model for psychic energy transformations. we want to elevate the crucial difference of the energy transfer from the information field to social atoms from the energy transfer from the electromagnetic field to physical atoms. in physics, energy is assigned to photons carriers of information, an atom by absorbing a photon receives its energy. in our social model, an excitation of the information field just carries the social energy label e c . a social atom absorbs this label and generate the corresponding portion of energy by itself, by transforming its psychical energy into the social energy. in addition, the former is generated by neurophysiological activity in the brain and the nervous system from the physical metabolic energy. thus, by taking into account the psychic energy, we understand that even for cognitive systems the law of energy conservation is not violated. we remark that development of the social laser model has also some relevance to the interpretations of quantum mechanics. in this model, the quantum nature is apparent, because the smallest unit in a society is a human person. this is quite like the rdm (random discontinuous key: cord-265323-urecb44o authors: fraenkel, peter; cho, wonyoung l. title: reaching up, down, in, and around: couple and family coping during the corona virus pandemic date: 2020-06-26 journal: fam process doi: 10.1111/famp.12570 sha: doc_id: 265323 cord_uid: urecb44o the worldwide corona virus (covid‐19) has had profound effects on all aspects of life: physical health, the ability to travel locally or to more distant destinations, material and financial resources, and psychosocial wellbeing. couples, families, and communities and individual persons in those relationships have struggled to cope with emerging depression, anxiety, and trauma, and the rise of relational conflict. in this article, we suggest that the existential nature of the pandemic’s challenges require more than just the usual psychosocial interventions. we propose a taxonomy of responses to foster coping and resilience – “reaching up, down, in, and around”. “reaching up” includes accessing spiritual, religious, and ethical values. “reaching down” includes ideas and practices that foster a revised relationship with the earth and its resources, and that engage families to participate in activities that aid the earth’s recovery from decades of human‐caused damage. “reaching in” represents a turn towards experiences available in the mind and in shared minds in relationships that provide pleasure, excitement, joy, and peace, given that external sources of these emotions are of limited availability due to quarantine. “reaching around” involves reframing the mandate for “social distancing” as fostering social connection and support while maintaining physical distancing. the challenges for family therapists, whose practices are confined largely to online therapy, and who are struggling with the same fears and constraints as those persons they are attempting to help, are also discussed. the worldwide corona virus pandemic has presented extreme and unfamiliar challenges to couples, families, and communities, and the individuals living within these social groupings. much as the attacks on 9/11 shattered americans' and others' sense of safety and forced adoption of a "new normal" (fraenkel, 2001a (fraenkel, , 2002 , the pandemic has prompted the entire world to revise this definition of "new normal" once again, this time centered on beliefs about the preservation of health and confidence that illnesses will more often than not be met with successful treatment. challenges include illness, death, and the fears thereof; employment and economic losses the growing evidence of heath care disparities between persons of differing social locations in terms of race, ethnicity, socioeconomic status, profession, and citizenship status; fears of losing housing, access to food and other basic needs; lack of consistent information about the level of risk of infection or guidance about best practices to reduce that risk; the need to quarantine with partners and family members despite conflicts that are usually mitigated somewhat by daily distance through going to work and school, and on the other hand, interminable separations between family members, friends, and community; a sense of foreboding, isolation, and lack of social support; and disruption of life plans and rituals such as birthdays, weddings, religious holidays, recreational activities, and funerals. it has also presented new and unusual challenges to family therapists dedicated to serving these couples, families, and communities, including the need to adapt care efforts to teletherapy; how to address not only psychological and relational problems but also the above-mentioned concrete needs and larger systems forces that create or accentuate psycho-relational difficulties; and how to address therapists' own personal challenges due to the same issues facing clients while maintaining a therapeutic, caretaking role. we suggest that the crisis cannot be met simply with traditional psychotherapeutic interventions, but rather, requires all persons to step back from conflict and draw upon philosophic, this article is protected by copyright. all rights reserved ethical, spiritual, and religious values (up); become better grounded in our relationship to the earth and to core needs for existence as opposed to strivings for material goods and the quest for new experiences (down); turn towards internal means of promoting engaging and pleasurable experiences (in); and use technologies to foster social support and connection with others while following requirements to maintain physical distancing (around). this taxonomy -reaching up, down, in, and around --as categories for particular activities, is of course based on common socially-constructed metaphors of location in "psychological geography", and is therefore somewhat arbitrary from an empirical perspective. for instance, describing spiritual and religious values as "higher" (and therefore, located up or above) is likely based on the trans-religious notion of god and heaven as existing "above" the earth, or perhaps based on a rank ordering from top to bottom, with such values being ranked highest. yet these values and their associated behaviors could be viewed as the basis or foundation of successful human existence, and therefore, situated below all other endeavors (and so, located down). likewise, concern for the state of the earth includes not only its surface, its oceans, and the animals and plants that inhabit it, but the sky above (up), or could be conceptualized as all around us. nevertheless, we believe this taxonomy has a kind of cultural "face validity" and we chose to employ it to organize our reflections on coping and resilience-building practices. although we hope that our taxonomy represents a novel and useful way to think about families meeting contemporary challenges, we build upon important related developments in the field. in terms of the coping approaches that constitute what we mean by "up", over the past two decades, family therapy has begun to address the need to incorporate fully the spiritual dimension of families' lives, both in general (walsh, 2009 ) and as a major active ingredient in family resilience (walsh, 2016) . indeed, walsh (2016) argues that the original systemic framework of "biopsychosocial" now must be recast as "bio-psycho-social-spiritual". some family and couple therapists outside the pastoral counseling profession and the field of counseling conducted explicitly within particular religious this article is protected by copyright. all rights reserved communities (for instance, premarital counseling in the jewish faith, christian counselors) have also turned to moral, spiritual, and religious principles to guide the conduct and goals of therapy (doherty, 1996; fishbane, 1998) , or have emphasized the importance of addressing particular religious ideas and practices central to a family's cultural traditions (beach, hurt, fincham, franklin, mcnair, & stanley, 2011; boyd-franklin & lockwood, 2009; elliot, 2009; falicov, 2009; fincham, 2014; marks & dollahite, 2017) . in terms of the attitudes and activities clustered under "down", although the systemicecological perspective in principle has always included the physical ecology and environment, only more recently has the field addressed in depth the link between family health and the health of the planet (laszloffy & twist, 2019) . the pandemic has raised concerns about the safety of our environment beyond the corona virus, and families are often unsure how to cope with these fears. in terms of the activities we categorize as "in", doherty (1999 doherty ( , 2000 has long described how couples and families are pulled apart by over-engagement in the quest for new experiences, especially extracurricular activities deemed by middle-to-upper-class parents to be essential to their children's development (and to building their cvs for college applications). the pandemic has all but eliminated access to these outside activities, leaving children, teens, and families at loose ends and often unable to generate sources of pleasure and endeavor among themselves to fill the time, other than increasing the already high levels of tv and internet activity (statista, 2013) . in terms of what we designate as activities that constitute the category of "around", research has long established the importance for families of social support and involvement in community (miller, 2001) , especially when children or adults suffer from health issues (varda & talmi, 2018) . given that families either are dealing with an ill member, or are worried about infection from the virus, connection this article is protected by copyright. all rights reserved with other families, neighbors, and community members is essential to coping with the stress of the pandemic. described initially to be "the great equalizer" (mein, 2020) -with ample coverage of privileged, high-profile white persons like prime minister boris johnson and newscaster chris cuomo --further studies have found that persons of color, especially african-descended and latinx persons, have significantly higher rates of infection and mortality than whites. national data from 40 states plus the district of columbia found death rates for black americans "2.4 as high as the rate for whites and 2.2 times as high for asians and latinos" (apm lab staff, 2020). put another way, the death rates per 100,000 people found blacks suffered 61.6 deaths, and native american groups 36.0, whereas latinx, asians and whites have suffered lower rates -28.2, 26.3 and 26.2 deaths, respectively (apm lab staff, 2020). as mein (2020) succinctly summarizes, these unsurprising ethnic and racial differences have emerged during all pandemics over the past hundred years, due to a cluster of factors. racial and ethnic minorities are proportionally more likely to be below the poverty line, and to work in service industries, many of which have been deemed "essential services", requiring workers to show up or face dismissal. to maintain employment, they must be at the worksite (unable to work in the shelter of home) and must utilize public transportation, all increasing exposure risk. they are less likely to have health insurance, sick leave (paid or unpaid), and less likely to use sick leave or quit a job to protect themselves from illness due to their economic precariousness. they are also more likely to have preexisting this article is protected by copyright. all rights reserved conditions associated with greater rates of severe illness and death, such as diabetes, hypertension, coronary heart disease, and respiratory ailments. although of course it is low-income persons of color who suffer most from these disparities, it is also painful for persons of greater racial/ethnic and economic privilege who care about injustice to witness these inequities and feel they have little power to rectify them at least in the short run. 1 one white upper-class italian ex-patriot client -whose country of origin has socialized medicine --spent several sessions talking about her sense of horror and rage about the socioeconomic conditions and political trends in the u.s. that have resulted in these disparities, and her sense of having little potential influence aside from donating some funds to organizations attempting to ameliorate current suffering. disparities aside, the virus's novelty means there is no reliable existing treatment or preventative vaccine. for most persons, having grown up in an era of significant medical advances even in treatment of diseases initially considered a likely death sentence (cancer, hiv/aids), this has altered the general assumption that reliable, effective health care is available for any condition. this has resulted in a significant increase in level of fear and sense of existential unpredictability in persons' lives. unemployment is at its highest level since the great depression. as of a may 8, 2020 report by the bureau of labor statistics, unemployment in april was 20.5 million people, with a rise in unemployment of 14.7 percent (bureau of labor statistics, 2020). although all industries are affected, losses in leisure and hospitality industries (restaurants, hotels) are particularly high, and these industries employ a disproportionate number of low-wage earners of color. as of may 16, approximately 3,543,000 persons had applied for unemployment (department of labor, 2020). as was noted above, 1 note that this article was written just before the murder of george floyd by a minneapolis police officer and the subsequent weeks of protests, in which persons from a wide range of socioeconomic and racial/ethnic backgrounds participated. many of the socioeconomic issues that resulted in differential illness and death rates have been named in these protests. this article is protected by copyright. all rights reserved financial instability and risk of illness are synergistic -those persons with less financial resources are more likely to stay in a job that puts them at risk than are those who have a buffer of savings, or paid leave. given the huge number of families now without income, there are grave concerns about their housing stability. consider new york city. the nyu furman center (nyu furman center, 2020), which studies housing, real estate, land use, and neighborhoods in the united states towards informing public policy, found that:  "out of almost 3.2 million households in new york city, almost 1,032,000 (totaling nearly 3.5 million people) had at least one household member that worked in a vulnerable occupation, and that person earned about 67 percent of the total income for the household.  in about 549,000 households, all earners worked in vulnerable occupations, making these households hyper-susceptible to income loss.  for households that earned less than $150,000 and had at least one worker in a vulnerable occupation in 2018, the median household monthly income was about $4,580 and the median rent was about $1,430.  hispanic workers in particular disproportionately worked in vulnerable occupations in 2018. the potential negative impact for low-income people of color, who are predominantly renters, could be at a scale equivalent to the effects of the foreclosure crisis." (nyu furman center, 2020) how unemployed and precariously-housed families would cope with the very real prospect of inability to pay rent, mortgage foreclosures, and possible homelessness is beyond comprehension or feasible this article is protected by copyright. all rights reserved government planning. new york city currently has 15,000 families living in shelters, and the shelters are at capacity (coalition for the homeless, 2020). the effects of living through a pandemic include worsening of existing mental health issues, new onset of anxiety, fear, and depression, disrupted sleep and eating patterns, concern about becoming ill and about worsening of existing conditions. if ill from the virus, persons may experience guilt about not being able to function in one's usual roles, about receiving help from others, fears of not being able to receive proper medical treatment should the condition worsen, fear of death, or anxiety and depression about being alone with the illness (cdc, 2020; apa, 2020). many family members who are so far healthy but living in close quarters with an ill family member with little ability to create consistent physical distance have anxiety about seemingly imminent infection. and of course, families of persons who died from the virus are mourning this loss, if the family member dies while hospitalized, families are unable to be with them, and in many cases unable to hold funerals in the fashion prescribed by their religions (frayer, estrin & arraf, 2020), or even locate space in cemeteries to bury them, or in crematoriums to cremate them (feuer & rashbaum, 2020) . parents are suffering great levels of stress as a result of needing to care for their children 24/7 and aid in their online education and homework while attempting to fulfill job responsibilities. the harris poll conducted for apa between april 24 and may 4 found that the average stress level of adults was 5.4 (this compared to 4.9 in 2019); but for parents with children under 18 years old, the average was 6.7 (compared to nonparent adults' average of 5.5), with 46% of parents rating their stress levels between 8 and 10 on a ten point scale. seventy percent (70%) of parents reported significant stress about meeting basic needs such as housing and food, as compared to 44% of nonparents; and 66% of parents rated access to health care as a stressor, compared to 44% of nonparents (apa, 2020). this article is protected by copyright. all rights reserved unfortunately, rather than coming together to cope as best as possible with these stressors, many couples are descending into their most destructive patterns. according to reports by the council on foreign relations (bettinger-lopez & bro, 2020 ), the who regional office for europe (kluge, 2020) , reuters (sigal, ramos miranda, martinez, & machicao, 2020) , and the un (un women. (n.d.) rates of domestic violence have skyrocketed globally, many due to "situational couple violence," in which conflicts that usually do not involve physical violence have escalated due to added stress and unrelenting proximity (university of nevada las vegas, 2020). couples on the brink of divorce --"last chance couples", in which partners may already have separated (fraenkel, 2019 ) --may be particularly at risk for increased conflict, because their commitment, cooperation, and collaboration levels are low, their communication skills are limited, and they are now quarantining together. once again, couples with more limited financial and housing resources, higher rates of unemployment, and at higher risk of contracting the corona virus, are at higher risk of conflict due to these enhanced stressors. in part as a response to the flood of information and specific advice from psychotherapists on the internet, which can feel overwhelming, generic, and unintegrated to disoriented families, we offer the following simple four-part framework of reaching up, down, in, and around as an organizing, flexible, culturally-adaptable guide for couples and families, as well as for individuals and communities. this pandemic and all its accompanying challenges present an existential challenge to couples and families (and societies more broadly) that exceeds simple psychological and relational techniquespractices such as good communication and problem-solving skills, creating a regular but flexible daily schedule that allows both partners to balance work obligations with parenting and domestic chores, mindfulness practices for soothing oneself and others, statements of mutual appreciation, and creating this article is protected by copyright. all rights reserved moments of pleasurable connection despite anxiety, fear, and mourning. although we strongly endorse these and other couple and family practices for highly distressed couples and families (fraenkel, 2011 (fraenkel, , 2019 , something more seems needed in the face of an unpredictable, largely uncontrollable, existential, and pervasive crisis like covid-19. we suggest that couples and families need to reflect on their higher and broader values -whether derived from spirituality, formal religion, moral philosophy, or other sources of personal/humanitarian ethics. these values are often implicit and unexamined in how persons construct their lives (dreyfus, 2014) , but certain extreme conditions tend to force a reexamination of these underlying values and principles, so as to provide a psychosocial compass to guide traversing an unfamiliar life terrain. just as other crises have prompted reflection on the nature of being and human life, couples and families, as well as family therapists, need to engage their higher values to reflect on the following sorts of questions:  what are the essential components and features of a reasonably secure, satisfying, meaningful life? how much --money and material goods, novel and exciting experiences, influence over life outcomes --is enough? and what can we do without?  how can we go on living with a sense of hope and purpose in the face of a situation that may bring great reductions in our material wellbeing, and that may result in illness and death?  what is the source and nature of courage, of hope, and of faith in a better future, and how do we sustain those qualities and energy? this article is protected by copyright. all rights reserved inform building a new norm for our lives. reaching up is an integral part of this life reconstruction project, because it often prompts a kind of reflection that seeks a broader meaning, and thus creates space for new possibilities. reaching up can also shift the focus from individual and human-centered experience -what hernandez-wolfe (2019) has termed "anthropocentrism" --embedded in the assumed values of our cultural and societal norms, to adopting a wider framework that de-centers human experience and is more inclusive of ecosystems (discussed further in the section on reaching down). many religious, faith-based, and spiritual communities in western and non-western cultures provide such frameworks. many therapists feel uncomfortable asking couples and families to reflect on their spiritual, religious, and ethical beliefs. this is a time to venture into this important territory, because such beliefs may be crucial to promoting coping and resilience. walsh (2009) writes: spirituality is a powerful dimension of human experience involving transcendent beliefs and practices that foster meaning, well-being, and connectedness. a spiritual worldview orients individuals and families over the life course and across generations. it provides larger values and purpose, guides daily actions and relationships, and strengthens resilience in overcoming adversity. a growing body of research documents the powerful influence of personal faith, prayer, and meditation, and a faith community on physical, emotional, and relational well-being and on recovery from illness and trauma. spiritual distress or a spiritual void in one's life and relationships can contribute to suffering and block positive growth. yet, until recently, spirituality was regarded as "off limits" in clinical training and practice, leaving most therapists and counselors uncertain how to approach it, if at a. (walsh, 2009, p. xi) . before rushing haphazardly to "adopt" the forgotten wisdom of certain religions or indigenous cultures, it is crucial to examine the worldviews (sire, 2015) at foundation of the family therapy field. this includes naming and re-examining the assumed secularism underpinning the theories and practices of mainstream family therapy, because therapists often interpret client(s) life experiences, relationships, and meaning-making through these non-spiritual lenses. furthermore, when conversations about spirituality, religion, and philosophy that de-centers human experiences are examined through the lens this article is protected by copyright. all rights reserved of secularism, what often results is stripping a rich, nuanced worldview into simply a coping strategy for people to turn to in times of crisis. i (wc) have heard well-meaning non-religious and non-spiritual therapists merely tolerate spirituality in their practice, presumably because it is the "culturallyappropriate, politically-correct" thing to do, and observe that "it is a nice value system that people lean on to cope with difficult circumstances." the assumption underpinning this stance is that spirituality or religious frameworks are created by humans, rather than through a relationship with a deity or spiritual power, as a coping mechanism (thus, a human-centered interpretation). this implies that non-spiritual reality is true. moreover, it invites the interpretation that those who need this imaginary framework to cope are intellectually compromised -an arrogant stance that can range from benign infantilization of religious and spiritual communities to belittling dismissal. we are not suggesting that we and all our clients must all become spiritual and religious. rather, i (wc), as a christian, would suggest that even non-religious and non-spiritual realities are based on a system of beliefs (e.g. poplin, 2014) . in this regard, traditional religious and spiritual frameworks are not too far out of reach from the secularism that underpins the practices and theories of family therapy. foundational to family systems theory is the premise that individuals' minds, experience, and behavior are intertwined with their relationships to others in their immediate and larger sociocultural contexts. all religious and spiritual beliefs also understand the individual as relational, but include relationships with non-human, spiritual beings such as god, or a universal energy. therefore, in therapeutic work with couples and families, and for families coping with the pandemic on their own, reaching up involves articulating the worldviews embedded in expectations about life and relationships (sire, 2015) , revisiting and possibly revising their relationships to higher values. this article is protected by copyright. all rights reserved (bynner, 1944) , he wrote: existence is beyond the power of words to define: terms may be used but are none of them absolute"….. if name be needed, wonder names them both: from wonder into wonder existence opens. most of all, in the spirit of wonderment, it is a time to step back from the daily relational grind and appreciate more deeply one's partner and kids; for kids and teens, to get to know one's parents through asking about their opinions, and stories from their childhood, and for all family members to enjoy each others' enjoyment -of music, ideas, art, books, sports, and other passions. research on the 2 although taoism, or daoism, is often referred to as a religion, it actually has two branches, one philosophic,and the other religious (amore, hussain, & oxtoby, 2019). philosophic taoism, upon which the present comments are based, has no concept of god or deity, no belief in an afterlife, no prescribed rituals, no sacred text, and no established institution of religious leaders or devotees. taosim developed in the 4th century bce in part as a counterpoint and criticism of the dominant confucian religion of the time, with its emphasis on social hierarchy and respect for those higher in the hierarchy, as well as moral and emotional discipline that aligned with adhering to that hierarchy, religious taoism, which developed much later (2nd c, bce), developed all the typical beliefs, institutions, and rituals of a religion. this article is protected by copyright. all rights reserved relationship-strengthening effects of such positive psychology practices as inviting someone to lunch to tell them how much they have meant to you (seligman, 2004) , or gottman's (2015) research demonstrating the long-term positive impact of partners expressing admiration and appreciation for one another, support this activity. couple and family members can look at one another, listen to one another more fully and patiently, and be grateful that the other is not ill, or worse, dead from the corona virus. this can be a time to learn to respect gravity, to slow one's movements -physical, cognitive, and emotional. although the initial weeks of responding to the pandemic resulted in frantic gathering of food and toilet paper, and gathering needed work materials from the office, families and couples have come to recognize that the adverse conditions will not change so soon, and that they must slow the pace. it can be useful to suggest to couples that gravity has two meanings: it refers to the physical force that binds us to the earth, and it also is used to characterize some problems as serious. surely, this pandemic and its ramifications are grave, and it can be best to adopt a slowed-down means of discussing how best to meet new and old challenges. empirically-validated communication practices like the speaker-listener technique from the prevention and relationship enhancement program (prep; this article is protected by copyright. all rights reserved markman, stanley, & blumberg, 2010 ) -which couples sometimes balk at due to its initially artificial feel -can be introduced through this spiritual/philosophic perspective on the value of slowness. taoism also promotes a stance of choosing patient inaction or "going with the flow" over vigorous endeavor and attempts to assert control when "hard trying" is likely to result in frustration because of larger forces. laotzu (bynner, 1944) writes: because when a (person) is in turmoil how shall (they) find peace save by staying patient till the stream clears? how can a person's life keep its course if they will not let it flow? those who flow as life flows know they need no other force: they feel no wear, they feel no tear, they need no mending, no repair. various buddhist texts suggest a similar stance in the face of overwhelming, largely uncontrollable conditions. of course, families should continue to follow suggestions of science-based policies on limiting exposure to the virus. but couples and families need to cultivate greater acceptance of their inability to completely control their lives, to embrace uncertainty (chodron, 2018) and accept, even if painfully, the numerous cancellations of trips, family events, academic plans, and even employment stability if it is clear nothing can be done to alter the situation. finally, taoism suggests that formalized learning borne in the academy has its limits. he writes: leave off find learning! end the nuisance of saying yes to this and perhaps to that, what slightest use are they! if one man leads, another must follow, how silly that is and how false! this article is protected by copyright. all rights reserved professionals' recommendations for strengthening resilience, drawn from careful social science research and clinical practice, is only one set of knowledges that can be useful like other american products and practices touted to be better (and needed for advancement) than those created in the host countries, our professional knowledge may disrespectfully displace equal or even superior knowledge about coping with adversity, and lead persons in those countries to second-guess their own coping wisdom. indeed, we argue that this is a time to learn from such societies about longstanding skills about surviving and thriving despite adversity, developed by them due to limited material resources, political and economic oppression, and without western healthcare technologies and practices. when therapists introduce ideas or practices (such as mindfulness) drawn from a spiritual or religious tradition to couples and families, it is important to preface one's comments with a statement that one is not attempting to recruit the couple or family into a particular belief system. rather, these ideas and practices are viewed by the therapist as cultural products that the couple or family may find useful, in the same manner that the therapist might allude to music, film, art, poetry, or other cultural products that represent wisdom or that capture some aspect of their experience (fraenkel, 2020) . clients are asked to reflect on the ideas and practices introduced by the therapists, especially regarding whether these are helpful or not to them. likewise, when inquiring about clients' existing spiritual beliefs or religious faith, the therapist should be clear that she/he/they are not attempting to transform the therapy into a faith-based approach, but rather, is adopting a stance of respectful curiosity similar to how one would explore any other aspect of the clients' cultures of origin, or any aspect of their intersectional social locations (fraenkel, 2009 ). this article is protected by copyright. all rights reserved many of the root causes of climate change also increase the risk of pandemics. deforestation, which occurs mostly for agricultural purposes, is the largest cause of habitat loss worldwide. loss of habitat forces animals to migrate and potentially contact other animals or people and share germs. large livestock farms can also serve as a source for spillover of infections from animals to people. less demand for animal meat and more sustainable animal husbandry could decrease emerging infectious disease risk and lower greenhouse gas emissions….we have many reasons to take climate action to improve our health and reducing risks for infectious disease emergence is one of them. even without clear evidence of a link between disruptions in the global ecology and the pandemic, it has alerted the entire world to the uncontrollable forces of nature. one of us (pf) has noticed that since the beginning of the pandemic and quarantining, couples in therapy have, for the first time, described anxieties about the state of the planet and how global warming and other repercussions of environmental degradation may be related to the pandemic -despite the fact that damage to the natural world has been obvious and well covered in the media for several years, and even has resulted in new laws around recycling and forbidding use of single-use plastics (bottles, bags). sadly, this confirms that for many people, concern about humans' effects on the ecology only become salient when they experience the direct effects of negative environmental changes (swim et al., 2010 ). marshall (2014 hypothesizes that a combination of the brain's biologically-based cognitive responses of denial to overwhelming fear, coupled with an implicit social consensus not to discuss such overwhelming fears, has resulted in ignoring the ecological crisis. the proximal nature of the pandemic seems to be bursting through this denial. this article is protected by copyright. all rights reserved thus, in many ways, reaching down is an extension or corollary of reaching up, leading us to widen our perspectives and re-examine our expectations of life. the pandemic has halted the well-oiled machine of modern life in most countries and in our daily activities, centered around the human experience of production and consumption. this pause has put into question what we expect from our future, and consequently increased the general anxiety that comes with facing the unknown. it has also given us room to stop running ahead long enough to really take a good look around us -what is happening to the land; the oceans, lakes, and rivers; the sky; and all the nonhuman beings with whom we cohabit this planet. for many, it has provided time to reflect upon what the decades of industrialization and modernity has severed our lives from our ecosystem, which nevertheless is the direct source of our livelihood, food, and general wellbeing. social and physical distancing policies can be respected while spending time outdoors, close to the earth, and tending to nonhuman beings within and outside of our living spaces. this is easier for me not everyone is privileged to take leisurely walks during the pandemic. as we described above, there are pressing concerns including economic instability, job losses, food insecurities, and escalated relational conflicts that make taking a moment to walk through nature difficult. thus, it is essential that therapists encourage couples and families to explore and expand the possibilities within the constrained this article is protected by copyright. all rights reserved realities of their physical and economical contexts. to expand their sense of possibilities, families can start by drawing upon their surroundings to begin to redefine how they construe relational health and individual wellbeing. the pandemic has alerted us that reaching down to reconnect with our environment is not peripheral to the human experience. it is vital to our very survival on this planet. in addition to tending to the relationship with our surroundings, we suggest that couples and families can respond to their increased awareness of and anxiety about environmental disruption by learning more about their role in the environmental effects of human activities. we also suggest that couples and families turn to nature as a source of recreation and pleasure. our colleague, family psychologist dr. monica sesma, a mexican now living and working in calgary, in alberta, canada, where the weather is cold much of the year, has encouraged families to grow vegetables and other plants in their homes, and has observed the therapeutic effects of family members collaborating in these growing projects, as well as pride in providing themselves inexpensive, healthy food (fraenkel, sesma-vazquez, & freeman, 2019) . ron finley, living in the inner city of south los angeles, started a neighborhood movement to grow his own food on vacant lots, and during a ted talk observed that "gardening is the most therapeutic and defiant act you can do, especially in the inner city" (finley, 2013) . systemic therapists must consider helping clients reintegrate all that surrounds them. as hernandez-wolfe (2019) writes, "human survival depends on our effectively relating to everything that surrounds us" (p. 43). it is important, especially in this current context of the pandemic that is quickly and permanently changing the modern lifestyle, that we invest in this relationship with our surroundings by reaching down and widen our meaning of what it means to be well. the dangers of the pandemic have driven individuals and families to "shelter at home" and stay confined to limited physical spaces for an extended period of time. for example, the requirement to this article is protected by copyright. all rights reserved shelter at home has disrupted the increasing pattern of families dining out (saksena, okrent, & hamrick, 2018) . by 2010, the percentage of meals prepared and eaten out of the home rose to 50.2%, up from 44% in 1987. as noted earlier, children's and teens' extracurricular activities -sports, music, dance, and art lessons, volunteering, religious instruction, and informal time with friends has been all but eliminated. the most recent survey on screen time conducted in august 2019 (commonsensemedia, 2019) indicated teens spent an average of seven hours twenty-two minutes on phones or computers, and tweens, four hours and forty-four minutes -not including time spent for school or homework. with extracurricular activities on hold, parents are now facing childrens' and teens' intense demands for even more screen time (commonsensemedia, 2020) , which was already a major source of conflict between parents and kids (doherty, 2000; author, 2001c) . as the themes of coping -reaching up, down, in, and around --are related, some guidance for families on how to generate novel forms of individual and collective entertainment have already been this article is protected by copyright. all rights reserved and their behavior towards one another. the partners noted, with an expression of genuine surprise, that they had never thought about that discrepancy, and went on to discuss in a helpful manner how to bring those values and their treatment of one another into better alignment. likewise, families can use being stuck together in quarantine as a time to engage in learning and reflecting on the global ecological crisis and planning changes in their patterns of consumption (reaching down). other "analog world" activities in the category of reaching in that avoid increasing online/screen time include reading to one another, playing games, singing and playing music (rather than just listening to professionally-produced music; goodchild, 2015) , writing stories and poems, making art (parents and children doing origami together is often quite pleasurable), building things with legos or blocks, creating skits or whole plays, including about the pandemic; exercising together, and doing mindfulness activities together like mindful breathing, walking, and qi gong, which creates a climate of calmness and compassion, useful in times of stress and frustration (fraenkel, 2019) . parents can also use this opportunity to get to know their children's musical and other tastes (books, video games) in more depth, as can couple partners. best of all, these activities are free, which is important in this time of economic precarity. gaston bachelard (1958 bachelard ( /2014 described the way in which physical spaces become imbued with relational and other meanings. one of the assumptions that the pandemic has put into question is what the expected ratio of relatedness and autonomy is in relationships (kagitcibasi, 2005; kerr & bowen, 1988) . oftentimes, this expected ratio is assumed, socialized, and normed by the sociocultural context and intergenerational patterns within family units. broadly speaking, at least in the sociocultural context of the united states, the expected ratio is usually tipped in favor of more autonomy than relatedness. this can be seen in the way physical spaces in homes are often conceptualized -each child should have a private room, each partner is given a separate bathroom sink, and large spaces in the home is divided for breakfast, formal dining, entertaining, and family leisure. while not all have access to such physical this article is protected by copyright. all rights reserved spaces, this is what is largely expected and idealized. if these idealized floorplans of homes are symbolic of our expected levels of relatedness and autonomy, autonomy is valued and thus expected within relationships. those families whose economic means do not allow such individualized private spaces, or whose cultural traditions favor more shared spaces (for instance, parents and children sleeping together, siblings sharing a bedroom and study space) may see themselves as inferior to the largely white, middle-to-upper class assumption of physicalized separateness and autonomy; and therapists sharing this bias towards autonomy and privacy among family members may subtly communicate their concern or even disapproval for families members sharing spaces, as well as the ratio of time spent together versus apart. as available physical spaces become limited due to the public health crisis, the expected ratio of relatedness and autonomy needs to be revisited and adapted to the new reality. what are the expectations of the ratio for close relationships within the shared living space? by articulating the assumed ratio of relatedness and autonomy, the individuals within the unit become aware of their bias and the differing levels within their assumptions. this process then creates space for communication, adjustment, and attunement to one another within the relational unit that share living spaces in the new sociocultural context of the post-virus era. additionally, there is a starker distinction between those who are in-group (that is, a unit of relationships within a shared living space) and those who are out of this designated group. what is the expected ratio of relatedness and autonomy with those outside of this designated unit, both physically and emotionally? once expected and assumed norm of the ratio is identified, it is important to collaborate with the couples and families we are working with on what is pragmatic and reasonable in these current times when physical space and autonomy is limited. the work of adjusting to this new norm requires not only the adjustment of expectations, but our underlying definitions of healthy relationships and mental wellness. shifting both the relational norms of the client(s) and the norms of the therapist(s) is required this article is protected by copyright. all rights reserved to adjust to the new realities we are now living in. it requires the negotiation of new expectations, and the following work of growing each individual's capacity for more relatedness and less autonomy within the relational units. again, it is important to note that racial, ethnic, and cultural diversity provides a wealth of local knowledges (canagarajah, 2002) on what relationships with varying ratios of relatedness and autonomy looks like. we would do well to listen and learn from these communities. and again, before rushing haphazardly into adopting relational knowledge from other cultures that have been historically marginalized and discredited, it is critical to tread carefully with an ever-present suspicious eye on our own bias and attitudes embedded in our quest for knowledge. as couple and family researcher paula pietromonaco notes, "social distancing and staying home are key to reducing the transmission of covid-19, but these safeguards disrupt couples' and families' routines" (association for psychological science, 2020, n.p.). social support outside the couple relationship is well known as a protective factor, and is important to relieve stress and protect physical health (pietromonaco & collins, 2017) . one of the most unfortunate aspects of the government's and scientific community's suggestions for containing the virus' spread was utilizing the term "social distancing" (italics added). instead, we suggest rephrasing the safeguarding strategies as "physical distancing" while promoting social connectedness. although during "normal" times, communication technologies and social media can have deleterious effects on couple intimacy and family connectedness (fraenkel, 2001b (fraenkel, , 2001c turkle, 2015) , these technologies have become useful tools to fostering family and community social support. video chats and virtual conferences are being used to take the place of face-to-face meetings. although these virtual formats of connection cannot fully take the place of face-to-face connections, they seem to meet some of the needs of social support that physical distancing has created. these virtual formats have been used to replace social gatherings (e.g. this article is protected by copyright. all rights reserved video conferencing gatherings for birthday celebrations, using the video chat feature on smartphones to call extended family members). the same technology has also been utilized to replace professional and educational gatherings as well -both of us have held classes and conducted supervision online since the pandemic started, and i (pf) have seen couples and families online, without difficulty. indeed, online therapy eliminates for couples with young kids the challenge of arranging childcare, and commuting to and from sessions. as we work and socialize virtually from our living spaces, the various roles and identities in our lives are starting to blend and blur. for instance, clients have at least a limited view of our homes, which many therapists have found enhances emotional connection and the therapeutic alliance, and "humanizes" the therapist. as a therapist who integrates music and other arts and literature in couple and family therapy (fraenkel, 2020) , i (pf) have ready access to my instruments and books with which to make therapeutic points in more powerful ways than with regular "psycho-prose". and the fact that we are "all in this together" has strengthened the bond between therapists and clients. likewise, when we interface with co-workers for a work meeting, we are working from our living rooms, dining tables, or bedrooms. the others quarantined in the same living space may be sitting just off the screen or walking across the screen in the background. during virtual meetings, children may be making noises, vying for attention, or sleeping in the background. dogs are barking in the other room and cats are walking across the desk or demanding lap time, potentially disrupting but sometimes enhancing connection and a sense of humor and perspective. meetings may unpredictably be interrupted by deliveries or knocks on the door by neighbors. if in our pre-covid lives we had been able to limit the exposure of the various facets of our lives to specific groups (e.g. presenting only as a professional to co-workers, clients, and students, and as mother or father only to our children, other extended family members and friends), the intersections of our various roles as professionals, caretakers, life partners, and more are now being exposed to various communities. the sociocultural this article is protected by copyright. all rights reserved and professional norms of social connection and support need to broaden. that is, we must come to see and consider individuals in their intersections of multiple roles in various facet of the human life rather than a single-faceted relationship. we posit that the individuals, couples, and families with whom we work must rise to this challenge and start intentionally seeing one another more transparently, fully, and respectfully as having multiple roles and responsibilities, and as existing in multiple, overlapping social contexts. more than ever before, we need to be more deliberate in sustaining and nurturing our social connections --what john green (2015) describes in his ted talk as "imagining others more complexly" -and as noted earlier, in our connection to the ecosystem. we are suggesting that we reconsider our assumptions and norms around "boundaries" in relationships and widen the capacity of social connection from an individual, one-dimensional construction of others based on the main purpose of our relationship (work, partner, child, family, community) to construe persons as systemic beings -for instance, making room for our co-workers or employees to tend to a fussy baby in the middle of a work meeting, and having patience with them when they run off screen to stop their cats from knocking off objects on shelves. as systemic and relational therapists, we have the concepts to provide leadership in the mental health community, as well as in the communities we serve and in which we live. widening the capacity for social connection ultimately means to de-center the experience of an individual self to consider contexts in all our relationships. with this exponentially complex conceptualization of the other, it becomes impossible to know someone fully, in all of the intersections of their life. thus, rather than seeking to know a person fully, we must adopt the assumption that one cannot be fully known. this assumption that there is something more than meets the eye leaves room for consideration and curiosity. furthermore, it creates space and flexibility in the relationship to decenter the self and "give the benefit of the doubt" to the other, and requires higher values of compassion, grace, patience, humility, and generosity of time and attention. this article is protected by copyright. all rights reserved couple, family, and community approaches to coping and adjusting to the covid-19 pandemic require more than the usual panoply of techniques offered by family therapists. the pandemic and its sequelae, which will last well beyond the advent of vaccines and diminishment of the virus's spread, requires all of us around the world to critically examine our way of life. we need to revisit how we define and promote positive functioning and wellness at all levels of our bio-psycho-social-spiritual lives, the ecology, as well as in economic and political forces that remain biased in favor of persons in certain intersectional social locations and against others. now more than ever, systemic therapists, scholars, and researchers must provide leadership not just within the four walls of the office (or at present, on video screens) the virtual (literally and figuratively) explosion of advice from therapists and other professionals that has accompanied the coronavirus is well intentioned, but can leave distressed couples and families overwhelmed with information and suggested "best practices". we offer our simplified taxonomy -up, down, in, and around -as an easily memorable and culturally-flexible set of resilience principles and guideposts for our journey through the "psycho-relational geography" of coping. one of us (pf) was fortunate to study with one of the founders of the field, salvador minuchin, from whom he learned, among many other craft principles of therapy, the importance of "building intensity". for minuchin, "building intensity" meant the use of novel, memorable, engaging, short phrases and visual imagery (as well as novel relational enactments in session) to transmit a therapeutic message more powerfully than often does scientifically-accurate but plain, unimaginative, explanatory therapeutic prose (minuchin, reiter & borda, 2014) . we believe that powerful interventions must "capture the imagination" of couples and families (fraenkel, 2020) , and metaphorically speaking, "ring in their heads and conversations" like a clear bell. we suggest that the phrase up, down, in, and around represents just such a novel, salient therapeutic message. this article is protected by copyright. all rights reserved reaching up, down, in and around are interconnected categories of family reflection and activity which inform and borrow from one another. as an overarching "four-post" guide to foster coping and resilience, it represents various vantage points on the same call to widen our perspective on what phenomenological-existential philosopher martin heidegger called "dasien" or being-in-the-world (dreyfus, 2014) , what laotzu called the tao, or way of life (bynner, 1944) , and from a christian perspective is about rediscovering and adhering to god's original design for life (lewis, 1952 (lewis, /1980 as systemic therapists, the assumed norms of relationships need to include considerations of bio-psycho-social-spiritual aspects of the human experience. by reaching up, down, in and around, we can sift through the assumptions and values that determine how we understand and study relational wellness, and begin to build a new normal better fitted to the drastic transformations to the world caused or exacerbated by the virus and its many sequelae. the color of coronavirus: covid-19 deaths by race and ethnicity in the pandemic effects on marriage and relationships the poetics of space the sound of a wild snail eating enhancing marital enrichment through spirituality: efficacy data for prayer focused relationship 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family therapy: challenging certainties nysdoh covid-19 tracker thich nhat hanh: essential writings savor: mindful eating, mindful life policy minute: protecting housing stability amidst the covid-19 crisis interpersonal mechanisms linking close relationships to health is reality secular?: testing the assumptions of four global worldviews america's eating habits: food away from home authentic happiness: using the new positive psychology to realize your potential for lasting fulfillment accepted article this article is protected by copyright. all rights reserved another pandemic': in latin america, domestic abuse rises amid lockdown naming the elephant: worldview as a concept psychology & global climate change: addressing a multifaceted phenomenon and set of challenges. a report of the american psychological association task force on the interface between psychology & global climate change most popular leisure activities among adults in the united states as of coronavirus and climate change reclaiming conversation: the power of talk in the digital age covid-19 and ending violence against women and girls 020/issue-brief-covid-19-and-ending-violence-against-women-and-girls-en love under lockdown: how couples can cope during covid-19 (interview with katherine hertlein, phd) the wiley handbook of existential therapy social connectedness in family social support networks: strengthening systems of care for children with special health care needs. egems the journal of electronic health data and methods (generating evidence & methods to improve patient outcomes spiritual resources in family therapy strengthening family resilience (3 rd ed.) the earth shall weep: a history of native america this article is protected by copyright. all rights reserved key: cord-315126-713k0b9u authors: rudolph, cort w.; rauvola, rachel s.; costanza, david p.; zacher, hannes title: generations and generational differences: debunking myths in organizational science and practice and paving new paths forward date: 2020-09-04 journal: j bus psychol doi: 10.1007/s10869-020-09715-2 sha: doc_id: 315126 cord_uid: 713k0b9u talk about generations is everywhere and particularly so in organizational science and practice. recognizing and exploring the ubiquity of generations is important, especially because evidence for their existence is, at best, scant. in this article, we aim to achieve two goals that are targeted at answering the broad question: “what accounts for the ubiquity of generations despite a lack of evidence for their existence and impact?” first, we explore and “bust” ten common myths about the science and practice of generations and generational differences. second, with these debunked myths as a backdrop, we focus on two alternative and complementary frameworks—the social constructionist perspective and the lifespan development perspective—with promise for changing the way we think about age, aging, and generations at work. we argue that the social constructionist perspective offers important opportunities for understanding the persistence and pervasiveness of generations and that, as an alternative to studying generations, the lifespan perspective represents a better model for understanding how age operates and development unfolds at work. overall, we urge stakeholders in organizational science and practice (e.g., students, researchers, consultants, managers) to adopt more nuanced perspectives grounded in these models, rather than a generational perspective, to understand the influence of age and aging at work. people commonly talk about generations and like to make distinctions between them. purported differences between generations have been blamed for everything from declining interest in baseball (keeley, 2016) to changing patterns of processed cheese consumption (mulvany & patton, 2018) . in the workplace, generations and generational differences have been credited for everything from declining levels of work ethic (e.g., cenkus, 2017; cf. zabel, biermeier-hanson, baltes, early, & shepard, 2017) , to higher rates of "job-hopping" (e.g., adkins, 2016; cf. costanza, badger, fraser, severt, & gade, 2012) . despite their ubiquity, a consensus is coalescing across multiple literatures that suggests that all the attention garnered by generations and generational differences (e.g., lyons & kuron, 2014; twenge, 2010) has been "much ado about nothing" (see rudolph, rauvola, & zacher, 2018; rudolph & zacher, 2017) . that is to say, the theoretical assumptions upon which generational research is based have been questioned and there is little empirical evidence that generations exist, that people can be reliably classified into generational groups, and, importantly, that there are demonstrable differences between such groups that manifest and affect various work-related processes (heyns, eldermire, & howard, 2019; jauregui, watsjold, welsh, ilgen, & robins, 2020; okros, 2020; stassen, anseel, & levecque, 2016) . indeed, a recent consensus study published by the national academies of sciences, engineering, and medicine (nasem) concluded that "categorizing workers with generational labels like 'baby boomer' or 'millennial' to define their needs and behaviors is not supported by research, and cannot adequately inform workforce management decisions…" (nasem, 2020a; see also nasem, 2020b) . of equal importance to the theoretical limitations, common research methodologies used to study generations cannot unambiguously identify the unique effects of generations from other time-bound sources of variation (i.e., chronological age and contemporaneous period effects). given all of this, some have argued that there has never actually been a study of generations , and thus, the entire body of empirical evidence regarding generations is, to a large extent, wrong. still, it is easy to find examples of empirical research that claim to find evidence in favor of generational differences (e.g., dries, pepermans, & de kerpel, 2008; twenge, 2000 ; see costanza et al., 2012 , for a review) and theoretical advancements that aim to direct such empirical inquiries (e.g., dencker, joshi, & martocchio, 2008) . moreover, some see generations as a useful heuristic in the process of social sensemaking: generations are recognized as social constructions, which help give meaning to the complexities and intricacies of aging and human development in the context of changing societies (e.g., campbell, twenge, & campbell, 2017; lyons, urick, kuron, & schweitzer, 2015) . considering all of this, we are faced with a variety of competing and contradictory issues when trying to sort out what bearing, if any, generations have on organizational science and practice. on the one hand, evidence for the existence of generations and generational differences is limited. on the other hand, the idea of generations is pervasive and is used to explain myriad patterns of thinking, feeling, and behaving that we observe day-to-day, especially in the workplace. thus, there exists a tension between what science "says" about generations and what people "do" with the idea of generations. given this, the continued popularity of generations as a means of understanding work-related processes is worthy of closer investigation. this popularity begs the question, "what accounts for the ubiquity of generations, despite a lack of evidence for their existence and impact?" this manuscript explores two answers to this question. one answer to this question is a lack of knowledge about what the science of generations tells us, leading to misunderstandings of the evidence about generations, their existence, and their purported impact. thus, the first goal of this article will be to review and debunk ten common myths about generations and generational differences at work and beyond. a second answer to this question is a lack of knowledge regarding, and exposure to, alternative theoretical explanations for understanding (a) the role of age and aging at work and (b) the persistence of generations as a tool for social sensemaking. more specifically, we argue that, owing to a lack of knowledge about alternative explanations and supported by their ubiquity and popular acceptance (e.g., in the popular business and management press; see howe & strauss, 2007; knight, 2014; shaw, 2013) , generations are more often than not the "default" mode of explanation for complex age-related phenomena observed in the workplace and beyond (e.g., because they are familiar and comfortable explanations, which are easy to adopt, and seem legitimate on their face). accordingly, the second goal of this paper is to further advance two alternative models for understanding age and aging at work that do not rely on generational explanations and that can explain their existence and popularity-the social constructionist perspective and the lifespan development perspective. this is an important contribution, because simply pointing out the obvious pitfalls of generations and generational explanations can only go so far toward changing the way that people think about, talk about, study, and enact practices that involve generations. just advising people to drop the idea of generations without providing alternative models would be counterproductive to the goal of enhancing the credibility of organizational science and practice. thus, our hope is that by providing workable alternatives to generations, researchers and practitioners will be encouraged to think more carefully about the role of age and the process of aging when enacting the work that they do. the social constructionist perspective offers that generations and differences between them are constructed through both the ubiquity of generational stereotypes and the socially accepted nature of applying such labels to describe people of different ages (e.g., consider the recent "ok boomer" meme; hirsch, 2020) . the social constructionist perspective helps address and explain the question of why generations are so ubiquitous. complementing this, the lifespan perspective is a well-established alternative to thinking about the process of aging and development that does not require one to think in terms of generations. the lifespan perspective frames human development as a lifelong process which is affected by various influences-not including generations-that predict developmental outcomes. despite its longstanding role in research on aging at work (e.g., baltes, rudolph, & zacher, 2019) , the lifespan perspective has been infrequently considered as an alternative model to generations, perhaps because it has not often been treated in accessible terms. these complementary approaches-the social constructionist and the lifespan development perspective-offer alternative paths forward for studying age and age-related processes at work that do not require a reliance on generational explanations. thus, as described further below, these perspectives by-and-large circumvent the logical and methodological deficiencies of the generations perspective. they also offer actionable theoretical and practical guidance for identifying the complexities involved in understanding age and aging at work. first, we outline and "bust" ten myths about generations and generational differences (see table 1 for a summary). these myths were chosen in particular, because we deemed them to be the most pressing for research and practice in the organizational sciences, broadly defined, in that they reflect commonly highlighted topics, and bear potential risks if not properly addressed. then, we introduce and outline the core tenets of the social constructionist and lifespan development perspectives, giving examples of how their applications can complement each other in supplanting generational explanations in both science and practice. finally, we conclude by drawing lines of integration between these two perspectives, in the hopes that these alternative ways of thinking will inspire myth #1: generational "theory" was meant to be tested -the sociological concept of "generations" has been re-characterized and misappropriated over time. -generational "theory" is not falsifiable, nor was it intended to be. -culture, and the generational groups it forms and is formed by, cannot be disentangled. myth #2: generational explanations are obvious -the mechanisms by which generations emerge are oversimplified in the literature. -explanations for social phenomena are more likely associated with other time-based sources of variation than generations. -sources of time-based variability are often conflated and confused with one another in popular discourse and in research. myth #3: generational labels and associated age ranges are agreed upon -the specific birth year ranges that define each generational grouping vary substantially. -there are notable differences in the ways researchers address cross-cultural variability in generational research. -inconsistencies in labeling have significant conceptual and computational implications for the study and understanding of generations. myth #4: generations are easy to study -the conceptualization of generations as the intersection of age and period make them impossible to study. -there exists no research design that can disentangle age, period, and cohort effects. -artificially grouping ages into "generations" does nothing to solve the confounding of age, period, and cohort effects. myth #5: statistical models can help disentangle generational differences -no statistical model exists that can unambiguously identify generational effects. -as long as age, period, and cohort are defined in time-related terms, they will be inextricably confounded with one another. -this issue has befuddled social scientists for so long that it has been called "a futile quest." myth #6: generations need to be managed at work -research generally does not and cannot support the existence of generational differences, so there is nothing to "manage" in this regard. -generations give a convenient "wrapper" to the complexities of age and aging in dynamic environments. -generations are highly deterministic. -it is more rational and defensible to suggest that individuals' age, life stage, social context, and historical period intersect across the lifespan. myth # 9: studying age at work is the antidote to the problems with studying generations -age and aging research are neither remedies for nor equivalent approaches to the study of generations. -despite its limitations, aging research draws on sound theories, research designs, and statistical modeling approaches. -studying age alone is not a substitute for generational research; rather, it transcends generational approaches and engenders more useful and tenable conclusions for researchers and practitioners alike. myth #10: talking about generations is largely benign -talking about generations is far from benign: it promotes the spread of generationalism, which can be considered "modern ageism." -generationalism is defined by sanctioned ambivalence and socially acceptable prejudice toward people of particular ages. -use of generations to inform differential practices and policies in organizations poses great risk to the age inclusivity, and the legal standing, of workplaces. researchers and practitioners to adopt alternatives to thinking about aging at work in generational terms. myth #1: generational "theory" was meant to be tested the sheer number of empirical studies purporting to test generational "theory" would suggest that such theory was intended for testing. however, this is far from the case. the concept of generations as we know it stems from early functionalist sociological thought experiments, derived from foundational work by mannheim (1927 mannheim ( /1952 and others (e.g., ortega y gasset, 1933; see also kertzer, 1983) . adopting the term in a largely historical, rather than familial or genealogical, sense, these authors offered "generations" as social units that account for broad societal and cultural change. generations were suggested to emerge through "shared consciousness," which developed across individuals (e.g., those at similar life stages) after common exposure to formative events (e.g., political shifts, war, disaster; see ryder, 1965 ). this consciousness, in turn, was theorized to shape unique values, attitudes, and behaviors that characterize a given generation's members, especially to distinguish one generation from its predecessor. these attributes subsequently impact how these individuals interact with and influence society. here, a tautology emerges: culture begets generations and generations beget culture. this is a potentially useful perspective for describing macro-scale interactions between social groups and the social environments in which they live-that is, it is useful as a functionalist sociological mechanism, as the concept of generations was intended. however, this perspective also implies that culture, and the generational groups it forms and is formed by, cannot be disentangled. generational "theory" is not falsifiable, nor was it intended to be. attempts to empirically study generations have extended these ideas into positivist and deterministic practices for which they were not intended. even life course research (e.g., elder, 1994) , which centers on the impact of social change and forces on individuals' lives as opposed to societal change, does not directly "test" for generational differences, per se. instead, it uses generations conceptually in explicating the roles that historical, biological, and social time play in life trajectories. in fact, mannheim's (1927 mannheim's ( /1952 work was partly a critique of the overemphasis on absolutist/biological perspectives in the study of social and historical development, including the objective treatment of time (pilcher, 1994) . this makes it all the more puzzling and problematic that generational "theory" has been applied to discrete quantitative increments (i.e., age and year ranges to define cohorts), and in a fashion that ignores the "non-contemporaneity of the contemporaneous" (i.e., the fact that being alive at the same time, or even being alive and of a similar age at the same time, does not mean history is experienced uniformly; troll, 1970, p. 201) . when considering the roots of "generations," it is apparent that the concept has been re-characterized and misappropriated. one appealing, if overstated, quality of generations is that there are unique characteristics that are (assumed to be) associated with various cohorts. moreover, it is assumed that lines can be drawn between generations to distinguish them from one another on the basis of such characteristics. these characteristics, which are said to be influenced by the various events that supposedly give rise to generations in the first place, "make sense" in a way that give generations an air of face validity. for example, it seems very rational and indeed quite self-evident to many that living through the great depression made the silent generation more conservative and risk-avoidant and that helicopter parents and the rise of social media made millennials narcissistic and cynical. these and other observed social phenomena such as job-hopping and materialism are frequently ascribed to generations. however, looking more deeply into the identification of these critical events, as well as the mechanisms by which generations supposedly emerge, reveals a far more complex, nuanced picture than a generational explanation would have us believe. in order to understand why the events that created generations may, or may not, have been impactful, it is important to understand how the critical events purported to give rise to them are identified. as one example, in their popular book, strauss and howe (1991) offer a taxonomy of generations, developed by tracing historical records in search of what they called "age-determined participation in epochal events…" (p. 32). to strauss and howe, such events were deemed to be so critical that they contributed to the creation of a unique generation. this post hoc historical demographic approach benefits from the passage of time: it is far easier to identify critical events retrospectively, rather than when they are actually occurring. although major events like economic depressions and wars likely qualify as epochal, dozens of other events have been proposed to be critical in the formation of generations, only to fade into historical oblivion within a matter of a few years. for example, in defining supposedly seminal events in the development of the millennial generation, howe and strauss (2000) cite the case of "baby jessica" (n.b. on october 14, 1987, 18-month-old jessica mcclure morales fell into a well in her aunt's backyard in midland, texas. after 56 h, rescue workers eventually freed her from the 8-in. well casing 22 ft below the ground; helling, 2017) . why this event should help form a generation is uncertain, as is whether or not millennials were or have been systematically impacted by her saga and subsequent rescue. rather than being obviously generational, explanations for many social phenomena are more likely to be associated with age or period effects, both of which are other time-based sources of variation that are often conflated with generational cohorts. specifically, there are three sources of time-based variation that need to be accounted for to make claims about generations: age, period, and cohort effects (see glenn, 1976 glenn, , 2005 . age effects refer to variability due to time since birth, in that chronological age is simply an index of "life lived" (e.g., wohlwill, 1970) . period effects refer to variability due to contemporaneous time and refer to the effects of a specific time and place (i.e., the year 2020). finally, cohort effects are those that are typically taken as evidence for generations, referring to the year of one's birth. to make claims about generations, therefore, it is necessary to rule out the effect of age (i.e., developmental influences) and period (i.e., contemporaneous contextual influences). there are numerous examples of how these sources of variability are conflated and confused with one another. consider that popular press accounts of millennials have until recently painted them to be dedicated urban dwellers who favored ridesharing services and eschewed traditional families (e.g., barroso, parker, & bennet, 2020; godfrey, 2016) . however, adults in this age range have more recently been observed moving to the suburbs, buying houses and cars, and having children (e.g., adamczyk, 2019) . this is not a generational effect but rather a phenomenon attributable to the fact that millennials are reaching the normative age where people get married, start families, and purchase houses. this is a product of age and context, not generation or period. the picture becomes even more complex given other contextual factors not necessarily bound to time, for example, when considering that the average age of first conception is higher in urban, compared to rural, areas (bui & miller, 2018) . another example comes from data showing that high school and college students are less likely to hold summer jobs today than 20 years ago (desilver, 2019) . this is not a generational effect, but rather is attributable to contemporaneous economic conditions. as a final example, after 9/11, there was a modest increase in the number of people enlisting in the united states army, which is an example of a period effect (dao, 2011) . however, this change has also been misattributed in various ways to a generational effect (e.g., graff, 2019) . notably, iñ 2019 (i.e., when those born in~2001 turned~18 and were eligible to join the army), there were historically low rates of enlistment (goodkind, 2020) . if this rate had been particularly high, one might conclude evidence for a generational effect, such that people born in 2001 grew up in a time and place that demanded enlistment. however, this is not the case-growing up in a post 9/11 world did not make this cohort more likely than others to join the army. in summary, whereas certain historical events might be easily identifiable as epochal, the extent to which recent events are defined as such might not be known for some time. moreover, this idea assumes that epochal events actually matter for the formation of distinct generations, a key argument in generations theory that is by-and-large untested, and indeed untestable. moreover, consider that "global" events (i.e., those that affect all members of a population regardless of age, not just those born in a particular time and place, like a global pandemic) almost certainly manifest as period, not generational cohort effects (rudolph & zacher, 2020a . generations and the events that are purported to give rise to them are far from obvious and to attribute current individual characteristics to the occurrence of specific events is misguided. furthermore, many of the "obvious" generational effects often attributed to such events are much more likely due to other factors associated with age and/or period. whereas generational labels are well-known and widely recognized, the specific birth year ranges that define each generational grouping and the consistency with which such groupings are applied across time, studies, and location, vary substantially. for example, smola and sutton (2002, p. 364 ) identified a great deal of variation in the start and end years that define different generational groups and the names used to describe various generations, noting "gener-ations…labels and the years those labels represent are often inconsistent" (p. 364). in their meta-analysis, costanza et al. (2012) found similar discrepancies with variations in start and end dates ranging from 3 to 9 years depending on the study, the variables of interest, and the source of the generational year ranges being used. similar conclusions were reached by in their review of generations in the leadership literature. beyond these definitional inconsistencies, there are notable differences in the way researchers address cross-cultural variability in generational research. the ubiquity of the labels and their pervasiveness in the literature has led researchers from countries other than the usa to use labels (e.g., "baby boomers") when doing so does not make sense, as the events that supposedly influenced individuals and gave rise to these generations in the first place clearly differ from country to country. moreover, consider that the term "millennials" is not meaningful in countries that use chinese, islamic, jewish, buddhist, sakka, or kolla varsham calendars (deal, altman, & rogelberg, 2010) and that generations are often labeled based on political or cultural events and epochs. for instance, members of the greek workforce have been categorized into the divided generation, the metapolitefsi generation, and the europeanized generation (papavasileiou, 2017) . in israel, generations are identified by wars and thus have shorter ranges (deal et al., 2010) . the german media has variously labeled younger people as generation c64, generation golf, or generation merkel. in china, generations are pragmatically called the post-50s generation, post-60s generation, and so on, whereas in india, the three main generational groups are labeled conservatives, integrators, and y2k (srinivasan, 2012) . one approach researchers have adopted for dealing with the complexities of cross-cultural variation in generational labeling is to ignore the issue and simply use us-based generational labels and years when studying individuals in other countries. for example, yigit and aksay (2015) looked at turkish gen x and gen y health professionals, roughly using us date ranges for these groups. a second approach has been to use the date ranges associated with us generations but assign country-specific labels to those same periods. utilizing this approach, weiss and zhang (2020) picked birth year ranges and adopted or developed generational labels in three different countries. for example, for the years 1946-1965, they labeled the generations as the "68er generation" in germany, "baby boomer" in the usa, and the "new china generation" in china. a third approach has been to develop country-specific generational groups based on local events that impacted people in that county, a strategy used by to and tam (2014) who identified four distinct post-wwii generations in china. inconsistencies in labeling have significant conceptual and computational implications for the study and understanding of generations and especially so if one wishes to conduct comparative cross-national and/or cross-cultural research. importantly, we would argue that the validity of the generations concept and its utility for understanding individual, group, and organizational phenomena is very limited due to a number of factors, including (a) researchers' inability to agree on the start and end dates for different generations; (b) inconsistencies in the classification and labeling systems that characterize them; (c) disagreement on the specific significant influencing events that supposedly gives rise to them, such as the extent to which the timing of events plays a role, including the length of time that is associated with their influence, and the lag required to observe such influences; and (d) the issue of cross-cultural equivalencies. as such, defining generations represents a moving target, which is a significant liability for science and evidence-based practice. although there have been numerous attempts to study generations and generational differences, it is clear that these phenomena have not been studied very well. indeed, it is not only difficult to study generations as they have been framed in the literature but also impossible. as noted above, research on generations is typically based upon birth year ranges, which is to say that they are derived from information about birth cohorts. a common problem emerges when one tries to study cohort effects in cross-sectional (i.e., single time point) research designs, which are the most commonly applied designs used to make inferences about generations (see costanza et al., 2012) . namely, age, period, and cohort effects are confounded with each other in such designs. this confounding is best understood through an example. let us assume that a hypothetical cross-sectional study is conducted in the year 2020 (i.e., the year constitutes the "period effect" in this case). if we reduce the logic of generations a bit and define a cohort effect in terms of a single birth year (e.g., those born in 1980), then the effect of age (i.e., time since birth; 40 years) is completely confounded with cohort. this is because: in this example, any differences that researchers observe as a function of assumed cohort variability may instead be due to the age of the individuals when they were studied. this pattern would likewise be extrapolated to any age-cohort combinations studied in a single period. the linear dependency among the three effects means that unique effects of age cannot be separated from whatever cohort effect might exist and vice versa. one common attempt to circumvent this confounding is to artificially group members of different cohorts together to form generational groups. however, this practice is likewise fraught with the same issues raised just above. another hypothetical cross-sectional study helps to illustrate why: in this study, let us assume that we want to define two arbitrary groupings of birth cohorts, representing people born between 1981 and 1990 ("generation a") and those 1991-2000 ("generation b"), to disentangle age and cohort effects from one another. the variability due to birth cohort in each generation is 10 years; however, as in our previous example, the age range within cohorts is likewise 10 years. thus, this approach does little to solve the dependency other than shifting the scaling of age. as the rank order of cohort versus age has not changed (relatively older people are in "generation a" and relatively younger people are in "generation b"), there is still a correlation between age and generational groups in this study. moreover, this approach has other limitations, including the loss of statistical power to detect age effects (see rudolph, 2015) and a confusing logic of cohort versus age effect interpretations (e.g., the oldest members of "generation a" are closer in age to the youngest members of "generation b" than to the average age of their own generational group). from a research design standpoint, this issue of confounding represents an unresolvable problem, which has long been known and lamented in the literature (e.g., glenn, 1976 glenn, , 2005 . other research designs are unfortunately no better geared than cross-sectional designs to address this issue, or they do not address variability in cohort effects at all. for example, in typical longitudinal designs, cohort effects are held constant (i.e., from the first time point, people's birth year does not vary) and period is allowed to vary (i.e., as data are collected from the same people across multiple time points). however, in such designs, period effects are conflated with age (i.e., as people "get older" across time). expanded longitudinal approaches, such as cohort sequential designs (e.g., sampling 20-year-olds at each time point, t 1 − t k , adding successive cohorts of 20-year-olds at each time point) may be able to separate age/aging from period and cohort effects, depending on how "cohort" is defined. however, such studies require immense resources and time (e.g., 20+ years or more of data collection, including long-term data management and subject retention efforts; see baltes & mayer, 2001) . as such, and perhaps not surprisingly, we are unaware of any applications of such designs to the study of generations at work. an alternative that has been employed by some researchers (e.g., twenge, konrath, foster, campbell, & bushman, 2008) is a cross-temporal approach, often employing time-lagged panels or cross-temporal meta-analyses (discussed further below). cross-temporal approaches use data collections from members of different cohort groups, collected during different periods, holding age constant (e.g., data from panels of 25year-olds and 50-year-olds collected in 2000, 2010, and 2020 or research done on college students every year from 1990 to the present). the logic of cross-temporal methods is to compare groups of similarly aged individuals (i.e., to "control" for age by holding its value constant) across time and then argue that cohort effects are more likely the cause of any observed differences than period effects. among other issues, crosstemporal approaches have been criticized for their reliance on ecological correlations (i.e., correlations among variables that represent group means) and design assumptions (see trzesniewski & donnellan, 2010; trzesniewski, donnellan, & robins, 2008) raising significant concerns about them as a way to study generations. specifically, ecological correlations can misrepresent relationships when contrasted with correlations among individual observations (see robinson, 1950) . overall, the methodological and design challenges associated with studying generations are substantial and the conceptualization of generations as the intersection of age and period makes them impossible to study. thus, studying generations is only "easy" to the extent that one is willing to ignore the issues raised here. given these concerns, we echo the recommendations of rudolph and zacher (2017) , who suggest that "…both research and practice would benefit from a moratorium on time-based operationalizations of generations as units for understanding complex dynamics in organizational behavior" (p. 125). given the design challenges noted above, it is perhaps not surprising that researchers have tried a variety of statistical techniques to resolve the age, period, and cohort confounding problem. unfortunately, the great majority of generational studies to date have employed the least useful approach to doing so, pairing cross-sectional designs with comparisons of generational cohort means (e.g., typically via linear models, such as t tests or other variants of anova-type models). as noted, cross-sectional approaches control for period effects but confound cohort and age effects with one another and this confounding cannot be resolved statistically through any means. to be clear, this is not a function of a lack of innovation regarding statistical modeling techniques. on the contrary, as long as age, period, and cohort are defined in timerelated terms, they will be inextricably confounded with one another in cross-sectional research designs. with respect to cross-temporal approaches, some researchers have implemented a specific technique referred to as "cross-temporal meta-analysis" (ctma). ctma shares certain features with traditional meta-analysis (e.g., studies assumed to be representative of a population of all possible studies on a given phenomenon are taken from the literature and synthesized). in a typical ctma, age is more or less held constant by narrowing the sampling frame of studies included (e.g., by only considering studies of college age students). by holding age constant and looking at the effects of time on outcomes (i.e., by considering the relationship between year of publication and mean levels of a given phenomenon derived from contributing studies), ctma models change over time in a phenomenon. however, although age is to some extent held constant, recall that cross-temporal methods inherently confound period and cohort effects with one another. thus, any identified cohort effect cannot be unambiguously separated from period effects in ctma. although research employing ctma has argued that generations are more likely than period effects to explain observed differences, such work also recognizes that period effects are equally likely explanations for any results derived therefrom (e.g., twenge & campbell, 2010) . furthermore, a recent paper by rudolph, costanza, wright, and zacher (2019) used monte carlo simulations to test the underlying assumptions of ctma, finding that it may misestimate cohort effects by a factor of three to eight times, raising questions about both the source and magnitude of any differences identified. a final analytic technique that has been occasionally employed to disentangle age, period, and cohort effects is cross-classified hierarchical linear modeling (cchlm; yang & land, 2006 . applying cchlm to generational research, age is treated as a fixed effect and period and cohort are allowed to vary as random effects. importantly, however, decisions about how such effects should be specified are somewhat arbitrary, because it is also possible that cohort and period could be fixed and age random in the population, resulting in different outcomes and conclusions from such models that are largely dependent on analytic decisions rather than reflecting "true" population effects. thus, without generally unknowable insights into "what" to hold constant in estimating such models, cchlm results in ambiguous parameter estimates for age, period, and cohort effects. to this end, a series of simulation studies by bell and colleagues (bell & jones, 2014 ; see also bell & jones, 2013 , for further commentaries) has shown that the yang and land methodology for separating age, period, and cohort effects simply does not "work." even ignoring this issue, cchlm does little to solve the problem of age, period, and cohort confounding, because the three variables are still linearly dependent upon each other and hence computationally inseparable. something (typically age) has to be held constant in such models to separate these variables from one another, and even then, ambiguities in how to interpret confounded effects of period and cohort still abound. in short, none of the statistical techniques that have been used to study generations can fully separate age, period, and cohort effects (see costanza, darrow, yost, & severt, 2017 , for a full discussion) and cannot solve the conceptual or design problems noted earlier. this known issue has befuddled social scientists for quite some time. for example, more than 40 years ago glenn (1976) referred to this problem as "a futile quest." given the proliferation of research and popular press articles identifying generational differences, it is not surprising that practitioners and academics have suggested that people in different generations need to be managed differently at work (e.g., baldonado, 2013; lindquist, 2008) . there are two main problems with these recommendations. first, as has been noted, research generally does not and cannot support the existence of generational differences. conceptual, theoretical, methodological, and statistical issues abound in this literature, and absent clear, convincing, and valid evidence for the existence of generational differences, there is no justification for managing individuals based on their supposed generational membership (nasem, 2020a (nasem, , 2020b rudolph & zacher, 2020c) . eschewing the notion of generations does not mean that one must ignore that individuals change over the course of their lifespan or that their needs at different stages in their careers will vary. however, it is important to note that there is not a credible body of evidence to suggest that such changes are generational or that they should be managed as "generational differences" at work. indeed, as already noted, much of what lay people observe as "generational" at work is likely more accurately attributed to either age or career stage effects masquerading as generational differences. there is a broad and well-supported literature on best practices for hr, leadership, and management (e.g., kulik, 2004) and customizing policies and practices based on those recommendations rather than generational stereotypes makes much more sense. furthermore, there is a burgeoning literature on the positive influence that agetailored policies (e.g., age-inclusive human resource practices that foster employees' knowledge, skills, and abilities, motivation, effort, and opportunities to contribute, irrespective of age) for building positive climates for aging at work and supporting worker productivity and well-being (see böhm, kunze, & bruch, 2014; rudolph & zacher, 2020d) . for example, research suggests that workers of all ages benefit from flexible work policies that allow for autonomy in choosing the time and place where work is conducted (see rudolph & baltes, 2017) . second, as alluded to earlier, management strategies that are based on generations have the potential to raise legal risks for organizations. for example, in the usa, provisions of the civil rights act of 1964, the age discrimination in employment act of 1967, and the americans with disabilities act of 1991 disallow the mistreatment of individuals from certain groups based on a variety of characteristics. although generational membership is not directly covered by such legislation, under the adea, age is a protected class for workers aged 40+. given the conflation of generational effects with age, life, and career stage, employment-related decisions tied to generations could be interpreted as prima facie evidence of age-related discrimination (e.g., swinick, 2019) . indeed, organizations that market themselves to and build personnel practices around generations and generational differences have been implicated in age discrimination lawsuits (e.g., rabin vs. pricewaterhousecoopers, 2017). combined with the absence of valid studies supporting generationally based differences, organizations open themselves up to an unnecessary liability if they manage individuals based on generational membership (costanza & finkelstein, 2015 ; for a related discussion of various policy implications of managing generations, see rudolph, rauvola, costanza, & zacher, 2020) . recently, costanza, finkelstein, imose, and ravid (2020) reviewed the applied psychology, hr, and management literatures looking for studies about how organizations should manage generations in the workplace. they identified a range of inappropriate inferences and unsupported practical recommendations and systematically refuted them based on legal, conceptual, practical, and theoretical grounds. we echo their conclusion here, regarding advice from managing based on generational membership (p. 27): "instead of customizing hr policies and practices based on such [generational] differences, organizations could use information about their overall workforce and its characteristics to train recruiters, develop and refine policies, and offer customizable benefits packages that appeal to a broad range of employees, regardless of generation." that said, we do not think that the idea of generations should be ignored altogether in the development of management strategies. instead, the focus should be shifted away from managing assumed differences between members of different generations and toward managing perceptions of generations and generational differences. considering evidence that people's beliefs and expectations about age and generations feed into the establishment of stereotypes that interfere with work-relevant processes (e.g., king et al., 2019; perry, hanvongse, & casoinic, 2013; raymer, reed, spiegel, & purvanova, 2017; van rossem, 2019) , this is a particularly important consideration and is, in and of itself, a topic worthy of further study. while it may feel "new" to blame members of younger generations for changes in the work environment, this is a form of uniqueness bias: we think our beliefs and experiences are new, when in reality similar complaints have been levied against relatively younger and older people for millennia. indeed, generationalized beliefs about the inflexibility and "out of touch" nature of older generations, or the laziness, self-centeredness, and entitlement of younger generations, have repeated with remarkable consistency across recorded history (rauvola, rudolph, & zacher, 2019) . one of the more obvious examples is in referring to generations with self-referent terminology: new york magazine wrote about youth in the so-called "me" decade (wolfe, 1976) over 30 years prior to twenge's (2006) work on "generation me," time magazine's (stein, 2013 ) publication on the "me me me" generation, and even the british army's recent use of the phrase "me me me millennials…your army needs you and your self belief" in recruitment ads (nicholls, 2019) . lamentations about young people "killing things" are far from radical as well. modern claims are made about youth ending an absurd number of facets of life, ranging from institutions such as marriage and patriotism to household products like napkins, bar soap, and "light" yogurt (bryan, 2017) . moreover, similar concerns have been voiced throughout the years regarding the rise and fall of consumer preferences, including concerns about young people upending and revolutionizing romantic relationships and transportation (e.g., thompson, 2016) , or being corrupted by new forms of popular media like the radio in the 1930s (schwartz, 2015) . a more realistic explanation exists for both shifts in consumer preferences as well as changes and disruptions in the nature of work: the contemporaneous environment, and innovations and unexpected changes therein. to take a recent example, the global covid-19 pandemic has tremendously impacted and transformed how and where work is conducted (kniffin et al., 2020; . while "non-essential" workers are conducting more work virtually and with more flexible hours, other workers deemed "essential" are working in environments with new health and safety protocols and often with different demands and resources in place (e.g., with respect to physical equipment, coworker and customer contact). even more workers have been furloughed or laid off altogether, with the need to turn to alternative forms of work to maintain income or, when feasible, resorting to early retirement (see bui, button, & picciotti, 2020; kanfer, lyndgaard, & tatel, 2020; van dalen & henkens, 2020) . these changes have led to a dramatic pivot for many organization, managers, and individual workers, far surpassing the speed and degree to which more gradual, "generational" workplace changes have supposedly occurred. not only this, but such changes have had outcomes for workers and society that contradict what generational hypotheses would predict. for example, generational stereotypes suggest that relatively older workers would struggle with technological changes at work while relatively younger workers would thrive. however, the move to work-from-home arrangements has resulted in positive benefits for some, including helpful and flexible accommodations, or health and safety protections, as well as new challenges for others, such as the need to balance childcare or eldercare with work while at home, while still others face newfound isolation and lack of in-person social support coupled with great uncertainty (alon, doepke, olmstead-rumsey, & tertilt, 2020; douglas, katikireddi, taulbut, mckee, & mccartney, 2020) . these changes create a diverse set of advantages and disadvantages for individuals of all ages. rather than blaming those of younger generations for disrupting work and life more generally, societal trends and events are a more appropriate, fitting, and ultimately addressable explanation (i.e., through non-ageist interventions and policies). myth #8: generations explain the changing nature of work (and society) generations are an obvious and convenient explanation for the changing nature of work and societies. however, as discussed previously, convenience and breadth in applying generational explanations does not translate into validity. because they can easily and generally be applied to explain age-related differences, generations give a convenient "wrapper" to the complexities of age and aging in dynamic environments (i.e., both within and outside of organizations). however, this wrapper restricts and obscures the complexities inherent to both individuals and the environments in which they operate. generations are highly deterministic, suggesting that individuals "coming of age" at a particular time (i.e., members of the same cohort) all experience aging and development uniformly (i.e., cohort determinism; walker, 1993) . with so many other demonstrable age-related and person-specific factors (e.g., social identities, personality, socioeconomic status) that have bearing on individuals' attitudes, values, and behaviors, as well as how these interact with contextual and environmental influences, the prospect of generations overriding all such explanations is implausible. assuming otherwise wipes away a tremendous amount of potentially useful detail and heterogeneity. moreover, this perspective stipulates that events in a given time period impact younger people and not older people, such that historical context only influences individuals up to a certain (early) point in their development. this aligns with the idea that identity is "crystallized" or "ratified" at a certain age and development or change is more or less halted thereafter (ryder, 1965) . however, ample evidence suggests that this is far from the case, with age-graded dynamics in such areas as personality emerging across the breadth of the lifespan (e.g., bianchi, 2014; donnellan, hill, & roberts, 2015; staudinger & kunzmann, 2005) and alongside external forces (e.g., economic recessions). our ability to dismiss crystallization claims is not merely empirical: although current methods and analyses used cannot fully disentangle age from cohort, lifespan development theory promotes the ideas of lifelong development, multiple intervening life influences, and individuals' agency in shaping their identity and context (e.g., baltes, 1987) . accordingly, it is more rational and defensible to suggest that individuals' age, life stage, social context, and historical period intersect across the lifespan. these intersections, in turn, produce predictable as well as unique effects that translate into different attitudes, values, and behaviors, but not as a passive and predetermined function of an individual's generation. myth # 9: studying age at work is the antidote to the problems with studying generations age and aging research are neither remedies for nor equivalent approaches to the study of generations. first, there are a broad range of phenomena encompassed in both research on "age at work" and "aging at work" (e.g., see discussion of "successful aging" research components in zacher, 2015a). these two areas are related but distinct, spanning the study of age as a discrete or sample-relative sociodemographic (i.e., age as a descriptive device, especially between person), age as a compositional unit property (e.g., age diversity in a team, organization), and age as a proxy for continuous processes and development over time (i.e., age representing the passage of time, especially within-person in longitudinal research). each of these forms has a multitude of potential contributions to our understanding of the workplace, and these contributions should not (and cannot) be reduced to generational cohortbased generalizations. second, and as noted earlier, although aging research is confounded by cohort effects, it draws on sound theories, research designs, and statistical modeling approaches (bohlmann, rudolph & zacher, 2018) . the study of generations at work, however, relies upon theories unintended for formal testing and flawed data collection methods and analyses (costanza et al., 2017) . moreover, whereas both age and aging research treat time continuously, generational research groups people into cohort categories. this results in a loss of important nuance and information about individuals, with results prone to either over-or underestimated age effects. the practice of cohort grouping also creates a "levels" issue in generational research to which age and aging research are not subject: studying aging focuses on the individual level of analysis, whereas (sociological) generational research "groups" individuals into aggregates and then incorrectly draws inferences about individual outcomes. this mismatch of levels can produce ecological or atomistic fallacies (i.e., assumptions that group-level phenomena apply to the individual level and vice versa), depending on whether group-or individual-level data are used to draw conclusions (rudolph & zacher, 2017) . thus, although age and aging research present robust opportunities for understanding how to support the agediverse workforce, generational research provides incomplete conclusions about, and unclear implications for, understanding trends in the workplace. studying age alone is not a substitute for generational research; rather, it transcends generational approaches and engenders more useful and tenable conclusions for researchers and practitioners alike. talking about generations is far from benign: it promotes the spread of generationalism, which can be considered "modern ageism." just as "modern racism" is characterized by more subtle and implicit, yet no less discriminatory or troubling, racist beliefs about black, indigenous, and people of color (bipoc; e.g., mcconahay, hardee, & batts, 1981) , generationalism is defined by sanctioned ambivalence and socially acceptable prejudice toward people of particular ages. these beliefs are normalized and pervasive, reiterated across various forms of popular media and culture to the point that they seem innocuous. however, generationalism leads to decisions at a variety of levels (e.g., individual, organizational, institutional) that are harmful, divisive, and potentially illegal. media outlets play a large role in societal tolerance and acceptance of generationalism (rauvola et al., 2019) . new "generations" are frequently proposed in light of current events, and age stereotyping becomes further trivialized with each iteration. adding to this, an abundance of generational labels "stick" while others do not-"igen," "generation wii," "generation z," and "zoomers" all vie to define the "post-millennial" generation (raphelson, 2014) , and "generation alpha" (a name inspired in part by naming conventions during the 2005 hurricane season; mccrindle & wolfinger, 2009) now faces competition from "gen c" to define the next generation. "gen c" (or "generation corona;" see rudolph & zacher, 2020a has gained traction in the media alongside the recent covid-19 pandemic, with some suggesting that "coronavirus has the potential to create a generation of socially awkward, insecure, unemployed young people" (patel, 2020) . these labels differ markedly by country as well, as noted earlier, adding to the trivialization and confusion. more and more, these labels are also used to add levity, and/ or to avoid blatant ageism, to deep-seated sociopolitical divides and conflicts portrayed in the media. take, for example, the rise of "ok boomer" alongside resentment toward conservatism (romano, 2019) , or the labeling of the "karen generation" to encapsulate white privilege and entitlement, especially among middle-to upper-class suburban women (strapagiel, 2019) . although often treated as harmless banter, this lexicon filters into influential research and policy-based organizations (e.g., "gen c" in the lancet, 2020), legitimizing the use of generational labels and associated age stereotypes in discourse and decision-making. as suggested above, in many countries, age is a protected class and the use of generations to inform differential practices and policies in organizations (e.g., hiring, development and training, benefits) poses great risk to the age inclusivity, and the legal standing, of workplaces (see also costanza et al., 2020) . whether a generational label is new and catchy or accepted and seemingly mundane, it is built on the back of modern ageism, and generationalism-just like other "isms"-is far from benign. with the preceding ten myths serving as a backdrop, we next introduce two models-the social constructionist perspective and the lifespan development perspective-that serve as alternative and complementary ways of thinking about, and understanding thinking about, generations and generational differences. indeed, we propose that these are complementary models. specifically, whereas the social constructionist perspective serves as a way of understanding why people tend to think about age and aging in generational terms, the lifespan development perspective serves as an alternative to thinking about age and aging in generational terms. considering the ten myths reviewed above, it is clear that the evidence for the existence of generations and generational differences is lacking. moreover, when applying a critical lens, what little evidence does exist does not hold up to theoretical and empirical scrutiny. what, then, are we left to do with the idea of generations? that is to say, how can we rationalize the continued emphasis that is placed on generations in research and practice despite the lack of a solid evidence base upon which these ideas rest? on the surface, this may seem to be a conceptually, rather than a practically, relevant question. however, there is a booming industry of advisors, gurus, and entire management consulting firms based around the idea of generations (e.g., hughes, 2020) . in whatever form it takes, generationally based practice is built upon the rather shaky foundations of this science, putting organizations and their constituents at risk-not only of wasted money, resources, and time, but of propagating misplaced ideas based on a weak, arguably non-existent evidence base . as the organizational sciences move toward the ideals of evidence-based practice, generations and assumed differences between them are quickly becoming yet another example of a discredited management fad (see abrahamson, 1991 abrahamson, , 1996 røvik, 2011) . borrowed from sociological theoretical traditions, the social constructionist perspective focuses on understanding the nature of various shared assumptions that people hold about reality, through understanding the ways in which meanings develop in coordination with others, and how such meanings are attached to various lived experiences, social structures, and entities (see leeds-hurwitz, 2009 )-including generations. comprehensive treatments of the core ideas and tenets of the sociological notion of social constructionism can be found in burr (2003) and lock and strong (2010) . the social constructionist perspective on generations, which is based upon the idea that generations exist as social constructions, has been advanced as a means of understanding why people often think about age and aging in discrete generational, rather than continuous, terms (e.g., rudolph & zacher, 2015 ; see also lyons & kuron, 2014; lyons & schweitzer, 2017; weiss & perry, 2020) . the social constructionist perspective has utility as a model for understanding various processes that give rise to generations and for understanding the ubiquity and persistence of generations and generationally based explanations for human behavior. in an early conceptualization of this perspective, zacher and rudolph (2015) proposed that two processes reinforce each other to support the social construction of generations. specifically, (1) the ubiquity and knowledge of generational stereotypes drive (2) the process of generational stereotyping, which is by-and-large socially sanctioned. these two processes fuel the social construction of generational differences, which have bearing on a variety of work-related processes, not least of which is the development of "generationalized" expectations for work specific attitudes, values, and behaviors. such generationalized expectations set the stage for various forms of intergenerational conflicts and discrimination (i.e., generationalism; rauvola et al., 2019) at work. the social constructionist perspective on generations is grounded in three core principles: (1) generations are social constructs that are "willed into being"; (2) as social constructs, generations exist because they serve a sensemaking function; and (3) the existence and persistence of generations can be explained by various processes of social construction. the social constructionist perspective is gaining traction as a viable alternative to rather rigid, deterministic approaches of conceptualizing and studying generations, even among otherwise staunch proponents of these ideas. for example, campbell et al. (2017) offer that "…generations might be best conceptualized as fuzzy social constructs" (p. 130) and lyons et al. (2015) echo similar sentiments about the role and function of generations. to further clarify this perspective, we next expand upon these three core ideas that are advanced by the social constructionist perspective, providing more details and examples of each, and offering supporting evidence from research and theory. first, the social constructionist perspective advances the idea that generations and generational differences do not exist objectively (see berger & luckman, 1966 , for a classic treatment of this idea of the "socially constructed" nature of reality). rather, generations are "willed into being" as a way of giving meaning to the complex, multicausal, multidirectional, and multidimensional process of human development that we observe on a day-to-day basis, especially against the backdrop of rapidly changing societies. adopting a social constructionist framework motivates an understanding of the various ways in which groups of individuals actively participate in the construction of social reality, including how socially constructed phenomena develop and become known to others, and how they are institutionalized with various norms and traditions. to say that generations are "social constructs," or that generations reflect a process of "social construction," implies that our understanding of their meanings (e.g., the "notion" of generations; the specific connotations of implying one generation versus another) exists as an artifact of a shared understanding of "what" generations "are," and that this is accepted and agreed upon by members of a society. moreover, and to the second core principle, the social constructionist perspective suggests that generations serve as a powerful, albeit flawed, tool for social sensemaking. generations provide a heuristic framework that greatly simplify people's ability to quickly and efficiently make judgments in social situations, at the risk of doing so inaccurately. in other words, generations offer an easy, yet overgeneralized, way to give meaning to observations and perceptions of complex age-related differences that we witness via social interactions. this idea is borrowed from social psychological perspectives on the development, formation, and utility of stereotypes. when faced with uncertainty, humans have a natural tendency to seek out explanations of behavior (i.e., their own, but also others'; see kramer, 1999) . this process reflects an inherent need to makes sense of one's world through a process of sensemaking. an efficient, albeit often flawed, strategy to facilitate sensemaking is the construction and adoption of stereotypes (hogg, 2000) . stereotypes are understood in terms of cognitive-attitudinal structures that represent overgeneralizations of others-in the form of broadly applied beliefs about attitudes, ways of thinking, behavioral tendencies, values, beliefs, et cetera (hilton & von hippel, 1996) . applying these ideas, the adoption of generations, and the accompanying prescriptions that clearly lay out how members of such generations ought to think and behave, helps people to make sense of why relatively older versus younger people "are the way that they are." additionally, generational stereotypes can be enacted as an external sensemaking tool, as described, but also for internal sensemaking (i.e., making sense of one's own behavior). indeed, there is emerging evidence that people internalize various generational stereotypes and that they enact them in accordance with behavioral expectations (i.e., a so-called pygmalion effect, see eschleman, king, mast, ornellas, & hunter, 2016) . third, the social constructionist perspective offers that generations are constructed and supported through different mechanisms. the construction of generations can take various forms, for example, in media accounts of "new" generations that form as a result of major events (e.g., pandemics; rudolph & zacher, 2020a , political epochs (e.g., "generation merkel" mailliet & saltz, 2017 ; "generation obama," thompson, 2012) , economic instability (e.g., "generation recession," sharf, 2014) , and even rather benign phenomena, such as growing up in a particular time and place (e.g., "generation golf," illies, 2003) . a major source of generational construction can be traced to various "think tank"-type groups that purport to study generations. from time to time, such groups proclaim the end of one generation and the emergence of new generational groups (e.g., dimock, 2019) . these organizations legitimize the idea of generations in that they are often otherwise trusted and respected sources of information and their messaging conveys an associated air of scientific rigor. relatedly, authors of popular press books likewise tout the emergence of new generations. for example, twenge has identified "igen" (twenge, 2017) as the group that follows "generation me" (twenge, 2006) , although neither label has found widespread acceptance outside of these two texts. importantly, all generational labels, including these, exist only in a descriptive sense, and it is not always clear if the emergence of the generation precedes their label, or vice versa. for example, consider that twenge has suggested that the term "igen" was inspired by taking a drive through silicon valley, during which she concluded that "…igen would be a great name for a generation…" (twenge, as quoted in horovitz, 2012) , a coining mechanism far from mannheim's original conceptualization of what constitutes a generation. the contemporary practice of naming new generations has its own fascinating history (see raphelson, 2014) . indeed, the social constructionist perspective recognizes that the idea of generations is not a contemporary phenomenon; there is a remarkable historical periodicity or "cycle" to their formation and to the narratives that emerge to describe members of older versus younger generations. as discussed earlier, members of older generations have tended to pan members of younger generations for being brash, egocentric, and lazy throughout history, whereas members of younger generations disparage members of older generations for being out of touch, rigid, and resource-draining (e.g., protzko & schooler, 2019; rauvola et al., 2019) . likewise, the social constructionist perspective underlines that generations are supported through both the ubiquity of generational stereotypes and the socially accepted nature of applying such labels to describe people of different ages. in summary, the social constructionist perspective offers a number of explanations for the continued existence of generations, especially in light of evidence which speaks to the contrary. specifically, by recognizing that generations exist as social constructions, this perspective helps to clarify the continued emphasis that is placed on generations in research and practice, despite the lack of evidence that support their objective existence. moreover, the social constructionist perspective offers a framework for guiding research into various processes that give rise to the construction of generations and for understanding the ubiquity and persistence of generations and generationally based explanations for human behavior. next, we shift our attention to a complementary framework-the lifespan perspective-which likewise supports alternative theorizing about the role of age and the process of aging at work that does not require the adoption of generations and generational thinking. then, we will focus on drawing lines of integration between these two perspectives. the lifespan development perspective is a meta-theoretical framework with a rich history of being applied for understanding age-related differences and changes in the work context (baltes et al., 2019; baltes & dickson, 2001; rudolph, 2016) . more recently, the lifespan perspective has also been advanced as an alternative to generational explanations for work-related experiences and behaviors (see rudolph & zacher, 2017; zacher, 2015b) . contrary to generational thinking and traditional life stage models of human development (e.g., erikson, 1950; levinson, darrow, klein, levinson, & mckee, 1978) , the lifespan perspective focuses on continuous developmental trajectories in multiple domains (baltes, lindenberger, & staudinger, 1998) . for instance, over time, an individual's abilities may increase (i.e., "gains," such as accumulated job knowledge), remain stable, or decrease (i.e., "losses," such as reduced psychomotor abilities). baltes (1987) outlined seven organizing tenets to guide thinking about individual development (ontogenesis) from a lifespan perspective. specifically, human development is (1) a lifelong process that involves (2) stability or multidirectional changes, as well as (3) both gains and losses in experience and functioning. moreover, development is (4) modifiable at any point in life (i.e., plasticity); (5) socially, culturally, and historically embedded (i.e., contextualism); and (6) determined by normative age-and history-graded influences and nonnormative influences. regarding the final tenet, normative age-graded influences include person and contextual determinants that most people encounter as they age (e.g., decline in physical strength, retirement), normative history-graded influences include person and contextual determinants that most people living during a certain historical period and place experience (e.g., malnutrition, recessions), and non-normative influences include determinants that are idiosyncratic and less "standard" to the aging process (e.g., accidents, natural disasters). finally, baltes (1987) argued that (7) understanding lifespan development requires a multidisciplinary (i.e., one that goes beyond psychological science) approach. in summary, the lifespan perspective recognizes that individuals' development is continuous, malleable, and jointly influenced by both normative and non-normative internal (i.e., those that are genetically determined; specific decisions and behaviors that one engages in) and external factors (i.e., the sociocultural and historical context). a generational researcher may ask research questions like (a) "how does generational membership influence employee attitudes, values, and behaviors?" or (b) "what differences exist between members of different generations in terms of their work attitudes, values, or behaviors?" then, likely based on the results of a cross-sectional research design that collects information on age or birth year and work-related outcomes, a generational researcher would likely categorize employees into two or more generational groups and take mean-level differences in outcomes between these groups as evidence for the existence of generations and differences between them. contrary to this, a lifespan researcher would be more apt to ask research questions like (a) "are there age-related differences or changes in work attitudes, values, and behaviors?" or (b) "what factors serve to differentially modify employees' continuous developmental trajectories?" they would seek out cross-sectional or longitudinal evidence for age-related differences or changes in attitudes, values, and behaviors, as well as evidence for multiple, co-occurring factors, including person characteristics (e.g., abilities, personality), idiosyncratic factors (e.g., job loss, health problems), and contextual factors (e.g., economic factors, organizational climate) that may predict these differences or changes. the lifespan perspective generally does not operate with the generations concept, but does distinguish between chronological age, birth cohort, and contemporaneous period effects. as described earlier, generational groups are inevitably linked to group members' chronological ages, as they are based on a range of adjacent birth years and typically examined at one point in time. accordingly, tests of generational differences involve comparisons between two or more age groups (e.g., younger vs. older employees). in contrast to tenets #1, #2, and #3 of the lifespan perspective, generational thinking is static in that differences between generations are assumed to be stable over time. the possibility that members of younger generations may change with increasing age, or whether members of older generations have always shown certain attitudes, values, and behavior, are rarely investigated. moreover, generational thinking typically adopts a simplistic view of differences between generational groups (e.g., "generation a" has a lower work ethic than "generation b") as compared to the more nuanced lifespan perspective with its focus on stability or multidirectional changes, as well as the joint occurrence of both gains and losses across time. with regard to the lifespan perspective's tenet #4 (i.e., plasticity), generational researchers tend to treat generational groups as immutable (i.e., as they are a function of one's birth year) and their influences as deterministic (i.e., all members of a certain generation are expected to think and act in a certain way; so-called cohort determinism). in contrast, the lifespan perspective recognizes that there is plasticity, or within-person modifiability, in individual development at any age. changes to the developmental trajectory for a given outcome can be caused by person factors (e.g., knowledge gained by longterm practice), contextual factors (e.g., organizational change), or both. for instance, lifespan researchers assume that humans enact agency over their environment and the course of their development. development is not only a product of the context in which it takes place (e.g., culture, historical period) but also a product of individuals' decisions and actions. this notion underlies the principle of developmental contextualism (lerner & busch-rossnagel, 1981) , embodied within the idea that humans are both the products and the producers of their own developmental course. research on generations and intergenerational exchanges originated and still is considered an important topic in the field of sociology (mayer, 2009) , which emphasizes the role of the social, institutional, cultural, and historical contexts for human development (settersten, 2017; tomlinson, baird, berg, & cooper, 2018) . in contrast, the lifespan perspective, which originated in the field of psychology, places a stronger focus on individual differences and within-person variability. nevertheless, the lifespan perspective's tenet #5 (i.e., contextualism) suggests that individual development is not only influenced by biological factors but also embedded within the broader sociocultural and historical context. this context includes the historical period, economic conditions, as well as education and medical systems in which development unfolds. even critics have acknowledged that these external factors are rather well-integrated within the lifespan perspective (dannefer, 1984) . that said, most empirical lifespan research has not distinguished between birth cohort and contemporaneous period effects. for example, studies in the lifespan tradition have suggested that there are birth cohort effects on cognitive abilities and personality characteristics (elder & liker, 1982; gerstorf, ram, hoppmann, willis, & schaie, 2011; nesselroade & baltes, 1974; schaie, 2013) . possible explanations for these effects may be improvements in education, health and medical care, and the increasing complexity of work and home environments (baltes, 1987 ). an important difference to generational research is that these analyses focus on individual development and outcomes and not on group-based differences. in contrast to research in the field of sociology, the lifespan perspective generally does not make use of the generations concept and associated generational labels. instead, in addition to people's age, lifespan research sometimes focuses on birth year cohorts (baltes, 1968) . however, the lifespan perspective does not assume that all individuals born in the same birth year automatically share certain life experiences or have similar perceptions of historical events (kosloski, 1986) . according to baltes, cornelius, and nesselroade (1979) , researchers interested in basic developmental processes (e.g., child developmental psychologists) that were established during humans' genetic and cultural evolution may treat potential cohort effects as error or as transitory, historical irregularities. in contrast, other researchers (e.g., social psychologists, sociologists) may focus less on developmental regularities and treat cohort effects as systematic differences in the levels of an outcome, with or without explicitly proposing a substantive theoretical mechanism or process variable that explains these cohort differences (e.g., poverty, access to high-quality education). empirical research on generations is typically vague with regard to concrete theoretical mechanisms of assumed generational differences (i.e., beyond the notion of "shared life events and experiences," such as the vietnam war, 9/11, or the covid-19 pandemic) and typically does not operationalize and test these mechanisms. in proposing the general developmental model, schaie (1986) suggested decoupling the "empty variables" of birth cohort and time period from chronological age and reconceptualizing them as more meaningful variables. specifically, he re-defined cohort as "the total population of individuals entering the specified environment at the same point in time" and period as "historical event time," thereby uncoupling period effects from calendar time by identifying the timing and duration of the greatest influence of important historical events (schaie & hertzog, 1985, p. 92) . thus, the time of entry for a cohort does not have to be birth year and can include biocultural time markers (e.g., puberty, parenthood) or societal markers (e.g., workforce entry, retirement; schaie, 1986) . similarly, the more recent motivational theory of lifespan development has discussed cohort-defining events as age-graded opportunity structures (heckhausen, wrosch, & schulz, 2010) . thus, from a lifespan perspective, cohorts are re-defined as an interindividual difference variable, whereas period is re-defined as an intraindividual change variable (schaie, 1986) . tenet #6 of the lifespan perspective suggests that individuals have to process, react to, and act upon normative age-graded, normative history-graded, and non-normative influences that co-determine developmental outcomes (baltes, 1987) . the interplay of these three influences leads to stability and change, as well as multidimensionality and multidirectionality in individual development (baltes, 1987) . importantly, the use of the term "normative" is understood in a statistical-descriptive sense here, not in a value-based prescriptive sense; it is assumed that there are individual differences (e.g., due to gender, socioeconomic status) in the experience and effects of these influences (baltes & nesselroade, 1984) . moreover, the relative importance of these three influences can be assumed to change across the lifespan (baltes, reese, & lipsitt, 1980) . specifically, normative age-graded influences are assumed to be more important in childhood and later adulthood than in adolescence and early adulthood (i.e., due to biological and evolutionary reasons). in contrast, normative history-graded determinants are assumed to be more important in adolescence and early adulthood than in childhood and old age (i.e., when biological and evolutionary factors are less important). finally, non-normative influences are assumed to increase linearly in importance across the lifespan (baltes et al., 1980 ; see also rudolph & zacher, 2017) . indeed, the assumed differential importance of these influences across the lifespan differs markedly from the cohort deterministic approach implied in generational theory and research. according to baltes et al. (1980) , idiosyncratic life events become more important predictors of developmental outcomes with increasing age due to declines in biological and evolutionary-based genetic control over development and the increased heterogeneity and plasticity in developmental outcomes at higher ages. despite the assumed relative strengths of these normative and non-normative influences across the lifespan, they are at no point completely irrelevant to individual development. for example, in the work context, the theoretical relevance of history-graded influences on work-related outcomes may be a factor that determines the strength of potential effects (zacher, 2015b) . for instance, experiencing a global pandemic is more likely to influence the development of individuals' attitudes-not an entire generations' collective attitudes-toward universal health care than it is to influence their job satisfaction. moreover, individuals' level of job security may not only be influenced by the pandemic but also by their profession and levels of risk tolerance. in summary, the lifespan development perspective offers a number of alternative explanations for the role of age and the process of aging at work that do not rely in generational explanations. specifically, by recognizing that development is a lifelong process that is affected by multiple influences, this perspective helps to clarify the complexities of development, particularly the processes that lead to inter-and intraindividual changes over time. with a clearer sense of these two alternative perspectives, we next shift our attention to outlining various points of integration between them. with a clearer sense of the core tenets of the social constructionist and lifespan development perspectives, we now turn our attention to clarifying lines of integration between these two approaches. while seemingly addressing different "corners" of the ideas presented here, there are a number of complementary features of the social constructionist and lifespan development perspectives to be noted. first, both perspectives generally eschew the idea that generations exist objectively and are meaningful units of study for explaining individual and group differences. second, both perspectives offer that the complexities that underlie the understanding of age and the process of aging at work cannot be reduced to rather simple mean-level comparisons. third, both perspectives are generative, in that they encourage research questions that go beyond common ways of thinking. fourth, and relatedly, both perspectives provide frameworks for more "directly" studying aging and development-whether in the form of how we collectively understand and conceptualize these processes (the social constructionist perspective), or how individuals continuously and interactively shape their own life trajectory (the lifespan development perspective). together, rather than relying on determinism, these perspectives capitalize on the subjective, dynamic, and agentic aspects of life in organizations and society, allowing for more rigorous and representative research into meaning, creation, stability, and change in context. beyond these complementary features, we propose six additional commonalities that serve as the basis for a more formal integration of these two perspectives with one another (see table 2 for a summary). first, both perspectives recognize the role of context, in that both development (the lifespan development perspective) and sensemaking (the social constructionist perspective) occur within social contexts. second, both perspectives describe processes of action, creation, negotiation, and/or codification. whereas the lifespan perspective focuses on how these processes create identity, beliefs, and habits or behaviors that emerge over time through active self-regulatory, motivational processes, discovery, and (self)acceptance/selectivity, the social constructionist perspective focuses more so on the development of truths and meaning that emerge from collective dialogues, understandings, and traditions through acceptance and institutionalization. third, both perspectives acknowledge the fundamental roles of internal and external comparisons. for example, the lifespan perspective offers that successful development is judged both externally (e.g., in comparison with important others, normative age expectations, or timetables) and internally (e.g., in comparison with younger or desired state selves). similarly, social constructions can be focused externally (e.g., in the form of stereotypes) as well as internally (i.e., to make sense of one's own behavior or identity). fourth, both perspectives highlight learning and reinforcement processes that are derived from environmental sources. the lifespan perspective offers that adaptiveness (e.g., how successfully someone is developing/aging) and the self (as well as identities, values, behaviors, etc.) are learned from and reinforced by feedback from various aspects of the environment. similarly, social constructions are derived from and reinforced by multiple environmental sources, including those with perceived status, "weight," and legitimacy. fifth, by offering that development is a modifiable, discontinuous process (the lifespan development perspective) and that social constructions are constantly re-defined and re-emerge into public consciousness (the social constructionist perspective), both perspectives focus on continuous evolution, revision, and change. the final commonality to be drawn across these two perspectives is that they both focus on predictable influences that characterize certain spans of time, especially around significant events or "turning points." the lifespan perspective offers that, although complex and plastic, development does have some predictable aspects and influences due to their significance in the life course (e.g., age-graded events). complimenting this, many social constructions, although in constant flux and redefinition, fall back on the same key concepts due to their pervasiveness in public consciousness (e.g., the laziness of youth) at certain "key moments" in history (e.g., to explain or cope with societal change). beyond the benefits of considering alternative models to generations, and integrations thereof, it is important to mention the limitations of these alternative perspectives. for example, it could be argued that, because it does not provide formalized predictions, the social constructionist perspective is "hard to study." additionally, the lifespan perspective can be -identity, beliefs, and habits or behaviors emerge over time through active self-regulatory and motivational processes, discovery, and (self-)acceptance and selectivity. commonality #3: fundamental roles of internal and external comparison -social constructions are applied externally (e.g., stereotypes) as well as internally (i.e., to make sense of one's own behavior and identity). -"successful development" is compared externally (e.g., in comparison with important others, normative age expectations and timetables) and internally (e.g., in comparison with younger or desired state selves). commonality #4: learning and reinforcement from environmental sources -constructions are derived from and reinforced by multiple sources, including those with perceived status, "weight," and legitimacy. -both adaptiveness (e.g., how "well" someone is developing/aging) and the self (as well as identities, behaviors, etc.) are learned from and reinforced by feedback from various aspects of environment. commonality #5: continuous evolution, revision, and change -social constructions are constantly re-defined and re-emerge into public consciousness. -there is no single linear or normatively staged process that can define development; development is modifiable across the full lifespan. commonality #6: predictable influences characterize certain spans of time, especially around a significant event or "turning point" -many social constructions, although in constant flux and redefinition, fall back on the same key concepts due to their pervasiveness in public consciousness (e.g., laziness of youth) at certain "key moments" in history (e.g., to explain or cope with societal change). -although complex and plastic, development has certain predictable aspects and influences due to their significance in the life course (e.g., age-graded socialization events). criticized, just as it is lauded, for its focus on individual agency: as noted earlier, psychological perspectives often place a premium on studying individual-level mechanisms rather than other levels of influence . thus, without directed efforts on the part of researchers to attend to these aspects of lifespan development theory in their work, it can be easy to fall into the "trap" of ignoring structural factors (e.g., socioeconomic status, governmental policy, institutionalized discrimination) that have bearing on and may constrain individuals' agentic influence on their life trajectory (for an integration of the psychological lifespan perspective and the sociological life course perspective in the context of vocational behavior and career development, see zacher & froidevaux, 2020) . still, and for the many reasons noted throughout this manuscript, we do not contend that generational cohort membership is one of these structural factors, and a generational approach ignores these other forces even more flagrantly. overall, we argue that organizational researchers and practitioners should move beyond the notion of generations for understanding the complexities of age at work. to do so, we urge the adoption of the alternative theoretical models we have outlined here, as well as considerations of their integration. to this end, those interested in studying the role of age at work should adopt a lifespan, rather than a generational, perspective, whereas those interested in studying the persistence of generational thinking would be well served to consider the adoption of a social constructionist perspective. moreover, to understand more holistically the role of age and the construction of aging at work, it may be useful to adopt an integrative view on these two perspectives, embodied within the six commonalities between them that we have outlined above (see also table 2 ). generational thinking is problematic because it assumes that aggregate social phenomena can explain individual-level attitudes, values, and behavior. in contrast, adopting a lifespan perspective means taking a multidisciplinary lens to understanding age-related differences and changes at work by specifically focusing on how the interplay between person characteristics and contextual variables serve to modify individual development. moreover, the social constructionist perspective offers guidance for unpacking the meanings people attach to assumptions that are made about these aggregate social phenomena, further aiding in understanding the complexities at play here. we consider recommendations for research and practice adopting these perspectives, next. the social constructionist perspective on generations highlights a number of potential areas for research and practice. given their longstanding and culturally/historically embedded nature, the social constructionist perspective recognizes that the idea of generations is not likely to go away, even with a lack of empirical methods or evidence to support their existence. instead, this perspective calls for a paradigm shift in generational research and practice, away from the rather positivist notion of "seeking out" generational differences and instead toward a focus on studying and understanding those processes that support the social construction of generations to begin with. considering research, the focus could be on those antecedents (e.g., intergroup competition and discrimination; north & fiske, 2012; i.e., to address the question, "why do these social constructions emerge?") and outcomes (e.g., selffulfilling prophecies-i.e., to address the question, "what are the consequences of willing generations into being?") of socially constructed generations. conducting research from a social constructionist perspective requires adopting methodologies that may not be common in organizational researchers' "tool kits." for example, rudolph and zacher (2015) used sentiment analysis, a natural language processing methodology, to analyze the content of twitter dialogues concerning various generational groups to understand the relative sentiment associated with each. indeed, it would arguably be difficult to study generations from this perspective by adopting a typical frequentist approach to hypothesis testing. this perspective is less about gathering evidence "against the null hypothesis" that generations or differences between them exist in a more or less "objective" (i.e., measurable) way. instead, it is more about understanding, phenomenologically, the various processes that give rise to people's subjective construction of generations, the systems that facilitate attaching meaning to generational labels, and the structures that support our continued reliance on generations as a sensemaking tool in spite of logical and empirical arguments against doing so. more practically, understanding why people think in terms of generations can help us to develop interventions that are targeted at helping people think less in terms of generations and more in terms of individuating people on the basis of the various processes outlined in our description of the lifespan perspective (i.e., personal characteristics; idiosyncratic and contextual factors). the social constructionist perspective also encourages changing the discourse among practitioners, shifting the focus away from managing generations as discrete groups and toward developing more age-conscious personnel practices, policies, and procedures that support workers across the entirety of their working lifespans (e.g., rudolph & zacher, 2020c) . we thus urge practitioners to adopt a social constructionist perspective and shift focus away from promoting processes to manage members of different generations to a focus on managing the perceptions of generations and their differences. by recognizing the constructed nature of generations, the social constructionist perspective decouples beliefs about generations from these broad and overgeneralized assumptions about their influence on individuals. just as the social constructionist perspective highlights a number of potential areas for research and practice, so too does the lifespan perspective. to this end, and to move research on the lifespan perspective on generations forward, rudolph and zacher (2017) argued that, at the individual level of analysis, the influence of age-graded and historical/contextual influences are inherently codetermined and inseparable. accordingly, in their lifespan perspective on generations, they proposed that the influence of historically graded and sociocultural context variables occurs at the individual level of analysis only, and not as a manifestation of shared generational effects (proposition 1). they suggested that future research should focus on individual-level indicators of historical and sociocultural influences. furthermore, they argued that age, period, and cohort effects are both theoretically and empirically confounded and, thus, inseparable (proposition 2). finally, consistent with schaie's (1986) general developmental model, they suggested that cohorts should be operationalized as interindividual differences, whereas period effects should be defined in terms of intraindividual changes (proposition 3). in terms of more practical implications of the lifespan perspective, we urge practitioners to adopt principles of lifespan development in the design of age-conscious work processes, interventions, and policies that do not rely on generations as a means of representing age. indeed, researchers and practitioners alike should take steps to avoid the pitfalls of "generational thinking," which yields several dangers that can be overcome by lifespan thinking (rauvola et al., 2019; rudolph & zacher, 2020c) . first, generational thinking categorizes individuals into arbitrary generational groups based on a single criterion (i.e., birth year) and is therefore socially exclusive rather than inclusive; in contrast, the lifespan perspective conceptualizes and operationalizes age directly as a continuous variable (baltes, 1987) . second, generational thinking reduces complex age-related processes into a simplistic dichotomy at a single point in time; the lifespan perspective adopts a multidimensional, multidirectional, and multilevel approach to represent the complexities of aging more appropriately. third, generational thinking overemphasizes the role of (ranges of) birth cohorts in influencing work outcomes; in contrast, the lifespan perspective emphasizes interindividual differences and intraindividual development (as well as interindividual differences in intraindividual development). finally, generational thinking is dangerous because it assumes that generational group membership determines individual attitudes, values, and behavior. in contrast to this, the lifespan perspective, which entails the notion of plasticity, suggests that intraindividual changes in developmental paths are possible at any age and that individuals can enact control and influence their own development. this manuscript sought to achieve two goals, related to helping various constituents better understand the complexities of age and aging at work, and dissuade the use of generations and generational differences as a means of understanding and simplifying such complexities. first, we aimed to "bust" ten common myths about generations and generational differences that permeate various discussions in organizational sciences research and practice and beyond. then, with these debunked myths as a backdrop, we offered two complementary alternative models-the social constructionist perspective and the lifespan perspective-with promise for helping organizational scientists and practitioners better understand and manage age and the process of aging in the workplace and comprehend the pervasive nature of generations as a means of social sensemaking. the social constructionist perspective calls for a shift in thinking about generations as tangible and demonstrable units of study, to socially constructed entities, the existence of which is in-and-of-itself worthy of study. supplementing these ideas, the lifespan perspective offers that rather than focusing on simplified, rather deterministic groupings of people into generations, development occurs in a continuous, multicausal, multidirectional, and multidimensional process. our hope is that this manuscript helps to "redirect" talk about 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x and generation y in terms of individual innovativeness behavior: the case of turkish health professionals generational differences in work ethic: fact or fiction? successful aging at work using lifespan developmental theory and methods as a viable alternative to the study of generational differences at work. industrial and organizational psychology life stage, lifespan, and life course perspectives on vocational behavior and development: a theoretical framework, review, and research agenda publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-013385-6nq4yzvz authors: yang, fan; jiang, yao title: heterogeneous influences of social support on physical and mental health: evidence from china date: 2020-09-18 journal: int j environ res public health doi: 10.3390/ijerph17186838 sha: doc_id: 13385 cord_uid: 6nq4yzvz employing a national representative survey (the china labor-force dynamics survey 2016, clds2016) data (n = 14246), this paper examines the heterogeneous influences of social support on individual physical and mental health in china. social support is characterized by four dimensions: emotional support, tangible or instrumental support, interaction or exchange support, and community support. physical health is measured by self-rated health and body mass index (bmi), while mental health is measured by depression, hopelessness, failure, fear, loneliness, and meaninglessness. the results indicate that different dimensions of social support have heterogeneous effects on individual physical and mental health. specifically, the correlation between emotional support and individual physical health is not significant, but emotional support is significantly related to some mental health variables. tangible or instrumental support is significantly related to individual self-rated physical health but not to bmi or mental health. interaction or exchange support is significantly correlated with individual self-rated health and some mental health variables. in general, there are significant correlations between community support, and individual physical and mental health. the results also suggest that the influences of social support on physical and mental health of individuals at different ages (<60 years and ≥60 years) are heterogeneous. the results of this study provide direction for the dimension selection of social support to promote individual health. individuals are embedded within a society, and social support affects multitudinous aspects of individuals, including health. individual good health is a valuable aspect of life and social development, and the relationship between social support and individual health is receiving increased academic attention [1] [2] [3] . while social support can affect both individual physical and mental health [4] , it is unclear which is more closely related to social support. this paper investigates whether there is any heterogeneity in the effects of multidimensional social support on physical and mental health. further, the influences of multidimensional social support on health at various ages are investigated. answers to the above issues have not reached academic consensus, as evidenced by a literature review conducted in this study. social support refers to the care and support that social members can receive from others [5] . it can improve individual social adaptability [6] and is a potential social factor affecting individual health [7] . as early as the 1940s, the world health organization (who) presented a multidimensional definition of health, which was a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity [8] . as can be seen from this definition, health is a multidimensional concept, including not only physical health but also mental health. from 1990 to 2016, the burden of mental disorders globally was enormous, with an estimated 1.1 billion population affected by mental or substance use disorders [9] . a growing body of literature has demonstrated that the amount and quality of social support from relatives, friends, neighbors, and the community are pivotal factors in positively affecting a person's physical and mental health [10] [11] [12] and acts as a form of prevention against harmful behaviors and distressing emotions [13] . social support is one of the well-documented factors influencing physical health outcomes [14, 15] . the most compelling evidence on the physical health outcomes of social support is a meta-analysis of the existing literatures that found that social support significantly lowers the risk for mortality [16] . studies have shown that, the stronger a person's social support network, the more likely they are to obtain more wealth, higher social status, as well as medical resources to prevent diseases and to maintain good physical health [17, 18] . these individuals with strong social support networks can use these supports to receive good treatment when faced with disease [19] . conversely, those who do not have much social support may not have enough resources to remain healthy. when they are suffering from disease, it is also challenging for them to obtain good medical resources or to pay for treatment, which causes their health to further deteriorate [19] . previous studies have argued that social support is a factor affecting mental health, and these studies have shown that there are two primary ways that social support affects individual mental health [20, 21] . the first is main (or additive) effects of social support on health [22] . it is argued that social support has a generally beneficial effect. when the amount of social support increases, the level of individual mental health improves [22] . the second is stress-buffering (also termed moderating or interactive) effects of social support on mental health [23] . in this case, research suggests that social support only plays a role in mental health under stress. social support minimizes the impacts of stress from negative life events on psychological health [24] . however, empirical studies do not reach a consensus on the two ways that social support affects individual mental health. some studies have found evidence of the main or stress-buffering effect of social support on health [25] [26] [27] [28] . for example, a study on the mental health of incarcerated offenders showed that perceived social support helps safeguard the mental health of offenders [29] . further, a study of college students with disabilities showed that both the main and buffering effects of social support effectively relieve their financial pressure [30] . conversely, other studies have shown that the effect of social support on mental health is not significant [31, 32] . for example, a five-year longitudinal study has found that social support does not uniformly mitigate the effects of stressors on health for individuals living in urban poverty [33] . in conclusion, previous researchers have mainly studied the correlations between social support and health from the two perspectives of physical and mental health [34, 35] . these two perspectives should be compared, but the results of the presented works may be incomplete if analyzed from one perspective alone. social supports are multifaced [36, 37] . previous studies mainly used functional and global functional concepts to measure it. functional social support refers to the functions performed for individuals by significant others or secondary group members. the most frequently noted functions are emotional, informational, and instrumental assistance [36] . the measurement of global functional social support combines the functional social supports mentioned above into a single index [38] . in this paper, under the consensus that total social support influences individual health, we do not intend to combine varying functional social supports into a single index. instead, we investigate the heterogeneous influences of various functional social supports on individual physical and mental health. based on previous studies, we divided social support into four dimensions: emotional support, tangible or instrumental support, interaction or exchange support, and community support [39, 40] . emotional support plays a protective role in individual physical and mental health. for physical health, studies have demonstrated that individuals who lack emotional support are twice as likely to commit suicide and to suffer from myocardial death and cardiac disease compared to individuals who have emotional support [41, 42] . for mental health, emotional support is associated with a reduction in psychological distress and anxiety [43, 44] . tangible or instrumental support refers to giving individuals practical support, such as financial assistance [45] . effective tangible or instrumental support can help individuals maintain their general health or recover from illness [22] . from the perspective of psychology, productive interaction or exchange support involves having people who can discuss important personal issues. not only does this release individual anxiety and pressure but also this kind of support enables collaborative solutions to be reached. [46] . in china, with the improvement of rural and urban community management, the grassroots community plays an increasingly vital role in people's lives, which includes their health [47] . members of a community often form an intimate group. through mutual acquaintance, trust-building, and mutual assistance, they can become a source of social support for each other [10] . in terms of specific measurement indicators, the number of friends a person has is used to measure emotional support [48] . tangible or instrumental support is commonly measured by the number of people that an individual can borrow money from [49, 50] . interaction or exchange support is usually measured by the number of people who can discuss important personal issues together [51] . community members' familiarity, trust, and mutual assistance is used to measure the level of community support [52] . in addition to social support, individual health is also affected by other factors. gender, age, religion, marital status, health habits, and socioeconomic status are individual characteristics that are intimately related to health [53] . gender is a widely documented determinant of health. studies have indicated that feminine and undifferentiated gender roles are related to poor self-rated health and that the average health status of men is better than that of women [54] . it is recognized that individual health declines with age [55, 56] . regarding an individual's marital status, single people experience higher mortality and poorer health than married people [57] . studies on the link between religion and mental health have consistently revealed that spiritual people turn to their religious beliefs as one of the first resources when faced with traumatic life events or significant stressors [58, 59] . multiple studies of the factors influencing individual health have found compelling evidence concerning damaging health habits and behaviors such as smoking, drinking, and beneficial habits like regular physical activity [60] . an individual's socioeconomic position involves the indicators of income, occupational prestige, and attaining education, which are intimately linked to health care accessibility and health literacy [61, 62] . studies have consistently documented that individuals with high incomes and good education are healthier than poorer, less educated people [63] [64] [65] . apart from individual characteristics, the environment in which the person is located also influences individual health. a growing, global body of literature has focused on the negative impacts of environmental pollution, especially air pollution, on individual health [66] [67] [68] [69] [70] [71] . studying the health of chinese people has great social significance for both the general public and for the chinese government. first, according to data released by the chinese government, about 40% of the poverty experienced by china's rural population is caused by health problems [72] . this means that, with increased social support, improving people's health can play a role in alleviating poverty. second, there was a large seasonal and internal migrant population in china, consisting of around 250 million people at the end of 2019 [73] . they migrated from rural areas where their household was registered to urban places to seek work. in this process, whether social support is available may affect individual income as well as health. additionally, the first blue book of chinese mental health (2017-2018), released by the chinese academy of sciences institute of psychology, shows that an increasing number of individuals experience psychological problems in china [74] . the chinese government is committed to building a healthy population in china. citizens' health is a symbol of national prosperity. the government is gradually improving national health policies to provide people with comprehensive health services. improving individual social support is part of these policies. in conclusion, it is of great pragmatic significance to study the effect of social support on the health of chinese people. this paper aims to fill some of the gaps in current studies on individual health. based on big data from china, this study adopts quantitative research methods to analyze the heterogenous affecting of social support on individual physical and mental health. first, this study attempts to give a description of the influence of multidimensional social support on both individual physical and mental health. second, this study shows a comparison of each dimension of social support on individual physical and mental health, which strongly proves the varied effects of social support on health. finally, this study expands the heterogeneity to age and effectively identifies the heterogeneous influence of each dimension of social support on different ages' mental health. the data of this paper comes from the china labor-force dynamics survey 2016 (clds2016) carried out by sun yat-sen university in 2016. the survey covers education, work, migration, health, economic activities, and other interdisciplinary aspects. in this survey, a multi-stage, multi-level probability sampling method proportional to the size of the labor force is adopted. to ensure national representation, the samples cover 29 provincial administrative units (hong kong, macao, taiwan, tibet, and hainan are not included). therefore, this dataset is highly representative of china. it is a public dataset that all researchers can use by applying to sun yat-sen university. the survey is conducted by computer assisted personal interviewing (capi) technology. in order to reduce the estimation bias as much as possible, this paper removes invalid samples in the original data table. specifically, the samples with the following characteristics have been deleted: refusing to answer key questions or answering "inapplicable, unclear" and obvious logical contradictions. finally, 14,246 valid samples were used in this paper. therefore, the data this paper employed can be regarded as big data in terms of both the national representation of the survey scope and the absolute number. two dimensions, physical health and mental health, of respondents were measured. for the first dimension, physical health, survey participants were asked, "how do you evaluate your current health (variable named self-rated health)?" the answer was measured using a five-point likert scale ranging from "1" to "5". an answer of "very bad" was coded as "1", "bad" was coded as "2", "normal" was coded as "3", "good" was coded as "4", and "very good" was coded as "5". considering the subjectivity of self-rated health, this paper also used body mass index (bmi) to measure the physical health of respondents. in the standards provided by the world health organization (who), 18.5 ≤ bmi < 24 refers to a normal weight range [75] . however, according to a study published in the lancet by who experts, a normal bmi between 18.5-23 may be more appropriate for asians [76] . therefore, we chose the range of bmi from 18.5 to 23 as normal weight. if 18.5 ≤ bmi < 23, it was coded as "1"; otherwise, it was coded as "0". individuals who develop mental health problems may experience feelings of depression, hopelessness, failure, fear, loneliness, and meaninglessness [77] . therefore, for the second dimension, mental health, respondents were asked six questions: "how often do you feel depressed (variable named depression)?", "how often do you feel like there is no hope (variable named hopelessness)?", "how often do you feel you have failed (variable named failure)?", "how often do you experience fear (variable named fear)?", "how often do you feel lonely (variable named loneliness)?", and "how often do you feel life is meaningless (variable named meaninglessness)?" the answers were coded from "1" (very low frequency) to "4" (very high frequency), which meant that the individual mental health status was ranked from good to poor [78, 79] . explanatory variables in social support include four dimensions: emotional support, tangible or instrumental support, interaction or exchange of support, and community support. for the first dimension, emotional support, respondents were asked two questions: "how many friends do you have locally (variable named friends)?" and "how many people can you speak your mind to (variable named speaking one's mind)?" the answers to both questions were numerical. in other words, emotional support was defined by two variables: friends and speaking one's mind. for the second dimension, tangible or instrumental support, respondents were asked, "how many people can you borrow money from (variable named borrowing money)?" the answer to the question was also numerical. it meant that tangible or instrumental support was defined by the variable of borrowing money. for the third dimension, interaction or exchange of support, respondents were asked, "how many people can you discuss important personal issues with (variable named discussion)?" the answer was still numerical. in other words, interaction or exchange of support was defined by the variable of discussion. for the fourth dimension, community support, respondents were asked three questions: "how familiar are you with the members in your community (variable named familiarity)?" the answer was measured by a five-point likert scale ranging from "1" (very unfamiliar) to "5" (very familiar). "to what extent do you trust the members in your community (variable named trust)?" the answer was also measured using a five-point likert scale ranging from "1" (very distrustful) to "5" (very trustful). the final question of the fourth dimension was "do you have mutual aid with the members in your community (variable named mutual aid)?" the answer was again measured by a five-point likert scale ranging from "1" (very little) to "5" (very much). it meant that community support was defined by three variables: familiarity, trust, and mutual aid. according to the analysis in the introduction section, the control variables of this paper included gender, age, education, marital status, religion, income, working time, smoking, drinking, exercise, and region. gender was a dummy variable. male was coded as "1", and female as "0". age was a continuous variable. education referred to the number of years of schooling, which was also a continuous variable. marital status was a dummy variable, which was divided into "single", "married", "divorced", and "widowed". religion was a dummy variable, which was clustered into "western religion (including catholicism, christianity, and the eastern orthodox church)", "eastern religion (including southern buddhism, tibetan buddhism, taoism, islam, and folk religions)", and "no religion". income was a continuous variable, which referred to the total income of respondents in 2015, mainly composed of wage income, operating income, property income, and transfer income. in regression analysis, we took the logarithm of income. working time was measured by the average number of days respondents worked in one month ranging from "0" to "31". smoking and drinking both were dummy variables with "1" representing "yes" for each of the two variables. exercise was measured by asking the question, "do you exercise regularly in your daily life?", with "1" representing "yes". region was a dummy variable and was measured by the provinces where respondents were located. the eight measures of outcome, (1) self-rated health, (2) bmi, (3) depression, (4) hopelessness, (5) failure, (6) fear, (7) loneliness, and (8) meaninglessness, were used as the dependent variables. the ordered probit (oprobit) regression models were used to estimate the results of (1) self-rated health, (3) depression, (4) hopelessness, (5) failure, (6) fear, (7) loneliness, and (8) meaninglessness, due to these dependent variables being ordered discrete data. the logistic regression model was used to estimate the result of (2) bmi, due to the bmi being measured as binary. the statistical software stata version 13.1 mp was used to implement the analysis (statacorp. lp., college station, tx, usa). there are two main limitations of this paper. one is in research and design. our data is second-hand data collected by other research institutions. health and social support are only part of this dataset. in addition, mental health is a complex concept, so it is extremely difficult to quantify accurately. therefore, we only use six indicators to measure mental health, which is obviously not enough to represent its complexities. future research can cautiously expand the dimensions of mental health. the second limitation of this paper is in the methods used. this is also related to the data. due to the cross-sectional nature of the data, this paper does not explore the internal mechanisms of social support for physical and mental health. future research can continue to expand on this point. in terms of physical health, the average value of self-rated health is 3.65 (sd = 0.97). bmi shows that 46.1% of the respondents' weights were within the normal range. in terms of mental health, the mean values of six indicators are all less than 2, among which, the mean value of depression is when reviewing social support factors that may influence physical and mental health, on average, respondents had 12.33 friends, 4.88 respondents had people with whom they could speak their mind, 5.08 people from whom they could borrow money, and 4.01 people with whom they could discuss important personal issues. in terms of community support, the average degree of familiarity of the respondents and other members of the community is 3.81, the average degree of trust of the respondents and the other members of the community is 3.68, and the average value of mutual aid between the respondents and the other members of the community is 3.36. the influences of the social support factors on the two physical health dimensions, self-rated health and bmi, are estimated separately by an oprobit regression model and a logistic regression model. the results are shown in table 2 . the number of samples used in the estimations is 14,246. varied technical diagnostic tests were conducted [80, 81] , and the results show that the two models are good fits. it can be observed from table 2 that the influences of social support on self-rated health and bmi are heterogeneous. specifically, the two indicators of emotional support (friends and speaking one's mind) do not significantly affect self-rated health and bmi. tangible or instrumental support (borrowing money) significantly and positively affects self-rated health but not bmi. this result means that, with the increase of tangible or instrumental support (borrowing money), individual self-rated health level is correspondingly higher on average. similarly, interaction or exchange support (discussion) affects self-rated health significantly and positively but not bmi. on average, individuals with more people to discuss important personal issues with have higher self-rated health. in terms of community support, the respondents' degree of familiarity with other members of the community has a significant and positive effect on the self-rated health of the respondents and has a significant and negative effect on bmi. the degree of trust that the respondents have with the other members in their community has a significant positive effect on both self-rated health and bmi. the frequency of mutual aid behavior of the respondents and community members significantly and positively affects the self-rated health of the respondents but not their bmi. for the results of the control variables, on average, the older the respondent is, the lower their self-rated health level is. similarly, the older the respondent is, the lower the probability that their weight is within the normal range. for education, the more years of schooling the respondent has, the higher their self-rated health level is. in terms of income, the self-rated health level of the respondent increases with the increment of annual income. finally, people who adhere to regular exercise have higher self-rated health levels compared with those who do not exercise regularly. oprobit regression models are used to estimate the influences of social support factors on the six mental health dimensions in this study (depression, hopelessness, failure, fear, loneliness, and meaninglessness). the results are shown in table 3 . the number of samples used in the estimations is also 14,246, and the models are found to be a good fit [80] . notes: standard errors in parentheses; *** p < 0.01, ** p < 0.05, * p < 0.1. table 3 shows that the more friends the respondents have, the higher frequency they feel depression, failure, and fear; the more people the respondent has to discuss important personal issues with, the less likely respondents will experience feelings of hopelessness, failure, and loneliness; and the more familiar the respondents are with members of their community, the better their mental health is, that is, the less likely the respondents will feel depressed, hopeless, afraid of failure, fearful, lonely, and meaningless. similar results appeared as the respondents were more trusted within their community. the more mutual aid behaviors the respondents have with other members of their community, the better their mental health is, and respondents thus experience less frequent feelings of hopelessness, failure, loneliness, and meaninglessness. in the control variables, on average, compared with women, men's mental health is better. they spend less time feeling depressed, hopeless, like a failure, fearful, lonely, and meaningless than women do. the amount of time that respondents feel these variables increases with age. the higher the level of education of the respondents, the lower the frequency of depression, hopelessness, failure, fear, loneliness, and meaninglessness they feel. regarding marital status, compared with single people, married respondents have better mental health. they spend less time feeling the above variables than single people do. the more income the respondents earn, the less likely they are to feel depressed, hopeless, failed, feared, lonely, and meaningless. respondents who exercise regularly are also less likely to feel these variables. age is significantly associated with mental health [82] . as such, we grouped the samples into two subgroups-respondents below 60 and those 60 and over-to check the heterogeneous influence of emotional, tangible or instrumental, interaction or exchange, and community support on individual mental health at different ages. the results are reported in table 4 . it can be observed from table 4 that not all the variables (friends and speaking one's mind) related to emotional support have significant effects on individual mental health across the two different age subgroups. specifically, the number of friends that respondents have has significant negative effects on the mental health variables of depression, failure, and fear in the below-60 subgroup. the variable of speaking one's mind shows a significant positive effect on easing the feeling of failure in the 60-and-over subgroup, while it has no significant effects on the other mental health variables. for tangible or instrumental support, the variable of borrowing money only has a significant positive effect of relieving feelings of depression, hopelessness, and loneliness in the 60-and-over subgroup. the variable did not affect the mental health of those aged below 60. in terms of interaction or exchange support, the coefficients of variables of discussion are insignificant across the two subgroups, demonstrating that the interaction or exchange of support does not affect respondents' mental health status positively or negatively. overall, community support is the most crucial dimension of social support affecting individual mental health. the degree of familiarity respondents share with the other members of their community has significant, positive influences on every assessed mental health status in the below-60 subgroup. in contrast, in the 60-and-over subgroup, the degree of familiarity lessens the feelings of depression and fear significantly. the degree of trust that the respondents share with the other community members improves overall mental health across the two different subgroups significantly. alternatively, the trust between community members shows that there is a strong association of mental health with community support among individuals. the mutual aid behaviors of the respondents and other community members is significantly and positively correlated with alleviating feelings of hopelessness, failure, and meaninglessness but significantly exacerbates the feeling of fear in the 60-and-over subgroup. for the below-60 subgroup, the effects of mutual aid are significantly positive and help alleviate loneliness and meaninglessness. notes: standard errors in parentheses; *** p < 0.01, ** p < 0.05, * p < 0.1. by analyzing updated and representative survey big data from china, this paper examines the influence of social support on individual health. different from previous studies, we examine the influences of social support on individual physical and mental health and attempt to find heterogeneity between them. we find that the number of friends that respondents have has no significant influence on their own physical health (self-rated health and bmi). however, the number of friends has a significant influence on some aspects of respondents' mental health (depression, failure, and fear). we questioned why people with more friends feel more depressed, failed, and fearful. we speculate that this is related to the comparative effect. to a large extent, the psychological problems of individuals come from people close to them, such as family members and friends, rather than strangers [83, 84] . the more friends a person has, the more people the person can compare themselves with. generally, the more friends a person has, the greater the probability of having more highly accomplished friends. comparing oneself with those talented friends may induce depression, a sense of failure, and fear. this is not the fault of the friends but instead how people think about the role of friends in their lives. the number of people that the respondents could borrow money from significantly affects the respondents' self-rated health but does not significantly affect bmi and mental health. based on these results, we can argue that the influence of tangible or instrumental support on individual health, especially mental health, is limited. therefore, these results above provide evidence for future studies to reconsider the heterogeneous effects of different dimensions of social support on individual health. additionally, there is the potential for future studies to consider whether tangible or intangible support has the most significant effect on individual health. having more people with whom the respondent can discuss important personal issues not only can improve the self-rated health of respondents but also can make them feel less hopeless, failed, and lonely. the importance of discussion is reflected in that it can reduce the cognitive limitations of an individual, can open one's mind, can find solutions to problems, and can create a sense of hope. helping individuals find others to discuss things with will be a potential way that government and nongovernmental organizations (ngos) can provide social support for individuals. specifically, the government and ngos can set up community-based advice agencies to provide constructive suggestions on the problems that individuals encounter in daily life to increase their social support. the more familiarity the respondents have with other community members, the higher their self-rated health level is but the greater the probability that their bmi is within an abnormal range. although it is difficult to give a reasonable explanation for the above results, it shows that different choices of health indicators may produce different results. whether to choose subjective or objective indicators to measure physical health is worthy of further study. however, the influence of this variable (familiarity) on the mental health of respondents is consistent. it has a significant positive effect on the six variables (depression, hopelessness, failure, fear, loneliness, and meaninglessness) of mental health. the more familiar the respondents are with other community members, the better their mental health is and the less depressed, hopeless, failed, fearful, lonely, and meaningless they feel. this is evidence that community support has a significant effect on individual mental health, consistent with previous studies [85] . this result suggests that community involvement should be emphasized when strengthening social support. specific measures may include holding communal activities for promoting fellowship, so that community residents can be well acquainted with each other. there is a significant correlation between the degree of trust of respondents with the other community members and the respondents' mental health. the more trust the respondents have with other community members, the better their mental health is. trust is the foundation of mental health [86, 87] . against the social background of the trust crisis in china [88] , this result reminds us again that we cannot ignore the role of trust in people's mental health. positive measures should be taken to maintain interpersonal trust, which is not only beneficial to the mental health of social members but also beneficial to the healthy development of the whole society. mutual aid behavior has a significant correlation with hopelessness, failure, loneliness, and meaninglessness. the more the members of a community help each other, the less time members experience hopelessness, a sense of failure, loneliness, and meaninglessness. however, the frequency of mutual aid behavior within a community significantly affects the self-rated health of respondents but not bmi. the results remind us again that, in the process of measuring health, choosing different indicators may produce different results. additionally, the above results suggest that mutual aid behavior is beneficial to people's mental health. therefore, it is necessary for the community to establish a set of effective mechanisms to stimulate community members to help each other. to conclude, community support plays a prominent role in the four dimensions of social support. our study shows that age plays a moderating role in the impact of social support on mental health. people under the age of 60 and people aged 60 and above have heterogeneous perceptions about the effects of various social support dimensions on different mental health indicators. therefore, the social support measures provided to these two age groups to help them improve their health must also be heterogeneous and targeted. specifically, according to the results of this paper, community support is needed by both age groups (<60 and ≥60), tangible or instrumental support is needed more by the age group over 60 (including 60) , and more emotional support should be given to the age group below 60. for the control variables, the results are mostly consistent with previous studies. in particular, we find that the influence of gender on mental health is heterogeneous. on average, compared with women, men's mental health is better. in addition to the psychological and physiological differences of gender, it may also be related to the different social division of labor between men and women in china. although the status of women has been greatly improved in china, generally, most women are still in a subordinate position in a family. household chores are dealt with mainly by women, which can easily lead to mental health issues [89] . therefore, women's mental health problems deserve further attention. reasonable family division of labor may help to alleviate this problem. in addition, we find that marriage is a way to alleviate mental health problems. compared with single people, those who are married enjoy better mental health. they spend less time feeling depressed, hopeless, like a failure, fearful, lonely, and meaninglessness than single people. good interaction and communication between a husband and wife are beneficial to one's mental health [90] . in conclusion, this paper has shown that different social support dimensions have heterogeneous effects on individual physical and mental health. specifically, tangible or instrumental support (borrowing money), interaction or exchange support (discussion), and community support (familiarity, trust, and mutual aid) are significantly correlated with individual self-rated health. community support (familiarity and trust) is significantly correlated with individual bmi. compared with the other three dimensions, community support plays the most important role in individual mental health. this paper finds that friends do not play a positive role in the depression, failure, and fear dimensions of individual mental health. the results also suggest that the effects of social support on the physical and 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supporting child mental health assertiveness and organizational trust as predictors of mental and physical health in a romanian oil company epa guidance on building trust in mental health services trust collapse caused by the changsheng vaccine crisis in china urban/rural and gender differentials in suicide rates: east and west does marriage have positive effects on the psychological well-being of the individual? key: cord-282035-jibmg4ch authors: dunbar, r. i. m. title: structure and function in human and primate social networks: implications for diffusion, network stability and health date: 2020-08-26 journal: proc math phys eng sci doi: 10.1098/rspa.2020.0446 sha: doc_id: 282035 cord_uid: jibmg4ch the human social world is orders of magnitude smaller than our highly urbanized world might lead us to suppose. in addition, human social networks have a very distinct fractal structure similar to that observed in other primates. in part, this reflects a cognitive constraint, and in part a time constraint, on the capacity for interaction. structured networks of this kind have a significant effect on the rates of transmission of both disease and information. because the cognitive mechanism underpinning network structure is based on trust, internal and external threats that undermine trust or constrain interaction inevitably result in the fragmentation and restructuring of networks. in contexts where network sizes are smaller, this is likely to have significant impacts on psychological and physical health risks. the processes whereby contagious diseases or information propagate through communities are directly affected by the way these communities are structured. this has been shown to be the case in primates [1] [2] [3] and has been well studied in humans in the form of epidemiological [4] and information diffusion (opinion dynamics or voter) models [5] . the ising phase state model (originally developed to describe the magnetic dipole moments of atomic spin in ferromagnetism) has been the workhorse of most of these models and of many of the models currently used to calculate the value of the r-number (or reproduction rate) used to drive current covid-19 management strategies. most early models were mean field models that assumed panmixia. however, human social networks are highly structured and small world: most people interact with only a very small number of individuals whose identities remain relatively stable over time. when it became apparent that the structure of networks could dramatically affect the flow of information (or infections) through networks [6, 7] , structure began to be incorporated into epidemiological models [8] [9] [10] [11] [12] . many of the best current models are 'compartmental models' which represent structure by the fact that a community consists of households or other small population units [11, 12] . in effect, these use spatial structure as a proxy for social structure, which has the advantage of ensuring that the models compute easily. in reality, of course, it is people's interactions with each other that give rise to the spatial structure represented by households. while it is true that most (but not all) individuals see and interact with household or family members more often than with anyone else, in fact this dichotomizes what is in reality a continuum of interaction that flows out in ripples from each individual. these ripples create social layers of gradually declining amplitude that spread through the local community well beyond the household. my aim in this paper is to examine the social and psychological processes that underpin natural human sociality in order to better understand how these affect both network structure and the way information or diseases propagate through them. like all monkeys and apes, humans live in stable social groups characterized by small, highly structured networks. individuals do not interact with, let alone meet, everyone else in their social group on a regular basis: a very high proportion of their interactions are confined to a very small subset of individuals. these relationships are sometimes described as having a 'bonded' quality: regular social partners appear to be fixated on each other [13, 14] . the mechanisms that underpin these relationships have important consequences for the dynamics of these networks. i will first briefly review evidence on the size and structure of the human social world. i will then explain how the cognitive and behavioural mechanisms that underpin friendships in all primates give rise to the particular form that human networks have. finally, i explore some of the consequences of this for information and disease propagation in networks, and how networks respond to external threats. humans have lived in settlements only for the past 8000 years or so, with mega-cities and nation states being at all common only within the last few hundred years. prior to that, our entire evolutionary history was dominated by very small-scale societies of the kind still found in contemporary hunter-gatherers. our personal social worlds still reflect that long evolutionary history, even when they are embedded in connurbations numbering tens of millions of people. table 1 summarizes the sizes of egocentric personal social networks estimated in a wide variety of contexts ranging from xmas card distribution lists (identifying all household members) to the number of friends on facebook, with sample sizes varying between 43 and a million individuals. the mean network size varies across the range 78-250, with an overall mean of approximately 154. table 1 also lists a number of studies that have estimated community size in a variety of pre-industrial societies as well as some contemporary contexts where it is possible to define a personalized community within which most people know each other on a personal level. these include the size of hunter-gatherer communities, historical european villages from the eleventh to the eighteenth centuries, self-contained historical communes, academic subdisciplines (defined as all those who pay attention to each other's publications) and internet communities. the average community sizes range between 107 and 200, many with very large sample sizes, with an overall mean of approximately 158. christmas card distribution list 43 153.5 [16] . [20] . the value of approximately 150 as a natural grouping size for humans was, in fact, originally predicted from an equation relating social group size to relative neocortex size in primates before this empirical evidence became available [38] . this prediction had a 95% confidence interval of 100-250, very close to the observed variance in the data. in primates as a whole (but not other birds and mammals), social group size is a function of neocortex volume, and especially the more frontal neocortex regions (the social brain hypothesis [39] ). in the last decade, neuroimaging studies of both humans [40] [41] [42] [43] [44] [45] [46] [47] [48] [49] [50] and monkeys [51, 52] indicate that the relationship between personal social networks (indexed in many different ways) and brain size also applies within species at the level of the individual as well as between species. the social brain relationship arises because primates are unusual in that they live in relatively large, stable, bonded social groups [53] . in contrast with the more casual groups (i.e. herds, flocks) of most mammals and birds, the problem with bonded groups is that they are, in effect, a version of the coupled oscillator problem. if animals' foraging and resting schedules get out of synchrony, . . some individuals will drift away when others go to rest, resulting in the fragmentation of the group [54, 55] . individuals have to be willing to accept short-term costs (mainly in relation to the scheduling of foraging) in order to gain greater long-term benefits (protection from predators by staying together). maintaining spatial coherence through time is cognitively difficult. it depends on two key psychological competences that appear to be unique to the anthropoid primates: the ability to inhibit prepotent actions (a prepotent response is the tendency to take a small immediate reward in preference to waiting for a larger future reward) and the capacity to mentalize. inhibition depends on the volume of the brain's frontal pole [56] , while mentalizing depends on a dedicated neural circuit known as the theory of mind network (also known as the default mode neural network) that integrates processing units in the brain's prefrontal, parietal and temporal lobes [57] , supplemented by connections with the limbic system [41, 42] . the frontal pole is unique to the anthropoid primates [56] ; the default mode network that underpins mentalizing is also common to both humans and monkeys [58] . maintaining group cohesion is not simply a memory problem (though it is commonly misunderstood as such). rather, it is one of predicting others' future behaviour under different conditions (e.g. knowing how others will respond to one's own actions) and being able to gauge the future reliability (trustworthiness) of other individuals [38, 59] . this is much more costly in terms of both neural activity and neural recruitment than simple factual recall [60] . in humans, the number of friends is directly correlated with mentalizing skills [44, 61] , and mentalizing skills are, in turn, correlated with the volumetric size of the brain's default mode neural network [62, 63] . the latter relationship has recently been shown to extend to primates as a whole [64] . social networks have generally been viewed from two different perspectives. network analysts with a statistical physics background have tended to view them top-down as macroscopic phenomena (i.e. from above looking down on the spatial distribution of a population of nodes), whereas sociologists have tended to view them from below as egocentric networks (the individual's experience of that population). on the whole, the first group have tended to focus on large-scale patterns in very large networks, often with an emphasis on triadic closure (heider's structural balance theory [65] ) as the glue that gives structure to a network; the second have focused on the micro-structure of individual's personal social networks, often focusing on the inner core of intimate friendships immediately beyond the simple triad. an important finding from the second approach has been that networks actually consist of a series of layers that correspond to relationships of different quality [16, 59, 66] . seen from an egocentric point of view, the frequency with which an individual contacts the members of their network does not follow a conventional power law distribution but, on closer inspection, contains a series of plateaux. cluster analyses of very large datasets invariably reveal that these personal networks contain four layers within them (figure 1). this gives the network a layered structure, where individual alters in a given layer are contacted with more or less similar frequency and there is a sharp drop-off in contact frequencies to the next layer. it turns out that, while there is some individual variation, these layers have quite characteristic sizes. moreover, when counted cumulatively, they have a very distinct scaling ratio: each layer is approximately three times the size of the layer immediately inside it (figure 2). this layered structure in figure 2 (referred to as a dunbar graph [67] ) has been identified, with virtually the same numerical layer values, in surveys of network size, the calling patterns in national cellphone databases, science co-author networks and the frequencies of reciprocated postings in both facebook and twitter (table 2). each layer seems to correspond to a very specific frequency of interaction (figure 3), and these frequencies are remarkably consistent across media [66] , suggesting both that they are hardwired and that communication media are substitutable. one way this structure might arise would be if the basal layer of five people represented, for example, a family or household, such that the next layer of 15 consists of three families with an especially close relationship, and the 50-layer beyond that consisted of three of these trios. this [19] . (b) optimal number of clusters identified by k-means clustering algorithm in three online datasets. reproduced from [68] . pattern, however, is likely to reflect small-scale traditional communities; in more mobile, postindustrial societies, figure 2 can arise simply a consequence of the patterns of interaction between individuals and need have no family-based (or spatial) underpinning to it at all. it is notable, nonetheless, that the same patterns emerge in either case, suggesting that there is an underlying universal constraint on how networks are constructed. this same pattern, with the same layer sizes, has also been identified in a number of topdown analyses of the social (or spatial) organization of human populations (table 2), including hunter-gatherers, the size distribution of irish bronze age stone circles (as estimates of local population distribution), the sizes of residential trailer parks, the structure of modern armies, the size of communities of practice in the business world and even the patterns of alliance formation in massive online multiplayer games (moms). this pattern, with the same scaling ratio, has also been noted in the political organization of a large sample of historical city states [69] . in fact, this layered structure with a consistent scaling ratio was first noted in an analysis of huntergatherer societies in the early 1980s by johnson [70] , who suggested that it was a 'span on control' management solution in response to internal stresses created as grouping size increases. more surprisingly, perhaps, these same numbers reappear in both the distribution of primate social group sizes [71] and in the layered structure of groups for those mammals that live in multilevel social systems (mainly baboons, chimpanzees, elephants and dolphins) [72, 73] (table 2) . animal societies with stable groups do not extend beyond the 50-layer, but all the internal layers are present. the fact that these numbers are so consistent across so wide a range of species perhaps suggests that they may be the outcome of natural scaling effects due to the structural stresses that social groups incur as they grow in size in response to ecological demands. as a result, social evolution in primates [74] occurs as a result of a stepwise increase in group size [71] achieved by bolting together several basal subgroups to create successive layers rather than through a continuous adjustment of group sizes as in most birds and mammals. primate species achieve larger groups by delaying group fission that would normally act as a nonlinear oscillator to keep group size within a defined range around the local mean [81] [82] [83] . the process thus seems to behave more like a series of phase transitions triggered by a natural fractionation process. although, in humans, there is remarkably little variation in both overall network size and layer sizes across samples, irrespective of sample size, sample origin and cluster detection algorithm, nonetheless within populations, there is considerable variation between individuals (figure 1a). some of this variation is due to sex (women tend to have larger inner layers than men [ but smaller outer layers [84] ), some due to age (network and layer sizes are an inverted-jshaped function of age, peaking in the 20s-30s [16, 24, 86] ) and personality (extroverts have larger networks at all layer levels than introverts [85] [86] [87] [88] ). in addition, all human social networks are divided into two components, family and friends. although in small-scale societies, virtually everyone in your network is a member of your extended family, in the post-industrial world with our lower birth rates, the typical network is split roughly 50 : 50 between family and friends [59, 66, 89] . however, it still seems that preference is given to family: those who come from large extended families have fewer friends [17, 66] . in effect, family and friends form two largely separate subnetworks that are interleaved through the layers of the network, with a roughly even split in the two innermost 5-and 15-layers, friends predominating in the middle 50-layer and family predominating in the outer 150-layer [59] . the latter seems to reflect the fact that friends are more costly to maintain in terms of time investment than family members [17] , and hence survive less well in the outermost layer (see below). conventional top-down networks tend to focus on the degree of individual ego's, usually with some kind of cut-off to define how many primary contacts an individual has. irrespective of where the cut-off is taken to be, these relationships tend to be viewed as one-of-a-kind. dunbar graphs, by contrast, recognize that individuals have relationships of different quality with many individuals, which might be viewed as primary, secondary, tertiary, etc. relationships. the first will usually be a subset of the second. in this section, i provide a brief explanation of how the primate bonding process works. the main purpose is to stress that it is both complex and time-consuming. this will help explain some of the patterns we will meet in the following two sections where i discuss network dynamics and their consequences. primate social groups are implicit social contracts designed to ensure protection from predators and, secondarily, rival conspecifics through group augmentation selection effects [90] . group-living is often mistaken for a cooperation problem, but it is in fact a coordination problem. cooperation problems invariably involve a public goods dilemma (cooperators pay an upfront cost), whereas a coordination problem does not (you are either in the group or not, and everyone pays the same simultaneous cost) [91] . the problem animals have to solve is how to maintain group stability (i.e. coordination) in the face of the stresses that derive from living in close proximity [81, 83, 92] which would otherwise cause the members to disperse (as happens in herd-and flock-forming species [54, 55] . the primate solution to this problem is bonded relationships, since this ensures that individuals will maintain behavioural synchrony and stay together as a group. in primates, relationships are built up by social grooming [93] . grooming is an exceptionally time-costly activity, with some species devoting as much as one-fifth of their entire day to this seemingly trivial activity [93] . grooming creates a sense of reciprocity, obligation and trust (operationally, a form of bayesian belief in the honesty and reliability of an alter's future behaviour [94] ). the layered structure of human social networks is a consequence of how we choose to distribute our social time around the members (figures 2 and 3). in both monkeys [92] and humans [59, 94] , the quality of a relationship (indexed by its likelihood of producing prosocial support when it is needed) depends directly on the time invested in it. however, the time available for social interaction is severely limited [17, 85, 95] , and this forces individuals to make trade-offs between the benefits offered by relationships of different strength and the costs of maintaining those relationships. the process involved is a dual process mechanism that involves two separate mechanisms acting in parallel. one is a psychopharmacological mechanism acting at the emotional (raw feels) level that is mediated by the way social grooming triggers the brain's endorphin system (part of the pain management system); the other is the cognitive element that forms the core of the social brain itself [96] . social grooming is often assumed to have a purely hygienic function. while it certainly has this effect, in primates it has been coopted to form a far more important function in social bonding. the action of leafing through the fur during grooming triggers the endorphin system in the brain [97, 98] via a specialized neural system, the afferent c-tactile (or ct) fibres [99] . these are highly specialized nerves that respond only to light, slow stroking at approximately 2.5 cm s â��1 (the speed of hand movements in grooming), and nothing else [100] . endorphin activation and uptake in the brain creates an opioid-like sense of relaxation, contentment and warmth [101, 102] that seems to provide a psychopharmacological platform for bondedness [101, [103] [104] [105] off which the second process, a cognitive sense of trust and obligation, is built. endorphins have a relatively short half-life (around 2.5 h), and so the system needs constant activation via grooming to maintain the requisite bonding levels, thereby making the system very time-costly. physical touch in the form of stroking and casual touch continues to form an important part of human social interaction and yields exactly the same endorphin effect [98] as it does in primate grooming. however, physical contact has an intimacy that limits it mainly to the inner layers of our networks [106, 107] . moreover, it is physically impossible to groom with more than one individual at a time with the same focused attention that seems to be important in its execution. this, combined with the constraints on time and the minimum time required to maintain a working relationship, ultimately places a limit on the number of relationships an animal can bond with using only this mechanism. in primates, this limits group size to about 50 individuals (the upper limit on average species group size in primates [68] ). groups larger than this are prone to fragmentation and ultimately to fission [108] . in order to be able to increase group size, humans discovered how to exploit other behaviours that also trigger the endorphin system in a way that is, in effect, a form of grooming-at-adistance. these include laughter [109] , singing [110] , dancing [111] , emotional storytelling [112] , and communal eating [113, 114] and drinking (of alcohol) [115] , all of which trigger the endorphin system and do so incrementally when done in synchrony [116, 117] . because they do not involve direct physical contact, more individuals can be 'groomed' simultaneously, thereby allowing a form of time-sharing that makes it possible to reach more individuals and so increase group size. the second component of this system is a cognitive mechanism. it centres around the knowledge of other individuals that can be built up by being in close contact. evolutionary studies of cooperation tend to view relationships as a form of debt-logging. such knowledge would not necessarily require frequent interaction since that can be done by third-party observation. rather, interacting closely with others allows an individual to get to know them well enough to predict their behaviour-to know that they really will come to your aid when you really need them, not because they owe you a favour but because they have a sense of obligation and commitment to you. in effect, it creates a sense of trust that acts as a rapid, intuitive (albeit imperfect) cue of reliability. in humans, this has been augmented by a capacity to build a more detailed 'picture' of another individual through conversation in a way that short circuits the need to invest excessive amounts of time in getting to know them. in other words, we can form a near-instantaneous impression of a stranger and use that as the basis for decisions about whether or not to engage with them. we do this by evaluating an individual's status on a set of largely exogenous cultural dimensions known as the seven pillars of friendship [96] . the seven pillars are: language (or, better still, dialect), place of origin, educational trajectory, hobbies and interests, worldview (religious/moral/political views), musical tastes and sense of humour. the more of these we share in common with someone, the stronger the relationship between us will be and the more altruistic we will be to each other [118] . this 'birds of a feather flock together' phenomenon is termed homophily [119] . the seven pillars are cues of membership of the same community. in small-scale societies, they would identify an extended kinship group, where kin selection (the 'kinship premium' [120] ) provides an additional guarantee of trustworthiness [94] . in effect, they function as a cultural totem pole at the centre of the metaphorical village green on which the community can hang its hats-an emotional consensus of who we are as a community and how we came to be that way, a way of building up mutual trust. in the contemporary context, it still identifies your (now reduced) kin group, but it also seems to identify the small community where you spent your formative years-the period when you acquired your sense of who you are and what community you belong to. this is the community whose mores and behaviour you understand in a very intuitive way, and it is this understanding that determines your sense of how well you can trust its members. homophily in friendships has also been documented in respect of a number of endogenous traits, including gender [17, 24, 66, 121] , ethnicity [122] and personality [85, 123] . gender has a particularly strong effect: approximately 70% of men's social networks consist of men, and approximately 70% of women's networks consist of women, with most of the opposite sex alters in both cases being extended family members. one reason for this is that the two sexes' style of social interaction is very different. women's relationships are more dyadic, serviced mainly by conversation and involve significantly more physical touch, whereas men's relationships are more group-based, typically involve some form of activity (sports, hobbies, social drinking) rather than conversation, and make much less use of haptic contact [106, 124, 125] . men's friendships are also typically less intense, more casual and more substitutable than women's: women will often try to keep core friendships going long after one of them has moved away (e.g. through e-mail or facebook), whereas men simply tend to find someone else to replace the absent individual(s) in a rather out-of-sight-out-of-mind fashion. homophily enables interactions (and hence relationships) to 'flow', both because those involved 'understand' each other better and because they share strategic interests. between them, these emotional and cognitive components create the intensity of bonds that act as the glue to bind individuals together. human, and primate, friendships are often described in terms of two core dimensions: being close (desire for spatial proximity) and feeling close (emotional proximity) [126] . between them, these ensure that bonded individuals stay together so that they are on hand when support is needed, thereby ensuring group cohesion through a drag effect on other dyads created by the ties in the network. since bonding, and the time investment this is based on, is in principle a continuum, this will not, of itself, give rise to the layered structure of a dunbar graph. to produce this, two more key components are needed: a constraint on time and the fact that friendships provide different kinds of benefits. the next section explains how this comes about. two approaches have been used to understand why social networks might have the layered structures they do. one has been to use agent-based models to reverse engineer the conditions under which the intersection between the time costs of relationships and the benefits that these provide give rise to structured networks. the other has been to solve the problem analytically as an optimal investment decision problem. in many ways, these represent top-down and bottom-up approaches, with the first focusing on the macro-level exogenous conditions that produce layered networks, and the second focusing on the micro-decisions that individuals have to make within these environments when deciding whom to interact with. building on the time budget models of dunbar et al. [95] , sutcliffe et al. [127] conceived the problem as the outcome of trying to satisfy two competing goals (foraging and socializing, where socializing provides a key non-foraging ecological benefit such as protection against internal or external threats) in a time-constrained environment. the aim was to identify which combination of strategies and cost/benefit regimes reproduced the exact layer structure of human social networks (for these purposes, taken as the 5, 15 and 150 layers) when agents try to maximize fitness (with fitness being the additive sum of five proximate components that reward social strategies differentially). in the model, 300 agents armed with different strategic preferences for investing in close versus distant ties interacted with each other to form alliances that provided access to different resources. in each run, the population initially consisted of equal numbers of agents pursuing each of three investment preference strategies. following the conventional design for models of this kind, at the end of each round (generation) the 20% of agents with the lowest fitness were removed (died) and were replaced by offspring produced by the top 20% (duplicating the parent's strategy), thereby allowing the size of the population to remain constant but its composition to evolve. the model was allowed to run until the distribution of strategy types reached an equilibrium (typically 2000 cycles). the outcomes from greater than 3000 runs (in which weightings on the fitness functions were systematically varied) were sorted into clusters using k-mean cluster analysis with quantitative fit to the dunbar numbers as the criterion. numerically, strategies that favour having just a few strong ties dominate the fitness landscape, yielding the kinds of small monogamous or harem-based societies that are widely common in mammals. the second most common strategy was the one where agents have no preferences for forming close ties of any kind and instead form large, anonymous herds with no internal structure similar to those characteristic of herd-forming mammals. by contrast, multilevel social structures of the kind found in many primates, and especially those with the specific layer sizes of human social networks, were extremely rare (accounting for less than 1% of runs). they occurred only under a very limited set of circumstances, namely when a capacity for high investment in social time (i.e. sufficient spare time over that needed for foraging), preferential social interaction strategies, high mortality risk and steep reproductive differentials between individuals coincided. these are all traits characteristic of primates. the alternative approach considers the investment decisions themselves. tamarit et al. [128] developed a one-parameter bayesian statistical urn model in which individuals choose to invest their limited social capital in relationships that provide different benefits (identified here as network layers). the model seeks to optimize the distribution of effort across relationship types where s k is the cost of a relationship in layer kâ��1,2 . . . r, k is the number of alters assigned to layer k (with l = î£l k ), s is the total amount of resource (time) available, n is the total population size and âµ is the lagrange multiplier associated with the constraint imposed by total resources. when the cost (i.e. the time investment that has to be made in a relationship) is a monotonic negative function of layer (as in figure 3 ), this yields layered structures of exactly the kind found in human social networks-few close ties and many weak ones (the lower curve in figure 4 ). however, it turned out that the structure of the network inverts (more close ties and few distant ties) when the lagrange multiplier falls below âµ = 0 (upper curve in figure 4 ). one context in which this might happen is when the available community of alters to choose from is small, and so there is spare resource capacity per available alter. a comparison of migrant versus host communities in spain revealed that there is indeed a phase transition between conventionally structured networks (layers with a concave structure, i.e. a few close friends, more intermediate friends and many casual friends) to inverted networks (convex structures, in which ego has more close friends, some intermediate friends and only a few casual friends) at âµ â�� 0 [128] . this had not been noted previously because in the normal population, most individuals fall in the âµ > 0 region; the very small number falling in the âµ < 0 region had simply been viewed as statistical error. however, most migrants, who typically have fewer social opportunities, fall in the âµ < 0 region and so have inverted (convex) networks as a result, with only a small number having standard (i.e. concave) networks. this seems to suggest that, when surplus time is available, people prefer to invest more heavily in their closest ties rather than distributing their effort more evenly because the emotional and practical support offered by these inner layer ties is more valuable to them. this may explain the structure of primate groups where the inner core of strong ties typically represents a larger proportion of group size in species that live in smaller groups. the fact that the scaling ratio is consistently approximately 3 in human (and primate) social networks raises the possibility that heider's structural balance triads might explain the layered structuring. this possibility was considered by klimek et al. [129] who studied an ising-type coevolutionary voter model in a context where there are several social functions (say, friendship and business alliances) such that there are separate linked networks where most individuals occupy positions in each network. they showed that when the networks (i.e. functions) vary in rewiring probability (slow versus fast turnover in relationships), the single large network will eventually undergo a phase transition known as shattered fragmentation in which the community fractures into a large number of small subnetworks (or cliques). this happens only when one of the rewiring frequencies reaches a critically high level. when klimek et al. examined data from the pardus online mom game world, they found that the slow rewiring network (friendship) produced a weakly multimodal right-skewed, fattailed distribution with modal group sizes at 1-2 and approximately 50 players with a few very large super-communities centred around 160 or 1200 members. by contrast, the two fast rewiring networks (in this context, trading and communication functions) both underwent fragmentation into a large number of smaller subnetworks, with a single peak in group size at approximately 50 in both cases, just as the model predicts. when the three networks were projected onto a single multidimensional mapping, very distinct peaks emerged in the distribution of group sizes in both model and data at approximately 40, 150 and 1200, much as we find in table 2. this seems to suggest that when triadic closure is a criterion for relationship stability and there is more than one criterion by which individuals can form ties, layering emerges naturally in networks through self-organizing fragmentation effects. so far, we have considered hierarchically inclusive layer structures. in these, the whole population is contained in the lowest layer, and the higher layers are created by successively bolting together, layer by layer, the groupings that make up each lower layer rather in the way military units are structured [130] . most social networks seem to work like this. however, layers can also arise when some individuals are allocated positions of status, so that the members of the community are distributed across different layers with most individuals in the base layer and a few individuals in one or more higher layers. networks of this kind are characteristic of management structures and the kinds of social hierarchies found in feudal societies. layered structures of this kind seem to emerge rather easily when individuals differ in their willingness to compromise. dã¡vid-barrett & dunbar [131] used an agent-based model to investigate the processes of group coordination when a community has to converge on an agreed compass direction (a proxy for any communal action or opinion that has the advantage of allowing up to 360 different values to be held rather than just two as in more conventional ising models), but one group member is so convinced they have the right answer that they refuse to compromise. if agents can assign weightings to each other on the basis of some preference criterion, however arbitrary, a layered structure emerges with an 'elite' subgroup that acts, in effect, as a management clique. multilevel structures of this kind have the advantage that they increase the speed with which decisions are adopted. multilayer networks are optimal when the costs associated with maintaining relationships, combined with the costs of information flow, are high. in such cases, a social hierarchy can be adaptive: when the hierarchy is steep, information needs to traverse fewer relationships (shorter path lengths), either because the elite effectively act as bridges between lower level groups (distributed management) or because the elite imposes its decisions on the individuals in the lower strata (dictatorial management). falling communication costs lead to a less steep hierarchy when socially useful information is evenly distributed, but to a steeper hierarchy when socially useful information is unevenly distributed. in human social networks, the layers have very characteristic interaction frequencies with ego ( figure 3) . approximately 40% of all social effort (whether indexed as the frequency or duration of interaction) is directed to the five individuals in the closest layer, with another 20% devoted to the remaining 10 members of the second layer. thus, 60% of social time is devoted to just 15 people. comparable results have been reported from large-scale surveys in the uk [8] and in china [10] . this will inevitably affect the rate with which information, innovations or disease propagate through a network. however, network structure can speed up or slow down the rate of propagation, depending on the precise nature of the social processes involved. in a very early (1995) analysis of this, we used boyd & richerson's [5] mean field ising model of cultural transmission to study what happens when these kinds of models are applied to structured networks [130] . in the model, individuals acquire their information from n cultural parents, each of whom can differ in their cultural state. the model was run with a population of 10 000 agents mapped as nodes on a 100 * 100 lattice wrapped on a torus so as to prevent edge effects. structure was imposed by allowing nodes to interact only with their eight closest neighbours on the lattice. on a regular lattice, these consist of two distinct sets: direct contacts (the four adjacent nodes on the main diagonals) and indirect contacts (the four corner nodes that can only be reached indirectly through the four adjacent nodes). in effect, these are equivalent to friends and friends-of-friends. at each generation, a node can change its cultural variant either by mutation or by imitation from one of its neighbouring nodes, with transition probabilities determined by a three-element vector specifying node-specific values of the boyd-richerson cultural inheritance bias functions (one reflecting the self-mutation rate, the other two the transmission, or copying, rates from the four 'friends' and the four 'friends-of-friends', with the proviso that all three sum to 1). when the spatial constraint is dropped and everyone is allowed to interact with everyone else, the model replicates exactly the findings of the boyd-richerson [5] cultural inheritance model. the population evolves to full penetrance by a mutant cultural variant initially seeded at just one node (i.e. with a probability of occurrence of just 0.0001) in 75-150 generations. with spatial (or social) constraints in place, however, two important effects emerge. first, depending on the steepness of the inheritance bias functions, 44-60% of mutant seedings went extinct before achieving full penetrance, apparently because they often became trapped in eddies at particular locations and could not break out before going extinct. in those runs where the mutant achieved full penetrance (i.e. all nodes became mutants), the time to penetrance was 150-300 generations for the same set of transmission biases. in other words, the mutant trait took far longer to spread through the population. once again, the time taken to break out of local eddies was the main reason for the much slower penetrance. the difference between these runs and those where the mutant went extinct depended on the balance between the stochastic rates at which new 'infected' clusters were created and died out. if a local extinction occurred early in the system's evolution when few mutant clusters had become established, global extinction was more likely (the classic small population extinction risk phenomenon in conservation biology [132] ). changing population size or the number of cultural 'parents' had a quantitative effect, but did not change the basic pattern. the cumulative probability asymptotes at a network size of approximately 150, but the optimum number of alters is 50 (identified by the point at which the curve begins to decelerate, defined by e â��1 of the way down from the asymptote) since after this, the benefits of increasing network size diminish exponentially. reproduced from [130] . (b) effect on reachability of removing nodes in different layers of egocentric twitter graphs: the larger the effect, the greater the disruption on information flow. the horizontal dotted lines demarcate 1/eth from the asymptote, and the vertical dotted line the optimal group size for information diffusion. data from [133] . penetrance was slower if there were fewer cultural 'parents', for example, or if the population size was larger. to explore the rate at which information flows through a community, dunbar [130] modelled the likelihood that ego (at the centre of the network) would hear about a novel innovation via direct face-to-face contact for communities of different size (5, 15, 50, 150 , 500, 1500 and 5000 individuals), given the layer-specific rates of contact shown in figure 3 (extrapolated out to the 5000 layer). the probability, p i , of hearing about an innovation seeded somewhere in a network with i layers is the conjoint probability of encountering any given individual in a network layer of size n i and the likelihood that any one of these individuals would have the trait in question (i.e. be infected), summed across all layers where n i is the number of individuals in the ith annulus (network layer), r k is the likelihood that any one of them will have the trait (here taken to be constant, and equivalent to r k = 0.01), c i [f2f] is the likelihood of contacting any given individual face-to-face. figure 5a plots the results. the probability of acquiring information reaches an asymptotic value at a community size of approximately 1500, with no further gain in the likelihood of hearing about an innovation as community size increases beyond this. the optimal community size for information transmission can be identified by the inflection point (the point at which the marginal gain begins to diminish). with a graph of this form, this occurs at the value on the x-axis when the asymptotic value on the y-axis is reduced by 1/e. this is at a community size of exactly 50. the gains to be had by increasing community size beyond approximately 50 diminish exponentially and become trivial beyond a community size of approximately 150 individuals. this was later confirmed by arnaboldi et al. [133] who modelled information diffusion in actual twitter networks. figure importantly, and contrary to granovetter's [134] well-known claim, it seems that it is the inner layers (stronger ties) that may have most impact on the likelihood of acquiring information by diffusion, not the outermost layer (weak ties). the outermost 150-layer (which is disproportionately populated by distant kin [59, 135] ) presumably serves some other function such as a mutual support network [133] . this finding appears to conflict with earlier analyses [6, 137] that have emphasized the importance of weak links (long-range connections) in the rate at which infections or information are propagated in networks. the issue, however, hinges on which layers are counted as strong (short-range) and which weak (long-range). previous analyses, including granovetter himself, have tended to be unspecific on this point. if what he had in mind as weak ties was the 50-layer, then his claim holds; if he was thinking of the 150-or even 5000layer, then it seems he was wrong. even so, it seems that the information value of 50-layer ties is considerably less than that of alters in the 5-and 15-layers, who are also likely to be considered more trustworthy sources of information. nonetheless, granovetter might still be right if either of two conditions hold. one is that the analyses considered only ego acquiring information by direct personal contact; the models did not consider the impact of upward information flow through the network from the source of the information towards ego. the other is that granovetter might have been right for the wrong reason: the function of networks is not information flow (or acquisition) but the provision of direct functional support such as protection against external threats or sources of economic support (a view which would accord better with the view of primate social systems elaborated in â§4). in other words, as is the case in primate social systems, information flow is a consequence of network structure, not its driving force in terms of evolutionary selection [39] . it may, nonetheless, be that the 150-layer provides the principal access channels to the global network beyond the individual's primary personal social sphere. this is suggested by an analysis that used m-polynomials derived from chemical graph theory to integrate dunbar graphs into the milgram small world 'six degrees of separation' phenomenon. the capacity to reach an unknown remote individual in 4-6 links is only possible if, at each step in the chain, the message-holder can access a large number of alters in their personal network [67] . however, this analysis only considered 15 versus 150 network contacts, and 150 significantly over-engineers the solution. further work is needed to explore the optimal network size and structure for transmission in more detail. a moot point, of course, is whether the capacity to send letters to a remote stranger is ever of any real functional value to us, or simply an amusing but unimportant by-product of the way personal networks interface with each other in global networks. one complicating aspect of real social networks not usually considered in these models is the fact that social subnetworks are characterized by a high level of homophily, especially in the inner layers. in other words, people's friends tend to resemble them on an array of social and cultural dimensions [118, 119, 123] . analysing a large (20 million users) cellphone dataset, miritello et al. [85] differentiated, on the basis of calling patterns, two distinct phenotypes: 'social keepers' who focused their calls on a small, stable cohort of contacts (introverts?) and 'social explorers' who had a larger number of contacts with high churn (social butterflies, or extraverts?). each tended to exhibit a strong preference for its own phenotype. assuming that phone contact rates mirror face-to-face contact rates (as, in fact, seems to be the case [68, 133, 138] ), explorers were more likely to contact an infected individual because they were more wide-ranging in their social contacts. keepers remained buffered by their small social radius for longer. this reinforces the suggestion made earlier that innovations frequently go extinct in structured networks because they get trapped in eddies created by network structuring and risk going extinct before they can escape into the wider world. the role of extraverts in facilitating information flow was also noted by lu et al. [139, 140] in a study of networks parametrized by personality-specific contact rates from the community studied by [125] . they found that information flow was more efficient if the network consisted of two distinct phenotypes (in this case, actual introvert and extravert personality types) than if all community members were of the same phenotype. in large part, this was because extraverts (those who opted to prioritize quantity over quality of relationships) acted as bridges between subnetworks, thereby allowing information to flow more easily through the network as a whole. much of the focus in network dynamics has been on disease propagation. in most models, networks are assumed to remain essentially static in structure over time. this may not always be the case, since network structure may itself respond to both internal threats (stress or deception) and external threats (such as disease or exploitation or attack by outsiders). this is because threats such as disease or exploitation cause a breakdown in trust and trust is, as we saw, central to the structure of social networks. other factors that might cause networks to restructure themselves include a reduction in the time available for social interaction, access to a sufficiently large population to allow choice [128] or a change in the proportion of phenotypes (sex, personality or family size) when these behave differently. methods for studying networks that change dynamically through time have been developed [142] , although in practice these typically reflect past change rather than how networks are likely to respond to future challenges. here, my concern is with how networks might change as a consequence of the internal and external forces acting on them. because of the way relationships are serviced in social networks ( â§4), a reduction in time devoted to a tie results in an inexorable decline in the emotional strength of a tie, at least for friendships ( figure 6) . note, however, that family ties appear to be quite robust in the face of lack of opportunity to interact. figure 6 suggests that this effect happens within a matter of a few months (see also [143, 144] ). saramã¤ki et al. [145] reported a turnover of approximately 40% in the network membership of young adults over an 18-month period after they had moved away from their home town, most of which occurred in the first nine months. a similar effect will occur when there is a terminal breakdown in a relationship. these seem to occur with a frequency of about 1% of relationships per year, though it is clear that some people are more prone to relationship breakdown than others [146] . most such breakdowns occur because of a breakdown in trust [59, 146] . although almost never considered in models of network dynamics, the division between family and friends can have significant consequences for the dynamics of networks, especially when comparing natural fertility (no contraception) with demographic transition fertility regimes (those that actively practise contraception). friendships require significantly more time investment than family relationships to maintain at a constant emotional intensity, especially so in the outer layers [147, 148] , and because of this are more likely to fade (and to do so rather quickly) if contact is reduced [147] ( figure 6 ). family relationships, on the other hand, are more forgiving of breaches of trust and underinvestment. in addition, when family relationships breakdown, they are apt to fracture catastrophically and irreparably [146] , creating structural holes. by contrast, most friendships die quietly as a result of reduced contact, in many cases because they are simply replaced by alternatives. this probably means that, when a network is under threat, friendship ties are more likely to be lost than family ties. this would seem to be born out by casual observation of the response to the covid-19 lockdown: virtual zoom-based family gatherings seem to be much more common than friendship-based meetings. under normal circumstances, the gaps left by the loss of a tie following a relationship breakdown are filled by moving someone up from a lower layer or by adding an entirely new person into the network from outside. saramã¤ki et al. [145] noted that, when this happens, the new occupant of the vacated slot is contacted with exactly the same frequency as the previous occupant, irrespective of who they are. it seems that individuals have a distinctive social fingerprint, and this fingerprint is very stable across time [145] . however, if the opportunity for social interaction is restricted, or there is widespread breakdown in the level of trust (as when many people cease to adhere to social rules, or a culture of deception or antisocial behaviour evolves), then the inevitable response is for networks to fragment as individuals increasingly withdraw from casual contacts and focus their attention on those whom they trust most (normally the alters in the innermost layers of their network). iã±iguez et al. [149] and barrio et al. [150] modelled the effect of two kinds of deception (selfish lies versus white lies) on network structure. selfish lies are those that benefit the liar, while white lies are those that benefit either the addressee or the relationship between the liar and the addressee (e.g. 'likes' on digital media). these two phenotypes differ radically in the effect they have on the relationship between the individuals concerned: the first will cause a reduction in the frequency of contact resulting in a fragmentation of the network, whereas the second often reinforces network cohesion. if networks shrink sufficiently under stress, they may invert (figure 4). there is indirect evidence for this in the effect that parasite load has on the size of communities in tribal societies: these decline in size the closer they are to the equator (the tropics being the main hotspot for the evolution of new diseases), and this correlates in turn with a corresponding increase in the number of languages and religions, both of which restrict community size [151, 152] . at high latitudes, where parasite loads tend to be low and less stable climates make long-range cooperation an advantage, community sizes are large, people speak fewer languages and religions tend to have wider geographical coverage, which, between them, will result in more extensive global networks [151, 152] . similar effects have been noted in financial networks, where network structure between institutions that trade with each other also depends on trust. there has been considerable interest in how network structure might influence the consequences of contagion effects when financial institutions collapse. network structure can affect how shocks spread through networks of banks, giving rise to default cascades in ways not dissimilar to the way diseases propagate through human social networks. although well-connected banks may be buffered against shocks because of the way the effects are diluted [153] [154] [155] much as a well-connected individuals may be buffered against social stresses, a loss of trust between institutions invariably results in the contraction of networks, associated with more conservative trading decisions and a greater reluctance to lend [156] in ways reminiscent of social networks fragmenting in the face of a loss of trust. if effective network size (i.e. the number of ties an individual has) is reduced as a result of such effects, more serious consequences may follow at the level of the individual for health, wellbeing and even longevity. smaller social networks are correlated with increasing social isolation and loneliness, and loneliness in turn has a dramatic effect on morbidity and mortality rates. there is now considerable evidence that the number and quality of close friendships that an individual has directly affects their health, wellbeing, happiness, capacity to recover from surgery and major illness, and their even longevity (reviewed in [96, 157] ), as well as their engagement with, and trust in, the wider community within which they live [114, 115] . indeed, the effects of social interaction can even outweigh more conventional medical concerns (obesity, diet, exercise, medication, alcohol consumption, local air quality, etc.) as a predictor of mortality [158] . most epidemiological studies have focused on close friends, but there is evidence that the size of the extended family can have an important beneficial effect, especially on children's morbidity and mortality risks [159] . these findings are mirrored by evidence from primates: the size of an individual's intimate social circle has a direct impact on its fertility, survival, how quickly it recovers from injury, and ultimately its biological fitness [160] [161] [162] [163] [164] [165] [166] . it is worth noting that dunbar graphs, with their basis in trust, have been used to develop online 'secret handshake' security algorithms for use in pervasive technology (e.g. safebook [167, 168] ). pervasive technology aims to replace cellphone masts by using the phones themselves as waystations for transmitting a call between sender and addressee. the principal problem this gives rise to is trust: a phone needs to be able to trust that the incoming phone is not intent on accessing its information for malicious purposes. safebook stores the phone owner's seven pillars as a vector which can then be compared with the equivalent vector from the incoming phone. a criterion can be set as to how many 'pillars' must match for another phone to be considered trustworthy. the dunbar graph has also been used to develop a bot-detection algorithm by comparing a node's network size and shape with that of a real human (i.e. a dunbar graph): this algorithm out-performs all other currently available bot-detection algorithms [169] . we might ask what effects we might expect in the light of this from the lockdowns imposed by most countries in 2020 in response to covid-19. i anticipate four likely effects. one is that if lockdown continues for more than about three months, we may expect to see a weakening of existing friendships, especially in groups like the elderly whose network sizes are already in age-dependent decline. since older people find it more difficult to make new friends, an increased level of social isolation and loneliness is likely to result, with consequent increases in the diseases of old age, including dementia and alzheimer. second, we may expect to see an increased effort to recontact old friends, in particular, immediately after lockdown is lifted. we already see evidence for this in telephone call patterns: if there is a longer than normal gap before an alter is called again, the next call is significantly longer than average as though attempting to repair the damage to relationship quality [170] . third, the weakening of friendship quality can be expected (i) to make subsequent meetings a little awkward because both parties will be a little unsure of how they now stand when meeting up again and (ii) to result in some churn in networks where new friendships developed through street-based covid community groups are seen as more valuable (and more accessible) than some previous lower rank friendships. finally, we may expect the fear of coronavirus contagion (an external threat) to result in a reduction in the frequency with which some individuals (notably introverts and the psychologically more cautious) visit locations where they would come into casual contact with people they do not know. they may also reduce frequencies of contact with low-rank friends, and perhaps even distant family members, whose behaviour (and hence infection risk) they cannot monitor easily. this is likely to result in more inverted networks, as well as networks focused mainly on people who are more accessible. although this effect will weaken gradually with time, and network patterns are likely to return to pre-covid patterns within 6-12 months, some friendship ties may have been sufficiently weakened to slip over the threshold into the 500 (acquaintances) layer. my aim in this paper has been to introduce a rather different perspective on the social structure of communities than that normally considered in disease propagation models, and to explain the forces that underpin real-world social networks. i have presented evidence to suggest that human social networks are very much smaller and more highly structured than we usually assume. in addition, network size and composition can vary considerably across individuals as a function of sex, age, personality, local reproductive patterns and the size of the accessible population. while casual contacts might be important for the spread of highly infectious diseases [ social time is actually devoted to no more than 15 individuals and this will slow down rates of transmission if physical contact or repeated exposure to the same individual is required for successful infection. both external and 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thank the reviewers for drawing my attention to some useful additional material. key: cord-005242-9g2w16d6 authors: shek, daniel t. l.; wu, florence k. y. title: the social indicators movement: progress, paradigms, puzzles, promise and potential research directions date: 2017-01-11 journal: soc indic res doi: 10.1007/s11205-017-1552-1 sha: doc_id: 5242 cord_uid: 9g2w16d6 this paper is a response to the article entitled “fifty years after the social indicators movement: has the promise been fulfilled?” by ken land and alex michalos (2015) which constitutes a careful review of the historical development of the social indicators movement, utility of social indicators in shaping the concept of quality of life and subjective well-being, and issues deserving social indicators research in future. in this response paper, we join in the discussion by highlighting five issues—progress, paradigms, puzzles, promise, and potential research directions of social indicators research. in terms of progress, while we have accomplished many tasks proposed by solomon et al. (the quality of life, sage, london 1980), some of them are yet to be achieved. regarding research paradigms surrounding social indicators, researchers have primarily used positivistic or post-positivistic orientation to conduct and interpret social indicators research, with relatively fewer studies using interpretive, constructionist or critical theory perspective. there are also several puzzles deserving consideration. these include (a) the use of “other types of evidence”, particularly qualitative data; (b) evaluation of social programs; (c) feasibility of assessing “social progress”; (d) choice of social indicators; (e) interpretation of findings; (f) methodological debates; and (g) explanations for social change. finally, the promise of social indicators research to promote quality of life and potential future research directions of social indicators research are discussed. it is indeed my honor to write this paper responding to the groundbreaking paper entitled ''fifty years after the social indicators movement: has the promise been fulfilled?'' by ken land and alex michalos (2015) . after reading the paper, my immediate reaction is that the paper is an outstanding contribution to the field of social indicators because it carefully charts the history of the social indicators movement and highlights some important future research directions. as it is a ''heavy weight'' paper written by two gurus in the field of social indicators, it is a ''must read'' paper by students and researchers in the field of social indicators research. the paper by land and michalos (2015) is a comprehensive paper that gives both a historical and critical perspective on the social indicators movement. the paper starts by describing the social indicators movement in the 1960s and its evolution in the past half of a century such as the development of different social indicators systems and academic journals. then the authors describe the contemporary state of social indicators, quality of life and well-being studies and conclude that ''numerous composite indices exist at all levels of analysis-from international comparisons to national-level indices to subnational/ regional levels and for various sub-populations' ' (p. 28) and five examples are presented to illustrate such indicators. finally, agenda for future with reference to possible research directions is included in the paper. in this response article, we will add my two cents on several issues, including progress, paradigms, puzzles, promise and potential research directions (i.e., 5 ''ps''). i will discuss the progress of the social indicator movement with reference to the tasks that social indicators researchers should accomplish as described by solomon et al. (1980) . concerning paradigms of research on social progress, we argue that quality of life research in different paradigms generates different pictures on ''social progress''. regarding puzzles in social indicators research, we consider several issues, including the role of qualitative data, role of evaluation in social programs, feasibility of assessing social progress, choice of social indicators to be used, interpretations of findings, methodological debates and explanations for social change. we will then examine, how social indicators research findings can inform policy according to its original promise. finally, future research directions will be highlighted. solomon et al. (1980) suggested a list of tasks to be undertaken at the initial stage of the social indicators movement. it would be interesting to ask the extent to which such tasks are accomplished after roughly 36 years. • task 1-''studying objective life conditions and subjective life quality experience and their inter-relationships'' as pointed out by land and michalos (2015) , many frameworks for measuring objective life conditions have been developed and numerous studies have been conducted. similarly, many studies on subjective life quality experience have been conducted. however, studies on the inter-relationships between these two domains seem not to have been the primary focus in the field. thus, it is important to find ways to align these two domains in future. • task 2-''beyond description of conditions and experiences and to explore relationships amongst interdependent factors'' while models of objective indicators and experiences of life quality have been constructed and tested, more work is needed to explore the ''interdependent'' factors. • task 3-''to examine life quality not just on the societal level but also group and individual levels, and investigate their inter-relationships'' while most of the existing studies have examined quality of life at the societal level, there are comparatively fewer studies examining group and individual life quality. there are even fewer studies investigating the inter-relationships amongst quality of life on the different levels. • task 4-''to understand how individuals and groups participate to create their life quality'' most of the related studies focus on quality of life outcomes (social indicators of outcomes) with few studies examining how people create their life quality and the related process. there is a need to focus more on the human agency. • task 5-''to treat quality of life as a dynamic process than a static state'' although objective social indicators are usually collected over time, researchers usually regard the construct as static state. explanations of the changes are commonly ad hoc in nature. moreover, longitudinal research on subjective life studies is not common. • task 6-''foster cross-cultural comparisons and encourage institutions and international organizations to collaborate'' there are emerging studies examining crosscultural comparisons but the development is still in its infancy (shek et al. 2005a; shek 2010 shek , 2011 . collaboration amongst institutions and international organizations is growing but is yet to mature. • task 7-''to stimulate quality of life research in places without related research tradition'' we have seen some progress in non-western contexts, such as studies conducted in asia (chua et al. 2010; ip and shek 2014) . however, the five illustrative examples given by land and michalos are all projects in english speaking communities. • task 8-''reflection and recognition about cultural differences'' this is a neglected aspect in the movement. social indicators researchers have commonly assumed that the indicators are universally valid, and can be used in different cultures. even though some social indicators researchers recognize cultural differences, the related reflection is not substantial. • task 9-''promoting inter-disciplinary projects'' we witnessed inter-disciplinary collaboration amongst sociologists, political scientists, social workers, and social policy scholars who were more focused on the ''macro'' aspect of quality of life. however, the link between macro and micro disciplines (such as psychology) remains to be achieved. for example, epidemiological studies are commonly conducted in psychology, psychiatry or mental health. however, such findings are seldom mentioned in social indicators research. • task 10-''regard biophysical and social environment and their perception as basic elements of quality of life'' most studies have actually mostly done this. however, the spiritual dimension, despite its importance, is not commonly included in social indicators research. • task 11-''conduct projects that have relevance for decision-makers'' some studies have attempted to do this, although some social indicators research (particularly those involving ranking of different sites) simply promote understanding without much relevance to decision-makers. social science research is inevitably shaped by the research paradigm one adopts (kuhn 1962) . the choice of research paradigm does not only dictate the research methods but also the interpretations of findings (neuman and kreuger 2003) . hence, it is important to reflect about social indicators research conducted within different paradigms. to be simple, we can regard paradigm as a lens through which we can see and understand the reality, such as social progress. it addresses the issue of ontology (i.e., the nature of reality one assumes, including whether it exists or not), epistemology (i.e., the question of ''how do we know?'') and methodology (i.e., ways through which the reality can be known). looking back in history, social indicators research is guided primarily by statistical data and analyses. in terms of paradigm, it is a product within positivism or post-positivism lincoln 1998, 2011) . positivistic or post-positivistic research on social progress demands the use of social science methods involving deductive logic and precise observations with the research objectives of discovering and testing generalizable nomothetic universal laws, which can predict human behavior. researchers adopting a positivistic or post-positivistic paradigm typically assume that social reality is stable over time and preexisting regularities can be scientifically studied. through precise instruments and objective research methods, social indicator researchers can know the reality just like pressing a button of the camera. to maintain neutrality in research, common sense and values do not enter into the picture of positivistic social indicators investigation. while social science has made much progress based on positivistic or post-positivistic paradigms, there is growing dissatisfaction regarding whether it can give a ''true snapshot'' of the reality lincoln 1998, 2011) . first, while positivistic research assumes that we can understand social reality in a ''social vacuum'', there is growing criticism of this ''context stripping'' view and there is a call for contextual understanding of observed social phenomena. second, the dualist assumption of the separation between theories and observations of facts is questionable and many researchers argue that ''facts'' are in fact theory-laden (i.e., thinking shaped by some existing preoccupation). third, the thesis that it is possible to be totally objective may not be tenable because values and facts are value-laden and interdependent. finally, there is the criticism that it is impossible to have impartial observers because inquirers might influence the observation process lincoln 1998, 2011) . while positivists put up theories and test the related hypotheses, interpretive and constructionist social scientists define research studies as attempts to investigate meaningful social action and create as well as maintain understandings and interpretations of people. instead of relying on hypothetical-deductive models and supposedly ''objective'' observations, the purpose of research is to understand social reality that cannot be fully understood in terms of causal laws. as it is assumed that social reality is fluid and there are no preexisting regularities, individual interpretations and social constructions are important. according to this paradigm, common sense is an important source of understanding and values are indispensable in the research process. in contrast to the positivistic practice of using precise measurement, interpretive and constructionist social scientists commonly use interviews, narrative research, natural observations, qualitative studies, and ethnography. hence, profiles based on social indicators are regarded as ''naive realism'' because social reality is always fluid and thus beyond the description by static statistical indicators. statistical models can generate good maps but such maps are without ''blood and flesh'' and ''lived experience'' that cannot help people understand the experience of individuals and social groups. while interpretive and constructionist social science provides an alternative paradigm, through which we can understand social progress, there are several problems associated with this position. primarily, adopting a relativistic epistemology, no objective indicators of social progress are possible, because there can be different interpretations and constructions of the term. second, while interpretive studies can generate unique pictures based on individual or group experiences, how to construct an aggregated and presumably consistent picture on the ''profile'' would be a problem. thirdly, interpretive and constructionist research studies have been criticized as subjective and unscientific. critical social science endorses a critical process of inquiry which attempts not just to look at the ''observables'' (which are superficial illusions) but to examine the underlying structures and processes, which shape the real world phenomena (neuman and kreuger 2003) . besides looking at the underlying power relations that cannot be seen on the surface, critical social scientists help people build a better world for themselves. for example, according to neo-marxian thoughts, growth in gdp does not necessarily reflect social progress because the working class is exploited by the capitalists. in fact, because of its dynamic nature, exploitation, inequalities and injustice cannot be fully reflected in statistical measures. as far as preferred research methods are concerned, although quantitative and qualitative research methods can be used, critical theorists argue against the use of ''dominant'' methods (which create illusory pictures) and favor action research and participative research. obviously, different paradigms have different views on how to use social indicators to perform social auditing. positivistic and post-positivistic researchers would use valid and reliable measures to collect data from large samples to generate information about social progress. using housing and quality of life as an example, indices and profiles of housing affordability have been developed which help to assess the quality of life of the residents. for interpretive and constructionist researchers, instead of primarily collecting figures and statistical profiles, they tend to collect lived stories and listen to the voices of the unheard who are neglected in the mainstream discourses so that the fluid social reality can be better illustrated. using housing quality of life as an example, instead of building up ''profiles'' of housing quality of life, interpretive and constructionist social scientists would attempt to illustrate the subjective experiences of the informants and socially constructed realities in different groups of people on housing experience. for example, they would understand the subjective experiences of those who have to pay high mortgage or live in places with very bad environment, such as sub-divided flats and ''coffin rooms'' (very small rooms in hong kong). finally, critical theorists argue that the profiles related to housing quality of life shown by social indicators may be illusory and misleading. while positivistic researchers chart changes in housing affordability, critical social scientists look at the underlining power relations leading to such fluctuation, which is not only shaped by the home owners and buyers, but also by the interests and power relations amongst the real estate developers (who build the houses), bankers (who lend money to the buyers for mortgage) and the government (who owns the land and makes related regulations). in the seminal work on social indicators, bauer (1966) stated that ''this volume as a whole is devoted to the topic of social indicators-statistics, statistical series, and all other forms of evidence-that enable us to assess where we stand and are going with respect to our values and goals, and to evaluate specific programs and determine their impact'' (p. 1, emphasis added). obviously, there has been an abundance of statistical studies and statistical series in this area in the past 50 years. nevertheless, the use of ''other forms of evidence'' such as qualitative data and mixed-methods data to reflect our position and direction is comparatively less widespread. there are several fundamental features of quantitative research (leung and shek 2011; lincoln and guba 2000; patton 2002a, b) . firstly, its philosophical orientation is positivistic or post-positivistic and it assumes that the nature of reality is independent of human consciousness and that it is governed by causal laws. secondly, it aims at discovering universal laws (i.e. nomothetic emphasis). thirdly, the knowledge is achieved through ''fact accumulation'' where the facts are presumed to be derived from sense-impressions, which are value-neutral. fourthly, the role of research is to explain and predict phenomena using measured variables with reliability and validity as quality criteria. fifthly, quantitative research attempts to confirm theories through testing hypothetical deductive models. lastly, to ensure the objectivity of a study, quantitative research favors artificial research arrangement where the variables can be controlled. concerning quantitative researchers' characteristics, they are expected to be neutral and value free. to maintain objectivity, quantitative researchers should serve as outsiders controlling bias through error elimination and maintaining a distant, detached and neutral relationship with the subjects. on the other hand, subjects are expected to be passive in quantitative research. quantitative researchers also have certain beliefs about the research process: literature review is regarded as fundamental and as the skeleton for theory and hypotheses; operationalization of concepts; structured, predetermined and strictly planned research design; preference for random and representative samples; use of standardized and validated instruments; use of complex statistical analyses; generalization of findings. on the other hand, the philosophical orientation of qualitative research is derived from constructionist and interpretive philosophies which assume that the nature of reality is individually or socially constructed. on the nature of science, qualitative research takes an idiographic stand focusing on individual or group uniqueness. it looks at the nature of knowledge as construction of reality and understanding of meanings and interpretations, which are fluid in nature. qualitative research primarily attempts to induce theories through naturalistic and context-sensitive methodologies. instead of asking researchers to be value free, qualitative research expects that researchers to be reflexive and serve as the research instrument. to ensure context-specific study, qualitative researchers favor naturalistic research arrangements in the real world and regard research as understanding the reality focusing on individual unique experiences and/or group characteristics. for the quality criteria, it highlights trustworthiness and authenticity, including credibility, transferability, dependability and confirmability. concerning qualitative researchers' characteristics, they are expected to be empathetic and sensitive to feelings of people. to gain an in-depth understanding of human behavior, qualitative researchers should serve as insiders with close and empathetic neutrality. at the same time, participants are expected to be active in qualitative research. researchers doing qualitative research believe that in the research process literature review is auxiliary and helps to gain a better understanding of human experiences, and that there is no need to operationalize concepts. the research design should be unstructured, flexible and evolving. there is no preference for random and representative samples, and analyses should be qualitative and thematic. researchers are instruments in the research process. lastly it is believed that in qualitative research the findings should be conceptually generalized. according to flick (2014) , the dominant positivist approach to doing research requires the researchers to be emotionally distanced, unbiased and absolutely objective. however, qualitative researchers argue that it is virtually impossible to be totally value-free or objective. in mainstream social sciences research, quantitative research methods and statistical analyses are the conventional strategies while qualitative methods are regarded as a less preferred option which is less rigorous (flick 2014; griffin 2004; marshall and rossman 2011) . patton (2002c) proposed five sets of criteria for judging the quality and credibility of qualitative research. these include: (a) traditional scientific research criteria (e.g., objectivity of inquirer, correspondence of findings to reality, systematic rigor of research procedures), (b) constructivist criteria (e.g., authenticity, connects and moves the audience, reflexivity), (c) artistic and evocative criteria (e.g., aesthetic quality, creativity, interpretive vitality), (d) critical change criteria (e.g., increase of consciousness about injustice, voices of less powerful group, historical and value contexts); and (e) pragmatic criteria (e.g., utility, feasibility and balanced approach). patton (2002c) pointed out that ''many researchers mix and match approaches'' (p. 271) and he has ''worked with and mixed criteria from all five frameworks to match particular designs to the needs and interests of specific stakeholders and clients' ' (p. 271-272) . the advantages and limitations of using qualitative research have been discussed in the scientific literature (flick 2014; griffin 2004; marshall and rossman 2011; willig 2001) . one of the advantages of using qualitative research is that it can enable researchers to focus on the uniqueness and individuality of the informants (i.e., meaning-making process of the informants). qualitative research best addresses the complexity and multiplicity of individual's lived experiences. the meanings of these experiences are usually understood through in-depth qualitative investigation on informants' frames of reference. this allows the researchers to understand the inconsistencies and contradictions within themselves and across different people. in addition, the face-to-face interactions between the researchers and the informants help develop the relationship of trust and they help to understand sensitive issues. another advantage of qualitative research is its flexible research design. the iterative process of the qualitative research practice helps the researcher situate himself/herself in the field of study and develop more and more knowledge about the field and people in it. in addition, qualitative researchers can explore in detail the experiences, motives and opinions of others and learn to see the world from perspective other than his/her own by using in-depth interviewing. with this new perspective, the long-held assumptions may be challenged and thus recasting reflections (griffin 2004; marshall and rossman 2011) . the more the researchers find out, the wider the perspective and horizons would be formed in the specific field. the third advantage of administering qualitative research is providing an emic understanding of the personal experiences of the informants (lincoln and guba 1985; marshall and rossman 2011; rubin and rubin 2012 ). the qualitative researchers are able to investigate the complexity and multiplicity of the context offers. by situating the researchers in the field and going into the contexts, researchers can elicit multiple constructed realities and study holistically the phenomena and thus obtain the tacit emic knowledge and subjective understandings and interpretations (marshall and rossman 2011; patton 2002a) . whilst qualitative research methods can inquire the processes in particular contexts in considerable depth, sample size in qualitative research is usually small (flick 2014) . the statements are often based on analyses of relations, conditions and process in certain contexts. this rootedness in contexts often allows qualitative researcher a specific expressiveness and thus the knowledge produced might not generalize to other contexts. as such, academics, practitioners or policy makers may not take the related findings seriously (griffin 2004) . recently, some eminent qualitative researchers (see maxwell 2012; flick 2014) set forth some possible ways of mapping out the path from the case to the theory that will allow the qualitative researchers to reach at least a certain level of generalization. another limitation of utilizing qualitative research is that the analysis procedures are time-consuming and therefore expensive (griffin 2004) . while crafting the analyses, qualitative researchers have to carefully examine the recordings, field notes, verbatim and other relevant documents in detail and the process takes quite much time in digging in the depth of the informants' inferences. hennink et al. (2011) alerted the qualitative researchers the significance of this crafting process to gain verstehen, which is to understand the life of the people from their own perspective in their own contexts, though the researchers might spend prolonged time in the field and the analysis process. besides quantitative and qualitative methods, there is also a growing tendency to mix quantitative and qualitative data (creswell 1994 (creswell , 2003 tashakkori and teddlie 2003) . according to datta (1994) , there are five forceful and pragmatic reasons for integrating these two methods: (a) researchers have used both methods for a long time; (b) there are arguments supporting the use of both methods; (c) both methods are supported by funding bodies; (d) both methods and related findings have been used in social policies; and (e) we have learned much from both paradigms. greene et al. (1989) also noted five reasons to combine quantitative and qualitative methods in a single study. first, mixing methods (especially triangulation) can help to seek convergence of findings. for example, it is possible to show by using statistical data and subjective interviews that ordinary people cannot afford to buy a flat. second, complementarity mixed methods study is able to bring out different opinions about a phenomenon. for example, while quantitative housing affordability index suggests that housing is not affordable, qualitative interview data can give some indication how paying the high mortgage affects negatively people's lives. third, researchers can combine qualitative and quantitative methods in a developmental manner where the first method helps to inform the second method. for example, based on the housing affordability index information which suggests that housing is a problem, researchers can then carry out field observations about the lived experiences of people. fourth, mixed methods research can help to deal with contradictions in findings with the emergence of fresh perspectives (i.e., initiation). for example, researchers can use qualitative methods to understand the contradiction observed in the quantitative data, such as increase in income but decrease in happiness. finally, mixed methods can be used to add more understanding to a study (i.e., expansion). for example, qualitative research can be carried out to understand the information provided by the housing affordability index. there are an increasing number of mixed methods studies investigating quality of life. (e.g., mitra et al. 2013) . roy et al. (2015) used quantitative survey, qualitative interviews and participatory approach to construct social indicators of well-being ''by exploring the limits of quantification and considering an alternative action theory'' (p. 689). tonon (2015) also advocated qualitative methodology in quality of life research and proposed mixed methods as the ''third methodological approach'' in quality of life studies, which are guided by some conceptual and methodological criteria (shek et al. 2005b ). besides describing and monitoring social progress, social indicators can also be used as outcome indicators to measure changes after implementation of social intervention. interestingly, two observations can be highlighted on the use of social indicators in the evaluation of social programs. first, comparing with description and monitoring functions of social indicators, the evaluation function of social indicators has been given relatively weaker weight. one possible explanation is that macro social indicators such as indicators at the national level may not be sensitive measures for social programs, which may be more individualistic and community-based. it also takes time for social intervention programs to create outcomes, which can impact on changes in social indicators. nevertheless, for specific areas such as welfare, security and health, social indicators have been frequently used to reflect the effect of social intervention-poverty rates have been used to reflect the effectiveness of poverty alleviation programs; substance abuse rates have been used to reflect community anti-drug programs; infection diseases rates have been used to reflect flu shot programs. second, often social indicators research and evaluation research have been regarded as two separate research areas in the field and the literature has not been seriously addressing the possible linkages between these two domains. program evaluation has been defined by rossi et al. (2004) as ''the use of social research methods to systematically investigate the effectiveness of social intervention programs in ways that are adapted to their political and organizational environments and are designed to inform social action in ways that improve social conditions'' (p. 16, emphasis added). according to patton (2008) , program evaluation is ''the systematic application of research to inform evaluative judgments. it involves the systematic collection of empirical information about the activities, characteristics, and outcomes of programs to make judgments about the program's merit or worth, improve program effectiveness, and/or inform decisions about future programming'' (p. 683, emphasis added). obviously, it is possible to use social indicators on different levels as outcome indicators in evaluation research. the standards and principles in different evaluation models (e.g., american evaluation association 2004; european commission 2003; joint committee on standards for educational evaluation 2008; united nations evaluation group 2005a, b) enlighten researchers in the field of social indicators research on at least two aspects. first, it is important to engage different stakeholders in the process. instead of just involving the experts in the process, other relevant stakeholders should be engaged as well. second, multiple types of evaluation and multiple data should preferably be used to evaluate social programs. different paradigms define social progress in different ways. positivists and post-positivists see social progress as something that can be assessed by social indicators. for interpretivists and constructionists, social progress is either subjectively experienced or socially constructed. hence, static averaged social indicators cannot capture the fluid nature of social reality. for critical theorists, it is possible to chart social progress, but it must be understood in terms of the historical perspective that helps to reveal the underlying contradictions. moreover, the concept of social progress is a rather philosophical one with an evaluative component attached to it. for example, while we enjoy many benefits of industrialization and urbanization, such as systematic provision of public utilities and affluence of material life, we also witness many problems, such as environmental pollution. similarly technological advancement has brought us the internet and smart phones. these technologies have freed many from the traditional working hours, but they have also often brought along increased stress and decreased face-to-face interaction between people. thus, many skeptics would argue that the costs we have to pay for all these social progresses are much greater than the benefits. unfortunately, there is a clear lack of discussion on the value bases of social indicators of the different schemes in the field. assuming that social progress can be measured, the next question that should be asked is what indicators should be used to chart social change. for researchers with different orientations, they have different views on what indicators constitute good measures of social indicators. there are three other issues that should be taken into consideration. first, for many social indicators research frameworks, there is a lack of credible and critical theoretical model. second, while some of the social indicators are common to all paradigms, there are also variations. while it is reasonable to gradually refine the indicators and find out whether it would be possible to use same indicators, the existing variations may also simply suggest that different value judgments are attached to different indicators. third, experts are usually involved in deciding what indicators should be included in a system. according to social constructionists, this is a form of social construction as it would be likely that the selected social indicators would be biased to fit the world views of the experts or elite academics. the choice of indicators is particularly critical when selecting social indicators to measure non-western cultures. for example, in the report titled ''reconceptualizing social indicators in the caribbean: a review and discussion'' (economic commission for latin america and the caribbean 2000), it is noted that a list of ''new indicators proposed by the eclac latin american meeting has been adapted to the caribbean reality for the purpose of inclusion into the framework of existing indicators on the family'' (p. 16). to illustrate this problem further, an example from the european union can be used. atkinson et al. (2002) found in their analysis several properties that should be used in constructing social indicators that help to monitor national performance of the countries in the eu: 1. ''an indicator should identify the essence of the problem and have a clear and accepted normative interpretation. 2. an indicator should be robust and statistically validated. 3. an indicator should be responsive to effective policy interventions but not subject to manipulation. 4. an indicator should be measurable in a sufficiently comparable way across member states, and comparable as far as practicable with the standards applied internationally by the un and the oecd. 5. an indicator should be timely and susceptible to revision. 6. the measurement of an indicator should not impose too large a burden on member states, on enterprises, or on the union's citizens. of these principles, three refer to the portfolio of indicators as a whole. 7. the portfolio of indicators should be balanced across different dimensions. 8. the indicators should be mutually consistent and the weight of single indicators in the portfolio should be proportionate. 9. the portfolio of indicators should be as transparent and accessible as possible to the citizens of the european union' ' (p. 190) . there are at least four further implications that can be drawn from this. first, it is not clear why a ''clear and accepted normative interpretation'' is important and whether it is possible to achieve. second, it is difficult, if not impossible for a social indicator not to be subjected to manipulation because of political consideration and the rise of social media. third, the requirement that social indicators ''should not impose too large a burden on member states'' is problematic because the concept of large is very vague and leaves too much opportunity for interpretation. fourth, the requirement of ''mutually consistent'' is a conceptual ideal only. for example, is the inclusion of indicators of economic development and poverty mutually consistent? the requirement of proportionate weight of single indicators is also unclear because weighting is commonly done in research. as statistical profiles are commonly used in social indicators research, many statistical issues are involved. perhaps a critical evaluation of the human development index can illustrate the existing methodological and conceptual issues highlighted in puzzle 4. for example, chakraborty (2002) argued against aggregation of scores across different domains for several reasons. first, aggregation would lead to a loss of important information because a composite index can contain only the information that the individual indicators are providing. ''it only presents that information in a form that is more convenient, more clearly understandable, and more amenable to some forms of analysis. but in the process, much useful information may be lost. this loss should be weighed against the gain from avoidance of the trouble of handling a large set of data'' (p. 1199). chakraborty (2002) further pointed out that ranking in hdi is problematic because ''even for planning purposes, the usefulness of an ordinal ranking of districts is not very clear'' (p. 1200). as the assessment units in hdi are not measured at an individual level, it is impossible to tell how human development attributes are distributed amongst individuals. finally, chakraborty (2002) argued that hdi only gives a state rather than a process view on human development. according to kovacevic (2011) , there are many criticisms of the human development index, including inability to assess human development accurately, over-simplification based on low quality data, high correlation between different components of hdi and hdi, biases and measurement errors in international data, problems of using composite measures, focusing on averages with under-focus on the vulnerable groups. several measures were proposed to improve the quality of the hdi. klugman et al. (2011) further pointed out several limitations of the hdi. they noted that the hdi was criticized as ''too simplistic, while others who accepted its self-imposed limitations still questioned its choice of indicators and its computational methodology'' (p. 249). there was also a criticism on its lack of conceptual or theoretical basis (p. 259). regarding the choice of indicators, hdi was criticized as excluding other important aspects of well-being such as equity, social justice, political openness, and happiness. besides, the choice of indicators was questioned and there were queries on the choice of using equal weights. although additional measures have been developed paradigms, puzzles… 985 adjusted hdi, the gender inequality index, and the multidimensional poverty index), such measures have not received enough attention from the field. klugman et al. (2011) further presented three reasons why it is not recommendable for societies to try to maximize the hdi. first, the indicators in hdi are not able to reflect various aspects of human development, and also their weighting is problematic. second, focus on capability should not be regarded as the overriding concern. finally, it is very likely that policymakers in any particular country possess much more superior information to help them in decision-making. in response to the criticisms on the human development index several researchers have suggested alternative indicators. for example, pereira and mota (2016) proposed an alternative approach using the electre tri-c multicriteria method. neri (2016) argued for the use of perceived income, health and education to construct the perceived human development index (phdi). one key issue in social science research is interpretation of findings. it is noteworthy that social indicators research (particularly those on social indicators profiles) is primarily descriptive in nature, leaving the question of explanation and interpretation a thorny one. noll (2004) argued that ''using objective indicators starts from the assumption that living conditions can be judged to be favourable or unfavourable by comparing real conditions with normative criteria like values, goals or objectives. an important precondition, however, is that there is a societal or even political consensus about three key issues: first, about the dimensions that are relevant for welfare considerations; second, about good and bad conditions; third, about the direction in which society should move' ' (p. 158) . to illustrate the difficulties highlighted by noll (2004) , we can refer to an example based on divorce rates. can we interpret that an increase in divorce rates is an indication of ''negative'' social development? people with religious beliefs may think so. however, radical feminists and those who are committed to liberation of women might interpret it as a good sign for women to liberate themselves. similarly, can we say that science and technology development brings forth positive social development? with rapid industrialization and urbanization, we witness the global warming effect, which might adversely affect the climate of the earth. in fact, the progress of humans also means worse development or even extinction for non-human species. these examples clearly highlight one important issue surrounding the interpretation of findings of social indicators researchthat value base affects how the findings are interpreted. in future, it would be helpful to further re-think the value choices and priorities in social indicators research. it is difficult to explain changes in social indicators and there are several issues involved. first, for cross-sectional studies utilizing social indicators, it is difficult to locate the causal relationships between changes in policies and social indicators outcomes. because data are collected at a single time point, it would be impossible to ascertain the cause-effect relationship. second, for longitudinal studies using macro social indicators, explanations may become post hoc in nature, if no a priori models are proposed. third, as sample size based on social indicators at the national level is small (such as income per capita in different countries and places), multivariate statistical analyses may not necessarily meet the assumptions of multivariate statistics. fourth, for subjective quality of life studies, it would be easier to propose models because data are usually collected at the individual level. nevertheless, we also need good theoretical models on the determinants of subjective well-being, which are not commonly seen in the field. in short, we need more effort to formulate models that can account for changes in social indicators across time and place. the original idea of social indicators research is to utilize social reporting or auditing to identify gaps in social policies that will lead to social intervention. thus, the problem of whether it is possible to use these findings to make policy and services initiatives arises. there are two observations regarding the potential use of social indicators research. first, application of findings to social intervention appears to be not sufficient. brown and corbett (1997) pointed out that social indicators have five basic policy uses where the ''hierarchical typology of uses which incur progressively exacting demands: description, monitoring, setting goals, outcomes-based accountability and evaluation'' (p. iii). according to noll (2004) , ''while social indicators and social reports have successfully been used as descriptive monitoring tools, their application and use for purposes like setting goals and priorities, or the choice and evaluation of political programs still seems to be problematic and questionable'' (p. 176). fortunately, they also pointed out that there was a rising trend of using social indicators for policy making particularly in european countries. second, while some overarching social indicators such as the ones used in the human development index may not be strongly linked to social policies, social indicators in specific areas have impact on social intervention. for example, in the area of substance abuse, rise in the substance abuse figures in the last quarter would alert the law enforcement agencies to see whether there are any changes in the supply of or demand for drugs and what additional initiatives should be stepped up. similarly, rise in suicide rates among the elderly would prompt the government to re-think about the elderly policies and whether adequate support is given for old people. in the area of health, statistics on infectious diseases would engender quick response from the government to curb the problem as early as possible. in short, the relevance of social indicators related to social problems may capture greater attention of the government than social indicators related to the general well-being of the place. obviously, how those general social indicators can lead to social policies is an important issue to be addressed. in their paper, land and michalos pointed out several limitations in existing social indicators research. these included negligence of human agency, lack of multi-level studies, few longitudinal studies and few initiatives in building theories. they further pointed out that the drastic changes in social and economic structures (e.g., post-industrialization, globalization, digitalization, and rise of social media) have generated interesting topics for future research, such as social stratification, issues related to income disparity and migration issues. obviously, these are important and interesting directions for future research. there are several other areas that researchers in the field of social indicators research may consider (shek 2014) . the first issue is quality of life in the notion of ''uncertain world'' (farber 1999; inglehart 2000; manski 2013) where uncertainty emerging from different domains constitutes excellent research opportunities. regarding economic uncertainties, the economic cycle has become short and economic turbulence such as the financial tsunami in 2008 has become more frequent. besides, vocational uncertainties caused by the use of automation and information technology have reduced the demand for labor and employment opportunities. concerning political uncertainties, with the lost promise of capitalism and socialism, people in different parts of the world are also losing their confidence in the government. in particular, people lose confidence in those governments where welfare expenses and related debts are huge (e.g., greece). for social uncertainties, the emergence of the ''m-shaped'' society (i.e., growing upper and lower class with shrinking middle class) and lack of upward mobility amongst young people are also important social conditions affecting quality of life. besides, growing relationship uncertainties such as rise of marital disruption rates (e.g., divorce rates) and inter-group conflict also have adverse impact on quality of life. culturally speaking, uncertainties surrounding changing values and world views are emerging. with growing materialism, consumption and moral diversity, it is theoretically and practically important to ask how such cultural uncertainties influence quality of life. finally, growing global uncertainties such as health hazards (e.g., sars and ebola virus disease), global warming resulting in more extreme weather conditions, and mass extinction of non-human species also constitute quality of life issues for human beings throughout the world. obviously, issues surrounding the uncertain world constitute excellent research opportunities for future studies on social indicators and quality of life. in fact, research in response to these issues clearly underscores the importance of social indicators research in monitoring the improving quality of life. the second research direction is to promote more inter-disciplinary collaboration. an examination of the current picture shows that social indicators research involves primarily scholars and researchers from the more ''macro'' disciplines, including economics, sociology and political science, although the concept of health-related quality of life is also embraced by psychologists, psychiatrists, nurses, occupational therapists, counselors and other allied health professionals on the more ''micro'' level. it is noteworthy that many studies conducted by such ''micro'' researchers have great relevance to social indicators, such as epidemiological studies on mental disorders and surveys on happiness in different patient populations. hence, how to promote the collaboration between the ''macro'' and ''micro'' researchers would be a challenge. as a start, it would be conceptually stimulating to examine the concept of quality of life and the role of social indicators in different disciplines so that some conceptual integration can be achieved. for example, how we can shape the discourse that epidemiological studies on mental health issues address quality of life issues and that the related findings are regarded as social indicators would be exciting topics for future studies. as social scientists, critical appraisal is important. for positivists and post-positivists, it is important to use logical reasoning and critical debates in understanding human societies. for constructivists and critical theorists, adopting a reflective stand is important. hence, it is indispensable to reflect on some of the fundamental methodological and interpretational issues in the social indicators movement. essentially, we believe that human beings are capable of taking a step backward to ask questions about the reality. in this response article, the progress, paradigms, puzzles, promise and possible future directions 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research qualitative research design: an interactive approach: an interactive approach implementing a multidimensional poverty measure using mixed methods and a participatory framework a perceived human development index social work research methods: qualitative and quantitative approaches social indicators and quality of life research: background, achievements and current trends qualitative research & evaluation methods designing qualitative studies. qualitative research and evaluation methods two decades of developments in qualitative inquiry program evaluation human development index based on electre tri-c multicriteria method: an application in the city of recife evaluation: a systematic approach the challenges of participatory construction of social indicators of well-being qualitative interviewing: the art of hearing data special issue: quality of life of chinese people in a changing world special issue: quality in life research: responses to emerging issues in a changing world applied research in quality of life (arqol): where are we and issues for consideration special issue: quality of life research in chinese, western and global contexts evaluation of evaluation studies using qualitative research methods in the social work literature (1990-2003): evidence that constitutes a wake-up call unesco's policy-relevant quality of life research program handbook of mixed methods in social and behavioral research qualitative studies in quality of life: methodology and practice standards for evaluation in the un system introducing qualitative research in psychology: adventures in theory and method acknowledgements the preparation for this paper is financially supported by the hong kong jockey club charities trust. key: cord-286610-woqb1t06 authors: choukér, alexander; stahn, alexander c. title: covid-19—the largest isolation study in history: the value of shared learnings from spaceflight analogs date: 2020-10-22 journal: npj microgravity doi: 10.1038/s41526-020-00122-8 sha: doc_id: 286610 cord_uid: woqb1t06 the world is currently experiencing the largest isolation experiment in history. in an attempt to slow down the spread of the covid-19 pandemic numerous countries across the world have been shutting down economies, education, and public life. governments have mandated strict regulations of quarantine and social distancing in an unprecedented manner. the effects of these measures on brain, behavior, neuro-humoral and immunological responses in humans are largely unknown. life science research for space exploration has a long history in using high-fidelity spaceflight analogs to better understand the effect of prolonged isolation and confinement on genes, molecules, cells, neural circuits, and physiological systems to behavior. we here propose to leverage the extensive experience and data from these studies and build a bridge between spaceflight research and clinical settings to foster transdisciplinary approaches to characterize the neurobehavioral effects on the immune system and vice versa. these approaches are expected to develop innovative and efficient health screening tools, diagnostic systems, and treatments to mitigate health risks associated with isolation and confinement on earth and during future exploratory spaceflight missions. throughout history infectious diseases have been one of the greatest threats to global public health. viruses have killed by far more humans than other disease, war or natural disaster. the outbreak of the novel coronavirus sars-cov-2 shows that the risk of infectious diseases can rapidly put our health systems to the test and turn the world economy, education, and public life upside down. research is just beginning to understand the full impact of the disease. there is increasing evidence that the current pandemic affects global health and well-being in many more ways than a respiratory disease, including the central nervous system and neurological diseases 1 . the brain's susceptibility to sars-cov-2 could also be a potential risk factor for alzheimer's disease 2 . in addition to the clinical manifestations associated with covid-19, physical distancing policies to control the spread of the diseases have led to large-scale and unprecedented social isolation across the globe. the prevalence of social isolation and loneliness in response to the covid-19 pandemic is currently unclear, with estimates varying between 16 and 25% 3 . it is considered the greatest international biopsychosocial emergency the world has faced for a century 4 . recent research reviewed the psychological implications of prolonged isolation and confinement associated with quarantine, reporting posttraumatic and acute stress symptoms, confusion, and anger in response to quarantaine 5 . the interventions to mitigate the negative effects on mental health and well-being include befriending schemes, individual and group therapies, various shared activity programs, social prescription by healthcare providers, and diverse strategies using information and communication technologies, but their effectiveness and relevance to different age groups remains to be determined 3 . reduced sensory stimulation and sensory monotony experienced in isolated, confined, and extreme (ice) environments are also expected to be a major risk during future spaceflight exploratory class missions 6 . the "absence of environmental stimulation" is expected to account for sleep disruptions, impaired cognitive performance, negative affect, and interpersonal tension and conflict during exploratory spaceflight missions 7 . space agencies and their human research programs have a long history of seeking to understand the effects of isolation and confinement on astronaut health and performance. consequently, developing strategies to mitigate the risks of adverse behavioral conditions and psychiatric disorders associated with human spaceflight are of critical importance 8 . it may therefore not be surprising that the value of shared learnings from spaceflight during covid-19 has been emphasized in numerous news reports and social media channels, providing anecdotal evidence for the parallelism of isolation and confinement in extreme environments and in the current pandemic [9] [10] [11] . here, we summarize the opportunities of spaceflight analogs to accelerate (1) the understanding of the neurobehavioral and immunological consequences of social isolation during the covid-19 pandemic, and (2) the development of innovative and efficient treatment strategies to mitigate adverse behavioral conditions. more than 50 years of research in space has revealed how the unique physiological conditions and stresses of space affect almost every biological system in all kingdoms of life; from plants, to bacteria, to humans. man evolved in a world where newton's apple never fails to fall and at no stage did evolution prepare us for the eventuality that we may one day be exposed to life in zero gravity while confined in a hazardous environment. spaceflight affects the entire human body. the lack of gravity results in considerable bone loss much akin to osteoporosis and muscle wasting 12 , cardiovascular deconditioning 13 , renal stones and kidney dysfunction 14 . however, besides these physiological effects of microgravity and multiple environmental toxicants in space, the psychological stressors are exhaustive and additive: life in a tin can, lack of privacy, separation from friends and family, high workload, operational and interpersonal distress, dietary restrictions, noise, circadian disorders and sleep loss 15 . the development of adverse behavioral conditions and psychiatric disorders during future long-duration space missions (ldsm) are considered one of the most serious, but also least understood risks 6 . isolation and confinement are significant contributors to these unmitigated risks, and can lead to mental health symptoms, impulse control deficits, workplace errors, and even increased mortality 16 . the beginning of the study of isolation and confinement can be marked by polar expeditions, providing anecdotal evidence of the psychological and physiological challenges associated with prolonged isolation and confinement such as sleep disorders, mood disturbances, depression, anxiety, paranoia, and suicide 7 . the european space agency (esa) early recognized the need to study the effects of isolation and confinement on mental wellbeing and performance to enable safe and successful spaceflight. since the 1990s the european space agency (esa) has been consistently sponsoring studies in isolated, controlled and confined analogs (icc), starting with the 30-day campaign "isolation study for the european manned space infrastructure" (isemsi) campaign in bergen norway in 1990 17 , followed by the 60-day study "experimental campaign for the european manned space infrastructure (exemsi) carried out at the german aerospace center (dlr) in cologne, germany in 1992 18 . in 1994 esa cooperated with the institute of biomedical problems (ibmp) in moscow, russia, to further the understanding of the psychophysiological effects of isolation and confinement and extended the duration of the isolation period to 135 days in the "human behaviour in extended spaceflight" (hubes) 19 experiment, and up to 240 days (two crews were isolated for 110 days, and one crew was isolated for 240 days, respectively) in the "simulation of the flight of the international crew on space station" (sfincss) experiment. these studies lay the groundwork for the longest isolation experiment in history, i.e., the mars500 study, which exposed six international crewmembers to 520 days of isolation and confinement in ibmp's nek facility in 2011 20 . the success of the isolation studies at ibmp is now continued in close collaboration with nasa and esa in a series of isolation studies as part of the "scientific international research in unique terrestrial station" (sirius) project 21 . in 2001 nasa started to simulate operations and test spacewalk techniques using a highly unique underwater habitat (nasa extreme environment mission operations, neemo) with mission durations of up to three weeks 22 . since 2013 nasa has also been supporting prolonged isolation studies using an analog habitat hi-seas (hawai'i space exploration analog and simulation) on the island of hawaii 23 . more recently, nasa has been using its human exploration research analog (hera) facility at johnson space center to investigate the effects of isolation and confinement for up to 45 days 24 . except for several russian studies using the nek complex [19] [20] [21] , and chinese experiments in chinese celss (controlled ecological life support system) 25 , laboratory-based isolation studies in isolated, controlled and confined analogs (icc) have often been rather short in duration (<60 days). submariners and antarctic stations can provide excellent opportunities to study the effects of prolonged isolation and confinement in real extreme environments (isolated, confined and extreme environments, ice). despite more than 80 antarctic research stations, only very few qualify as high-fidelity analogs for space research. suitable stations are characterized by a small crew sizes (i.e., <10), extended mission duration of one year or longer, and include complex logistical operations with only limited or no rescue capabilities during the antarctic winter. the complications associated with isolations and confinement depend on a plethora of factors including individual issues such as personality, coping strategies, psychological support, crew dynamics, and mission duration. physical isolation may also not necessarily have any adverse effects per se. physical isolation and perceived social isolation, the subjective distressed feeling of being alone or separated can be related, but physical isolation is not a sufficient condition for loneliness 26 . a common denominator of perceived social isolation is that it translates to physiological stress responses via the sympathetic nervous system and the hypothalamic-pituitary-adrenal (hpa) axis. loneliness has been shown to increase chronic sympathetic tone, oxidative stress, and hpa activation, and to decrease anti-inflammatory responses, and the expression of genes regulating glucocorticoid responses, ultimately leading to glucocorticoid resistance 27 . two organ systems that are profoundly challenged by stress responses pertain to our host defense and our central control: the brain and the immune system. stress can impact nearly any brain region, but one brain structure that is of particular importance is the hippocampus. the hippocampus plays a pivotal role in episodic memory formation, mapping spatial relationships and performing navigational tasks. given the importance of visuospatial abilities during operations such as docking, landing, exploring and navigating in new environments and on planets with low gravity, it is imperative to understand the impact of spaceflight on spatial cognition and its neural basis. because of the high density of corticosteroid receptors in the hippocampus it is not surprising that this brain region is very vulnerable to increased stress levels 28 . both short-and long-term social isolation has been shown to reduce hippocampal long-term potentiation in rodents 29, 30 . the dentate gyrus (dg) of the hippocampus is likely to play a key role in defining the impact of stress on hippocampal functioning. we recently published data on neuroendocrine and brain changes in response to antarctic expeditions at the german neumayer iii station characterized by multiple stressors including environmental deprivation and prolonged physical and social isolation 31 . our data demonstrated considerable decreases in dentate gyrus volume that were associated with changes in key neurotrophins such as brain-derived neurotrophic factor (bdnf). the reductions in dentate gyrus volume were also associated with lower cognitive performance in tests of spatial processing and the resolution of response conflicts test but there was no reduction in performance in other cognitive tests relying primarily on motor speed and attention, and manual dexterity. these data confirm the impact of environmental and social variation on hippocampal plasticity in humans 32 . the distinct changes of the dentate gyrus to environmental deprivation in comparison to other hippocampal subfields is similar to findings from animal models, suggesting a possible link between hippocampal neurogenesis, stress-induced behavioral changes, and environmental deprivation [33] [34] [35] . furthermore, whole-brain analysis using voxel-based morphometry revealed significant decreases in gray matter volume of the right dorsolateral prefrontal cortex (dlpfc), and left orbitofrontal cortex (ofc) after the 14-month expedition 31 . the dlpfc and the ofc are pivotal for executive control such as response inhibition, working memory and cognitive flexibility 36 , but also the generation of and regulation of emotion 37 . projections between the hippocampus and orbitofrontal cortex (ofc), and to some extent also the dlpfc 38 , can foster cross-structural communication, and might interact to influence behavior 39 . data from the icc analog nek also suggest decreases in white matter integrity of the right temporoparietal junction (tpj) after prolonged isolation and confinement 40 . whereas these data need to be interpreted cautiously because of their cross-sectional nature (reductions in white matter integrity were not reported within subjects over time), and a very small sample size, the results raise interesting questions about the effects of sensory deprivation on the brain during isolation and confinement that should be considered in future ice/icc experiments. the right tpj integrates multisensory information and has been suggested to play a critical role for reorienting of attention, i.e., being able to respond quickly to unexpected events in the surroundings, and social processes 41 . we attribute these effects to both sensory deprivation as well as lack of diverse social interactions associated with the prolonged isolation and confinement. together, these data suggest that prolonged isolation and confinement can have considerable, differential effects on brain structures involved in various complex cognitive controls including learning and memory formation, spatial navigation, self-control, planning, problem-solving, and emotional control. notably, these data are characterized by considerable inter-individual differences in their response to social and environmental monotony. in addition, the recovery of these changes is currently unknown. the immune system could be a critical pathway in better understanding the specific neurobehavioral phenotypes. for instance, recent nasa funded research suggests that social isolation influences cytokine levels in the hippocampus 42 . the immune system is among the largest human organs and consists of more than four trillion cells. it affects every organ and influences almost every disease state from infection, to cancer, to cardiovascular disease and bone homeostasis. most remarkable about the immune system is its adaptability to protect us rapidly and efficiently from the pathogenesis and progression of bacterial and viral infections. using an orchestra of innate and adaptive response, it regulates a critical and delicate balance between health and disease. any disruption of this equilibrium can lead to life threatening infections, autoimmune diseases, and cancer. understanding this balance is vital to ensuring adequate immunity and health, which in a case of imbalance can lead to immune aging, viral reactivation, and hypersensitivities/allergies 43 . these gradual and inter-individual effects of psychological and environmental stressors are true for astronauts 44 , overwintering crews 45 and participants voluntarily isolated and confined for the sake of research 46 , and also thereafter, when being re-exposed to everyday life again 47 . at the same this applies as much to people on earth exposed to chronic emotional and physical stress-as it is happening right now around the world as a consequence of the covid-19 pandemic. the parallels between social distancing and isolation and confinement and spaceflight analogs offer opportunities for shared learnings between these settings. for example, shedding of dormant herpes virus in saliva might be a very helpful surrogate marker of immune dysfunction. this could be internationally set and include many cases as clustered in different areas. care points or pharmacies could enable data collections on a consensual basis. in addition, crowdsourcing could be supported by smart phone-based applications collecting self-reported data. an example is the epb (european polar board)-esa project 'choicee' for the monitoring immune deficiencies after isolation 48 , and its potential applicability also in following the impact of infections with sars-cov-2 and the quarantine effects. a caveat of such epidemiological studies is often the lack of pre-pandemic reference data. cross-sectional data from health controls including pre-mission data from spaceflight and spaceflight analogs can serve as a comparison for evaluating the effects of the covid-19 pandemic. data collected before the pandemic could be particularly valuable for establishing such a reference. for instance, the combination of self-reported data, medical records, biospecimen and neuroimaging collected during the previous 6 months prior to the covid-19 pandemic and medical records could be considered either as a reference for between-subject comparisons or extended by follow up data collections, to foster a pre/post comparison within subjects. in particular, investigating brain morphological changes in a longitudinal manner could provide valuable information about the effects of social isolation on the brain plasticity, and verify the data we previously reported in response to prolonged isolation and confinement in extreme environments 31 . further, future isolation and confinement studies of healthy individuals without a history of covid-19 will remain a critical source for maximizing the synergies between spaceflight research and the clinical manifestations associated with social isolation. need for countermeasures against the detrimental effects of isolation and confinement to mitigate the adverse health effects associated with isolation and confinement, innovative countermeasures are critically needed. this need was recognized as early as the one of the first antarctic expeditions. the crew of the belgian expedition "belgica" led by adrien de gerlache de gomery became the first to endure an antarctic winter after being accidentally trapped among ice packs in the bellinghausen sea in 1898. frederick cook's reports from that expedition can perhaps be considered as one of the observations of melancholy and depression observed during prolonged isolation and confinement. to counter these symptoms cook prescribed two actions, which may be considered as one of first exercise and light interventions to treat depression 15, 49 . first, the "baking treatment" had crew members stay in front of the stove's fire for several hours each day 50 . the radiant heat and light associated with the fire were expected to foster relaxation and restoration, and induce positive mood. second, cook requested the crew to take daily walks around the ship to engage in physical activity, which became known as the "madhouse promenade" 50 . about 100 years later, there is increasing scientific evidence about the role of exercise as a means of active release, enhancing brain structure and function, and improving cognitive performance 51, 52 . acute and chronic exercise has also been shown to improve innate and adaptive immunity [52] [53] [54] . recent research highlights physical activity is an important clinical target to sustain and improve mental health during the current pandemic 55 . in addition to exercise, target-specific countermeasures will be needed to specifically address the risks associated with perceived social isolation and sensory deprivation. these could deliver similar restorative effects like the "baking treatment" during the belgica expedition. virtual reality (vr) technologies are likely to play an important role in meeting these requirements 6 . they can foster a "virtual window", i.e., exploring virtual worlds and induce a high degree of a first-person immersive experience of "being there" 56 , which has been suggested to be of central importance for eliciting restorative effects. the positive outcomes of exposure therapies in vr which include mood induction procedures 57,58 , stress reduction 59 , treatment of ptsd 60 , anxieties 61,62 and proenvironmentalist behavior 63 with immersive vr altogether have demonstrated the usefulness of this medium in changing our cognitive and emotional mechanisms. currently, various projects sponsored by dlr, esa, nasa and trish have been investigating the potential of vr as a countermeasure to mitigate sensory deprivation and social isolation. for instance, the nasa sponsored project "hybrid training -a sensory stimulation countermeasure for long duration space exploration missions" combines physical exercise with an interactive virtual environment to enhance sensory augmentation and stimulate brain plasticity during prolonged isolation and confinement 64 . the combination of vr technologies and physical exercise was also recently recognized as a. choukér and a.c. stahn a promising coping strategy to promote health and wellness during covid-19 65 . former astronaut jay c. buckey and his team developed the dartmouth path program, a series of self-help tools designed by to relieve stress, improve mood, and maintain relationships during prolonged isolation and confinement associated with spaceflight. ongoing research currently investigates whether the path program also help people cope with the emotional stresses brought on by covid-19 66, 67 . likewise, the nasa supported project ansible (a network of social interactions for bilateral life enhancement) delivered a multi-modal digital toolset that leverages virtual worlds to provide a space where humans and intelligent virtual agents can be companions, advisors, provided psychological support, and share experiences 68 . it is intended to virtually connect with their family, friends, and the ground crew to provide a sense of social consistency and permanence. another digital resource to support astronauts during exploration class missions is the crew interactive mobile companion (cimon) project supported by dlr 69 . cimon is a virtual voice-controlled interactive assistant that uses artificial intelligence to foster social interactions between humans and machines, and support astronauts during routine tasks. such approaches could also directly translate to immunological benefits. it has become clear that the immune system is not autonomous and is not solely affected by pathogens alone. instead how we feel, how we interact with others, the conditions in which we live all influence its function. this interaction between our social and emotional lives and the immune system take place via the central nervous system. stress-sensitive neural systems and cells together with humoral pathways coordinate immune cell maturation, responsiveness and their interactions 43 . recently, an international team of esa, nasa and ibmp experts proposed a specific and personalized immune countermeasure prescription for prospective astronauts embarking on deep-space voyage 70 . the combination of different physical, medical and behavioral interventions including therapeutics, nutrient-enriched diets, regular exercise, adequate rest, and stress-relief could be expected to go beyond supporting immunologic responses by affecting other organ systems including the central nervous system. in particular, it is possible that the full synergistic potential of the proposed measures could be further enhanced by combining it with some of the behavioral strategies outlined above. along these lines data collected before the pandemic could be particularly valuable for establishing such a reference. for instance, the combination of self-reported data, medical records, biospecimen and neuroimaging collected during the previous 6 months prior to the covid-19 pandemic and medical records could be considered either as a reference for between-subject comparisons or extended by follow up data collections, to foster a pre/post comparison within subjects. in particular, investigating brain morphological changes in a longitudinal manner could provide valuable information about the effects of social isolation on the brain plasticity, and verify the data we previously reported in response to prolonged isolation and confinement in extreme environments 51 . further, future isolation and confinement studies of healthy individuals without a history of covid-19 will remain a critical source for maximizing the synergies between spaceflight research and the clinical manifestations associated with social isolation. spaceflight-related research offers a variety of unique experimental approaches and designs that can foster basic research in life science and drive innovative medical and health-related applications (fig. 1 ). for instance, bedrest studies which can serve as a model for the aging population, and provide highly standardized and controlled conditions to assess the efficacy of new interventions and treatments to mitigate musculoskeletal, cardiovascular, and neurobehavioral risks brought by a lack of physical activity and/or immobilization 71 . likewise, given the specific requirements of spaceflight health monitoring technologies such as size, mass, ease of operation, and non-invasiveness, human spaceflight research programs can promote health technologies on earth. an example is the application of a heat flux-based approach to noninvasively determine core body temperature at the head 72 . the technology was validated and tested in spaceflight analogs and on iss 73, 74 . the system is now available for patient monitoring in the clinical setting because temperature monitoring is critical for treating infections, detecting complications, and reducing postoperative mortality rates 75 . at the same emerging terrestrial biomedical research and technology development can accelerate the mitigation of risks associated with human spaceflight by providing promising new approaches, treatments, countermeasures or technologies that have practical application to spaceflight. the full scope of the synergies between terrestrial and spaceflight applications remains to be uncovered. recent reviews highlight the need to increase the awareness, training, and collaboration of the research community for revealing the true potential of applying these space technologies to global health settings 76 . several space agencies have begun to address this need and developed initiatives to foster productive crossdisciplinary collaboration between universities, non-university institutions, companies, and governmental and international entities. for instance, the dlr initiatives innospace® masters and space2health seek the development of innovative space technologies and services using expertise from various industries combined with existing technologies, services and applications care astronaut health and performance applications. the continuation and extension of these approaches is a key factor to help bridging the gap between experts in spaceflight life sciences, basic life science, and stakeholders in health technology innovation. this is particularly true for mitigating the risks of adverse behavioral conditions associated with isolation and confinement. along this line trish has announced an "industry program 2020" grant call for industry and academic behavioral health experts to contribute towards the development of specific key areas of interest including novel anxiety and stress monitoring techniques, and unobtrusive health monitoring technologies. similar to the oecd council's "recommendation on responsible innovation in neurotechnology" the trish program seeks to provide guidance at each step of the innovation process so that the benefits are maximized and risks minimized. this includes providing companies and pre-companies with (1) access to experts working in space health care and at nasa, (2) rapid technology maturation and de-risking, (3) preparation for transfer to commercial healthcare markets, and (4) pathways to government sales in the emerging space market. "facts are the air of scientists. without them you can never fly" (linus pauling). that is why space agencies are taking research to the skies and are supporting innovative approaches to better understand how the human body copes with extreme conditions, and how this knowledge can be transferred to and benefit the people on earth. here we used the parallels of spaceflight analogs and the covid-19 pandemic to illustrate the value of shared learnings for gaining a better understanding of the neurobehavioral and immunological implications of social isolation and how to mitigate related adverse health conditions. since space research is addressing and increasingly influencing the traditional fields of medicine including neurobiology, clinical immunology, and public health of an aging society, this pandemic, the re-entry to normal life and its aftermath should strengthen current inter-and transdisciplinary collaborative research initiatives between space life sciences, basic biomedical science, clinical applications, and industrial stakeholders to mitigate the negative effects of physical and social isolation in health and disease. such collaborative research initiatives combined with historic data from spaceflight analogs could lead to a better understanding of the cause and effects of social distancing and quarantine on health and mental well-being. they can also provide the basis to develop innovative and efficient health screening tools, diagnostic systems, and personalized treatments to mitigate health risks associated with isolation and confinement. partnerships between space agencies, non-space funding bodies, academic institutions and companies will continue to play an important role to translate research from space to earth and scale it effectively. received: 7 may 2020; accepted: 21 september 2020; neurological manifestations of patients with covid-19: potential routes of sars-cov-2 neuroinvasion from the periphery to the brain neurologic and immunologic 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managing psychosocial problems on longduration spaceflights maintaining psycho-social health on the way to mars and back cimon-the intelligent astronaut assistant-dlr portal specific immunologic countermeasure protocol for deep-space exploration missions bed rest and accelerated aging in relation to the musculoskeletal and cardiovascular systems and frailty biomarkers: a review the double sensor-a non-invasive device to continuously monitor core temperature in humans on earth and in space circadian rhythms in bed rest: monitoring core body temperature via heat-flux approach is superior to skin surface temperature increased core body temperature in astronauts during longduration space missions tcore tm temperature monitoring system safe, accurate, non-invasive applications of space technologies to global health: scoping review the work was supported by the german space agency (dlr) on behalf of the federal ministry of economics and technology/energy (bmwi) through grants 50wb1319, 50wb0919, 50wb1622, 50wb1931, 50wb1915, 50wb1525; and the european space agency (esa, elips and scispace programs, topical team #21183/07/nl/vj). we thank the alfred wegener institute, helmholtz centre for polar and marine research in bremerhaven, germany, and the french (ipev) and italian (pnra) polar institutes for continuous logistical and technical support in conducting research in icc. we also like to acknowledge the support from ibmp, dlr, esa and nasa for their initiatives and research support in studies at the nek and hera space analogs. we thank judith-irina buchheim, hanns-christian gunga and david f. dinges for the constructive discussions. the authors declare no competing interests.a. choukér and a.c. stahn correspondence and requests for materials should be addressed to a.c. or a.c.s.reprints and permission information is available at http://www.nature.com/ reprintspublisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons license, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this license, visit http://creativecommons. org/licenses/by/4.0/. key: cord-031482-atltc10d authors: arkow, phil title: human–animal relationships and social work: opportunities beyond the veterinary environment date: 2020-09-05 journal: child adolesc social work j doi: 10.1007/s10560-020-00697-x sha: doc_id: 31482 cord_uid: atltc10d a species-spanning approach that incorporates clients’ relationships with their companion animals into family genograms, schools of social work curricula, continuing education, interviews, assessments, and interventions offers increased career opportunities, professional and personal growth and development, and a more comprehensive resolution of clients’ issues, social justice concerns, and the prevention of family violence. this article identifies six reasons why social workers should be cognizant of human–animal relationships and introduces nine ways, with action steps, in which social workers can include these relationships into training and practice outside the more developed field of veterinary social work. these venues include: agencies working in child protection and child sexual abuse; children’s advocacy centers and courthouse facility dogs; animal shelters; domestic violence shelters; public policy advocacy; clinical practice; agencies working with older and disabled populations; veterinary sentinels for intimate partner violence; and pet support services for homeless populations. such attention to the human–animal bond can utilize social workers’ problem-solving skills to improve delivery of services, identify clients’ risk and resiliency factors, enhance social and environmental justice, expand academic inquiry, and increase attention to all of the vulnerable members of families and communities. system arousal, and improving physical fitness by providing an impetus to exercise (friedmann, 2019) . there is, conversely, substantial evidence of animal abuse as a potential precursor and indicator of interpersonal violence often linked to child maltreatment, intimate partner violence and elder abuse (arkow, 2015a) . pets occupy central roles in many interpersonal and intrafamilial relationships (turner, 2006) . they may serve as significant others, confidants, attachment figures, and sources of companionship (mcnicholas & collis, 2006) . they can be vital members of an individual's support system and facilitators to foster social capital, trust, civic participation and a sense of safety and community (wood, martin, christian, houghton, & kawachi, 2017) . the relationships between humans and animals in a household may mirror the status of the health and safety of the people in that family (hoffer, hargreaves-cormany, muirhead & meloy, 2018) . inquiring about children's and adolescents' experiences with animals can help social workers address risk and resilience factors. pets' physical condition and behaviors can provide clues to human experiences and family functioning. human-animal relationships are contextual for learning and resilience in the wake of family violence. strengthening these relationships, and helping people better understand their animals' behaviors, can promote well-being in both species and enable people to leverage inclusion and a sense of belonging in community relationships. animal rights arguments about inherent "speciesism" in humans' relationships with other animals should resonate well with social work's commitment to social justice and fighting oppression (national link coalition, 2019a) . this article explores six reasons why human-animal relationships can be significant to social workers' responsiveness to their clients and nine areas outside the veterinary social work environment where an understanding of clients' interactions with animals can be directed into enhanced professional and personal growth, innovative species-spanning solutions, and potential career opportunities. the american veterinary medical association (2018) estimated that 57% of u.s. households owned a pet, including 76.8 million dogs, 58.3 million cats, plus birds, horses and other companion animals. pets are predominantly found in households self-defined as "family" rather than "non-family" and the highest rates of dog and cat ownership continue to be among households with children. primary responsibility for pets' care continues to rest overwhelmingly with the female members of the household. pet ownership rates are higher in rural areas and lower in densely urbanized cities. there are unexplained racial and ethnic disparities in the rates of pet ownership; pets are found in 64.7% of white households, compared with latino/hispanic (61.4%), asian (46.6%), and black/african american (36.9%). some pet owners describe veterinarians as "the other family doctor" (national link coalition, 2019b) . two studies reported that 87% (risley-curtiss et al. 2006a; risley-curtiss, holley, & wolf, b) and 97% (risley-curtiss et al., 2006a, b) of multi-ethnic pet owners agreed that their pets are members of the family. in short, social workers exploring a client's home life and family dynamics may be missing a significant piece of the puzzle if they neglect to inquire about the client's animals and the attachments, relationships, and problems with them. in addition to appreciating a client's individual and familial attachments or antipathy toward pets, social workers can achieve a fuller understanding of a client's connectivity or isolation from the community by seeing human-animal relationships in a social context. social capital (as contrasted with human capital, economic capital, cultural capital, technological capital, or other community resources) is the connectivity among people which enhances cooperation for mutual benefit. the concept was popularized by putnam (2000) describing the networks and other forces that build social cohesion, personal investment, reciprocity, civic engagement, and interpersonal trust among community residents. notably absent, however, from the work of putnam and other social capital researchers was inclusion of the influence of pets in a community (arkow, 2013) . this knowledge gap was addressed by wood et al. in studies in australia (wood, giles-corti, & bulsara, 2005; wood, giles-corti, bulsara, & bosch, 2007 and the u.s. (2017) which reported companion animal ownership to be positively associated with social capital, civic engagement, perceptions of neighborhood friendliness, and a sense of community. the ability of pets to generate interpersonal communications was greater than minor conversational exchanges among dog-walkers: the visible presence of people walking dogs and the impetus dogs provide for people to be outdoors and use park areas ameliorated negative mental health conditions and gave residents a feeling of greater collective safety and sense of community. companion animal owners were found to be more likely to participate in volunteer, school and sports activities, professional associations and environmental campaigns. they were reported to be more likely to vote and to exchange favors with neighbors. arkow (2019a, 2013) proposed a converse, that the absence of companion animals in communities where rates of pet ownership are lower and incidence of animal problems is greater might contribute to less social connectivity and cohesion. levinthal (2010) used geospatial mapping techniques to correlate the distribution and prevalence of animal neglect, abuse and dog fighting in philadelphia with domestic violence and child maltreatment. she reported a highcrime neighborhood seemed to predict animal abuse, and that animal neglect correlated with demographic, cultural, and structural aspects of block groups, suggesting social disorganization may lead to animal neglect. campbell (2019) used geospatial mapping techniques to report direct correlations between animal control complaints and domestic violence incidents in neighborhoods in indianapolis. bruni (2019) suggested a way to push back on "the degradation of our country's civil culture" can be found in walking one's dog in public spaces. dog walks encourage "honest-to-goodness conversations with actual strangers" that leave their owners "feeling a little less isolated, a little less disconnected" and discourage americans retreating into "increasingly homogeneous enclaves." dog-walking encourages mutual courtesy and reciprocal generosity. "when you're about to bend down and scoop up your beloved's odoriferous bequest, there's no snobbery and no timidity, only solidarity," he wrote. there is something immensely powerful about animals that attracts and motivates humans, a force that is especially compelling with youths. whether discussing pet ownership, fascination with wild animals, or imaginary animals, children are particularly engaged, and asking about animalrelated experiences can provide important information and establish a caring persona and a trusting relationship (melson & fine, 2015; boat, 2010) . a pet is a communication waiting to happen. a recurring theme in the literature is that companion animals are what messent (1983, p. 37) first called "social lubricants," icebreakers who facilitate social support and interpersonal communications (garrity & stallones, 1998) . the nonjudgmental nature and unconditional positive regard of human-animal interactions can be a useful bridge for establishing rapport between therapists and clients (arkow, 2015b). because animals slip under the radar of human defense mechanisms, clients who are fearful, traumatized or under stress may be more willing to talk about their concerns for their animals before opening up and describing their own vulnerabilities (melson & fine, 2015) . fawcett and gullone (2001) reported that even the mere observation of animals can result in reduced physiological responses to stressors and increased positive mood. lange, cox, benert, & jenkins (2006) reported animals can introduce a calming effect, stress-reducing humor, increased feelings of safety, experienced empathy, and motivation among adolescents attending anger management sessions. chandler (2005) wrote that discussing pets can easily segue into a discussion about the client's family support system and how well he or she is utilizing personal resources. an interaction with a therapy animal can enhance social workers' listening responses, convey empathy and help the client access feelings. she observed that it is not the mere presence of an animal, but rather the orchestrated child-dog and child-therapist interactions, that can facilitate client motivation and participation, enhance the relationship with the client, stimulate client focus and attention to task, and reinforce positive client change. margaret mead's oft-quoted adage (1964) that "one of the most dangerous things that can happen to a child is to kill or torture an animal and get away with it" has been substantiated with research. a growing body of evidence suggests that bonds formed or broken with companion animals in childhood reverberate and resonate across the lifespan (jalongo, 2004) . childhood acts of committing or witnessing animal cruelty: may be sentinel warnings that a child is living in a dysfunctional environment and may be exhibiting other antisocial behaviors (gullone, 2012) ; are a prime risk factor for perpetrating animal cruelty, bullying behaviors and violence against humans; and may lead to desensitization, decreased empathy, learned maladaptive coping mechanisms, and unresolved feelings of anger, fear and resentment, particularly if the child is also experiencing co-occurring family violence (ladny & meyer, 2019) . correlations between childhood exposure to animal abuse and bullying behaviors have been reported by several authors (for example, see baldry, 2005; gullone & robertson, 2008; henry & sanders, 2007; parkes & signal, 2017; sanders & henry, 2015; vaughn et al., 2011; walters, 2019) . currie (2006) reported that children exposed to domestic violence were three times more likely to have been cruel to animals than children not exposed to intimate partner violence (ipv). there is increasing academic and programmatic recognition of animal abuse and neglect as sentinel indicators of concurrent or future family violence, particularly child maltreatment and child sexual abuse, ipv and elder abuse. social workers may find that when animals are abused people are at risk, and when people are abused animals may be at risk (arkow, 2019b) . emotional attachments to companion animals are often exploited by abusers in violence-prone households to control and coerce victims in domestic violence, sexual assault, child abuse, and elder abuse situations (ascione & arkow, 1999) and fear of leaving a pet behind is a significant barrier that keeps women and children from extricating themselves from abusive situations (roguski, 2012; ascione, 2007) . households marked by ipv have higher-than-average rates of pet ownership and are extreme high-risk environments when animal abuse is also present: nearly 80% of ipv survivors where suspects also had histories of animal abuse feared they would be killed, 76% had been strangled and 26% had been forced into non-consensual sex. multidisciplinary collaborations were seen as critical in prevention, detection and intervention to address substantial risk of harm for all children, adults and animals residing in the home (campbell, hicks, thompson, & wiehe, 2017) . grief over the loss of a pet is a broad, complex construct, which can be complicated by pet owners' perceptions that they have minimal social support sources and negative veterinary interactions (rémillard, meehan, kelton, & coe, 2017) . the loss of a pet through death or disappearance, and the decisions inherent in determining whether euthanasia of a beloved animal companion is necessary and appropriate, can generate significant emotional trauma for human members of families as well as staffs of veterinary facilities and animal shelters (see, e.g., barnard-nguyen, breit, anderson, & nielsen, 2016; carmack, 2003; dunn, mehler, & greenberg, 2005; laing & maylea, 2018; miller, prout, rourke, lefkowitz, & boyer, 2014; ross, 2005) . social workers who have had training in grief and loss theory are well positioned to be resources for individuals experiencing these emotions and can aid them in making difficult decisions and navigating the options available. because pets generally have shorter lifespans than humans, families are likely to witness significant life-cycle events such as birth, serious illness and death of their animal companions, who are often seen by children as peers and family members. the inevitable death of a pet can bring a profound sense of loss, with patterns of bereavement similar to those experienced with the death of a human family member or friend, and thus an opportunity for social work intervention. several studies have reported that by adolescence the majority of children have experienced pet loss through death or disappearance (melson & fine, 2015) . social workers can play important roles in offering grieving clients opportunities for validation of their feelings, memorialization of the animal, resolution of potential feelings of guilt, and closure. social work's interest in human-animal relationships has its origins in the practitioner-client-patient dynamics of the veterinary hospital or clinic. from modest beginnings at the veterinary hospital of the university of pennsylvania in 1978 (quackenbush, 1981; quackenbush & glickman, 1983) , the field of veterinary social work has grown dramatically in recent years. the term veterinary social work is believed to have been coined in 2002 by elizabeth strand, founding director of the veterinary social work certificate program at the university of tennessee-knoxville. today, dozens of students have been trained in the four areas of veterinary social work: the link between human and animal violence; grief and loss; animal-assisted interactions; and compassion fatigue management. this work may include: • supportive grief support and counseling with end-of-life decisions and follow-up. • advocacy and brokering of resources. • circulating reading materials and educational packets. • crisis intervention. • assessment of suicidal tendencies, mental health issues and domestic violence issues. • facilitation of a pet loss support group for hospital clientele and the community. • staff debriefing sessions. • client consultations and follow-up. • presentations to staff. • referral of mental health services for staff. • recommendations to administrators. • making improvements to client comfort on-site. (larkin, 2016) as the field of veterinary social work gains additional recognition both within and outside the world of social work, additional opportunities will continue to emerge whereby an understanding of human-animal relationships becomes a valuable asset in many aspects of social work practice. this process can begin with something as simple as routinely including pets in family genograms and adding relevant coursework in schools of social work and continuing education as well as field placement opportunities. by demonstrating additional opportunities for social workers to include human-animal relationships in interventions and assessments and to be aware of community resources that can resolve clients' animal-related concerns, social workers can be more holistic and effective in resolving clients' needs and challenges and preventing further abuse of vulnerable members of families and communities. social work's legacy of facilitating collaborative community change can open up many new career opportunities by incorporating human-animal relationships into social work practice. inquiring about the presence (or absence), stability (or turbulence), attachments, dangerousness, history, and status of animals within clients' lives can help social workers to obtain more comprehensive family assessments, validate important intra-familial relationships, build stronger support networks, support resiliency, gain earlier recognition of abusive behaviors, and address clients' animal care concerns with practical, appropriate and affordable solutions. these emerging opportunities include: despite the social reformer origins of child protective services established by humane societies and spcas in the latter third of the 19th century (hoy-gerlach, delgado, sloane, & arkow, 2019), there is a peculiar and unfortunate irony in that child and animal welfare agencies today operate wholly independently with little to no trans-species cross-fertilization of ideas, information or collaboration (arkow, 2010; walker, 1980; zilney & zilney, 2005) . this inter-agency communications gap can have tragic consequences, as with a case in brooklyn, n.y. in which a child whose family was under investigation by child protective services was killed by a dangerous dog in the home (baker & stelloh, 2011) . the author has heard anecdotally of three children under the aegis of child protection agencies in oxford, fla., and st. john, n.b., canada, who were killed by pet snakes. the potential impact of animals in the lives of children cannot be overstated and warrants expanding the ecological lens of child welfare work to include animals (risley-curtiss, 2013). companion animals are found in 67.7% of households with children under age 6 and 74.6% of households with children over age 6 (avma, 2007). melson (2001) reported that pets are more likely to be a part of children's growing up than are siblings or fathers, and that animals are pervasive in children's media, stories, imagination, and play. she reported that words for different animals-dog, cat, duck, horse, bear, bird and cow-are among the first 50 words that toddlers learn; children include dog and cat in their initial productive vocabularies more than any other words except mama and daddy. an estimated 80 to 90% of children first confront the loss of a loved one when a pet dies, disappears, or is abandoned (melson & fine, 2015) . melson (2013) reported that children, from an early age, view animals as living actors who have autonomy, intentionality and feeling. children are often animals' caregivers; since opportunities for and encouragement of nurturing others are rare in childhood, nurturing animals makes up a large proportion of childhood caregiving experiences. because caring for pets is gender-neutral, companion animals may develop innate nurturing skills in boys and feelings of mastery and self-efficacy among children who feel dependent and powerless. many children turn to their pets for reassurance and emotional support during times of stress. companion animals may assist children in feeling security and unconditional love and contribute to a child's cognitive and language development (risley-curtiss, 2013) . companion animals may be sentinels of unsafe environmental conditions, mirroring family tensions and serving as cues in assessments that explore family issues. as one of the sub-systems within a complex family system, the inclusion of questions and observations about the current and past presence of animals in a child's environment, the meaning those animals have for each family member, their care, and whether any of them have been killed or hurt can be important to effective family-centered practice (risley-curtiss, 2013) . children may feel safer talking about their pets' experiences before they disclose their own, thereby opening a friendly channel where children can provide important information (melson & fine, 2006; boat, 2010) . introducing therapy animals into the interview process can further advance this process, easing the stresses of such sessions, establishing rapport, providing the child with a sense of comfort, and creating a less threatening environment (menzies, 2003) , particularly in working with sexuallyabused children (reichert, 1998) . of particular concern is the nexus of animal sexual abuse or bestiality with child sexual abuse. edwards (2019) reported 31.6% of animal sex offenders also had histories of sexually offending children or adults and 10.8% had prior convictions for child pornography. her survey of 456 offenders arrested for bestiality between 1975 and 2015 found at least 213 children and 28 adults had been directly sexually victimized by the offenders, and that in 25 arrests (5.5%) animal pornography had been used to groom a child for sexual behavior. the canadian centre for child protection (2018) reported significant overlaps of animal and human sexual abuse in a study of 38 cases of bestiality. in 82% of cases, sexual abuse of children occurred as frequently as, if not more frequently, than coerced sexual abuse of an animal. in 68% of cases involving both child and animal sexual abuse, the offender was in a position of trust over the child, usually a close family member. child welfare workers can obtain more accurate and useful assessments of child safety and well-being by taking several steps: • in conducting child welfare checks and ongoing case management, look for: potentially abused, neglected or dangerous animals (e.g., aggressive dogs, poisonous reptiles, exotic species, dog-and cock-fighting paraphernalia); animals needing veterinary care; excess numbers of animals; and inadequate food, water or shelter. animal health issues such as fleas or other parasites could have a direct impact on the health of the humans in the home. include these findings in evaluations of the child's living environment, lifestyle and risk factors as potential threats to the child's well-being. such conditions may also be illegal under a jurisdiction's laws. • consider a turbulent history of frequent turnover of animals as potential indicators of a family's inability to make strong, lasting emotional attachments. • include the child's emotional attachment to pets as a key support which may help build resiliency and a protective factor that mitigates. treat the death or disappearance of animals as potentially as emotionally charged as the death of a human family member. • identify whether the child has been traumatized by witnessing or causing the abuse or death of animals. • consider animal maltreatment as a factor that supports a finding of child abuse or neglect. • report suspected animal maltreatment to the animal control/services, humane society/spca, or law enforcement agency in that jurisdiction. 1 the reporter need not prove that animal abuse occurred, but rather introduces the case into those agencies' investigative systems to vet the information and follow through as appropriate. confidentiality restrictions may be waived in reporting to another such law enforcement agency, or when the welfare of the client and others in the household is threatened. establishing channels of communication with animal welfare agencies in advance can simplify the cross-reporting process when a case of suspected abuse occurs. • a history of animal cruelty, and a child's emotional attachments to animals, may have evidentiary importance in court trials, dispositions and hearings involving child maltreatment, custody, visitation, removal, and protection orders. by asking three simple open-ended questions, social workers can learn much about a child's experiences with the animals and humans who share his or her environment: • are there animals at home? • how are they cared for? • are you worried about their welfare? follow-up questions about their names, breeds, play activities, deaths or disappearances, recent health problems or injuries, and secrets the child shares with them may fill in details of the family dynamics, patterns of power and control, and risk and resiliency factors in the child's life. facility animals in children's advocacy centers, casa (court appointed special advocates), guardians ad litem programs, and courtrooms provide emotional support to sexual abuse survivors as they undergo forensic examinations, re-live their experiences, and confront their abusers (labahn, 2015) . as of may, 2020, an estimated 238 dogs are working in courtrooms and children's advocacy centers in 40 states, plus others in canada, australia, chile, and europe (courthouse dogs foundation, 2020a , 2020b , 2020c . elaborate precautions prevent handlers from violating client confidentiality and keep the dog's presence from adversely eliciting sympathy from a jury. judges must balance the accommodation for a vulnerable witness with the potential for prejudice which could impact the defendant's right to a fair trial. extensive guidelines on best practices protect the interests of the animal, the victim, the defendant, and the criminal justice system (courthouse dogs foundation, 2015) . social workers in victim services can be trained to be facility animal handlers or secondary dog handlers to allow the children to spend more time with the dogs after concluding their testimony. they can facilitate interactions between the dogs and distraught family members and stressed facility staff and be resources who connect individuals and institutions with facility animals in their community. nonprofit animal welfare and governmental animal control agencies have historically operated in isolation outside the purview of human services agencies, leading to a "silo" effect in which cross-disciplinary and trans-species collaborations rarely occur (becker & french, 2004) due to increased specialization, avoidance of "mission creep" and fear of violating confidentialities. consequently, interagency cooperation and cross-training is minimal, resulting in a significant barrier to change. meanwhile, animal shelter workers experience significant stressors including animal suffering and euthanasia, responsibility for life, abusive clients, negative public perceptions, and attachments to animals under their care (schneider & roberts, 2016) without recognizing that their counterparts in human services often experience similar stressors. this lack of knowledge and coordination among community systems constricts the potential for creative and effective collaborations and can increase the risk of harm to people and animals in situations where both human and animal abuse co-occur. social workers can facilitate bridging these segregated service delivery systems through the profession's longstanding commitment to community-level action, intervention and change. social workers can work with animal shelters to organize species-spanning community coalitions, link organizational champions, and connect consumers and professionals for the well-being of underserved and at-risk individuals and family members (long & kulkarni, 2013) . social workers can help animal shelters build capacity by coordinating inter-disciplinary interaction and communication, gathering data, conducting research, and building resources. increasing cross-systems knowledge and promoting individual and institutional relationships across systems, particularly vis-à-vis cross-reporting animal, child and elder abuse, can protect vulnerable 1 unlike coordinated state-run child protection systems, animal protection is handled exclusively on the local level by a fragmented patchwork of independent government animal control/services agencies, municipal/county law enforcement, and nonprofit humane societies/spcas. a national directory of animal abuse investigation agencies in over 6,500 jurisdictions is available at https ://natio nalli nkcoa litio n.org/how-do-i-repor t-suspe cted-abuse . populations and develop stronger community services (long & kulkarni, 2013) . numerous animal shelters, often working with juvenile and adult detention centers, have implemented animal-assisted therapy interventions where individuals who have offended, or who are at risk, train dogs with behavior problems who are at risk of being euthanized. using positive reinforcement techniques, these programs teach teamwork, non-violent conflict resolution and collaboration skills to save animals' lives and modify the behaviors of abusive and traumatized individuals (arkow, 2019b). animal shelters appear poised for such systemic change. the service philosophy in the animal shelter community is evolving to recognize that treating the symptoms of animal welfare problems, such as animal homelessness, abuse and neglect, is only a stopgap solution: to be truly effective, underlying community and family dysfunction and violence must be addressed (petlynx, 2011). hoy-gerlach et al. (2019) described promising opportunities for social work field placements in community animal shelters, including: reducing staff and volunteers' compassion fatigue in an exceedingly difficult and emotionally draining work environment; placement of shelter pets as emotional support animals; strengthening community responsiveness to violence through assessing overlaps and differences between child, elder and animal abuse investigations; creating and implementing educational programming across child and animal protection systems; and increasing community awareness of the link between violence to animals and violence to humans. animal control and humane officers frequently have access to pet owners' homes in the course of their investigations, and in the process may observe conditions detrimental to the welfare of children, youth and others. in addition, cruelty investigations which result in the removal of animals from a home could be an additional stressor on the family system and could lead to increased risk for vulnerable family members. social workers can train shelter personnel on the intersectionality of animal abuse and human violence and the procedures for making referrals to social services agencies. other untapped social work opportunities in animal shelters might include: strengthening collaborations with domestic violence shelters and mobile meals programs; directing and expanding pet visitation programs for long-term care facilities and animal-assisted interventions for at-risk populations; developing pet loss grief support groups; developing safety net supportive programming for individuals who experience a medical, economic or housing crisis that temporarily makes it difficult to keep an animal; defusing contentious confrontations with shelter clients; resolving customers' complaints and needs for services; and connecting pet owners with community resources, such as low-cost pet and veterinary services, animal behavioral counselors, pet food banks, and social services agencies. social workers provide essential services to survivors of intimate partner violence and their children in numerous ways, including advocacy, practice and public policy. they serve as advocates in women's shelters, criminal courts, protective order offices, hospital ers, police victim services units, government and nonprofit agencies, military family advocacy centers, fatality review teams, and elsewhere. their work encompasses crisis intervention, investigations, counseling, case management, legal services, public policy, and referrals to and liaison with community resources. all of these aspects of social work practice can take on an additional dimension by incorporating human-animal relationships into the perspective. research findings suggest that in working with pet-owning domestic violence victims, social workers must consider the welfare of the women's pets in order to effectively help the women achieve safety for themselves and their families (strand & faver, 2005) . domestic violence shelters in the 1990s began raising awareness that significant numbers of survivors (usually, but not always, women) and their children are either turned away from safehouses that will not accept their pets or are refusing to leave abusive situations for fear of what would happen to their pets if they left. these fears range from the mundane-that no one remaining at home would provide adequate care-to the tragedies of seeing animals tortured and killed in an emotional extortion that warns partners that they themselves could be the abuser's next victims. the issue reached national awareness in 2006 when susan walsh, 50, told legislators in maine that her husband had retaliated against her and her children and prevented her from leaving a frightening relationship by killing her pets and farm animals: "it wasn't just the cats and the dogs i had, it was the sheep and the chickens -i was terrified for their welfare. i knew if i were to leave, he wouldn't hesitate to kill them. he had done it before." (belluck, 2006) . to address the problem, then-gov. john baldacci signed into law the first of what are now laws in 35 states plus puerto rico and the district of columbia specifically allowing courts to include pets and, in some cases, livestock in domestic violence protection-from-abuse orders. these allow courts to grant petitioners exclusive care, custody and control of animals, and to forbid respondents from harming, taking or disposing of animals or even coming near them (national link coalition, 2019c). abusers' obsessive jealousy and control can become a manipulative tool for power over partners and children by exploiting the vulnerability their emotional attachment to pets. 71% of battered women reported that their abusers had harmed, killed or threatened animals as coercive control (ascione, weber & wood, 1997) . 25% to 40% of abused women delay seeking safety in fear for the welfare of their animals (mcintosh, 2002) . 41% of ipv offenders had histories of animal cruelty (febres et al., 2014) , which is one of the four strongest risk factors for becoming a batterer (walton-moss, manganello, frye, & campbell, 2005) . animals are chosen as soft targets because abusers believe that they can get away with it because police generally don't care about animal abuse (roguski, 2012) . when perpetrators of ipv also have a history of animal abuse, victims experience 20 to 50 violent incidents before contacting police and the risk of lethality to first responders doubles (campbell, thompson, harris, & wiehe, 2018) . the risks encapsulated in these and similar findings are further escalated vis-à-vis the impact on children in these households: 87% of coercive ipv animal abuse incidents occurred in the presence of the woman; 75% occurred in the presence of the children (quinlisk, 1999) . 32% of domestic violence survivors in shelters reported their children had also harmed animals, repeating the intergenerational cycle of violence (ascione, 1998) . batterers have been reported to sexually abuse animals, threaten pets to get children to do something, or force the child to kill the pet (jury, thorburn, & burry, 2018) . the national link coalition (2017) modified the "power and control wheel" frequently used to graphically depict the dimensions of domestic violence to demonstrate how animal abuse is incorporated in abusers' coercive control tactics, as shown in fig. 1 . in response to these situations, domestic violence shelters are developing collaborative foster care programs with local animal welfare agencies to provide off-site "safe havens" for the animal survivors, thereby removing one barrier that prevents families from escaping abuse (ascione, 2000) . more recently, a program called saf-t-sheltering animals and families together-is helping more than 200 domestic violence shelters in the u.s. and other countries build co-sheltering facilities for pets to keep all family members together and safe (phillips, 2019) . grant funding is available to help shelters with capital costs and survivors with veterinary and boarding expenses (national link coalition, 2019d). these concerns dictate bringing social workers into the planning process for innovative and collaborative intakes, assessments, responses, and referrals that incorporate human-animal relationships. serious gaps often separate domestic violence and animal shelters: although concern for the safety of pets and livestock is a barrier to individuals leaving situations of ipv in urban and rural areas, one study reported that 76.92% of animal welfare representatives and 53.33% of human service representatives, respectively, reported no collaboration between their agencies (saskatchewan spca & stops, 2016). acts of animal cruelty in mental health assessments and rehabilitation of abusers and in the specialized domestic violence assessment of risk to children. • including relocation of pets in domestic violence agencies' safety plans (national link coalition, 2014). • obtaining information from local animal welfare and control agencies about prior investigations at the household. • inviting animal-assisted therapy teams into shelters to help comfort survivors. • counseling children regarding incidents of animal maltreatment, death or disappearance of pets that they may have witnessed or committed. • developing community education campaigns to alert the public and cross-train professionals about how animal abuse is linked with ipv. veterinarians, in particular, whose staffs and clients are predominantly female, should begin to recognize a responsibility to serve as resources for survivors of ipv (larkin, 2018; newland, boller, & boller, 2019) . the well-established role of social workers as advocates for social justice provides additional opportunities to advance legislation that recognizes human-animal relationships, the beneficial aspects of pet ownership on individual and community health and well-being, and the adverse effects of animal abuse on human welfare and safety. as an underserved population, animals are classified as property and have long been ignored by the legal system; legislators frequently trivialize campaigns to protect their interests for the simple reasons that animals don't vote and human concerns are widely viewed as being more pressing. however, recognition of the foundation that animal abuse is linked to human violence and therefore improving animal welfare improves human society is generating a new respect for animal welfare legislation. current relevant public policy issues include legislation that would: • allow courts to include pets and/or livestock in protection-from-abuse orders (currently enacted in 35 states, puerto rico and the district of columbia) (national link coalition, 2019c). • allow courts to award custody of pets in divorce and marriage dissolutions based upon the animals' best interests, similar to long-standing similar provisions affecting child custody (four states). • redefine animal abuse when committed as coercive control as also being an act of domestic or dating violence (11 states). • allow acts of violence against animals to be included in criteria for extreme risk protection orders that bar domestic violence abusers from obtaining firearms. • allow courts to appoint pro bono advocates to represent animals' interests in criminal cruelty cases, similar to established court appointed special advocates (casa) provisions for children (three states). • mandate or permit child welfare, adult protection and animal services agencies to cross-report incidents of suspected animal, elder and child abuse to each other, and veterinarians to report suspected animal, child and elder abuse to appropriate agencies, with immunity from civil and criminal liability and professional disciplinary sanctions. • increase penalties for bestiality (now often considered animal sexual abuse) based upon increased evidence of its co-occurrence with child sexual abuse and child pornography. as of august, 2020, having sex with animals is still legal in hawai'i, new mexico, west virginia, and wyoming. • increase penalties for acts of animal cruelty when committed in the presence of a child or adolescent. clinical social workers may become aware of clients' human-animal interactions through recognizing a client's attachments and issues vis-à-vis the animals in his or her environment and by introducing animals for therapeutic purposes to enhance the client-practitioner relationship. in one of the earliest writings on the nexus of social work and human-animal interactions, netting, wilson, & new (1987) outlined seven ways in which social workers can contribute to human-animal bonding: • being sensitive and supportive in counseling clients who have pet-related problems. • being aware of clients' relationships with their pets and assisting in locating support services that include pet care. • being aware of policies that affect pet ownership, such as restrictive housing conditions, and advocating for clients' pet-related interests. • assessing clients to determine their readiness to accept pet-related interventions. • being critical of how pet-related programs are developed and collaborating with animal professionals. • acknowledging potential benefits and problems which may accompany pet-related programs. • linking veterinarians into the human services referral network. more recently, silverman (2018) published a brief guide to ways in which social workers can utilize animals as a bridge between a therapist and patient in private practice. animals can expedite rapport building with patients who have issues with attachment disorders and enhance the motivation to attend the session which improves retention and treatment outcomes. animals may function as a surrogate of the therapist and allow for more ethical therapeutic touch, which could be a corrective experience for those with histories of trauma. fostering the human-animal connection may help patients identify sustainable, long-term support to manage symptoms and maintain functioning after the therapeutic relationship with a clinical social worker has ended. she identified four categories of animals utilized in a helping capacity: • service animals, which are individually trained to do specific tasks for a person with a physical or sensory disability. clinical social workers may recommend that a patient consider having a service animal and identify resources to obtain one. • emotional support animals, a newer and vaguer category, that provide emotional benefits to a person diag-nosed with a mental health disorder that impairs or limits functioning in one or more life domains. • comfort dogs, introduced in disaster responses to offer a calming presence to survivors and first responders. • animal-assisted therapy animals, professionally evaluated to be introduced in treatment plans with intentional, goal-directed activities to complement traditional interventions. social workers should note that spouses and partners may be jealous of a disabled individual's dependence upon and emotional attachment to a service animal. also, the emotional support animal system has a potential for egregious abuses by individuals getting their animals so designated solely to accompany them on airplane flights; online services will provide such documentation from mental health professionals who have never examined the client. human-animal bonds may be particularly robust with older clients and present unique challenges. for individuals who are socially isolated, pets may be a significantly vital source of companionship and emotional support. caring for a pet may be an especially strong motivator for a client to get out of bed, have a daily routine, nurture another being, or go for a walk. the animal may be a last link to a deceased spouse (arkow, 2015a). human-animal social work issues relevant to older adults include: • animal neglect: more than 92% of adult protective services respondents to a national survey reported animal neglect coexisting with a client's inability to care for himself/herself, indicating that reports of animal neglect may be an important warning sign for vulnerable adults' self-neglect (lockwood, 2002) . animals may be neglected by frail elders who lack financial resources, transportation, or physical or mental capacity to care for them adequately (peak, ascione & doney, 2012 ). • self-neglect: frail elders may neglect their own needs by spending limited financial resources on their animals' food and medications. some may refuse to go into hospitals, assisted living or long-term healthcare facilities unless provisions are made for their pets (boat & knight, 2000) . • coercive control: in more than two-thirds of domestic/ elder abuse cases, the perpetrators were family members who may neglect or abuse the elder's pet as a form of control or retaliation, out of frustration over their caretaking responsibilities, or as a way to extract financial assets from the victim (humane society of the u.s., 2005). • bereavement: isolated seniors may experience profound grief and depression upon the death of a beloved pet. some seniors are reluctant to replace departed pets in fear that the animals will outlive them (boat & knight, 2000) . many older adults, particularly the widowed and elderly, are at risk of emotional trauma and experience significant disruptions in eating, sleeping, job-related responsibilities and other daily routines and decreased socialization behaviors following the death of a pet (quackenbush, 1984) . • denied services: home health aides, social workers and other caregivers may be reluctant to enter seniors' dwellings if they fear the presence of aggressive animals or deteriorated environmental conditions linked with animal hoarding or neglect (boat & knight, 2000) . • animal hoarding: animal hoarders may come from any cohort but they are statistically over-represented by older women (patronek & nathanson, 2009 ). animal hoarders (and their children) often live in unhealthy environments surrounded by dozens and even hundreds of living and deceased animals in states of neglect, starvation and suffering. stereotypical hoarders, often labeled as "cat ladies," have been reported as living in a self-fulfilling cycle of social isolation: they gravitate towards animals because they are uncomfortable around people, and other people choose not to associate with them because of their excess number of animals. many are experiencing mental health issues and a collaborative, multi-agency response is invariably required (patronek, loar, & nathanson, 2006) . nathanson (2009) , in identifying four core barriers that limit adult protective services workers' involvement in these cases, called animal hoarding one of the most perplexing and problematic human-animal relationship and a deviant behavior associated with extremely deleterious conditions of comorbid animal and selfneglect. she identified training programs that can better prepare human services professionals to respond to these clients and engage in trans-species and interdisciplinary efforts essential for the safety, health and well-being of the hoarder, human and animal dependents, property, and community. social workers, whether in private practice, nonprofit organizations or governmental adult protective services agencies, can recognize the import of these human-animal relationships, locate support services for the animals and make appropriate referrals including temporary foster care and other pet services for owners who are in need of hospitalization, long-term care or other social services. social work input on multidisciplinary teams can help to resolve the particularly challenging psychosocial aspects of animal hoarding. and social workers should be attuned to the potential that a client's requesting a veterinarian to have all of his or her pets euthanized is a potential sentinel warning sign for suicidal behavior. social workers can help train veterinarians in recognizing this warning sign and responding with appropriate referrals. an emerging frontier is exploring veterinary medicine's response to suspected domestic violence. an incident in deland, fla. in 2018, when a woman being held captive at gunpoint by her abusive boyfriend was able to alert veterinary staff who in turn called the police (robbins, 2018) , brought to national attention what was just beginning to be discussed in professional journals: how should veterinarians and their staffs, the majority of whom now are women (kelly, 2017) , respond to suspected domestic violence in their clientele? (newland et al., 2019; larkin, 2018; allison, satterwhite, ramaswamy, hynek, & agnew-svoboda, 2017) . veterinarians in the united kingdom and new zealand have taken the most proactive responses in addressing this concern. medics against violence, a scottish collaborative of human and veterinary healthcare professionals, created a domestic abuse veterinary initiative to train veterinarians to help pet owners needing to escape domestic violence; the initiative was featured in a british veterinary association guidance for responses to suspected domestic abuse (animal welfare federation and the links group, 2016). in 2015, the scottish government put £115,000 into a national campaign to train 100,000 front-line professionals in the three fields identified as most likely to encounter domestic violence survivors: dentists, veterinarians and hairdressers (paterson, 2015) . the u.k.'s code of professional conduct for veterinary surgeons states, "given the links between animal, child and domestic abuse, a veterinary surgeon or veterinary nurse reporting suspected or actual animal abuse should consider whether a child or adult within that home might also be at risk" (royal college of veterinary surgeons, 2016). the new zealand veterinary association supported a national legislative response to family violence by describing veterinary medicine as a "three-dimensional profession" with a unique voice in issues that transcend animal life, human life and the environment. nzva called for domestic violence protection-from-abuse orders to specifically include animals, and for changing the definition of domestic violence to include "coercive control" which would cover emotional and psychological abuse to family members through threat or harm to pets or farm animals (national link coalition, 2015) . the veterinary council of new zealand (2013), whose code of professional conduct includes a recommendation that veterinarians confronted with situations of animal abuse should consider whether people within that home might also be at risk, published a guidance that included suggestions on preparing the practice and responding to domestic violence. social workers can help to introduce a response to intimate partner violence as a public health matter to a profession which has been reluctant to get involved, due to a lack of training and fears for personal safety, and help veterinary clinics develop protocols for response and dissemination of literature about community domestic violence resources to their clients. they can also coordinate programs linking students at colleges of veterinary medicine with local domestic violence shelters, such as has been done at texas a & m, mississippi state university, and the university of georgia. social workers can respond to the needs of pet owners who are homeless, whose attachments to their animal companions are often stronger compared with the general population (labrecque & walsh, 2011 ). an estimated 5% to 10% of the 3.5 million americans who experience homelessness every year have dogs and cats, with rates as high as 25% in some areas. because the vast majority of homeless shelters do not allow pets, these restrictions deter pet owners from seeking essential shelter (o'reilly-jones, 2019). many individuals who live on the street keep pets, primarily dogs, for emotional support, safety, a sense of responsibility, to combat loneliness (labrecque & walsh, 2011; williams & hogg, 2016; arnott, 2004) , and as social catalysts to attract passers-by who may offer them money (irvine, kahl, & smith, 2012; anderson, snow, & cress, 1994) . social workers can coordinate veterinary and foster care for the animals and advocate for pet-friendly co-shelters for the homeless much as has been done in domestic violence shelters (phillips, 2019) . social workers can participate in such programs as the street dog coalition, operating in 30 states, in which social work, veterinary and medical school students host clinics and provide resources to help the pets of homeless pet owners. an accurate representation of the roles of animals in families, and of social work's responsiveness to these dynamics, is compromised by several factors. despite the above-cited market research data indicating a widespread population of companion animals and their over-representation among families with children, relatively little is known about the racial, ethnic, socioeconomic, age-related, or geographic demographics of pet-owning families, as such information has never been included in the u.s. census (arkow, 2019a). meanwhile, until recently, social workers have historically ignored the central role that companion animals may play in the lives of their clients, adopting an anthropocentric view underpinned by human rights and social justice (laing & maylea, 2018) . this is reflected in reports (national link coalition, 2020) that identified only 24 schools of social work in the u.s. and seven in canada that are believed to include the topic of human-animal relationships in either undergraduate or graduate level study, or in the absence of such courses have a faculty member known to have a specialization in the human-animal bond. it is hoped that publications such as this will begin to address these shortcomings and increase awareness of human-animal relationships in the lives of social workers' clients. the inclusion of human-animal relationships should be considered more widely in training and practice as part of social work's commitment to social and environmental justice and fighting oppression and seen as an expanding opportunity for research, practice, advocacy, and advancing public policy. in the process, additional career opportunities may open up with this species-spanning approach to resolving individual, family and community challenges. such inclusion can begin with something as simple as routinely including companion animals in genograms, ecomapping, and definitions of family support systems (risley-curtiss, 2010; hodgson & darling, 2011) . as assessing clients' needs is an important step in developing the best plan to solve clients' problems, including pet protective factors in clients' ecologies should be considered a relevant environmental factor in social work practice theory (sato, 2011) . collecting information about all the pets and humans in a family communicates interest and concern for the whole family and demonstrates an integrated approach to care that can help in planning appropriate interventions and preventive care. human-animal bond awareness can be further expanded by adding relevant coursework and field placements in schools of social work and training programs in continuing education. given the established links between animal cruelty and other forms of violence within the family system (arkow, 2019b), questions about human-animal interactions and relationships and clients' committing and/or witnessing acts of animal abuse should be systemically, not just optionally, introduced in intakes and assessments. incorporating the significance of human-animal interactions can help modernize what has been an intrinsic anthropocentrism of social work's theoretical foundations. growing opportunities both within and beyond the veterinary environment will help convince educators, researchers and practitioners that this species-spanning approach is worthwhile and offers opportunities for career development, personal fulfillment and improved service delivery. veterinary social work blends the human side of veterinary medicine with the animal side of social work. as awareness of and interest in veterinary social work continues to grow, additional opportunities will emerge whereby social workers with an abiding interest in animals as well as people can help their clients, society, and the non-human members of families and communities. battered women's reports of their partners' and their children's cruelty to animals safe havens 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states: findings from a national sample guidance for veterinarians dealing with cases of suspected or actual animal abuse and family violence the link between interpersonal violence and animal abuse a study on the relationship of child abuse and pet abuse animal cruelty and bullying: behavioral markers of delinquency risk or causal antecedents of delinquent behavior? risk factors for interpersonal violence and associated injury among urban women the health and welfare of dogs belonging to homeless people wa: petcare information & advisory service and the centre for the built environment and health (school of population health) the pet connection: pets as a conduit for social capital? more than a furry companion: the ripple effect of companion animals on neighborhood interactions and sense of community social capital and pet ownership-a tale of four cities reunification of child and animal welfare agencies: cross-reporting of abuse in wellington county key: cord-034438-9kdmljoq authors: sepúlveda-loyola, w.; rodríguez-sánchez, i.; pérez-rodríguez, p.; ganz, f.; torralba, r.; oliveira, d. v.; rodríguez-mañas, leocadio title: impact of social isolation due to covid-19 on health in older people: mental and physical effects and recommendations date: 2020-09-25 journal: j nutr health aging doi: 10.1007/s12603-020-1500-7 sha: doc_id: 34438 cord_uid: 9kdmljoq objectives: to review the impact of social isolation during covid-19 pandemic on mental and physical health of older people and the recommendations for patients, caregivers and health professionals. design: narrative review. setting: non-institutionalized community-living people. participants: 20.069 individuals from ten descriptive cross-sectional papers. measurements: articles since 2019 to 2020 published on pubmed, scielo and google scholar databases with the following mesh terms (‘covid-19’, ‘coronavirus’, ‘aging’, ‘older people’, ‘elderly’, ‘social isolation’ and ‘quarantine’) in english, spanish or portuguese were included. the studies not including people over 60 were excluded. guidelines, recommendations, and update documents from different international organizations related to mental and physical activity were also analysed. results: 41 documents have been included in this narrative review, involving a total of 20.069 individuals (58% women), from asia, europe and america. 31 articles included recommendations and 10 addressed the impact of social distancing on mental or physical health. the main outcomes reported were anxiety, depression, poor sleep quality and physical inactivity during the isolation period. cognitive strategies and increasing physical activity levels using apps, online videos, telehealth, are the main international recommendations. conclusion: mental and physical health in older people are negatively affected during the social distancing for covid-19. therefore, a multicomponent program with exercise and psychological strategies are highly recommended for this population during the confinement. future investigations are necessary in this field. the covid-19 pandemic due to sars-cov-2 has rapidly spread all over the world since last december. although its prevalence in the community is uncertain due to the asymptomatic cases, all age groups seems to be similarly affected (1) . however, older people are at higher risk of suffering negative outcomes, which can lead to an elevated rate of mortality, being five times higher than the global average for those older than 80 years old (2) . over 95% of fatalities due to covid-19 in europe and around 80% in china have included people older than 60 years-old (3, 4) . in the us, 80% of deaths were among adults 65 and over (5) . hence, health strategies to avoid spread of coronavirus (such as quarantine and social distancing) are important (6, 7) . the world health organization (who) describes a close relationship between physical and mental functions with the level of self-governance and social participation in the community [8] . social participation has been defined as active participation in a religious, sports, cultural, recreational, political, and volunteer community organizations (9) (10) (11) (12) . various studies have reported protective effects of social participation for the health of the elderly, being considered as a stimulus to increase the level of physical activity and cognitive functions (9, 13, 14) . the social participation has been associated with a better quality of life, more muscle mass, balance, cognition and lower comorbidities and disability in older people (9, 13, (15) (16) (17) (18) (19) (20) . participating in social meetings and activities are stimuli that increase the level of physical activity as well as the interaction with other older adults stimulating sensory systems, self-esteem, affectivity, emotional and psychological support (9, 13, 21) . as a preventive measure during the covid-19 pandemic, community organizations have closed. old people are constrained from visits with family members, therefore the social participation have been restricted (7) . thus, the decreasing of social interaction produced by social distancing could have a negative impact on mental and physical health in older people (22) (23) (24) , since it has limited the social participation in community organizations and in family activities (23, 25) . who defines the 'intrinsic capacity' as the 'composite of all the physical, functional, and mental capacities of an individual' (26) (27) (28) , changing the focus from a negative aging (disability) towards a positive one (optimal aging), being related to the onset of autonomy decline, falls and death (27) . physical activity has a positive impact on the health and quality of life, reducing the risk of functional and cognitive impairment, falls and risk of fractures, depression, disability, risk of geriatrics syndromes, hospitalization rates and, consecutively, mortality in older people (29) . not only the physical activity is affected during quarantine, but also mental health. several studies have described mental health consequences in previous quarantines, such as higher risk of depression (30) , emotional disturbance (31) , stress (32), low mood (33), irritability (33) , or insomnia (33) , being also associated with higher rates of suicide in elderly population (34) . however, the effects of covid-19 quarantine on the health of older adults have not yet been broadly studied. hence, the aim of this review is to analyse the potential effects of social isolation caused by covid-19 pandemic on mental and physical health in older adults. additionally, we have analysed the recommendations and proposed activities to avoid mental and functional decline to carry out at home. in this narrative review, the literature search was performed by three authors (wsl, irs and rt). pubmed, scielo and google scholar databases were consulted using the following terms ('covid-19', 'coronavirus', 'aging', 'older people', 'elderly', 'social isolation' and 'quarantine'). articles of any type of methodological design published from 2019 to 2020 (may 20th), in english, spanish or portuguese were included. articles that did not include subjects >60 years old were excluded. additionally, we have searched papers, guidelines, recommendations and update documents from different international organizations related to mental and physical activity. the lists of articles in the databases were downloaded in "bib format" and stored in mendeley for analysis of duplicate articles, title, and abstract reading. the content of the review was divided into two main areas: 1) effect of the reduction of social participation produced by quarantine for covid-19 on mental and physical health in elderly people, and 2) recommendations for mental and physical health of older people during the covid-19 quarantine. a detailed summary of the literature search is provided in figure 1 . six hundred and ninety unique records were identified through database and handsearching, resulting in ten articles involving 20.069 participants included in the final review (women 58%) from asia, europe, and america. of these, 9 adopted a cross-sectional design, and 1 was a qualitative design. all of them are descriptive studies. additionally, 31 articles from experts and authors about recommendations were considered in the full-text review. a summary of the characteristics of the included studies is presented in table 1. selection process of studies our results are based on summary data from eight crosssectional studies (35) (36) (37) (38) (39) (40) (41) (42) . the prevalence of anxiety ranged from 8.3%, 18.7% and 35.1% to 49.7% (36, 38) ; corresponding values from depression were 14.6%, 20.1%, 32.8%, 37.8% and 47.2% (36) (37) (38) . finally, sleep disturbances were observed in 18.2% (38) and 36.4% (37) among the participants. six of them (36, (38) (39) (40) (41) (42) pointed out an increased level of psychological stress defined as higher anxiety (36, (38) (39) (40) (41) , depression (36, (38) (39) (40) (41) and loneliness (42) levels and poorer sleep quality (38) during the lock-down by coronavirus. nevertheless, in one study (35) isolation period by covid-19 turned out in a mild stressful impact. additionally, only one study (37) showed that people during quarantine had lower anxiety levels, but more sleep disturbances. risk factors associated to these results varied across the studies. being female (36, 39, 42) , having a negative selfperception of aging (42) , healthcare workers (38) , family and personal resources (42) , time devoted to covid-19 information (42), having an acquaintance or a family member infected with covid-19 or a previous history of medical problems (39) seem to act as potential risk factors. the impact on physical health of the social distancing was studied for two authors (43, 44) (table 1 ). goethals et al (43) reported that covid-19 pandemic has affected the number of seniors attending group physical activity programs. additionally, castañeda-babarro et al (44) observed that the physical activity was highly decreased during confinement in all population, especially the vigorous activities and walking time. there are several recommendations related to the patient to deal with this social isolation (table 2a) such as strengthen social connections (43, 45-48) (using internet apps, video chat (45, 47) ), telephone support lines or support groups (23, 35, 49) , changes on lifestyle (regular sleep-wake up circle (50), physical activity and nutrition habits (37, 51) ) and cognitive stimulation (using apps or stimulating mental exercises, especially in those people with previous cognitive impairment (50) (51) (52) ). caregivers have an important and crucial role guaranteeing the physical and mental well-being. to reduce anxiety and feeling of usefulness, letting the person participate in adapted daily activities depending on the cognitive status is recommended (51) . the exposure to media must be regulated (53) , avoiding doing it in excess and only from official sources (51, 54) , managing to control the effect of news with traumatic content (51) . explaining clearly (55) or accompanying information with illustrations (53) may help, especially in people with cognitive impairment. to improve older people resilience, a combination of health education and psychological counselling could be useful. reinforcing that being quarantined is helping to keep others safe (23, 35, 46, 49) , adopting inclusive language when talking about the elderly, valuing older people's contributions and avoiding negative emphasis on risk (46) could increase also elderly's resilience. during this covid-19 crisis, healthcare system have had to change completely implementing virtual consultations and telemedicine (video-tools, telephone hotlines or online consultations (49) , guaranteeing rapid access to health care (52, 56) . additionally, the scorare ga, an assessment tool, has been proposed for doing a telematic geriatric assessment (52) . in order to minimize isolation related stress, quarantine should be as short as possible. giving good quality information, using channels that older people use like traditional media is also important for reducing stress (23) . the social distancing has reduced the levels of physical activity, which could have a negative impact on physical health (43, 44) . in this review, we include recommendations about increasing physical activity levels from the following eight global organizations: american college of sports medicine (acsm) (57), american heart association (aha) (58) , american physical therapy association (apta) (59) , international association of physical therapists working with older people (iptop) (60), world health organization (who) (61), world confederation for physical therapy (wcpt) and international network of physiotherapy regulatory authorities (inptra) (62) . they recommended 150-300 minutes per week of moderate-intensity aerobic physical activity and two sessions per week of muscle strength training (57, 61) . additionally, exercise circuit at home with cardio and strength exercises in short bursts of 30 seconds for up to three minutes. finally, coordination, mobility and cognitive exercises are also necessary (63) ( table 2b ). the role of caregivers during the quarantine is to supervise the exercise in those patients with unstable chronic diseases (64) . for health professionals, the principal elements to consider when designing an exercise program for older people confined at home are exercise modality, frequency, volume, and intensity (63) . it is recommended the telehealth using online videos, apps online platform for phones and tablets through the internet system (60, 62, 65) . iptop has recommended a list of apps[60] such as "otago exercise programme", "clock yourself" and "iprescribe exercise". apta, acsm and aha recommended different online videos and websites (58, 65, 66) (table 2b ). this review suggests a general negative effect on mental health in general population during social isolation for covid-19. this implies higher levels of anxiety and depression as well as poorer sleep quality. the prevalence of anxiety and depression during covid-19 outbreak, varies across the studies, having a wide range from 8.3% (36) to 49.7% (42) for anxiety or 14.6% (36) to 47.2% (42) for depression, in consonance with previous studies of other epidemics. for instance, 39% of prevalence of anxiety was observed in france due to avian influenza (67); 48% of the general population in sierra leone experimented symptoms of anxiety or depression 1 year after ebola outbreak (68); in hong kong due to the sars epidemic, 73% and 57% of individuals presented low mood and irritability (respectively) (33) , as well as depression in 31.2% of 129 quarantined persons for sars epidemic in 2003 (69) . the lower rates of anxiety and depression observed in some studies of our review during activities to improve the mental and physical health at home coronavirus pandemic could be explained for several reasons. the first one is that, based on previous epidemics, strong and quickly measures to keep mental health could have been taken by the governments, avoiding a bigger psychological impact. as time goes by, there was more information about sars-cov-2, which could also lead to a better management of the situation. however, data were collected in a very earlier stage of the pandemic, hence, these results should be taken with caution. some of the risk factors associated to a higher risk of psychological distress have been also described in previous literature. after ebola outbreak, people who knew someone quarantined due to ebola or with any ebola experience were at higher risk of anxiety, depression and post-traumatic stress disorder (68) . additionally, being older than 60 or worried about the recurrence of sars have been also found as risk factors in previous studies (70) . however, we cannot conclude the same in this review, where a more intense effect on older people has not been reported. another parameter that should be taken into account is the duration of isolation, since it is related to the severity of psychological symptoms. a non-significant impact on patients' well-being has been demonstrated during short-term isolation (71) . health providers need to be aware that older adults are at higher risk of having mental health concerns during isolation, and they may have less resources to mitigate them. they should encourage old adults and their families to contact each other daily, as much as they can, to reduce isolation in this population. additionally, maintaining a positive life-style behavior such as regular sleep and meal times, keep a healthy diet, cognitive stimulation and perform physical activity need to be recommended. also, relaxation techniques which may include diaphragmatic respirations or muscular relaxation, practicing a regular routine, alternating with different activities during the day could be useful. it is important for people to be informed by reliable sources and spending a limited time for searching information, maximum once or twice per day. information given to the elderly should be simple, frequent, and displayed in appropriate media. this review has reported that social distancing because of the covid-19 pandemic could lead to negative consequences for the physical health of older adults. this is caused by the decrease of physical activity levels due to the total or partial restriction of social participation in community groups and family activities during the pandemic (42, 43, 44) . social participation has several positive effects on physical health in elderly people (72) . studies have reported that older adults who were enrolled into social activities presented better dynamic balance and muscle strength, healthy lung function and lower disabilities and chronic inflammation compared to those without social participation (14, 72) . for this reason, attending social activities is an important component for successful aging (14, 72) . the relationship between social interaction and physical health may operate through different pathways (14, 72) . a possible explanation for these findings is that participating in meetings or social activities stimulates the musculoskeletal, cardiovascular, respiratory and nervous systems through physical activity and social interaction (73) . physical activity generates benefits for the physical health of older adults, stimulating muscle contraction, energy expenditure, decreasing systemic inflammation and oxidative stress, reducing prevalence of chronic diseases, and geriatric syndromes such as sarcopenia, osteosarcopenia and frailty (74) . as expected decreasing or total restriction of social interaction could generate negative consequences for the health of elderly people, especially in those with chronic diseases, disabilities and geriatric syndromes (14, 63) . evidence has demonstrated a relationship between social isolation and loneliness with disability, chronic diseases, risk of mortality and physical inactivity in elderly population (9, 19, (75) (76) (77) (78) (79) . however, the effect of increased sedentary behavior and decreased physical activity on elderly people during the covid-19 pandemic is unclear. isolated older people have less physical activity and more sedentary behavior than those non-isolated [80] . physical activity is described as any body movement using skeletal muscle that results in energy expenditure > 1.5 metabolic equivalent of task (met), while sedentary behavior is defined as any waking behavior characterized by an energy expenditure 1.5 or less met while in a sitting, reclining or lying posture (81, 82) . increased sedentary behavior has been associated with the prevalence of different comorbidities in elderly people (83) . since a direct association has been reported between sedentary time and time spent at home in elderly people (84) , recommendations have to be made to prevent health consequences in people with social isolation associated to the pandemic covid-19. the global expert organizations included in this review have highlighted the importance of increasing or maintaining the physical activity levels during the pandemic (57-62). although those organization recommended different types of activities or exercises, they are in agreement of using online videos, apps online platform for phones and tablets through the internet system (60, 62, 65). acsm and who recommended 150-300 minutes per week of aerobic physical activity and 2 sessions per week of muscle strength training (57, 61) . however, recommendations for people with social isolation could consider studies that have reported benefits of replacing sedentary time with physical activity. for example, replacing sedentary behavior with 30 minutes of light physical activity and 20 minutes of moderate to vigorous physical activity could have beneficial effects on all cause mortality (85) . in addition, replacing 30 minutes per day of sedentary time with moderate to vigorous physical activity has been associated with a decreased frailty in older people (86) . this information could be used to recommend physical activity as appealing and feasible (87) . additionally, balance, coordination, mobility and cognitive exercises to stimulate neurological system are recommended for older people to reduce the risk of falls and cognitive declining (63) . in those older adults with geriatrics syndromes or unstable chronic diseases, it is recommended the supervision of caregivers to avoid falls, exacerbations and injuries during the exercise (64) . in addition, the health professionals should design the exercise program for older people confined at home with a specific exercise modality, frequency, volume, and intensity (63), using online videos, apps online platform for phones and tablets through the internet system (60, 62, 65) . finally, the quarantine implied a radical change in the lifestyle of elderly people, reducing the social interaction, participation in exercise group, religious or spiritual group which have negatively affected the mental and physical health in this population (88) . therefore, to maintain an active lifestyle at home is important for the health of older adults, especially those with chronic diseases and geriatrics syndromes. to summarize all the recommendations and articles included in this review, we have proposed different activities to improve the mental and physical health at home in figure 2 . to the best of our knowledge, this is the first review that includes assessing the physical and mental effects of social isolation by covid-19 among older people. however, this study has some limitations, which deserve to be mentioned. studies included in this review were cross-sectional design and not specific in elderly population. as all of them are descriptive studies, no control group was used. additionally, there is also a lack of evidence regarding the most appropriate psychological and physical recommendations and most of the interventions suggested are based on expert opinions and not on high evidence studies. future investigations should consider a longitudinal or cross-sectional design in older individuals, with larger sample size and different outcomes related to mental and physical health. in conclusion, our study suggests that the mental and physical health in older people are negatively affected during the social distancing for covid-19. the main mental and physical outcomes reported were anxiety, depression, poor sleep quality and physical inactivity during the isolation period. experts organizations and who have given different recommendations to keep older people mentally and physically healthy. therefore, an integrated and multidisciplinary assessment between geriatricians, 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research sedentary behavior and health outcomes among older adults: a systematic review physical activity in non-frail and frail older adults replacing sedentary time with physical activity: a 15-year follow-up of mortality in a national cohort reallocating accelerometer-assessed sedentary time to light or moderate-to vigorous-intensity physical activity reduces frailty levels in older adults: an isotemporal substitution approach in the tsha study the feasibility and longitudinal effects of a home-based sedentary behavior change intervention after stroke covid-19, mental health and aging: a need for new knowledge to bridge science and service declaration of conflict of interest: none.declaration of sources of funding: co-financed by the european regional development funds (rd120001/0043) and the centro de investigación biomédica en red en fragilidad y envejecimiento saludable-ciberfes (cb16/10/00464).author's contribution: study concept and design: all authors. data collection: wsl, irs, rt. draft of the manuscript: wsl, irs, ppr, fg, rt. full access to all of the data in the study and responsibility for the integrity of the data: wsl, irs. study supervision: lrm. all authors reviewed the manuscript for important intellectual content and approved the final version. key: cord-162326-z7ta3pp9 authors: shahi, gautam kishore title: amused: an annotation framework of multi-modal social media data date: 2020-10-01 journal: nan doi: nan sha: doc_id: 162326 cord_uid: z7ta3pp9 in this paper, we present a semi-automated framework called amused for gathering multi-modal annotated data from the multiple social media platforms. the framework is designed to mitigate the issues of collecting and annotating social media data by cohesively combining machine and human in the data collection process. from a given list of the articles from professional news media or blog, amused detects links to the social media posts from news articles and then downloads contents of the same post from the respective social media platform to gather details about that specific post. the framework is capable of fetching the annotated data from multiple platforms like twitter, youtube, reddit. the framework aims to reduce the workload and problems behind the data annotation from the social media platforms. amused can be applied in multiple application domains, as a use case, we have implemented the framework for collecting covid-19 misinformation data from different social media platforms. with the growth of the number of users on different social media platforms, social media have become part of our lives. they play an essential role in making communication easier and accessible. people and organisations use social media for sharing and browsing the information, especially during the time of the pandemic, social media platforms get massive attention from users talwar et al. (2019) . braun and gillespie conducted a study to analyse the public discourse on social media platforms and news organisation. the design of social media platforms allows getting more attention from the users for sharing news or user-generated content. several statistical or computational study has been conducted using social media data braun and gillespie (2011) . but data gathering and its annotation are time-consuming and financially costly. in this study, we resolve the complications of data annotation from social media platforms for studying the problems of misinformation and hate speech. usually, researchers encounter several problems while conducting research using social media data, like data collection, data sampling, data annotation, quality of the data, copyright © 2020, association for the advancement of artificial intelligence (www.aaai.org). all rights reserved. and the bias in data grant-muller et al. (2014) . data annotation is the process of labelling the data available in various formats like text, video or images. researchers annotate social media data for researches based on hate speech, misinformation, online mental health etc. for supervised machine learning, labelled data sets are required so that machine can quickly and clearly understand the input patterns. to build a supervised or semi-supervised model on social media data, researchers face two challenges-timely data collection and data annotation shu et al. (2017) . one time data collection is essential because some platforms either restrict data collection or often the post itself is deleted by social media platforms or by the user. for instance, twitter allows data crawling of only the past seven days (from the date of data crawling) by using the standard apis stieglitz et al. (2018) . moreso, it is not possible to collect the deleted posts from social media platforms. another problem stands with data annotation; it is conducted either in an in-house fashion (within lab or organisation) or by using a crowd-based tool(like amazon mechanical turk(amt)) aroyo and welty (2015) . both approaches of data annotations require an equitable amount of effort to write the annotation guidelines along with expert annotators. in the end, we are not able to get quality annotated data which makes it challenging to a reliable statistical or artificial intelligence based analysis. there is also always a chance of wrongly labelled data leading to bias in data cook and stevenson (2010) . currently, professional news media or blogs also cover the posts from social media posts in their articles. the inclusion of social media posts in the news and blog articles creates an opportunity to gather labelled social media data. journalists cover humongous topics of social issues such as misinformation, propaganda, rumours during elections, disasters, pandemics, and mob lynching, and other similar events. journalists link social media posts in the content of the news articles or blogs to explain incidents carlson (2016) . to solve the problems of on-time data collection and data annotation, we propose a semi-automatic framework for data annotation from social media platforms. the proposed framework is capable of getting annotated data on social issues like misinformation, hate speech or other critical social scenarios. the key contributions of the paper are listed below-• we present a semi-automatic approach for gathering an-arxiv:2010.00502v1 [cs.si] 1 oct 2020 notated data from social media platforms. amused gathers labelled data from different social media platform in multiple formats(text, image, video). • amused reduces the workload, time and cost involved in traditional data annotation technique. • amused resolves the issues of bias in the data (wrong label assigned by annotator) because the data gathered will be labelled by professional news editors or journalists. • the amused can be applied in many domains like fake news or propaganda in the election, mob lynching etc. for which it is hard to gather the data. to present a use case, we apply the proposed framework to gather data on covid-19 misinformation on multiple social media platforms. in the following sections, we discuss the related work, different types of data circulated and its restrictions on social media platforms, current annotation techniques, proposed methodology and possible application domain; then we discuss the implementation and result. we also highlight some of the findings in the discussion, and finally, we discuss the conclusion and ideas for future works. much research has been published using social media data, but they are limited to a few social media platforms or language in a single work. also, the result is published with a limited amount of data. there are multiple reasons for the limited work; one of the key reason is the availability of the annotated data for the research thorson et al. (2013) ; ahmed, pasquier, and qadah (2013) . chapman et al. highlights the problem of getting labelled data for nlp related problem chapman et al. (2011) . researchers are dependent on in-house or crowd-based data annotation. recently, alam et al. uses a crowd-based annotation technique and asks people to volunteer for data annotation, but there is no significant success in getting a large number of labelled data alam et al. (2020) . the current annotation technique is dependent on the background expertise of the annotators. on the other hand, finding the past data on an incident like mob lynching, disaster is challenging because of data restrictions by social media platforms. it requires looking at massive posts, news articles with an intensive amount of manual work. billions of social media posts are sampled to a few thousand posts for data annotation either by random sample or keyword sampling, which brings a sampling bias in the data. with the in-house data annotation, forbush et al. mentions that it's challenging to hire annotator with background expertise in a domain. another issue is the development of a codebook with a proper explanation forbush et al. (2013) . the entire process is financially costly and time taking duchenne et al. (2009) . the problem with the crowdbased annotation tools like amt is that the low cost may result in wrong labelling of data. many annotators who cheat, not performing the job, but using robots or answering randomly fort, adda, and cohen (2011); sabou et al. (2014) . with the emergence of social media as a news resources caumont (2013), many people or group of people use it for different purpose like news sharing, personal opinion, social crime in the form of hate speech, cyber bullying. nowadays, the journalists cover some of the common issues like misinformation, mob lynching, hate speech, and they also link the social media post in the news articles cui and liu (2017) . in the proposed framework, we used the news articles from profession news website for developing the proposed framework. we only collect the news articles/blog from the credible source which does not compromise with the news quality meyer (1988) . in the next section, we discuss the proposed methodology for the amused framework. social media platform allows users to create and view posts in multiple formats. every day billions of posts containing images, text, videos are shared on social media sites such as facebook, twitter, youtube or instagram aggarwal (2011) . people use a combination of image, text and video for more creative and expressive forms of communication. data are available in different formats and each social media platform apply restriction on data crawling. for instance, facebook allows crawling data only related to only public posts and groups. giglietto, rossi, and bennato discuss the requirement of multi-modal data for the study of social phenomenon giglietto, rossi, and bennato (2012) . in the following paragraph, we highlighted the data format and restriction on several social media platforms. text almost every social media platform allows user to create or respond to the social media post in text. but each social media platform has a different restriction on the size of the text. twitter has a limit of 280 characters, while on youtube, users are allowed to comment up to a limit of 10000 characters. reddit allows 40,000 characters; facebook has a limit of 63206 characters, wikipedia has no limit and so on. the content and the writing style changes with the character limit of different social media platform. image like text, image is also a standard format of data sharing across different social media platforms. these platforms also have some restriction on the size of the image. like twitter has a limit of 5 megabytes, facebook and instagram have a limit of 30 megabytes, reddit has a limit of 20 megabytes. images are commonly used across different platform. it is common in social media platforms like instagram, pinterest. video some platforms are primarily focused on video like youtube. while other platforms are multi-modal which allows video, text and image. for video also there are restrictions in terms of duration like youtube has a capacity of 12 hours, twitter allows 140 seconds, instagram has a limit of 120 seconds, and facebook allows videos up to 240 minutes. the restriction of video's duration on different platforms catches different users. for instance, on twitter and instagram users post video with shorter duration. in contrast, youtube has users from media organisation, vlog writer, educational institution etc where the duration of video is longer. in the current annotation scenario, researchers collect the data from social media platforms for a particular issue with different search criteria. there are several problems with the current annotation approaches; some of them are highlighted below. • first, social media platforms restrict users to fetch old data; for example, twitter allows us to gather data only from the past seven days using the standard apis. we need to start on-time crawling; otherwise, we lose a reasonable amount of data which also contains valuable content. • second, if the volume of data is high, it requires filtering based on several criteria like keyword, date, location etc. these filtering further degrades the data quality by excluding the major portion of data. for example, for hate speech, if we sample the data using hateful keyword, then we might lose many tweets which are hate speech but do not contain any hateful word. • third, getting a good annotator is a difficult task. annotation quality depends on the background expertise of the person. even we hire annotator in our organisation; we have to train them for using the test data. for crowdsourcing, maintaining annotation quality is more complicated. moreover, maintaining a good agreement between multiple annotators is also a tedious job. • fourth problem is the development of annotation guidelines. we have to build descriptive guidelines for data annotation, which handle a different kind of contradiction. writing a good codebook requires domain knowledge and consultant from experts. • fifth, overall, data annotation is a financially costly process and time-consuming. sorokin and forsyth highlighted the issue of cost while using a crowd-based annotation technique sorokin and forsyth (2008) . • sixth, social media is available in multiple languages, but much research is limited to english. data annotation in other languages, especially under-resourced languages is difficult due to the lack of experienced annotators. the difficulty adversely affects the data quality and brings some bias in the data. in this work, we propose a framework to solve the above problems by crawling the embedded social media posts from the news articles and a detailed description is given in the proposed method section. in this section, we discuss the proposed methodology of the annotation framework. our method consists of nine steps, they are discussed belowstep 1: domain identification the first step is the identification of the domain in which we want to gather the data. a domain could focus on a particular public discourse. for example, a domain could be fake news in the us election, hate speech in trending hashtags on twitter like #blacklivesmatter, #riotsinsweden etc. domain selection helps to focus on the relevant data sources. step 2: data source after domain identification, the next step is the identification of data sources. data sources may consist of either the professional news websites or the blogs that talk about the particular topic, or both. for example, many professional websites have a separate section which discusses the election or other ongoing issues. in the step, we collect the news website or blog which discuss the chosen domain. step 3: web scraping in the next step, we crawl all news articles from a professional news website or blogs which discuss the domain from each data source. for instances, a data source could be snopes snopes (2020) or poynter institute (2020) . we fetch all the necessary details like the published date, author, location, news content. step 4: language identification after getting the details from the news articles, we check the language of the news articles. we use iso 639-1 codes wikipedia (2020) for naming the language. based on the language, we can further filter the group of news articles based on spoken language from a country and apply a language-specific model for finding meaning insights. step 5: social media link from the crawled data, we fetch the anchor tag( a ) mentioned in the news content, then we filter the hyperlinks to identify social media platforms like twitter and youtube. from the filtered link, we fetch unique identifiers to the social media posts, for instance, for a hyperlink consisting of tweet id, we fetch the tweet id from the hyperlink. similarly, we fetch the unique id to social media for each platform. we also remove the links which are not fulfilling the filtering criteria. step 6: social media data crawling in this step, we fetch the data from the respective social media platform. we build a crawler for each social media platform and crawl the details using unique identifiers or uniform resource locator (url) obtained from the previous step. due to the data restriction, we use crowdtangle team (2020) to fetch them from facebook and instagram posts. example-for twitter, we use twitter crawler using tweet id (unique identifier), we crawl details about the tweets. step 7: data labelling in this step, we assign labels to the social media data based on the label assigned to the news articles by journalists. often news articles describe the social media post to be hate speech, fake news, or propaganda. we assign the class of the social media post mentioned in the news article as a class described by the journalist. for example, if a news article a containing social media post s has been published by a journalist j and journalist j has described the social media post s to be a fake news, we label the social media post s as fake news. usually, the news article is published by a domain expert, and it assures that social media post embedded or linked in the news article is correctly labelled. step 8: human verification in the next step, to check the correctness, a human verifies the assigned label to the social media post and with label mentioned in the news articles. if the label is wrongly assigned, then data is removed from the corpus. this step assures that the collected social media post contains the relevant post and correctly given label. a human can verify the label of the randomly selected news articles. step 9: data enrichment in this, we merge the social media data with the details from the news articles. it helps to accumulate extra information which might allow for further analysis. data merging provides analysis from news authors and also explains label assigned to the social media post. in this section, we consider the possible application domains of the proposed framework. nevertheless, the framework is a general one, and it can be tailored to suit varied unmentioned domains as well where the professional news website or blogs covers the incident like election, fake news etc. "fake news is an information that is intentionally, and verifiable false and could mislead readers" allcott and gentzkow (2017) . misinformation is part of fake news which is created deliberately intended to deceive. there is an increasing amount of misinformation in the media, social media, and other web sources. in recent years, much research has been done for fake news detection and debunking of fake news zhou and zafarani (2018) . in the last two decades, there is a significant increase in the spread of misinformation. nowadays more than 100 fact-checking websites are working to tackle the problem misinformation cherubini and graves (2016) . fact-checking websites can help to investigate claims and assist citizens in determining whether the information used in an article is true or not. in a real-world scenario, people spread a vast amount of misinformation during the time of a pandemic, an election or a disaster. gupta et al. (2013) . there is a 3v problem of fake news -volume -a large number of fake news, velocity -during the peak the speed of propagation also intensifies, variety -different formats of data like images, text, videos are used in fake news. still, fake news detection requires a considerable effort to verify the claims. one of the most effective strategies for tackling this problem is to use computational methods to detect false news. misinformation has attracted significant attention in recent years as evidenced in recent publications li et al. (2012) ; li, meng, and yu (2011); li et al. (2016) ; popat et al. (2016) . additionally, misinformation is adopted across language borders and consequently often spread around the globe. for example-one fake news "russia released lions to implement the lockdown during covid-19" was publicised across multiple countries in different languages like italian and tamil poynter (2020). mob lynching is a violent human behaviour where a group of people execute the legal practice without a trial which ends with a significant injury or death of a person apel (2004) . it is a worldwide problem, the first case executed in the 15th century in ireland, then it was trending in the usa during the 18-19th century. often, mob lynching is initiated by rumours or fake news which gets triggered by the social media by a group of peoplearun (2019). the preventive measures taken by the government to overcome all obstacles and prevent further deaths were not successful in its entirety. getting the data for analysis of mob lynching is difficult because of the unexpected events occurring throughout the year, mainly in remote areas. there is no common search term or keyword that helps to crawl social media. so, if we fetch the specific social media post from the news articles which is covering analysis about the mob lynching arun (2019), we can use it for several studies. it will also help to analyse the cause and pattern from the previous incident griffin (1993) . online abuse is any kind of harassment, racism, personal attacks, and other types of abuse on online social media platforms. the psychological effects of online abuse on individuals can be extreme and lasting mishra, yannakoudakis, and shutova (2019) . online abuse in the form of hate speech, cyberbullying, personal attacks are common issue mishra, yannakoudakis, and shutova (2019) . many research has been done in english and other widely spoken languages, but under-resourced languages like hindi, tamil (and many more) are not well explored. gathering data in these languages is still a big challenge, so our annotation framework can easily be applied to collect the data on online abuse in multiple languages. in this, we discuss the implementation of our proposed framework. as a case study, we apply the amused for data annotation for covid-19 misinformation in the following way: step 1: domain identification out of several possible application domains, we consider the spread of misinformation in the context of covid-19. we choose this the topic since because, december 2019, the first official report of covid-19, misinformation spreading over the web shahi and nandini (2020). the increase of misinformation is one of the big problems during the covid-19 problems. the director of the world health organization(who), considers that with covid, we are fighting with both pandemic and infodemic the guardian (2020). infodemic is a word coined by world health organization (who) to describe the misinformation of virus, and it makes hard for users to find trustworthy sources for any claim made on the covid-19 pandemic, either on the news or social media world health organization and others (2020); zarocostas (2020). one of the fundamental problems is the lack of sufficient corpus related to pandemic shahi, dirkson, and majchrzak (2020) . content of the misinformation depends on the domain; for example, during the election, we have a different set of misinformation compared to a pandemic like covid-19, so domain identification helps to focus on specif topic. step 2: data sources for data source, we looked for 25 fact-checking websites(like politifact, boomlive) and decided to use the poynter and snopes. we choose poynter figure 1 : amused: an annotation framework for multi-modal social media data because poynter has a central data hub which collects data from more 98 fact-checking websites while snopes is not integrated with poynter but having more than 300 fact-checked articles on covid-19. we describe the two data sources as follow-snopes-snopes snopes (2020) is an independent news house owned by snopes media group. snopes verifies the correctness of misinformation spread across several topics like election, covid-19. as for the fact-checking process, they manually verify the authenticity of the news article and performs a contextual analysis. in response to the covid-19 infodemic, snopes provides a collection of a fact-checked news article in different categories based on the domain of the news article. poynter-poynter is a non-profit making institute of journalists institute (2020). in covid-19 crisis, poynter came forward to inform and educate to avoid the circulation of the fake news. poynter maintains an international fact-checking network(ifcn), the institute also started a hashtag #coronavirusfacts and #datoscoronavirus to gather the misinformation about covid-19. poynter maintains a database which collects fact-checked news from 98 factchecking organisation in 40 languages. step 3: web scraping in this step, we developed a pythonbased crawler using beautiful soup richardson (2007) to fetch all the news articles from the poynter and snopes. our crawler collects important information like the title of the news articles, name of the fact-checking websites, date of publication, the text of the news articles, and a class of news articles. we have assigned a unique identifier to each of them and its denoted by fcid. a short description of each element given in table 1. step 4: language detection we collected data in multiple languages like english, german, hindi etc. to identify the language of the news article, we have used langdetect shuyo (2014) , a python-based library to detect the language of the news articles. we used the textual content of new articles to check the language of the news articles. our dataset is categorise into 40 different languages. step 5: social media link in the next step, while doing the html crawling, we filter the url from the parsed tree of the dom (document object model). we analysed the url pattern from different social media platforms and applied keyword-based filtering from all hyperlinks in the dom. we store that urls in a separate column as the social media link. an entire process of finding social media is shown in figure 2 . some of the url patterns are discussed below-twitter-for each tweet, twitter follows a pattern twitter.com/user name/status/tweetid. so, in the collection hyperlink, we searched for the keyword, "twitter.com" and "status", it assures that we have collected the hyperlink which referring to the tweet. youtube-for each youtube video, youtube follows a pattern hwww.youtube.com/watch?v=vidoeid. so, in the collection hyperlink, we searched for the keyword, "youtube.com" and "watch", these keyword assures that we have collected the hyperlink which referring to the particular youtube video. reddit-for each subreddit, reddit follows a pattern www.reddit.com/r/subreddit topic/. so, in the collection hyexample news id we provide a unique identifying id to each news articles. we use acronym for news source and the number to identify a news articles. newssource url it is a unique identifier pointing to the news articles. https://factcheck.afp.com/vi deo-actually-shows-anti-gove rnment-protest-belarus news title in this field, we store the title of the news articles. a video shows a rally against coronavirus restrictions in the british capital of london. published date each news articles published the fact check article with a class like false, true, misleading. we store it in the class column. news class we provide a unique identifying id to each news articles. false published-by in this field, we store the name of the professional news websites or blog, for example, afp, quint etc. country each news articles published the fact check article with a class like false, true, misleading. we store it in the class column. we provide a unique identifying id to each news articles. english table 1 : name, definition and an example of elements collected from new articles. perlink, we searched for the keyword, "reddit.com" and a regex code to detect "reddit.com/r/", which confirms that we have collected the hyperlink which referring to the particular subreddit. similarly, we followed the approach for other social media platforms like facebook, instagram, wikipedia, pinterest, gab. in the next step, we used the regex code to filter the unique id for each social media post like tweet id for twitter, video id for youtube. step 6: social media data crawling after web scraping, we have the unique identifier of each social media post like tweet id for twitter, video id for videos etc. we build a python-based program for crawling the data from the respective social media platform. we describe some of the crawling tool and the details about the collected data. twitter-we used python crawler using tweepy roesslein (2020), which crawls all details about a tweet. we collect text, time, likes, retweet, user details such as name, location, follower count. youtube-for youtube, we built a python-based crawler which collects the textual details about the video, like title, channel name, date of upload, likes, dislikes. we also crawled the comments of the respective. similarly, we build our crawler for other platforms, but for instagram and facebook, we used the crowdtangle for data crawling, data is limited to posts from public pages and group team (2020). step 7: data labelling for data labelling, we used the label assigned in the news articles then we map the social media post with their respective news article and assign the label to the social media post. for example, a tweet extracted from news article is mapped to the class of the news article. an entire process of data annotating shown in figure 3. step 8: human verification in the next step, we manually overlook each social media post to check the correctness of the process. we provided the annotator with all necessary information about the class mapping and asked them to verify it. for example-in figure 3 , human open the news article using the newssource url and verified the label assigned to the tweet. for covid-19 misinformation, a human checked randomly sampled 10% social media post from each social media platforms and verified the label assign to the social media post and label mentioned in the news articles. with the random checks, we found that all the assigned labels are correct. this helps make sure the assigned label is correct and reduces the bias or wrongly assigned label. we further normalise the data label into false, partially false, true and others using the definitions mentioned in shahi, dirkson, and majchrzak (2020) . the number of social media post found in four different category is shown in table 3 . step 9: data enrichment in this step, we enrich the data by providing extra information about the social media post. the first step is merging the social media post with the respective news article, and it includes additional information like textual content, news source, author. the detailed analysis of the collected data is discussed in the result section. based on the results, we also discuss some of the findings in the discussion section. a snapshot of the labelled data from twitter is shown in figure 4. we will release the data as open-source for further study. for the use case of misinformation on covid-19, we identified ifcn as the data source, and we collected data from different social media platforms. we found that around 51% of news articles contain linked their content to social media websites. overall, we have collected 8077 fact-checked news articles from 105 countries in 40 languages. a detailed description of social media data extracted using the amused framework is presented in table 2. we have cleaned the hyperlinks collected using the amused framework. we filtered the social media posts by removing the duplicates using a unique identifier of social media post. we have presented a timeline plot of data collected from different social media platforms in figure 5 . we plotted the data from those social media platform which has (2020) figure 5: a timeline distribution of data collected from a number of different social media platform from january 2020 to august 2020, we have presented the platform having data count more than 25. facebook 2776 325 94 6 instagram 166 28 2 1 pinterest 3 0 0 0 reddit 21 9 2 1 tiktok 9 0 0 0 twitter 1318 234 50 13 wikipedia 154 18 3 1 youtube 739 164 13 0 table 3 : summary of covid-19 misinformation data collected from different social media platforms, deleted and duplicate posts are excluded in the count. the total number of post more than 25 unique posts in table 3 because it depreciates the plot distribution. we dropped the plot from pinterest (3), whatsapp(23), tiktok (25), reddit(43) . the plot shows that most of the social media posts are from facebook and twitter, then followed by youtube, then wikipedia and instagram. we have also presented the class distribution of these social media post in table 3. the figure 5 shows that the number of post overall social media post was maximum during the mid-march to mid-may, 2020. misinformation also follows the trend of the covid-19 situation in many countries because the number of social media post also decreased after june 2020. the possible reason could be either the spread of misinformation is reduced, or fact-checking websites are not focusing on this issue as during the early stage. from our study, we highlighted some of the useful points. usually, the fact-checking website links the social media post from multiple social media platforms. we tried to gather data from various social media platforms, but we found the maximum number of links from facebook, twitter, and youtube. there are few unique posts from reddit (21), tik-tok(9) but they were less than what we were expecting brennen et al. (2020) . surprisingly there are only three unique posts from pinterest, and there are no data available from gab, sharechat, and snapchat. however, gab is well known for harmful content, and people in their regional languages use sharechat. there are only three unique posts from pinterest. many people use wikipedia as a reliable source of information, but there are 393 links from wikipedia. hence, overall fact-checking website is limited to some trending social media platforms like twitter or facebook while social media platforms like gab, tiktok is famously famous for malformation, misinformation brennen et al. (2020) . what-sapp is an instant messaging app, used among friends or group of people. so, we only found some hyperlink which links to the public whatsapp group. to increase the visibility of fact-checked articles, a journalist can also use schema.org vocabulary along with the microdata, rdfa, or json-ld formats to add details about misinformation to the news articles shahi, nandini, and kumari (2019) . another aspect is the diversity of social media post on the different social media platforms. more often, news articles mention facebook, twiter, youtube but less number of post from instagram, pinterest, no post from gab, tiktok. there might be these platforms actively ask or involve the factchecking website for monitoring the content on their platform, or the journalists are more focused on these platforms only. but it would be interesting to study the proposition of fake news on different platforms like tiktok, gab. we have also analysed the multi-modality of the data on the social media platform. in the case of misinformation on covid-19, the amount of misinformation on text is more compare to video or image. but, in table 3 we show that apart from text, the fake news is also shared as image, video or mixed-format like image+text. it will also be beneficial to detect fake news on different platforms. it also raises the open question of cross-platform study on a particular topic like misinformation on covid-19. someone can also build a classification model shahi et al. (2018) ; nandini et al. (2018) to detect a class of fake news into true, false, partially false or other categories of news articles. while applying amused framework on the misinformation on covid-19, we found that misinformation across multiple source platform, but it mainly circulated across facebook, twitter, youtube. our finding raises the concern of mitigating the misinformation on these platforms. in this paper, we presented a semi-automatic framework for social media data annotation. the framework can be applied to several domains like misinformation, mob lynching, and online abuse. as a part of the framework, we also used a python based crawler for different social media websites. after data labelling, the labels are cross-checked by a human which ensures a two-step verification of data annotation for the social media posts. we also enrich the social media post by mapping it to the news article to gather more analysis about it. the data enrichment will be able to provide additional information for the social media post. we have implemented the proposed framework for collecting the misinformation post related to the covid-19 as future work, the framework can be extended for getting the annotated data on other topics like hate speech, mob lynching etc. amused will decrease the labour cost and time for the data annotation process. amused will also increase the quality of the data annotation because we crawl the data from news articles which are published by an expert journalist. an introduction to social network data analytics key issues in conducting sentiment analysis on arabic social media text fighting the covid-19 infodemic in social media: a holistic perspective and a call to arms social media and fake news in the 2016 election imagery of lynching: black men, white women, and the mob truth is a lie: crowd truth and the seven myths of human annotation on whatsapp, rumours, and lynchings hosting the public discourse, hosting the public: when online news and social media converge types, sources, and claims of covid-19 misinformation embedded links, embedded meanings: social media commentary and news sharing as mundane media criticism 12 trends shaping digital news overcoming barriers to nlp for clinical text: the role of shared tasks and the need for additional creative solutions the rise of fact-checking sites in europe automatically identifying changes in the semantic orientation of words how does online news curate linked sources? a content analysis of three online news media automatic annotation of human actions in video was coronavirus predicted in a 1981 dean koontz novel? what a catch! traits that define good annotators amazon mechanical turk: gold mine or coal mine? the open laboratory: limits and possibilities of using facebook, twitter, and youtube as a research data source enhancing transport data collection through social media sources: methods, challenges and opportunities for textual data narrative, event-structure analysis, and causal interpretation in historical sociology faking sandy: characterizing and identifying fake images on twitter during hurricane sandy a dean koontz novel the international fact-checking network truth finding on the deep web: is the problem solved? a survey on truth discovery t-verifier: verifying truthfulness of fact statements defining and measuring credibility of newspapers: developing an index tackling online abuse: a survey of automated abuse detection methods modelling and analysis of temporal gene expression data using spiking neural networks credibility assessment of textual claims on the web russia released 500 lions beautiful soup documentation corpus annotation through crowdsourcing: towards best practice guidelines fakecovid -a multilingual cross-domain fact check news dataset for covid-19 analysis, classification and marker discovery of gene expression data with evolving spiking neural networks an exploratory study of covid-19 misinformation on twitter inducing schema. org markup from natural language context fake news detection on social media: a data mining perspective language-detection library snopes. 2020. collections archive utility data annotation with amazon mechanical turk social media analytics-challenges in topic discovery, data collection, and data preparation why do people share fake news? associations between the dark side of social media use and fake news sharing behavior crowdtangle. facebook, menlo park, california the guardian. 2020. the who v coronavirus: why it can't handle the pandemic youtube, twitter and the occupy movement: connecting content and circulation practices list of iso 639-1 codes world health organization and others world report how to fight an infodemic fake news: a survey of research, detection methods, and opportunities key: cord-018821-e9oxvgar authors: webber, quinn m. r.; willis, craig k. r. title: sociality, parasites, and pathogens in bats date: 2016-04-27 journal: sociality in bats doi: 10.1007/978-3-319-38953-0_5 sha: doc_id: 18821 cord_uid: e9oxvgar little is known about the ecology of many of the parasites and pathogens affecting bats, but host social behavior almost certainly plays an important role in bat-parasite dynamics. understanding parasite dynamics for bats is important from a human public health perspective because of their role as natural reservoirs for recent high-profile emerging zoonotic pathogens (e.g. ebola, hendra) and from a bat conservation perspective because of the recent emergence of white-nose syndrome (wns) in north america highlighting the potential population impacts of parasites and pathogens. although some bat species are among the most gregarious of mammals, species vary widely in terms of their social behavior and this variation could influence pathogen transmission and impacts. here, we review the literature on links between bat social behavior and parasite dynamics. using standardized search terms in web of science, we identified articles that explicitly tested or discussed links between some aspect of bat sociality and parasite transmission or host population impacts. we identified social network analysis, epidemiological modeling, and interspecific comparative analyses as the most commonly used methods to quantify relationships between social behavior and parasite-risk in bats while wns, hendra virus, and arthropod ectoparasites were the most commonly studied host-parasite systems. we summarize known host-parasite relationships in these three systems and propose testable hypotheses that could improve our understanding of links between host sociality and parasite-dynamics in bats. parasitism is ubiquitous in nature. parasites affect fitness of their hosts and thus can shape host population dynamics. defined broadly, a parasite is any organism that grows, feeds, and/or is sheltered at the expense of another organism (i.e. the host). parasites can be categorized into different ways but one common approach is to differentiate microparasites, which are typically unicellular or multicellular microbes (e.g. bacteria, prions, viruses, protozoans, fungi) with short generation times and a life cycle that occurs entirely on/in the host, from macroparasites which are multicellular parasites with longer generation times and more complex life cycles that may include multiple host species (table 5 .1; anderson and may 1979; hudson et al. 2002) . many microparasites can be pathogenic and cause identifiable disease in their hosts with recognizable physiological or behavioral signs or symptoms (table 5 .1). for example, batrachochytrium dendrobatiidis is a fungal microparasite of amphibians that infects keratinized tissues, thickens the epidermis, and eventually causes mortality, all of which are identifiable signs of the associated disease, chytridiomycosis (voyles et al. 2009; rosenblum et al. 2010) . macroparasites tend to result in chronic infections of their definitive hosts, decrease host fecundity, and usually cause morbidity rather than mortality (hudson et al. 2002) . experimental infection of great tits (parus major) with the hen flea (ceratophyllus gallinae) resulted in reduced reproductive success via increased nest failure during incubation and the nestling period (fitze et al. 2004) . parasite dynamics and impacts are often quantified using two metrics: intensity (i.e. load) and prevalence. intensity quantifies the number of infections per individual host within a given population, while prevalence is measured as a proportion of infected individuals within a sample from a given host population (table 5 .1). understanding variation in parasite prevalence and intensity can thus be important for making inferences about the evolution of social behavior and the potential fitness consequences associated with parasite infection. although empirical data from wild host populations are surprisingly scarce, host behavior is considered an important predictor of parasite intensity, prevalence, and impacts (moore 2002) . a longstanding hypothesis in parasite ecology predicts an influence of the host social system, and the duration and frequency of social contacts within host populations, on parasite prevalence or intensity (loehle 1995; altizer et al. 2003) . social systems, defined as groups of conspecifics that regularly interact more frequently with one another than with members of other groups, represent the highest level of sociality, while social organization and social structure describe the size, composition, and spatiotemporal distribution and cohesion of social systems (table 5 .2; whitehead 2008) . social systems can be further subdivided into two categories: colonies and aggregations, and this distinction is important for understanding host-parasite dynamics in bats. colonies are groups of individuals that may or may not be genetically related but which exhibit non-random patterns of association, and frequent close contact with each other (kerth 2008) . it is often assumed that groups of bats roosting in a common structure represent a colony but often such groups may not meet the colony definition and, instead, represent aggregations. aggregations are defined as assemblages of individuals that happen to occur in a shared environment at the same time, perhaps due to an attraction to that environment rather than social bonds with other individuals (table 5 .2). variation in social dynamics within and between colonies and aggregations can mediate host-parasite dynamics (webber et al. 2016 ). host an animal or plant on which a parasite lives. martin (2010) reservoir host (ecological definition) hosts that do not exhibit clinical disease as a result of infection. nunn and altizer (2006) reservoir host (medical definition) hosts that serve as a source of infection and potential reinfection of people and sustain parasite populations when humans are not available. martin (2010) parasite (ecological definition) any organism that lives on and draws nutrients from another living organism (the host), usually to the host's detriment. nunn and alitzer (2006) parasite (medical definition) an organism that grows, feeds, and is sheltered on (ectoparasite) or in (endoparasite) a different organism while contributing nothing to survival of its host. martin (2010) microparasite pathogens, or disease-causing microbes (viruses, bacteria, protozoa, fungi). anderson and may (1979) macroparasite multicellular parasites (helminthes, arthropods, most ectoparasites) may and anderson (1979) disease (ecological definition) pathology caused by infection, including outward physical signs and internal or behavioral changes. nunn and alitzer (2006) disease (medical definition) a disorder with a specific cause (may or may not be known) and recognizable signs and symptoms. martin (2010) pathogen disease-causing agent. nunn and alitzer (2006) virulence (ecological definition) disease-induced host mortality and/or reductions in fecundity nunn and alitzer (2006) virulence (medical definition) the disease-producing (pathogenic) ability of a microorganism. martin (2010) infection invasion of the body by harmful organisms (pathogens), such as bacteria, fungi, protozoa, or viruses. martin (2010) prevalence a measure of morbidity based on current levels of disease in a population; measured as a proportion (i.e. number of infections divided by number of individuals). martin (2010) intensity a measure of morbidity based on current levels of disease in a population; measured as an absolute number (i.e. the total number of infections). martin (2010) epidemiology the science concerned with the study of the factors determining and influencing the frequency and distribution of disease in a defined human or animal population. martin (2010) relationships between host social systems and parasite dynamics are complex, but several mechanisms are predicted to influence these patterns and are likely important for bats. for example, hosts that occur in large, high-density colonies are predicted to have more frequent interactions resulting in more opportunities for parasite transmission (stanko et al. 2002; tompkins et al. 2011) . dense aggregations may result in contacts that are fewer and shorter in duration than those occurring in colonies, but are still likely to provide more opportunities for parasite transmission than might occur for solitary bats or those in very small colonies. this variation in host density also has the potential to influence one of the most fundamental parameters of disease ecology, the basic reproduction number or basic reproductive ratio (r 0 ). r 0 is an important metric of parasite fitness typically defined, for microparasites, as the number of secondary infections caused by an infectious individual in an entirely susceptible population or, for macroparasites, the number of female larvae established from a single female worm (hudson et al. 2002) . when r 0 > 1 infection persists within the host population and when r 0 < 1 infection cannot become established (perkins et al. 2003) . variation in social behavior can impact r 0 if certain individual hosts disproportionately infect a large an individual's reaction to a novel object or situation. réale et al. (2007) number of conspecifics, and thus inflate r 0 above the persistence threshold of one (lloyd-smith et al. 2005) . although empirical data from numerous vertebrates (e.g. ungulates: ezenwa 2004) and invertebrates (e.g. bees: otterstatter and thomson 2007 ) support theoretical relationships between parasitism and sociality, there are few data for most host-pathogen systems involving wild mammals, including bats. bats are among the most ecologically diverse of mammals with an enormous range of social systems (kunz and lumsden 2003; kerth 2008; johnson et al. 2013) . for example, colony or aggregation sizes of bats range from completely solitary to millions of individuals, while social systems range from small, closed societies with potentially long-term social bonds (e.g. thyroptera tricolor: chaverri 2010) to enormous, likely passive aggregations of individuals attracted to high-quality habitats (e.g. myotis lucifugus during autumn swarming : fenton 1969) . social behavior in bats presumably evolved in response to the costs and benefits associated with close conspecific contact. benefits of social roosting may be numerous and include social thermoregulation, cooperative behavior, and information transfer. many temperate bats rely on social thermoregulation to decrease energy expenditure during periods of energy limitation, such as pregnancy and lactation (e.g. eptesicus fuscus: willis and brigham 2007) , while some tropical species also appear to exploit social thermoregulation (e.g. uroderma bilobatum: lewis 1992) . the evolution of cooperative behavior in bats was likely facilitated by strong female philopatry and stable group structure (emlen 1994) . vampire bats (desmodus rotundus) are well known for their cooperative behavior (i.e. reciprocal altruism) and females rarely transfer between groups (wilkinson 1987; carter and wilkinson 2013) . this combination suggests an evolutionary scenario, where stable group structure ultimately led to selection favoring cooperative behavior. information transfer about predation risk (e.g. kalcounis and brigham 1994) and high-quality foraging sites (e.g. mccracken and bradbury 1981) are also commonly cited as potential benefits of sociality for bats. despite these potential benefits of social behavior, risk of infection with microand macroparasites is thought to represent a potentially pronounced fitness cost of being social (côté and poulin 1995) . this cost is illustrated most obviously by the recently emerged infectious disease white-nose syndrome (wns), which is caused by the fungal microparasite pseudogymnoascus destructans (blehert et al. 2009 ). wns has resulted in catastrophic declines of temperate hibernating bats in north america (frick et al. 2010 ) and prompted urgent conservation and management attention fenton 2012) . p. destructans is an invasive pathogen that appears to have evolved with bats from the old world, where it does not cause mortality of infected hosts, and to date, is known to occur on at least 15 hibernating bat species (puechmaille et al. 2011; zukal et al. 2016) . p. destructans grows in exposed skin of the muzzle, ears, and wing membranes of bats during hibernation (blehert et al. 2009; warnecke et al. 2012) . for north american species, infection with p. destructans causes an increase in energy expenditure (verant et al. 2014) and arousal frequency (boyles and willis 2010; reeder et al. 2012; warnecke et al. 2012 ) which lead to premature depletion of fat stores during hibernation. although the mechanism inducing increased energy expenditure and arousals by infected bats is still not fully understood (for review see willis 2015) , variation in social behavior could mediate fungal transmission and growth, especially since affected species tend to hibernate in large colonies or aggregations in caves or mines. understanding host-parasite dynamics in the context of social behavior for wns is therefore important from a conservation perspective. in addition to serious conservation threats for some species, bats also appear to be reservoir hosts for a number of emerging infectious diseases (eids) of public health concern (luis et al. 2013; plowright et al. 2015) . reservoir hosts tend not to exhibit clinical disease as a result of infection (baker et al. 2013 ) and reservoir host populations may therefore provide large pools of infected hosts that could facilitate spillover events to heterospecifics, including humans, livestock, or pets (luis et al. 2013; plowright et al. 2015) . interestingly, their apparent ability to tolerate infection with a wide diversity of viral parasites is one factor supporting the recent hypothesis that bats are 'special' with respect to their propensity to host zoonotic microparasites (luis et al. 2013; brook and dobson 2015) . the recent identification of a number of viral, protozoan, and bacterial microparasites in bats supports this hypothesis and has prompted significant analysis and discussion about bats as natural hosts to microparasites associated with eids of humans or livestock luis et al. 2013; olival and hayman 2014; veikkolainen et al. 2014) . for example, recent evidence suggests that bats host more zoonotic viruses per species compared to rodents, and human encroachment into bat habitats, particularly in the tropics, could facilitate spillover events (daszak et al. 2000; luis et al. 2013) . several hypotheses have been proposed to explain the apparent zoonotic potential of bats. enormous variation in body temperature (t b ) and metabolic rate (mr) between rest and sustained flight in many heterothermic bats could reduce fitness or pathogenicity for many viral parasites (o'shea et al. 2014) . interestingly, widespread torpor expression in bats appears to reduce the likelihood of hosting zoonotic viruses, possibly because viral replication decreases as a result of reduced t b and mr during torpor (luis et al. 2013; stawski et al. 2014 ). this hypothesis suggests physiological tolerance as a mechanism allowing bats to serve as reservoir hosts, but evidence linking host sociality as an additional mechanism is limited . despite the fundamental evolutionary importance, and conservation and public health significance of bat-parasite interactions, studies of the influence of bat sociality on parasite transmission and acquisition are limited, especially for microparasites. here, we review the literature on relationships between social behavior of bats and their associated parasites. first, we provide an overview of the tools, techniques, and methodologies that have been used to quantify relationships between sociality and parasitism in bats, as well as relevant techniques that have been used for other vertebrates and which could be applied to bats. second, we summarize the role of sociality in three relatively well-studied bat-parasite systems: wns, hendra virus (hev), and arthropod macroparasites. finally, we propose testable hypotheses and observational and experimental studies important for understanding the influence on parasite dynamics of two important concepts in behavioral ecology of bats: fission-fusion social organization and individual behavioral tendencies (i.e. personality). we conducted an extensive search of the literature and compiled a list of articles based on combinations of key word searches on web of science. we searched the term "chiroptera" and "bat" with every possible combination of social*, gregarious*, colony, aggregation, fission-fusion (i.e. a common type of bat social system, see below), viral, pathogen, disease, ectoparasite*, endoparasite*, parasite*, infection* and epidemiology*. our initial search yielded 223 unique articles but we eliminated articles that did not explicitly quantify or discuss a link between some aspect of sociality and parasite risk. this left only 35 articles that fully satisfied our search criteria. four of these used comparative analyses to examine effects of species-specific socioecological traits on parasite risk (table 5 .4), 15 addressed sociality in the context of microparasites (table 5 .4), and 16 addressed sociality in the context of macroparasites (table 5 .5). the studies we identified employed a range of methodologies to quantify links between sociality and parasite risk (tables 5.3, 5.4 and 5.5). methods included social network analysis (n = 3), epidemiological modeling (n = 5), and interspecific comparative analyses (n = 4). details about the underlying theory and the implementation of these methods is available elsewhere (e.g. social network analysis: croft et al. 2008; epidemiological modeling: may 2006 ; comparative analyses: garland et al. 2005) , and here we focus on the progress that has been made to date in identifying knowledge gaps where future research on bat-parasite dynamics could be focused. social network analysis is based in mathematical graph theory and has been widely applied in human sociobiology, since the 1950s (e.g. cartwright and harary 1956; wasserman and faust 1994) . for studies of wildlife, network analysis was first applied in primate sociobiology (e.g. sade and dow 1994) , and has recently been applied more broadly to many other taxa (e.g. fewell 2003; hamede et al. 2009; drewe 2010) , including bats (for review see johnson et al. 2013) . networks consist of nodes (individuals or locations) and edges (interactions between nodes) through which a variety of individual and group level metrics can be quantified (wey et al. 2008) . the roles and importance of individuals or locations can then be assessed based on these metrics (see croft et al. 2008 for review). for example, individuals with certain combinations of traits can influence network dynamics by potentially acting as intermediaries connecting smaller subgroups within larger groups (wey et al. 2008; krause et al. 2010 ). in addition, bipartite networks (or two-mode networks) can be constructed to assess associations between individuals and ecologically relevant locations (e.g. a population of organisms and their nesting sites). network metrics are especially useful because they can be used as predictor variables for relevant-dependent variables (e.g. infection status or parasite intensity) in standard statistical models (e.g. general linear models). network analysis has allowed disease ecologists and parasitologists to make important strides quantifying how non-random social interactions affect parasite transmission and dynamics (for review see godfrey 2013). network analyses have become increasingly popular for studies of bats (johnson et al. 2013) . for instance, network analyses have been applied in a bat-habitat management context by identifying critical roosting locations that serve as 'hubs' within a roost network and simulating the consequences of removing those key sites for stability of the social group (rhodes et al. 2006; silvis et al. 2014) . network analyses have also been used to identify and quantify fission-fusion behavior within bat colonies (fortuna et al. 2009; patriquin et al. 2010; kerth et al. 2011; johnson et al. 2012 ). in the context of disease ecology, so far only two studies have connected social networks with epidemiological models to make inferences about host-pathogen dynamics (e.g. fortuna et al. 2009; webber et al. 2016) . fortuna et al. (2009) showed that giant noctule bats (nyctalus lasiopterus) form highly modular, fission-fusion colonies, and used an epidemiological model, parameterized using network metrics, to show that this arrangement reduces the spread of information or disease within the population because the colony was effectively segregated into modules divided among many roost trees (n = 73 trees for 25 bats: fortuna et al. 2009 ). for big brown bats (eptesicus fuscus), webber et al. (2016) recently showed that network structure depends on the habitat context. although tree-roosting e. fuscus reuse tree hollows between years (willis et al. 2003) , they frequently switch roosts within years (on average every 1.7 days: willis and brigham 2004) and rarely return to the same roost within a given summer. in building roosts, however, e. fuscus switch much less frequently and commonly return to the same roost repeatedly within the same year (ellison et al. 2007; webber et al. 2016) . webber et al. (2016) applied epidemiological models to social networks constructed based on these patterns of roosting behavior in forests versus buildings and found that parasite dynamics should vary between these habitat contexts with more rapid pathogen dissemination within building roosting colonies. constructing epidemiological models from empirical data undoubtedly improves inference for predicting epidemic outcomes, but as yet there are no studies that quantify real-world relationships between the social behavior of bat hosts and their parasites to test predictions of epidemiological models (table 5 .3). although this form of data collection can be labor-intensive and potentially expensive (craft and caillaud 2011) , there are numerous examples of network analysis being used to integrate information on host-contact patterns and parasitism in systems with highly gregarious hosts. for example, network analysis elucidated the role of meerkat (suricatta suricata) allogrooming as a predictor for the prevalence of myobacterium tuberculosis, the microparasite that causes tuberculosis (drewe 2010) . quantifying association patterns of meerkats was largely conducted via focal animal observation, a type of data collection that is nearly impossible for free-ranging bats. thus, advances in technology, such as passive transponders (pit tags), data-logging telemetry, and/or proximity data loggers may be useful for quantifying association patterns and constructing social networks for bats with implications for epidemiology and disease ecology (e.g. willis and brigham 2004; patriquin et al. 2010; kerth et al. 2011; johnson et al. 2012 ). although empirical data are sparse, host-parasite dynamics, and the impacts of parasites on host populations have a rich theoretical history founded on anderson and may's (1979) seminal models. their classic microparasite epidemiological model conceptualizes host population dynamics in terms of susceptible (s), exposed (e), infected (i), and resistant/recovered (r) population pools, and these pools can be combined in a range of ways depending on the nature of host-pathogen interactions in the wild (e.g. si, sis, sir, seir models). in a standard sir model, individuals transition from s to i as a function of transmission rate (β) and from i to r as a function of survival of infection (v), while birth (a), and death rates (b, a + b for infected hosts) of each pool drive overall population dynamics (fig. 5.1 ; anderson and may 1979) . since being developed, sir epidemiological models have been widely used to infer microparasite impacts on host populations for humans (e.g. anderson and may 1982) , wildlife (e.g. mccallum et al. 2009 ) and plants (e.g. gilligan et al. 1997) . although appropriate for modeling the impacts of many infectious diseases (e.g. measles, whooping cough: anderson and may 1992) , classic sir models compartmentalize individuals into broad categories which may fail to capture variation in aspects of host biology that could influence parasite dynamics and impacts (keeling and eames 2005) . for example, classic sir models often assume that individual hosts in the population associate at random but, particularly for highly social species, non-random association patterns are far more likely in nature. incorporating network structure into epidemiological models eliminates random-mixing assumption of classic sir models by assigning each individual a finite number of permanent or temporary contacts between which transmission can occur (keeling and eames 2005; may 2006) . implications for network epidemiological modeling include the ability to identify highly connected individuals that may be involved in a disproportionate number of transmission events (e.g. super-spreaders: lloyd-smith et al. 2005) and weakly connected individuals that may benefit from lower risk of infection. epidemiological models informed by variation in social connectedness can be highly effective for predicting pathogen dynamics (lloyd-smith et al. 2005) but, as noted above, so far only two studies have applied these methods specifically to bats (fortuna et al. 2009; webber et al. 2016) . however, to our knowledge no study has explicitly tested model predictions on a natural bat-parasite system in the wild. an alternative to network epidemiological models informed by short-term (i.e. one season) association data, is the use of long-term population data for model parameterization. these data ideally include information on changes in population or colony sizes and changes in population demographic structure and/or vital rates. most often for bats, long-term field data on colony size and population connectivity, in combination with laboratory data on immune physiology have been used (table 5 .4; george et al. 2011; plowright et al. 2011) . for example, field and laboratory data were combined to model ecological factors driving hev spillover events occurring in australia from flying foxes (pteropus sp.) to horses and predicted that decreased migratory behavior of the host increased host density in urban areas, which contributed to the duration and intensity of hev outbreaks (plowright et al. 2011, see below) . similarly, mark-recapture data, combined with birth and death rates of different demographics, have been used to parameterize models of rabies dynamics (george et al. 2011) . rabies in e. fuscus is highly seasonal, with peaks in prevalence at maternity colonies (i.e. during june and july) after parturition when pups provide a supply of immunologically naive hosts (george et al. 2011 ). thus, the chance of spillover is greatest during the post-parturition period when females roost in large colonies and the influx of juveniles in the population increases overall prevalence. these studies highlight the value of predictive models incorporating the behavior of bats to make predictions about parasite dynamics, with potential implications for human public health. however, even models which incorporate host ecology and behavior (e.g. habitat selection) do not typically account for variation in social behavior which could also play an important role (moore 2002) . for microparasites, the two most likely parameters influenced by variation in social behavior are transmission rate (β) and the survival and subsequent reproduction of infected individuals (fig. 5.1 ). for example, recent appreciation of individual differences in host behavior has led to the realization that homogenous mixing or so-called 'mass action' transmission may not reflect the dynamics of most host-parasite systems (mccallum et al. 2001; moore 2002; barber and dingemanse 2010) . despite this realization, though, for many host-pathogen systems, estimating β can be difficult and modeling studies tend to rely on some plausible range of values for β (e.g. griffin and nunn 2012) . for some microparasites, however, it may be possible to experimentally manipulate transmission and determine β empirically. for example, a basic pairwise experiment, where pairs of individuals (one infected, one susceptible) are housed together could help to determine the proportion of contacts that result in transmission, and narrow the range of plausible β values. incorporating empirically derived data on association patterns of individual bats into epidemic models could help to improve our predictions of potential epidemic scenarios. these analyses (i.e. informed by empirical data) are still relatively scarce for bats (table 5 .4), but recent interest in host-parasite interactions and social network analysis provides an excellent opportunity to connect real data with model predictions. comparative analyses provide insight into potential species-specific variation in evolutionary adaption (i.e. changes in response to natural selection) within a group of organisms (garland et al. 2005) . from the perspective of parasites, a host is effectively a habitat, which means principles of community ecology, and biotic and abiotic characteristics of the "host ecosystem," can be used to explain patterns of parasite community composition (morand and poulin 1998) . thus, in contrast to intraspecific analyses which typically assess variation in prevalence or intensity of infection among individuals, comparative studies typically examine interspecific variation in parasite species richness among host species because intensity and prevalence are unlikely to be comparable in terms of their impacts, across different host and parasite species. in most cases, comparative studies of parasite species richness "correct for" host phylogeny. two closely related species are more likely to share similar functional traits compared to two more distantly related species because of their more recent evolutionary history (ives and garland 2010) . more parasites are also likely to have been identified for host species that have been well-studied so, in addition, most comparative studies also account for publication bias by including the total number of publications on a given host species as a covariate in statistical models, or by using residuals of a linear regression between number of publications and parasite species richness as the response variable (e.g. nunn et al. 2003; lindenfors et al. 2007; turmelle and olival 2009 ). to date, relatively few studies have used comparative analyses to test effects of social behavior on parasite species richness in bats and, so far, most have focused on viruses with one quantifying macroparasites (table 5 .3). in contrast, studies of primates, the best-studied mammalian taxon in terms of relationships between social behavior and parasite richness, focus on a wider breadth of parasites (i.e. ecto and endoparasites as well as bacterial and viral pathogens: nunn et al. 2003; vitone et al. 2004; griffin and nunn 2012) . for bats, colony size appears to be one of the most important predictors of viral richness, and epidemiological and evolutionary theory predict that highly colonial bat species should harbor greater parasite diversity, because of increased opportunities for parasite reproduction and evolution . however, observed relationships have not always followed this pattern for bats (turmelle and olival 2009; gay et al. 2014) . turmelle and olival (2009) found no effect of colony size on viral richness in bats but, rather, identified species' conservation status and global f st (i.e. population genetic structure) as the most important predictors. on the other hand, among southeast asian bats, gay et al. (2014) found a negative relationship between colony size and viral richness, which contradicts epidemiological theory (loehle 1995) . one potential limitation of these results could be that the authors used a categorical metric of population size (i.e. small, medium or large), which likely underrepresents the complexity of social behavior (gay et al. 2014) . alternatively, in the case of gay et al.'s (2014) results, it could be that bats in large colonies express immune or behavioral traits that provide protection from increased parasite risk in that social context. although they have still not been widely used, in our view comparative studies have great potential to help understand how bat social behavior influences parasite diversity and co-evolves with parasites, in part because bats are so diverse and exhibit a wide range of social and mating systems. for example, promiscuous bat species should host a greater number of parasite species compared to harem-breeding and monogamous bats because, independent of colony size or density, polygynandrous species presumably come in contact with a greater number of conspecifics during mating compared to polygynous species, which likely has implications for host-parasite coevolution. however, it is important to note that mating systems vary considerably among bats (mccracken and wilkinson 2000) and other aspects of bat social systems (e.g. degree of fission-fusion or roost fidelity: see below) likely co-vary with mating system and are equally important as predictors of parasite richness. thus, we recommend that future studies attempt to include more detailed information on bat social systems in comparative analyses. for example, a meta-analysis of primate social structure showed that differences in social network modularity (i.e. sub-grouping within a larger group) in 19 species led to differences in disease dynamics among species (griffin and nunn 2012) . although it may not be possible to include such detailed social association data for bats at present, as more social network studies accumulate, we recommend the use of network metrics as predictor variables of parasite richness in comparative analyses. species-specific data on typical contact rates among individuals and demographics, and between sympatric species, as well as data on dispersal patterns and group stability within bat species (e.g. fission-fusion) would also be valuable as predictor variables to better understand how host social traits in bats influence their parasite ecology and evolution. although very different in terms of their ecology and population impacts, based on our literature review, the relationship between bat sociality and parasite impacts and dynamics has been relatively well-studied for three sets of parasites: p. destructans, the cold-tolerant fungal pathogen of bats that causes wns; hev, which can lead to potentially fatal zoonotic disease in humans and horses; and the many species of arthropod ectoparasites which have been relatively well-studied because they can be easily sampled from bats captured in the field. we also identified four articles which addressed the relationship between rabies, or european lyssavirus, and bat social behavior (table 5 .4), but rabies in bats has been the focus of a number of reviews (e.g. messenger et al. 2003; kuzmin and rupprecht 2006; rupprecht et al. 2011; o'shea et al. 2011 ) so here we focus on less well-characterized bat-parasite interactions. wns is an eid of urgent conservation concern because it is causing staggering rates of mortality among hibernating bats in eastern north america (blehert et al. 2009; frick et al. 2010; wilder et al. 2011; langwig et al. 2012; frick et al. 2015) . despite its recent emergence , however, wns is among the most well-studied microparasites of bats in the context of social behavior. interestingly, one of the hallmark behaviors observed for p. destructans infected bats, both in the wild and in the laboratory, is a reduction in clustering behavior as wns infection progresses over the course of hibernation (langwig et al. 2012; wilcox et al. 2014 ). this phenomenon could lead to increased energy expenditure or evaporative water loss which has implications for survival and potentially future reproduction (willis et al. 2011; boratyński et al. 2015) . reduced clustering could be part of a stereotyped behavioral response by animals to infection, known as "sickness behavior" (hart 1988) , which could either reduce the likelihood of becoming infected, or reinfected, by sick individuals in the hibernaculum or reduce the likelihood of infecting susceptible individuals, which could be important for inclusive fitness if bats cluster with kin during hibernation (wilcox et al. 2014; bohn et al., in review) . in the laboratory, transmission occurs via direct physical contact and there is no evidence of airborne transmission (lorch et al. 2011) , while environmental transmission in the wild likely contributes strongly to infection dynamics because p. destructans can survive in hibernacula in the absence of bats (verant et al. 2012; hoyt et al. 2015) . although the most adversely affected bat species tend to associate with large numbers of conspecifics throughout the year, transmission appears to occur almost exclusively within hibernacula during autumn and throughout the winter . variation in sociality within and between bat species appears to influence host-parasite dynamics in wns. in the context of host density, there are two theories relevant to the relationship between transmission and host-parasite dynamics. first, density-dependent transmission predicts that host infection scales as a function of host density so that, at low host density, pathogen transmission declines, and a given pathogen fades out (greer et al. 2008) . second, frequency-dependent transmission predicts that host infection is driven by the total number of interactions among infected and susceptible individuals in the population, regardless of population density, so that when host density is low, a given pathogen can persist (greer et al. 2008) . interestingly, the relationship between wns transmission and host density during hibernation appears to be species-specific. among relatively solitary species (i.e. perimyotis subflavus and myotis septentrionalis) that hibernate individually or in small clusters, aggregation size (i.e. the numbers of bats in the hibernaculum) best predicted the number of surviving bats within a given hibernaculum, with larger aggregations experiencing faster apparent declines (langwig et al. 2012 ). this observation is consistent with density-dependent transmission models. in contrast, for species that vary more widely in aggregation size (i.e. m. lucifugus and m. sodalis), mortality was equally severe across a range of aggregation sizes (langwig et al. 2012) , which is consistent with frequency-dependent transmission models. this suggests that differences in species-specific social behavior during hibernation can modulate wns transmission and infection. unlike other infectious diseases of bats (e.g. rabies: george et al. 2011 ) demographic structure in the active season does not appear to drive wns dynamics. healthy m. lucifugus emerge from hibernation over an approximately eight-week period in spring (norquay and willis 2014; czenze and willis 2015) . females tend to emerge prior to males, with the females in the best condition emerging first. this is presumably because larger fat reserves allow females to cope with potentially inclement weather, but also initiate reproduction earlier by exploiting warmer, passively heated maternity roosts, and occasional warm nights with flying insects available (norquay and willis 2014) . however, bats infected with p. destructans tend to emerge from hibernation much earlier than healthy bats presumably because their fat stores are depleted. moreover, bats that survive hibernation with wns often have severe wing damage in spring and individuals with the most damaged wings tend to have the smallest energy reserves (fuller et al. 2011 ). for many diseases, an influx of immunologically naive hosts (i.e. juveniles) leads to a dramatic increase in prevalence immediately following reproduction due to vertical transmission from mothers to offspring. in wns, however, seasonal dynamics of the disease are driven by dramatic seasonal changes in host physiology, specifically sustained low body temperature during hibernation (warnecke et al. 2012; langwig et al. 2012 langwig et al. , 2015 . for p. destructans-infected bats in spring and early summer, an increase in body temperature limits infection and transmission despite the fact that females tend to aggregate in potentially large maternity colonies . although transmission likely does not occur readily for females at maternity colonies, high mortality rates during hibernation may decrease the number of potentially reproductive females that form maternity colonies . therefore, normal benefits incurred from colonial roosting, such as social thermoregulation, may be dramatically reduced for wns-surviving bats, which could have additional negative impacts on survivors. for example, the energetic costs of wound healing may be significant for infected individuals upon emergence from hibernation (fuller et al. 2011 ) and the decreased availability of social thermoregulation and increased likelihood of roosting solitarily may further increase energetic expenditure (wilcox and willis 2016) . therefore, for species affected by wns, the lack of potential colony members, and thus potential for social thermoregulation, during spring and early summer could ultimately result in decreased survival and reproduction . in addition to influencing transmission of p. destructans, theory predicts that population size influences risk of extinction (de castro and bolker 2005) . using counts of bats during winter hibernaculum surveys as a proxy for population size, frick et al. (2015) showed that, for five of six wns-affected species, probability of local extinction from a given hibernaculum decreased as population size increased. this suggests that host aggregation and social behavior could influence risk of extinction from wns. one possible mechanism is that larger populations have greater flexibility to cope with decreases in population numbers, and are thus less likely to face declines below population thresholds where extinction becomes inevitable. interestingly, social behavior may also help to explain differences in the consequences of p. destructans infection for european versus north american bats. prior to the emergence of wns, hibernating aggregations of affected north american species were approximately tenfold higher, on average, than colony sizes of ecologically similar european species . however, after wns emergence, colonies of affected north american species have declined precipitously and appear to be stabilizing at sizes similar to those of european bats . this suggests the possibility that european colony sizes could have been larger in the past and similar to pre-wns colony sizes in north america (frick et al. 2016) . taken together, empirical data from north america and inferences from europe suggest that wns could select against larger colony sizes (frick et al. 2016 ) resulting in remnant colonies which are, on average, smaller and less social than pre-wns colonies. we suggest that future studies attempt to quantify social tendencies at the individual and population levels for pre-and post-wns infected populations to assess the impact of this conservation pathogen for social evolution in bats. in australia, bats from the genus pteropus are reservoir hosts for hev, a recently emerged zoonotic virus from the family paramyxoviridae. flying foxes are only briefly infectious with no clinical disease but shed hev in urine, saliva, feces, and placental fluids (halpin et al. 2011) . hev is lethal to horses and humans, and transmission presumably occurs when horses ingest food or water contaminated by bats (plowright et al. 2008) . horses appear to act as amplifier hosts (daszak et al. 2006) , as all human cases have been directly traced back to an infected horse (field et al. 2012) . although, spillover events from flying foxes to horses are complex and few data exist linking individual social tendencies of the bats to hev transmission, host socioecology likely mediates host-pathogen dynamics for this zoonotic disease. colony/aggregation sizes of pteropus species can range from as few as 10,000 individuals in p. alecto maternity colonies to millions of individuals for p. scapulatus. based on experimental data and closely related human paramyxoviruses (e.g. measles), hev may require large host population sizes to provide enough susceptible individuals for persistence because of a relatively short infectious phase and life-long host immunity (daszak et al. 2006) . historically, naturally occurring nectar resources in native forests supported large, seasonally-migrating flying fox populations (eby 1991; plowright et al. 2015) but human-mediated habitat alterations have resulted in patchily distributed natural food resources, which were already ephemeral in nature (i.e. seasonally produced nectar). therefore, flying foxes have begun to colonize urban and periurban areas to exploit highly abundant, consistently available anthropogenic food resources, such as fruiting trees planted in gardens or horse paddocks (eby et al. 1999) . in many cases, urban bats do not migrate because food resources are consistently available, which increases the likelihood of hev-positive bats coming in contact with horses (plowright et al. 2011) . therefore, recent emergence and spillover of hev in australia appears directly linked to increases in the size and abundance of urban bat colonies as well as reduced migratory behavior (plowright et al. 2015) . although urban bat aggregations appear to remain relatively large throughout the year, temporal dynamics of hev are at least partially mediated by host socioecological traits such as colony size and migration (plowright et al. 2011). as noted above, social group size has been identified as a potentially important predictor of parasitism, with larger groups generally hosting more parasites (côté and poulin 1995; rifkin et al. 2012; patterson and ruckstuhl 2013) . among temperate bats, sexual segregation and variation in social group size between sexes appears to be among the most important mediators of ectoparasitism. adult males tend to roost individually or in small groups, while females form maternity colonies (kunz and lumsden 2003) . for males, parasitism tends to remain low-throughout spring and early summer and as the mating season progresses ectoparasite prevalence and intensity increases (webber et al. 2015a) . most studies investigating the link between colony size and ectoparasitism in bats have found the predicted positive relationship (e.g. luçan 2006; reckardt and kerth 2009; encarnaçao et al. 2012) , although this is not always the case (e.g. zhang et al. 2010; postawa and szubert-kruszynska 2014) . one explanation for lack of correlation between group size and ectoparasitism at female colonies in some studies may be linked to variation in host association patterns and roost selection/ephemerality. for instance, bamboo shoots used as roosts by flat-headed bats (tylonycteris pachypus and t. robustula) are highly ephemeral and likely contribute to frequent roost-switching (lewis 1995) as well as variation in group size and composition (zhang et al. 2010) . frequent roost switching breaks up social contacts that could favor direct host-host transmission of ectoparasites. meanwhile, because some ectoparasites rely on stable roost structures for a portion of their reproductive cycles, bats that use ephemeral roosts rarely come in contact with ectoparasites that rely on a stable roost for reproduction (lewis 1995) , which could supersede the theoretical relationship between colony size and parasite risk. although, social contacts among females help to explain observed patterns of ectoparasitism at maternity colonies, social organization (i.e. composition of groups) can also mediate ectoparasitism. most females present at maternity colonies are either pregnant or lactating and links between temporal variation in social organization (i.e. transition from pregnancy to lactation) and ectoparasitism are supported by co-evolution of some host-ectoparasite reproductive cycles (christe et al. 2000) . for example, reproductive cycles of some mite species respond to pregnancy hormones of their female hosts (lourenço and palmeirim 2007) . once pups are born there is also a pulse of mites, which results in significant vertical transmission from adult females to juveniles (christe et al. 2000; luçan 2006) . lactating females may also tolerate significant ectoparasite burdens. during lactation, females may have less energy available to mount behavioral (i.e. grooming) or immunological responses to infection (zuk and mckean 1996; christe et al. 2000) . thus, while females are lactating and pups are non-volant, ectoparasite prevalence, and intensity can be exceptionally high. however, once pups have been weaned and are volant, they tend to be more heavily parasitized than females until the colony disperses because they presumably have a naive immunoresponse and less-experience grooming (christie et al. 2000; czenze and broders 2011) . although ectoparasitism tends to increase with colony size, juveniles are usually the most infected hosts at maternity colonies. adult females still face significant ectoparasite burdens, while ectoparasitism for adult males generally increases throughout swarming as conspecific contact rates increase (webber et al. 2015a) . many bat ectoparasites are also vectors for bacterial pathogens (e.g. bartonella sp., veikkolainen et al. 2014 ). transmission of bacterial or viral pathogens via ectoparasite vectors among bat hosts could be influenced by sociality, especially for highly gregarious females at maternity colonies. in theory, the same principles which regulate host-pathogen dynamics should also apply to host-vector-pathogen dynamics, where the duration and frequency of host-host contact facilitates ectoparasite transmission, which in turn facilitates vector-based pathogen transmission. for instance, recent empirical evidence suggests that wing mites (spinturnix sp.) can transmit p. destructans propagules among hibernating bats in europe, a chain of transmission which is facilitated by direct host-host contact (luçan et al. 2016) . we suggest that more future studies quantify links between host sociality, vector ectoparasites, and vector-borne bacterial, viral, and fungal pathogens. progress has been made in identifying relationships between some aspects of sociality and parasitism in bats, but much more empirical data from wild and captive bats of more species is certainly needed. we propose a series of testable hypotheses and possible experimental and observational studies about the role of bat sociality in parasite dynamics. we focus on two aspects of sociality which have been relatively little-studied for bats in the context of parasitism: fission-fusion dynamics and consistent individual differences in behavior or personality. fission-fusion is the temporary splitting and reforming of colonies, where lack of consensus, or even conflict, result in temporary fission, but the cost of remaining apart is greater than subsequent fusion (sueur et al. 2011) . within maternity colonies, females exhibit fission-fusion sociality (e.g. m. bechsteinii: kerth and könig 1999; nyctalus lasiopterus: popa-lisseanu et al. 2008 ) and change roosts every few days but not all members of the group will move together, resulting in variable group size and composition (e.g. patriquin et al. 2010) . fission-fusion sociality and frequent roost switching by forest-living bats may have evolved as a mechanism to avoid parasites (reckardt and kerth 2007; bartonička and gaisler 2007) , although a trade-off between the costs of parasitism and benefits of remaining loyal to high-quality roosts likely exists. empirical data have linked fission-fusion behavior to ectoparasite avoidance (e.g. reckardt and kerth 2007) and some theoretical modeling also supports this hypothesis (kashima et al. 2013) . however, there are currently no studies investigating microparasite transmission within fission-fusion societies. we hypothesize that the relationship between fission-fusion dynamics and parasite risk and impacts will vary depending on the mode of transmission for a given type of parasite. we expect that for most microparasites and some ectoparasites (e.g. basilia nana: reckardt and kerth 2007) that require direct contact between hosts for transmission, fission-fusion dynamics could serve to disrupt parasite transmission. bats that display fission-fusion behavior typically switch roosts every 1-2 days (willis and brigham 2004) and data from m. bechsteinii suggest that bats are able to detect roosts that have recently been occupied by other bats (reckardt and kerth 2007) . thus, when bats switch roosts they appear to select sites that have not been occupied recently which could help them avoid infested roosts. in contrast, we expect that for macroparasites with alternative transmission strategies, such as mobile ectoparasites (e.g. crawling or flying), fission-fusion dynamics are likely to be less effective as a parasiteavoidance strategy. in fact, theory predicts that bats would be more likely to avoid mobile ectoparasites if they remained in a single, large group because of encounter-dilution effects (côté and poulin 1995; rifkin et al. 2012) . we suggest studies employing social network analysis of wild bats, combined with estimates of micro-and macroparasite prevalence, and intensity to disentangle relationships between host social behavior, including fission-fusion dynamics, and the ecology of parasite transmission (for review see godfrey 2013). animal personality refers to consistent individual differences in behavior that are stable within an individual across time and situations (sih et al. 2004; wolf and weissing 2012) . recently, personality has become more widely appreciated as a possible explanatory variable for a number of ecologically relevant traits including juvenile development (stamps and groothuis 2010) , energy expenditure (careau et al. 2008 ) and social structure (krause et al. 2010; wolf and krause 2014) . because personality influences non-random association patterns observed within social groups (krause et al. 2010) , between-individual variation in personality traits are expected to influence parasite transmission patterns within and between groups (barber and dingemanse 2010; kortet et al. 2010) . in general, the most active, exploratory or sociable (see table 5 .2 for definitions) individuals are expected to face greater risk of transmitting and/or acquiring parasites (barber and dingemanse 2010; kortet et al. 2010) . despite enormous recent interest in animal personality among behavioral ecologists, evolutionary physiologists, and conservationists (for review see sih et al. 2004; réale et al. 2007; careau et al. 2008; wolf and weissing 2012) , there are currently only three published studies examining effects of personality on any ecological trait in bats (menzies et al. 2013; kilgour and brigham 2013; webber et al. 2015b ). these studies highlight that individual bats, like many other vertebrates exhibit differences in personality but there is clearly room for much more research on personality in bats, especially in the context of parasite dynamics. we propose a series of hypotheses that would help to understand relationships between personality and parasite prevalence/intensity and transmission in the context of sociality. as for the implications of fission-fusion dynamics described above, these hypotheses vary for contact-mediated micro-and macroparasites versus mobile macroparasites with host-seeking behavior. first, we hypothesize a relationship between individual sociability and parasitism for contact-mediated parasites. theory predicts a positive relationship between host sociability and parasite risk, because the most sociable individuals are the most highly connected group-members within the social network and may therefore be exposed to, and themselves transmit, a disproportionate number of infections (barber and dingemanse 2010) . by contrast, for parasites with active host-seeking behavior, individual activity and exploration may be most important because less active or exploratory individuals may be easier targets for mobile macroparasites. webber et al. (2015b) identified the expected negative relationship between the prevalence and intensity of fleas (a relatively mobile ectoparasite) and the activity component of personality for female, but not male m. lucifugus, which highlights the potential complexity of these relationships. personality may have had a larger effect on females because females may be selective with their mating partners, so if less active females mate with fewer males they may retain a higher proportion of fleas, which would otherwise be transmitted during mating (webber et al. 2015b ). we suggest that future studies attempt to disentangle relationships between contact versus mobile parasites and sociability, activity, and exploration components of personality in bats. studies of host-parasite dynamics in bats are important from both a conservation and human public health perspective and, as we describe above, the implications of bat social behavior for parasite risk can be dramatic. based on our review of the literature, we identified social network analysis, epidemiological modeling (often, though not always, parameterized using empirically-derived data), and phylogenetically-informed comparative analyses as the methods most commonly used for quantifying links between sociality and parasitism in bats. in general, these studies suggest complex relationships and studies aimed at fully elucidating these links may require integration of techniques and data collection from multiple disciplines (e.g. behavior, ecology, epidemiology, parasitology, and physiology/immunology). we also found that, despite its recent emergence, wns is already among the best-studied pathogens of bats in the context of sociality perhaps, in part because researchers who focus on bats have brought behavioral and ecological expertise to bear on this important conservation problem. the link between host social aggregation and hev is also well established, again likely because of perceived societal importance, in this case 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white-nose syndrome without borders: pseudogymnoascus destructans infection tolerated in europe and palearctic asia but not in acknowledgments we thank jorge ortega for inviting us to contribute to this interesting book project and an anonymous reviewer for comments on an earlier version of this chapter. qmrw was funded through a manitoba graduate scholarship (mgs). funding for ckrw's research on host-parasite dynamics in bats is provided by a discovery grant and a discovery accelerator supplement from the natural sciences and engineering research council (nserc, canada). key: cord-335658-7mkj518c authors: chowdhury, imran title: bridging the rural–urban divide in social innovation transfer: the role of values date: 2020-10-05 journal: agric human values doi: 10.1007/s10460-020-10132-7 sha: doc_id: 335658 cord_uid: 7mkj518c this study examines the process of knowledge transfer between a pair of social enterprises, organizations that are embedded in competing social and economic logics. drawing on a longitudinal case study of the interaction between social enterprises operating in emerging economy settings, it uncovers factors which influence the transfer of a social innovation from a dense, population-rich setting to one where beneficiaries are geographically dispersed and the costs of service delivery are correspondingly elevated. evidence from the case study suggests that institutional bricolage—the crafting of improvised solutions in resource-constrained settings—can serve as potent driving force in driving innovation transfer, and that this process of re-combining available resources may be facilitated by the extent to which the values between partner social enterprises are aligned. with such alignment, social enterprise partners may be able to increase trust, develop a smoother knowledge-transfer process, and find practical solutions which facilitate the transfer of life-enhancing social innovations to neglected rural settings. in recent years, the growth of social enterprises, which provide vital services across diverse sectors of the economy such as education, healthcare, and enterprise development, has received significant popular and academic attention. for instance, the growth of microfinance organizations, both for-profit and not-for-profit, has captured the imagination of government and non-governmental organization officials and generations of students in public policy and business schools across the world (zhao 2014; battilana and dorado 2010) . the rapid increase in attention to these firms reflects not only the tremendous demand for the services they provide, but also the potential for these services to reach a wider audience. in short, there is a clear and compelling case for social enterprises to "scale" their successful models and practices beyond their local area to maximize their impact on society. while a number of options for scaling the impact of this knowledge exist, including developing franchises or diffusing best practices via mediating bodies such as multilateral organizations, partnering with other social enterprises remains among the most popular options (bloom and chatterji 2009; van wijk et al 2018) . traditional research on inter-organizational partnerships has considered the value of partnerships in gaining access to new markets and technologies, sharing knowledge, engaging in organizational learning, and developing greater levels of mutual dependence between partners (horowitz and mcgahan 2019) . more recently, research on partnerships has examined organizations in a cross-sector setting (vurro et al. 2010 ; ahmadsimab and chowdhury 2019), or in the context of public-private partnerships (saz-carranza and longo 2012; bishop and waring 2016) . in both streams of research, a focus on organizations which operate with primarily profit-maximizing or primarily social logics, has shifted in recent years to organizations where profit-making and social motivations co-exist (greenwood et al 2011) . what these studies have not considered in depth, however, is situations in which different forms of social logics co-exist, where the rationality for generating social impact varies between organizations in a partnership (friedland 2013) . social logics vary widely, and interact in distinct ways with the commercial logic. for instance, research by peifer et al. has examined how actors navigate logics such as religion in the context of science commercialization and in the mutual fund industry (peifer et al. 2019; peifer 2014) . in the case of religious mutual funds, organizations operating at the intersection of the competing logics of religion and finance engage in specific kinds of boundary work which leads to situations of enduring institutional complexity (peifer 2014) . other studies have looked at social logics in terms of structural roles, for instance, farmers operating as artists in commercial wine production (voronov et al. 2013) , or social logics manifested as social welfare logics in the case of work-integration enterprises (pache and santos 2013) or development logics in the microfinance sector (battilana and dorado 2010) . partnerships between social enterprises thus offer an ideal setting for the study of these phenomena, wherein different social logics may interact with each other in addition to their interactions with the commercial logic. organizations operating with a multiplicity of institutional demands, or in situations of institutional complexity, have varying responses to these demands (oliver 1991; mars and schau 2017; piatti and dwiartama 2016) . when these demands conflict, as may be the case with organizations that balance social and economic goals, an organization's response may be a function of the nature of the conflicting demands or the way this conflict is dealt with by organization members santos 2010, 2013; wijers 2019) . this thus paper seeks to better understand partnership between social enterprises (mair and marti 2006) where the goal is transferring knowledge (boxenbaum and battilana 2005; lounsbury 2007 ) for the purpose of scaling up social innovations (bloom and chatterji 2009) . in focusing on factors which influence the transfer of a social innovation from a dense, population-rich setting to one where beneficiaries are geographically dispersed and the costs of service delivery are correspondingly elevated, this article helps to develop a better understanding of the ways in which organizations manage relationships with partners that have different logics. further, by examining the spiritual and social welfare logics as distinct rationalities for generating social impact (gümüsay 2017) , and the ways in which these logics may align or clash in the context of a partnership, this study may also be able to better elucidate factors which facilitate or inhibit knowledge transfer between social enterprises and other hybrid organizations. finally, by examining innovation transfer from urban to rural areas, the article focuses on a long-neglected domain in studies of social enterprise which may have significant policy impacts (jia and desa 2018) . in order to address these questions i draw from a fieldworkbased case study of the transfer of affordable eye-care services from the aravind eye hospitals system in india to an eye hospital in paraguay. evidence from this case study suggests that institutional bricolage may serve as potent force in driving innovation transfer, and that the process of re-combining available resources can be facilitated by the extent to which the values between partner social enterprises are aligned. such alignment aided the social enterprise partners in this study to increase trust and to develop a smoother knowledge-transfer process, wherein potential areas of conflict were pre-emptively managed by focusing on points of commonality between the partner organizations. the paper makes three principal contributions. first, it provides evidence that alignment between the logics of social enterprise partners may influence the strategies firms use to transfer their knowledge while retaining the fidelity of that knowledge (ansari et al. 2010) . second, it points to the importance of such logics alignment in facilitating the institutional bricolage (baker and nelson 2005; desa 2012; clough et al. 2019) which enables a search for practical solutions geared towards bringing a life-enhancing social innovation to neglected rural settings. the third contribution brings together the first two and points towards an enhanced understanding of how social logics can co-exist in the context of a partnership, and how they may impact broader processes of organizational efficiency and economic concerns as organizations attempt to scale their social impact beyond their local areas of operation. the remainder of the article is organized as follows. in the next section, i offer a short overview of the literatures on institutional complexity and bricolage, concentrating in particular on how these literatures converge upon the phenomenon of innovation transfer. subsequently, in the third section of the article, i outline the study's methods. i present the case study upon which i draw for this article, including the broader study of which it is part. i also describe the data collection and data analysis process that i undertook. in the fourth section of the article, i present the findings from this study, including the diverse social logics that were identified in the case and the ways in which the social enterprise partners managed the innovation transfer process. in the fifth, and concluding, section, i discuss the implications of these findings to the broader fields of institutions and entrepreneurial bricolage, and for the literature on "scaling" social innovations. some practical applications of the study are also discussed for managers, consultants, and others working with social enterprises. fundamental to the world in which social enterprises operate (mair and marti 2006; greenwood et al 2011; skelcher and smith 2014) . this research builds on prior work on institutional dynamics, which tends to see institutional change as driven by changes in a single, dominant logic (thornton and ocasio 2008; thorton and ocasio 1999) . while a move from a focus on dominant institutional logics to multiple, coexisting logics offers numerous opportunities to re-conceive organizations and their broader environment, a number of challenges also arise. when new institutional logics prevail in the environment, organizations tend to imitate the most successful organizations embedded in and identified with these logics. when there are multiple logics in the environment, however, organizations have greater freedom with respect to the institutional pressures that they choose to comply with. in such instances, organizations may choose to adopt and re-interpret successful practices and standards as exemplified by institutional logics by means of a process of translation (czarniawska and sevon 1996) or editing (sahlin-andersson 1996) . a plurality of institutional logics impacts upon questions of identity as well. as scholars have noted, identity plurality in organizations, often emerging from environments with different sets of norms, may lead to tensions and conflicts within organizations (wry and york 2017; smith et al 2014; fiol et al. 2009 ). while greater attention is now being focused on multiple institutional logics and their impact on organizational fields and within organizations themselves, for the most part researchers haven't focused on how multiple logics can influence inter-organizational processes within the context of organizational hybrids such as social enterprises. this is important because the interorganizational setting allows us to see how alignment or non-alignment of logics between organizations may impact organizational processes. this setting also allows researchers to observe how organizational processes unfold and are interpreted by the parties in these interactions. additionally, an examination of organizational processes in social enterprises must take into account some of the fundamental mechanisms used by entrepreneurs to manage their environments and to ensure their survival. prior work in the realm of entrepreneurship and organizational studies has discussed the importance of bricolage in actors' attempts to craft solutions to existing problems under situations of resource constraint (baker and nelson 2005; lévi-strauss 1966) . in essence, by making do with the materials and structures and processes available at hand, entrepreneurs are able to overcome constraints which seemingly limit their freedom of action and ability to achieve their goals (fisher 2012) . more recently, scholars of social entrepreneurship have observed the applicability of bricolage concept in resource-constrained settings where organizations are attempting to move forward social goals and social value creation using processes and techniques borrowed from the business world (di domenico et al 2010; desa 2012; desa and basu 2013; mcdermott et al 2018; chowdhury 2019) . this research has started to bridge the institutional complexity and bricolage perspectives in the social enterprise context. for instance, in a study of the challenges encountered by international technology social entrepreneurs, desa (2012) finds that the conditions for resource mobilization are simultaneously enabled and constrained by the cognitive, normative, and regulative institutional pillars. though social enterprises embedded in supportive institutional contexts more easily gain legitimacy and access to standard resources, less-embedded social entrepreneurs are freer to engage in bricolage activities that challenge the norms of existing institutional arrangements to their benefit. relatedly, a recent study of australian social enterprises finds that entrepreneurial bricolage proceeds differently in rural versus urban settings. while rural social enterprises made relatively greater use of financial and physical assets accessed through networks within their communities, urban social enterprises were more likely to draw on assets via corporate partnerships and structured philanthropic ventures (barraket et al 2018) . the present study builds this prior work on institutions and bricolage in order to gain a deeper understanding of the ways in which social enterprises manage relationships with partner organizations to transfer innovations that cross the rural-to-urban divide, a domain that heretofore remains under-studied. in addition, it examines the role played by the alignment of institutional logics in facilitating innovation transfer processes. i highlight some of the principal differences for innovation transfer between the traditional commercial entrepreneurship space and the emerging social entrepreneurship space in table 1 below. in order to understand how social enterprises transfer innovations from population-rich settings to rural areas with dispersed populations, i draw on a 2-year-long qualitative field study of partnerships between social enterprises in developing countries that encompasses 83 semi-structured interviews, 9 weeks of on-the-ground observations, and the examination of extensive archival material and documents including emails, meeting minutes, annual reports, project reports and updates, briefs and monographs, books written about the social enterprises being studied, consulting evaluations, and survey data. these organizations were drawn from a sample of sixteen finalist organization pairs from the proposal submission process to a well-known european foundation. organizations submitted proposals jointly (generally in pairs) in the hopes of receiving funding for the transfer of a social innovation between a source and target organization. five winning proposals were selected from the sixteen finalist proposals which submitted applications, and i had access to the full proposals of all these organizations. the applications were a rich source of information regarding the organizations, the innovation being transferred, and the expected parameters and scope of their partnerships. i also had access to the full list of applicants and letters of interest for the competition, and administered a survey to all 16 finalist source organizations (with 15 responses) to capture information on their social innovations and their past, extant, and future knowledge transfer partnerships. subsequently i completed field visits to four of the five winning sets of organizations (the fifth set of visits was not undertaken due to logistical and financial constraints), starting with a pilot study between a pair of indian social enterprises. the bulk of interviews, observations, and archival material and documents were collected during these field visits. further details regarding the data collection process for the full study are included in table 2 . from the full sample of organizational partnerships described above, i selected a set of three social enterprises that had partnered for the purpose of transferring a system of affordable eye-care services. i specially chose this partnership for further study for two reasons. first, the innovation transferred was in the domain of healthcare within developing countries, a domain with broad potential implications in a broad range of geographies facing resource constraints. prior research in both urban and rural settings has pointed to the importance of health-focused social enterprises in delivering care to a range of disadvantaged communities (nirmalan et al. 2004; james 2014; chowdhury 2015; mcnamara et al. 2018) . second, i selected this set of organizations as the eye care system transferred by the source organization can be configured for a range of different health care environments across different geographic regions, in particular in resource-constrained emerging (developing) economy settings. due to the relatively repetitive nature of the refraction pilot study an initial case study was conducted on-site at one pair of source and target organization partners, both located in india, to gain insight into the social innovation transfer process. this pilot study allowed the "field-testing" of interview protocol which was refined for use subsequent datagathering 3 field visits and interviews researcher visited source and target social enterprises in the 3 remaining partnerships, located in bangladesh, india, paraguay, and sri lanka 4 follow-up and data analysis following and concurrent to field data collection i gathered updates on the progress of the knowledge transfer processes via email exchanges and telephone calls. i also had access to the periodic updates sent by each pair of organizations to the funding agency, up to and including the final reports. subsequently, final phone calls with both source and target organizations were conducted techniques, examination procedures, cataract surgeries, and administrative and support operations associated with the system, it can potentially be deployed across a range of settings with varying endowments of local resources. this contextual modularity may thus have important practical considerations for the eye care setting and, more broadly, the public health domain as well. as noted above, the organizations i focused on in this study included one source (transferring knowledge) organization and one primary target (receiving knowledge), and operated within the field of eye-care services and ophthalmology. in addition, the given the greatly varied geographical scope (dense population vs. dispersed, rural population) between the source and target organizations, a third (local) partner joined the organization to help with the implementation of the social innovation (see fig. 1 below) . the transferring organization, the aravind eye hospital (aravind) is located in madurai, india and has been working since 1976 to eliminate needless blindness by providing comprehensive eye care services to the poor. its technology has allowed millions of poor people to work, support their families, and lead fuller, more productive lives. one of the most productive eye care facilities in the world, aravind has reached impressive scale; in 2017-2018 it recorded nearly 4.2 million outpatient visits, and performed over 478,000 surgeries. of these surgeries, nearly 49% were delivered free of charge to the patient. aravind also has proven methodology for transferring its model to other eye care providers in developing countries through the lions aravind institute of community ophthalmology (laico). this system was being transferred via the partnership examined in this article: designing services-both range and the volume, based on the community need is the key for an effective eye care program. aravind, through laico tries to design services based on community need by sharing its model of high volume, high quality and affordable eye care through structured consultancy & capacity building processes. this starts with gap analysis to facili-tate eye care programs, developing a good strategic plan, and providing need-based assistance during plan implementation. this process is based on four core principles in eye care-demand generation, resource utilization, quality of services, and becoming financially viable. over a period of time, fundación visión will become a similar resource center for hospitals from latin and south american countries. the receiving, or target, organization was fundación visión. founded in 1992, this hospital system is the leader in blindness prevention in paraguay, and operates a 6000 m 2 hospital in in central asuncion, the capital of paraguay. fundación visión is the only institution in the country that provides regular monthly ophthalmologist care in rural areas of the country and trains "eye health promoters" to seek out persons in need of treatment for blindness and other eye problems. the partnership with aravind was undertaken so that fundación visión could increase the "quality, volume and sustainability of the eye care services" and improve the quality of its ophthalmology training programs. at the same time, fundación visión also wished to increase the options for financing of eye care procedures in paraguay, and, despite a strong in-country network of clinics, was constrained in its ability to reach the most remote parts of the country. paraguay is country with relatively low population density of about 15 people per square kilometer (versus 416 per square kilometer in india), and outside of its four largest cities (asuncion, ciudad del este, san lorenzo, capiata) and surrounding areas much of the population lives in small towns and villages that are very dispersed. as a result, it partnered with fundación paraguaya, one of the leading microfinance providers in paraguay, to gain access to its deep network of offices and broad contacts with the rural poor in the most remote parts of paraguay, and also to access the organization's expertise in finance to help patients pay for what could be very expensive surgeries. founded in 1985, fundación paraguaya generates most of its revenue through its microfinance operations, but is also involved in other operations such as the junior achievement program and an agricultural school for youth which teach the values of entrepreneurship throughout paraguay and beyond. this study uses four data sources: (1) semi-structured interviews; (2) field observations; (3) results from a preliminary survey of the partner organizations; and (4) archival data and documents. the primary source is semi-structured interviews with individual respondents. a total of 32 individual interviews were conducted. these interviews were conducted in-person in india and paraguay with senior managers and program implementation and monitoring staff at aravind (11 interviews), fundación visión (10 interviews), and fundación paraguaya (11 interviews) . interview questions focused on the innovation being transferred, the focal organization's history, operations and objectives, and the dynamics of the partnership being examined (see appendix for full list of questions). the interviews were recorded and transcribed, and i took extensive field notes during the course of my site visits to each of the three organizations. interviews and notes were transcribed and summarized within 24 h of the interview's completion. table 3 provides further information regarding the interviews. i supplemented my interview findings with field observation, including visits to field offices, screening camps, and project sites. i jotted notes on a paper pad during these visits, including notes from discussions with beneficiaries and local staff going about these work. these notes were later re-written into the field journal i kept on my laptop computer, and served as an important means for me to triangulate data obtained from in-person interviews and from company documents. finally, as part of my collection of archival material and documents at aravind, fundación visión, and fundación paraguaya, i was able to access both publiclyavailable and internal organizational records. these included emails, meeting minutes, annual reports, project reports and updates, briefs, monographs, and consulting evaluations. as befits the exploratory nature of this study, no testable hypotheses were formed prior to data collection (glaser and strauss 1967) . rather, the goal of the study to use the data collected to develop specific theoretical constructs and related propositions which advance current theory in novel directions (suddaby 2006 ). this approach is particularly suitable for studies of social entrepreneurship and bricolage as it allows the development of concepts in close connection to previous theorizing, important given the dearth of prior empirical work at the intersection of these two fields (miles and huberman 1994) . the data was analyzed iteratively, followed the principles of open-ended, inductive theory building, as i kept going back and forth between theory development and empirical data analysis. i worked between interviews, field notes, company documents, archival records, and relevant literature to develop themes and codes in order to categorize findings related to the management of partnerships by social enterprises, including the impact of institutional logics and their alignment (or non-alignment) on organizational processes. the principal unit of analysis for understanding the impact of institutional complexity (greenwood et al. 2011) on the innovation transfer partnership between aravind and its collaborators in paraguay, fundación visión and alonso (branch office) director, agricultural school director, regional microcredit offices (asuncíon) director, business development fundación paraguaya. i attempted to make sense of the data using "temporal bracketing," in line with recommendations from langley (1999) . for the sake of clarity, i present the three steps of data analysis in greater detail below, and in summary form in table 4 . step one: identifying key moments in the partnership in the first step of analysis, i identified key moments in the partnership, including partnership formation and development. by extracting a chronology of events for each case in this manner, i was able to develop narratives documenting how the interactions between aravind and fundación visión and fundación visión and fundación paraguaya evolved as the tri-partite collaboration developed. step two: coding institutional logics and key interactions during the second stage of data analysis, i coded and compared moments in the partnerships which were associated with the social and commercial logics, the initial theoretical frame drawn from the institutional complexity literature i used to guide my analysis, cycling iteratively between data and emerging concepts related to the tensions in both cases (suddaby 2006) . what i found was that the simple "social" logic was insufficient to explain what was going on. rather, it became clear that the social logic was actually manifesting as distinct spiritual logic and social welfare logics. whereas the social welfare logic obtains legitimacy by making products and delivering services to address local social needs, the spiritual logic obtains legitimacy by linking the provision of social services and goods to an association with deities and faith as its fundamental guiding mechanism (pache and santos 2013; gümüsay 2017). these spiritual and social welfare logics, along with the commercial logic, became the organizing frame for my understanding of the interactions between the social enterprises in this study. subsequently, i used "pattern matching" (miles and huberman 1994) to categorize the interactions between the based on the dominant institutional logic at play: (1) spiritual logic; (2) social welfare logic; and (3) commercial logic. these categories were derived from my data and existing theory (gümüsay 2017; pache and santos 2013) , and i attempted to identify how the three social enterprises dealt with alignment or non-alignment of logics by examining themes in the interviewees' comments. i found that senior executives, mid-level managers, and front-line employees at all three organizations identified tensions in their relationships, but at the same time a subset of these individuals identified specific ways in which these tensions were dealt with in order to advance the innovation transfer process. step three: tying together logics, interactions, and emerging constructs my third step was to tie the emergent spiritual logic, the social welfare logic, and the economic logic to the interactions between the three organizations in the innovation transfer partnership examined in this study. this was not a linear process. rather, my analysis proceeded recursively (pratt 2009; langley 1999 ) until i had a grasp of the emerging constructs related to the management of the operations of the partnership. codes consisting of several of the primary constructs of entrepreneurial bricolage (e.g., seeking resources, "making do", avoiding challenges) were used to capture the operations and activities used by the social enterprises in this study to negotiate the alignment or non-alignment of logics and the worldviews which influenced them. additionally, i identified one important emergent conceptual category, or mechanism, used by aravind and fundación visión to ensure the impact of aravind's model as it was transferred from india to paraguay, and also identified sources of tension that emerged in the course of the innovation transfer process. these constructs and interactions are outlined in detail below. step name outcomes identified 1 identifying key moments in the partnership (1) partnership formation (2) partnership development (3) narratives around partnership maintenance 2 coding institutional logics and key interactions (1) identifying three dominant institutional logics: spiritual, social welfare, and economic (2) describing points of tension in partnership related to logics non-alignment or alignment 3 tying together logics, interactions, and emerging constructs (1) identifying entrepreneurial bricolage processes (e.g., seeking resources, "making do", avoiding challenges) (2) innovation fidelity: developing and defining the construct findings prior work on multiple or conflicting logics in organizations has highlighted the role of a dominant logic or competing logics in guiding or constraining organizational action (pache and santos 2013; battilana and dorado 2010) . this study points to broader and richer sets of logics which prior work has not systematically considered. for instance, i found that social enterprises are not uniformly impacted by one or two dominant logics of action (e.g., a social logic and an economic logic). rather, a rich set of logics, multiple in nature, impact their actions. while other scholars have focused on social and economic logics in the past, only recently has research started to examine how spiritual logics can guide the actions of enterprises (gümüsay et al 2019; gümüsay 2017; tracey 2012) . my research attempts to characterize how the values linked to a spiritual logic are manifested not only within the focal organization (friedland 2013) , but also how they link to inter-organizational interactions (ahmadsimab and chowdhury 2019; vurro et al 2010) with partner organizations in the innovation transfer context. transfers of innovations between social enterprise partners offer a unique setting for studying institutional complexity. i found that logics may channel and guide the process of innovation transfer by impacting micro-processes of transfer as they are enacted at the organizational level by social enterprises, including the role played by institutional bricolage in this process (baker and nelson 2005; desa 2012 ). specifically, different social logics and the commercial logic impact the ways in which social enterprises incorporate different practices and innovations from partners, the solutions they craft to "make do" with the resources at their disposal, and the nature of the conflicts they encounter in the course of their partnerships. this, in turn, impacts the potential for "scaling" social innovations beyond the focal organization in which it was developed. these findings are discussed in detail in the sections which follow. recent work (battilana and lee 2014; ebrahim et al. 2014) has examined the conditions that encourage the persistence of multiple logics in a field, in particular when the organizations contained within the field are characterized by hybridity. among the factors proposed are multiple local contexts for practice diffusion (and thereby local adaptation) and the lack of a dominant, overarching regulatory or professional framework that is able to impose field-level standards. both these factors exist in varying degrees for the organizations examined in this paper. as a result, the actions of organizational actors in this study seem to be influenced by multiple logics, including one which has only recently been characterized in the institutions literature. at the level of social logics, i found the most variation between the organizations. for, aravind and fundación visión, i identified an underlying "spiritual logic" rooted in their own organizations' histories which, in turn, influenced their social logic. for fundación paraguaya, the social welfare logic aligned with the economic logic, in line with prior work on microfinance organizations (zhao 2014; jia et al 2015) . below, i discuss on findings related to these logics in detail, highlighting both points of convergence and divergence for the three organizations in this study. table 5 characterizes the spiritual, social welfare, and economic logics in summary fashion. i found that aravind, and fundación visión were guided by a core spiritual logic in their actions. this was in addition to the social logic common to all organizations in this study. aravind is a pioneer in the provision of comprehensive eye care services to the poor. its late founder, dr. g. venkataswamy, was fifty-eight years old and recently retired from the indian civil service when he started the organization as an 11-bed hospital founded in a private residence in 1976. dr. venkataswamy-or "dr. v." as he was affectionately known-was inspired by the teachings of sri aurobindo, one of the leading hindu sages of southern india. this spiritual beneficiaries to be served, particularly those who are seen as more or less "deserving" of "support" clients to be served with a focus on efficiency and on generating demand for future interventions operational principles design interventions to serve beneficiaries, to relieve beneficiaries' suffering, and to serve a "higher power" design interventions to maximize impact of available funds on social impact and positive social outcomes maximize surplus revenue through efficiency of operations and demand generation commitment is a core guiding principle of the organization, this philosophy was clearly reflected in dr. v.'s writings and in the interviews that he gave. some of these words are quoted each year in aravind's annual reports. one of the clearest statements of the link between aravind's spiritual roots and its activities is found on the third page of the 2008 annual report, which quotes dr. v.: our effort is to make aravind an instrument of the divine will. we strive to forget our limitations and work with the direction of the divine will, not in a vain superficial way but with a deep commitment and faith that guidance comes from a higher level of consciousness. then one is able to work with the great confidence that comes only with that faith and realization that we are all part of a spiritual capacity or spiritual power. it is then that all of nature works with you. you don't feel that you are a superior being but you are an instrument in the hands of a higher force and it is in that spirit that we meet our day to day struggles and successes. more recently, in the 2018 annual report, dr. v.'s words are again used to reflect the importance of the divine, especially as reflected in hindu philosophy, in aravind's work: the bhagavad gita became popular and people started reading it to understand kharma yoga. i remember well reading it in those days. at the same time swami vivekananda became very popular with us. his speeches were so powerful and inspiring, they made me look forward to doing something challenging and great. i also read the teachings of sri ramakrishna paramahamsa, who had very little schooling, but who had known god in person. all these contacts influenced our thinking in those days. we were not thinking of amassing money as our goal in life. we always aspired to some perfection in our lives, like the realization of god, or reaching of higher level consciousness in yoga. this organization-level commitment is manifest in the daily operations of the organization, and influences the actions of organizational members. for instance, the chief medical officer of an aravind district hospital similarly referenced a "higher power" guiding the organization: … i don't know whether you believe it or not, but in this part of country, and on the indian subcontinent, i think it's believed everywhere, that we are instruments only. somebody else has decided that what i should do. whatever we are doing, i don't think it's our effort only. many people put the same amount of effort or more, but they don't achieve that. somebody wants us to do that much, so we are able to do it. whatever we are doing, that divine force is there, a higher power is pushing us. our mission is "to be a leading institution in the prevention of blindness, in the promotion of ocular health and in the delivery of high-quality services, as well as in the training of new professionals for community health." the work of the organization rests on christian principles and relies on the bible as the sufficient rule of faith and conduct. (fundación visión web site; accessed: 30 may 2018). this commitment to a christian god was confirmed by the physician who served as the director of operations at fundación visión, who noted how its influence extended to the care and treatment of patients at the organization: fv is also a christian organization. dr. reinhold started in a loaned operating theatre in another hospital; he was driven by his christian values to do this. fv now has 6000 patients per year, and the result of the care that they receive here means that patients can have a better life with god. the way we interact with patients is the way god or jesus would act with patients. the staff are devoted to the patients. parboteeah et al. (2009) have noted that religion has a strong norm-setting influence with respect to work, which is seen as an obligation to society. in this way religion creates important work expectations for individuals, expectations which grow stronger when this work is situated in religious contextual environments. within these two hospital systems spiritual values were an integral part of the work environment. this was manifested not just in the statements of organizational members and in official documents, but also in the physical symbols and objects which reinforced these values within these organizations. for instance, statues and pictures of sri aurobindo are found in the main entrance of all the major buildings within the aravind system that i visited. the spiritual logic is important in this context as it helps to create a sense of common purpose and unity not just within the organization itself and between organizational members, but also between other organizations which share the same or similar values. the spiritual logic also informed the way actors at aravind and fundación visión approached their tasks within the health care realm, with their patients, and with respect to their interactions with members of other organizations. aravind's executive director saw this connection in terms of spirituality and purpose-though aravind is named after and inspired by the teachings of a hindu sage and fundación visión is inspired by christian teachings-as a point of commonality to build upon, one that would help overcome differences in "detail" and level of maturity between the two organizations: at some level they [fundación visión] and aravind share the same foundational mission. at one level there is similarity in terms of the purpose and the leadership orientation and those kinds of things, a lot of similarity. for instance, we are both in some way fundamentally committed to some higher values, you know? we are inspired by the teachings of sri aurobindo, and they have a lot of connection to the christian church. some of the difference is more on the detail, i think we probably have a lot of alignment than they have within the organization. and i think they are --they are not very young but they probably have a lot more maturing to go through in terms of systems and processes and all of that. at fundación paraguaya, the social welfare logic, rather than a spiritual logic, informed decision-making vis-à-vis the social impact of the organization's activities. this set fundación paraguaya apart from fundación visión, its incountry partner, and led to tensions in the relationship which were primarily manifested as clashes around the economic logic as outlined below. the social welfare logic at fundación paraguaya was structured around providing products, services, and support to address local social needs. as detailed in table 5 , in terms of target populations served what separated the social welfare logic from the spiritual logic was the former's emphasis on identifying those who were more "deserving" of support. for instance, one of my main interlocuters at the fundación paraguaya head office told me that while the main focus of the organization was "social," it was nevertheless focused on "selecting people for success" using different criteria took into account loan recipients' ability to "help themselves" and to build and grow successful businesses (my field notes). similarly, at one of fundación paraguaya's branch offices, the local manager told me that his field officers visited potential clients' homes to determine their level of cleanliness, the orderliness of their living conditions, and the general level of progress and order in their lives (my field notes). these criteria were seen as important determinants of individuals' worthiness for different social and credit programs. in this sense, the social welfare logic is more tightly coupled to the economic logic than a spiritual logic, which seeks to help the poor and marginalized without taking into account who might or might not be more deserving based on economic potential (though presumably there might be a bias towards those who show more devotion or faithfulness). for fundación paraguaya, the social welfare logic fed directly into the economic resources derived from an organization's various activities, including micro-financing of business opportunities and selling various services and products, and thus provided a framework for the operational principles need for the organization to achieve its goals (pache and santos 2013) . beyond the spiritual and social welfare logics logic, and consistent with theory in social entrepreneurship, the economic logic was embedded in the necessities of the sector in which the organizations operated, and were related to issues of operational efficiency and demand generation for the services that they provide (battilana and lee 2014) . in addition, fundación paraguaya had a "strong" form of this economic logic impacting its actions, whereas fundación visión had a "weak" form. aravind's economic logic strength was somewhere in-between as the organization focused heavily on efficiency, but was at the same time foundationally committed to the idea of serving a "higher power" in serving patients, especially the ones least able to pay. my point of departure from prior work is in the way in which i found that economic logics and the spiritual and social welfare logics mentioned above interacted in the inter-organizational setting. where differences appeared in the interactions between the organizations in this study was at the level of the strength of the economic logic, which was more closely aligned with the social welfare logic. specifically, even when there was no alignment between the strength of the economic logic (e.g., medium-weak in the case of aravind-fundación visión), clashes at the level of operations related to the partnership were muted due to alignment on the spiritual logic aspect. however, a mismatch between the strength of the economic logic between fundación visión and fundación paraguaya (i.e., weak-strong) exacerbated already existing tensions at the level of social logic, where the lack of alignment between the spiritual logic and the social welfare logic meant that there was no means to diminish tensions between the organizations. in prior work on social enterprises, the economic logic has been found to counterbalance the social welfare logic and focus organizations on questions such as demand generation and efficiency (pache and santos 2013; battilana and dorado 2010) . in this study, the economic logic differed in strength across companies-for fundación paraguay, primarily a microfinance organization, it was a major driving force; for fundación paraguay it was far less important or even de-emphasized; for aravind, social and spiritual commitments were balanced with a focus on delivering services efficiently. this focus on operational efficiency, as much as any spiritual element, was considered by aravind's executive director as the fundamental pre-requisite for transferring knowledge to partners: i think most essential [element of the aravind model to be transferred] is the mindset. because i think the process… you can say one thing is more important than the other. for a given hospital something can be more important than the other, you know, like certain hospitals they could be already having a tremendous number of patients, you know, but then their conversion rate, they are having very low acceptance or so there we do not focus too much on marketing, you know, that will be institution-specific. but fundamentally the most important thing is the mindset, how they start thinking…. the market focus, customer focus, all of that… wanting to become efficiency focused or wanting to become self-supporting. you know, if you are always having the mindset that you can always raise money, you are never going to become efficient. this efficiency focus was mirrored at fundación paraguaya, but in the opposite direction: the company's deep social and community connections were seen as its "differentiating" factor against versus other microfinance operators in paraguay. here, the emphasis was on the business or economic side, and the company's social programs-such as its agricultural school for disadvantaged but entrepreneurial young paraguayans-fed into its money-making microcredit initiatives. the company's director of planning noted: we see our programs as separate in budgetary financial terms, but they are integrated at the operational level. the principles of how to run a sound microfinance program are the same principles that we used to run the agriculture school, we used the junior achievement team methodology to teach entrepreneurship at the agriculture school. the agriculture school takes the sons and daughters of microfinance clients as their students, and the microfinance program gives graduates of the agriculture school lines of credit… on the other hand, for staff at fundación visión, the social service of their business was paramount, even for staff at the operational rather than executive level. for instance, the manager of information technology noted to me that patient care and the spiritual side were the key drivers of the organization. the coordinator of one of the clinics at the base hospital said that the focus on caring for patients was what separated fundación visión from other hospitals and clinics in paraguay. finally, the organization's manager of social work noted that fundación visión is committed to its patients both inside and outside of the hospital setting. this stemmed, she felt, from its foundation in "christian values": fundación visión was deeply involved in charity for patients; it is not a business, like so many other eye clinics and hospitals in paraguay. that a spiritual logic was found at aravind and fundación visión is noteworthy, but unsurprising given the preponderance of faith-based organizations working on health and development issues. what is interesting, however, is how organization-level action can be influenced and guided by such spiritual values. my case data suggest that aravind and fundación visión developed emergent strategies to ensure that their business models and innovations got scaled up. these strategies are deeply rooted in not only the process of scaling, but also the way different institutional logics at the source and target enterprise interact, and the extent to which the logics of the source enterprise and the target enterprises are aligned. they are also tied to what prior work has called "making do" with resources available in the local environment, or entrepreneurial bricolage (desa and basu 2013; durand et al. 2013; desa 2012; baker and nelson 2005) . for instance, my case data indicate that the source social enterprises may be able to actively manage their partners using inter-related strategies related to the underlying balance between multiple institutional logics. these tactics can be broadly organized into one major process: maintaining innovation fidelity. in other words, the source enterprise, aravind in this case, attempts to maintain the fidelity of their original model or innovation at the target site to preserve the intended social impact. they achieve this goal through a number of tactics, including bargaining with managers at the target organization to adopt practices and techniques developed by the source entrepreneur to ensure that the success of the original model and innovation in its new locale. as described below, the process of maintaining innovation fidelity is related to separate aspects of the social enterprises' indirect ability to influence other organizations. this process enables source organizations with limited resources and a constrained direct ability to control of their partners' actions to exercise significant influence despite the absence of an ownership stake or even a principal-agent relationship at the target organization (ansari et al. 2010) . for aravind, a primary way to ensure that the impact of the knowledge transferred was maintained was to induce adherence to the fidelity of their inter-linked eye care management methodology and practices (see "methods" section for detailed description of the social innovation being transferred). thus, their focus was on maintaining basic operating principles which could be shared with fundación visión and which would allow their system to transfer over to paraguay. several aravind managers commented to me about these principles, including the importance of starting the day early and keeping a focus on being organized to do good work. this was true of staff members both at headquarters (e.g., at laico, the lions aravind institute of community ophthalmology, aravind's training arm, and at the madurai base hospital) and in field locations. for instance, a faculty member at laico commented: … we are trying to share principles, you know, it may not be exactly that you can replicate all our procedures but the principles can always be replicated anywhere … for example, i will tell you, we start everyday at 7 o'clock, 7 am in the operating theatre, 7:30 am in the out-patient department.... we don't say, you also should start at 7, if you start at 7 well and good, but not necessary. you can start at 8 o'clock, 8:30, 9 o'clock, fine… but how you start is what's important, how you are organized to do good work…. in the places where it is possible we suggest that they should start little early or something… fundación visión , time is not a problem for them, they start early. at the theni field hospital, the medical director made a similar comment: … we follow certain principles, the basic principle on with the hospital aravind eye care to ensure those things. for instance, like discipline. we start 7:30 in the morning… whatever we have committed has to be honored. it's written that at 7:30 the hospital starts, and a patient coming at 7:30 should be able to see it. for aravind, at the root of transferring technical procedures related to information technology, patient management, and community engagement is a focus on developing values which help organizations improve in each of these areas. this was the feeling of fundación visión's chief operating officer as well: aravind helps us to improve our procedures and improve the way we are attending the community. they are helping us to improve the attention we give to our patients, and they are telling us to correct some procedures, so we can have a better flow of patients or we can attend more volumes. so they are helping us technically but they are also saying that we have to develop our values, and our discipline too. so they are saying we have to do both. while aligned spiritual logics were a source of partnership strength for aravind and fundación visión, the mis-aligned spiritual and social welfare logics were a source of conflict between fundación visión and fundación paraguaya. these difficulties arose as fundación visión sought to work with fundación paraguaya to fully implement one aspect of aravind's model: demand generation for eye care services through screening camps. at these camps, patients are screened for cataract and other diseases, and those that are identified as needing follow-up treatment are referred for further follow-up. in southern india, with its great population density even at the village level, aravind is able to use these camps to generate a constant flow of patients to its base and district hospitals. in paraguay, with a much more dispersed population, this level of demand generation was not possible. rather, camps have to be set up in the most rural locations to find potential patients. this situation provided an opportunity for institutional bricolage (desa 2012; clough et al. 2019 ). while fundación visión had its own infrastructure in place for performing this screening function prior to the collaboration with aravind, they did not have the reach of fundación paraguaya, which offers its microfinance and related products in the most remote regions of paraguay. facing resource constraints which did not allow it to operate these camps regularly beyond the major urban centers of paraguay, fundación visión thus entered into partnership with fundación paraguaya to access its network of contacts across the country. thus, fundación visión "made do" with the resources at their disposal (desa and basu 2013; baker and nelson 2005) by reaching potential patients needing cataract surgery and other services in rural areas where fundación paraguaya was able to use its resources to perform vision screenings for its customers and other community members. however, this use of fundación paraguaya's network by fundación visión also led to conflict between the organizations. in particular, fundación paraguaya's staff felt that fundación visión was not concerned enough about promoting financing of different surgeries for patients screened at these camps. they felt that these surgeries would have been a "win-win" in the sense that fundcion visión would earn revenue from performing them, and fundación paraguaya would earn revenue by financing the operations. in addition, staff at fundación paraguay felt that fundación visión should have been more flexible about having more camps, by working in closer coordination the two organizations could build a future cataract surgery and eye care financing business in paraguay. the conflict which emerged between fundación paraguaya felt that fundación visión vis-à-vis the vision camps and associated promotion of financing options can be tied to the mis-alignment between the social welfare logic and "strong" form of the commercial logic at fundación paraguaya and the spiritual logic and "weak" commercial logic at fundación visión. in this sense, tensions which emerged between the two organizations mirror issues encountered by social enterprise partners where values and identities are mis-aligned (chowdhury and santos 2010; smith et al. 2014) . this finding relates to recent work by arjaliès and durand (2019) , which suggests that values are embedded in the choices made by market actors in choosing investment product categories such as socially responsible investment funds, and that tensions may arise when there is a mis-match between the normative values of producers and consumers. similarly, chowdhury and santos (2010) discuss a case wherein differing approaches to "social impact" between two partnering social enterprises, a kind of mis-alignment, led to difficulties in the transfer process and to a partial failure of the collaboration. finally, and quite interestingly, the impact of cultural differences on the innovation transfer process was relatively muted compared to the institutional factors discussed above. instead, what i found was that organizations tended to refer to geographic differences only with respect to actual or potential pitfalls in the transfer process; otherwise, the issue was for the most part in the background. this finding tended to go counter to expectations, as i assumed that cultural differences would be greatest when the members of the sourcetarget pair were located in different countries, and especially where the "cultural difference" between the organizations' home countries was greatest-i.e., between india and paraguay in the case of aravind and fundación visión. however, in the case of aravind and fundación visión, which are located nearly ten thousand miles (16,000 km) apart, geographic separation provided an opportunity rather than a barrier for transfer, according to aravind's executive director: i saw an opportunity to create synergy because latin america is a place where there isn't any place to just do high volume affordable care. i think it is largely a mindset kind of a thing, their models are very heavily driven by the us model. so they practice very expensive medicine, which benefits 2% of the population, and a vast majority cannot afford that price. so, but this guy really genuinely wanted to help the poor people, reinhold dirks [head of fundación visión]. that's how that idea came up and martin [burt, head of fundación paraguaya] was willing, reinhold was willing… we were trying to create a win-win model. it might be the case the "foreignness" of fundación visión relative to aravind actually spurred effort on the part of both parties to make the relationship work. that is, due to the potential for miscommunication organizational members actually made a greater effort to communicate effectively with their counterparts from across the world. a number of scholars have called for research which highlights the distinctive nature of organizational processes in a social entrepreneurial context, where multiple institutional logics operate (battilana and lee 2014; pache and santos 2010; dees et al. 2004) , and in particular for those areas outside of metropolitan centers which are less conducive to developing thriving social enterprise ecosystems (jia and desa 2018) . the present research addresses these calls by examining how social enterprises manage partnerships with other organizations that have related or distinct guiding logics and, ultimately, how social enterprises use partnerships to transfer innovations across geographic boundaries. in this sense, the article interrogates knowledge transfer processes across inequities of power, resources, market access, and governance (wijers 2019; piatti and dwiartama 2016; doering 2016; seelos and mair 2010; hodge and greve 2007) , though it explores these issues in the relatively unique context of a "south-to-south" collaboration between organizations in india and in paraguay. the article makes three contributions. first, this work helps to illuminate the extent to which organizations which operate in environments with multiple institutional demands and with multi-dimensional goals manage their organizational processes and behaviors in order to achieve increased impact nationally and internationally . in particular, by illuminating the heretofore under-examined spiritual logic, it provides opportunities for researchers to develop these concepts further. recent work in institutional theory has pointed to the relatively unexplored domain of religion in the study of modern organizations, and in the domain of international development in particular (gümüsay 2017; tracey 2012; parboteeah et al 2009; ver beek 2000) . for instance, gümüsay (2017) argues that a heterogeneous intra-institutional religious logic may help scholars to theorize across different contexts about the impact of religion on organizational practices and values. while this macro-level focus is welcome, the present study goes beyond such broad-level constructs to illuminate the role that a spiritual logic may play in facilitating the transfer of ideas and practices between organizations, even when they are located at different ends of the earth. both aravind and fundación visión had prior collaboration experience with other spiritually-oriented hospitals. where there were potential pitfalls due to language barriers, aravind sent staff to work extensively on-site to ensure that practices were transferred, and this resulted in the successful transfer of their patient care and patient management practices to fundación visión. beyond this, what is particularly noteworthy about the partnership is the fact that while fundación visión is a christian organization, aravind's spiritual dimension is rooted in hinduism. nevertheless, despite vastly different religious traditions, with one organization rooted in western, christian, traditions even if located in a developing country setting, and the other linked to an ancient "eastern" religion, the organizations' underlying commitment to a "higher power" served as an important point of commonality which seemed to have facilitated their collaboration. importantly, such a focus on common values between aravind and fundación visión links to the "old institutionalism" idea that values and norms, versus scripts and other taken-for-granted processes as prescribed by neo-institutional theory, can serve as a primary guide for organizational action (gehman 2020; gümüsay 2017; tracey 2012; dorado 2006) . this values turn in the study of institutions can be linked to the recent work of friedland, who argues for greater focus on "the internal institutional order" of organizational actions as opposed to the "external conditions of their possibility" (2013). fundamentally, the notion of "internal institutional order" links to the idea that values are embedded in an organization's practices (klein jr. 2015) , a notion that this study seemingly substantiates in its exploration of organizational practices focused on care for patients as constituted by spiritual organizations such as aravind and fundación visión. in these two hospital systems, the act of delivering eye care is intimately linked to the idea of a "higher power" and serving humanity as confirmed by a range of informants, organizational documents, and artifacts reflecting the influence of the divine in structuring organizational action. what this study didn't do, however, is examine how the distinct religious traditions underlying the two principal organizations in this study, hinduism and christianity, differ in the ways that they influenced aravind and fundación visión, respectively. future research might explore these differences (gümüsay 2017; peifer 2014; ver beek 2000) . a second contribution of this paper is to highlight the tactics used by source firms to manage knowledge transfer partnerships with geographically distant partners that are operating in contexts very different to their own. a number of recent studies suggest that different institutional logics guide organizational behavior by providing specific scripts for action and by establishing core principles for organizing activities and channeling interests (ahmadsimab and chowdhury 2019; ebrahim et al. 2014; battilana and dorado 2010) . these studies provide little insight into the role played by divergent or convergent social logics on the unfolding of a partnership. because values determine how partnership goals may be accomplished, this is an area of both theoretical and practical concern. for organizations with social goals, partnership is a means to "create social value" and indeed to spread the organization's key values to other organizations and locales. the organizational field plays a major role in shaping these values and the nature of the partnership (dimaggio and powell 1983; friedland and alford 1991; thornton and ocasio 1999) . alignment of partner social enterprises' values may thus facilitie interorganizational collaboration. when alignment isn't there, however, cultural and institutional factors become more important in determining the direction and success of a partnership (palis 2006) , and bricolage mechanisms (desa 2012; baker and nelson 2005) have the potential to gain heightened importance. for instance, while fundación visión entered into the partnership initially to gain access to new technologies and resources related to eye care delivery and process management, they nevertheless encountered difficulties vis-à-vis their cooperation with fundación paraguaya, their in-country (local) partner. specifically, these difficulties stemmed from divergent perceptions relating to efficiency with respect to their vision camps operated distant rural areas using fundación paraguaya's networks but which combined both organizations' personnel. in addition, fundación paraguaya staff members were "disappointed" with the approach of fundación visión towards revenue-generating operations such as the financing of different surgeries. here, the strong economic logic driving the microfinance organization, fundación paraguaya, came into conflict with the weaker economic logic of the eye hospital. thus, what emerged from the rich case data which constitute this study is that the form of inter-organizational partnership is influenced by the extent to which the source organization manages to balance its multiple logics with those of its partners. while the balance between the two hospital systems was maintained via a strong spiritual logic alignment, differences in the prioritization of the economic logic between fundación visión and its in-country partner, fundación paraguya, speak to the challenges encountered between organizations which may be operating even in the same local context when their values are not aligned (bacq and janssen 2011; friedland 2013; klein jr. 2015; jia et al 2015) . building on this second contribution, by situating institutional complexity research in an inter-organizational setting, this study also begins to unpack the processes which emerge when the logics of different organizations have to be simultaneously considered. in doing this, it addresses the following questions: are these mechanisms indeed different from the traditional knowledge transfer mechanisms studied by organizational scholars? how do partners in a dyadic transfer relationship coordinate their efforts and to what extent to they ensure the fidelity of the innovation is maintained across settings (ansari et al. 2010) ? by answering these questions, scholars may get closer to an understanding of institutional logics as strategic resources as proposed by durand et al. (2013) ; this promising line of inquiry may have much do contribute to the ways in which the logics of different organizations interact in an inter-organizational context. additionally, the study advances knowledge of institutional bricolage mechanisms (desa 2012; clough et al. 2019 ) by linking these processes to settings where a dyadic transfer relationship has to be taken into account. while institutional bricolage mechanisms may enable a search for practical solutions in the social entrepreneurship setting (desa and basu 2013) , clashes between institutional logics may also hinder the implementation of such solutions when two or more social enterprise partners are involved. third, and finally, this research contributes to the emerging literature on "scaling" entrepreneurial innovations in social settings (seelos and mair 2017; desa and koch 2014; chowdhury and santos 2010; bloom and chatterji 2009 ). it does this by: (1) introducing the concept of "innovation fidelity" as a mechanism for managing the transfer process; and (2) by offering possible a view of "scaling" solutions in the social sector which takes into account the notion of logics alignment between partner organizations. with respect to the former, this study highlights how source social enterprises may use refer to the maintenance of the core features of a focal social innovation to manage partners during the transfer process. innovation fidelity thus relies on using inter-related tactics related to the underlying balance between multiple institutional logics, and has implications in terms of convergent (matching) and divergent (non-matching) social logics in the context of urban-rural transfer settings. such tactics include including bargaining with managers at the target organization to adopt practices and techniques developed by the source entrepreneur, and emphasizing the principles underlying the impact of the social innovation being transferred. ultimately, source organizations attempt to maintain innovation fidelity to ensure that the success of the original model and innovation in its new locale. where the notion of scaling solutions in the social sector links with values is in the degree of alignment between logics. for instance, alignment vis-à-vis the spiritual logic between aravind and fundación visión, between the source and the target organization, helped to facilitate the process of maintaining innovation fidelity and, ultimately, the scaling of aravind's model of delivering eye care. this was noted by managers at both organizations in terms of how organizing principles (such as discipline) were linked to the values that the organizations shared. on the other hand, attempts to maintain innovation fidelity may be less successful when logics are mis-aligned. this situation was apparent in the conflict which emerged between fundación paraguaya and fundación visión vis-à-vis the vision camps example referenced above, wherein divergent perceptions, rooted in different levels of strength (strong vs. weak) of the economic logic at the two organizations, relating to efficiency and revenue generation led to tensions between the two organizations. with respect to the broader debate on scaling in the social sector, much discussion has focused on "scaling organizations" as the primary means to expand the scope and reach of innovations developed by social entrepreneurs. for instance, desa and koch (2014) suggest three underlying requirements for scaling a venture across regions: compatibility of the social innovation, a market penetration strategy, and a design for affordability. whereas the affordable design aspect and compatibility of the eye care services delivered by fundación visión and aravind was a primary driver for the development of the partnership, fundaction visión had to "make do" (baker and nelson 2005) with the resources available to it in paraguay in terms of delivering its services to under-served rural markets in paraguay. in particular, the on-the-ground partnership between fundación visión and fundación paraguay allowed the former organization to utilize and country-wide network developed for the microfinance context to access greater numbers of potential patients for its eye care services. while there were clashes with respect to the social motivation of fundación paraguaya's approach, which sought to promote microenterprise approaches to addressing poverty (doering 2016) , versus the more spiritually-grounded social motivation of fundación visión, ultimately this "making do" with available resources allowed the expansion of aravind's approach to delivering eye care services to paraguay. in this sense, by highlighting the possibility of instead "scaling solutions" (dees et al 2004) through inter-organizational partnership as a means to achieve similar impact, the study puts forward novel approaches that organizations may undertake to address the issue of increased impact. finally, in addition to the theoretical contributions highlighted, the study also has practical implications for program managers, consultants and other actors working with social enterprises to scale the impact of their innovations. recent work by the psychologist jonathan haidt haidt and treviño 2017) highlights the importance of developing and strengthening ethical organizational cultures as a way to deal with conflicting sets of foundational beliefs, including divergent political beliefs. the present study, by how examining varying social motivations (emerging from varied social logics) can manifest as tensions or conflicts in partnerships, builds on haidt's notions by providing a basis for developing mechanisms for resolving these organizational tensions as they emerge in practice. for instance, it defines some of the tactics used by social entrepreneurs to manage the scaling of social innovations via partnering with other social enterprises (e.g., maintaining innovation fidelity). while these tactics may be less efficacious when values are not aligned, negotiating in good faith with partners may result in a positive outcome that both parties can live with. as the world deals with the current global pandemic of covid-19, two final practical implications from this study may be particularly relevant. first, managers must understand the importance of modifying practices to fit the reality of contextual conditions where a partner (target) organization is located. while this study took into account the unique resource constraints encountered by organizations seeking to expand their social impact to rural settings, in a covid-19-affected world those constraints could well apply to the urban areas which have been hardest hit by the pandemic. second, in the context of the pandemic, the issue of value alignments and mis-alignments has played out on a global scale. one short illustration of this phenomenon can be seen in the relative willingness to wear face masks as a preventive measure. in countries such as taiwan and south korea, universal acceptance of masks (values alignment) has led, up to this point, relatively rapid declines in infection rates and overall disease burden. in contrast, in countries where mask wearing has been contested (values mis-alignment), infection rates have taken longer to decline (taleb 2020 demographic, health, and other relevant data for geographic areas served by the organization (e.g., at the district, town, village levels) what was your role in this process? how much of your time did you spend working on the [target organization]? staff (ask for percentage was this innovation changed for [target organ-ization]? in some way vs. how it was done at [source entrepreneur] originally? how so? when was it developed? can you tell me how it was developed within your organization? when did you feel you had made the desired impact in your local area? when was the decision to expand beyond your local area made? how did you come to select [target organiza-tion]? as a partner for the transfer of this technology? please describe this process for me thing the transfer process has been going? are the villagers at the pilot [target organization]? site using this technology per your conversations with [target organi-zation]?? 9 reflecting back on the transfer of sanitation technology between [source entrepreneur] and [tar-get organization]?, what would have been the single most important action to facilitate the transfer does [source entrepreneur] have a precise visión about how to conduct social change? if so what values drive [source entrepreneur]? have these changed over time? what is the guiding force behind the organization's actions? social mission? science? organizational evolution (top executives only) 1. imagine that you're writing a history of is this still the mission of the organization? if not, what has changed? references ahmadsimab, a., and i. chowdhury. 2019. managing tensions and divergent institutional logics in 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approach based on ideal types acknowledgements i thank the guest editors of the special issue, geoffrey desa and xiangping jia, as well as three anonymous reviewers for their guidance during the review process. i also thank filipe santos, anca metiu, ignasi martí, and wim van lent for their comments on earlier versions of this paper. finally, i am indebted to the social enterprises discussed in this article for the access which allowed me to complete this project. key: cord-274307-kl0uvrbw authors: bordet, régis title: is the drug a scientific, social or political object? date: 2020-05-23 journal: therapie doi: 10.1016/j.therap.2020.05.012 sha: doc_id: 274307 cord_uid: kl0uvrbw nan randomized controlled trials are based on two principles: comparison and comparability. these two principles allow dispensing first with the natural evolution of the disease, particularly in infectious diseases, and second the placebo effect, which can now be corroborated by brain imaging studies. without respect for these two principles, it is impossible to establish the role of the drug in the clinical effects observed when testing a new pharmacological approach. paradoxically, the methodological rigour inherent to controlled trials and the role of the pharmaceutical industry in promoting these trials have ended up bringing discredit to this approach, which is, however, the best method for establishing the proven effect of a drug, in part of the population. the craze that has arisen for the distribution of hydroxychloroquine, based on a very preliminary study and the analysis of a cohort without a comparator group, was, from this point of view, very emblematic of the fact that belief can quickly replace scientific demonstration. this is not new and already exists for alternative therapeutic methods that refuse to fall under the caudine forks (so named in reference to the battle at the end of which the romans had to submit to the samnites) of clinical trial methodology. this attitude has, however, taken an emotional and claiming side in the context of the anxiety and fear generated by the covid-19 pandemic and its lethal risk. empiricism seems to be trying to take again a top position over the rational approach, which some consider too dogmatic, especially in critical situations. is it necessary, because it is urgent, to abandon all the scientific principles of clinical trials that have previously led to undeniable therapeutic progress? undoubtedly not, which does not mean that the experimental design of the trials should not be adapted, in an approach reminiscent of charles peirce and william james theorising pragmatism as a third way transcending the empiricism/rationalism opposition. for more than thirty years, french medical pharmacologists and therapists have been contributing to an international movement of methodological diversification through a think tank (called "ateliers de giens") bringing together the academic, industrial and institutional worlds. pragmatic trials, adaptive trials using the bayesian approach, studies with external comparators, trials on small samples, taking into account secondary assessment criteria and the use of biomarkers are all methodological innovations that aim to make the framework of controlled trials more flexible in order to speed up or improve the evaluation of drugs, without abandoning the major and basic principle of comparison [1, 2] . the media outburst against methodology rightly clashes with the convictions of the vast majority of health professionals, who have perhaps not sufficiently integrated the fact that drugs, which they consider above all as a scientific object that is their prerogative, have also become an issue that the social body has taken up. it is above all through the drug risk and its often-mediatized affairs that society has integrated drugs as a social fact [3] . the so-called "mediator" affair has had a major impact on populations, in this case the french one, with the realization that drugs can be also dangerous, even in the long term. the front pages of newspapers and magazines devoted to medicines and their risks have been booming, like the questions addressed to the regional pharmacovigilance centres. the development of social networks has had an amplifying effect on the emergence of medicines as a social issue, by bringing it out of the circle of health professionals, previously considered as the only "knowers". some years ago, several episodes of reporting adverse drug reactions linked to changes in thyroid hormone formulation have emerged as a viral relay on social networks. social demand may lead regulatory agencies to re-evaluate positions that were initially scientifically based, or to speed up market entry. recently, the film "120 beats per minute" recalled the interactions, sometimes violent, between patient associations, pharmaceutical industry and regulatory agencies in order to bypass the usual marketing rules, in view of the mortality caused by hiv. this is reminiscent of what we are experiencing today with molecules reputed to be potentially effective against sars-cov-2, recalling what we have previously seen with other products, such as baclofen in alcohol use disorders. while society may request answers from public authorities and healthcare professionals regarding the risks/benefits balance of drugs, social facts may also influence the medical use or diversion of medicines, or even investment in their development. the cult of thinness, advocated year-round in all magazines, was undoubtedly the main factor that triggered the misuse of the mediator, replacing dexfenfluramine, which, a few years earlier, had been withdrawn from the market because of its valvular risk. our modern societies, based on the over-emphasis on performance, generate a diversion of drugs, particularly psychotropic ones, for the purpose of cognitive doping. however, anxiety induced by loss of social bearings or by suffering at work linked to the search for profitability at all costs explains the over-consumption of psychotropic tranquillizers or antidepressants. the social context may therefore explain the emergence of a pattern of use or an increase in the prescribing or consumption of a particular drug, which then escapes rational, evidence-based use, necessitating regulatory measures to control prescribing or dispensing. the current health crisis has highlighted the immediate link between the announcement of preliminary or hypothetical results on the efficacy of a particular drug against coronavirus and its dispensing, and often consumption, outside of any regulatory framework. taking into account the social dimension of the drug reveals, however, a contradiction in the demand of the social body, which has been amplified during the health crisis. on the one hand, there is an expectation for information that has been scientifically validated by health professionals. in the space of one month, the pharmacovid site [4] set up on 21 march was consulted nearly 300,000 times, with many questions asked by the current health crisis may be leading to a turning point, with drugs becoming a political football. it is first of all an object in the international political games, because it is clear that states have lost their sovereignty over the production of medicines, which, like other manufactured products, has become one of the goods of globalized capitalism. the current crisis, however, has made us aware that drugs are above all a common good, since they affect one of the essential elements for humanity, namely health. if tomorrow a vaccine or treatment against coronavirus is found, will we witness a war between states to control supply, as happened with masks? will the world balance between states be altered? will the ability to control drug policy in all its aspects (innovation, rapid assessment, production) become a diplomatic weapon or even a propaganda tool for external or internal propaganda? because drugs have also become a domestic political issue, as we have seen with chloroquine and hydroxychloroquine, with partisan confrontations or positions taken without scientific basis by a head of state announcing his belief in the interest of chloroquine, in a country that was the first to create a regulatory agency. the balance between political power and regulatory agencies may be shifting, as shown by the announcement by the president of the united states of america, in person, of the authorisation of an antiviral by the fda, developed by an american company, even though the results of clinical trials are still contradictory. it is the same with a nationalist attitude for the priority delivery of vaccine. will drug policy tomorrow become a subject of electoral debate, on a par with fiscal or educational policy, and an argument for economic nationalism? how can we reconcile this irruption in the public or political debate and the maintenance of a sufficient level of expertise to avoid falling into the populism we know in other fields, with its share of false or truncated information? the participants of giens xxxv round table clinical research. from single-arm studies to externally controlled studies. methodological considerations and guidelines quelle utilisation et quelle hiérarchisation pour les critères de jugement secondaires social pharmacology: a new topic in clinical pharmacology pharmacovid plateform: questions and answers for the public about drugs in the context of the covid-19 key: cord-287036-swo90ji2 authors: rauchbauer, birgit; grosbras, marie-hélène title: developmental trajectory of interpersonal motor alignment: positive social effects and link to social cognition date: 2020-08-09 journal: neurosci biobehav rev doi: 10.1016/j.neubiorev.2020.07.032 sha: doc_id: 287036 cord_uid: swo90ji2 interpersonal motor alignment is a ubiquitous behavior in daily social life. it is a building block for higher social cognition, including empathy and mentalizing and promotes positive social effects. it can be observed as mimicry, synchrony and automatic imitation, to name a few. these phenomena rely on motor resonance processes, i.e., a direct link between the perception of an action and its execution. while a considerable literature debates its underlying mechanisms and measurement methods, the question of how motor alignment comes about and changes in ontogeny all the way until adulthood, is rarely discussed specifically. in this review we will focus on the link between interpersonal motor alignment, positive social effects and social cognition in infants, children, and adolescents demonstrating that this link is present early on in development. yet, in reviewing the existing literature pertaining to social psychology and developmental social cognitive neuroscience, we identify a knowledge gap regarding the healthy developmental changes in interpersonal motor alignment especially in adolescence. in our everyday social lives, we unconsciously and automatically align our behavior to the people around us. we define this interpersonal alignment as the reciprocal matching of behavior, posture, facial or vocal expression to the interaction partner. we propose to review the development of interpersonal motor alignment appearing as synchrony, mimicry or automatic imitation, the former two being ubiquitous in daily social life. we focus on interpersonal motor alignment that is automatic, spontaneous and mostly unconscious, as opposed to interpersonal coordination that is intentional and conscious, such as in cooperative tasks. synchrony refers to the temporally matched behaviors of interaction partners. through temporal motor matching, it allows precise prediction of interactive behavior (hove & risen, 2009; wiltermuth & heath, 2009) . synchrony may include verbal and non-verbal communicative, as well as emotional behaviors (leclère et al., 2014) . in this review we focus on studies investigating the temporal and rhythmic matching of topographically isomorph and dynamic behaviors, such as during dance, but will also touch upon rhythmic vocal and musical synchrony, such as during singing and drumming. while synchrony refers to simultaneous motor behavior, mimicry refers to the matching of behavior occurring with a slight temporal delay, of the order of 3 -5 seconds (chartrand & bargh, 1999) . this phenomenon has also been coined the chameleon-effect (chartrand & bargh, 1999) , alluding to the way chameleons change their colour to fit their environment. automatic imitation on the other hand, is, with the exception of the kids' play "simon says" that is prominent in different cultures and languages, mainly used as an experimental paradigm in cognitive psychology/neuroscience to assess underlying mechanisms of motor alignment (brass, bekkering, wohlschläger, & prinz, 2000) . automatic imitation is most often instantiated in a stimulus-response compatibility (src) paradigm (e.g. (brass et al., 2000; kilner, paulignan, & blakemore, 2003) ), in which observing an irrelevant movement interferes with target movement execution. if the irrelevant action matches the target movement, response execution is facilitated, while a mismatch requires inhibition of the perceived action representation to execute the target response and thus impairs execution. this paradigm has the advantage of high experimental controllability, implementation as a within-subject, repeated measures design and suitability for neuroscientific investigations, with, for example functional magnetic resonance imaging (fmri) j o u r n a l p r e -p r o o f own movement. it may also involve brain mechanisms related to temporal processing (see e.g., (coull, cheng, & meck, 2011; merchant, harrington, & meck, 2013) , for detecting timing of events and rhythmic properties. there is a tight relationship between these brain circuits and neural networks implicated in motor processes, as evidenced also by the fact that action facilitates time estimation in adults and children (monier, droit-volet, & coull, 2019) . in particular, the striatum and the supplementary motor area have been shown to be involved in perceiving time as well as in producing timed motor actions, rhythmic sequences and coordination of motor actions (coull et al., 2011; merchant et al., 2013) , and are thus likely to play a key role in interpersonal motor alignment. yet, the interactions between motor resonance mechanisms and temporal processing may differ between synchrony, mimicry and automatic imitation given their specific reliance on precise timing. from a developmental perspective, interpersonal motor alignment is tightly linked to the ongoing discussion of the origins of the human mirror mechanisms. debated accounts range from completely innate mechanisms evolved through selection pressure (meltzoff & moore, 1997) , to a sole product of associative sensorimotor learning (keysers & perrett, 2004; oostenbroek et al., 2016) , and experience (catmur et al., 2007; catmur, walsh, & heyes, 2009; heyes, 2011; heyes, bird, johnson, & haggard, 2005; ray & heyes, 2011) with mixed-accounts in between (farmer, ciaunica, & hamilton, 2018; quadrelli & turati, 2015) . while it is not our goal to contribute directly to this discussion, we argue that a critical review of the literature on the development of interpersonal motor alignment and its link to the construction of social abilities across the lifespan is currently lacking in this debate. yet, including developmental aspects not just at the beginning of life, but at all ages until adulthood, may advance apprehension of the underlying mechanisms of interpersonal motor alignment. considering the positive effects of interpersonal (motor) alignment, a deeper insight into its underlying processes at different stages of development across the lifespan, may offer a more nuanced, targeted insight. synchrony and mimicry both have been suggested to promote positive social behaviors. joint singing, for instance, has positive, and fast, "ice-breaking" (pearce, launay, & dunbar, 2015) effects on social bonding (pearce et al., 2015; weinstein, launay, pearce, dunbar, & stewart, j o u r n a l p r e -p r o o f 2016). the accelerated positive effects of joint singing may be product of multimodal motor synchronization of laryngeal muscles and respiration patterns and the production and perception of the same sounds (good & russo, 2016) . relatedly, synchronized activation during joint laughter (dunbar et al., 2011) , physical activity, such as dance and rowing (cohen, ejsmond-frey, knight, & dunbar, 2010) , leads to similar cohesive group effects. group synchrony may reinforce a group's cooperative tendency (reddish, fischer, & bulbulia, 2013) . a group moving together may become a collective social unit (good & russo, 2016) through boundary loss and getting into a "we"-mode (mcneill, 1997) . but apart from (inter)active motor alignment, already the mere observation of interpersonal coordination enhances the perception of commitment to joint action (michael, sebanz, & knoblich, 2016) , rapport (miles, nind, & macrae, 2009 ), a feeling of unity (lakens, 2010; lakens & stel, 2011) , and of a shared goal and cohesiveness (ip, chiu, & wan, 2006) . in line with this, mimicry has been suggested to enhance liking, social cohesion and prosocial behavior towards the interaction partner (chartrand & lakin, 2013; chartrand, maddux, & lakin, 2005; duffy & chartrand, 2015; van baaren, janssen, chartrand, & dijksterhuis, 2009) . prosociality after being mimicked may be enhanced towards the mimicking confederate, but moreover extends to an unknown experimenter and to charities (duffy & chartrand, 2015; van baaren, holland, kawakami, & van knippenberg, 2004; van baaren et al., 2009) , as well as strangers on a street (fischer-lokou, martin, guéguen, & lamy, 2011) . mimicry has thus been suggested to act as a "social glue" that may have an evolutionary function for establishing and maintaining social relations (lakin, jefferis, cheng, & chartrand, 2003) or to regain inclusion into a group (lakin, chartrand, & arkin, 2008) . while some reports suggest that interpersonal motor alignment is enhanced towards in-, as compared to out-group members (e.g. (bourgeois & hess, 2008; yabar, johnston, miles, & peace, 2006) , studies show that the positive effects of interpersonal motor alignment extend to intergroup relations. enhanced synchrony with an out-group member may reduce intergroup boundaries and support closeness (miles, lumsden, richardson, & macrae, 2011) , which may be mediated by an increased perception of interpersonal similarity through the display of interpersonal synchrony (rabinowitch & knafo-noam, 2015; valdesolo & desteno, 2011; valdesolo, ouyang, & desteno, 2010) . likewise, mimicry increases sympathy, closeness and the perception of harmonious interaction with an virtual avatar posing as an out-group member j o u r n a l p r e -p r o o f (hasler, hirschberger, shani-sherman, & friedman, 2014) . synchronous and mimicry behavior may enhance perceived self-other overlap between self-generated and other-produced movements. a constant matching between interactive movements may enforce an overlap in the shared representations of perception and execution of an action. this self-other overlap may lead to social cohesion (lang, bahna, shaver, reddish, & xygalatas, 2017; tarr, launay, & dunbar, 2014) , extending also to out-group members and contribute to overcoming group boundaries. the positive intergroup effects of interpersonal motor alignment have also been demonstrated using the tightly controlled automatic imitation tasks. it has been suggested that automatic imitation measures covert (cracco et al., 2018; cracco & brass, 2019; heyes, 2011) , and to some extent overt, imitation (cracco & brass, 2019) , but this has recently been a matter of debate (cf. (cracco & brass, 2019; ramsey, 2018) . while mimicry and automatic imitation may not be correlated (genschow et al., 2017) , being mimicked may reduce inhibitory mechanisms of automatic imitation (rauchbauer, dunbar, & lamm, 2020) , potentially indicating an interrelationship between the two phenomena. in any case, automatic imitation tasks allow investigators to test a variety of modulatory factors in controlled settings using both behavioral and neuroscientific methods. thereby they have provided evidence that interpersonal motor alignment is modulated by social context, like group membership (gleibs, wilson, reddy, & catmur, 2016; marsh, bird, & catmur, 2016; rauchbauer, majdandžić, hummer, windischberger, & lamm, 2015; rauchbauer, majdandžić, stieger, & lamm, 2016) , social contagion and group size , eyecontact (marsh et al., 2016; wang, newport, & hamilton, 2011) , and emotional facial stimuli (butler, ward, & ramsey, 2016 ) (see also for meta analyses: (cracco et al., 2018) ). they may also have the potential to contribute to identifying the factors that link interpersonal motor alignment and positive social behaviors. divergent accounts suggest that increased social closeness and helping behavior may either rely on topographically isomorphic body movements , whereas other reports suggest a role of perceived contingency (i.e., predictive relationship) of one's own and the interaction partner's movements, rather than on their similarity (i.e., topographic isomorphism) (catmur & heyes, 2013 ). yet again, other accounts suggest that social affiliation may not only be linked to high contingency, but also high contiguity (i.e., temporal proximity) of j o u r n a l p r e -p r o o f movements (dignath, lotze-hermes, farmer, & pfister, 2018) and effector matching (sparenberg, topolinski, springer, & prinz, 2012) . moreover, both synchronous movements and exertion have been shown to induce beneficial social effects (tarr, launay, cohen, & dunbar, 2015) . similarly, the choice of control condition in a mimicry or synchrony induction could potentially influence social-cognitive variables. while prominent studies on mimicry have used control conditions without any movement (e.g., (chartrand & bargh, 1999; r. b. van baaren et al., 2004) , other studies have used anti-mimicry conditions (dalton, chartrand, & finkel, 2010; finkel et al., 2006; kühn et al., 2010; rauchbauer et al., 2020) . in an anti-mimicry control condition, the confederate's movements will be topographically misaligned to the participant's, as compared to the mimicry condition in which they are aligned. a control condition without movement may itself evoke negative social effects due to perceiving the interaction partner uninterested and passive. conversely, an anti-mimicry condition may also induce positive effects itself in case of perceived temporal contingency (catmur & heyes, 2013) or high exertion (tarr et al., 2015) of movements. thus, the mechanisms by which mimicry and synchrony may induce positive social-cognitive effects may not be entirely clear yet and lead to divergent results. as such, it has recently been suggested that being mimicked by topographically isomorph postures as compared to an anti-mimicry condition, does not influence experienced social cohesion with the confederate, measured with a rating scale (rauchbauer et al., 2020) . thus, there are certain contradictions in the literature of interpersonal motor alignment, which may require in-depth analysis. to date it remains unclear as to which conditions and mechanisms may give rise to which positive socialcognitive effects via synchrony or mimicry. for example, while mimicry seems to evoke a kind of generalized prosociality, synchronous behavior may rather evoke directed prosociality (cirelli, 2018) . however, some studies have demonstrated that also synchrony induces generalized prosocial behavior (reddish, bulbulia, & fischer, 2014; reddish, tong, jong, lanman, & whitehouse, 2016) . the aforementioned studies rely only on adult populations. yet, interpersonal motor alignment is pertinent throughout ontogeny and may play an important part of a healthy social life, as a building block for higher social cognition, including empathy. indeed inter-individual differences in experience of and ability for interpersonal motor alignment early in infancy is associated with empathic abilities in adolescence as well as with the ability to engage in intimate j o u r n a l p r e -p r o o f relationships across the lifespan (feldman, 2007b (feldman, , 2007c , suggesting a protective buffering role against psychosocial maladjustment. the "motor theory of empathy" suggests that human mirror mechanisms may mediate the understanding of others' intentions and feelings (rizzolatti & fabbri-destro, 2008) and that empathy may originate from the perception-action link (iacoboni, 2009 ; leslie, johnson-frey, & grafton, 2004) ). as such, action understanding may play a role in feeling emotions and empathizing with others (carr, iacoboni, dubeau, mazziotta, & lenzi, 2003 ). yet, this theory has also been criticized, arguing that contrary to previously mentioned findings, empathy does not necessarily involve the activation of the mirror neuron system (mns) (de vignemont & singer, 2006) , or that its involvement may depend on the specific form of empathy (baird, scheffer, & wilson, 2011) . regardless of this debate, studies show that right after birth, social contingencies in the form of multimodal responses by the mother to the infant's signals, and contingency detection on the side of the infant, aid to form reliable reciprocal interactions. synchronous interactions, starting with caregiver-infant interactions, may provide a buffer against psychosocial maladjustment, shape empathic capacities in adolescents and lay the basis for engagement in intimate relationships across the lifespan (feldman, 2007b (feldman, , 2007c . therefore, it is important to integrate the ontogenetic dimension while building accounts of these functions during typical and atypical developments. in the next sections we review existing behavioral and neuroimaging research on synchrony, mimicry and automatic imitation in infants, children and adolescents. for this we conducted a systematic search on pubmed (https://pubmed.ncbi.nlm.nih.gov/; as of 15 may 2020), presented in tables 1-3, and analysed the main findings. keywords included (infant or development) and (mimicry or synchrony or automatic imitation or action observation) and (experiment or eeg or fmri or fnirs or eeg). then results were filtered to select only the studies that focused on interpersonal motor alignment as we have circumscribed above, in particular excluding experiments on instructed or delayed imitation. we also excluded studies that concerned only atypical populations, or that did provide only qualitative data. this list, while probably not exhaustive due to limitations of the search algorithm, provides a panorama of the state of the research in this domain so far. we analyzed the main findings with regards to the nature of interpersonal motor alignment and its relationships with other social behaviors, on the one hand, and its neural mechanisms, on the other hand, at different ages. humans may be biologically prepared for coordinated interaction due to their responsiveness to rhythmical information and build-in tendency to detect contingencies (feldman, 2007b) . a recent review suggests that the establishment of interpersonal synchrony in reciprocal interactions is supported by adults' rhythmical information to their infants (markova, nguyen, & hoehl, 2019) . these rhythms are often spontaneously displayed by caregivers in the form of affective touch or singing to aid the infant's affect regulation (provasi, anderson, & barbu-roth, 2014 ). the caregiver's adaptive signals to the newborn's behavior form social contingencies, which the infant readily detects. these interpersonal mechanisms appearing in the first months of life may be multimodal precursors for synchronous interactions, including, apart from movements, vocalizations, gaze, touch, affect, position or proximity to each other. as the infant grows, the time lag between behavior and response diminishes and social contingencies develop into synchronous behaviors (feldman, 2007b (feldman, , 2007c . a longitudinal study points towards crucial positive long-term effects of socially contingent and synchronous interactions. affective synchrony in mother-infant interaction from three and nine months of age predicted self-regulatory capabilities in two, four-and six-year olds. the same study also found that synchronous mother-infant interactions at three months of age predicted empathic abilities in thirteen-year old adolescents (feldman, 2007a) . apart from interactions with their primary caregiver, 12-and 14-month-old infants already use interpersonal movement information to guide social expectations. as such they attend to and interpret interpersonal synchronous and asynchronous behavior in a socially meaningful way (cirelli, 2018; fawcett & tunçgenç, 2017) . they seem to prefer synchronously moving partners and show spontaneous helping behavior towards them and their affiliates (cirelli, einarson, & trainor, 2014; cirelli, wan, & trainor, 2016; tunçgenç, cohen, & fawcett, 2015) . even more so, when observing asynchronous dyadic interactions, infants believe the interaction partners to be nonaffiliates (cirelli, wan, johanis, & trainor, 2018) . this suggests that they can infer thirdparty affiliation on the basis of synchrony (cirelli, 2018; fawcett & tunçgenç, 2017) . synchrony, as a social signal per se, may be a cue for self-similarity from the beginning of life on (leclère et al., 2014; xavier et al., 2016) , increasing prosocial behavior and encouraging empathy and affiliation (for review see cirelli, 2018) . in four-year-old children, synchronous interactions of only three minutes may already lead to enhanced peer cooperation. in children of eight to nine years of age they enhance closeness and feelings of similarity (rabinowitch & knafo-noam, 2015; rabinowitch & meltzoff, 2017a) . these positive effects extend from synchrony in direct interaction to joint music making and rhythmic synchrony. children synchronize drumming with higher accuracy in a social condition, which elicits cooperative behavior and fairness (kirschner & tomasello, 2009 , 2010 rabinowitch & meltzoff, 2017a) . also cooperative singing with peers, as reported for adults (pearce et al., 2015) , increases group cooperation in children of seven to eight years more than art or competitive games (good & russo, 2016) . furthermore, the positive effects of synchronous singing have been reported to contribute to feelings of social inclusion in refugee children (marsh, 2017; marsh & dieckmann, 2017) . this suggests, that singing in synchrony, just as moving in synchrony (tunçgenç & cohen, 2016) or joint music making (marsh, 2012 (marsh, , 2017 , may support the establishment of a collective group membership by forging intergroup bonds. in summary, synchronous behaviors can be observed, in different forms, throughout infancy and childhood (for a list of experimental studies on interpersonal motor alignment in developmental population see tables 1-3) . first mainly restricted to caregivers, they extend to peer relations and can also be recognized in other dyads during observation. in all cases the ability to engage in synchronous behavior has positive prosocial outcomes especially with regards to interpersonal affiliation, similarly to what we have discussed in adults. interpersonal motor alignment in neonates has been evidenced by seminal studies showing imitative hand opening and mouth protrusion movements (meltzoff & moore, 1997) . this finding has led to an ongoing debate on whether spontaneous imitation is innate or not (see for example (anisfeld, 1996; s. jones, 2017; kennedy-costantini et al., 2017; keven & akins, 2017; libertus, libertus, einspieler, & marschik, 2017; meltzoff, 2017; meltzoff et al., 2018; oostenbroek et al., 2016) ). alternatively, it has been suggested that imitation is learned through an associative learning sequence (catmur et al., 2009) , hebbian learning (keysers & perrett, j o u r n a l p r e -p r o o f 2004) and correlated sensorimotor experiences, forming perception-action couplings through interaction with the primary caregiver (de klerk, lamy-yang, & southgate, 2019). as mentioned above, it is not our aim to contribute to this discussion in the present article, but rather to summarize facts about interpersonal motor alignment and their social correlates at different ages. a large corpus of work shows that, during the first two years of life, infants faithfully imitate adults actions or just their goal (social or instrumental) in a variety of contexts (yu & kushnir, 2014) . children of pre-school age imitate not only causally relevant, but also irrelevant actions (i.e. sequences of movements that are not necessary to achieve the desired goal). this "over-imitation" (e.g., nielsen & blank, 2011; over & carpenter, 2012 , may be an important learning mechanism to acquire cultural expertise. it seems to also have social reasons, such as the identification with a model and the social group in general. it may occur through social pressure (over & carpenter, 2012) , but can also be used to overcome in-group ostracism (over & carpenter, 2009; watson-jones, whitehouse, & legare, 2016) . the dual role of imitation, for social learning and for establishing group cohesion is supported by studies showing that 14-month-olds are more likely to imitate communicative gestures and familiar actions performed by same-age infants, than when they are performed by older children and adults (zmyj, aschersleben, prinz, & daum, 2012) . nevertheless, in a context when they are presented with a novel object, they are more likely to reproduce the action that they have seen an adults perform on this object (zmyj, daum, prinz, nielsen, & aschersleben, 2011) . this suggests that infants and toddlers may more likely align their behavior to that of an adult role-model in a learning context. in an affiliative context though it seems that children would preferentially imitate their peers, potentially to enhance group cohesion. similarly, having been mimicked by an adult, 14 -18-month-olds learned better by observation (somogyi & esseily, 2014) , and were more prone to help this adult (over & carpenter, 2013) . this prosocial behavior can also extend to a stranger (carpenter, uebel, & tomasello, 2013) . this suggests that being mimicked may evoke a generalized prosociality (cirelli, 2018) . the positive effects of interpersonal motor alignment throughout development are not only shown during imitation, mimicry and synchrony, but also in the more experimental environment of automatic imitation. in motor interference tasks, children are asked to perform straight lines in a vertical or horizontal movement on a tablet computer screen using a stylus, while an interaction partner performs a congruent or incongruent drawing movement (marshall, j o u r n a l p r e -p r o o f bouquet, thomas, & shipley, 2010; saby, marshall, smythe, bouquet, & comalli, 2011; van schaik, endedijk, stapel, & hunnius, 2016) . using this task, automatic imitation was increased in four-to six-year-olds when interacting with an out-group member . this suggests, in line with adult studies , that even during automatic imitation the regulation of interpersonal motor alignment may be used to overcome intergroup differences. also, 4-year-old children show a greater motor interference effect in interaction with peers, rather than adults (marshall et al., 2010) , in line with the studies mentioned above on imitation (zmyj et al., 2012 (zmyj et al., , 2011 . thus, already during childhood, group membership seems to influence the perception-action link. this is also demonstrated in a study with children of four and five years of age in which automatic imitation is modulated according to animacy beliefs of an interaction puppet (saby et al., 2011 ). yet, a recent meta-analyses suggested that automatic imitation may not be sensitive to animacy beliefs (cracco et al., 2018) . group membership may influence interpersonal motor alignment via top-down modulation. for instance, it has been suggested that during conscious imitation neural activity in a wide range of brain areas, and not only early visual areas, is modulated by the race of the model (losin, iacoboni, martin, cross, & dapretto, 2012) . this may be driven by socially learned associations concerning race, rather than self-similarity (losin, cross, iacoboni, & dapretto, 2014) . this seems in line with motivational theories of automatic imitation, such as the social top-down response modulation account (storm; wang & hamilton, 2012) . these accounts suggest that the motivation to affiliate (the wish to be liked by the interaction partner) may increase imitation. this has also been suggested to influence mimicry, via a strengthened the perception-action link (chartrand et al., 2005; lakin et al., 2008) . group membership may be one salient social factor activating affiliative motivation. high motivation to affiliate with the in-group has been shown to moderate the influence of group membership during imitation (genschow & schindler, 2016) . other studies have found higher imitation for out-group members, which could suggest affiliative motivation for appeasement (rauchbauer et al., 2015 . contrary to these studies conducted in adult samples, social modulation of automatic imitation may be absent in adolescents. while automatic imitation has been observed to the same level as in adults in adolescents, no modulation by pro-social priming has been observed (cook & bird, 2011) . this would indicate that the adaptability and social function of interpersonal motor alignment is still fine tuning in adolescence. apart from cook & bird (2011) and as pointed in the previous sections, to this date, investigation of interpersonal motor alignment in adolescence is scarce (see table 3 ). this may be due to the assumption of social cognitive maturity by mid-childhood (blakemore & mills, 2014) , leading to a wealth of studies of interpersonal motor alignment during child-and adulthood, but skipping the period of adolescence. yet, adolescence is an important social transition period, with ongoing brain development. this absence of studies warrants conclusions of social effects of adolescent interpersonal motor alignment and encourages further investigation of its potential positive effects. this is especially the case since adolescence is a period of enhanced importance of the peer group, sensitivity for social acceptance and rejection, as well as continuing structural and functional brain development (rev in blakemore & mills, 2014; grosbras et al., 2007; mills et al., 2016) . a more in-depth investigation of interpersonal motor alignment during adolescent interaction could inform on healthy adolescent social cognitive development. this could have implications with respect to psychopathology with a prevalent onset in adolescence like conduct disorder, social anxiety or schizophrenia. as these disorders have been associated with altered brain development, it is also paramount to link those observations to knowledge about subserving brain organisation and its development. in the next section we review studies using neuroscientific methods to investigate brain correlates of interpersonal motor alignment across development. the neural correlates of interpersonal motor alignment have been investigated in adults in three different categories of studies. first, the regulation of automatic imitative tendencies, second, motor resonance phenomena investigated via action observation studies, and third, synchronized brain activity. here we give only a brief overview of some adult studies that have used various neuroscientific methods, as our aim is to focus on the developmental aspect. this section illustrates that, although neural correlates of interpersonal motor alignment have been investigated broadly, both with respect to experimental paradigms and research methods, as a j o u r n a l p r e -p r o o f whole the corpus evidence converges to show that specific brain circuits and mechanisms are involved in the aligment of behaviors during interaction. automatic imitation tasks have been used to assess brain regions specifically involved in the control of imitative tendency. functional magnetic resonance imaging (fmri) studies indicate the engagement of prefrontal (inferior frontal and medial prefrontal) and parietotemporal regions when subjects imitate a movement (carr et al., 2003) or perform a motor interference task (e.g., mengotti et al., 2013; rauchbauer et al., 2015) . patients with frontal lobe lesions tend to over-imitate, which suggests the existence of specific mechanisms to control this function (brass, derrfuss, matthes-von cramon, & von cramon, 2003) . non-invasive brain stimulation studies also show that disruption in inferior frontal regions interferes with imitation of simple finger movements (heiser, iacoboni, maeda, marcus, & mazziotta, 2003) . moreover, stimulating posterior regions in the parietal opercular region (mengotti et al., 2013) or temporo-parietal junction (s sowden & catmur, 2013) impedes the ability to repress the automatic tendency to imitate. motor resonance phenomena, tightly linked to automatic imitation, can also be revealed in passive action observation tasks that do not require explicit control over imitation. already observing other people's actions consistently engages a set of brain regions to a greater extent than watching other categories of visual movement. this "action observation network" (aon) encompasses the human mirror neuron system, which, alongside fronto-parietal regions and temporal cortices, is also engaged during action execution (caspers, zilles, laird, & eickhoff, 2010; grosbras, beaton, & eickhoff, 2012) . thus, it contains an implicit "motor resonance" system, coupled with a mechanism to inhibit actual movement. this is also evidenced in indirect electrophysiological measures of brain activity using electro-or magneto-encephalography (eeg and meg), which show the same signature of brain activity, namely a decrease in power in mu (8-13 hz), and often also beta (15-20 hz), frequency bands over the motor cortex (central electrodes) for both action execution and observation (rev. in (marshall & meltzoff, 2011) . experiments in non-human primates indicate that the mu rhythm would reflect activity of motor and mirror neurons (bimbi et al., 2018) . in addition, interpersonal synchrony has been associated to inter-brain synchrony, which has been measured directly during hyperscanning that is data recorded using neuroscientific methods, such as eeg or fmri, simultaneously on multiple partners engaged in interpersonal j o u r n a l p r e -p r o o f motor alignment. simultaneous eeg recordings in a dyad showed enhanced correlation in the theta and beta frequencies across brains during the execution of simple coordinated finger or hand movements (dumas, nadel, soussignan, martinerie, & garnero, 2010; yun, watanabe, & shimojo, 2012) . in cooperative settings, inter-brain activity coherence was also demonstarted using near-infrared spectroscopy (nirs) (cui, bryant, & reiss, 2012; funane et al., 2011) . cooperative or affiliative behavior in economic games (astolfi et al., 2014; de vico fallani et al., 2010) , as well as in more ecological situations like flight behavior cooperation in professional pilots (toppi et al., 2016) and interaction in romantic partners (kinreich, djalovski, kraus, louzoun, & feldman, 2017) was furthermore predicted by different patterns of brain-tobrain synchrony (most often in theta range and frontal cortex). in the same vein, it has been suggested that the greater the coupling between speakers' and listeners's brains, the greater the understanding between partners in communication (stephens, silbert, & hasson, 2010) . a recent study showed a causal effect of neural synchrony on behavioral synchrony by entraining the motor activity of two individuals at the same time with transcranial alternating current stimulation: in-phase 20hz stimulation facilitated the establishment interpersonal movement synchrony in a joint finger tapping task (novembre, knoblich, dunne, & keller, 2017) . describing inter-brain coupling throughout development is a key part of gaining full understanding of these meachnisms. yet, developmental brain imaging studies have been mainly concerned with single subjects set ups, only a few implementing dual scanning paradigms. next, we review the main findings in infants and toddlers, primarily using electroencephalography (eeg) and functional near-infrared spectroscopy (fnirs), and then turn to studies involving children and adolescents, which are mainly using fmri. table 1 -3 present a more complete list of developmental studies involving the different sorts of interpersonal motor alignment in these populations, as given by a systematic search on pubmed. experiments using eeg or fnirs have described components of the action observation network present very early on in infancy (see table 1 ). desynchronisation of the equivalent of the mu rhythm in infants (6-9 hz over central cortex) (marshall & meltzoff, 2011) , has been reported in 4-11-month-olds when seeing adults walking (virji-babul, rose, moiseeva, & makan, 2012). similarly, 9-month-old infants show mu rhythm desynchronization while they observe actors performing reach and grasp movements (debnath, salo, buzzell, yoo, & fox, 2019; southgate, johnson, osborne, & csibra, 2009 ). this was also reported in 9-and 12-month-olds observing tool use (yoo, cannon, thorpe, & fox, 2015) , and in 18-36 month-olds watching actors pantomime actions without an actual object present . moreover, mu rhythm desynchronization has been shown in 12-month olds observing unusual movements depending on the use of objects (e.g., bringing a phone to the mouth compared to a cup) (stapel, hunnius, van elk, & bekkering, 2010) and in 12-14 month olds depending on the unexpected use of effectors for the action (e.g., while having the hands free, using the head to turn on a lamp) (langeloh et al., 2018) . mu desynchronization in 30-month-old infants during observation of facial movements furthermore suggests an already functioning mirror mechanism of facial expressions during early stages of development (rayson, bonaiuto, ferrari, & murray, 2016) . desynchronization in the motor cortex in the frequency range of 8-12 hz for both execution and observation of drawing actions has been confirmed in a 36-month-old child with pre-surgical cortical electrodes implantation using intracranial recording (fecteau et al., 2004) . using fnirs, shimada and hiraki (2006) showed that 6-7 months infants who passively observed objected directed hand-arm actions engaged, although to a lesser extent, the same brain regions that when they manipulated the object themselves (shimada & hiraki, 2006) . thus, these studies converge to indicate an overlap between action execution and observation very early on in development. the relevance of automatic motor system engagement during passive action observation for studying interpersonal motor alignment is further supported by studies showing that motor resonance in 14-month-old infants is enhanced in an interaction context compared to the direct copying of adults' gestures. this points towards a stronger mirror resonance mechanism during interaction already in infants (reid, striano, & iacoboni, 2011; saby, marshall, & meltzoff, 2012 ). yet, the automatic engagement of neural mirror mechanism may depend on experience (rev. in (marshall & meltzoff, 2014) ). this is reflected in studies showing that 4-month-olds show the same response to movements performed by an artificial agent or by a human (grossmann, cross, ticini, & daum, 2013) . furthermore, studies have reported that the degree of mu desynchronization during action observation is cumulatively correlated with motor skills according to experience ((e.g. grasping or crawling (van elk, van schie, hunnius, vesper, & bekkering, 2008)). as such, stronger mu-and beta-desynchronization have been observed in 14-to 16-month-olds watching videos of other infants crawling, as compared to seeing them walking, for which they hadn't developed rich experience yet (van elk et al., 2008) . interestingly, similar findings have also been reported in very young macaques who exhibit signs of eeg desynchronization in sensorimotor cortices during grasping observation in the first two weeks of life, increasing as a function of rudimentary grasp development (festante et al., 2018) . these findings are compatible with a narrowing processing dependent on motor experience (lloyd-fox, wu, richards, elwell, & johnson, 2013) . however, these results are contradicted by a study, showing that sensorimotor activation in response to videos of someone walking is present even for infants (4-11 months old) who don't yet walk. this could suggest that visual familiarity with an action is sufficient to drive motor resonance, without direct implication for behavior . in the same vein, shimada and hiraki (2006) showed that motor engagement during action observation in 6-month-olds was larger for live than videotaped stimuli, the latter being supposedly less familiar at this age. alternatively, some authors have suggested that the relationship between motor competencies and motor resonance might be more apparent in older than younger infants (12-month-old compared to 9 month olds) (yoo et al., 2015) . in addition, experience beyond specific action execution skills may also be important. as such, general early life history may have an impact on the degree of interpersonal brain resonance. fourteen-month-old preterm infants show mu suppression during action observation only in the right parietal regions, whereas full term infants showed the effect in a bilateral frontoparietal network. yet, no difference between groups was observed for action execution (montirosso et al., 2019) . another line of research has looked at interpersonal neural synchrony during infant social interactions. for instance, leong and colleagues (2017) showed that phase-locking of brain activity between infants and parents was related to communication features, like direct gaze or duration of vocalizations. this finding could be interpreted as a mechanism for aligning the periods of higher sensory receptivity between interpersonal partners (giraud & poeppel, 2012) and facilitate learning. recently, some studies have used dual fnirs scanning to look at correlation in brain activity between infant and parent. the strength of association between parent and child activity in prefrontal regions was increased when they were engaged in cooperative as compared to independent behavior (miller et al., 2019) . thus, some mirror like j o u r n a l p r e -p r o o f mechanisms seem to be present in the brain early in life and well established in the first two years potentially supporting learning, as well as sensorimotor and socio-emotional development. more data is needed to draw stronger conclusions, however, in particular with respect to their link to the positive social effects described in the first section. most often data from infant populations are directly compared to adult studies, leading to discontinuity in the literature with respect to changes later in development. the reason for this may be that the methods and questions are often different when studying older children and adolescents. for these age groups most investigation has focused on action observation paradigms, which can give first insights into the perception-action link underlying interpersonal motor alignment during these years of development (see tables 2 and 3) . a handful of studies have investigated motor activity during observation of others in older children and young adolescents using the mu suppression index, confirming findings from infants and adult studies. eismont and colleagues (2017) reported desynchronization of the mu rhythm (taking into account the differences in dominant mu frequencies at different age ranging from 6-13hz) over central electrodes in children aged 4-14 years, during execution, observation and imitation of arm movements, with a stable effect across ages. similar effects were also reported from other research groups, in 2-,4-, 5-, and 11-year-olds respectively (cochin, barthelemy, roux, & martineau, 2001; lepage & théoret, 2006; martineau & cochin, 2003) . extending these results, bernier and colleagues, while showing similar effects in 5-7 year-olds, demonstrated that the strength of the interpersonal motor resonance effect was correlated with a measure of facial imitation abilities (bernier, aaronson, & mcpartland, 2013) . altogether these eeg studies demonstrate a signature of the engagement of children's own motor system when they observe actions from others that may be stable during childhood. nonetheless pulling data from five different studies oberman and colleagues (2013) concluded that mu suppression might indeed decrease with age (between 6 and 17). this is consistent with the report of cheng and colleagues who observed higher mu suppression in 3-to 9-year-old children compared to adults (cheng, chen, & decety, 2014 ). yet, this is inconsistent with other reports of weaker suppression in 8-12 year old children compared to adults, especially when watching movements from an allocentric perspective (nishimura, ikeda, suematsu, & higuchi, 2018) , or of an j o u r n a l p r e -p r o o f increase from 10 to adulthood (brunsdon, bradford, smith, & ferguson, 2020) . more data from adolescents would be needed to ascertain this developmental trajectory. other modulating factors such as attention and engagement with the stimulus, for example due to affiliation should also be investigated. interestingly, cheng and colleagues reported that contrary to adults, mu suppression in children was not modulated by the emotional content (painful or not) of the observed videos. this is in line with a study that used transcranial magnetic stimulation of motor cortex in combination with electromyography to measure motor resonance, and showed that contrary to adults, motor resonance was not modulated by emotion in 17 year olds (salvia, süß, tivadar, harkness, & grosbras, 2016) . the presence of motor activity during action observation is confirmed using other methodologies. in a small sample of pre-adolescents (age 9-13), kajume and colleagues used fnirs and reported increased activity, compared to a baseline control, in the inferior-frontal / premotor regions when participants observed or imitated object-directed actions (kajiume, aoyama-setoyama, saito-hori, ishikawa, & kobayashi, 2013) . a handful of fmri studies also confirm that children and adolescents, similarly to adults, recruit the aon when observing object-directed hand actions (biagi et al., 2016; ohnishi et al., 2004; shaw, grosbras, leonard, pike, & paus, 2011a , 2011b . when comparing the activity in the aon directly between children (7-15) and adults, biagi and colleagues (2016) observed less lateralization to the left in children. this is partly consistent with a longitudinal study showing decreasing activity with age in the right parietal cortex during action observation (although mainly in males) (shaw et al., 2011b) . assessing both action execution and observation suggests that the extent of shared activation, reflecting mirror activity, would increase from child-(age 7-10) to adulthood (morales, bowman, velnoskey, fox, & redcay, 2019) . structurally also, areas in the aon, as well as other regions of the social brain, undergo developmental changes throughout adolescence (mills et al., 2016) . moreover, the activation of the mirror system or the aon is modulated by personal and social factors in development. for instance, children and adolescents (age 9-15) with autism showed higher precentral and middle temporal activity in an action simulation task (i.e., when simulation is necessary to solve a problem), than age-matched control participants (wadsworth 2017) . for passive observation of emotional actions, adolescents with a higher resistance to peer pressure show more coordinated brain activity in the right dorsal premotor and the left j o u r n a l p r e -p r o o f dorsolateral prefrontal cortex, than adolescents with low resistance to peer pressure. thus, the propensity to withhold social peer pressure seems related to neural interaction when observing emotional actions (grosbras et al., 2007) . indeed, the aon seems to be modulated by the emotional connotation of the observed action, with higher activity in fronto-parietal regions and additional supramarginal medial prefrontal and amygdala activity for angry as compared to emotionally neutral hand movements (grosbras et al., 2007; shaw et al., 2011b) . this emotional modulation is however expressed differently in boys and girls across development. at the age of 10 and 11.5 years, both girls and boys show a common level of activity in the aon during observation of angry hand movements, specifically in the posterior parietal cortex, extending into the parieto-occipital junction, the fusiform gyrus, cerebellum, right inferior parietal lobule (ipl), dorsal pre-motor cortex (pmc), intraparietal sulcus (ips) and orbito-frontal cortex (ofc). yet, by the age of 13 the same male participants showed higher engagement of a "socioemotional" network than the aon, as compared to their female counterparts. this network comprised brain regions of the so-called social brain, specific to the processing of emotional actions including the temporo-parietal junction, the orbitofrontal cortex and the insula. this suggests that male adolescents around the age of thirteen years do not recruit action observation, but rather socioemotional processes when observing angry hand actions (shaw et al., 2011a) .these findings are paralleled by observations of structural brain development: adolescents with a higher degree of resistance to peer influence show higher interregional correlation of cortical thickness between nodes of the aon (paus, toro, et al., 2008) . this underlines that the importance of the peer group on behavior could be related to brain development of areas related to social cognition. another line of investigation looked directly at interindividual brain synchrony in social settings, using dual-functional fnirs in naturalistic interactions between caregivers and their children of preschool (mean age of five years) (nguyen et al., 2020) and school age (five to nine years of age) (reindl, gerloff, scharke, & konrad, 2018) . high neural synchrony between children and caregivers correlated positively with behavioral reciprocity, predicted problemsolving success (nguyen et al., 2020) and cooperative performance (reindl et al., 2018) . it has thus been suggested that neural synchrony may be a biomarker for interaction quality between a child and the caregiver, representing a neural mechanism for emotional connection linked to the development of adaptive emotion regulation. in a study on adolescents (17 and 18 years), dikker and colleagues (2017) used portable eeg devices in a highschool classroom and observed that j o u r n a l p r e -p r o o f general measures of synchrony in the group (i.e., coherence between responses in multiple brain areas) were highly correlated with the level of engagement and enjoyment reported by students. furthermore, they showed that, as in adults, social priming through engagement in eye contact increased interbrain synchrony within student pairs. nonetheless, in another study with the same protocol, bevilacqua and colleagues (2019) reported that the level of "interbrain synchrony" was not related to memory retention. research in this direction should be pursued to explore to what extent interpersonal neural synchrony relates to interpersonal alignment and to social facilitation at different stages of development. in particular, the continuing development brain areas important for social processing during adolescence suggests interpersonal motor alignment as a potential connective element between the two networks for healthy adolescent development. this could furthermore inform maladaptive development, for example in autism spectrum disorder (asd) and psychopathologies, such as schizophrenia, social anxiety and depression, whose onsets often fall into adolescence (paus, keshavan, & giedd, 2008) . adolescence, as a formative transition period from child-, to adulthood, may be the optimal period to intervene and prevent psychopathologies (eldreth, hardin, pavletic, & ernst, 2013) implications: the importance of studying interpersonal motor alignment in healthy development, including adolescence as we hope to have demonstrated, interpersonal motor alignment is an important social signal for the establishment and maintenance of relationships and group cohesion throughout development. even more so, the lack of coordinated interactions starting already at birth may lead to persistent difficulties throughout life in domains of social and emotional development, as well as self-regulation and the capacity for intimate relationships (feldman, 2007b (feldman, , 2007c . we contend that this importance of interpersonal motor alignment continues throughout development, extending from early relations with primary caregivers to family and peer relationships. especially during adolescence, given the reorientation of the social focus to peers and away from family members, social contingencies and interpersonal behavioral alignment with peers may come into focus. reliable reciprocated interpersonal motor alignment throughout childhood and adolescence could contribute to strengthen the link between functional and structural brain development in areas related to the social brain and the aon and thereby enhance social and emotional resilience during adolescence. this is underlined by findings showing that socially contingent and synchronous interactions between caregivers and infants predict adolescent empathic abilities (feldman, 2007a) . but also, adolescents with higher resistance to peer influence show higher cortical thickness between nodes of the aon (paus, toro, et al., 2008) and highly coordinated brain activity in areas related to action perception and decision making (grosbras et al., 2007) . conversely, unreliable alignment with peers or the family could augment feelings of social rejection and stress, in a period already marked by heightened sensitivity to peer rejection (sebastian, viding, williams, & blakemore, 2010) . social stressors such as (cyber-) bullying (crick et al., 2001) , social exclusion (crone & konijn, 2018) and enhanced risk-taking behavior (chein, albert, o'brien, uckert, & steinberg, 2011; van oosten & vandenbosch, 2017) peak during adolescence. moreover, adolescence, as a time of substantial neurobiological and behavioral changes, confers a vulnerability for certain types of psychopathologies (paus, keshavan, et al., 2008) . continuing interpersonal motor alignment throughout adolescence may strongly support the establishment and maintenance of resilience and coping mechanisms. yet research in this domain is critically lacking. indeed, as demonstrated throughout this article, reliable reciprocity through interpersonal motor alignment has positive social and emotional effects, which are, with the exception for action observation, underinvestigated during adolescence. yet, especially its potentially strengthening effects of interpersonal motor alignment through mimicry and synchronous behavior on the connection between the aon and other brain regions implicated in social cognition, may have beneficial effects on adolescent resilience. this remains to be investigated, but interpersonal motor alignment programs to strengthen social resilience during adolescence and intervention programs targeting adolescents' psychological or psychiatric problems could be envisioned. this could be implemented, in (online) video games and social media to strengthen healthy adolescent development through interpersonal motoric reciprocity. implementation on social media, via videoconferencing tools or on-or offline video games, may help reaching out to adolescents and making interventions more accessible to them. yet, while this idea is attractive, technical limitations, such as delays of timing due to different internet connections, may hinder smooth interaction and impede mechanisms mediating positive effects. aiming to overcome this problem, several software programs have been suggested for musicians and to sing together 1 . social media and videoconferencing tools allow adolescents to stay connected, even in the face of isolation. this could be observed recently during social isolation in the wake of the covid-19 pandemic, when two third of american teenagers reported using video chat to stay connected with their peers 2 . this makes this avenue worth pursuing. this is the first integrative review of interpersonal motor alignment and its positive social functions from a developmental perspective. it highlights the importance of reliable interpersonal motor alignment for healthy social development and especially points towards the need to extend this research to adolescence, a period of enhanced social sensitivity. indeed, although interpersonal motor alignment may link social cognition to cognitive control and may have an important role in healthy adolescent interactions, it is still underinvestigated during adolescence. moreover, since adolescence is a time of substantial neurobiological and behavioral changes, it may confer a psychopathological vulnerability (paus, keshavan, et al., 2008) . studying interpersonal motor alignment as one of the links between social cognition and cognitive control may inform motor therapies for prevention and recovery and aid healthy adolescent development. cracco, e., & brass, m. (2018) . the role of sensorimotor processes in social group contagion. table 1 : experimental studies on interpersonal motor alignment on infants. systematic search of studies on interpersonal motor alignment in infants (age <30 months) the table shows references with authors and year of publication, the type of interpersonal motor alignment (ima), main findings and method used; * denotes studies mentioned in the text, eeg = electroencephalography, (f)nirs = (functional) near-infrared spectroscopy, emg = electromyography, n= number of participants (in the final sample of analyzed data). only tongue protrusion modeling is matched by neonates when age matters: differences in facial mimicry and autonomic responses to peers' emotions in teenagers and adults investigating the neural basis of cooperative joint action. an eeg hyperscanning study mirror neuron system involvement in empathy: a critical look at the evidence parieto-frontal circuits during observation of hidden and visible motor acts in children. a high-density eeg source imaging study the role of imitation in the observed heterogeneity in eeg mu rhythm in autism and typical development brain-to-brain synchrony and learning outcomes vary by student-teacher dynamics: evidence from a real-world classroom electroencephalography study action observation network in childhood: a comparative fmri study with adults simultaneous scalp recorded eeg and local field potentials from monkey ventral premotor cortex during action observation and execution reveals the contribution of mirror and motor neurons to the mu-rhythm is adolescence a sensitive period for sociocultural processing? the impact of social context on mimicry compatibility between observed and executed finger movements: comparing symbolic, spatial, and imitative cues imitative response tendencies in patients with frontal brain lesions the inhibition of imitative and overlearned responses: a functional double dissociation imitation: is cognitive neuroscience solving the correspondence problem? inhibition of imitative behaviour and social cognition short-term physical training enhances mirror system activation to action observation effects of active and observational experience on eeg activity during early childhood neural circuits involved in the recognition of actions performed by nonconspecifics: an fmri study making children laugh: parent-child dyadic synchrony and preschool attachment the influence of facial signals on the automatic imitation of hand actions action observation and acquired motor skills: an fmri study with expert dancers relations between infants' emerging reach-grasp competence and event-related desynchronization in eeg being mimicked increases prosocial behavior in 18-month-old infants neural mechanisms of empathy in humans: a relay from neural systems for imitation to limbic areas ale meta-analysis of action observation and imitation in the human brain is it what you do, or when you do it? the roles of contingency and similarity in pro-social effects of imitation making mirrors: premotor cortex stimulation enhances mirror and counter-mirror motor facilitation sensorimotor learning configures the human mirror system associative sequence learning: the role of experience in the development of imitation and the mirror system the chameleon effect: the perception-behavior link and social interaction the antecedents and consequences of human behavioral mimicry beyond the perception-behavior link the ubiquitous utility and motivational moderators of nonconscious mimicry. the new unconscious peers increase adolescent risk taking by enhancing activity in the brain's reward circuitry an eeg/erp investigation of the development of empathy in early and middle childhood how interpersonal synchrony facilitates early prosocial behavior. current opinion in psychology interpersonal synchrony increases prosocial behavior in infants infants' use of interpersonal asynchrony as a signal for third-party affiliation social effects of movement synchrony: increased infant helpfulness only transfers to affiliates of synchronously moving partners electroencephalographic activity during perception of motion in childhood rowers' high: behavioural synchrony is correlated with elevated pain thresholds social attitudes differentially modulate imitation in adolescents and adults neuroanatomical and neurochemical substrates of timing automatic imitation: a meta-analysis automatic imitation of multiple agents: simultaneous or random representation? j o u r n a l p r e -p r o o f regulation mimicry and propagation of prosocial behavior in a natural setting impairments of social motor synchrony evident in autism spectrum disorder neural processing and production of gesture in children and adolescents with autism spectrum disorder synchronous activity of two people's prefrontal cortices during a cooperative task measured by simultaneous near-infrared spectroscopy the influence of group membership on cross-contextual imitation mimicry and automatic imitation are not correlated cortical oscillations and speech processing: emerging computational principles and operations group dynamics in automatic imitation singing promotes cooperation in a diverse group of children not so automatic imitation: expectation of incongruence reduces interference in both autism spectrum disorder and typical development neural mechanisms of resistance to peer influence in early adolescence brain regions involved in human movement perception: a quantitative voxel-based meta-analysis action observation in the infant brain: the role of body form and motion virtual peacemakers: mimicry increases empathy in simulated contact with virtual outgroup members the essential role of broca's area in imitation contagious yawning in autistic and typical development automatic imitation experience modulates automatic imitation eight problems for the mirror neuron theory of action understanding in monkeys and humans it's all in the timing: interpersonal synchrony increases affiliation imitation, empathy, and mirror neurons birds of a feather and birds flocking together: physical versus behavioral cues may lead to trait-versus goal-based group perception automatic facial mimicry in response to dynamic emotional stimuli in five-month-old infants can newborn infants imitate why do i like you when you behave like me? neural mechanisms mediating positive consequences of observing someone being imitated movement synchrony and perceived entitativity if they move in sync, they must feel in sync: movement synchrony leads to attributions of rapport and entitativity the chameleon effect as social glue: evidence for the evolutionary significance of nonconscious mimicry using nonconscious behavioral mimicry to create affiliation and rapport i am too just like you nonconscious mimicry as an automatic behavioral response to social exclusion sync to link: endorphin-mediated synchrony effects on cooperation reduced mu power in response to unusual actions is context-dependent in 1-year-olds synchrony as an adaptive mechanism for large-scale human social bonding why synchrony matters during mother-child interactions: a systematic review speaker gaze increases information coupling between infant and adult brains system in children eeg imaging of toddlers during dyadic turn-taking: mu-rhythm modulation while producing or observing social actions what" matters more than" why"-neonatal behaviors initiate social responses cortical activation to action perception is associated with action production abilities in young infants cortical activation to action perception is associated with action production abilities in young infants neural processing of race during imitation: self-similarity versus social status race modulates neural activity during imitation activation of mirror neuron regions is altered in developmental coordination disorder (dcd)-neurophysiological evidence using an action observation paradigm how imitation affects empathy and prosocial behavior: the role of movement congruency and temporal contingency neurobehavioral interpersonal synchrony in early development: the role of interactional rhythms . frontiers in psychology the beat will make you be courage": the role of a secondary school music program in supporting young refugees and newly arrived immigrants in australia creating bridges: music, play and well-being in the lives of refugee and immigrant children and young people contributions of playground singing games to the social inclusion of refugee and newly arrived immigrant children in australia the imitation game: effects of social cues on 'imitation'are domain-general in nature motor contagion in young children: exploring social influences on perception-action coupling neural mirroring systems: exploring the eeg mu rhythm in human infancy neural mirroring mechanisms and imitation in human infants visual perception in children: human, animal and virtual movement activates different cortical areas impaired cortical activation in autistic children: is the mirror neuron system involved? keeping together in time elements of a comprehensive theory of infant imitation explaining facial imitation: a theoretical model re-examination of oostenbroek et al.(2016): evidence for neonatal imitation of tongue protrusion imitating others' actions: transcranial magnetic stimulation of the parietal opercula reveals the processes underlying automatic imitation neural basis of the perception and estimation of time joint action modulates motor system involvement during action observing joint action: coordination creates commitment do birds of a feather move together? group membership and behavioral synchrony the rhythm of rapport: interpersonal synchrony and social perception inter-brain synchrony in mother-child dyads during cooperation: an fnirs hyperscanning study structural brain development between childhood and adulthood: convergence across four longitudinal samples the beneficial effect of synchronized action on motor and perceptual timing in children exploring the eeg mu rhythm associated with observation and execution of a goaldirected action in 14-month-old preterm infants an fmri study of action observation and action execution in childhood single-neuron responses in humans during execution and observation of actions the effects of interaction quality on neural synchrony during mother-child problem solving imitation in young children: when who gets copied is more important than what gets copied effect of visual orientation on mu suppression in children: a comparative eeg study with adults deficits in visuo-motor temporal integration impacts manual dexterity in probable developmental coordination disorder interpersonal synchrony enhanced through 20 hz phase-coupled dual brain stimulation automatic imitation effects are influenced by experience of synchronous action in children developmental changes in mu suppression to observed and executed actions in autism spectrum disorders modulation of mu suppression in children with autism spectrum disorders in response to familiar or unfamiliar stimuli: the mirror neuron hypothesis the neural network for the mirror system and mentalizing in normally developed children: an fmri study comprehensive longitudinal study challenges the existence of neonatal imitation in humans priming third-party ostracism increases affiliative imitation in children putting the social into social learning: explaining both selectivity and fidelity in children's copying behavior the social side of imitation why do many psychiatric disorders emerge during adolescence? morphological properties of the action-observation cortical network in adolescents with low and high resistance to peer influence the ice-breaker effect: singing mediates fast social bonding the action observation system when observing hand actions in autism and typical development infant negative reactivity defines the effects of parent-child synchrony on physiological and behavioral regulation of social stress rhythm perception, production, and synchronization during the perinatal period origins and development of mirroring mechanisms: a neuroconstructivist framework synchronous rhythmic interaction enhances children's perceived similarity and closeness towards each other joint rhythmic movement increases 4-year-old children's prosocial sharing and fairness toward peers synchronized movement experience enhances peer cooperation in preschool children what are reaction time indices of automatic imitation measuring? being mimicked affects inhibitory mechanisms of imitation distinct neural processes are engaged in the modulation of mimicry by social group-membership and emotional expressions the modulation of mimicry by ethnic group-membership and emotional expressions event-related potentials of automatic imitation are modulated by ethnicity during stimulus processing, but not during motor execution imitation in infancy: the wealth of the stimulus mu desynchronization during observation and execution of facial expressions in 30-month-old children does synchrony promote generalized prosociality? religion let's dance together: synchrony, shared intentionality and cooperation collective synchrony increases prosociality towards non-performers and outgroup members neural correlates of dyadic interaction during infancy brain-to-brain synchrony in parentchild dyads and the relationship with emotion regulation revealed by fnirs-based hyperscanning the mirror neuron system the mirror system and its role in social cognition neurophysiological mechanisms underlying the understanding and imitation of action neural mirroring during the observation of live and video actions in infants exploring the role of neural mirroring in children with autism spectrum disorder neural correlates of being imitated: an eeg study in preverbal infants an investigation of the determinants of motor contagion in preschool children infants' somatotopic neural responses to seeing human actions: i've got you under my skin mirror neurons system adults while viewing emotional gestures enhancing social ability by stimulating right temporoparietal junction social brain development and the affective consequences of ostracism in adolescence development of functional connectivity during adolescence: a longitudinal study using an actionobservation paradigm development of the action observation network during early adolescence: a longitudinal study infant's brain responses to live and televised action what's so special about verbal imitation? investigating the effect of modality on automaticity in children mimicry enhances observational learning in 16-month-old infants predictive motor activation during action observation in human infants the role of the right temporoparietal junction in the control of imitation the role of the right temporoparietal junction in the control of imitation minimal mimicry: mere effector matching induces preference motor activation during observation of unusual versus ordinary actions in infancy speaker-listener neural coupling underlies successful communication developmental differences in cortical activation during action observation, action execution and interpersonal synchrony: an fnirs study . frontiers in human neuroscience synchrony and exertion during dance independently raise pain threshold and encourage social bonding music and social bonding: "self-other" merging and neurohormonal mechanisms silent disco: dancing in synchrony leads to elevated pain thresholds and social closeness investigating cooperative behavior in ecological settings: an eeg hyperscanning study movement synchrony forges social bonds across group divides interpersonal movement synchrony facilitates pro-social behavior in children's peer-play rock with me: the role of movement synchrony in infants' social and nonsocial choices infants' grip strength predicts mu rhythm attenuation during observation of lifting actions with weighted blocks the modulation of facial mimicry by and their underlying affiliation motives in 3-year-olds: an emg study synchrony and the social tuning of compassion the rhythm of joint action: synchrony promotes cooperative ability mimicry and prosocial behavior where is the love? the social aspects of mimicry you'll never crawl alone: neurophysiological evidence for experience-dependent motor resonance in infancy sexy online self-presentation on social network sites and the willingness to engage in sexting: a comparison of gender and age young children's motor interference is influenced by novel group membership little chameleons: the development of social mimicry during early childhood modulating mimicry: exploring the roles of inhibitory control and social understanding in 5-year-olds' behavioral mimicry cooperative learning and interpersonal synchrony neural correlates of action understanding in infants: influence of motor experience neural correlates of action understanding in infants: influence of motor experience the action imitation network and motor imitation in children and adolescents with autism social top-down response modulation (storm): a model of the control of mimicry in social interaction eye contact enhances mimicry of intransitive hand movements infants' mu suppression during the observation of real and mimicked goal-directed actions in-group ostracism increases high-fidelity imitation in early childhood singing and social bonding: changes in connectivity and pain threshold as a function of group size synchrony and cooperation interpersonal synchronization, motor coordination, and control are impaired during a dynamic imitation task in children with autism spectrum disorder a developmental and clinical perspective of rhythmic interpersonal coordination: from mimicry toward the interconnection of minds implicit behavioral mimicry: investigating the impact of group membership desynchronization in eeg during perception of means-end actions and relations with infants' grasping skill social context effects in 2-and 4-year-olds' selective versus faithful imitation interpersonal body and neural synchronization as a marker of implicit social interaction the peer model advantage in infants' imitation of familiar gestures performed by differently aged models fourteen-month-olds' imitation of differently aged models. infant and child development this work was supported by the fondation pour la recherche médicale (frm, spf20171039127) to br, the grants from the agence nationale de la recherche (anr, france) anr-14-achn-0023 and anr-11-idex-0001-02) to mhg and benefited from the grants anr-16-conv-0002 (ilcb), anr-11-labx-0036 (blri) and the excellence initiative of aix-marseille university (a*midex). j o u r n a l p r e -p r o o f key: cord-288159-rzqlmgb1 authors: marin, lavinia title: three contextual dimensions of information on social media: lessons learned from the covid-19 infodemic date: 2020-08-26 journal: ethics inf technol doi: 10.1007/s10676-020-09550-2 sha: doc_id: 288159 cord_uid: rzqlmgb1 the covid-19 pandemic has been accompanied on social media by an explosion of information disorders such as inaccurate, misleading and irrelevant information. countermeasures adopted thus far to curb these informational disorders have had limited success because these did not account for the diversity of informational contexts on social media, focusing instead almost exclusively on curating the factual content of user’s posts. however, content-focused measures do not address the primary causes of the infodemic itself, namely the user’s need to post content as a way of making sense of the situation and for gathering reactions of consensus from friends. this paper describes three types of informational context—weak epistemic, strong normative and strong emotional—which have not yet been taken into account by current measures to curb down the informational disorders. i show how these contexts are related to the infodemic and i propose measures for dealing with them for future global crisis situations. from the beginning, the pandemic was reflected in the online realm of social media by a flood of redundant information (the so-called infodemic) out of which a significant percentage was made up of misinformation and disinformation (mdi). mdi is used here as one umbrella term for two distinct phenomena: misinformation, which is usually defined as false information shared without knowledge that it is false, while disinformation is fabricated information distributed with the clear intention to mislead (fallis 2014, p.136) . however, on social media, these distinctions are hard to maintain sharply, since we cannot always know who created a piece of misleading information and with what purpose. the infodemic is understood as "an overabundance of information-some accurate and some not-that makes it hard for people to find trustworthy sources and reliable guidance when they need it" (world health organization 2020). this concept is similar with that of information pollution which was defined as "irrelevant, redundant, unsolicited and low-value information" (wardle and derakhshan 2018, p.10) but applied to a crisis situation when an infodemic can become dangerous (tangcharoensathien et al. 2020, p. 2) . already since february 2020, the world health organization had singled the infodemic as an emerging problem in the context of the covid-19 pandemic. one of the most problematic aspects of an infodemic is that it creates information overload which leads to information fatigue for online users: the user's capacity for paying attention to information is limited and tends to exhaust quickly. studies in the psychology of social media have shown that, under conditions of informational overload, users will revert to using mental shortcuts or heuristics for assessing new information. by employing cognitive heuristics, social media users tend to rely on their friends and their endorsements in selecting what information to trust or engage with (koroleva et al. 2010, p. 5) . taking these mental shortcuts occurs "in conditions of low motivation and limited ability to process the incoming information" (koroleva et al. 2010, p. 5) which is arguably the case when dealing with information overload. trying to save their mental energy, users will tend to delegate their critical engagement to their social network, trusting their peers, or to become disengaged from so many news and revert to apathy. both strategies are dangerous because social media users are also citizens who are instrumental in the efforts to curb down the pandemic. if citizens do not correctly understand what they have to do in a pandemic situation, then governmental measures will be ineffective. online information about the covid-19 pandemic posted on social media displayed two seemingly distinct problems: the rapid propagation of misinformation and disinformation (mdi) and the so-called infodemic. both problems concerned how information travels in an online social networking medium, but only one of them was tackled with some degree of efficiency. social media platforms rapidly stepped up their pre-existing measures of dealing with mdi and targeted specifically the covid-19 related misleading information, whereas the infodemic remained untouched (howard 2020) . the infodemic was seen as a side-effect of the intensification of user interactions on social media, some informational noise that accompanied the humming of online communications. in this article, i will argue that both informational problems are related with and symptomatic of a deeper problem embedded in social media: the contextual design of the user's interactions with information. while we certainly need to pay attention to the quality of informational content (floridi and illari 2014) distributed on social media, similar attention should be paid to the quality of the user's interaction with the informational context. measures focusing solely on the factual content of information distributed online risk ignoring a significant aspect of social media, its particular context of engaging with information. the paper is structured as follows: first, i briefly review the measures taken by social media platforms to deal with the covid-19 related mdi, classifying them in view of the content or context focus. secondly, i describe three dimensions of the informational context on social media which made mdi particularly difficult to deal with during the pandemic and, by extension, aggravated the infodemic. finally, drawing from the contextual approach to information, i propose some measures to tackle informational disorders online for future similar global crisis situations. mdi related to covid-19 was tackled visibly by most mainstream social media platforms. this was possible because there were already some methods in place for dealing with mdi. starting with the 2016 elections and the cambridge analytica scandal, social media platforms began paying attention to the mdi shared by their users. in recent years, social media platforms have been testing methods of content curating by using external fact-checking organisations, flagging the misinforming content, and sometimes removing it (howard 2020) . in the wake of the covid-19 pandemic, these efforts for fact-checking were accelerated to an impressive extent: "the number of english-language fact-checks rose more than 900% from january to march" (brennen et al. 2020 ). this concentration of effort from disparate organisations was motivated by the emergency of the situation but also by the topic of covid-19 which rendered itself easier to fact-check: it was more or less clear what was false content 1 and what not-as opposed to previous cases of political mdi (brennen et al. 2020) . table 1 below summarises the main measures taken by social media platforms for dealing with mdi during the pandemic. 2 most approaches listed in the previous table were primarily content-focused as they were targeting the factual or descriptive content of the information, by checking it against existing evidence and reducing its visibility. however, the context of mdi is just as important as its content (wardle and derakhshan 2018) . contextual mdi may appear when placing genuine information in a fabricated setting, for example, a private statement cited as if it were a public one, a personal opinion as to represent the views of an organisation, mixing facts with irrelevant comments, or changing the date or place where a photo was taken. a large extent of covid-19 related mdi shared on social media was contextual or, as some have put it, reconfigured: "most (59%) of the misinformation in our sample involves various forms of reconfiguration, where existing and often true information is spun, twisted, recontextualised, or reworked. less misinformation (38%) was completely fabricated" (brennen et al. 2020) . even those measures which combined content with context awareness (such as numbers 3,5,6 and 7 in the table 1), the content was the primary focus. these measures relied on someone checking first what information was good enough and then proposing some contextual measures. content-focused approaches are not misguided, but tend to give most of the agency to the social media platform, while the users are left with a passive role, to click and react to what they are shown. meanwhile, when a measure is both content and context focused, the user's agency starts to play a significant role. no matter how many alternative sources of information one is exposed to (as it is the case with measures 5,6,7 in the table 1) , the user has still the final choice to engage with them or not. by contrast, a context-focused approach would presuppose that the user has the freedom to use the social media platform in a way that stimulates and recognises other kinds of engagement with information, regardless whether the information at hand is genuine or mdi. a context-focused approach creates informational environments which accommodate the possibility that the users may engage differently with and interpret differently the same information. this approach would aim to stimulate the users in becoming more sensitive to the modes in which the information is presented to them, educating them in the long run. this notion of context-sensitivity was inspired by similar constructs encountered in human-computer interaction studies such as "contextual design" (wixon et al. 1990 ) and "context-aware computing" (schilit et al. 1994 (schilit et al. -1994 . context sensitivity in design starts from the idea that the user's perspective is not that predictable, and that there is not one single context of use, accepting that users make sense of an interface in various ways, hence proposing that the designer accommodates for multiple meanings and complex interactions right from the start. in the long run, a contextual approach can educate the users without trying to change their beliefs or attitudes about the informational content as such. the contextual information approach is inspired by value sensitive design (friedman 1996; van den hoven 2007) which is complemented by paying attention to three particular dimensions of informational context on social media, described in the next section. the strong emotional context before the pandemic, it was already shown that mdi propagates on social media platforms by playing on the emotional reactions of the online audience (zollo et al. 2015; khaldarova and pantti 2016) , aiming to deliberately stir powerful emotions in their readers. some researchers called this feature of mdi a form of "empathic optimisation" (bakir and mcstay 2018, p. 155) . emotional manipulation in news items (especially click-bait) is an efficient way of capturing user's attention since emotion-stirring news are usually more interacted with than the neutral ones (bakir and mcstay 2018, p. 155) . it may seem that only mdi is emotionally loaded, whereas genuine news sound more sober and neutral. but this would be a misleading view of how information travels on social media platforms. emotional reactions do not belong to misleading information alone, rather these are a normal side-effect of the emotional infrastructure already embedded in most social media platforms. users of social media platforms are allowed a palette of actions and reactions: some are seemingly neutral (commenting, sharing and posting) while others have a clear emotional valence: liking and using other emoticons to endorse or dislike a post. these emotionally charged reactions are easier to perform than the neutral ones: it takes a split second to click like on a post, but some more time to comment on fig. 1 ). the assumption was that now, more than ever, users needed to express emotions online with a richer palette. however the simplistic way of expressing such emotions did not change, it was part of the interaction design from the beginning. the emotional infrastructure of social media was not something requested by users but designed from the start. major social media platforms are oriented towards maximising the user's engagement, i.e. how much time one spends on a specific platform and how much attention is consumed (whiting and williams 2013) . these kinds of interactions actively promote the user's "attention bulimia" i.e. a behaviour oriented towards "maximizing the number of likes" (del vicario et al. 2016, p. 1) and presumably other positive reactions. most buttons for emotional reactions are of positive emotions (like, love, hug, laugh) while in recent years facebook added some more nuanced emotions such as angry, sad or cry. but the overwhelming effect of these emotional reactions is to make other users feel liked by their social network hence, to make the platform a place where one wants to keep returning to for emotional gratification. for many users confined to their homes by the pandemic, social media platforms became a window to the world, as the television set used to be in older days and the easiest way of relating to others. in such times of distress and uncertainty, users posted more frequently than usual (cinelli et al. 2020 ) but some of the information posted was not meant to inform others, but rather to express one's concerns and emotions related to the pandemic. posts were also meant to get reactions from one's friends in an attempt to confirm that the others were also feeling the same way as one does. posting about the pandemic became a strategic way of gauging other's emotions on the crisis situation and gathering some feeling of consensus from one's social network. the consensus sought on social media was of an emotional nature which may be at odds with an epistemic consensus about the nature of the facts at hand. during the pandemic, several epistemologists and philosophers of science stepped up and tried to educate the general public on what sources to trust as experts and how to discern facts from fiction about the pandemic-in podcasts, opinion pieces and on their social media accounts (weinberg 2020) . while this effort is laudable, it needs to be complemented with another approach, taking into account the wider epistemic context in which information travels on social media. this is a particularly weak epistemic context in which information is not always shared to inform. social media platforms are not places where one usually goes to be informed. at least in regular, day to day situations, users turn to social media platforms to relate, to communicate and to be entertained (fuchs 2014) . the weak epistemic context of social media is ruled by serendipity (reviglio 2017) , meaning that many users get to be informed by accident. in a crisis situation, users tend to change how they use the platform and shifting towards the communication of vital information such as imminent risks or their location and also seeking to be informed by latest developments from people from the local site of the disaster. the entertainment function tends to become secondary in emergencies (zeng et al. 2016 ). in the 2020 pandemic situation, the difference was that the crisis was global and that the duration was rather long. this time, the uncertainty that accompanies a crisis situation was extended over months. as epistemic agents, online users tried to make sense of what was going on with them, what they could expect and to assess the personal risks, over a longer period. the pandemic was an extended crisis situation compounded with social alienation on top. this made users feel lost and overwhelmed by problems one could not understand. hence the desire-legitimate to a point-for everyone to be an expert so that they could at least understand what was happening to them. people did not want to be experts in epidemiology, quarantine measures, and home remedies for viruses because of a sudden surge of intellectual curiosity. they needed a way of coping that was also understandable to them. meanwhile, the official discourse of "trust the experts" and "please don't share information you do not understand" incapacitated them as epistemic agents. requiring users to do nothing and just comply went against the general desire to do something, as a way to take control. given the increase in posts on the pandemic by regular users, it may seem that many have tried to become experts overnight in epidemiology, viruses and vaccines. the comic below (fig. 2) illustrates the frequent situation emerging during the pandemic of members of the lay public hijacking the role of the expert. a discussion on conditions of trust and expertise makes sense in a regular epistemic context when agents try to acquire knowledge about a domain they know nothing about, having to choose which experts to trust (goldman and o'connor 2019) . however, acquiring knowledge was probably not the main goal of social media users who started posting scientific information which they did not understand. rather, many users tried to build some understanding of the situation, to make sense of the events. in these cases, shared understanding in a circle or network of friends seemed to be more important for users than gaining access to expertise. the scientific information was posted by lay users to back one's personal opinions, to urge for a certain course of action, or to gather consensus. given these weak epistemic uses of information targeted at emotional fulfilment and networking purposes, the regular content-focused measures would probably be less effective than predicted on such users. related to the previous point and stemming from it, most factual information shared around on social media had some normative implications which often shadowed any knowledge claim. descriptive information was used for prescriptive or evaluative aims. scientific expertise was co-opted strategically to enforce one's own pre-existing evaluative opinions. typical mdi claims are not merely descriptive claims of a state of affairs in the world, but often embedded in a normative context be those prescriptive or evaluative claims, both types are meant to change attitudes of the online users. mdi was shared because it prescribed actions or led to evaluations of the state of affairs which users already agreed with. hence debunking the facts would have solved only half of the puzzle, since the user's motivation to believe these normative claims would have not been dealt with. one example of the strong normative context for mdi, also involving a clear "politicisation" of mdi during the pandemic (howard 2020) , concerns one of the most popular types of claims analysed by eu vs disinfo (2020) in which the eu was depicted as powerless and scattered in dealing with the pandemic. this claim was traced back to russianbacked agencies which aimed to make users believe that, ultimately, russia was stronger than the eu (howard 2020). such claims can be debunked by showing that there were fig. 2 everyone is an expert. image source: https ://xkcd.com/2300/ coordinated measures taken by the eu, however, the implicit claim that other states dealt better with the pandemic than the eu is hard to debunk since it is not explicitly stated. this is just one type of difficulty with mdi which cannot be tackled with a content-focused approach: implicit evaluative claims in which one term of the comparison is not named. some evaluative claims can be checked (if these involve relational predicates which are measurable such as "better than" or "more efficient than") however others, incidentally the politicised evaluative claims, are harder to assess. in russian-backed claims against the eu, the name of "russia" is not mentioned anywhere in the text of the "news", since the aim is to erode the trust in eu from its citizens. if these citizens happen to be in eastern europe, this erosion of trust could lead to an anti-eu generalised feeling, and ultimately bottom-up pressures to exit the eu. these kinds of campaigns cannot be easily fact-checked since the effect is achieved by playing the long game. what looks like news about the pandemic is a dog-whistle about something else. the strong normative context is visible also when using scientific expertise co-opted to back up prescriptive claims otherwise untenable. one example is an unpublished paper by blocken et al. titled "towards aerodynamically equivalent covid19 1.5 m social distancing for walking and running" (2020) in which an animated image showed a simulation of how joggers coughing will spread particles of droplets when running at a distance of 1.5 m from each other. the paper became viral on social media despite not being peerreviewed nor published on a pre-print website. the visual animation showing the spread of droplets was understandable by every lay member of the public, without needing to have specialised knowledge of actual aerodynamics, and presumably made the paper so popular among non-scientists who used it to make prescriptive claims by non-scientists. while the authors hypothesised that it might be unsafe to run close to another-and that even 1.5 m distance might not be enough for jogging-the social media audience took this as a reason to shame the runners in their neighbourhoods (koebler 2020). meanwhile, the first author of the study posted a document on his website answering certain questions about the study 3 and refused to draw any epidemiological conclusions, urging for other's expertise. but social media users did not shy from becoming experts and drawing the conclusions themselves, as the information in the blocken et al. paper was just ammunition in a larger informational battle about what others should do. even if the scientific claims of regular users are checked, their aim remains to prescribe actions for others and to evaluate the world in a way that will be endorsed by one's community of friends. for these purposes, other pieces of news will be co-opted if the first ones were flagged as hoaxes. content-based approaches are then ineffective against this strong desire of social media users to emit evaluative or prescriptive claims about the world and strategically use science-looking sources to back these up. one should address the very desire of regular users to evaluate the world from the little soap-boxes that social media affords. the three dimensions of the informational context on social media previously mentioned (strong emotional, strong normative and weak epistemic) have been analytically distinguished but they function simultaneously to promote certain user behaviours which one could call irresponsible information sharing on social media. the weak epistemic context re-enforces the strong normative claims which are coupled with emotional reactions leading users to become strongly attached to their claims and indifferent to their debunking. while the three dimensions of the informational context work together to produce a perfect storm of low-quality and redundant information-an infodemic-one could still try to design modes of interaction to deal with each of them. future measures dealing with mdi and infodemic in a global pandemic need to also tackle the high emotional load of most mdi items. a practical way of flagging this could be devised by modelling on facebook's "hoax alert" system which warns users that a certain post they are reading has been fact-checked and is probably a hoax. a similar system could be designing an "emotional alert" flag which appears below certain news-looking items which have an unusually high amount of emotional triggering words. this kind of alert would show to users when certain news-like items lead them to feel something quite specific. the readers would be still free to engage with such items, but at least they would be warned about possible emotional manipulation. such alert would also flag click-bait and irrelevant news which are not false in themselves, but which do contribute to the infodemic because of the high virality and potential for polarisation. the weak epistemic context needs to be tackled together with the high normative one. when users engage with newsitems relating to the pandemic (or any other crisis situation), they can be shown alternative news and pages or users to follow which are experts in the field. this has been already implemented, but with little success as it needs to be complemented by more context-aware measures. a new measure could be to try to increase the users' critical engagement with a certain class of news items. this could happen by posting a small survey under the tricky news items asking the users to answer the following questions: "what does this news lead me to believe?", "what does this post ask me to feel?", "please rate how strongly you agreed with these claims before reading this post". and, finally, after answering this mini-survey, the user could be shown a disclaimer stating, "now that you've read posts you agreed with, how about trying something different?"-and the alternative sources with diverse information from experts could be displayed, but after the user has been primed to be more critical and diversify one's information sources. to incentivise users to fill in these surveys, they could receive certain bonus points on the social media platform and, once they accumulate a certain number of points, they could get a badge next to their name of "critical media user" or "critical thinker" which would ensure visibility of their informational skills. these sample measures i have proposed-and presumably other context-sensitive measures-are fit to be implemented only in crisis situations and only targeting the user's posts about the current crisis situation. it is, of course, possible to integrate these measures in the day to day users' interaction. however, social media fulfils certain deep emotional needs of users such as expressing strong normative opinions and seeking emotional consensus. if these contexts are strongly discouraged, the users may find other platforms to do so and they may abandon the too critical platforms. meanwhile, in a crisis situation, these dimensions could be targeted specifically and confined to users that share mdi and redundant information about the crisis at hand. this paper outlined three types of informational context which have not yet been taken into account by the current measures to curb down disinformation and the amount of irrelevant information on social media platforms. mdi countermeasures taken thus far have a limited effect because these did not account for the diversity of information contexts on social media. these measures do not address the primary causes of the infodemic itself, namely the user's need to post content as a way of making sense of the situation and of expressing one's opinion as a way of gathering consensus reactions. in light of these considerations, we need a value-sensitive design re-assessment of how users interact on social media among themselves as well as with the information found online in crisis situations. designing for thoughtful, critical and meaningful user interaction should become an explicit aim for the future of social media platforms in times of pandemics and other global emergencies. fake news and the economy of emotions towards aerodynamically equivalent covid19 1.5 m social distancing for walking and running. questions and answers. website bert blocken, eindhoven university of technology (the netherlands) and ku leuven (belgium) retrieved from https ://reute rsins titut e.polit ics.ox.ac.uk/ types -sourc es-and-claim s-covid -19-misin forma tion the covid-19 social media infodemic echo chambers: emotional contagion and group polarization on facebook throwing coronavirus disinfo at the wall to see what sticks. eu vs disinfo the varieties of disinformation the philosophy of information quality value-sensitive design social media: a critical introduction social epistemology misinformation and the coronavirus resistance fake news the viral 'study' about runners spreading coronavirus is not actually a study stop spamming me! exploring information overload on facebook the covid-19 'infodemic': a new front for information professionals serendipity by design? how to turn from diversity exposure to diversity experience to face filter bubbles in social media context-aware computing applications the next phase in fighting misinformation. facebook newsroom framework for managing the covid-19 infodemic: methods and results of an online, crowdsourced who technical consultation ict and value sensitive design. the information society: innovation, legitimacy, ethics and democracy in honor of professor jacques berleur sj thinking about 'information disorder': formats of misinformation, disinformation, and malinformation the role of philosophy & philosophers in the coronavirus pandemic. daily nous why people use social media: a uses and gratifications approach contextual design: an emergent view of system design novel coronavirus(2019-ncov): situation report-13. who rumors at the speed of light? modeling the rate of rumor transmission during crisis emotional dynamics in the age of misinformation the author would like to thank samantha marie copeland for commenting on an earlier draft of this article and to the two reviewers for their insightful comments on the first version of the article.funding this project has received funding from the european union's horizon 2020 research and innovation programme under the marie skłodowska-curie grant agreement number. 707404. the opinions expressed in this document reflect only the author's view. the european commission is not responsible for any use that may be made of the information it contains. open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. key: cord-269643-12qm4h9w authors: liu, pai; beeler, payton; chakrabarty, rajan k. title: dynamic interplay between social distancing duration and intensity in reducing covid-19 us hospitalizations: a “law of diminishing returns” date: 2020-07-17 journal: chaos doi: 10.1063/5.0013871 sha: doc_id: 269643 cord_uid: 12qm4h9w we uncover and highlight the importance of social distancing duration and intensity in lowering hospitalization demand-to-supply during the coronavirus disease 2019 (covid-19) epidemic in the usa. we have developed an epidemic progression model involving the susceptible–exposed–infected–recovered dynamics, the age-stratified disease transmissibility, and the possible large-scale undocumented (i.e., asymptomatic and/or untested) transmission of covid-19 taking place in the usa. our analysis utilizes covid-19 observational data in the usa between march 19 and 28, corresponding to the early stage of the epidemic when the impacts of social distancing on disease progression were yet to manifest. calibrating our model using epidemiological data from this time period enabled us to unbiasedly address the question “how long and with what intensity does the usa need to implement social distancing intervention during the covid-19 pandemic?” for a short (i.e., up to two weeks) duration, we find a near-linear decrease in hospital beds demand with increasing intensity [formula: see text] of social distancing. for a duration longer than two weeks, our findings highlight the diminishing marginal benefit of social distancing, characterized by a linear decrease in medical demands against an exponentially increasing social distancing duration. long-term implementation of strict social distancing with [formula: see text] could lead to the emergence of a second wave of infections due to a large residual susceptible population which highlights the need for contact tracing and isolation before re-opening of the economy. finally, we investigate the scenario of intermittent social distancing and find an optimal social-to-no-distancing duration ratio of 5:1 corresponding to a sustainable reduction in medical demands. scitation.org/journal/cha to circumvent this situation and find a critical intermittent socialto-no-distancing duration ratio of 5:1, which facilitates up to 80% reduction in medical demands. exceeding this critical ratio, the marginal benefit of social distancing wanes off significantly. in december 2019, a novel coronavirus named sars-cov-2 began infecting residents of wuhan, china. 1-3 sars-cov-2 causes moderate to severe respiratory symptoms that can progress to severe pneumonia (coronavirus disease 2019, . 4 despite the extreme disease containment measures taken in china, 5 covid-19 has spread rapidly to numerous countries and evolved into a global pandemic. 1, 3 on january 30, 2020, the world health organization (who) declared a "public health emergency of international concern," 6 and on the following day the united states department of health and human services declared a public health state of emergency. 7 during the week of february 23, the us centers for disease control (us-cdc) reported new confirmed cases of covid-19 in california, oregon, and washington, indicating the onset of "community spread" across the usa. 7 until march 2, the total number of confirmed active covid-19 cases in the usa were 33 with new cases emerging in the states of texas, arizona, wisconsin, illinois, florida, new york, rhode island, and massachusetts. 8 in the following two weeks, this number rapidly increased from 527 confirmed cases on march 9 to 4216 cases on march 16. 8 the states of california and new york declared a state emergency on march 4 and 7, respectively. 9, 10 the white house declared a national emergency on march 13 11 foreseeing the inevitability of a major epidemic outbreak across the usa. as of may 14, the total number of confirmed cases in the usa has exceeded 1.4 × 10 6 . 8 based on past estimates of seasonality, immunity, and cross-immunity for betacoronaviruses oc43 and hku1, it is highly likely that recurrent wintertime outbreaks of sars-cov-2 will occur after the initial, most serve pandemic wave in the usa. 12 to prevent the rapid disease spread and alleviate the medical demands, social distancing has been adopted as a non-pharmaceutical measure across the country. such a nonpharmaceutical intervention aims to slow down epidemic progression and ultimately prevents the country's medical system from collapsing due to overburdening of covid-19 patients. it has also been suggested that prolonged or intermittent social distancing along with expanded critical care may be necessary until 2022. 12 however, effectiveness and marginal benefits of social distancing as a function of implementation duration, timing, and strategy, especially in the context of covid-19 epidemic, remain uncertain and is a critical knowledge gap. here, we address this gap by comprehensively investigating the effectiveness of social distancing as a function of implementation duration and intensity in reducing the peak number of hospitalizations 13 across the usa. we do so by calibrating an epidemic dynamic model with covid-19 observational data from the usa for the period march 19-28. this period was characterized by a rapid surge in covid-19 cases due to a ramp up in testing services and the onset of strict social distancing in most us states. more importantly, the benefits of social distancing in reducing the hospital bed demand-to-supply were yet to manifest during this period, which facilitated us to unbiasedly address the research questions posed as part of this study. our metapopulation epidemiological model involves the susceptible, exposed, infected, and recovered (seir) dynamics, 1,2,14-16 the age-stratified disease transmissibility, [16] [17] [18] and the possible largescale undocumented transmission 16, 19 taking place in the 50 us states, washington dc, and puerto rico (hereafter, they are generically denoted as states). for each state n, the local population was classified into four categories-susceptible, exposed, infected, and recovered-with the fraction of population within each category denoted as s n , e n , j n and r n , respectively. 20 the infected category was further divided into two sub-classes: the infected-and-documented (j r n ) and the infected-and-undocumented (j u n ), i.e., j n = j r n + j u n . this treatment accounts for the substantial influence of the asymptomatic (or mildly symptomatic) covid-19 carriers on accelerating the epidemic spread. 19 furthermore, the population within each category of s n , e n , j r n , j u n , and r n were divided into nine age-stratified compartments (hereafter age groups), in light of the strong agedependent hospitalization rate of covid-19 patients. 13 specifically, age group i (with 1 ≤ i ≤ 8) comprised of individuals aged between 10 × (i − 1) and 10 × i − 1 years, while the 9th age group included everyone aged 80 years and above. this age-stratification can be expressed as x n = i x n,i (here, x is used to generically denote s, e, j r , j u , and r). finally, the interstate exchange of individual within the s n , e n , j u n , and r n category was captured using a mobility matrix of p m,n quantifying the probability that an individual leaving state n ends up in m. [20] [21] [22] the governing equations of our model can therefore be expressed as a set of first-order differential equations with respect to time (t), here, r 0,n,i is an age-specific reproduction ratio representing the efficiency by which covid-19 (within state n) is transmitted to the local population in age group i. the values of r 0,n,i were mapped from a state-wise reproduction ratio (r 0,n ) per the assumption that the disease transmissibility between age groups i and k is directly proportional to the average daily time-of-exposure (t i,k ) chaos article scitation.org/journal/cha among their members: r 0,n,i = r 0,n k t i,k /q, where q is a proportionality factor taking values of the largest eigenvalue of the t i,k matrix. 17,18,23 d e and d i , respectively, represent the mean incubation period and mean infectious period of covid-19; 1,2,24 η n represents local documentation ratio of the infected individuals; ε is a constant factor denoting the mean elongation of infectious period for those undocumented covid-19 carriers; 19 f n,i is the fraction of local population within age group i, φ is the daily passenger flux of the entire traffic network; and represents the total us population. 20, 25 the ratio f n,i φ/ can be regarded as an interstate mobility parameter for members of age group i. our model was initialized on march 19 (t 0 ) with the documented active covid-19 cases j r n (t 0 ) acquired from a webbased dashboard for real-time epidemic tracking published by johns hopkins university. 8 next, we estimated the initial number of undocumented cases, per j u n (t 0 ) = (1/η n − 1) * j r n (t 0 ), and the exposed cases, per e n (t 0 ) = (1/ζ n ) * j r n (t 0 ) . (here, ζ n is the unknown documented-to-exposed ratio and η n is the unknown documentation ratio for state n. the acquisition of ζ n and η n is detailed below.) finally, the age-stratified compartments were initialized according to the state-wise demographic composition, i.e., x n,i (t 0 ) = f n,i x n (t 0 ). the mobility matrices p m,n and passenger flux φ were calculated using the latest monthly resolved aviation data (between september 2018 and august 2019) released by the united states bureau of transportation statistics 26 (refer to supplementary material for details). it was assumed in our model that the interstate exchange of passengers is predominately via air traffic since volume of groundbased exchange is negligible (see the supplementary material). we further assumed that the long-term international importation of individuals infected with covid-19 is minimal under a wholesale travel restriction enforced on international passengers that arrive from countries and regions where covid-19 is widespread. [27] [28] [29] the state-wise demographic composition f n,i was acquired from the database of the united states census bureau. 30 the matrix of t i,k was acquired from the work by zagheni et al. 17 wherein the age-specific time-of-exposure was calculated using american time use survey data (supplementary material). the epidemiological parameters d e , d i and ε of covid-19 were assumed to be 5.2 days, 2.3 days, 31 and 1.82, 2 respectively, per the values reported in the latest modeling study conducted on covid-19 epidemics in china. 2, 31 for simplicity, we assumed here that the country-wise variability in the incubation and infectious periods of coronavirus is insignificant. the unknown statewise parameters r 0,n , η n , and ζ n were inferred in a trial-and-error manner by fitting the model predicted j r n (t) to the observational data within a calibration period. specifically, the inference algorithm operates by iteratively guessing values of r 0,n , η n and ζ n for each state n. the ranges for parameters-r 0,n ∈ [0, 10], η n ∈ [0, 0.4] and ζ n ∈ [0, 1]-were chosen based on values deemed realistic before widespread testing of covid-19 was conducted. 2, 19, 32 this iteration process is repeated until attaining the optimal r 0 , η, and ζ arrays that minimize the root-mean-squared-error (rmse) between the model predicted j r n (t) and the ground truth. the calibration period was set to the ten-day period between march 19 and 28, a period characterized by a rapid surge in epidemic size with a basic reproduction ratio r 0 ≈ 4.87 (state-wise median value) and the onset of social distancing in most us states in conjunction with ramp up in testing services. however, the benefits of social distancing in reducing the hospital bed demand-to-supply only started to manifest after march 28. therefore, we term the period march 19-28 as the "latency period" (see the shaded area in fig. 1) , and the period thereafter as "benefits manifestation period." calibrating our model using baseline epidemiological data corresponding to the "latency period" enabled us to unbiasedly probe and address the question: how long and with what intensity does the us need to implement social distancing as a sustainable public policy during the covid-19 pandemic? the η ≈ 0.24 is in good agreement with the who situation report no. 34 31 which identifies that about 80% of all infected cases are undocumented. we estimate the demand on medical systems across the country by assuming that no effective containment intervention will take place and the epidemic will progress following the trend observed between march 19 and 28. in the context of this work, we interpret the burden on the medical resource using the local demand-tosupply ratio for hospital beds (y h,n ) at an epidemic peak, here, j * n,i is the peak value of j n,i (t); n n is the total population of state n 30 ; and p h,i denotes the age-specific rate at which covid-19 patients require hospitalization (data tabulated in the supplementary material of ref. 13); x h,n denotes the state-wise numbers of available hospital beds (data tabulated in the supplementary material of ref. 34). one should note that the y h,n can be overestimated because the undocumented cases are constituted in part by asymptomatic and/or untested covid-19 carriers, who might not require hospitalization. figures 3(a) and 3 (b) color each us state according to its corresponding y h,n value. if the epidemic progression remains unhalted, then the state-wise hospital beds could be overwhelmed by up to 12 times. similar trends were also observed in the evolution of the demand-to-supply ratio of intensive care unit (icu) beds, which can be found in the supplementary material of this work. figures 3(c) and 3(d) evaluate the effectiveness of various social distancing practices in balancing the medical demands and supply. herein, the decreases in the peak y h are plotted as functions of the social distancing intensity (ϕ)-defined as the percent reduction in time-of-exposure t i,k of the targeted age-group members. for example, school closure reduces the values of t i,k elements that are associated with individuals aged 1-19 years; and business closure and distancing the elder reduce t i,k for those aged 20-59 years and those aged 60-year-and-above, respectively. formally, this treatment is described with the following time-of-exposure matrix (t i,k,intv ) modified per the type of social distancing practice, the modification of the time-of-exposure matrix lasts for the duration of the epidemic. the side-by-side comparison in fig. 3 shows that business closure is the most effective practice, possibly because it targets at the majority of the population. at a fixed ϕ level, elder distancing achieves a better outcome than school closure. however, none of these practices could curb covid-19 adequately if they are implemented separately. instead, a wholesale social distancing with all practices in effect must be taken, and it takes at least an intervention intensity ϕ = 70% to reduce the medical demands week, stronger social distancing could lead to decreased medical demand if social distancing is implemented at the optimal time. (b) nationwide hospital bed demand-to-supply ratio (y h ) is plotted as a function of implementation timing for various social distancing intensities for a duration of ten weeks. for social distancing lasting ten weeks, stronger social distancing does not necessarily lead to decreased medical demand, even if social distancing is implemented at the optimal time (t i ). to a balanced level under the premise that the social distancing can last for indefinitely long time. a prolonged period of social distancing could have devastating socio-economic implications that outweighs its benefits. 35, 36 if society can only afford a finite-time social distancing, it is of utmost importance to understand when and for how long the intervention should be put into effect, so as to maximize the net benefit. show that unless the intervention could last indefinitely, a premature implementation could be counterproductive. it is also evident that the duration of social distancing greatly affects the optimal value of ϕ. figure 4(a) shows that for social distancing lasting for one week, increased ϕ leads to decreased medical demands. however, fig. 4(b) shows that for social distancing lasting for ten weeks, there is an optimal value of ϕ ≈ 70% which corresponds to the maximum achievable reduction in medical demands. increasing ϕ beyond this point decreases the effectiveness of the intervention. the minimum "valley" points corresponding to each curve denote the optimal t i as well as the corresponding maximum achievable reduction in y h . in fig. 5 , we highlight the diminishing marginal benefits of social distancing by plotting the maximum achievable reduction in y h as a function of social distancing duration (weeks). the figure clearly exhibits an emergence of two regimes. the first regime corresponds to social distancing duration <2 weeks (hereafter shortterm social distancing). within this regime, increased ϕ leads to a proportionate reduction in medical demands. the second regime corresponds to social distancing with duration ≥2 weeks (hereafter long-term social distancing). within this regime, a linear decrease in medical demands is achieved at the cost of an exponentially increasing social distancing duration. increasing ϕ >70% yields a significantly lower than expected reduction in medical demands. this decreased effectiveness of increasing intensity and duration of social distancing could be best described by the law of diminishing returns, where the benefits of the intervention dwindle with more units invested. it should be noted that if the social distancing duration were to be further increased, then the results would converge to those discussed in sec. iii b. we attempt to provide an explanation behind the phenomenon of reduced medical benefits for ϕ >70% observed during the longterm social distancing period. in fig. 6 , we explain the origin of this occurrence by elucidating the epidemic curves that evolve under a long-term social distancing period of 10 weeks for various ϕ. when ϕ ≥ 70%, there exists a large buildup of susceptible individuals, who remain prone to the infection at the end of the social distancing period. the possibility of this residual susceptible population to emerge as infectious with time remains very chaos article scitation.org/journal/cha fig. 5. exponentially diminishing benefits of social distancing. semi-log plot for the relationship between social distancing duration and the corresponding maximum attainable decrease in medical demands for social distancing of various intensities. the emergence of two regimes becomes clear, separated into short-term (duration <2 weeks) and long-term (duration ≥ 2 weeks, gray shaded region). for short-term social distancing, stronger social distancing (denoted by increasing intensity ϕ) leads to a monotonous decrease in medical demands. for long-term social distancing, the largest reduction in medical demands is achieved when ϕ ≈70%, beyond which the benefits of social distancing diminish. high. thus, one cannot rule out the possibility of a second wave of infections in the usa after the initial wave of pandemic dies out. 12 this non-linear dynamics of intensity and duration indicates that if social distancing cannot be maintained indefinitely, its intensity, implementation time, and duration must be considered carefully in order to maximize its benefits. another implication of our findings is that a premature removal of strict social distancing measures could lead to a large second wave of infections. the non-linear behavior of finite-time social distancing warrants the aggressive co-implementation of other interventions such as contact tracing. before re-opening of normal social-economic activities, efforts need to be taken on identifying the potential covid-19 carriers and physically isolating them from the large susceptible population, which will ultimately prevent the onset of second wave of infection. 37 we next evaluate the effectiveness of intermittent social distancing strategy-an arrangement comprising of alternating phases of social distancing and no-distancing that last for variable durations-as a sustainable solution. 38 figure 7 plots the hospital bed demand-to-supply ratio as a function of social distancing phase duration τ d , no-distancing (or normalcy) phase duration τ n , and intervention intensity ϕ. a comparison among each subpanel of fig. 7 indicates that the effectiveness of intermittent social distancing is positively correlated with ϕ. furthermore, when ϕ is fixed, the effectiveness of intermittent social distancing is determined by τ d /τ n -the characteristic intermittent distancing-to-no-distancing ratio. for instance, in fig. 7(d) , the intermittent arrangements fig. 6. epidemic dynamics of ten-week social distancing with varying intensities ϕ. epidemic dynamics for ten weeks social distancing initiated at t i with ϕ = 30% (a), ϕ = 70% (b), and ϕ = 90% (c). shaded regions denote the period where social distancing is in effect. the magnitude of the second peaks seen in panels (b) and (c) are controlled by the percentage of susceptible individuals (s) within the population when social distancing ends. if the susceptible population is very large when social distancing ends, a second wave of infections will spread throughout the population. corresponding to τ d /τ n = 1, 2, and 3 are marked with lines of various styles. one could observe that the arrangements with the same τ d /τ n result in the same demand-to-supply ratio outcome. the determining role of the characteristic τ d /τ n ratio is further elucidated in fig. 8 , wherein the percent reduction in hospital bed demand is plotted as a function of τ d /τ n and ϕ. these observed universal trends again imply that the marginal benefits of social distancing would diminish over a prolonged time. for 1 ≤ τ d /τ n ≤ 5, the effectiveness of social distancing-measured by the percent reduction in medical demands-increases rapidly with an increasing τ d /τ n . beyond the critical point of τ d /τ n ≈ 5, the increase in effectiveness due to a further increase in τ d /τ n becomes negligible. such an observation holds valid regardless of ϕ. take intermittent social distancing with ϕ = 70% as an example: an effective intermittent social distancing strategy would allow people to behave as normal for one day, followed by five days of social distancing, and then repeat. this strategy could alleviate medical burden up to 70% and could avoid some of the burdens of long-term social distancing. this behavior is also well described by the law of diminishing returns; there is an optimal distancing-to-no-distancing ratio, beyond which the time invested becomes greater than the benefits gained. in this work, we provide a comprehensive systematic analysis of the effectiveness of three social distancing methods in alleviating the burden of the covid-19 pandemic on nationwide medical resources. our baseline scenario represents a continuation of the epidemic dynamics observed between march 19 and 28, during which a rapid surge of covid-19 cases is observed in the united states and the effect of social distancing is yet to manifest. our findings suggest that under such a baseline condition, the state-wise hospital could be overwhelmed by up to 12 times. indefinite-time social distancing is found to balance the medical demand-to-supply chaos article scitation.org/journal/cha at epidemic peak provided a 70% reduction in the time-of-exposure of the population within all age groups is achieved. finite-time social distancing is found to follow two regimes; short-term (duration <2 weeks) and long-term (duration ≥2 weeks). short-term social distancing is characterized by a proportionate reduction in medical demands for increased social distancing intensity (ϕ). longterm social distancing is characterized by an optimal ϕ (∼70%), which yields the largest reduction in medical demands. long-term social distancing is also characterized by a linear decrease in medical demands for exponentially increasing social distancing duration. the non-linear dynamics between ϕ and hospitalization demand emphasize that precautions need to be taken when lifting strict social distancing measures abruptly, so as to prevent the onset of a second wave of infection. secondary interventions such as contact tracing are necessary for identifying and isolating the covid-19 carriers from a potential large susceptible pool of the population. intermittent social distancing is found to rapidly reduce medical demands, as long as the characteristic distancing-to-no-distancing ratio (τ d /τ n ) does not exceed 5. if τ d /τ n is increased beyond 5, the benefits begin to wane significantly. finite-time social distancing and intermittent social distancing are both found to be effective social distancing strategies in mitigating medical demands related to the covid-19 pandemic. however, the implementation of these strategies must be carefully considered, as their benefits are found to be well described by the law of diminishing returns. findings from this study may also apply to other regions of europe, as well as asia, where social distancing measures have been in effect to slow the epidemic spread. see the supplementary material for the following datasets: • time-of-exposure matrix: the daily average time-of-exposure of the age-stratified american population. units: minutes per day. • interstate mobility matrix: monthly resolved datasets quantifying the interstate mobility pattern in the usa. the matrix elements represent the probability that a passenger leaving a departure state (row) ends up in a destination state (column). units: dimensionless. • model calibration results: the state-wise epidemiological parameters that lead to the best fit between model prediction and observed epidemic trend. units: basic reproduction ratio, documentation ratio, exposed ratio: dimensionless; rmse: number of people. • hospitalization and critical condition rate: the age-specific probability by which an infected individual requires hospitalization, and the age-specific probability by which a hospitalized covid-19 patient develops into critical condition. units: dimensionless. • state-wise population: state-wise population and demographic composition. units: population: number of people; fraction of population within each age group: dimensionless. • state-wise medical resources: state-wise number of available hospital beds and icu beds. units: number of beds. the effect of travel restrictions on the spread of the 2019 novel coronavirus (2019-ncov) outbreak nowcasting and forecasting the potential domestic and international spread of the 2019-ncov outbreak originating in wuhan, china: a modelling study preparedness and vulnerability of african countries against importations of covid-19: a modelling study characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72314 cases from the chinese center for disease control and prevention statement in support of the scientists, public health professionals, and medical professionals of china combatting covid-19 statement-on-the-second-meeting-of-the-international-health-regulations-%282005%29-emergency-committee-regarding-the-outbreak-of-novel-coronavir us-%282019-ncov%29 for coronavirus disease 2019 (covid-19) situation summary an interactive web-based dashboard to track covid-19 in real time ernor-newsom-declares-state-of-emergency-to-help-state-prepare-for-broader-sp read-of-covid-19/ for "governor newsom declares state of emergency to help state prepare for broader spread of covid-19 cuomo declares state of emergency procla mation-declaring-national-emergency-concerning-novel-coronavirus-disease-co vid-19-outbreak/ for "proclamation on declaring a national emergency concerning the novel coronavirus disease (covid-19) outbreak projecting the transmission dynamics of sars-cov-2 through the postpandemic period impact of non-pharmaceutical interventions (npis) to reduce covid19 mortality and healthcare demand the mathematical theory of epidemics infectious diseases of humans: dynamics and control covid-19 medical demand forecast using time-use data to parameterize models for the spread of close-contact infectious diseases systematic selection between age and household structure for models aimed at emerging epidemic predictions substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov2) the hidden geometry of complex, networkdriven contagion phenomena forecast and control of epidemics in a globalized world reaction-diffusion processes and metapopulation models in heterogeneous networks using data on social contacts to estimate age-specific transmission parameters for respiratory-spread infectious agents the incubation period of 2019-ncov infections among travellers from shift in the velocity of a front due to a cutoff for more information about united states bureau of transportation statistics procla mation-suspension-entry-immigrants-nonimmigrants-persons-pose-risk-transm itting-2019-novel-coronavirus/ for "proclamation on suspension of entry as immigrants and nonimmigrants of persons who pose a risk of transmitting pro clamation-suspension-entry-immigrants-nonimmigrants-certain-additional-pers ons-pose-risk-transmitting-coronavirus/ for "proclamation on the suspension of entry as immigrants and nonimmigrants of certain additional persons who pose a risk of transmitting coronavirus europe blindsided by trump's travel restrictions, with many seeing political motive early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia the reproductive number of covid-19 is higher compared to sars coronavirus for more information about harvard global health institute a 'small-world-like' model for comparing interventions aimed at preventing and controlling influenza pandemics estimating the costs of school closure for mitigating an influenza pandemic quantifying sars-cov-2 transmission suggests epidemic control with digital contact tracing social distancing strategies against disease spreading authors' contributions p. l. and p. b. contributed equally to this manuscript. the authors thank the insightful comments and suggestions from two anonymous reviewers. funding support from the dean's office of the mckelvey school of engineering at washington university in st. louis is appreciated for conducting parts of this research. the data that support the findings of this study are available in the supplementary material and from the johns hopkins university covid-19 tracking website, ref. 8. key: cord-286128-i3lc5ykc authors: banerjee, debanjan; rai, mayank title: social isolation in covid-19: the impact of loneliness date: 2020-04-29 journal: int j soc psychiatry doi: 10.1177/0020764020922269 sha: doc_id: 286128 cord_uid: i3lc5ykc nan we need to revisit this statement by blaise pascal time and again to unearth something invaluable, to reinforce something primal, especially in times such as these where the whole world is in a state of lockdown, courtesy the corona virus disease 2019 . this disease caused by sars-cov-2, has literally brought the world down to its knees just within last few months. the world is facing a global public health crisis for the last three months, as the coronavirus disease 2019 (covid-19) emerges as a menacing pandemic. besides the rising number of cases and fatalities with this pandemic, there has also been significant socio-economic, political and psycho-social impact. billions of people are quarantined in their own homes as nations have locked down to implement social distancing as a measure to contain the spread of infection. those affected and suspicious cases are isolated. this social isolation leads to chronic loneliness and boredom, which if long enough can have detrimental effects on physical and mental well-being. the timelines of the growing pandemic being uncertain, the isolation is compounded by mass panic and anxiety. crisis often affects the human mind in crucial ways, enhancing threat arousal and snowballing the anxiety. rational and logical decisions are replaced by biased and faulty decisions based on mere 'faith and belief'. this important social threat of a pandemic is largely neglected. we look at the impact of covid-19 on loneliness across different social strata, its implications in the modern digitalized age and outline a way forward with possible solutions to the same. there is no doubt that national and global economies are suffering, the health systems are under severe pressure, mass hysteria has acquired a frantic pace and people's hope and aspirations are taking a merciless beating. the uncertainty of a new and relatively unknown infection increases the anxiety, which gets compounded by isolation in lockdown. as global public health agencies like world health organization (who) and centre for disease control and prevention (cdc) struggle to contain the outbreak, social distancing is repeatedly suggested as one of the most useful preventive strategies. it has been used successfully in the past to slow or prevent community transmission during pandemics (who, 2019). while certain countries like china have just started recovering from their three-month lockdown, countries like iran, italy and south korea have been badly hit irrespective of these measures and those like india have initiated nation-wide shutdown and curfews to prevent the community transmission of covid-19. ironically however, the social distancing is a misnomer, which implies physical separation to prevent the viral spread. the modern world has rarely been so isolated and restricted. multiple restrictions have been imposed on public movement to contain the spread of the virus. people are forced to stay at home and are burdened with the heft of quarantine. individuals are waking up every day wrapped in a freezing cauldron of social isolation, sheer boredom and a penetrating feeling of loneliness. the modern man has known little like this, in an age of rapid travel and communication. though during the earlier outbreaks of severe acute respiratory syndrome (sars), middle east respiratory syndrome (mers), spanish flu, ebola and plague the world was equally shaken with millions of casualties, the dominance of technology was not as much as to make the distancing felt amplified (smith, 2006) . in this era of digitalization, social media, social hangouts, eateries, pubs, bars, malls, movie theatres to keep us distracted creating apparent 'social ties'. humankind has always known what to do next, with their lives generally following a regular trail. but this sudden cataclysmic turn of events have brought them face to face with a dire reckoning -how to live with oneself. it is indeed a frightening realization when a whole generation or two knows how to deal with a nuclear fallout but are at their wit's end on how to spend time with oneself. ironically, however, it has international journal of social psychiatry 66 (6) stranded them with their families (those who are unaffected by the illness) and are expected to strengthen the bonds of relationship. but, as mentioned before, the 'virtual connectedness' provided by social media has probably made us forget what proximity in relationships feel like. this can be a double-edged sword, that can either mend or strain relations, based on the pre-existing intimacy and communication patterns. it feels like a monumental task to stay stuck with yourself and your loved ones, while the pandemic looms large over the world. loneliness is often described as the state of being without any company or in isolation from the community or society. it is considered to be a dark and miserable feeling, a risk factor for many mental disorders like depression, anxiety, adjustment disorder, chronic stress, insomnia or even late-life dementia (wilson et al., 2007) . loneliness is common in the old-age group, leading to increased depression rates and suicide. it has been well-documented that long periods of isolation in custodial care or quarantine for illness has detrimental effects on mental well-being (stickley & koyanagi, 2016) . loneliness is proposed to break this essential construct and disrupt social integration, leading to increase in isolation. this is a vicious cycle which makes the lonely individual more segregated into his own 'constricted' space. loneliness is also one of the prime indicators of social well-being (cacioppo & patrick, 2008) . most people cringe at the idea of this social isolation. they will do anything to keep themselves preoccupied or distracted, from acts of outrageous indulgences to preposterous shows of vanity and depravation. besides, loneliness has also shown to be an independent risk factor for sensory loss, connective tissue and autoimmune disorders, cardio-vascular disorders and obesity. if this self-isolation and lockdown is prolonged, it is likely that chronic loneliness will decrease physical activity leading to increased risk of frailty and fractures (mushtaq et al., 2014) . this covid-19 pandemic seems to have brought our frenzied speed of modern society to a grinding halt and has literally crushed the wings of unlimited social interaction. under these social restrictions, individuals are forced to reconcile with this terrifying reality of isolation which can contribute to domestic inter-personal violence and boredom. similar trends of increase in isolation and loneliness have been noticed among emergency workers and quarantined population in wuhan, china. this has increased the prevalence of depression, anxiety, post-traumatic stress disorders and insomnia in the population. it also contributes to fatigue and decreases performance in health-care workers (torales et al., 2020) . but neither life nor the society had probably readied us for this task. the concept of boredom and loneliness leads to anger, frustration on the authorities and can lead for many to defy the quarantine restrictions, which can cause dire public health consequences. emotional unpreparedness for such biological disasters have detrimental effects, as this situation is unprecedented in all measures. it also makes us take a step back and question: is social distancing only for a specific social class; as millions of migrant labourers, homeless individuals and daily wage workers stay stranded in their workplaces, railway and bus stations and factories with overcrowding and poor hygiene. when basic amenities of life are scarce, it is far-fetched myth to think about distancing or hand sanitization according to the prescribed standards (the print, 2020; www.theprint.in). isolation or loneliness for them is thus different. it is being away from their origins, their families and being deprived of basic human rights and self-dignity. segregation from selfidentity can also form the basis for loneliness, just that it reflects differently in different socio-economic strata (valkenburg & peter, 2008) . it is again ironic, how the construct of loneliness varies based on the social strata giving rise to dimensional psycho-social needs. first step in this journey is to transform this devious loneliness to solitude. loneliness, which on one hand is an emotion filled with terror and desolation, solitude, its cousin is full of peace and tranquillity. the primal answer to loneliness has always been in our roots: the ability to be at peace with oneself. this however has been a habit long lost by the humanity in the trends of globalization. many great works of art, philosophy, literature have emerged from solitude. this comes with enjoying one's existence and ability to cherish the bonds with others. this might be a good time to engage in long-forgotten hobbies, neglected passions and unfulfilled dreams. improving proximal bonds with family and loved ones is another opportunity. distancing from social media will be beneficial, as during times of pandemic it can contribute to 'infodemic' causing information overload. covid-19 by all means is a 'digital epidemic' where the related statistics spread faster than the virus itself. only relevant and updated information about the situation outside helps relieve anxiety during isolation (hyvärinen & vos, 2016) . it is vital that the virus does not invade us 'psychologically' which can last much beyond the resolution of this pandemic. as mental health professionals, we need to be sensitive to the personalized needs of those in quarantine and cater to them. their personal and psychological needs are to be adhered to. digital communication needs to be maintained with their loved ones. as mentioned, before social connectedness matters. similar protocols in china during the first stage of outbreak had shown to improve quality of lives of those isolated (duan & zhu, 2020) . need for community-based and brief psycho-social interventions have also been stressed upon by torales et al. (2020) in their recent article, acknowledging the chronic mental health impact of the ongoing pandemic situation. furthermore, research has shown that as simple as weekly telephonic sessions can help reduce anxiety at the time of pandemics. these sessions need to be brief and solutionfocused (yang et al., 2020) . social integration forms another important aspect, in which involvement of the associated people in life matters. taking care of the domestic helpers, the vendors, the security personnel, etc. or even a simple exchange of greetings with neighbors or strangers can give a feeling that 'we are all in this together'. the bonds of humanity turn even more important at such times, when the whole world shares the same threads of anxiety. similar sensitization needs to be done for the allied specialities to understand and appreciate the mental health needs of a biological disaster. the pandemic will eventually be over giving rise to two important lessons: the emotional preparedness for solitude at times of such crisis and psycho-social well-being forming the cornerstone of public health. the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. the author(s) received no financial support for the research, authorship, and/or publication of this article. debanjan banerjee https://orcid.org/0000-0001-8152-9798 loneliness: human nature and the need for social connection psychological interventions for people affected by the covid-19 epidemic communication concerning disasters and pandemics relationship between loneliness, psychiatric disorders and physical health? a review on the psychological aspects of loneliness the print responding to global infectious disease outbreaks: lessons from sars on the role of risk perception, communication and management loneliness, common mental disorders and suicidal behavior: findings from a general population survey the outbreak of covid-19 coronavirus and its impact on global mental health adolescents' identity experiments on the internet: consequences for social competence and self-concept unity loneliness and risk of alzheimer disease mental health services for older adults in china during the covid-19 outbreak key: cord-020210-k2l269la authors: shirish, anuragini; srivastava, shirish c.; shainesh, g. title: can technology be leveraged for bridging the rural-urban divide? date: 2020-03-10 journal: responsible design, implementation and use of information and communication technology doi: 10.1007/978-3-030-45002-1_25 sha: doc_id: 20210 cord_uid: k2l269la inequalities exist and persist in society in different forms and are often areas of prime concern for governments and policy makers around the globe. one such inequality that plagues societies is the rural-urban divide. several social entrepreneurs are attempting to leverage technology to bridge this divide. in our research-in-progress paper, we describe the case of an indian company, which is leveraging technology to create knowledge-based jobs for the rural indian population. the approach adopted by the company in initiating and sustaining such an effort was an inside-out approach in contrast to the usual approach of focusing only on the internal resources within the company. specifically, our research aims at abstracting the process mechanisms that enabled such an initiative. the unearthed mechanisms would inform future research on the modalities for orchestrating such an initiative. the findings would also help practitioners, especially social entrepreneurs, to think of innovative business models that would create value not only for the company but also for society as a whole. the delineated learnings would also help enthused social entrepreneurs to transplant such initiatives to other regions of the world. global wealth has risen to a new high of 361 trillion us dollars in 2019 but unfortunately, only a very small group at the top has captured most of the increase. the top 1% of the world's population accounts for nearly 45% of the total wealth, while the bottom 50% owns only 1% of the total wealth [5] . such stark inequalities exist and persist in the society in different forms (e.g. regional, racial and gender) and are often areas of prime concern for governments and policy makers around the globe. for example, the recent yellow vests protests (gilets jaunes) in france or the farmer protests in india are attributable to the growing discontentment due to the rural-urban divide [2, 3] . while governments are primarily responsible for reducing these inequalities are primarily viewed as governmental tasks, several grassroots social entrepreneurs, especially in developing countries are implementing innovative local solutions to bridge these gaps [11] . such innovative bridging solutions often involve extensive use of information and communication technologies (icts) [16] . however, the modalities and mechanisms through which these solutions are orchestrated are highly contextualized and need to be examined [1, 9] . deep theoretical abstractions emerging from an understanding of these inequality-bridging mechanisms can greatly benefit other inequality-ridden contexts and regions through the process of reverse innovation [7] . grounding our work in social resource-based view (srbv) and the literature on reverse innovation and information systems, we examine an impactful social entrepreneurship initiative in a developing country context, with a view to transplant the learnings to the required pockets in other developing and developed economies [6, 7, 12, 14, 17] . we believe that such an effort will be useful in developing impactful theories for reducing the inequalities within countries. in our study, we focus on bridging the urban-rural divide, as it is one of the areas that the governments of most countries around the world are concerned. in specific, we focus on a grassroots social entrepreneurship initiative (rather than focusing on government-sponsored initiatives) aimed at reducing the rural-urban inequalities. our study is set in the indian context, which serves as a fertile ground for many social entrepreneurship initiatives. as aforementioned, our focus will be on how the learnings/theoretical abstractions from this initiative could be translated to benefit other parts of the world. the two research questions that we intend to examine in our study are:-1. how are social entrepreneurship initiatives in developing countries conceptualized and executed to bridge the rural-urban divide? 2. what are the key enablers that facilitate delivery of such ict-enabled bridging solutions in the context of developing countries? to better appreciate the research setting and the problem proposed to be examined in our study, it would be necessary to understand the rural-urban divide in the indian context. according to the 2011 census report, 83.3% of india's population lives in rural areas. however, most economic and service benefits are accrued by the urban centers. for example, in the health care sector nearly 75% of medical dispensaries, 60% of the hospitals and 80% of doctors are located in urban areas. similarly, there are limited regular employment opportunities in rural areas leading to a large-scale migration to the urban centers creating undue pressure on the limited resources in indian cities. according to the 2017 national economic survey, 8 to 9 million people migrate for work opportunities within india annually, which is severely affecting the quality of life in urban centers. some studies have projected that by 2050, more than half of india will be living in urban areas, which will further accentuate the issues related to the quality of life in urban centers. we ground our research in the social resource-based view (srbv). so far literature has mainly used the resource based view (rbv) or natural resource based view (nrbv) approach to understand how companies can achieve economic performance or environmental performance as a competitive advantage by using their own internal resources and by deploying internal capabilities [8] . recent work by tate and bals [18] uses social entrepreneurship literature and extends the rbv and nrbv logic, which is primarily based on instrumental parameters of economic performance, to that of social performance. in summary, srbv integrates social capabilities with triple bottom line (tbl) sustainability outcomes related to social, economic and environmental impacts. tate and bals [18] , through inductive case studies, conceptualized several social strategic capabilities, social driving forces and key resources that contribute to shared tbl value creation. an srbv allows us to study social capabilities, allows us to examine complex stakeholders embedded in different domains such as those with economic, environmental, and/or social stakes. the theory also offers the possibility to link social capabilities and shared tbl value creation. thus, srbv allows us to study the social capabilities of grassroot social entrepreneurs acting as the micro-foundations for bringing about societal change. however, the propositions of srbv have not yet been tested empirically, and the process view on how the resource and capabilities integration takes place, needs further examination. because embedded innovation and social innovations are influenced by ambiguities and uncertainties in the external environment, exploring tbl value creation by social entrepreneurs is highly complex. research that demonstrates how social capabilities are orchestrated by hybrid organizations such as grassroots social entrepreneurs using srbv for alleviating social issues at the bottom of the pyramid (bop) will be a valuable contribution to academic literature as well as practice [8, 18] . we believe that actions taken at various stages of an entrepreneurship project in general and a resource-constrained social entrepreneurship project in particular are based on the ability of the entrepreneur to leverage the internal resources within the company and garner resources from outside the company (based on the emergent need) as shown by srbv. this resource orchestration exercise is a dynamic one that continuously evolves as the project unfolds. our aim is to understand this evolutionary process with a view to perhaps replicate it in other contexts. this research aims at theory building by adopting a social resource-based view (sbrv) perspective. we intend to use a qualitative case-based methodology and a process view to analyze data from an indian company (villagetechserv 1 ) (vts) to understand the social resource-based actions that the company undertook to fulfil their objective of creating jobs for the rural indian population. we will also examine how these patterns evolve over time [see 4, 13, 15] . consistent with the case study approach, we will provide an overview of some of the streams of research that will contribute to our theory building, namely, literature on social resource-based view and the role of ict for bridging societal inequalities. finally, we intend to situate each of our findings within the literature to contextualize the emergent theoretical concepts before arriving at our theoretical and practical implications. our study utilizes a mix of primary and secondary data to analyze the research problem. we have already conducted 42 interviews and have attended several presentations given by the senior management team of the vts. many of the key respondents were interviewed multiple times to clarify new facts as they emerged during the data collection process. we took detailed notes during all interviews. we also had email exchanges with officials for an in-depth understanding of the underlying processes, mechanisms, and interactions associated with their implementation process. we also visited the vts work centers at different locations in india and took detailed observational notes during the site visits, which will form part of the data for our analysis. for secondary data, we went through the organizations' activity reports, websites, published articles, internal reports, and video clips. we are using a process view to analyze the data, aimed at unearthing the patterns of their resource-based actions to understand how their implementation unfolded [4, 10] . india, traditionally has been one of the world's major it-services provider hub. however, these it service centers are primarily located in big cities such as bangalore, new delhi, hyderabad and chennai. vts was initiated in 2008 on the premise of creating knowledge-based jobs for rural indian population. the founder of vts had the idea of sourcing some of the knowledge work from the villages with a view to provide the rural population with steady incomes through meaningful employment. the mission of vts is a social one-to enskill, employ, empower and engage the rural youth. their objective is to provide sustainable employment to 100,000 rural youth by opening business process outsourcing (bpo) centers in each of the 500 rural districts of india. they particularly want to create shared value in tbl, i.e. on the economic front, the social front and the environmental front. they are a hybrid organization that focuses on integrating their resources and capabilities for creating shared values through impact souring, training, rural employment, family saving, social engagement and conserving environmental ecosystems of the local rural districts. as of 2019, they have 16 business process outsourcing (bpo) rural centers in north, south, east, west and central india. 65% of their clients are from the telecom sector and the remainder 35% comprise diverse sectors related to logistics and retail. vts is perhaps the world's largest and relatively oldest (10 years) rural it services company offering sustainable direct and indirect social value to its stakeholders since its inception. although setting a village it service center may appear to be a straightforward process, it is not a simple exercise. many of the taken for granted resources in the urban centers are unavailable in rural areas. the two primary contextual constraints, which made this venture extremely difficult, were (1) the rural areas did not have efficient internet connectivity and regular power supply, and (2) there was an absence of sufficiently trained employable workers for knowledge based it service jobs in rural areas. to tackle these challenges, vts took upon itself to arrange for the required infrastructure as well as to develop the required manpower skills for making the it-enabled service centers operational. apart from socially driven motivations, the founders of vts were confident that the trained employees would be permanent assets for the company because the jobs (or rather opportunities) had moved to their villages so there would be less attrition. job turnover or attrition is one of the major challenges faced by the it services sector in india (with attrition rates in some cities touching a high of 25%). in addition to having near zero attrition rates, the cost of wages are also much lesser in rural centers simply because the living costs in rural areas are significantly lesser than in cities. some measurable social value impacts created by vts include, providing direct employment for 5280 rural youth (in 2018). out of these 90% were internally trained after employment. 40% of employment was provided for the female youth. 5% of these beneficiary are persons with disabilities. the average family income increased by 65% from the current income level due to jobs at vts. at the societal level the rate of migration from rural area to cities in search of jobs have reduced to 55% in the villages where the initiative has been undertaken. a positive spinoff that the research team discovered in its initial interviews is that some of the villages that were initially selected by vts for starting it service centers now have permanent schools and the income levels in these villages have risen, leading to better quality of life for many people living in those villages. the journey of vts has been one of trial and error. in fact, following the philosophy of reverse innovation, vts has set up a centre in san jose, california to create employment opportunities to the underprivileged and disadvantaged youth. thus far, we see empirical evidence for propositions of the emergent theory on srbv. vts is an example of how tbl values are generated by grassroots social entrepreneurs who know how to use their social capabilities such as social innovative model, mission driven approach and stakeholder management for bridging opportunity divide in the society. social values that are generated by this initiative include providing access to food, access to decent livelihood, access to education, access to secure income, access to meaningful employment, access to equality and access to involve in community engagement. in our research, we seek to unravel these theoretical mechanisms which can perhaps be replicated by other aspiring social entrepreneurs. this allows us to understand how social entrepreneurship initiatives in developing countries can be conceptualized and executed to bridge the rural-urban divide. our study hopes to unearth specific key enablers for facilitating the delivery of ict-enabled bridging solutions in the context of developing countries. beyond contextualization: using context theories to narrow the macro-micro gap in management research farmers' protests brings urban rural divide to the fore rural france in revolt an exploration into the process requirements elicitation: a grounded approach global wealth report reverse innovation: create far from home, win everywhere reverse innovation, emerging markets, and global strategy a natural-resource-based view of the firm: fifteen years after the essential impact of context on organizational behavior explaining information system change: a punctuated sociotechnical change model institutional voids as spaces of opportunity social entrepreneurship research: past achievements and future promises exploring value cocreation in relationships between an erp vendor and its partners: a revelatory case study development as capability expansion fighting against windmills: strategic information systems and organizational deep structures what is your global innovation strategy? it prof bridging the service divide through digitally enabled service innovations: evidence from indian healthcare service providers achieving shared triple bottom line (tbl) value creation: toward a social resource-based view (srbv) of the firm key: cord-275622-v5o4uayk authors: bjursell, cecilia title: the covid-19 pandemic as disjuncture: lifelong learning in a context of fear date: 2020-10-30 journal: int rev educ doi: 10.1007/s11159-020-09863-w sha: doc_id: 275622 cord_uid: v5o4uayk the covid-19 pandemic has caused a number of fundamental changes in different societies, and can therefore be understood as creating “disjuncture” in our lives. disjuncture is a concept proposed by adult educator peter jarvis to describe the phenomenon of what happens when an individual is confronted with an experience that conflicts with her/his previous understanding of the world. faced with a situation that creates disjuncture, the person is compelled to find new knowledge and new ways of doing things; i.e., he/she must embark on a learning process. the recent introduction of social distancing as a measure aiming to reduce transmission of the covid-19 virus has dramatically changed people’s behaviour, but this measure does not only have preventive and desirable effects. there is an associated risk for increased isolation among the older generations of the population, as well as a change in intergenerational relationships. although the current pandemic (as disjuncture) may potentially initiate major learning processes in the human collective, we should remember that disjuncture is often theorised within neutral, or even positive, contexts. in a context of fear, however, learning may result in a narrowing of mindsets and a rejection of collective efforts and solidarity between generations. in terms of the types of learning triggered by the current pandemic (as disjuncture), one problem is non-reflective learning, which primarily occurs on a behavioural level. we need to recognise this and engage in reflective learning if we are to make the choices that will lead to a society that is worth living in for all generations. our goal must be to learn to be a person in a post-pandemic society. the covid-19 pandemic has created a major "disjuncture" in our existence. within a short period of time, our lives have been turned upside down, in a way no one could have imagined. on 11 march 2020, the world health organization (who) officially classified the spread of a novel coronavirus, sars-cov-2, as a pandemic, 1 prompting many communities to act by closing their borders and imposing curfews on the movement of people. to reduce the spread of infection, national governments recommended that their citizens should engage in "social distancing". social distancing means keeping a physical distance (in the current pandemic, the stipulated space varies between 1.5 to 2 metres) from other human beings. 2 the term refers to measures that people can/should take to reduce personal proximity, an integral part of their social interaction with other people, and thus help reduce the transmission of an infectious disease such as the coronavirus. these directives to change what was hitherto entirely "normal" behaviour among human beings has caused "disjuncture" in people's lives; namely, a disharmony between the world as we knew it and the state of the world during the current pandemic. disjuncture is a concept proposed by adult educator peter jarvis to describe the phenomenon of what happens when an individual is confronted with an experience that conflicts with her/his previous understanding of the world. our lives comprise a series of experiences made up in such a way that our biography appears as continuous experience added to by each unique episode of learning which we call an experience. but each of these unique episodes begins with the same type of question […] : why has this occurred? how do i do this? what does this mean? and so on. it can be cognitive, emotional or a combination of the two: it is this that i call disjuncture (jarvis 2012a, p. 76 ). according to lifelong learning 3 theory, disjuncture triggers learning, but what is it that we learn during a pandemic? italian philosopher giorgio agamben argues that panic has paralysed his country (italy) and that people have sacrifice [d] practically everything -the normal conditions of life, social relationships, work, even friendships, affections, and religious and political convictions -to the danger of getting sick (agamben 2020) . fear and panic can have serious long-term outcomes for individuals and society, including the worsening of existing problems, such as isolation among the older generations of the population and the gap between generations. it therefore seems likely that an examination of the changes that occur during a pandemic will be key to understanding the learning that takes place in a context of fear. as this article is being written during an ongoing pandemic, readers should bear in mind that the situation may change dramatically and we do not know how this might impact people's learning at different points in time. the discussion in this paper is intended to inform and stimulate debate and further research. the purpose of this article is to revisit the concept of disjuncture (jarvis 2012a) and to invoke lifelong learning theories because they have the potential to: (1) allow us to conceptualise the current pandemic as a learning process; (2) connect the 3 the holistic concept of lifelong learning is discussed in more detail in the next section. briefly, in practical terms, it comprises "cradle-to-grave" learning throughout a person's life and includes formal, nonformal and informal learning. formal learning occurs in education or training institutions (e.g. schools), non-formal learning (e.g. swimming classes, amateur music etc.) takes place outside the formal system; and informal learning is experience-based and often accidental, occurring e.g. at home, during a leisure activity or in the workplace. a doctoral student at the university of chicago who investigated this found the earliest mention in english in 1831, but the first use of its current meaning in 2004 in the context of airborne illness and sars (waxman 2020) . footnote 2 (continued) practice of social distancing to ongoing, long-term changes in society; and (3) highlight certain risks and possibilities which need to be addressed if our goal is to support people's engagement in the kind of learning that is directed towards achieving a better post-pandemic life and a better post-pandemic society. when lifelong learning became a central concept in global policy half a century ago, its proponents highlighted that: (1) learning is not only about child development, but continues throughout adult life; and (2) learning takes place in every context, not just within the confines of the school classroom. one of the seminal reports marking the establishment of lifelong learning as a concept was learning to be: the world of education today and tomorrow (faure et al. 1972) . 4 often referred to as "the faure report", it emphasised a humanist, holistic vision of education that was applicable to all members of society. since the release of this report, lifelong learning policies have addressed social problems on a global scale in conjunction with the emergence of key institutions in this field. moosung lee and tom friedrich (2011) discuss differences in underlying ideology between the united nations educational, scientific and cultural organization (unesco) on the one hand, and the organisation for economic cooperation and development (oecd), the european union (eu), and the world bank on the other. while unesco has had its own unique impact on international discussions, contemporary ideologies with respect to lifelong learning advanced by the other three organisations have been dominated by a neoliberal capitalist perspective (ibid.). this is unfortunate, because unesco's enlightenment tradition (which is based on rationalism, progress, freedom, emancipation, and the concept of human beings as masters of their own destiny) is at odds with, and is actually undermined by, the utilitarian view of education that comes with adopting a neoliberal capitalist perspective (elfert 2015) . this conflict is of particular interest during a pandemic such as the one we are currently experiencing, because many people will lose or have already lost their jobs, which is likely to strengthen the utilitarian view of education even more. maren elfert (ibid.) argues that the adoption of such an instrumental approach presents an obstacle to placing education in a wider societal context for those who aim to solve social problems on a global scale. instead of reducing the process of education to the mere creation of productive economic units, the purpose of education should be to offer learning opportunities which foster the development of people who think critically, but not cynically, which then enables them to act as responsible citizens (stanistreet 2020) . one effort in particular that should be made to effectively address social problems, namely, the promotion of an intergenerational society, is discussed later in this article. the concept of lifelong learning may lead to some confusion because in addition to being a core policy concept, it can also be invoked to refer both to an individual's spectrum of learning and to institutions which offer educational opportunities (jarvis 2004 (jarvis , 2014 . a singular focus on institutions which offer formal education is too narrow, because learning also takes place in professional settings, work environments, and in groups and gatherings of various kinds. it is therefore impossible to create a fully institutionalised system of lifelong learning; irrespective of where learning takes place, such learning must be recognised as part of the person's total learning. a shift in terminology from education to learning entails a shift in meaning and focus. it might be said that education gives the active part to the teacher, while learning represents the active learner's perspective. we thus observe a shift in focus from formal education to how an individual creates and transforms experiences into knowledge, skills, attitudes and values at every age, throughout this individual's life. another drawback that can be associated with an instrumental/utilitarian approach to education is that it excludes the possibility of adopting a holistic understanding of human learning. if one is to understand learning as something which grows out of the experience of living, being and becoming, 5 this demands that one understands that the self is shaped through thinking and doing over time, and is embedded in overlapping and contradictory life-worlds 6 (jarvis 2009 (jarvis , 2012a . as a philosophy of education, lifelong learning awards the individual's learning a central position and highlights the fact that this must be the starting point if we are to properly understand what learning is about. learning must be understood in its entirety and as the result of interaction between the individual and the individual's environment. it is important to note that it is the learner who enters situations that provide experiences by which learning takes place (jarvis 2007 ). jarvis emphasises the point that, by starting with the learner (and not with what is being learned) we are led to the understanding that the learner's biography is changed as a result of learning, irrespective of the person's age. when experience is processed, it is integrated into the person's being. this entails that a person experiences being and becoming in a lifelong process. jarvis opposes the dualistic view of the division between body and soul because, he claims, it is impossible to separate one from the other (jarvis 2009 ). to ground learning in the framework of being, rather than in a framework of having, entails that one accepts fluidity and dynamic movement as one strives to grasp one's manner of existing (su 2011) . to think of learning as the mere acquisition of knowledge is, therefore, insufficient. learning takes place by means of lived relationships in a cultural context, as instantiated by a particular society. each individual person's process of shaping their identity is key to learning, because lifelong learning involves the continued development of a new understanding of "the self", something which also entails a re-negotiation of one's identity. during the current pandemic, many activities have moved online, including, for example, adult education. even though teaching as such takes place in much the same manner as previously, this move to a digital environment entails a great deal of change and demands new competencies from teachers. these changes are so substantial that they give rise to questions concerning the individual's perception of their self and their professional performance as teachers. this shift from the classroom to a digital environment via the internet is not just a practical issue; it also entails a shift from one state of existence to another. in a similar manner, the implementation of a lockdown and social distancing creates a state of existence which prompts people to reflect on their selves and their situation. this can influence their perceptions of themselves and others. a pandemic such as the one we are currently experiencing influences individual people's lives as well as the behaviour displayed by society as a whole. according to the terminology used in the context of lifelong learning as a philosophy of education, we thus conclude that a pandemic causes a disjuncture. disjuncture has meanwhile become an established concept in lifelong learning which is used to explain a condition that enables learning. peter jarvis (2012b) proposed that learning in our everyday lives is often triggered by a gap between our expectations and an experience, i.e. disjuncture. disjuncture refers to a state of disequilibrium, where we feel uneasy, out of our depth. in response to this feeling, we seek change -in order to achieve equilibrium and stability again. the process of striving towards a new state of equilibrium triggers the learning that takes place: indeed, this state of disequilibrium is a fundamental cause of learning that is inextricably intertwined with being-in-the-world: it is a part of the human condition (jarvis 2016 (jarvis [2001 , p. 30). disjuncture, the gap between what we know and what we experience, provokes within us our initiative to understand and deal with particular situations, so that we can return to a harmonious state (jarvis 2012b), albeit a new one. in other words, the need to learn is a fundamental need. as mentioned above, our learning takes place in interaction with our physical and social surroundings. learning can be said to be the bridge that links the self to the world. when disjuncture occurs, a person may perceive a sense of detachment from the former self, because it no longer fits the new situation. learning is the activity that enables a person to deal with disharmony and involves the movement from one state of being to another. this transition from one state to another requires that learning reformats a person's previous knowledge and experience in relation to the new experience in a manner that could not be understood (by the individual) in terms of previously existing frameworks. eventually, the individual will initiate a concluding phase of the learning process when new knowledge is incorporated into her/his state of being and new frameworks emerge. by means of the process thus described, we say that the individual has learned something. this could also be regarded as the end of the learning process initiated by the disjuncture. however, it is in fact also part of the continuous flow of learning that takes place throughout a person's life and thus sets a new direction for future learning. in his book on learning in later life, peter jarvis notes that it is recognized here that more than ever before in the history of humankind we have the opportunity to create our own biography through the choices that we make and we recognize that learning is the force through which our biographies develop and expand (jarvis 2016 (jarvis [2001 , p. 45). being (and learning) always occurs in relation to a social situation. jarvis states that being is driven by the moral imperative about achieving potential as human beings for the community in which we live (jarvis 2012b) . engagement in the social world cannot be mastered by instinct. instead, it has to be mastered by learning if we are to obtain the knowledge that is needed to cope with living in the world. a pandemic such as the one we are currently experiencing presents a new social situation, and we need the process of learning to deal with the situation. however, there is also a risk that learning will not take place. with respect to an analysis of the effects of a pandemic as disjuncture, a typology of learning and non-learning is, therefore, of some help. the analysis i present below is guided by three categories of responses to new experiences, namely: (1) non-learning; (2) nonreflective learning; and (3) reflective learning (jarvis 2016 (jarvis [2001 ). within each category, there are three types of learning or non-learning (table 1) . first, the three types of non-learning are presumption, non-consideration and rejection. the three different types of non-learning all refer to the fact that people do not always learn from their experiences. "presumption" is a typical response to an experience that is familiar to the individual and the individual knows what to do, and therefore, there is no need for change. non-learning can also occur when a person experiences something that could be a potential learning experience, but either because they do not understand the situation or they are not conscious of the situation ("non-consideration") learning fails to take place. in addition, non-learning may be the case in situations where the person is aware of the potential for learning but they reject this possibility (hence the label "rejection"). the three types of non-reflective learning include preconscious learning, skills learning and memorisation. "preconscious learning" takes place when an individual monitors their actions on a low level of consciousness, such as when driving a car. "skills learning" occurs when skills are acquired in action through imitation. "memorisation" is the process of verbal imitation, for example, when a person memorises the words of the instructor so as to be able to reproduce them at a later time. nonreflective learning represents processes associated with social reproduction. these processes are commonly on the level of bodily experience, in contrast to the level of communicative interaction. lastly, the three types of reflective learning are contemplation, reflective skills learning and experimental learning. "contemplation" consists of focused thinking about an experience as one reaches a conclusion about the experience. "reflective skills learning" involves learning a skill whilst simultaneously learning the concepts that undergird the practice that one is engaged in, thus providing one with an understanding of why a skill should be performed in a certain way. "experimental learning" occurs when theory is tried out in practice, and leads to new practical knowledge for the individuals' everyday life. it should be noted that the non-reflective and reflective forms of learning can lead to either conformity or to change and innovation. furthermore, as stated above, individuals learn in relation to a social situation, and, as argued in this article, the introduction of social distancing changes the character of our social situation. lifelong learning is, as explained above, embedded in a cultural context. when a pandemic such as the one we are currently experiencing causes disjuncture, people find themselves in a situation where a major learning process is initiated. the point of interest in this article is the introduction of regulations for social distancing and how these regulations have already affected relationships as well as their longerterm effect. soon after the outbreak of the covid-19 pandemic, social distancing 7 was introduced in several countries as a general code of conduct to maintain a physical distance between oneself and others. in addition, people who are over the age of 70 have been identified as an especially "vulnerable group" who should stay at home and avoid social contact, even within the family. thus, the practice of social distancing has had, and continues to have, an impact particularly on people over the age of 70, but it also impacts other age groups in society. this is a situation where the elders of society are perceived as constituting a problem to be dealt with by means of special measures. potentially, this may, for example, contribute to strengthening ageism. 8 in fact, categorising people by the label of being "over the age of 70" in these national directives may in itself be a kind of ageism, since age is the only variable at play. certain governmental actions, such as the introduction of social distancing, will inevitably cause re-actions in society. these re-actions may be understood as expressions of learning processes, and they demonstrate that humans develop in ways which are often beneficial for the community, such as people's engagement in volunteering and performing acts of solidarity. however, certain other re-actions also reveal prejudices and negative perceptions which are sometimes associated with age. one aspect that we cannot review yet (since the pandemic is still ongoing at the time of writing), is how we will live together after the pandemic is over. nevertheless, we do know that our supposedly established models of coexistence have been challenged; not least by the phenomenon of social distancing. it is highly probable that these new social rules will have a long-term impact on interaction patterns and on the level of trust in society, even after the current pandemic is over. trust is a central concept in understanding how social ties serve as a resource in society. john field, professor emeritus in education at the university of stirling, has published a number of thoughts on the social effects of the lockdown on his blog (field 2020a (field , 2020b . he reports that studies of social capital, 9 including preliminary results from a number of covid-19 studies, show that the higher the level of social capital that is enjoyed within a society, the lower the rate of transmission of infection (field 2020a ). field also mentions that when the variable of "income" is included in the analysis, it has been observed that people with a high income or high-speed internet access are more likely to follow directives about staying at home. a combination of high income and high-speed internet could thus explain a high propensity for people to stay at home (chiou and tucker 2020) . "social capital" should, however, not be confused with "social connectedness"; i.e., the structure and interaction patterns of social networks. the structure of social networks can also be used to understand the spread of disease (kuchler et al. 2020 ). the primary results of these studies show that the disease is spread within families and between friends, i.e. among people who know each other well and trust each other. while this observation lends credence to the idea of keeping a physical distance, it is expected that in the longer term, this will entail a number of deep-rooted changes in the ways that social bonds are made, reinforced, and broken (field 2020b) . one direct, concrete effect of the kind of social distancing currently stipulated within our societies is isolation and loneliness. in several countries worldwide, isolation and loneliness already constituted a problem among the older generations in society before the current pandemic. socio-demographic changes, the crisis of the welfare state, and breakdowns in social norms have been identified as causing separation between generations (donati 2015) . from research in the domain of healthcare, we know that loneliness has a negative impact on a person's health. examples from the current situation caused by the implementation of social distancing include the presence of negative emotions. besides anger, covid-19 "is associated with anxiety, depression, distress, sleep disturbances and suicidality" (sher 2020, p. 124) . these increased in china during the initial covid-19 epidemic, while positive emotions and life satisfaction decreased (ibid.). in the care of older adults, profound isolation has become the norm. the extreme loneliness felt by many older people raises concern, because it is a known risk factor for poor health outcomes. however, some degree of social connectedness and information sharing between care facilities and families can be maintained with the support of digital tools (edelman et al. 2020; eghtesadi 2020) . in addition to global and national initiatives that are aimed at preventing the spread of covid-19, it is suggested in the literature that agencies setting up prevention regimes, such as who and national health authorities, also need to address the issue of social isolation so as to prevent the health hazard effects that are associated with social isolation. supporting intergenerational relationships is one way in which societies can deal with issues of loneliness and promote well-being. matthew kaplan and mariano sánchez (2014, p. 370) refer to "seven imperatives to justify our interest" in intergenerational issues: (1) demographic changes; (2) mutual support and reciprocal care in the family and in the community; (3) active aging; (4) improving social cohesion; (5) making communities more "livable"; (6) ensuring cultural continuity; and (7) strengthening our relational nature (ibid., pp. 370-375) . a loss of intergenerational contextual continuity is not only a problem for older generations; it also has consequences for the life courses of young people (donati 2015) . the perspective with respect to the concept of "generation" that is usually found in the field of intergenerational relationships is different from "generation" as a social category, which is comparable to the notion of "social class" or "cohort". by employing the concept in the context of generational theory, we draw attention to the dynamics of socialisation and generativity 10 that exist in the relationships between members of different generations (lüscher et al. 2017) . the point of using the term intergenerational is found in its prefix, inter -which highlights that which is between -i.e., the relationship (sánchez and díaz 2021) . however, the social advantages that can be built by strengthening bonds between generations are currently being put at risk because the measures adopted by society in response to the pandemic affect interpersonal contacts and restrict the spaces where social encounters can take place. in response to this situation, a group of international scholars and practitioners have joined forces in support of a manifesto entitled intergenerationality adds up lives (barragán et al. 2020) , which was published on 29 april 2020. in view of the fact that social distancing can have serious negative effects on people and society, the next section provides an analysis of the covid-19 pandemic as disjuncture and what this entails in terms of learning. to frame a pandemic as disjuncture, and thereby as a learning process, is one way of approaching an understanding of what it is that is going on, and how a pandemic might change us and society in a post-pandemic era (in the present case, the covid-19 pandemic). the typology of "non-learning", "non-reflective learning", and "reflective learning" (jarvis 2016 (jarvis [2001 ) described above (and summarised in table 1 ) will inform the analysis that follows with respect to becoming, during and after a pandemic more generally, but also with respect to the covid-19 pandemic specifically. as with all such typologies, it is important to acknowledge the possibility of varying overlaps between the types, and although this typology may be a bit schematic, it is a useful way of structuring an analysis. with respect to the first type, "non-learning", it would be difficult to imagine someone who is not aware of the current global pandemic, but although a person whose reaction to the experience is non-learning is likely to recognise a disjuncture, they may still reject the learning potential of the situation and merely wait for things to get back to normal. "normal" is attractive because normal circumstances correspond to our previous experiences where we knew what to do and how to act. nonlearning is, therefore, one highly probable outcome after the current pandemic. with regard to intergenerational relationships, non-learning entails that we will return to behaving in the same way as we did before the current pandemic. the second type of learning, "non-reflective learning", can be said to represent the learning that does not involve conscious thought and is not mediated by means of language. instead, it refers to learning that takes place at a preconscious 11 and bodily level. it may transpire that this is the most interesting type of learning occurring during the covid-19 pandemic. consequently, it is discussed in more detail below. "reflective learning" refers to situations where people consciously think about something and make an intentional effort try to understand why things are the way they are. this includes drawing on knowledge which is relevant to how a situation might be mastered and reaching conclusions which, in turn, become part of a new frame of reference. for example, a recurring reflective practice which has emerged in my own network in response to the current pandemic generates insight into how we can use digital tools in meetings with colleagues around the world. we have learned to provide online courses, conduct academic theses defences and convene board meetings, and these online activities have worked surprisingly well. there are many people who now understand the potential of combining online and faceto-face meetings to save time reduce travelling, and many of us want to see online options as a permanent alternative to "traditional" ways of working, in a post-pandemic society. the same conclusions have been reached in many private settings, where digital tools now connect family members separated by social distancing. but while it is easy to recognise the existence of learning on the level of functionality (for example, how to use digital tools), what is less frequently discussed is learning that concerns the understanding of cultural context and the self. furthermore, issues such as how the current situation might change our view of age and/ or of social interaction also remain a topic that has, so far, been neglected. in fact, this area of human experience might primarily be subject to examination on the nonreflective level, as discussed below. returning to "non-reflective learning", it is interesting to note that the covid-19 pandemic and the recommendations and directives that have been issued with respect to social distancing have already changed the way in which we behave. when people over 70 years of age self-isolate at home, other people have to go food shopping for them. thus, their children or grandchildren may only meet them in the carpark or outside the house when they hand over the shopping bags. there are a number of neighbourhood volunteer groups who have organised themselves via the internet who are willing to help people who do not have a "social safety net" within their family to fall back on in the current situation. numerous businesses have adapted their procedures and offer new types of services which are suited to times when social distancing is being practised, such as delivery of groceries and special hours for older people in shops, or online healthcare. in many instances, people have helped other people out and have shown a willingness to care for others. we thus note that these new behaviours and services which emerge during a pandemic constitute examples of learning where people develop in a positive way. at the same time, however, there exists a great deal of concern and even fear in society. this fear is also a driving force which may influence how individuals, companies and society behave and what they concern themselves with. on the one hand, the current pandemic has contributed to supporting relationships between the generations and between people in general, as demonstrated, for example, by volunteer services and acts of solidarity. on the other hand, however, different interests have been pitted against each other, for example by putting the economy in competition with public health and the protection of people from the virus. these tensions between competing interests create fear, and it is important that we acknowledge that fear is a negative driving force to be reckoned with in our efforts to direct events and developments associated with the current pandemic in a constructive manner. fear is an emotion which emerges when one's environment or some specific object is apprehended as a threat. this emotion may arise in response to an actual or an imagined threat. if the threat is real, our instinctive fear may well assist us in behaving in a manner which will allow us to avoid a risk or move ourselves away from a dangerous situation. unfortunately, however, fear itself can give rise to dangerous situations, for example, when people arm themselves with weapons out of fear of attack, but the weapon itself then creates unsafe situations. fear can also give rise to conflict, be a driving force for political change, and even influence what and how people learn. there are a large number of things to be fearful of during a pandemic, which also give rise to concern for the future. for example, the fact that we live in a globalised society may well create the feeling that we are all "citizens or the world" and that we have a shared responsibility to help each other. however, fear may cause some people to view others as a threat to their well-being. if we become bogged down with fear, we run the risk of entering a downward spiral of behaviour that puts our future development in jeopardy. the emotion of fear is a natural emotion, and sometimes a necessary one. fear is a driving force which can be exploited in different ways. but when fear gives rise to a persistent concern which dominates how we live our lives, then it is perhaps time to take a step back and ponder the consequences. there is a risk that the outcomes of the learning that takes place during a pandemic, in a context of fear, are not behaviours and ideas that contribute to the improvement of individuals and society. instead, such learning may cause isolation and loneliness, and lead to the "dehumanisation" of communities. in their manifesto, ángel barragán and colleagues (2020) warn that "preventive" attitudes regarding limiting contact between people of different ages, and especially between the young and the elderly, may reshape our social bonds and reduce inter-age relationships during the current pandemic and in the future. they argue that society needs to adapt existing policies that promote intergenerational contact to include new modes of communication and expand the range of opportunities where people of different ages can come into contact with each other. the intergenerational perspective proposed in the manifesto argues for the implementation of a new social model that integrates visions of people of all ages, and promotes the establishment of meeting spaces where people can interact with each other. in practical terms, this can be done by designing public services and community spaces that actually encourage interaction across generations. this may serve as a fruitful model for "learning to be a person" in a post-covid-19 society worth living in. if we perceive the current pandemic as disjuncture, we are confronted with a disconnect between the world as we knew it and the world as it is. the disjuncture between an individual's experience and a situation, which cannot be understood based on this experience, is the beginning of a learning process. in other words, the current pandemic does not only cause change, a transfer from one state to another, but is in effect a disjuncture that triggers learning, which entails a reshaping of the individual's frame of reference. the individual who faces a crisis and survives it will not be the exact same individual that s/he was before the crisis. this learning, as peter jarvis points out (jarvis 2009 ), lies at the heart of the processes through which we develop our own humanity. notwithstanding this observation, in certain lifelong learning theories, it is assumed that the individual will strive to become his or her best self. however, in the discussion presented above, questions have been raised regarding whether nonreflective learning can result in outcomes that are not conducive to the benefit of the individual or society. one view is to regard a pandemic as a crisis that leads to feelings of fear, prompting people to act on this fear without thinking of the (shortterm or long-term) consequences of their behaviour. the other view is to regard a pandemic as an opportunity to develop our own humanity and engage in constructive patterns of behaviour. to ensure that the outcome of the learning process we are currently engaged in is a positive one, we should engage with ideas about the world as we would like it to be. lifelong learning is based on a view that includes the concept of "unfolding potential", and is based on a fluid co-existence between being and becoming. learning is concerned with where we are and where we are going. the covid-19 pandemic has created a disjuncture which holds the potential to initiate major learning processes in the human collective. however, the relation between age, isolation, situation and learning is complex, and future studies are needed to better understand how they affect each other. a central assumption in lifelong learning, as a philosophy of education, is that learning starts with the individual, but always takes place in relation to an environment. the argument presented in this article endorses this assumption. consequently, the community and collective are emphasised as central elements, based on the idea that we constitute each other's environments. just as we belong together in society, we also become together. the covid-19 pandemic has created a disjuncture that introduced fear and uncertainty in this process of becoming. one dilemma i have addressed in this article is the introduction of social distancing as a protective measure. while measures which are intended to protect vulnerable groups, including the directive or recommendation to practise social distancing, make sense in terms of curbing infection rates, they may simultaneously increase the isolation experienced by members of older generations before the outbreak of the pandemic. it is important to remember that for this group, isolation was already a serious problem before the outbreak of the current pandemic. the other, related, dilemma is that there is also a risk that non-reflective learning takes place, the potential outcome of which is the strengthening or normalisation of a disconnection between generations. by verbalising this risk, and by consciously moving from non-reflective learning to reflective learning, we can identify and understand patterns of what takes place in a society which is subject to a pandemic. this is an important task, because, although lifelong learning theories tend to assume that all learning is good learning, the outcomes of learning during a pandemic may well result in the construction of a society that we do not want to live in. based on this insight, it is up to each person to ask themselves: how do we make the choices that will lead to a world worth living in, for all generations? funding open access funding provided by jönköping university. open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. translated into english by adam kotsko. itself.blog [blog post intergenerationality adds up lives. manifesto marking 29 the forms of capital social distancing, internet access and inequality report to unesco of the international commission on education for the twenty-first century 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public health date: 2014-10-10 journal: the new public health doi: 10.1016/b978-0-12-415766-8.00002-1 sha: doc_id: 303165 cord_uid: ikepr2p2 ancient societies recognized the needs of sanitation, food safety, workers’ health, and medical care to protect against disease and to promote well-being and civic prosperity. new energies and knowledge since the eighteenth century produced landmark discoveries such as prevention of scurvy and vaccination against smallpox. the biological germ theory and competing miasma theory each proved effective in sanitation, and immunization in control of infectious diseases. non-communicable diseases as the leading causes of mortality have responded to innovative preventive care of health risk factors, smoking, hypertension, obesity, physical inactivity, unhealthful diets, and diabetes mellitus. health promotion proved effective to modern public health in tackling disease origins, individual behavior, and social and economic conditions. the global burden of infectious and non-communicable diseases, aging and chronic illness faces rising costs and still inadequate prevention. the evolution of concepts of public health will have to address these new challenges of population health. the development of public health from its ancient and recent roots, especially in the past several centuries, is a continuing process, with evolutionary and sometimes dramatic leaps forward, and important continuing and new challenges for personal and population health and well-being. everything in the new public health is about preventing avoidable disease, injuries, disabilities, and death while promoting and maximizing a healthy environment and optimal conditions for current and future generations. thus, the new public health addresses overall health policy, resource allocation, as well as the organization, management, and provision of medical care and of health systems in general within a framework of overall social policy and in a community, state, national, transnational, and global context. the study of history (see chapter 1) helps us to understand the process of change, to define where we came from and where we are going. it is vital to recognize and understand change in order to deal with radical transformations in direction that occur as a result of changing demography and epidemiology, new science, evolving best practices in public health and clinical medicine, and above all inequalities in health resulting from societal system failures and social and economic factors. health needs will continue to develop in the context of environmental, demographic and societal adjustments, with knowledge gained from social and physical sciences, practice, and economics. for the coming generations, this is about not only the quality of life, but the survival of society itself. over the past century there have been many definitions of public health and health for all. mostly they represent visions and ideals of societal and global aspirations. this chapter examines the very base of the new public health, which encompasses the classic issues of public health with recognition of the advances made in health promotion and the management of health care systems as integral components of societal efforts to improve the health of populations and of individuals. what follows in succeeding chapters will address the major concepts leading to modern and comprehensive elements of public health. inevitably, concepts of public health continue to evolve and to develop both as a philosophy and as a structured discipline. as a professional field, public health requires specialists trained with knowledge and appreciation of its evolution, scientific advances, concepts, and best practices, old and modern. it demands sophisticated professional and managerial skills, the ability to address a problem, reasoning to define the issues, and to advocate, initiate, develop, and implement new and revised programs. it calls for profoundly humanistic values and a sense of responsibility towards protecting and improving the health of communities and every individual. in the twenty-first century, this set of values was well expressed in the human development index agreed to by 160 nations (box 2.1). public health is a multidimensional field and therefore multidisciplinary in its workforce and organizational needs. it is based on scientific advances and application of best practices as they evolve, and includes many concepts, including holistic health, first established in ancient times. the discussion will return to the diversity of public health throughout this chapter and book many times. in previous centuries, public health was seen primarily as a discipline which studies and implements measures for control of communicable diseases, primarily by sanitation and vaccination. the sanitary revolution, which preceded the development of modern bacteriology, made an enormous contribution to improved health, but many other societal factors including improved nutrition, education, and housing were no less important for population health. maternal and child health, occupational health, and many other aspects of a growing public health network of activities played important roles, as have the physical and social environment and personal habits of living in determining health status. in recent decades recognition of the importance of women's health and health inequalities associated with many high-risk groups in the population have seen both successes and failures in addressing their challenges. male health issues have received less attention, apart from issues associated with specific diseases, or those of healthy military personnel. the scope of public health has changed along with growth of the medical, social, and public health sciences, public expectations, and practical experience. taken together, these have all contributed to changes in the concepts and causes of disease. health systems that fail to adjust to changes in fundamental concepts of public health suffer from immense inequity and burdens of preventable disease, disability, and death. this chapter examines expanding concepts of public health, leading to the development of a new public health. public health has evolved as a multidisciplinary field that includes the use of basic and applied science, education, social sciences, economics, management, and communication skills to promote the welfare of the individual and the community. it is greater than the sum of its component elements and includes the art and politics of the funding and coordination of the wide diversity of community and individual health services. the concept of the interdependence of health in body and in mind has ancient origins. they continue to be fundamental to individuals and societies, and part of the fundamental rights of all humans to have knowledge of healthful lifestyles and to have access to those measures of good health that society alone is able to provide, such as immunization programs, food and drug safety and quality standards, environmental and occupational health, and universal access to high-quality primary and specialty medical and other vital health services. this holistic view of balance and equilibrium may be a renaissance of classical greek and biblical traditions, applied with the broad new knowledge and experience of public health and medical care of the nineteenth, twentieth, and the early years of the twenty-first centuries as change continues to challenge our capacity to adapt. the competing nineteenth-century germ and miasma theories of biological and environmental causation of illness each contributed to the development of sanitation, hygiene, immunization, and understanding of the biological and social determinants of disease and health. they come together in the twenty-first century encompassed in a holistic new public health addressing individual and population health needs. medicine and public health professionals both engage in organization and in direct care services. these all necessitate an understanding of the issues that are included in the new public health, how they evolved, interact, are put together in organizations, and are financed and operated in various parts of the world in order to understand changes going on before our eyes. great success has been achieved in reducing the burden of disease with tools and concepts currently at our disposal. the idea that this is an entitlement for everyone was articulated in the health for all concept of alma-ata in 1978. the health promotion movement emerged in the 1970s and showed dramatically effective results in managing the new human immunodeficiency virus (hiv) pandemic and in tackling smoking and other risk factors for non-communicable diseases (ncds). a health in all policy concept emerged in 2006 promoting the concept that health should be a basic component of all public and private policies to achieve the full potential of public health and eliminate inequalities associated with social and economic conditions. profound changes are taking place in the world population, and public health is crucial to respond accordingly: mass migration to the cities, fewer children, extended life expectancy, and the increase in the population of older people who are subject to more chronic diseases and disabilities in a changing physical, social, and economic climate. health systems are challenged with continuing development of new medical technologies and related reforms in clinical practice, while experiencing strong influences of pharmaceuticals and the medicalization of health, with prevention and health promotion less central in priorities and resource allocation. globalization of health has many meanings: international trade, improving global communications, and economic changes with increasing flows of goods, services, and people. ecological and climate change bring droughts, hurricanes, arctic meltdown, and rising sea levels. globalization also has political effects, with water and food shortages, terrorism, and economic distress affecting billions of people. in terms of health, disease can spread from one part of the world to others, as in pandemics or in a quiet spread such as that of west nile fever moving from its original middle eastern natural habitat to the americas and europe, or severe acute respiratory syndrome (sars), which spread with lightning speed from chinese villages to metropolitan cities such as toronto, canada. it can also mean that the ncds characteristic of the industrialized countries are now recognized as the leading causes of death in low-and middle-income countries, associated with diet, activity levels, and smoking, which are themselves pandemic risk factors. the potential for global action in health can also be dramatic. the eradication of smallpox was a stunning victory for public health. the campaign to eradicate poliomyelitis is succeeding even though the end-stage is fraught with setbacks, and measles elimination has turned out to be more of a challenge than was anticipated a decade ago, with resurgence in countries thought to have it under control. global health policies have also made the achievements of public-private partnerships of great importance, particularly in vaccination and acquired immunodeficiency syndrome (aids) control programs. there have been failures as well, with very limited progress in human resources development of the public health workforce in low-income countries. the new public health is necessarily comprehensive in scope and it will continue to evolve as new technologies and scientific discoveries -biological, genetic, and sociological -reveal more methods of disease control and health promotion. it relates to or encompasses all community and individual activities directed towards improving the environment for health, reducing factors that contribute to the burden of disease, and fostering those factors that relate directly to improved health. its programs range broadly from immunization, health promotion, and child care, to food labeling and fortification, as well as to the assurance of well-managed, accessible health care services. a strong public health system should have adequate preparedness for natural and human-made disasters, as seen in the recent tsunamis, hurricanes, biological or other attacks by terrorists, wars, conflicts, and genocidal terrorism (box 2.2) . the concepts of health promotion and disease prevention are essential and fundamental elements of the new public health. parallel scientific advances in molecular biology, genetics and pharmacogenomics, imaging, information technology, computerization, biotechnology, and nanotechnology hold great promise for improving the productivity of the health care system. advances in technology with more effective and less expensive drug and vaccine development, with improved safety and effectiveness, and fewer adverse reactions, will over time greatly increase efficiency in prevention and treatment modalities. the new public health is important as a conceptual base for training and practice of public health. it links classical topics of public health with adaptation in the organization and financing of personal health services. it involves a changed paradigm of public health to incorporate new advances in political, economic, and social sciences. failure at the political level to appreciate the role of public health in disease control holds back many societies in economic and social development. at the same time, organized public health systems need to work to reduce inequities between and inside countries to ensure equal access to care. it also demands special attention through health promotion activities of all kinds at national and local societal levels to provide access for groups with special risks and needs to medical and community health care with the currently available and newly developing knowledge and technologies. the great gap between available capabilities to prevent and treat disease and actually reaching all in need is still the the mission of the nph is to maximize human health and well-being for individuals and communities, nationally and globally. the methods with which the nph works to achieve this are in keeping with recognized international best practices and scientific advances: 1. societal commitment and sustained efforts to maximize quality of life and health, economic growth with equity for all (health for all and health in all). collaboration between international, national, state, and local health authorities working with public and private sectors to promote health awareness and activities essential for population health. 3. health promotion of knowledge, attitudes, and practices, including legislation and regulation to protect, maintain, and advance individual and community health. 4. universal access to services for prevention and treatment of illness and disability, and promotion of maximum rehabilitation. 5. environmental, biological, occupational, social, and economic factors that endanger health and human life, addressing: (a) physical and mental illness, diseases and infirmity, trauma and injuries (b) local and global sanitation and environmental ecology (c) healthful nutrition and food security including availability, quality, safety, access, and affordability of food products (d) disasters, natural and human-made, including war, terrorism, and genocide (e) population groups at special risk and with specific health needs. 6. promoting links between health protection and personal health services through health policies and health systems management, recognizing economic and quality standards of medical, hospital, and other professional care in health of individuals and populations. 7. training of professional public health workforces and education of all health workers in the principles of ethical best practices of public health and health systems. 8. research and promotion of current best practices: wide application of current international best practices and standards. 9. mobilizing the best available evidence from local and international scientific and epidemiological studies and best practices recognized as contributing to the overall goal. 10. maintaining and promoting equity for individual and community rights to health with high professional and ethical standards. source of great international and internal national inequities. these inequities exist not only between developed and developing countries, but also within transition countries, mid-level developing countries, and those newly emerging with rapid economic development. the historical experience of public health will help to develop the applications of existing and new knowledge and societal commitment to social solidarity in implementation of the new discoveries for every member of the society, despite socioeconomic, ethnic, or other differences. political will and leadership in health, adequate financing, and organization systems in the health setting are crucial to furthering health as an objective with defined targets, supported by well-trained staff for planning, management, and monitoring the population health and functioning of health systems. political leadership and professional support are both indispensable in a world of limited resources, with high public expectations and the growing possibilities of effectiveness of public health programs. well-developed information and knowledge management systems are required to provide the feedback and information needed for good management. it includes responsibilities and coordination at all levels of government. non-governmental organizations (ngos) and participation of a well-informed media and strong professional and consumer organizations also have significant roles in furthering population health. no less important are clear designations of responsibilities of the individual for his or her own health, and of the provider of care for humane, high-quality professional care. the complexities and interacting factors are suggested in figure 2 .1, with the classic host-agent-environment triad. many changes have signaled a need for transformation towards the new public health. religion, although still a major political and policy-making force in many countries, is no longer the central organizing power in most societies. organized societies have evolved from large extended families and tribes to rural societies, cities, regions, and national governments. with the growth of industrialized urban communities, rapid transport, and extensive trade and commerce in multinational economic systems, the health of individuals and communities has become more than just a personal, family, and/or local problem. an individual is not only a citizen of the village, city, or country in which he or she lives, but a citizen of a "global village". the agricultural revolutions and international explorations of the fifteenth to seventeenth centuries that increased food supply and diversity were followed only much later by knowledge of nutrition as a public health issue. the scientific revolution of the seventeenth to nineteenth centuries provided the basics to describe and analyze the spread of disease and the poisonous effects of the industrial revolution, including crowded living conditions and pollution of the environment with serious ecological damage. in the latter part of the twentieth century, a new agricultural "green revolution" had a great impact in reducing human deprivation internationally, yet the full benefits of healthier societies are yet to be realized in the large populations living in abject poverty in sub-saharan africa, south-east asia, and other parts of the world. global water shortages can be addressed with new methods of irrigation, water conservation and the application of genetic sciences to food production, and issues of economics and food security are of great importance to a still growing world population with limited supplies. further, food production capacity can and must be enlarged to meet current food insecurity, rising expectations of developing nations, and population growth. the sciences of agriculture-related fields, including genetic sciences and practical technology, will be vital to human progress in the coming decades. these and other societal changes discussed in chapter 1 have enabled public health to expand its potential and horizons, while developing its pragmatic and scientific base. organized public health in the twentieth century proved effective in reducing the burden of infectious diseases and has contributed to improved quality of life and longevity by many years. in the last half-century, chronic diseases have become the primary causes of morbidity and mortality in the developed countries and increasingly in developing countries. growing scientific and epidemiological knowledge increases the capacity to deal with these diseases. many aspects of public health can only be influenced by the behavior of and risks to the health of individuals. these require interventions that are more complex and relate to societal, environmental, and community standards and expectations as much as to personal lifestyle. the dividing line between communicable and non-communicable diseases changes over time. scientific advances have shown the causation of chronic conditions by infectious agents and their prevention by curing the infection, as in helicobacter pylori and peptic ulcers, and in prevention of cancer of the liver and cervix by immunization for hepatitis b and human papillomavirus (hpv), respectively. chronic diseases have come to the center stage in the "epidemiological transition", as infectious diseases came under increasing control. this, in part, has created a need for reform in the funding and management of health systems due to rapidly rising costs, aging of the population, the rise of obesity and diabetes and other chronic conditions, mushrooming therapeutic technology, and expanding capacity to deal with public health emergencies. reform is also needed in international assistance to help less developed nations build the essential infrastructure to sustain public health in the struggle to combat aids, malaria, tuberculosis (tb), and the major causes of preventable infant, childhood, and motherhood-related deaths. the nearly universal recognition of the rights of people to have access to health care of acceptable quality by international standards is a challenge of political will and leadership backed up by adequate staffing with public health-trained staff and organizations. the challenges of the current global economic crisis are impacting social and health systems around the world. the interconnectedness of managing health systems is part of the new public health. setting the priorities and allocating resources to address these challenges requires public health training and orientation of the professionals and institutions participating in the policy, management, and economics of health systems. conversely, those who manage such institutions are recognizing the need for a wide background in public health training in order to fulfill their responsibilities effectively. concepts such as objectives, targets, priorities, cost-effectiveness, and evaluation have become part of the new public health agenda. an understanding of how these concepts evolved will help the future health provider or manager to cope with the complexities of mixing science, humanity, and effective management of resources to achieve higher standards of health, and to cope with new issues as they develop in the broad scope of the new public health for the twenty-first century, in what breslow called the "third public health era" of long and healthy quality of life (box 2.3). health can be defined from many perspectives, ranging from statistics on mortality, life expectancy, and morbidity rates to idealized versions of human and societal perfection, as in the world health organization's (who's) founding charter. the first public health era -the control of communicable diseases. second public health era -the rise and fall of chronic diseases. third public health era -the development of long and high-quality life. preamble to the constitution of the who, as adopted by the international health conference in new york in 1946 and signed by the representatives of 61 states, entered into force on 7 april 1948, with the widely cited definition: "health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity". this definition is still important conceptually as an ideal accepted as fundamental to public policy over the years. a more operational definition of health is a state of equilibrium of the person with the biological, physical, and social environment, with the object of maximum functional capability. health is thus seen as a state characterized by anatomical, physiological, and psychological integrity, and an optimal functional capability in the family, work, and societal roles (including coping with associated stresses), a feeling of well-being, and freedom from risk of disease and premature death. deviances in health are referred to as unhealthy and constitute a disease nomenclature. there are many interrelated factors in disease and in their management through what is now called risk reduction. in 1878, claude bernard described the phenomenon of adaptation and adjustment of the internal milieu of the living organism to physiological processes. this concept is fundamental to medicine. it is also central to public health because understanding the spectrum of events and factors between health and disease is basic to the identification of contributory factors affecting the balance towards health, and to seeking the points of potential intervention to reverse the imbalance. as described in chapter 1, from the time of hippocrates and galen, diseases were thought to be due to humors and miasma or emanations from the environment. this was termed the miasma theory, and while without a direct scientific explanation, it was acted upon in the early to mid-nineteenth century and promoted by leading public health theorists including florence nightingale, with practical and successful measures to improve sanitation, housing, and social conditions, and having important results in improving health conditions. the competing germ theory developed by pioneering nineteenthcentury epidemiologists (panum, snow, and budd), scientists (pasteur, cohn, and koch), and practitioners (lister and semmelweiss) led to the science of bacteriology and a revolution in practical public health measures. the combined application of the germ (agent-host-environment) and miasma theories (social and sanitary environment) has been the basis of classic public health, with enormous benefits in the control of infectious and other diseases or harmful conditions. the revolutionary changes occurring since the 1960s have brought about a decline in cardiovascular and cancer mortality, and conceptual changes such as health for all and health in all to bring health issues to all policies at both governmental and individual levels. the concepts of public health advanced with the 1974 marc lalonde health field concept (new perspectives on the health of canadians, 1974) , stating that health was the result of the physical and social environment, lifestyle and personal habits, genetics, as well as organization and provision of medical care. the lalonde report was a key concept leading to ideas advanced at the alma-ata conference on primary care held in 1978 and more explicitly in the development of the basis for health promotion as articulated in the ottawa charter of 1986 on health promotion. this marked the beginning of a whole new aspect of public health, which proved itself in addressing with considerable success the epidemic of hiv and cardiovascular diseases. in the usa, the surgeon general's reports of 1964 on smoking and health, and of 1979 defining health targets as national policy promoted the incorporation of "management by objectives" from the business world applied to the health sector (see chapter 12). this led to healthy people usa 2000 and later versions, and the united nations (un) millennium development goals (mdgs), aimed primarily at the middle-and low-income countries (box 2.4). the identification of infectious causes of cancers of the liver and cervix established a new paradigm in epidemiology, and genetic epidemiology has important potential for public health and clinical medicine. in the basic host-agent-environment paradigm, a harmful agent comes through a sympathetic environment into contact with a susceptible host, causing a specific disease. this idea dominated public health thinking until the midtwentieth century. the host is the person who has or is at risk for a specific disease. the agent is the organism or direct cause of the disease. the environment includes the external factors which influence the host, his or her susceptibility to the agent, and the vector which transmits or carries the agent to the host from the environment. this explains the causation and transmission of many diseases. this paradigm (figure 2. 2), in effect, joins together the contagion and miasma theories of disease causation. a specific agent, a method of transmission, and a susceptible host are involved in an interaction, which are central to the infectivity or severity of the disease. the environment can provide the carrier or vector of an infective (or toxic) agent, and it also contributes factors to host susceptibility; for example, unemployment, poverty, or low education level. the expanded host-agent-environment paradigm widens the definition of each of the three components ( figure 2 .3), in relation to both acute infectious and chronic noninfectious disease epidemiology. in the latter half of the twentieth century, this expanded host-agent-environment paradigm took on added importance in dealing with the complex of factors related to chronic diseases, now the leading causes of disease and premature mortality in the developed world, and increasingly in developing countries. interventions to change host, environmental, or agent factors are the essence of public health. in infectious disease control, the biological agent may be removed by pasteurization of food products or filtration and disinfection (chlorination) of water supplies to prevent transmission of waterborne disease. the host may be altered by immunization to provide immunity to a specific infective organism. the environment may be changed to prevent transmission by destroying the vector or its reservoir of the disease. a combination of these interventions can be used against a specific risk factor, toxic or nutritional deficiency, infectious organism, or disease process. vaccine-preventable diseases may require both routine and special activities to boost herd immunity to protect the individual and the community. for other infectious diseases for which there is no vaccine (e.g., malaria), control involves a broad range of activities including case finding and treatment to improve the individual's health and to reduce the reservoir of the disease in the population, and other measures such as bed nets to reduce exposure of the host to vector mosquitoes, as well as vector control to reduce the mosquito population. tb control requires not only case finding and treatment, but understanding the contributory factors of social conditions, diseases with tb as a secondary condition (substance abuse and aids), agent resistance to treatment, and the inability of patients or carriers to complete treatment without supervision. sexually transmitted infections (stis) which are not controllable by vaccines require a combination of personal behavior change, health education, medical care, and skilled epidemiology. with non-infectious diseases, intervention is even more complex, involving human behavior factors and a wide range of legal, administrative, and educational issues. there may be multiple risk factors, which have a compounding effect in disease causation, and they may be harder to alter than infectious diseases factors. for example, smoking in and of itself is a risk factor for lung cancer, but exposure to asbestos fibers has a compounding effect. preventing exposure to the compounding variables may be easier than smoking cessation. reducing trauma morbidity and mortality is equally problematic. the identification of a single specific cause of a disease is of great scientific and practical value in modern public health, enabling such direct interventions as the use of vaccines or antibiotics to protect or treat individuals from infection by a causative organism, toxin, deficiency condition, or social factor. the cumulative effects of several contributing or risk factors in disease causation are also of great significance in many disease processes, in relation to infectious diseases such as nutritional status as for chronic diseases such as the cardiovascular group. the health of an individual is affected by risk factors intrinsic to that person as well as by external factors. intrinsic factors include the biological ones that the individual inherits and those life habits he or she acquires, such as smoking, overeating, or engaging in other high-risk behaviors. external factors affecting individual health include the environment, the socioeconomic and psychological state of the person, the family, and the society in which he or she lives. education, culture, and religion are also contributory factors to individual and community health. there are factors that relate to health of the individual in which the society or the community can play a direct role. one of these is provision of medical care. another is to ensure that the environment and community services include safety factors that reduce the chance of injury and disease, or include protective measures; for example, fluoridation of a community water supply to improve dental health, and seat-belt or helmet laws to reduce motor vehicle injury and death. these modifying factors may affect the response of the individual or the spread of an epidemic (see chapter 3). an epidemic may also include chronic disease, because common risk factors may cause an excess of cases in a susceptible population group, in comparison to the situation before the risk factor appeared, or in comparison to a group not exposed to the risk factor. these include rapid changes or "epidemics" in such conditions as type 2 diabetes, asthma, cardiovascular diseases, trauma, and other non-infectious disorders. disease is a dynamic process, not only of causation, but also of incubation or gradual development, severity, and the effects of interventions intended to modify outcome. knowledge of the natural history of disease is fundamental to understanding where and with what means intervention can have the greatest chance for successful interruption or change in the disease process for the patient, family, or community. the natural history of a disease is the course of that disease from beginning to end. this includes the factors that relate to its initiation; its clinical course leading up to resolution, cure, continuation, or long-term sequelae (further stages or complications of a disease); and environmental or intrinsic (genetic or lifestyle) factors and their effects at all stages of the disease. the effects of intervention at any stage of the disease are part of the disease process (figure 2 .4). as discussed above, disease occurs in an individual when agent, host, and environment interact to create adverse conditions of health. the agent may be an infectious organism, a chemical exposure, a genetic defect, or a deficiency condition. a form of individual or social behavior, such as reckless driving or risky sexual behavior, may lead to injury or disease. the host may be immune or susceptible as a result of many contributing social and environmental factors. the environment includes the vector, which may be a malaria-bearing mosquito, a contaminated needle shared by drug users, lead-contaminated paint, or an abusive family situation. assuming a natural state of "wellness" -i.e., optimal health or a sense of well-being, function, and absence of disease -a disease process may begin with the onset of a disease, infectious or non-infectious, following a somewhat characteristic pattern of "incubation" described by clinicians and epidemiologists. preclinical or predisposing events may be detected by a clinical history, with determination of risk including possible exposure or presence of other risk factors. interventions, before and during the process, are intended to affect the later course of the disease. the clinical course of a disease, or its laboratory or radiological findings, may be altered by medical or public health intervention, leading to the resolution or continuation of the disease with fewer or less severe secondary sequelae. thus, the intervention becomes part of the natural history of the disease. the natural history of an infectious disease in a population will be affected by the extent of prior vaccination or previous exposure in the community. diseases particular to children are often so because the adult population is immune from previous exposure or vaccinations. measles and diphtheria, primarily childhood diseases, now affect adults to a large extent because they are less protected by naturally acquired immunity or are vulnerable when their immunity wanes naturally or as a result of inadequate vaccination in childhood. in chronic disease management, high costs to the patient and the health system accrue where preventive services or management are inadequate, not yet available, or inaccessible or where there is a failure to apply the necessary interventions. the progress of diabetes to severe complications such as cardiovascular, renal, and ocular disease is delayed or reduced by good management of the condition, with a combination of smoking cessation, diet, exercise, and medications with good medical supervision. the patient with advanced chronic obstructive pulmonary disease or congestive heart failure may be managed well and remain stable with smoking avoidance, careful management of medications, immunizations against influenza and pneumonia, and other prevention-oriented care needs. where these are not applied or if they fail, the patient may require long and expensive medical and hospital care. failure to provide adequate supportive care will show up in ways that are more costly to the health system and will prove more life-threatening to the patient. the goal is to avoid where possible the necessity for tertiary care, substituting tertiary prevention, i.e., supportive rehabilitation to maximum personal function and maintaining a stable functional status. as in an individual, the phenomenon of a disease in a population may follow a course in which many factors interplay, and where interventions affect the natural course of the disease. the epidemiological patterns of an infectious disease can be assessed in their occurrence in the population or their mortality rates, just as they can for individual cases. the classic mid-nineteenth-century description of measles in the faroe islands by panum showed the transmission and the epidemic nature of the disease as well as the protective effect of acquired immunity (see chapter 1). similar, more recent breakthroughs in medical, epidemiological, biological, and social sciences have produced enormous benefit for humankind as discussed throughout this text, with some examples. these include the eradication of smallpox and in the coming years, poliomyelitis, measles, leprosy, and other dreaded diseases known for millennia; the near-elimination of rheumatic heart disease and peptic ulcers in the industrialized countries; vast reduction in mortality from stroke and coronary heart disease (chd); and vaccines (against hepatitis b and hpv) for the prevention of cancers. these and other great achievements of the twentieth and early part of the twenty-first centuries hold great promise for humankind in the coming decades, but great challenges lie ahead as well. the biggest challenge is to bring the benefits of known public health capacity to the poorest population of each country and the poorest populations globally. in developed countries a major challenge is to renew efforts of public health capacity to bear on prevention of chronic conditions such as diabetes and obesity, considered to be at pandemic proportions; and the individual and societal effects of mental diseases. in public health today, fears of a pandemic of avian influenza are based on transmission of avian or other animal-borne (zoonotic) prions or viruses to humans and then their adaptation permitting human-to-human spread. with large numbers of people living in close contact with many animals (wild and domestic fowl), such as in china and south-east asia, and rapid transportation around the world, the potential for global spread of disease is almost without historical precedent. indeed, many human infectious diseases are zoonotic in origin and transferred from natural wildlife reservoirs to humans either directly or via domestic or other wild animals, such as from birds to chickens to humans in avian influenza. monitoring or immunization of domestic animals requires a combination of multidisciplinary zoonotic disease management strategies, public education and awareness, and veterinary public health monitoring and control. rift valley fever, equine encephalitis, and more recently sars and avian influenza associated with bird-borne viral disease which can affect humans, each show the terrible dangers of pandemic diseases. ebola virus is probably sustained between outbreaks among fruit bats, or as recently suggested wild or domestic pigs, and may become a major threat to public health as human case fatality rates decline, meaning that patients and carriers, or genetic drift of the virus with possible airborne transmission, may spread this deadly disease more widely than in the past (see chapter 4). the health of populations, like the health of individuals, depends on societal factors no less than on genetics, personal risk factors, and medical services. social inequalities in health have been understood and documented in public health over the centuries. the chadwick and shattuck reports of 1840-1850 documented the relationship of poverty and bad sanitation, housing, and working conditions with high mortality, and ushered in the idea of social epidemiology. political and social ideologies thought that the welfare state, including universal health care systems of one type or another, would eliminate social and geographic differences in health status and this is in large part true. from the introduction of compulsory health insurance in germany in the 1880s to the failed attempt in the usa at national health insurance in 1995 (see chapters 1, 10 and 13) and the more recent achievements of us president obama in 2010-2011, social reforms to deal with inequalities in health have focused on improving access to medical and hospital care. almost all industrialized countries have developed such systems, and the contribution of these programs to improve health status has been an important part of social progress, especially since world war ii. but even in societies with universal access to health care, people of lower socioeconomic status (ses) suffer higher rates of morbidity and mortality from a wide variety of diseases. the black report (douglas black) in the uk in the early 1980s pointed out that the class v population (unskilled laborers) had twice the total and specific mortality rates of the class i population (professional and business) for virtually all disease categories, ranging from infant mortality to death from cancer. the report was shocking because all britons have had access to the comprehensive national health service (nhs) since its inception in 1948, with access to a complete range of services at no cost at time of service, close relations to their general practitioners, and good access to specialty services. these findings initiated reappraisals of the social factors that had previously been regarded as the academic interests of medical sociologists and anthropologists and marginal to medical care. more recent studies and reviews of regional, ethnic, and socioeconomic differentials in patterns of health care access, morbidity, and mortality indicate that health inequities are present in all societies including the uk, the usa, and others, even with universal health insurance or services. the ottawa charter on health promotion in 1986 placed a new paradigm before the world health community that recognized social and political factors as no less important ion health that traditional medical and sanitary public health measures. these concepts helped the world health community to cope with new problems such as hiv/aidsfor which there was neither a medical cure nor a vaccine to prevent the disease. its control came to depend in the initial decades almost entirely on education and change in lifestyles, until the advent of the antiretroviral drugs in the 1990s. there is still no viable vaccine. although the epidemiology of cardiovascular disease shows the direct relationship of the now classic risk factors of stress, smoking, poor diet, and physical inactivity, differences in mortality from cardiovascular disease between different classes among british civil servants are not entirely explainable by these factors. the differences are also affected by social and economic issues that may relate to the psychological needs of the individual, such as the degree of control people have over their own lives. blue-collar workers have less control over their lives, their working life in particular, than their white-collar counterparts, and have higher rates of chd mortality than higher social classes. other work shows the effects of migration, unemployment, drastic social and political change, and binge drinking, along with protective effects of healthy lifestyle, religiosity, and family support systems in cardiovascular diseases. social conditions affect disease distribution in all societies. in the usa and western europe, tb has re-emerged as a significant public health problem in urban areas partly because of high-risk population groups, owing to poverty and alienation from society, as in the cases of homelessness, drug abuse, and hiv infection. in countries of eastern europe and the former soviet union, the recent rise in tb incidence has resulted from various social and economic factors in the early 1990s, including the large-scale release of prisoners. in both cases, diagnosis and prescription of medication are inadequate, and the community at large becomes at risk because of the development of antibioticresistant strains of tubercle bacillus readily spread by inadequately treated carriers, acting as human vectors. studies of ses and health are applicable and valuable in many settings. in alameda county, california, differences in mortality between black and white population groups in terms of survival from cancer became insignificant when controlled for social class. a 30-year follow-up study of the county population reported that low-income families in california are more likely than those on a higher income to have physical and mental problems that interfere with daily life, contributing to further impoverishment. studies of the association between indicators of ses and recent screening in the usa, australia, finland, and elsewhere showed that lower ses women use less preventive care such as papanicolaou (pap) smears for cervical cancer than women of higher ses, despite having greater risk for cervical cancer. many factors in ses inequalities are involved, including transportation and access to primary care, differences in health insurance coverage, educational levels, poverty, high-risk behaviors, social and emotional distress, feeling a lack of control over one's own life, employment, occupation, and inadequate family or community social support systems. many barriers exist owing to difficulties in access and the lack of availability of free or low-cost medical care, and the absence or limitations of health insurance is a further factor in the socioeconomic gradient. the recognition that health and disease are influenced by many factors, including social inequalities, plays a fundamental role in the new public health paradigm. health care systems need to take into account economic, social, physical, and psychological factors that otherwise will limit the effectiveness of even the best medical care. the health system includes access to competent and responsible primary care as well as by the wider health system, including health promotion, specific prevention and population-based health protection. the paradigm of the host-agent-environment triad (figures 2.2 and 2. 3) is profoundly affected by the wider context. the sociopolitical environment and organized efforts at intervention affect the epidemiological and clinical course of disease of the individual. medical care is essential, as is public health, but the persistent health inequities seen in most regions and countries require societal attention. success or failure in improving the conditions of life for the poor, and other vulnerable "risk groups", affect national or regional health status and health system performance. the health system is meant to reduce the occurrence or bad outcome of disease, either directly by primary prevention or treatment as secondary prevention or by maximum rehabilitation as tertiary prevention, or equally important indirectly by reducing community or individual risk factors. the the effects of social conditions on health can be partly offset by interventions intended to promote healthful conditions; for example, improved sanitation, or through good-quality primary and secondary health services, used efficiently and effectively made available to all. the approaches to preventing disease or its complications may require physical changes in the environment, such as removal of the broad street pump handle to stop the cholera epidemic in london, or altering diets as in goldberger's work on pellagra. some of the great successes of public health have been and continue to be low technology. examples, among many others, include insecticide-impregnated bednets and other vector control measures, oral rehydration solutions, treatment and cure of peptic ulcers, exercise and diet to reduce obesity, hand washing in hospitals (and other health facilities), community health workers, and condoms and circumcision for the prevention of stis, including hiv and cancer of the cervix. the societal context in terms of employment, social security, female education, recreation, family income, cost of living, housing, and homelessness is relevant to the health status of a population. income distribution in a wealthy country may leave a wide gap between the upper and lower socioeconomic groups, which affects health status. the media have great power to sway public perception of health issues by choosing what to publish and the context in which to present information to society. modern media may influence an individual's tendency to overestimate the risk of some health issues while underestimating the risk of others, ultimately influencing health choices, such as occurred with public concern regarding false claims of an association between the measles-mumps-rubella (mmr) vaccine and autism in the uk (see the wakefield effect, chapter 4). the new public health has an intrinsic responsibility for advocacy of improved societal conditions in its mission to promote optimal community health. an ultimate goal of public health is to improve health and to prevent widespread disease occurrence in the population and in an individual. the methods of achieving this are wide and varied. when an objective has been defined in "social justice is a matter of life and death. it affects the way people live, their consequent chance of illness, and their risk of premature death. we watch in wonder as life expectancy and good health continue to increase in parts of the world and in alarm as they fail to improve in others. a girl born today can expect to live for more than 80 years if she is born in some countries -but less than 45 years if she is born in others. within countries there are dramatic differences in health that are closely linked with degrees of social disadvantage. differences of this magnitude, within and between countries, simply should never happen. these inequities in health, avoidable health inequalities arise because of the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. the conditions in which people live and die are, in turn, shaped by political, social, and economic forces. social and economic policies have a determining impact on whether a child can grow and develop to its full potential and live a flourishing life, or whether its life will be blighted. increasingly the nature of the health problems rich and poor countries have to solve are converging. the development of a society, rich or poor, can be judged by the quality of its population's health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantage as a result of ill-health." preventing disease, the next step is to identify suitable and feasible methods of achieving it, or a strategy with tactical objectives. this determines the method of operation, course of action, and resources needed to carry it out. the methods of public health are categorized as health promotion, and primary, secondary, and tertiary prevention (box 2.6). health promotion is the process of enabling people and communities to increase control over factors that influence their health, and thereby to improve their health (adapted from the ottawa charter of health promotion, 1986; box 2.7). health promotion is a guiding concept involving activities intended to enhance individual and community health and well-being (box 2.8). it seeks to increase involvement and control by the individual and the community in their own health. it acts to improve health and social welfare, and to reduce specific determinants of diseases and risk factors that adversely affect the health, well-being, and productive capacities of an individual or society, setting targets based on the size of the problem but also the feasibility of successful intervention, in a cost-effective way. this can be through direct contact with the patient or risk group, or act indirectly through changes in the environment, legislation, or public policy. control of aids relies on an array of interventions that promote change in sexual behavior and other contributory risks such as sharing of needles among drug users, screening of blood supply, safe hygienic practices in health care settings, and education of groups at risk such as teenagers, sex workers, migrant workers, and many others. control of aids is also a clinical problem in that patients need antiretroviral therapy (art), but this becomes a management and policy issue for making these drugs available and at an affordable price for the poor countries most affected. this is an example of the challenge and effectiveness of health promotion and the new public health. health promotion is a key element of the new public health and is applicable in the community, the clinic or hospital, and in all other service settings. some health promotion activities are government legislative and box 2.6 modes of prevention l health promotion -fostering national, community, and individual knowledge, attitudes, practices, policies, and standards conducive to good health; promoting legislative, social, or environmental conditions; promoting knowledge and practices for self-care that reduce individual and community risk; and creating a healthful environment. it is directed toward action on the determinants of health. l health protection -activities of official health departments or other agencies empowered to supervise and regulate food hygiene, community and recreational water safety, environmental sanitation, occupational health, drug safety, road safety, emergency preparedness, and many other activities to eliminate or reduce as much as possible risks of adverse consequences to health. l primary prevention -preventing a disease from occurring, e.g., vaccination to prevent infectious diseases, advice to stop smoking to prevent lung cancer. l secondary prevention -making an early diagnosis and giving prompt and effective treatment to stop progress or shorten the duration and prevent complications from an already existing disease process, e.g., screening for hypertension or cancer of cervix and colorectal cancer for early case finding, early care and better outcomes. l tertiary prevention -stopping progress of an already occurring disease, and preventing complications, e.g., in managing diabetes and hypertension to prevent complications; restoring and maintaining optimal function once the disease process has stabilized, e.g., promoting functional rehabilitation after stroke and myocardial infarction with long-term follow-up care. health promotion (hp) is the process of enabling people to increase control over, and to improve their health. hp represents a comprehensive social and political process, and not only embraces actions directed at strengthening the skills and capabilities of individuals. hp also undertakes action directed towards changing social, environmental, and economic conditions so as to alleviate their impact on public and individual health. health promotion is the process of enabling people to increase control over the determinants of health and thereby improve their health. participation is essential to sustain health promotion action. the ottawa charter identifies three basic strategies for health promotion. these are advocacy for health to create the essential conditions for health indicated above; enabling all people to achieve their full health potential; and mediating between the different interests in society in the pursuit of health. these strategies are supported by five priority action areas as outlined in the ottawa charter for health promotion: regulatory interventions such as mandating the use of seat belts in cars, requiring that children be immunized to attend school, declaring that certain basic foods must have essential minerals and vitamins added to prevent nutritional deficiency disorders in vulnerable population groups, and mandating that all newborns should be given prophylactic vitamin k to prevent hemorrhagic disease of the newborn. setting food and drug standards and raising taxes on cigarettes and alcohol to reduce their consumption are also part of health promotion. promoting a healthy lifestyle is a major known obesity-preventive activity. health promotion is provided by organizations and people with varied professional backgrounds working towards common goals of improvement in the health and quality of individual and community life. initiatives may come from government with dedicated allocation of funds to address specific health issues, from donors, or from advocacy or community groups or individuals to promote a specific or general cause in health. raising awareness to inform and motivate people about their own health and lifestyle factors that might put them at risk requires teaching young people about the dangers of sexually transmitted diseases, smoking, and alcohol abuse to reduce risks associated with their social behavior. it might include disseminating information on healthy nutrition; for example, the need for folic acid supplements for women of childbearing age and multiple vitamins for elderly, as well as the elements of a healthy diet, compliance with immunization recommendations, compliance with screening programs, and many others. community and peer group attitudes and standards affect individual behavior. health promotion endeavors to create a climate of knowledge, attitudes, beliefs, and practices that are associated with better health outcomes. international conferences following on from the ottawa charter were held in adelaide in 1988 , sundsvall in 1991 , jakarta in 1999 , mexico in 2000 , bangkok in 2005 , and nairobi in 2009 . the principles of health promotion have been reiterated and have influenced public policy regarding public health as well as the private sector. health promotion has a track record of proven success in numerous public health issues where a biomedical solution was not available. the hiv/aids pandemic from the 1980s until the late 1990s had no medical treatment and control measures relied on screening, education, lifestyle changes, and supportive care. health promotion brought forward multiple interventions, from condom use and distribution, to needle exchanges for intravenous drug users, to male circumcision in high-prevalence african countries. medical treatment was severely limited until art was developed. the success of art also depends on a strong element of health promotion in widening the access to treatment and the success of medications to reduce transmission, most remarkably in reducing maternal-fetal transmission (see chapter 4). similarly, in the battle against cardiovascular diseases, health promotion was an instrumental factor in raising public awareness of the importance of management of hypertension and smoking reduction, dietary restraint, and physical exercise. the success of massive reductions in stroke and chd mortality is as much the result of health promotion as of improved medical care (see chapter 5). the character of public health carries with it a "good cop, bad cop" dichotomy. the "good cop" is persuasive and educational trying to convince people to do the right thing in looking after their own health: diet, exercise, smoking cessation, and others. on the other side, the "bad cop" role is regulatory and punitive. public health has a serious responsibility and role in the enforcement of laws and regulation to protect the public health. some of these are restrictive box 2.8 elements of health promotion 1. address the population as a whole in health-related issues, in everyday life as well as people at risk for specific diseases. 2. direct action to risk factors or causes of illness or death. 3. undertake activist approach to seek out and remedy risk factors in the community that adversely affect health. 4. promote factors that contribute to a better condition of health of the population. 5. initiate actions against health hazards, including communication, education, legislation, fiscal measures, organizational change, community development, and spontaneous local activities. 6. involve public participation in defining problems and deciding on action. 7. advocate relevant environmental, health, and social policy. 8. encourage health professional participation in health education and health advocacy. 9. advocate for health based on human rights and solidarity. 10. invest in sustainable policies, actions, and infrastructure to address the determinants of health. 11. build capacity for policy development, leadership, health promotion practice, knowledge transfer and research, and health literacy. 12. regulate and legislate to ensure a high level of protection from harm and enable equal opportunity for health and well-being for all people. 13. partner and build alliances with public, private, nongovernmental, and international organizations and civil society to create sustainable actions. 14. make the promotion of health central to the global development agenda. of individual rights that may damage other people or are requirements based on strong evidence of benefits to population health. readily accepted are food and drug standards, such as pasteurization of milk, and iodization of salt; requirements to drive on the right-hand side of the road (except in some countries such as the uk), to wear seat belts and for motorcyclists to wear safety helmets; and not smoking in public places. enforcement of these and similar statutory or regulatory requirements is vital in a civil society to protect the public from health hazards and to protect people from harm and exploitation by unscrupulous manufacturers and marketing. cigarette advertising and sponsorship of sports events by tobacco companies are banned in most upper income countries. the use of transfats in food manufacturing and baking is now banned and salt reduction is being promoted and even mandated in many us local authorities to reduce cardiovascular disease. advertising of unhealthy snack foods on children's television programs and during child-watching hours is commonly restricted. banning high-sugar soda drink distribution in schools is a successful intervention to reduce the current child obesity epidemic. melamine use in milk powders and baby formulas, which caused widespread illness and death of infants in china, is now banned and a punishable offence for manufacture or distribution in china and worldwide. examples of this aspect of public health are mentioned throughout this text, especially in chapters 8 and 9 on nutrition, and environmental and occupational health, respectively. the regulatory enforcement function of public health is sometimes controversial and portrayed as interference with individual liberty. fluoridation of community water supplies is an example where aggressive lobby groups opposing this safe and effective public health measure are still common. this is discussed in chapter 7. equally important is the public health policy issue of resource allocation and taxation for health purposes. taxation is an unpopular measure that governments must employ and enforce in order to do the public's business. the debate over the patient protection and affordable care act 2010 (ppaca or "obamacare"), discussed elsewhere in this and other chapters, shows how bitter the arguments can become, yet the goal of equality of access to health care cannot be denied as a public good, demonstrably contributing to the health of the nation. primary prevention refers to those activities that are undertaken to prevent disease or injury from occurring at all. primary prevention works with both the individual and the community. it may be directed at the host to increase resistance to the agent (such as in immunization or cessation of smoking), or at environmental activities to reduce conditions favorable to the vector for a biological agent, such as mosquito vectors of malaria or dengue fever. landmark examples include the treatment and prevention of scurvy among sailors based on james lind's findings in a classic clinical epidemiological study in 1747, and john snow's removal of the handle from the broad street pump to stop a cholera epidemic in london in 1854 (see chapter 1). primary prevention includes elements of health protection such as ensuring water, food and drug, and workplace safety; chlorination of drinking water to prevent transmission of waterborne enteric diseases; pasteurization of milk to prevent gastrointestinal diseases; mandating wearing seat belts in motor vehicles to prevent serious injury and death in road crashes; and reducing the availability of firearms to reduce injury and death from intentional, accidental, or random violence. it also includes direct measures to prevent diseases, such as immunization to prevent polio, tetanus, pertussis, and diphtheria. health promotion and health protection blend together as a group of activities that reduce risk factors and diseases through many forms of intervention such as changing smoking legislation or preventing birth defects by fortification of flour with folic acid. prevention of hiv transmission by needle exchange for intravenous drug users, promoting condom usage, and promoting male circumcision in africa, and the distribution of condoms and clean needles for hivpositive drug users are recent examples of primary prevention associated with health promotion programs. primary prevention also includes activities within the health system that can lead to better health. this may mean, for example, setting standards and to reduce hospital infections, and ensuring that doctors not only are informed of appropriate immunization practices and modern prenatal care or screening programs for cancer of the cervix, colon, and breast, but also are aware of their vital role in preventing cardiovascular and other non-communicable diseases. in this role, the health care provider serves as a teacher and guide, as well as a diagnostician and therapist. like health promotion, primary prevention does not depend on health care providers alone; health promotion works to increase individual and community consciousness of self-care, mainly by raising awareness and information levels and empowering the individual and the community to improve self-care, to reduce risk factors, and to live healthier lifestyles. secondary prevention is early diagnosis and management to prevent complications from a disease. public health interventions to prevent the spread of disease include the identification of sources of the disease and the implementation of steps to stop it, as shown in snow's closure of the broad street pump. secondary prevention includes steps to isolate cases and treat or immunize contacts so as to prevent further cases of meningitis or measles, for example, in outbreaks. for current epidemics such as hiv/aids, primary prevention is largely based on education, abstinence from any and certainly risky sexual behavior, circumcision, and treatment of patients in order to improve their health and to reduce the risk of spread of hiv. for high-risk groups such as intravenous drug users, needleexchange programs reduce the risk of spread of hiv, and hepatitis b and c. distribution of condoms to teenagers, military personnel, truck drivers, and commercial sex workers helps to prevent the spread of stis and aids in schools and colleges, as well as among the military. the promotion of circumcision is shown to be effective in reducing the transmission of hiv and of hpv (the causative organism for cancer of the cervix). all health care providers have a role in secondary prevention; for example, in preventing strokes by early identification and adequate care of hypertension. the child who has an untreated streptococcal infection of the throat may develop complications which are serious and potentially life-threatening, including rheumatic fever, rheumatic valvular heart disease, and glomerulonephritis. a patient found to have elevated blood pressure should be advised about continuing management by appropriate diet and weight loss if obese, regular physical exercise, and long-term medication with regular follow-up by a health provider in order to reduce the risk of stroke and other complications. in the case of injury, competent emergency care, safe transportation, and good trauma care may reduce the chance of death and/or permanent handicap. screening and high-quality care in the community prevent complications of diabetes, including heart, kidney, eye, and peripheral vascular disease. they can also prevent hospitalizations, amputations, and strokes, thus lengthening and improving the quality of life. health care systems need to be actively engaged in secondary prevention, not only as individual doctors' services, but also as organized systems of care. public health also has a strong interest in promoting highquality care in secondary and tertiary care hospital centers in such areas of treatment as acute myocardial infarction, stroke, and injury in order to prevent irreversible damage. measures include quality of care reviews to promote adequate longterm postmyocardial infarction care with aspirin and betablockers or other medication to prevent or delay recurrence and second or third myocardial infarctions. the role of highquality transportation and care in emergency facilities of hospitals in public health is vital to prevent long-term damage and disability; thus, cardiac care systems including publicly available defibrillators, catheterization, the use of stents, and bypass procedures are important elements of health care policy and resource allocation, which should be accessible not only in capital cities but also to regional populations. tertiary prevention involves activities directed at the host or patient, but also at the social and physical environment in order to promote rehabilitation, restoration, and maintenance of maximum function after the disease and its complications have stabilized. the person who has undergone a cerebrovascular accident or trauma will reach a stage where active rehabilitation can help to restore lost functions and prevent recurrence or further complications. the public health system has a direct role in the promotion of disability-friendly legislation and standards of building, housing, and support services for chronically ill, handicapped, and elderly people. this role also involves working with many governmental social and educational departments, but also with advocacy groups, ngos, and families. it may also include the promotion of disability-friendly workplaces and social service centers. treatment for conditions such as myocardial infarction or a fractured hip now includes early rehabilitation in order to promote early and maximum recovery with restoration to optimal function. the provision of a wheelchair, walkers, modifications to the home such as special toilet facilities, doors, and ramps, along with transportation services for paraplegics are often the most vital factors in rehabilitation. public health agencies work with groups in the community concerned with promoting help for specific categories of risk group, disease, or disability to reduce discrimination. community action is often needed to eliminate financial, physical, or social barriers, promote community awareness, and finance special equipment or other needs of these groups. close follow-up and management of chronic disease, physical and mental, require home care and ensuring an appropriate medical regimen including drugs, diet, exercise, and support services. the follow-up of chronically ill people to supervise the taking of medications, monitor changes, and support them in maximizing their independent capacity in activities of daily living is an essential element of the new public health. public health uses a population approach to achieve many of its objectives. this requires defining the population, including trends of change in the age and gender distribution of the population, fertility and birth rates, spread of disease and disability, mortality, marriage and migration, and socioeconomic factors. the reduction of infectious disease as the major cause of mortality, increased longevity coupled with declining fertility rates, resulted in changes in the age composition, or a demographic transition. demographic changes, such as fertility and mortality patterns, are important factors in changing the age distribution of the population, resulting in a greater proportion of people surviving to older ages. declining infant mortality, increasing educational levels of women, the availability of birth control, and other social and economic factors lead to changes in fertility patterns and the demographic transition -an aging of the population -with important effects on health service needs. the age and gender distribution of a population affects and is affected by patterns of disease. change in epidemiological patterns, or an epidemiological shift, is a change in predominant patterns of morbidity and mortality. the transition of infectious diseases becoming less prominent as causes of morbidity and mortality and being replaced by chronic and non-infectious diseases has occurred in both developed and developing countries. the decline in mortality from chronic diseases, such as cardiovascular disease, represents a new stage of epidemiological transition, creating an aging population with higher standards of health but also long-term community support and care needs. monitoring and responding to these changes are fundamental responsibilities of public health, and a readiness to react to new, local, or generalized changes in epidemiological patterns is vital to the new public health. societies are not totally homogeneous in ethnic composition, levels of affluence, or other social markers. on one hand, a society classified as developing may have substantial numbers of people with incomes that promote overnutrition and obesity, so that disease patterns may include increasing prevalence of diseases of excesses, such as diabetes. on the other hand, affluent societies include population groups with disease patterns of poverty, including poor nutrition and low birth-weight babies. a further stage of epidemiological transition has been occurring in the industrialized countries since the 1960s, with dramatic reductions in mortality from chd, stroke and, to a lesser extent, trauma. the interpretation of this epidemiological transition is still not perfectly clear. how it occurred in the industrialized western countries but not in those of the former soviet union is a question whose answer is vital to the future of health in russia and some countries of eastern europe. developing countries must also prepare to cope with increasing epidemics of non-infectious diseases, and all countries face renewed challenges from infectious diseases with antibiotic resistance or newly appearing infectious agents posing major public health threats. demographic change in a country may reflect social and political decisions and health system priorities from decades before. russia's rapid population decline since the 1990s, china's gender imbalance with a shortage of millions of young women, egypt's rapid population growth outstripping economic capacity, and many other examples indicate the severity and societal importance of capacity to analyze and formulate public health and social policies to address such fundamental sociopolitical issues. aging of the population is now the norm in most developed countries as a result of low birth and declining mortality rates. this change in the age distribution of a population has many associated social and economic issues as to the future of social welfare with a declining age cohort to provide the workforce. the aging population requires pension and health care support which make demands of social security systems that will depend on economic growth with a declining workforce. in times of economic stress, as in europe, this situation is made more difficult by longstanding short working weeks, early pension ages, and high social benefits. however, this results in unemployment among young people in particular and social conflict. the interaction of increasing life expectancy and a declining workforce is a fundamental problem in the high-income countries. this imbalance may be resolved in part through productivity gains and switching of primary production to countries with large still underutilized workforces, while employment in the developed countries will depend on service industries including health and the economic growth generated by higher technology and intellectual property and service industries. the challenge of keeping populations and individuals healthy is reflected in modern health services. each component of a health service may have developed with different historical emphases, operating independently as a separate service under different administrative auspices and funding systems, competing for limited health care resources. in this situation, preventive community care receives less attention and resources than more costly treatment services. figure 2 .5 suggests a set of health services in an interactive relationship to serve a community or defined population, but the emphasis should be on the interdependence of these services with one other and with the comprehensive network in order to achieve effective use of resources and a balanced set of services for the patient, the client or patient population, and the community. clinical medicine and public health each play major roles in primary, secondary, and tertiary prevention. each may function separately in their roles in the community, but optimal success lies in their integrated efforts. allocation of resources should promote management and planning practices to assist this integration. there is a functional interdependence of all elements of health care serving a definable population. the patient should be the central figure in the continuum or complex of services available. effectiveness in use of resources means that providing the service most appropriate for meeting the individual's or group's needs at a point in time are those that should be applied. this is the central concept in currently developing innovations in health care delivery in the usa with organizations using terms such as patient centered medical home, accountable care organizations (acos), and population health management systems, which are being promoted in the obamacare health reforms now in process (see chapter 10) (shortell et al., 2010) . separate organization and financing of services place barriers to appropriate provision of services for both the community and the individual patient. the interdependence of services is a challenge in health care organizations for the future. where there is competition for limited resources, pressures for tertiary services often receive priority over programs to prevent children from dying of preventable diseases. public health must be seen in the context of all health care and must play an influential role in promoting prevention at all levels. clinical services need public health in order to provide prevention and community health services that reduce the burden of disease, disability, and dependence on the institutional setting. health was traditionally thought of as a state of absence of disease, pain, or disability, but has gradually been expanded to include physical, mental, and societal well-being. in 1920, c. e. a. winslow, professor of public health at yale university, defined public health as follows: "public health is the science and art of (1) preventing disease, (2) prolonging life, and (3) winslow's far-reaching definition remains a valid framework but is unfulfilled when clinical medicine and public health have financing and management barriers between them. in many countries, isolation from the financing and provision of medical and nursing care services left public health with the task of meeting the health needs of the indigent and underserved population groups with inadequate resources and recognition. health insurance organizations for medical and hospital care have in recent years been more open to incorporating evidence-based preventive care, but the organization of public health has lacked the same level of attention. in some countries, the limitations have been conceptual in that public health was defined primarily in terms of control of infectious, environmental, and occupational diseases. a more recent and widely used definition is: "public health is the science and art of preventing disease, prolonging life, and promoting health through the organized efforts of society." this definition, coined in 1988 in the public health in england report by sir donald acheson, reflects the broad focus of modern public health. terms such as social hygiene, preventive medicine, community medicine, and social medicine have been used to denote public health practice over the past century. preventive medicine is the application of preventive measures by clinical practitioners combining some elements of public health with clinical practice relating to individual patients. preventive medicine defines medical or clinical personal preventive care, with stress on risk groups in the community and national efforts for health promotion. the focus is on the health of defined populations to promote health and well-being using evidence-based guidelines for cost-effective preventive measures. measures emphasized include screening and follow-up of chronic illnesses, and immunization programs; for example, influenza and pneumococcal pneumonia vaccines are used by people who are vulnerable because of their age, chronic diseases, or risk of exposure, such as medical and nursing personnel and those providing other personal clinical services. clinical medicine also deals in the area of prevention in the management of patients with hypertension or diabetes, and in doing so prevents the serious complications of these diseases. social medicine is also primarily a medical specialty which looks at illness in an individual in the family and social context, but lacks the environmental and regulatory and organized health promotion functions of public health. community health implies a local form of health intervention, whereas public health more clearly implies a global approach, which includes action at the international, national, state, and local levels. some issues in health can be dealt with at the individual, family, or community level; others require global strategies and intervention programs with regional, national, or international collaboration and leadership. the social medicine movement originated to address the harsh conditions of the working population during the industrial revolution in mid-nineteenth-century europe. an eminent pioneer in cellular pathology, rudolph virchow provided leadership in social medicine powered by the revolutionary movements of 1848, and subsequent social democrat political movements. their concern focused on harsh living and health conditions among the urban poor working class and neglectful political norms of the time. social medicine also developed as an academic discipline and advocacy orientation by providing statistical evidence showing, as in various governmental reports in the mid-nineteenth century, that poverty among the working class was associated with short life expectancy and that social conditions were key factors in the health of populations and individuals. this movement provided the basis for departments in medical faculties and public health education throughout the world stressing the close relationship between political priorities and health status. this continued in the twentieth century and in the usa found expression in pioneering work since the 1940s at montefiore hospital in new york and with victor sidel, founding leader of the community health center movement the usa from the 1960s. in the twenty-first century this movement continues to emphasize relationships between politics, society, disease, and medicine, and forms of medical practice derived from it, as enunciated by prominent advocates such as harvardbased paul farmer in haiti, russia and rwanda, and in the uk by martin mckee and others (nolte and mckee, 2008) . similar concepts are current in the usa under headings such as family medicine, preventive medicine, and social medicine. this movement has also influenced sir michael marmot and others in the world health commission of health inequalities of 2008, with a strong influence on the un initiative to promote mdgs, whose first objective is poverty reduction (commission on inequalities report 2010). application of the idea of poverty reduction as a method of reducing health inequalities has been successful recently in a large field trial in brazil showing greater reduction in child mortality where cash bonuses were awarded by municipalities for the poor families than that observed in other similar communities (rasella, 2013). in the usa, this movement is supported by increased health insurance coverage for the working poor, with funding for preventive care and incentives for community health centers in the obamacare plan of 2010 for implementation in the coming years to provide care for uninsured and underserved populations, particularly in urban and rural poverty areas. the political aspect of social medicine is the formulation of and support for national initiatives to widen health care coverage to the 16 percent of the us population who are still uninsured, and to protect those who are arbitrarily excluded owing to previous illnesses, caps on coverage allowed, and other exploitative measures taken by private insurance that frequently deny americans access to the high levels of health care available in the country. the ethical base of public health in europe evolved in the context of its successes in the nineteenth and early twentieth centuries along with ideas of social progress. but the twentieth century was also replete with extremism and wide-scale abuse of human rights, with mass executions, deportations, and starvation as official policy in fascist and stalinist regimes. eugenics, a pseudoscience popularized in the early decades of the twentieth century, promoted social policies meant to improve the hereditary qualities of a race by methods such as sterilization of mentally handicapped people. the "social and racial hygiene" of the eugenics movements led to the medicalization of sterilization in the usa and other countries. this was adopted and extended in nazi germany to a policy of murder, first of the mentally and physically handicapped and then of "racial inferiors". these eugenics theories were widely accepted in the medical community in germany, then used by the nazi regime to justify medically supervised killing of hundreds of thousands of helpless, incapacitated individuals. this practice was linked to wider genocide and the holocaust, with the brutalization and industrialized murder of over 6 million jews and 6 million other people, and corrupt medical experimentation on prisoners. following world war ii, the ethics of medical experimentation (and public health) were codified in the nuremberg code and universal declaration of human rights based on lessons learned from these and other atrocities inflicted on civilian populations (see chapter 15). threats of genocide, ethnic cleansing, and terrorism are still present on the world stage, often justified by current warped versions of racial hygienic theories. genocidal incitement and actual genocide and terrorism have recurred in the last decades of the twentieth century and into the twenty-first century in the former yugoslav republics, africa (rwanda and darfur), south asia, and elsewhere. terrorism against civilians has become a worldwide phenomenon with threats of biological and chemical agents, and potentially with nuclear capacity. asymmetrical warfare of insurgencies which use innocent civilians for cover, as with other forms of warfare, carries with it grave dangers to public health, human rights, and international stability, as seen in the twenty-first century in south sudan, darfur, dr congo, chechnya, iraq, afghanistan, and pakistan. in 1961, kerr white and colleagues defined medical ecology as population-based research providing the foundation for management of health care quality. this concept stresses a population approach, including those not attending and those using health services. this concept was based on previous work on quality of care, randomized clinical trials, medical audit, and structure-process-outcome research. it also addressed health care quality and management. these themes influenced medical research by stressing the population from which clinical cases emerge as well as public health research with clinical outcome measures, themes that recur in the development of health services research and, later, evidence-based medicine. this led to the development of the agency for health care policy and research and development in the us department of health and human services and evidence-based practice centers to synthesize fundamental knowledge for the development of information for decision-making tools such as clinical guidelines, algorithms, or pathways. clinical guidelines and recommended best practices have become part of the new public health to promote quality of patient care and public health programming. these can include recommended standards; for example, follow-up care of the postmyocardial infarction patient, an internationally recommended immunization schedule, recommended dietary intake or food fortification standards, and mandatory vitamin k and eye care for all newborns and many others (see chapter 15). community-oriented primary care (copc) is an approach to primary health care that links community epidemiology and appropriate primary care, using proactive responses to the priority needs identified. copc, originally pioneered in south africa and israel by sidney and emily kark and colleagues in the 1950s and 1960s, stresses medical services in the community which need to be adapted to the needs of the population as defined by epidemiological analysis. copc involves community outreach and education, as well as clinical preventive and treatment services. copc focuses on community epidemiology and an active problem-solving approach. this differs from national or larger scale planning that sometimes loses sight of the local nature of health problems or risk factors. copc combines clinical and epidemiological skills, defines needed interventions, and promotes community involvement and access to health care. it is based on linkages between the different elements of a comprehensive basket of services along with attention to the social and physical environment. a multidisciplinary team and outreach services are important for the program, and community development is part of the process. in the usa, the copc concept has influenced health care planning for poor areas, especially provision of federally funded community health centers in attempts to provide health care for the underserved since the 1960s. in more recent years, copc has gained wider acceptance in the usa, where it is associated with family physician training and community health planning based on the risk approach and "managed care" systems. indeed, the three approaches are mutually complementary (box 2.9). as the emphasis on health care reform in the late 1990s moved towards managed care, the principles of copc were and will continue to be important in promoting health and primary prevention in all its modalities, as well as tertiary prevention with followup and maintenance of the health of the chronically ill. copc stresses that all aspects of health care have moved towards prevention based on measurable health issues in the community. through either formal or informal linkages between health services, the elements of copc are part of the daily work of health care providers and community services systems. the us institute of medicine issued the report on primary care in 1995, defining primary care as "the provision of integrated, accessible health care services by clinicians who are accountable for addressing the majority of personal health care needs, developing a sustained partnership with patients and practicing in the context of the family and the community". this formulation was criticized by the american public health association (apha) as lacking a public health perspective and failing to take into account both the individual and the community health approaches. copc tries to bridge this gap between the perspectives of primary care and public health. the community, whether local, regional, or national, is the site of action for many public health interventions. moreover, understanding the characteristics of the community is vital to a successful community-oriented approach. by the 1980s, new patterns of public health began to emerge, including all measures used to improve the health of the community, and at the same time working to protect and promote the health of the individual. the range of activities to achieve these general goals is very wide, including individual patient care systems and the community-wide activities that affect the health and well-being of the individual. these include the financing and management of health systems, evaluation of the health status of the population, and measures to improve the quality of health care. they place reliance on health promotion activities to change environmental risk factors for disease and death. they promote integrative and multisectoral approaches and the international health teamwork required for global progress in health. the definition of health in the charter of the who as a complete state of physical, mental, and social well-being had a ring of utopianism and irrelevance to states struggling to provide even minimal care in severely adverse political, economic, social, and environmental conditions (box 2.10). in 1977, a more modest goal was set for attainment of a level of health compatible with maximum feasible social and economic productivity. one needs to recognize that health and disease are on a dynamic continuum that affects everyone. the mission for public health is to use a wide range of methods to prevent disease and premature death, and improve quality of life for the benefit of individuals and the community. the world health organization defines health as "a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity" (who constitution, 1948) . in 1978 at the alma-ata conference on primary health care, the who related health to "social and economic productivity in setting as a target the attainment by all the people of the world of a level of health that will permit them to lead a socially and economically productive life". three general programs of work for the periods 1984-1989, 1990-1995, and 1996-2001 were formulated as the basis of national and international activity to promote health. in 1995, the who, recognizing changing world conditions of demography, epidemiology, environment, and political and economic status, addressed the unmet needs of developing countries and health management needs in the industrialized countries, calling for international commitment to "attain targets that will make significant progress towards improving equity and ensuring sustainable health development". the 1999 object of the who is restated as "the attainment by all peoples of the highest possible level of health" as defined in the who constitution, by a wide range of functions in promoting technical cooperation, assisting governments, and providing technical assistance, international cooperation, and standards. in the 1960s, most industrialized countries were concentrating energies and financing in health care on providing access to medical and hospital services through national insurance schemes. developing countries were often spending scarce resources trying to emulate this trend. the who was concentrating on categorical programs, such as eradication of smallpox and malaria, as well as the expanded program of immunization and similar specific efforts. at the same time, there was a growing concern that developing countries were placing too much emphasis and expenditure on curative services and not enough on prevention and primary care. the world health assembly (wha) in 1977 endorsed the primary care approach under the banner of "health for all by the year 2000" (hfa 2000) . this was a landmark decision and has had important practical results. the who and the united nations children's fund (unicef) sponsored a seminal conference held in alma-ata, in the ussr ( kazakhstan), in 1978, which was convened to refocus health policy on primary care. the alma-ata declaration stated that health is a basic human right, and that governments are responsible to assure that right for their citizens and to develop appropriate strategies to fulfill this promise. this proposition has come to be increasingly accepted in the international community. the conference stressed the right and duty of people to participate in the planning and implementation of their health care. it advocated the use of scientifically, socially, and economically sound technology. joint action through intersectoral cooperation was also emphasized. the alma-ata declaration focused on primary health care as the appropriate method of assuming adequate access to health care for all (box 2.11). many countries have gradually come to accept the notion of placing priority on primary care, resisting the temptation to spend high percentages of health care resources on high-tech and costly medicine. spreading these same resources into highly costeffective primary care, such as immunization and nutrition programs, provides greater benefit to individuals and to society as a whole. alma-ata provided a new sense of direction for health policy, applicable to developing countries and in a different way than the approaches of the developed countries. during the 1980s, the health for all concept influenced national health policies in the developing countries with signs of progress in immunization coverage, for example, but the initiative was diluted as an unintended consequence by more categorical programs such as eradication of poliomyelitis. for example, developing countries have accepted immunization and diarrheal disease control as high-priority issues and achieved remarkable success in raising immunization coverage from some 10 percent to over 75 percent in just a decade. developed countries addressed these principles in different ways. in these countries, the concept of primary health care led directly to important conceptual developments in health. national health targets and guidelines are now common in many countries and are integral parts of box 2.11 declaration of alma-ata, 1978: a summary of primary health care (phc) 1. reaffirms that health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity, and is a fundamental human right. existing gross inequalities in the health status of the people, particularly between developed and developing countries as well as within countries, are of common concern to all countries. 3. governments have a responsibility for the health of their people. the people have the right and duty to participate in planning and implementation of their health care. 4. a main social target is the attainment, by all peoples of the world by the year 2000, of a level of health that will permit them to lead a socially and economically productive life. 5. phc is essential health care based on practical, scientifically sound, and socially acceptable methods and technology. 6. it is the first level of contact of individuals, the family, and the national health system bringing health care as close as possible to where people live and work, as the first element of a continuing health care process. 7. phc evolves from the conditions and characteristics of the country and its communities, based on the application of social, biomedical, and health services research and public health experience. 8. phc addresses the main health problems in the community, providing promotive, preventive, curative, and rehabilitative services accordingly. 9. phc includes the following: (a) education concerning prevailing health problems and methods of preventing and controlling them (b) promotion of food supply and proper nutrition (c) adequate supply of safe water and basic sanitation (d) maternal and child health care, including family planning (e) immunization against the major infectious diseases (f) prevention of locally endemic diseases (g) appropriate treatment of common diseases and injuries (h) the provision of essential drugs (i) relies on all health workers … to work as a health team. 10. all governments should formulate national health policies, strategies and plans, mobilize political will and resources, used rationally, to ensure phc for all people. national health planning. reforms of the nhs -for example, as discussed in chapter 13, remuneration increases for family physicians and encouraging group practice with public health nursing support -have become widespread in the uk. leading health maintenance organizations, such as kaiser permanente in the usa and district health systems in canada, have emphasized integrated approaches to health care for registered or geographically defined populations (see chapters 11-13). this approach is becoming common in the usa in acos, which will be fostered by the 2010 obamacare legislation (ppaca). this systematic approach to individual and community health is an integral part of the new public health. the interactions among community public health, personal health services, and health-related behavior, including their management, are the essence of the new public health. how the health system is organized and managed affects the health of the individual and the population, as does the quality of providers. health information systems with epidemiological, economic, and sociodemographic analysis are vital to monitor health status and allow for changing priorities and management. well-qualified personnel are essential to provide services, manage the system, and carry out relevant research and health policy analysis. diffusion of data, health information, and responsibility helps to provide a responsive and comprehensive approach to meet the health needs of the individual and community. the physical, social, economic, and political environments are all important determinants of the health status of the population and the individual. joint action (intersectoral cooperation) between public and non-governmental or community-based organizations is needed to achieve the well-being of the individual in a healthy society. in the 1980s and 1990s, these ideas contributed to an evolving new public health, spurred on by epidemiological changes, health economics, the development of managed care linking health systems, and prepayment. knowledge and self-care skills, as well as community action to reduce health risks, are no less important in this than the roles of medical practitioners and institutional care. all are parts of a coherent holistic approach to health. the concept of selective primary care, articulated in 1979 by walsh and warren, addresses the needs of developing countries to select those interventions on a broad scale that would have the greatest positive impact on health, taking into account limited resources such as money, facilities, and human resources. the term selective primary care is meant to define national priorities that are based not on the greatest causes of morbidity or mortality, but on common conditions of epidemiological importance for which there are effective and simple preventive measures. throughout health planning, there is an implicit or explicit selection of priorities for allocation of resources. even in primary care, selection of targets is a part of the process of resource allocation. in modern public health, this process is more explicit. a country with limited resources and a high birth rate will emphasize maternal and child health before investing in geriatric care. this concept has become part of the microeconomics of health care and technology assessment, discussed in chapters 11 and 15, respectively, and is used widely in setting priorities and resource allocation. in developing countries, cost-effective primary care interventions have been articulated by many international organizations, including iodization of salt, use of oral rehydration therapy (ort) for diarrheal diseases, vitamin a supplementation for all children, expanded programs of immunization, and others that have the potential for saving hundreds of thousands of lives yearly at low cost. in developed countries, health promotions targeted to reduce accidents and risk factors such as smoking, high-fat diets, and lack of exercise for cardiovascular diseases are low-cost public health interventions that save lives and reduce the use of hospital care. targeting specific diseases is essential for efforts to control tb or eradicate polio, but at the same time, development of a comprehensive primary care infrastructure is equally or even more important than the single-disease approach. some disease entities such as hiv/aids attract donor funding more readily than basic infrastructure services such as immunization, and this can sometimes be detrimental to addressing the overall health needs of the population and other neglected but also important diseases. the risk approach selects population groups on the basis of risk and helps to determine interventional priorities to reduce morbidity and mortality. the measure of health risk is taken as a proxy for need, so that the risk approach provides something for all, but more for those in need, in proportion to that need. in epidemiological terms, these are people with higher relative risk or attributed risk. some groups in the general population are at higher risk than others for specific conditions. the expanded programme on immunization (epi), control of diarrhoeal diseases (cdd), and acute respiratory disease (ard) programs of the who are risk approaches to tackling fundamental public health problems of children in developing countries. public health places considerable emphasis on maternal and child health because these are vulnerable periods in life for specific health problems. pregnancy care is based on a basic level of care for all, with continuous assessment of risk factors that require a higher intensity of follow-up. prenatal care helps to identify factors that increase the risk for the pregnant woman or her fetus/newborn. efforts directed towards these special risk groups have the potential to reduce morbidity and mortality. high-risk case identification, assessment, and management are vital to a successful maternal care program. similarly, routine infant care is designed not only to promote the health of infants, but also to find the earliest possible indications of deviation and the need for further assessment and intervention to prevent a worsening of the condition. low birth-weight babies are at greater risk for many short-and long-term hazards and should be given special treatment. all babies are routinely screened for birth defects or congenital conditions such as hypothyroidism, phenylketonuria, and other metabolic and hematological diseases. screening must be followed by investigating and treating those found to have a clinical deficiency. this is an important element of infant care because infancy itself is a risk factor. as will be discussed in chapters 6 and 7 and others, epidemiology has come to focus on the risk approach with screening based on known genetic, social, nutritional, environmental, occupational, behavioral, or other factors contributing to the risk for disease. the risk approach has the advantage of specificity and is often used to initiate new programs directed at special categories of need. this approach can lead to narrow and somewhat rigid programs that may be difficult to integrate into a more general or comprehensive approach, but until universal programs can be achieved, selective targeted approaches are justifiable. indeed, even with universal health coverage, it is still important to address the health needs or issues of groups at special risk. working to achieve defined targets means making difficult choices. the supply and utilization of some services will limit availability for other services. there is an interaction, sometimes positive, sometimes negative, between competing needs and the health status of a population. public health identifies needs by measuring and comparing the incidence or prevalence of the condition in a defined population with that in other comparable population groups and defines targets to reduce or eliminate the risk of disease. it determines ways of intervening in the natural epidemiology of the disease, and develops a program to reduce or even eliminate the disease. it also assesses the outcomes in terms of reduced morbidity and mortality, as well as the economic justification in cost-effectiveness analysis to establish its value in health priorities. because of the interdependence of health services, as well as the total financial burden of health care, it is essential to look at the costs of providing health care, and how resources should be allocated to achieve the best results possible. health economics has become a fundamental methodology in policy determination. the costs of health care, the supply of services, the needs for health care or other health-promoting interventions, and effective means of using resources to meet goals are fundamental in the new public health. it is possible to err widely in health planning if one set of factors is overemphasized or underemphasized. excessive supply of one service diminishes the availability of resources for other needed investments in health. if diseases are not prevented or their sequelae not well managed, patients must use costly health care services and are unable to perform their normal social functions such as learning at school or performing at work. lack of investment in health promotion and primary prevention creates a larger reliance on institutional care, driving health costs upwards, and restricting flexibility in meeting patients' needs. the interaction of supply and demand for health services is an important determinant of the political economy of health care. health and its place in national priorities are determined by the social-political philosophy and resource allocation of a government. the case for action, or the justification for a public health intervention, is a complex of epidemiological, economic, and public policy factors (table 2 .1). each disease or group of diseases requires its own case for action. the justification for public health intervention requires sufficient evidence of the incidence and prevalence of the disease (see chapter 3). evidence-based public health takes into account the effectiveness and safety of an intervention; risk factors; safe means at hand to intervene; the human, social, and economic cost of the disease; political factors; and a policy decision as to the priority of the problem. this often depends on subjective factors, such as the guiding philosophy of the health system and the way it allocates resources. some interventions are so well established that no new justification is required to make the case, and the only question is how to do it most effectively. for example, infant vaccination is a cost-effective and cost-beneficial program for the protection of the individual child and the population as a whole. whether provided as a public service or as a clinical preventive measure by a private medical practitioner, it is in the interest of public health that all children be immunized. an outbreak of diarrheal disease in a kindergarten presents an obvious case for action, and a public health system must respond on an emergency basis, with selection of the most suitable mode of intervention. the considerations in developing a case for action are outlined above. need is based on clinical and epidemiological evidence, but also on the importance of an intervention in the eyes of the public. the technology available, its effectiveness and safety, and accumulated experience are important in the equation, as are the acceptability and affordability of appropriate interventions. the precedents for use of an intervention are also important. on epidemiological evidence, if the preventive practice has been seen to provide reduction in risk for the individual and for the population, then there is good reason to implement it. the costs, risks and benefits must be examined as part of the justification to help in the selection of health priorities. health systems research examines the efficiency of health care and promotes improved efficiency and effective use of resources. this is a vital function in determining how best to use resources and meet current health needs. past emphasis on hospital care at the expense of less development of primary care and prevention is still a common issue, particularly in former soviet and developing countries, where a high percentage of total health expenditure goes to acute hospital care with long length of stay, with smaller allocation to preventive and community health care. the result of this imbalance is high mortality from preventable diseases. new drugs, vaccines, and medical equipment are continually becoming available, and each new addition needs to be examined among the national health priorities. sometimes, owing to cost, a country cannot afford to add a new vaccine to the routine. however, when there is good evidence for efficacy and safety of new vaccines, drugs, diagnostic methods or other innovations, it could be applied for those at greatest risk. although there are ethical issues involved, it may be necessary to advise parents or family members to purchase the vaccine independently. clearly, recommending individual purchase of a vaccine is counter to the principle of equity and solidarity, benefiting middleclass families, and providing a poor basis of data for evaluation of the vaccine and its target disease. on the other hand, failure to advise parents of potential benefits to their children creates other ethical problems, but may increase public pressure and insurance system acceptance of new methods, e.g., varicella and hpv vaccines. mass screening programs involving complete physical examinations have not been found to be cost-effective or to significantly reduce disease. in the 1950s and 1960s, routine general health examinations were promoted as an effective method of finding disease early. since the late 1970s, a selective and specific approach to screening has become widely accepted. this involves defining risk categories for specific diseases and bearing in mind the potential for remedial action. early case finding of colon cancer by routine fecal blood testing and colonoscopy has been found to be effective, and pap smear testing to discover cancer of the cervix is timed according to risk category. screening for colorectal cancer is essential for modern health programs and has been adopted by most industrialized countries. outreach programs by visits, telephones, emails or other modern methods of communication are important to contact non-attenders to promote utilization, and have been shown to increase compliance with proven effective measures. these programs are important for screening, follow-up, and maintenance of treatment for hypertension, diabetes, and other conditions requiring long-term management. screening technology is changing and often the subject of intense debate as such programs are costly and their cost-effectiveness is an important matter for policy making: screening for lung cancer is becoming a feasible and effective matter for high-risk groups, whereas breast cancer screening frequency is now in dispute; while nanotechnology and bioengineering promises new methods for cancer screening. the factor of contribution to quality of life should be considered. a vaccine for varicella is justified partly for the prevention of deaths or illness from chickenpox. a stronger the right to health public expectation and social norms argument is often based on the fact that this is a disease that causes moderate illness in children for up to 2 weeks and may require parents to stay home with the child, resulting in economic loss to the parent and society. the fact that this vaccination prevents the occurrence of herpes zoster or shingles later in life may also be a justification. widespread adoption of hepatitis b vaccine is justified on the grounds that it prevents cancer of the liver, liver cirrhosis, and hepatic failure in a high percentage of the population affected. how many cases of a disease are enough to justify an intervention? one or several cases of some diseases, such as poliomyelitis, may be considered an epidemic in that each case constitutes or is an indicator of a wider threat. a single case of polio suggests that another 1000 persons are infected but have not developed a recognized clinical condition. such a case constitutes a public health emergency, and forceful organization to meet a crisis is needed. current standards are such that even one case of measles imported into a population free of the disease may cause a large outbreak, as occurred in the uk, france, and israel during 2007 through 2013, by contacts on an aircraft, at family gatherings, or even in medical settings. a measles epidemic indicates a failure of public health policy and practice. screening for some cancers, such as cervix and colon, is cost effective. screening of all newborns for congenital disorders is important because each case discovered early and treated effectively saves a lifetime of care for serious disability. assessing a public health intervention to prevent the disease or reduce its impact requires measurement of the disease in the population and its economic impact. there is no simple formula to justify a particular intervention, but the cost-benefit approach is now commonly required to make such a case for action. sometimes public opinion and political leadership may oppose the views of the professional community, or may impose limitations of policy or funds that prevent its implementation. conversely, professional groups may press for additional resources that compete for limited resources available to provide other needed health activities. both the professionals of the health system and the general public need full access to health-related information to take part in such debates in a constructive way. to maintain progress, a system must examine new technologies and justify their adoption or rejection (see chapter 15). the association between health and political issues was emphasized by european innovators such as rudolf virchow (and in great britain by edwin chadwick; see chapter 1) in the mid-nineteenth century, when the conditions of the working population were such that epidemic diseases were rife and mortality was high, especially in the crowded slums of the industrial revolution. the same observations led bismarck in germany to introduce early forms of social insurance for the health of workers and their families in the 1880s, and to britain's 1911 national health insurance, also for workers and families. the role of government in providing universal access to health care was a struggle in individual countries during the twentieth century and lasting into the second decade of the twenty-first century (e.g. president obama's affordable health care act of 2010). as the concept of public health has evolved, and the cost effectiveness of medical care has improved through scientific and technological advances, societies have identified health as a legitimate area of activity for collective bargaining and government. with this process, the need to manage health care resources has become more clearly defined as a public responsibility. in industrialized countries, each with very different political make-up, national responsibility for universal access to health has become part of the social ethos. with that, the financing and managing of health services have developed into part of a broad concept of public health, and economics, planning, and management have come to be part of the new public health (discussed in chapters 10-13). social, ethical, and political philosophies have profound effects on policy decisions including allocation of public monies and resources. investment in public health is now recognized as an integral part of socioeconomic development. governments are major suppliers of funds and leadership in health infrastructure development, provision of health services, and health payment systems. they also play a central role in the development of health promotion and regulation of the environment, food, and drugs essential for community health. in liberal social democracies, the individual is deemed to have a right to health care. the state accepts responsibility to ensure availability, accessibility, and quality of care. in many developed countries, government has also taken responsibility to arrange funding and services that are equitably accessible and of high quality. health care financing may involve taxation, allocation, or special mandatory requirements on employers to pay for health insurance. services may be provided by a state-financed and -regulated service or through ngos and/or private service mechanisms. these systems allocate between 6 percent and 14 percent of gross national product (gnp) to health services, with some governments funding over 80 percent of health expenditure; for example, canada and the uk. in communist states, the state organizes all aspects of health care with the philosophy that every citizen is entitled to equity in access to health services. the state health system manages research, staff training, and service delivery, even if operational aspects are decentralized to local health authorities. this model applied primarily to the soviet model of health services. these systems, except for cuba, placed financing of health low on the national priority, with funding less than 4 percent of gnp. in the shift to market economies in the 1990s, some former socialist countries, such as russia, are struggling with poor health status and a difficult shift from a strongly centralized health system to a decentralized system with diffusion of powers and responsibilities. promotion of market concepts in former soviet countries has reduced access to care and created a serious dilemma for their governments. former colonial countries, independent since the 1950s and 1960s, largely carried on the governmental health structures established in the colonial times. most developing countries have given health a relatively low place in budgetary allotment, with expenditures under 3 percent of gnp. since the 1980s, there has been a trend in developing countries towards decentralization of health services and greater roles for ngos, and the development of health insurance. some countries, influenced by medical concepts of their former colonial master countries, fostered the development of specialty medicine in the major centers with little emphasis on the rural majority population. soviet influence in many ex-colonial countries promoted state-operated systems. the who promoted primary care, but the allocations favored city-based specialty care. israel, as an ex-colony, adapted british ideas of public health together with central european sick funds and maternal and child health as major streams of development until the mid-1990s. a growing new conservatism in the 1980s and 1990s in the industrialized countries is a restatement of old values in which market economics and individualistic social values are placed above concepts of the "common good" of liberalism and socialism in its various forms. in the more extreme forms of this concept, the individual is responsible for his or her own health, including payment, and has a choice of health care providers that will respond with high-quality personalized care. market forces, meaning competition in financing and provision of health services with rationing of services, based on fees or private insurance and willingness and ability to pay, have become part of the ideology of the new conservatism. it is assumed that the patient (i.e., the consumer) will select the best service for his or her need, while the provider best able to meet consumer expectations will thrive. in its purest form, the state has no role in providing or financing of health services except those directly related to community protection and promotion of a healthful environment without interfering with individual choices. the state ensures that there are sufficient health care providers and allows market forces to determine the prices and distribution of services with minimal regulation. the usa retains this orientation in a highly modified form, with 86 percent of the population covered by some form of private or public insurance systems (see chapters 10 and 13). modified market forces in health care are part of health reforms in many countries as they seek not only to ensure quality health care for all but also to constrain costs. a free market in health care is costly and ultimately inefficient because it encourages inflation of provider incomes or budgets and increasing utilization of highly technical services. further, even in the most free market societies, the economy of health care is highly influenced by many factors outside the control of the consumer and provider. the total national health expenditure in the usa rose rapidly until reaching over 17.7 percent of gross domestic product (gdp) in 2011, the highest of any country, despite serious deficiencies for those without any or with very inadequate health insurance (in total more than 30 percent of the population). this figure compares to some 11.2 percent of gdp in canada, which has universal health insurance under public administration. following the 1994 defeat of president clinton's national health program, the conservative congress and the business community took steps to expand managed care in order to control costs, resulting in a revolution in health care in the usa (see chapters 11 and 13). in the 2011-2019 decade health expenditure in the usa is expected to rise to 19.6 percent of gdp, partly owing to increased population coverage with implementation of the ppaca (obamacare). reforms are being implemented in many "socialized" health systems. these may be through incentives to promote achievement of performance indicators, such as full immunization coverage. others are using control of supply, such as hospital beds or licensed physicians, as methods of reducing overutilization of services that generates increasing costs. market mechanisms in health are aimed not only at the individual but also at the provider. incentive payment systems must work to protect the patient's legitimate needs, and conversely incentives that might reduce quality of care should be avoided. fee-for-service promotes high rates of services such as surgery. increasing private practice and user fees can adversely affect middle-and low-income groups, as well as employers, by raising the costs of health insurance. managed care systems, with restraints on fee-for-service medical practice, have emerged as a positive response to the market approach. incentive systems in payments for services may be altered by government or insurance agencies in order to promote rational use of services, such as reduction of hospital stays. the free market approach is affecting planning of health insurance systems in previously highly centralized health systems in developing countries as well as the redevelopment of health systems in former soviet countries. despite political differences, reform of health systems has become a common factor in virtually all health systems since the 1990s, as each government searches for costeffectiveness, quality of care, and universality of coverage. the new paradigm of health care reform sees the convergence of different systems to common principles. national responsibility for health goals and health promotion leads to national financing of health care with regional and managed care systems. most developed countries have long since adopted national health insurance or service systems. some governments may, as in the usa, insure only the highest risk groups such as the elderly and the poor, leaving the working and middle classes to seek private insurers. the nature and direction of health care reform affecting coverage of the population are of central importance in the new public health because of its effects on allocation of resources and on the health of the population. the effects of the economic crisis in the usa are being felt worldwide. while the downturn has largely occurred in wealthier nations, the poor in low-income countries will be among those affected. past economic downturns have been followed by substantial drops in foreign aid to developing countries. as public health gained from sanitary and other control measures for infectious diseases, along with mother and child care, nutrition, and environmental and occupational health, it also gained strength and applicability from advances in the social and behavioral sciences. social darwinism, a political philosophy that assumed "survival of the fittest" and no intervention of the sate to alleviate this assumption, was popular in the early nineteenth century but became unacceptable in industrialized countries, which adopted social policies to alleviate the worst conditions of poverty, unemployment, poor education, and other societal ills. the political approach to focusing on health and poverty is associated with jeremy bentham in britain in the late eighteenth century, who promoted social and political reform and "the greatest good for the greatest number", or utilitarianism. rudolf virchow, an eminent pathologist and a leader in recognizing ill-health and poverty as cause and effect, called for political action to create better conditions for the poor and working-class population. the struggle for a social contract was promoted by pioneer reformists such as edwin chadwick (general report on the sanitary condition of the labouring population of great britain, 1842), who later became the first head of the board of health in britain, and lemuel shattuck (report of a general plan for the promotion of public and personal health, 1850) . shattuck was the organizer and first president of the american statistical association. the social sciences have become fundamental to public health, with a range of disciplines including vital statistics and demography (seventeenth century), economics and politics (nineteenth century), sociology (twentieth century), history, anthropology, and others, which provide collectively important elements of epidemiology of crucial significance for survey methods and qualitative research (see chapter 3). these advances contributed greatly to the development of methods of studying diseases and risk factors in a population and are still highly relevant to addressing inequalities in health. individuals in good health are better able to study and learn, and be more productive in their work. improvements in the standard of living have long been known to contribute to improved public health; however, the converse has not always been recognized. investment in health care was not considered a high priority in many countries where economic considerations directed investment to the "productive" sectors such as manufacturing and large-scale infrastructure projects, such as hydroelectric dams. whether health is a contributor to economic development or a drain on societies' resources has been a fundamental debate between socially and market-oriented advocates. classic economic theory, both free enterprise and communist, has tended to regard health as a drain on economies, distracting investment needed for economic growth. as a result, in many countries health has been given low priority in budgetary allocation, even when the major source of financing is governmental. this belief among economists and banking institutions prevented loans for health development on the grounds that such funds should focus on creating jobs and better incomes, before investing in health infrastructure. consequently, the development of health care has been hampered. a socially oriented approach sees investment in health as necessary for the protection and development of "human capital", just as investment in education is needed for the long-term benefit of the economy of a country. in 1993, the world bank's world development report: investing in health articulated a new approach to economics in which health, along with education and social development, is seen as an essential precondition for and contributor to economic development. while many in the health field have long recognized the importance of health for social and economic improvement, its adoption by leading international development banking may mark a turning point for investment in developing nations, so that health may be a contender for increased development loans. the concept of an essential package of services discussed in that report establishes priorities in low-and middle-income countries for efficient use of resources based on the burden of disease and cost-effectiveness analysis of services. it includes both preventive and curative services targeted to specific health problems. it also recommends support for comprehensive primary care, such as for children, and infrastructure development including maternity and hospital care, medical and nursing outreach services, and community action to improve sanitation and safe water supplies. reorientation of government spending on health is increasingly being adopted, as in the uk, to improve equity in access for the poor and other neglected sectors or regions of society with added funding for relatively deprived areas to improve primary care services. differential capitation funding as a form of affirmative action to provide for highneeds populations is a useful concept in public health terms to address the inequities still prevalent in many countries. as medical care has gradually become more involved in prevention, and as it has moved into the era of managed care, the gap between public health and clinical medicine has narrowed. as noted above, many countries are engaged in reforms in their health care systems. the motivation is largely derived from the need for cost containment, but also to extend health care coverage to underserved parts of the population. countries without universal health care still have serious inequities in distribution of or access to services, and may seek reform to reduce those inequities, perhaps under political pressures to improve the provision of services. incentives for reform are needed to address regional inequities, and preserving or developing universal access and quality of care, but also on inequities in health between the rich and the poor countries and within even the wealthy countries. in some settings, a health system may fail to keep pace with developments in prevention and in clinical medicine. some countries have overdeveloped medical and hospital care, neglecting important initiatives to reduce the risk of disease. the process of reform requires setting standards to measure health status and the balance of services to optimize health. a health service can set a target of immunizing 95 percent of infants with a national immunization schedule, but requires a system to monitor performance and incentives for changes. a health system may also have failed to adapt to changing needs of the population through lack, or misuse, of health information and monitoring systems. as a result, the system may err seriously in its allocation of resources, with excessive emphasis on hospital care and insufficient attention to primary and preventive care. all health services should have mechanisms for correctly gathering and analyzing needed data for monitoring the incidence of disease and other health indicators, such as hospital utilization, ambulatory care, and preventive care patterns. for example, the uk's nhs periodically undertakes a restructuring process of parts of the system to improve the efficiency of service. this involves organizational changes and decentralization with regional allocation of resources (see chapter 13). health systems are under pressures of changing demographic and epidemiological patterns as well as public expectations, rising costs of new technology, financing, and organizational change. new problems must be continually addressed with selection of priority issues and the most effective methods chosen. reforms may create unanticipated problems, such as professional or public dissatisfaction, which must be evaluated, monitored, and addressed as part of the evolution of public health. literacy, freedom of the press, and increasing public concern for social and health issues have contributed to the development of public health. the british medical community lobbied for restrictions on the sale of gin in the 1780s in order to reduce the damage that it caused to the working class. in the late eighteenth and the nineteenth centuries, reforms in society and sanitation were largely the result of strongly organized advocacy groups influencing public opinion through the press. such pressure stimulated governments to act in regulating the working conditions of mines and factories. abolition of the slave trade and its suppression by the british navy in the early nineteenth century resulted from successful advocacy groups and their effects on public opinion through the press. vaccination against smallpox was promoted by privately organized citizen groups, until later taken up by local and national government authorities. advocacy consists of activities of individuals or groups publicly pleading for, supporting, espousing, or recommending a cause or course of action. the advocacy role of reform movements in the nineteenth century was the basis of the development of modern organized public health. campaigns ranged from the reform of mental hospitals, nutrition for sailors to prevent scurvy and beriberi, and labor laws to improve working conditions for women and children in particular, to the promotion of universal education and improved living conditions for the working population. reforms on these and other issues resulted from the stirring of the public consciousness by advocacy groups and the public media, all of which generated political decisions in parliaments (box 2.12). such reforms were in large part motivated by fear of revolution throughout europe in the mid-nineteenth century and the early part of the twentieth century. trade unions, and before them medieval guilds, fought to improve hours, safety, and conditions of work, as well as social and health benefits for their members. in the usa, collective bargaining through trade unions achieved wage increases and widespread coverage of the working population under voluntary health insurance. unions and some industries pioneered prepaid group practice, the predecessor of health maintenance organizations and managed care or the more recent acos (see chapters 10 and 13). through raising public consciousness on many issues, advocacy groups pressure governments to enact legislation to restrict smoking in public places, prohibit tobacco advertising, and mandate the use of bicycle helmets. advocacy groups play an important role in advancing health based on disease groups, such as cancer, multiple sclerosis, and thalassemia, or advancing health issues, such as the organizations promoting breastfeeding, environmental improvement, or smoking reduction. some organizations finance services or facilities not usually provided within insured health programs. such organizations, which can number in the hundreds in a country, advocate the importance of their special concern and play an important role in innovation and meeting community health needs. advocacy groups, including trade unions, professional groups, women's groups, self-help groups, and many others, focus on specific issues and have made major contributions to advancing the new public health. the history of public health is replete with pioneers whose discoveries led to strong opposition and sometimes violent rejection by conservative elements and vested interests in medical, public, or political circles. opposition to jennerian vaccination, the rejection of semmelweiss by colleagues in vienna, and the contemporary opposition to the work of great pioneers in public health such as pasteur, florence nightingale, and many others may deter or delay implementation of other innovators and new breakthroughs in preventing disease. although opposition to jenner's vaccination lasted well into the late nineteenth century in some areas, its supporters gradually gained ascendancy, ultimately leading to the global eradication of smallpox. these and other pioneers led the way to improved health, often after bitter controversy on topics later accepted and which, in retrospect, seem to be obvious. advocacy has sometimes had the support of the medical profession but elicited a slow response from public authorities. david marine of the cleveland clinic and david cowie, professor of pediatrics at the university of michigan, proposed the prevention of goiter by iodization of salt. marine carried out a series of studies in fish, and then in a controlled clinical trial among schoolgirls in 1917-1919, with startlingly positive results in reducing the prevalence of goiter. cowie campaigned for the iodization of salt, with support from the medical profession. in 1924, he convinced a private manufacturer to produce morton's iodized salt, which rapidly became popular throughout north america. similarly, iodized salt came to be used in many parts of europe, mostly without governmental support or legislation. iodine-deficiency disorders (idds) remain a widespread condition, estimated to have affected 2 billion people worldwide in 2013. the target of international eradication of idds by 2000 was set at the world summit for children in 1990, and the who called for universal iodization of salt in 1994. by 2008, nearly 70 percent of households in developing countries consumed adequately iodized salt. china and nigeria, have had great success in recent years with mandatory salt fortification in increasing iodization rates, in china from 39 percent to 95 percent in 10 years. but the problem is not yet gone and even in europe there is inadequate standardization of iodine levels and population follow-up despite decades of work on the problem. professional organizations have contributed to promoting causes such as children's and women's health, and environmental and occupational health. the american academy of pediatrics has contributed to establishing and promoting high standards of care for infants and children in the usa, and to child health internationally. hospital accreditation has been used for decades in the usa, canada, and more recently in australia and the uk. it has helped to raise standards of health facilities and care by carrying out systematic peer review of hospitals, nursing homes, primary care facilities, and mental hospitals, as well as ambulatory care centers and public health agencies (see chapter 15). public health needs to be aware of negative advocacy, sometimes based on professional conservatism or economic self-interest. professional organizations can also serve as advocates of the status quo in the face of change. opposition by the american medical association (ama) and the health insurance industry to national health insurance in the usa has been strong and successful for many decades. the passage of the ppaca has been achieved despite widespread political and public opposition, yet was sustained in the us supreme court and is gaining widening popular support as the added value to millions of formerly uninsured americans becomes clear. in some cases, the vested interest of one profession may block the legitimate development of others, such as when ophthalmologists lobbied successfully against the development of optometry, now widely accepted as a legitimate profession. political activism for reform in nineteenth-century britain led to banning and suppressing the slave trade, improvements in working conditions for miners and factory workers, and other major political reforms. in keeping with this tradition, samuel plimsoll (1824-1898), british member of parliament elected for derby in 1868, conducted a solo campaign for the safety of seamen. his book, our seamen, described ships sent to sea so heavily laden with coal and iron that their decks were awash. seriously overloaded ships, deliberately sent to sea by unscrupulous owners, frequently capsized, drowning many crew members, with the owners collecting inflated insurance fees. overloading was the major cause of wrecks and thousands of deaths in the british shipping industry. plimsoll pleaded for mandatory load-line certificate markers to be issued to each ship to prevent any ships putting to sea when the marker was not clearly visible. powerful shipping interests fought him every inch of the way, but he succeeded in having a royal commission established, leading to an act of parliament mandating the "plimsoll line", the safe carrying capacity of cargo ships. this regulation was adopted by the us bureau of shipping as the load line act in 1929 and is now standard practice worldwide. jenner's discovery of vaccination with cowpox to prevent smallpox was adopted rapidly and widely. however, intense opposition by organized groups of antivaccinationists, often led by those opposed to government intervention in health issues and supported by doctors with lucrative variolation practices, delayed the implementation of smallpox vaccination for many decades. ultimately, smallpox was eradicated in 1972, owing to a global campaign initiated by the who. opposition to legislated restrictions on private ownership of assault weapons and handguns is intense in the usa, led by well-organized, well-funded, and politically powerful lobby groups, despite the amount of morbidity and mortality due to gun-associated violent acts (see chapter 5). fluoridation of drinking water is the most effective public health measure for preventing dental caries, but it is still widely opposed, and in some places the legislation has been rescinded even after implementation, by wellorganized antifluoridation campaigns. opposition to fluoridation of community water supplies is widespread, and effective lobbying internationally has slowed but has not stopped progress (see chapter 6). despite the life-saving value of immunization, opposition still exists in 2013 and harms public health protection. opposition has slowed progress in poliomyelitis eradication; for example, radical islamists killed polio workers in northern nigeria in 2012, one of the last three countries with endemic poliomyelitis. resistance to immunization in the 1980s has resulted in the recurrence of pertussis and diphtheria and a very large epidemic of measles across western europe, including the uk, with further spread to the western hemisphere in 2010-2013 (see chapter 4). progress may be blocked where all decisions are made in closed discussions, not subject to open scrutiny and debate. public health personnel working in the civil service of organized systems of government may not be at liberty to promote public health causes. however, professional organizations may then serve as forums for the essential professional and public debate needed for progress in the field. professional organizations such as the apha provide effective lobbying for the interests of public health programs and can have an important impact on public policy. in mid-1996, efforts by the secretary of health and human services in the usa brought together leaders of public health with representatives of the ama and academic medical centers to try to find areas of common interest and willingness to promote the health of the population. in europe too, increasing cooperation between public health organizations is stimulating debate on issues of transnational importance across the region, which, for example, has a wide diversity of standards on immunization practices and food policies. public advocacy has played an especially important role in focusing attention on ecological issues (box 2.13). in 1995, greenpeace, an international environmental activist group, fought to prevent the dumping of an oil rig in the north sea and forced a major oil company to find another solution that would be less damaging to the environment. an explosion on an oil rig in the gulf of mexico in 2010 led to enormous ecological and economic damage as well as loss of life. damages levied on the responsible company (british petroleum) amount to some $4.5 billion dollars and several criminal negligence charges are pending. greenpeace also continued its efforts to stop the renewal of testing of atomic bombs by france in the south pacific. international protests led to the cessation of almost all testing of nuclear weapons. international concern over global warming has led to growing efforts to stem the tide of air pollution from fossil fuels, coal-burning electrical production, and other manifestations of carbon dioxide and toxic contamination of the environment. progress is far from certain as newly enriched countries such as china and india follow the rising consumption patterns of western countries. public advocacy and rejection of wanton destruction of the global ecology may be the only way to prod consumers, governments, and corporate entities such as the energy and transportation industries to change direction. the pace of change from fossil fuels is slow but has captured public attention, and private companies are seeking more fuel efficiency in vehicles and electrical power production, mainly though the use of natural gas instead of fuel oil and coal for electricity production or better still by wind and solar energy. the search for "green solutions" to the global warming crisis has become increasingly dynamic, with governments, the private sector, and the general public keenly aware of the importance of the effort and the dangers of failure. in the latter part of the twentieth century and the early twenty-first century, prominent international personalities and entertainers have taken up causes such as the removal of land mines in war-torn countries, illiteracy in disadvantaged advocacy is a function in public health that has been important in promoting advances in the field, and one that sometimes places the advocate in conflict with established patterns and organizations. one of the classic descriptions of this function is in henrik ibsen's play an enemy of the people, in which the hero, a young doctor, thomas stockmann, discovers that the water in his community is contaminated. this knowledge is suppressed by the town's leadership, led by his brother the mayor, because it would adversely affect plans to develop a tourist industry of baths in their small norwegian town in the late nineteenth century. the young doctor is taunted and abused by the townspeople and driven from the town, having been declared an "enemy of the people" and a potential risk. the allegory is a tribute to the man of principle who stands against the hysteria of the crowd. the term also took on a far more sinister and dangerous meaning in george orwell's novel 1984 and in totalitarian regimes of the 1930s to the present time. populations, and funding for antiretroviral drugs for african countries to reduce maternal-fetal transmission of hiv and to provide care for the large numbers of cases of aids devastating many countries of sub-saharan africa. rotary international has played a key role in polio eradication efforts globally. the public-private consortium global alliance for vaccines and immunization (gavi) has been instrumental in promoting immunization in recent years, with participation by the who, unicef, the world bank, the gates foundation, vaccine manufacturers, and others. this has had an important impact on extending immunization to protect and save the lives of millions of children in deprived countries not yet able to provide fundamental prevention programs such as immunization at adequate levels. gavi has brought vaccines to low-income countries around the world, such as rotavirus vaccine, pentavalent vaccine in myanmar, and pneumococcal vaccine for children in 15 countries in sub-saharan africa, including dr congo. the bill & melinda gates foundation pledged us $750 million in 1999 to establish gavi, with us $75 million per year and us $1 billion in 2010 to promote the decade of vaccines. international conferences help to create a worldwide climate of advocacy for health issues. international sanitary conferences in the nineteenth century were convened in response to the cholera epidemics. international conferences continue in the twenty-first century to serve as venues for advocacy on a global scale, bringing forward issues in public health that are beyond the scope of individual nations. the who, unicef, and other international organizations perform this role on a continuing basis (see chapter 16). criticisms of this approach have focused on the lack of similar effort or donors to address ncds, weak public health infrastructure, and that this frees national governments from responsibility to care for their own children. no one can question, however, that this kind of endeavor has saved countless lives and needs the backing of other aid donors and national government participation. consumerism is a movement that promotes the interests of the purchaser of goods or services. in the 1960s, a new form of consumer advocacy emerged from the civil rights and antiwar movement in the usa. concern was focused on the environment, occupational health, and the rights of the consumer. rachel carson stimulated concern by dramatizing the effects of ddt on wildlife and the environment but inadvertently jeopardized anti-malarial efforts in many countries. this period gave rise to environmental advocacy efforts worldwide, and a political movement, the greens, in western europe. ralph nader showed the power of the advocate or "whistle-blower" who publicizes health hazards to stimulate active public debate on a host of issues related to the public well-being. nader, a consumer advocate lawyer, developed a strategy for fighting against business and government activities and products which endangered public health and safety. his 1965 book unsafe at any speed took issue with the us automobile industry for emphasizing profit and style over safety, and led to the enactment of the national traffic and motor safety act of 1966, establishing safety standards for new cars. this was followed by a series of enactments including design and emission standards and seat-belt regulations. nader's work continues to promote consumer interests in a wide variety of fields, including the meat and poultry industries, and coal mining, and promotes greater government regulatory powers regarding pesticide usage, food additives, consumer protection laws, rights to knowledge of contents, and safety standards. consumerism has become an integral part of free market economies, and the educated consumer does influence the quality, content, and price of products. greater awareness of nutrition in health has influenced food manufacturers to improve packaging, content labeling, enrichment with vitamins and minerals, and advertisement to promote those values. low-fat dietary products are available because of an increasingly sophisticated public concerned over dietary factors in cardiovascular diseases. the same process occurred in safe toys and clothing for children, automobile safety features such as mandatory use of car seats for infants, and other innovations that quickly became industry standards in the industrialized world. dangerous practices such as the use of lead paint in toys and melamine contamination of milk products from china capture the public attention quickly and remind public health authorities of the importance of continuous alertness to potential hazards. consumerism can also be exploited by pharmaceutical companies with negative impacts on the health system, especially in the advertising of health products which leads to unnecessary visits to health providers and pressure for approval to obtain the product. the internet has provided people with access to a vast array of information and opinion, and to current literature otherwise unavailable because of the often inadequate library resources of medical and other health professionals. the very freedom of information the internet allows, however, also provides a vehicle for extremist and fringe groups to promote disinformation such as "vaccination causes autism, fluoridation causes cancer", which can cause considerable difficulties for basic public health programs or lead to self-diagnosis of conditions, with often disastrous consequences. advocacy and voluntarism go hand in hand. voluntarism takes many forms, including raising funds for the development of services or operating services needed in the community. it may take the form of fund-raising to build clinics or hospitals in the community, or to provide medical equipment for elderly or handicapped people; or retirees and teenagers working as hospital volunteers to provide services that are not available through paid staff, and to provide a sense of community caring for the sick in the best traditions of religious or municipal concerns. this can also be extended to prevention, as in support for immunization programs, assistance for the handicapped and elderly in transportation, meals-on-wheels, and many other services that may not be included in the "basket of services" provided by the state, health insurance, or public health services. community involvement can take many forms, and so can voluntarism. the pioneering role of women's organizations in promoting literacy, health services, and nutrition in north america during the latter part of the nineteenth and the early twentieth centuries profoundly affected the health of the population. the advocacy function is enhanced when an organization mobilizes voluntary activity and funds to promote changes or needed services, sometimes forcing official health agencies or insurance systems to revise their attitudes and programs to meet these needs. by the early 1970s, canada's system of federally supported provincial health insurance plans covered all of the country. the federal minister of health, marc lalonde, initiated a review of the national health situation, in view of concern over the rapidly increasing costs of health care. this led to articulation of the "health field concept" in 1974, which defined health as a result of four major factors: human biology, environment, behavior, and health care organization (box 2.14). lifestyle and environmental factors were seen as important contributors to the morbidity and mortality in modern societies. this concept gained wide acceptance, promoting new initiatives that emphasized health promotion in response to environmental and lifestyle factors. conversely, reliance primarily on medical care to solve all health problems could be counterproductive. this concept was a fundamental contributor to the idea of health promotion later articulated in the ottawa declaration, discussed below. the health field concept came at a time when many epidemiological studies were identifying risk factors for cardiovascular diseases and cancers that related to personal habits, such as diet, exercise, and smoking. the concept advocated that public policy needed to address individual lifestyle as part of the overall effort to improve health status. as a result, the canadian federal government established health promotion as a new activity. this quickly spread to many other jurisdictions and gained wide acceptance in many industrialized countries. concern was expressed that this concept could become a justification for a "blame the victim" approach, in which those ill with a disease related to personal lifestyles, such as smokers or aids patients, are seen as having chosen to contract the disease. such a patient might then be considered not to be entitled to all benefits of insurance or care that others may receive. the result may be a restrictive approach to care and treatment that would be unethical in the public health tradition and probably illegal in western jurisprudence. this concept was also used to justify withdrawal from federal commitments in cost sharing and escape from facing controversial health reform in the national health insurance program. during the 1960s and 1970s, outspoken critics of health care systems, such as ivan illytch, questioned the value of medical care for the health of the public. this became a widely discussed, somewhat nihilistic, view towards medical care, and was influential in promoting skepticism regarding the value of the biomedical mode of health care, and antagonism towards the medical profession. in 1976, thomas mckeown presented a historicalepidemiological analysis showing that up to the 1950s, medical care had only a limited impact on mortality rates, although improvements in surgery and obstetrics were notable. he showed that crude death rates in england averaged about 30 per 1000 population from 1541 to 1750, declining steeply to 22 per 1000 in 1851, 15 per 1000 in 1901, and 12 per 1000 in 1951, when medical care became truly effective. mckeown concluded that much of the improvement in health status over the past several centuries was due to reduced mortality from infectious diseases. this he related to limitation of family size, increased food supplies, improved nutrition and sanitation, specific preventive and therapeutic measures, and overall gains in quality of life for growing elements of the population. he cautioned against placing excessive reliance for health on medical care, much of which was of unproved effectiveness. this skepticism of the biomedical model of health care was part of wider antiestablishment feelings of the 1960s and 1970s in north america. in 1984, milton roemer pointed out that the advent of vaccines, antibiotics, antihypertensives, and other medications contributed to great improvements in infant and child care, and in the management of infectious diseases, hypertension, diabetes, and other conditions. therapeutic gains continue to arrive from teaching centers around the world. vaccine, pharmaceutical, and diagnostic equipment manufacturers continue to provide important innovations that have major benefits, but also raise the cost of health care. the latter issue is one which has stimulated the search for reforms, and search for lower cost technologies such as in treatment of hepatitis c patients, a huge international public health issue. the value of medical care to public health and vice versa has not always been clear, either to public health personnel or to clinicians. the achievements of modern public health in controlling infectious diseases, and even more so in reducing the mortality and morbidity associated with chronic diseases such as stroke and chd, were in reality a shared achievement between clinical medicine and public health (see chapter 5). preventive medicine has become part of all medical practice, with disease prevention through early diagnosis and health promotion through individual and community-focused activities. risk factor evaluation determines appropriate screening and individual and community-based interventions. medical care is crucial in controlling hypertension and in reducing the complications and mortality from chd. new modalities of treatment are reducing death rates from first time acute myocardial infarctions. better management of diabetes prevents the early onset of complications. at the same time, the contribution of public health to improving outcomes of medical care is equally important. control of the vaccine-preventable diseases, improved nutrition, and preparation for motherhood contribute to improved maternal and infant outcomes. promotions of reduced exposure to risk factors for chronic disease are a task shared by public health and clinical medical services. both clinical medicine and public health contribute to improved health status. they are interdependent and rely on funding systems for recognition as part of the new public health. during the 1950s, many new management concepts emerged in the business community, such as "management by objective", a concept developed by peter drucker at general motors, with variants such as "zero-based budgeting" developed in the us department of defense (see chapter 12). they focused the activities of an organization and its budget on targets, rather than on previous allocation of resources. these concepts were applied in other spheres, but they influenced thinking in health, whose professionals were seeking new ways to approach health planning. the logical application was to define health targets and to promote the efficient use of resources to achieve those targets. this occurred in the usa and soon afterwards in the who european region. in both cases, a wide-scale process of discussion and consensus building was used before reaching definitive targets. this process contributed to the adoption of the targets by many countries in europe as well as by states and many professional and consumer organizations. the usa developed national health objectives in 1979 for the year 1990 and subsequently for the year 2000, with monitoring of progress in their achievement and development of further targets for 2010 and now for 2020. beginning in 1987, state health profiles are prepared by the epidemiology program office of the centers for disease control and prevention based on 18 health indicators recommended by a consensus panel representing public health associations and organizations. the eight mdgs adopted by the un in 2000 include halving extreme poverty, reducing child mortality by twothirds, improving maternal health, halting the spread of hiv/aids, malaria, and other diseases, and providing universal primary education, all by the target date of 2015. the mdgs form a common blueprint agreed to by all countries and the world's leading development institutions. the process has galvanized unprecedented efforts to meet the needs of the world's poorest, yet 2008 reviews of progress indicate that most developing nations will not meet the targets at current rates of progress. the united nations development programme (undp) global partnership for development 2012 report on the mdgs states that if the national development strategies and initiatives are supported by international development partners, the goals can be achieved by 2015. the mdgs were adopted by over 120 nations and provided guidance for national policies and for international aid agencies. the focus was on middle-and low-income countries and their achievements have been considerable but variable (see box 2.15 and chapter 16) . as of july 2012, extreme poverty was falling in every region, the poverty reduction target had been met, the world had met the target of halving the proportion of people without access to improved sources of water, and the world had achieved parity in primary education between girls and boys. further progress will require sustained political commitment to develop the primary care infrastructure: improved reporting and epidemiological monitoring, consultative mechanisms, and consensus by international agencies, national governments, and non-governmental agencies. the achievement of the targets will also require sustained international support and national commitment with all the difficulties of a time of economic recession. nevertheless, defining a target is crucial to the process. there are encouraging signs that national governments are influenced by the general movement to place greater emphasis on resource allocation and planning on primary care to achieve internationally recognized goals and targets. the successful elimination of smallpox, rising immunization coverage in the developing countries, and increasing implementation of salt iodization have shown that such goals are achievable. while the usa has not succeeded in developing universal health care access, it has a strong tradition of public health and health advocacy. federal, state, and local health authorities have worked out cooperative arrangements for financing and supervising public health and other services. with growing recognition in the 1970s that medical services alone would not achieve better health results, health policy leadership in the federal government formulated a new approach, in the form of developing specific health targets for the nation. in 1979, the surgeon general of the usa published the report on health promotion and disease prevention (healthy people). this document set five overall health goals for each of the major age groups for the year 1990, accompanied by 226 specific health objectives. new targets for the year 2000 were developed in three broad areas: to increase healthy lifespans, to reduce health disparities, and to achieve access to preventive health care for all americans. these broad goals are supported by 297 specific targets in 22 health priority areas, each one divided into four major categories: health promotion, health protection, preventive services, and surveillance systems. this set the public health agenda on the basis of measurable indicators that can be assessed year by year. reduce child mortality -progress on child mortality is gaining momentum. the target is to reduce by two-thirds, between 1990 and 2015, the under-5-year-old mortality rate, from 93 children of every 1000 dying to 31 of every 1000. child deaths are falling, but much more needs to be done in order to reach the development goal. revitalizing efforts against pneumonia and diarrhea, while bolstering nutrition, could save millions of children. l mdg5. improve maternal health -maternal mortality has nearly halved since 1990, but levels are far removed from the 2015 target. the targets for improving maternal health include reducing by three-quarters the maternal mortality ratio and achieve universal access to reproductive health. poverty and lack of education perpetuate high adolescent birth rates. inadequate funding for family planning is a major failure in fulfilling commitments to improving women's reproductive health. l mdg6. combat hiv/aids, malaria, tuberculosis, and other diseases -more people than ever are living with hiv owing to fewer aids-related deaths and the continued large number of new infections. in 2011, an estimated 34.2 million were living with hiv, up 17 percent from 2001. this persistent increase reflects the continued large number of new infections along with a significant expansion of access to lifesaving antiretroviral therapy, especially in more recent years. l mdg7. ensure environmental sustainability -the unparalleled success of the montreal protocol shows that action on climate change is within grasp. the 25th anniversary of the montreal protocol on substances that deplete the ozone layer, in 2012, had many achievements to celebrate. most notably, there has been a reduction of over 98 percent in the consumption of ozone-depleting substances. further, because most of these substances are also potent greenhouse gases, the montreal protocol has contributed significantly to the protection of the global climate system. the reductions achieved to date leave hydrochlorofluorocarbons (hcfcs) as the largest group of substances remaining to be phased out. l mdg8. a global partnership for development -core development aid fell in real terms for the first time in more than a decade, as donor countries faced fiscal constraints. in 2011, net aid disbursements amounted to $133.5 billion, representing 0.31 percent of developed countries' combined national income. while constituting an increase in absolute dollars, this was a 2.7 percent drop in real terms over 2010. if debt relief and humanitarian aid are excluded, bilateral aid for development programmes and projects fell by 4.5 percent in real terms. equitable and sustainable funding of health services. 18. developing human resources (educational programs for providers and managers based on the principles of the health for all policy). 19. research and knowledge: health programs based on scientific evidence. 20. mobilizing partners for health (engaging the media/ television/internet). 21. policies and strategies for health for all -national, targeted policies based on health for all. a 2010-2012 review has been commissioned by the european office of the who to assess inequalities in the social determinants of health. while health has improved there are still significant inequalities. factors include variance in local, regional, national, and global economic forces. the european union and the european region of who are both working on health targets for the year 2020. there are competing demands in society for expenditure by the government, and therefore making the best use of resources -money and people -is an important objective. the uk has devolved many of the responsibilities to the constituent countries (england, wales, scotland, and northern ireland) within an overall national framework (box 2.17). of the health consequences of their decisions and to accept responsibility for health. health promotion policy combines diverse but complementary approaches, including legislation, fiscal measures, taxation, and organizational change. it is a coordinated action that leads to health, income, and social policies that foster greater equity. joint action contributes to ensuring safer and healthier goods and services, healthier public services, and cleaner, more enjoyable environments. health promotion policies require the identification of obstacles to the adoption of healthy public policies in non-health sectors, and ways of removing them. built on progress made from the declaration on primary health care at alma-ata, the aim was to make the healthier choice the easier choice for policy makers as well. the logo of the ottawa charter has been maintained by the who as the symbol and logo of health promotion. health promotion represents activities to enhance and embed the concept of building healthy public policy through: l building healthy public policy in all sectors and levels of government and society l enhancing both self help and social support l developing personal skills through information and education for health l enabling, mediating, and advocating healthy public policy in all spheres l creating supportive environments of mutual help and conservation of the natural environment l reorienting health services beyond providing clinical curative services with linkage to broader social, political, economic, and physical environmental components. (adapted from ottawa charter; health and welfare canada and world health organization, 1986) an effective approach to health promotion was developed in australia where, in the state of victoria, revenue from a cigarette tax has been set aside for health promotion purposes. this has the effect of discouraging smoking, and at the same time finances health promotion activities and provides a focus for health advocacy in terms of promoting cessation of cigarette advertising at sports events or on television. it also allows for assistance to community groups and local authorities to develop health promotion activities at the workplace, in schools, and at places of recreation. health activity in the workplace involves reduction of work hazards as well as promotion of a healthy diet and physical fitness, and avoidance of risk factors such as smoking and alcohol abuse. in the australian model, health promotion is not only the persuasion of people to change their life habits; it also involves legislation and enforcement towards environmental changes that promote health. for example, this involves mandatory filtration, chlorination, and fluoridation for community water supplies, vitamin and mineral enrichment of basic foods. primary care alliances of service providers are organized including hospitals, community health services serving a sub-district population for more efficient and comprehensive care. these are at the level of national or state policy, and are vital to a health promotion program and local community action. community-based programs to reduce chronic disease using the concept of community-wide health promotion have developed in a wide variety of settings. such a program to reduce risk factors for cardiovascular disease was pioneered in the north karelia project in finland. this project was initiated as a result of pressures from the affected population of the province, which was aware of the high incidence of mortality from heart disease. finland had the highest rates of chd in the world and in the rural area of north karelia the rate was even higher than the national average. the project was a regional effort involving all levels of society, including official and voluntary organizations, to try to reduce risk factors for chd. after 15 years of follow-up, there was a substantial decline in mortality with a similar decline in a neighboring province taken for comparison, although the decline began earlier in north karelia. in many areas where health promotion has been attempted as a strategy, community-wide activity has developed with participation of ngos or any valid community group as initiators or participants. healthy heart programs have developed widely with health fairs, sponsored by charitable or fraternal societies, schools, or church groups, to provide a focus for leadership in program development. a wider approach to addressing health problems in the community has developed into an international movement of "healthy cities". following deliberations of the health of towns commission chaired by edwin chadwick, the health of towns association was founded in 1844 by southwood smith, a prominent reform leader of the sanitary movement, to advocate change to reduce the terrible living conditions of much of the population of cities in the uk. the association established branches in many cities and promoted sanitary legislation and public awareness of the "sanitary idea" that overcrowding, inadequate sanitation, and absence of safe water and food created the conditions under which epidemic disease could thrive. in the 1980s, iona kickbush, trevor hancock, and others promoted renewal of the idea that local authorities have a responsibility to build health issues into their planning and development processes. this "healthy cities" approach promotes urban community action on a broad front of health promotion issues (table 2. 2). activities include environmental projects (such as recycling of waste products), improved recreational facilities for young people to reduce violence and drug abuse, health fairs to promote health awareness, and screening programs for hypertension, breast cancer, and other diseases. it combines health promotion with consumerism and returns to the tradition of local public health action and advocacy. the municipality, in conjunction with many ngos, develops a consultative process and program development approach to improving the physical and social life of the urban environment and the health of the population. in 1995, the healthy cities movement involved 18 countries with 375 cities in europe, canada, the usa, the uk, south america, israel, and australia, an increase from 18 cities in 1986. the model now extends to small municipalities, often with populations of fewer than 10,000. networks of healthy cities are the backbone of the movement, with more than 1400 member towns and cities across europe. the choice of core themes offers the opportunity to work on priority urban health issues that are relevant to all european cities. topics that are of particular concern to individual cities and/or are challenging and cutting edge for innovative public health action are especially emphasized. healthy cities encourages and supports experimentation with new ideas by developing concepts and implementing them in diverse organizational contexts. a healthy city is a city for all its citizens: inclusive, supportive, sensitive and responsive to their diverse needs and expectations. a healthy city provides conditions and opportunities that encourage, enable and support healthy lifestyles for people of all social groups and ages. a healthy city offers a physical and built environment that encourages, enables and supports health, recreation and well-being, safety, social interaction, accessibility and mobility, a sense of pride and cultural identity and is responsive to the needs of all its citizens. the apha's formulation of the public health role in 1995, entitled the future of public health in america, was presented at the annual meeting in 1996. the apha periodically revises standards and guidelines for organized public health services provided by federal, state, and local governments ( table 2 .4). these reflect the profession of public health as envisioned in the usa where access to medical care is limited for large numbers of the population because of a lack of universal health insurance. public health in the usa has been very innovative in determining risk groups in need of special care and finding direct and indirect methods of meeting those needs. european countries such as finland have called for setting public health into all public policy, which reflects the vital role that local and county governments can play in developing health-oriented policies. these include policies in housing, recreation, regulation of industrial pollution, road safety, promotion of smoke-free environments, bicycle paths, health impact assessment, and many other applications of health principles in public policy. public health involves both direct and indirect approaches. direct measures in public health include immunization of children, modern birth control, and chronic disease case finding -hypertension, diabetes, and cancer. indirect methods used in public health protect the individual by community-wide means, such as raising standards of environmental safety, ensuring a safe water supply, sewage disposal, and improved nutrition (box 2.18). in public health practice, the direct and indirect pproaches are both relevant. to reduce morbidity and mortality from diarrheal diseases requires an adequate supply of safe water and waste disposal, and also education of the individual in hygiene and the mother in use of ort, and rotavirus vaccination of all children. the targets of public health action therefore include the individual, family, community, region, or nation, as well as a functioning and health system adopting current best practices for health care and health protection. the targets for protection in infectious disease control are both the individual and the total group at risk. for vaccine-preventable diseases, immunization protects the individual but also has an indirect effect by reducing the risk even for non-immunized persons. in control of some diseases, individual case finding and management reduce risk of the disease in others and the community. for example, tb requires case finding and adequate care among high-risk groups as a key to community control. in malaria control, case finding and treatment are essential together with environmental action to reduce the vector population, to prevent transmission of the organism by the mosquito to a new host. control of ncds, where there is no vaccine for mass application, depends on the knowledge, attitudes, beliefs, and practices of individuals at risk. in this case, the social context is of importance, as is the quality of care to which the individual has access. control and prevention of noninfectious diseases involve strategies using individual and population-based methods. individual or clinical measures include professional advice on how best to reduce the risk of the disease by early diagnosis and implementation of appropriate therapy. population-based measures involve indirect measures with government action banning cigarette advertising, or direct taxation on cigarettes. mandating food quality standards, such as limiting the fat content of meat, and requiring food labeling laws are part of the control of cardiovascular diseases. the way individuals act is central to the objective of reducing disease, because many non-infectious diseases are dependent on behavioral risk factors of the individual's choosing. changing the behavior of the individual means addressing the way a person sees his or her own needs. this can be influenced by the provision of information, but how someone sees his or her own needs is more complex than that. an individual may define needs differently from the society or the health system. reducing smoking among women may be difficult to achieve if smoking is thought to reduce appetite and food intake, given the social message that "slim is beautiful". reducing smoking among young people is similarly difficult if smoking is seen as fashionable and diseases such as lung cancer seem very remote. recognizing how individuals define needs helps the health system to design programs that influence behavior that is associated with disease. public health has become linked to wider issues as health care systems are reformed to take on both individual and population-based approaches. public health and mainstream medicine have found increasingly common ground in addressing the issues of chronic disease, growing attention to health promotion, and economics-driven health care reform. at the same time, the social ecology approaches have shown success in slowing major causes of disease, including heart disease and aids, and the biomedical sciences have provided major new technology for preventing major health problems, including cancer, heart disease, genetic disorders, and infectious diseases. technological innovations unheard of just a few years ago are now commonplace, in some cases driving up costs of care and in others replacing older and less effective care. at the same time, resistance of important pathogenic microorganisms to antibiotics and pesticides is producing new challenges from diseases once thought to be under control, and newly emerging infectious diseases challenge the entire health community. new generations of antibiotics, antidepressants, antihypertensive medications, and other treatment methods are changing the way many conditions are treated. research and development in the biomedical to improve the quality of public health practice and performance of public health systems sciences are providing means of prevention and treatment that profoundly affect disease patterns where they are effectively applied. the technological and organizational revolutions in health care are accompanied by many ethical, economic, and legal dilemmas. the choices in health care include heart transplantation, an expensive life-saving procedure, which may compete with provision of funds and labor resources for immunizations for poor children or for health promotion to reduce smoking and other risk factors for chronic disease. new means of detecting and treating acute conditions such as myocardial infarction and peptic ulcers are reducing hospital stays, and improving long-term survival and quality of life. imaging technology has been an important development in medicine since the advent of x-rays in the early twentieth century. technology has forged ahead with high-technology instruments and procedures, new medication, genetic engineering, and important low-technology gains such as impregnated bed nets, simplified tests for hiv and tb, and many other "game changers". new technologies that can enable lower cost diagnostic devices, electronic transmission, and distant reading of transmitted imaging all open up possibilities for advanced diagnostic capacities in rural and less developed countries and communities. molecular biology has provided methods of identifying and tracking movement of viruses such as polio and measles from place to place, greatly expanding the potential for appropriate intervention. the choices in resource allocation can be difficult. in part, these add political commitment to improve health, competent professionally trained public health personnel, the public's level of health information, and legal protection, whether through individuals, advocacy, or regulatory approaches for patients' rights. these are factors in a widening methodology of public health. the centers for disease control and prevention (morbidity and mortality weekly report) in 1999 summarized 10 great achievements of public health in the usa, with an extension of the lifespan by over 30 years and improvements in many measures of quality of life. they were updated in a similar summary report in 2011, showing continuous progress, and a global version which was also encouraging in its scope of progress (table 2 .5). these achievements were also seen in all developed countries over the past century and are beginning to be seen in developing countries as well. they reflect a successful application of a broad approach to prevention and health promotion along with improved medical care and growing access to its benefits. in the past several decades alone, major new innovations are leading to greater control of cardiovascular disease, cancer prevention, and many other improvements to health affecting hundreds of millions of people. a similar 2011 report by the cdc shows global progress in the first decade of the twenty-first century, while mdg reports show progress on all eight target topics, although not at uniformly satisfactory rates. these achievements are discussed throughout this text. this successful track record is very much at the center of a new public health involving a wide range of programs and activities, shown to be feasible and benefiting from continuing advances in science and understanding of social and management issues affecting health care systems worldwide. public health issues have received new recognition in recent years because of a number of factors, including a growing understanding among the populace at different levels in different countries that health behavior is a factor in health status and that public health is vital for protection against natural or human-made disasters. the challenges are also increasingly understood: preparation for bioterrorism, avian influenza, rising rates of diabetes and obesity, high mortality rates from cancer, and a wish for prevention to be effective. health systems offer general population benefits that go beyond preventing and treating illness. appropriately designed and managed, they: l provide a vehicle to improve people's lives, protecting them from the vulnerability of sickness, generating a sense of life security, and building common purpose within society l ensure that all population groups are included in the processes and benefits of socioeconomic development l generate the political support needed to sustain them over time. health systems promote health equity when their design and management specifically consider the circumstances and needs of socially disadvantaged and marginalized populations, including women, the poor, and groups who experience stigma and discrimination, enabling social action by these groups and the civil society organizations supporting them. health systems can, when appropriately designed and managed, contribute to achieving the millennium development goals. the mdgs selected by the un in 2000 have eight global targets for the year 2015, including four directly related to public health (discussed above, box 2.15). these are a recognition and a challenge to the international community and public health as a profession and as organized systems. formal education in newly developing schools of public health is increasing in europe, including many countries of eastern europe, and beginning to develop in india and sub-saharan africa. but there is delay in establishing centers of postgraduate education and research in many developing countries which are concentrating their educational resources on training physicians. many physicians from developing nations are moving to the developed countries, which have become dependent on these countries for a significant part of their supply of medical doctors. progress in implementation of the mdgs is mixed in sub-saharan africa, making some progress in immunization, but falling back on other goals. proposals to renew global health targets following the 2015 end-stage of the mdg health goals will need to add a focus on ncds, which account for 60 percent of global deaths, including 8.1 million premature deaths below the age of 60 (undp). economic growth has been hampered by the global recession since 2008, which will affect continued progress with many other factors of changing population dynamics, the economics of prevention versus expensive treatment costs, and the high costs of health care. environmental degradation with high levels of carbon dioxide contamination is a growing concern, with disastrous global warming and consequent effects of drought, flooding, hurricane, and elevated particulate matter-induced asthma and effects on cardiovascular disease. the potential for the development of basic and medical sciences in genetics, nanotechnology, and molecular biology shows enormous promise for health benefits as yet unimagined. at the same time, the effectiveness of health promotion has shown dramatic successes in reducing the toll of aids, reducing smoking, and increasing consciousness of nutrition and physical fitness in the population, and of the tragic effects of poverty and poor education on health status. the ethics of public health issues are complex and changing with awareness that failure to act on strong evidence-based policies is itself ethically problematic. the future of public health is not as a solo professional sector; it is at the heart of health systems, without which societies are open to chronic and infectious diseases that are preventable, affecting the society as a whole in economic and development matters. there is an expanding role of private donors in global health efforts, such as the rotary club and the polio eradication program, gavi with immunization and bed-nets in sub-saharan africa, and bilateral donor countries' help in reducing the toll of aids in sub-saharan africa. the new public health has emerged as a concept to meet a whole new set of conditions, associated with increasing longevity and aging of the population, with the post-world war ii baby-boom generation reaching the over-65 age group facing the growing importance of chronic diseases. inequalities in health exist in and between affluent and developing societies, as well as within countries, even those having advanced health care systems. regional inequalities are seen across the european region in an east-west gradient and globally a north-south divide of extremes of inequality. the global environmental and ecological degradation and pollution of air and water present grave challenges for developed and developing countries worldwide. yet optimism can be derived from proven track records of success in public health measures that have already been implemented. many of the underlying factors are amenable to prevention through social, environmental, or behavioral change and effective use of medical care. the new public health idea has evolved since alma-ata, which articulated the concept of health for all, followed by a trend in the late 1970s to health in all policies and establishing health targets as a basis for health planning. during the late 1980s and early 1990s, the debate on the future of public health in the americas intensified as health professionals looked for new models and approaches to public health research, training, and practice. this debate helped to redefine traditional approaches of social, community, and preventive medicine. the search for the "new" in public health continued with a return to the health for all concept of alma-ata (renewed in 2008) and a growing realization that the health of both the individual and the society involves the management of personal care services and community prevention, with a comprehensive approach taking advantage of advancing technology and experience of best practices globally. the new public health is an extension of the traditional public health. it describes organized efforts of society to develop healthy public policies: to promote health, to prevent disease, and to foster social equity within a framework of sustainable development. a new, revitalized public health must continue to fulfill the traditional functions of sanitation, protection, and related regulatory activities, but in addition to its expanded functions. it is a widened philosophy and practical application of many different methods of addressing health, and preventing disease and avoidable death. it necessarily addresses inequities so that programs need to meet special needs of different groups in the population according to best standards, limited resources, and population needs. it is proactive and advocates interventions within legal and ethical limits to promote health as a value in and of itself and as an economic gain for society as well for its individual members. the new public health is a comprehensive approach to protecting and promoting the health status of the individual and the society, based on a balance of sanitary, environmental, health promotion, personal, and community-oriented preventive services, coordinated with a wide range of curative, rehabilitative, and long-term care services. it evolves with new science, technology, and knowledge of human and systems behavior to maximize health gains for the individual and the population. the new public health requires an organized context of national, regional, and local governmental and non-governmental programs with the object of creating healthful social, nutritional, and physical environmental conditions. the content, quality, organization, and management of component services and programs are all vital to its successful implementation. whether managed in a diffused or centralized structure, the new public health requires a systems approach acting towards achievement of defined objectives and specified targets. the new public health works through many channels to promote better health. these include all levels of government and parallel ministries; groups promoting advocacy, academic, professional, and consumer interests; private and public enterprises; insurance, pharmaceutical, and medical products industries; the farming and food industries; media, entertainment, and sports industries; legislative and law enforcement agencies; and others. the new public health is based on responsibility and accountability for defined populations in which financial systems promote achievement of these targets through effective and efficient management, and cost-effective use of financial, human, and other resources. it requires continuous monitoring of epidemiological, economic, and social aspects of health status as an integral part of the process of management, evaluation, and planning for improved health. the new public health provides a framework for industrialized and developing countries, as well as countries in political-economic transition such as those of the former soviet system. they are at different stages of economic, epidemiological, and sociopolitical development, each attempting to ensure adequate health for its population with limited resources. the challenges are many, and affect all countries with differing balances, but there is a common need to seek better survival and quality of life for their citizens (table 2 .6). the object of public health, like that of clinical medicine, is better health for the individual and for society. public health works to achieve this through indirect methods, such as by improving the environment, or through direct means such as preventive care for mothers and infants or other atrisk groups. clinical care focuses directly on the individual patient, mostly at the time of illness. but the health of the individual depends on the health promotion and social programs of the society, just as the well-being of a society depends on the health of its citizens. the new public health consists of a wide range of programs and activities that link individual and societal health. the "old" public health was concerned largely with the consequences of unhealthy settlements and with safety of food, air, and water. it also targeted the infectious, toxic, and traumatic causes of death, which predominated among young people and were associated with poverty. a summary of the great achievements of public health in the twentieth and in the early twenty-first century in the industrialized world is included in chapter 1 and throughout this text. these achievements are reflective of public health gains throughout the industrialized world and are encourage and leverage national, state, and local partnerships to build a stronger foundation for public health preparedness and investigate health problems and health hazards in the community 3. inform, educate, and empower people about health issues 4. mobilize community partnerships to identify and solve health problems 5. develop policies and plans that support individual and community health efforts 6. enforce laws and regulations that protect health and ensure safety 7 evaluate effectiveness, accessibility, and quality of personal and population-based health services vision, mission and goals guidelines on food fortification with micronutrients. who, geneva. alliance for health policy and systems research 10 essential public health services healthy communities, 2000. model standards for community attainment of the year 2000 national health objectives determinants of adult mortality in russia: estimates from sibling data commission on social determinants and health. closing the gap in a generation: health equity through action on the social determinants of health compression of morbidity in the elderly institute of medicine. who will keep the public healthy? educating public health professionals for the 21st century global alliance for vaccine and immunization (gavi) chronic disease prevention and the new public health the evolution, impact and significance of healthy cities/healthy communities world health organization. ottawa charter for health promotion: an international conference on health promotion behavioral and social sciences and public health at cdc. mmwr health in all policies: seizing opportunities, implementing policies. ministry of social affairs and health new perspectives on the health of canadians: a working document new perspective on the health of canadians: 28 years later the us healthy people initiative: its genesis and its sustainability mortality from cardiovascular and cerebrovascular diseases in europe and other areas of the world: an update strategic review of health inequalities in england post. department of health primary care (extended version): ten key actions could globally ensure a basic human right at almost unnoticeable cost public health in europe: power, politics, and where next health: a vital investment for economic development in eastern europe and central asia. european observatory on health systems and policies. who, european regional office it is not just the broad street pump addressing the epidemiologic transition in the former soviet union: strategies for health systems and public health reform in russia what is the "new public health"? millenium development goals: 2013 progress chart united nations development programme, millennium development goals. eight goals for healthy people 2020 healthy people. the surgeon general's report on health promotion and disease prevention the millennium development goals: a cross-sectoral analysis and principles for goal-setting after selective primary health care: an interim strategy for disease control in developing countries declaration of alma-ata. international conference on primary health care healthy cities networks across the who, european region preamble to the constitution of the world health organization as adopted by the international health conference regional office for europe. health 21 -health for all in the 21st century. who regional office for europe, copenhagen. world health organization, 2012. regional office for europe. who european healthy cities network. available at:. who regional office for europe leading health indicators selected for 2010 incorporate the original 467 objectives in healthy people 2010, which served as a basis for planning public health activities for many state and community health initiatives. for each of the leading health indicators, specific objectives and subobjectives derived from healthy people 2010 are used to monitor progress. the specific objectives set for healthy people 2020 are listed in box 2.16. thirteen new topic areas are listed for 2020, such as older adults, genomics, dementias, and social determinants of health. these provide guidelines for national, state, and local public health agencies as well as insurance providers, primary care services, and health promotion advocates. a key issue will be in reducing regional, ethnic, and socioeconomic health disparities.the process of working towards health targets in the usa has moved down from the federal level of government to the state and local levels. professional organizations, ngos, as well as community and fraternal organizations are also involved. the states are encouraged to prepare their own targets and implementation plans as a condition for federal grants, and many states require county health departments to prepare local profiles and targets.diffusion of this approach encourages state and local initiatives to meet measurable program targets. it also sets a different agenda for local prestige in competitive terms, with less emphasis on the size of the local hospital or other agencies than on having the lowest infant mortality or the least infectious disease among neighboring local authorities. the who european region document "health 21 -health for all in the 21st century" addresses health in the twentyfirst century, with 21 principles and objectives for improving the health of europeans, within and between countries of europe. the health 21 targets include:1. closing the health gap between countries. 2. closing the health gap within countries. 3. a healthy start in life (supportive family policies). 4. health of young people (policies to reduce child abuse, accidents, drug use, and unwanted pregnancies). 5. healthy aging (policies to improve health, self-esteem, and independence before dependence emerges). 6. improving mental health. 7. reducing communicable diseases. 8. reducing non-communicable diseases. 9. reducing injury from violence and accidents. 10. a healthy and safe physical environment. 11. healthier living (fiscal, agricultural, and retail policies that increase the availability of and access to and consumption of vegetables and fruits). 12. reducing harm from alcohol, drugs, and tobacco. 13. a settings approach to health action (homes should be designed and built in a manner conducive to sustainable health and the environment).14. multisectoral responsibility for health.15. an integrated health sector and much stronger emphasis on primary care. 16. managing for quality of care using the european health for all indicators to focus on outcomes and compare the effectiveness of different inputs. the uk national health service (nhs) has semi-autonomous units in england, scotland, wales, and northern ireland. they are funded from the central uk nhs but with autonomy within national guidelines. the nhs has defined national health outcomes for improvements grouped around five domains, each comprised of key indicators aimed at improving health with reducing inequalities. l preventing people from dying prematurely from causes amenable to health care for all ages: l the target diseases include cardiovascular, respiratory, and liver diseases, and cancer (with focus on cancer of breast, lung, and colorectal cancer) l reducing premature death in people with serious mental illnesses l reducing infant mortality, neonatal mortality, still births, and deaths in young children l increasing 5-year survival for children with cancer. health improvement; help people to live healthy lifestyles, healthy choices, reduce health inequalities, protection from major incidents and other threats, while reducing health inequalities. l health care, public health and preventing premature mortality; reduce the numbers of people living with preventable ill-health and people dying prematurely, while reducing the gap between communities.source: uk department of health. available at: https://www.gov.uk/government/organisations/department-of-health/about#our-priorities, https:// www.gov.uk/government/uploads/system/uploads/attachment_data/ file/193619/improving-outcomes-and -supporting-transparency-part-1a.pdf. pdf, and https://www.gov.uk/government/uploads/system/uploads/attach-ment_data/file/127106/121109-nhs-outcomes-framework-2013-14.pdf. pdf [accessed 24 june 2013] . national policy in health ultimately relates to health of the individual. the various concepts outlined in the health field concept, community-oriented primary health care, health targets, and effective management of health systems, can only be effective if the individual and his or her community are knowledgeable participants in seeking solutions. involving the individual in his or her own health status requires raising levels of awareness, knowledge, and action. the methods used to achieve these goals include health counseling, health education, and health promotion (figure 2 .6).health counseling has always been a part of health care between the doctor or nurse and the patient. it raises levels of awareness of health issues of the individual patient. health education has long been part of public health, dealing with promoting consciousness of health issues in selected target population groups. health promotion incorporates the work of health education but takes health issues to the policy level of government and involves all levels of government and ngos in a more comprehensive approach to a healthier environment and personal lifestyles.health counseling, health education, and health promotion are among the most cost-effective interventions for improving the health of the public. while costs of health care are rising rapidly, demands to control cost increases should lead to greater emphasis on prevention, and adoption of health education and promotion as an integral part of modern life. this should be carried out in schools, the workplace, the community, commercial locations (e.g., shopping centers), and recreation centers, and in the political agenda.psychologist abraham maslow described a hierarchy of needs of human beings. every human has basic requirements including physiological needs of safety, water, food, warmth, and shelter. higher levels of needs include recognition, community, and self-fulfillment. these insights supported observations of efficiency studies such as those of elton mayo in the famous hawthorne effect in the 1920s, showing that workers increased productivity when acknowledged by management in the objectives of the organization (see chapter 12). in health terms, these translate into factors that motivate people to positive health activities when all barriers to health care are reduced.modern public health faces the problem of motivating people to change behavior; sometimes this requires legislation, enforcement, and penalties for failure to comply, such as in mandating car seat-belt use. in other circumstances it requires sustained performance by the individual, such as the use of condoms to reduce the risk of sti and/or hiv transmission. over time, this has been developed into a concept known as knowledge, attitudes, beliefs, and practices (kabp), a measurable complex that cumulatively affects health behavior (see chapter 3). there is often a divergence between knowledge and practice; for example, the knowledge of the importance of safe driving, yet not putting this into practice. this concept is sometimes referred to as the "kabp gap". the health belief model has been a basis for health education programs, whereby a person's readiness to take action for health stems from a perceived threat of disease, a recognition of susceptibility to disease and its potential severity, and the value of health. action by an individual may be triggered by concern and by knowledge. barriers to appropriate action may be psychological, financial, or physical, including fear, time loss, and inconvenience. spurring action to avoid risk to health is one of the fundamental goals in modern health care. the health belief model is important in defining any health intervention in that it addresses the emotional, intellectual, and other barriers to taking steps to prevent or treat disease.health awareness at the community and individual levels depends on basic education levels. mothers in developing countries with primary or secondary school education are more successful in infant and child care than less educated women. agricultural and health extension services reaching out to poor and uneducated farm families in north america in the 1920s were able to raise consciousness of safe self-health practices and good nutrition, and when this was supplemented by basic health education in schools, generational differences could be seen in levels of awareness of the importance of balanced nutrition. secondary prevention with diabetics and patients with chd hinges on education and awareness of nutritional and physical activity patterns needed to prevent or delay a subsequent myocardial infarction. the who sponsored the first international conference on health promotion held in ottawa, canada, in 1986 ( figure 2.7) . the resulting ottawa charter defined health promotion and set out five key areas of action: building healthy public policy, creating supportive environments, strengthening community action, developing personal skills, and reorienting health services. the ottawa charter called on all countries to put health on the agenda of policy makers in all sectors and at all levels, directing them to be aware a typical healthy city has a population in the multiple thousands, often multilingual, with an average middleclass income. a healthy cities project builds a coalition of municipal and voluntary groups working together in a continuing effort to improve quality of service, facilities, and living environment. the city is divided into neighborhoods, engaged in a wide range of activities fostered by the project. municipalities have traditionally had a leading role in sanitation, safe water supply, building and zoning laws and regulation, and many other responsibilities in public health (see chapter 10). the healthy cities or communities movement has elevated this to a higher level with policies to promote health in all actions. some examples are listed of municipal, advocacy group, and higher governmental activities for healthier city environments: working with senior levels of government, other departments in the municipalities, religious organizations, private donors, and the ngo sector to innovate and especially to improve conditions in poverty-afflicted areas of cities is a vital role for health-oriented local political leadership. human ecology, a term introduced in the 1920s and revived in the 1970s, attempted to apply theory from plant and animal life to human communities. it evolved as a branch of demography, sociology, and anthropology, addressing the social and cultural contexts of disease, health risks, and human behavior. human ecology addresses the interaction of humans with and adaptation to their social and physical environment.parallel subdisciplines of social, community, and environmental psychology, medical sociology, anthropology, and other social sciences contributed to the development of this academic field with wide applications in health-related issues. this led to the incorporation of qualitative research methods alongside the quantitative research methods traditionally emphasized in public health, providing crucial insights into many public health issues where human behavior is a key risk factor.health education developed as a discipline and function within public health systems in school health, rural nutrition, military medicine, occupational health, and many other aspects of preventive-oriented health care, and is discussed in later chapters of this text. directed at behavior modification through information and raising awareness of consequences of risk behavior, this has become a longstanding and major element of public health practice in recent times, being almost the only effective tool to fight the epidemic of hiv and the rising epidemic of obesity and diabetes.health promotion as an idea evolved, in part, from marc lalonde's health field concepts and from growing realization in the 1970s that access to medical care was necessary but not sufficient to improve the health of a population. the integration of the health behavior model, social ecological approach, environmental enhancement, or social engineering formed the basis of the social ecology approach to defining and addressing health issues (table 2 .3).individual behavior depends on many surrounding factors, while community health also relies on the individual; the two cannot be isolated from one another. the ecological perspective in health promotion works towards changing people's behavior to enhance health. it takes into account factors not related to individual behavior, which are determined by the political, social, and economic environment. it applies broad community, regional, or national approaches that are needed to address severe public health problems, such as controlling hiv infection, tb, malnutrition, stis, cardiovascular disorders, violence and trauma, and cancer. beginning to affect the health situation in countries in transition from the socialist period. countries emerging from developing status are also showing signs of mixed progress in the dual burden of infectious and maternal/child health issues, along with growing exposure to the chronic diseases of developed nations such as cardiovascular diseases, obesity, and diabetes. the new public health synthesizes traditional pub lic health with management of personal services and community action for a holistic approach. evaluation of costeffective public health and medical interventions to reduce the burden of disease also contributes to the need to seek and apply new approaches to health. the new public health will continue to evolve as a framework drawing on new ideas, science, technology, and experiences in public health throughout the world. it must address the growing recognition of social inequality in health, even in developed countries with universal health programs with improved education and social support systems. for a complete bibliography and guidance for student reviews and expected competencies please see companion web site at http://booksite.elsevier.com/9780124157668 bibliography key: cord-258125-2kkqqgop authors: wagner, peter title: knowing how to act well in time date: 2020-08-25 journal: j bioeth inq doi: 10.1007/s11673-020-10018-7 sha: doc_id: 258125 cord_uid: 2kkqqgop numerous scholars in the social sciences and humanities have speedily analysed and interpreted the covid-19-induced social and political crisis. while the commitment to address an urgent topic is to be appreciated, this article suggests that the combination of confidence in the applicability of one’s tools and belief in the certainty of the available knowledge can be counter-productive in the face of a phenomenon that in significant respects is unprecedented. starting out from the plurality of forms of knowledge that are mobilized to analyse covid-19 and its consequences as well as the lack of any clearly hegemonic knowledge, the article tries to understand how a limited convergence in the politico-medical responses to the crisis emerged, and speculates on what would have happened if this had not been the case. in conclusion, it is argued that this pandemic demands a greater awareness of the uncertainty of our knowledge and of the consequences of our actions, both in terms of being situated in time and of aiming at timeliness. abstract numerous scholars in the social sciences and humanities have speedily analysed and interpreted the covid-19-induced social and political crisis. while the commitment to address an urgent topic is to be appreciated, this article suggests that the combination of confidence in the applicability of one's tools and belief in the certainty of the available knowledge can be counterproductive in the face of a phenomenon that in significant respects is unprecedented. starting out from the plurality of forms of knowledge that are mobilized to analyse covid-19 and its consequences as well as the lack of any clearly hegemonic knowledge, the article tries to understand how a limited convergence in the politico-medical responses to the crisis emerged, and speculates on what would have happened if this had not been the case. in conclusion, it is argued that this pandemic demands a greater awareness of the uncertainty of our knowledge and of the consequences of our actions, both in terms of being situated in time and of aiming at timeliness. keywords action . covid-19 . democracy . knowledge . pandemic . technocracy . time . uncertainty there is no shortage of analyses and interpretations of the crisis that the covid-19 has inflicted on humankind and of its consequences. as it seems, many of my colleagues in the social sciences and humanities only had to take out their toolkit and put it to use on this new phenomenon. at times, one could even have the impression that they were waiting for something like this to happen for them to rush to go public with their analyses and proposals. characteristically, the interpretations of the crisis come in two forms. the optimists hold that humankind will grow through this experience. the world after covid-19 will show more solidarity, moral commitment, and concern for the common good. the era of unrestrained profit-making, boundless pleasure-seeking, and selfish pursuit of one's goals without concern for others will come to an end. these observers call for action to grasp the unique occasion for creating a better world, unique because, for once, the world is already moving in that direction. in turn, the critics observe a crisis-driven move to authoritarianism, to new nationalism and restrictions to movement, to technocracy with political decisions based on expertise rather than deliberation, in short, the return to disciplinary society combined with isolation of individuals and loss of sociality. the short era of liberal democracy and convivial civil society during which the power of dominating groups could effectively be limited will come to an end. these observers call, if they do, for resistance, and their view is marked by suspicion and denunciation of the politicians and their advisors whom we see and hear every day now. faced with this avalanche of striking analyses, i have asked myself: why do i not have anything to contribute to this debate? it's not that i lack the impetus. like many others, i have the impression to experience a sociopolitical event of possibly greater significance than any other during my lifetime. and as someone who studies society, history, and politics, i feel i should have something to say on this event. and if so, i should say so loudly, to be heard. so, why don't i? helped by the postponement of other commitments due to the lockdown, at the time of writing (mid-april 2020) already in its fifth week in spain where i live, i collect as widely as possible information on the ongoing events but also on their background and their conditions. thus, despite not having specific medical expertise, i do not feel that i know too little-too little in the sense of knowing so much less than others that i should keep my mouth shut. rather, i feel that we all know too littletoo little to be certain to act well, as far as the politicians and medical advisors are concerned, and too little to understand well what the appropriate action is, as concerns all others, for most of us. this lack may be exactly that which is most characteristic of the current situation. covid-19 emerged at a moment when, despite evident and accumulating signs to the contrary, the view was still widespread that we have all the knowledge we need and all the required understanding for necessary action; that things are basically under control or can at least be brought under control; and that this control emerges as the aggregate outcome of uncoordinated action rather than through communication and coordination among those affected and involved. this is a view that our current "modernity" is largely built on. covid-19 shakes the building and imposes a reflection on our assumptions about knowledge, action, and time. what follows is a small step in that direction. epidemiology and virology, so i learnt quickly, were expecting something like this to happen. they have accumulated knowledge of considerable quality and coherence, dating back at least to the influenza pandemic of 1918-1920 (still known as the spanish flu; a century ago, such an inadequate naming could still be made to stick) and building up in concise terms with hiv, sars, h1n1, ebola, and mers across the past few decades. the problem, though, is that every virus is specific and the behavioural properties of this one were unknown and are still not sufficiently known. they can be understood only through observation, after it already emerged. while comparing covid-19 with its predecessors could usefully guide research, drawing conclusions from quickly made comparisons could easily mislead-or delay-remedial action. in the next step, the gradually increasing knowledge about the virus is confronted with two other kinds of knowledge. on the one side, techniques of mathematical modelling have considerably developed in recent time. they are at the forefront of attempts at trying to understand uncertain futures. they have a prominent place in the deliberations of the international panel on climate change (ipcc), and for good reason, since without them little would be understood at all. but public debate-and already preceding it, public science communication-tends to forget about the degree of uncertainty. with regard to climate change, a reasonable maxim for action can rather easily be devised: it is better to err on the side of prudence. with regard to covid-19, conclusions are less straightforward. among other institutions, the institute for health metrics and evaluation (ihme) at the university of washington has become widely known for its predictions of covid-19 infections and deaths in the united states and elsewhere. reasonably, the researchers steadily update their findings-and their modelling-by introducing new data. as a consequence, though, their predictions are corrected day by day, and they change by considerable margins. rather than orienting public debate and action, their effect is disorientation. it might be advisable to refrain from publishing these figures-even though this would less be a call on the researchers, who will wish to enhance timely scholarly collaboration, rather than on the media, which at the very least could underline the extremely fragile nature of this knowledge. on the other side, neither the virus nor mathematics know anything about institutions. but the number of medical doctors, nurses, intensive care units, personal protection equipment, and their distribution and availability across space and time is crucial for the development of the pandemic and for the chances of slowing it down or stopping it. this is knowledge that public health research can provide, but the recommendations that follow from it may be quite different from those that would be arrived at when relying only on epidemiology, virology, and mathematical modelling. there is evidence that such a knowledge clash occurred over covid-19, more pronounced in the early weeks of the pandemic, and in some countries, in particular in the united kingdom and sweden, with more consequences than in others. governments all across the planet claim that their covid-19 policies are "science-based." heads of government and ministers of health appear always accompanied by leading medical experts in their press conferences. some observers have seen this as a sign of an emerging new technocracy, with expertise overriding democratic deliberation. given the multiple kinds of knowledge, however, this seems far from the case. let us look at two earlier political uses of scientific expertise in comparison. after the second world war, the slogan about the "civilian use of nuclear energy" promised a radiant future based on an endless supply of cheap energy and, consequently, infinite growth of the wealth of all nations with guaranteed satisfaction of every material need. science seemed truly to have become the "endless frontier." it took considerable time and effort to change public debate by underlining not only the danger of operating nuclear power stations but also the hubris of claiming to control nuclear waste sites over millennia to come. this was gradually achieved by the late 1970s, and the transformation of the debate was not least due to the elaboration of counter-expertise of such a scholarly quality that it could no longer be easily rejected or ignored. at about the same time, the late 1970s, a shift in hegemony occurred within the economic sciences. as keynesian demand management seemed to have failed to effectively respond to the economic problems of the early 1970s, a return to more conventional versions of neo-classical economics happened, which in policy terms demanded the reduction of public debt, of labour cost, and of taxation of profits, supposedly to unleash again the beneficial workings of markets. the new policies clearly benefitted certain business interests and worked against the less well-off in society. in this light, it remains a bit of an enigma why also centre-left (social democrat) politicians complied with this new doctrine, but what we may call epistemic domination certainly played a role: the economic sciences claimed to have understood why earlier policies failed and, based on these insights, arrived at an apparently clear view of the unalterable laws of market economies. in this case, there was a preceding "counter-expertise," but it was discredited by having failed to avert crises. in both of these cases, therefore, there was a monopoly or hegemony of expertise, and the recommendations following from such expertise served powerful interests in society, served (parts of) the dominating groups, as one used to say. the critical theories of technocracy, as they were elaborated during the 1960s and 1970s, were based on observations of such a situation. but none of this is characteristic of the present moment, for at least two reasons. first, whatever there is in terms of hegemonic expertise is of a different nature. one may say that, after all, most governments follow the guidelines for dealing with pandemics that had been elaborated by the world health organisation (who) and the respective national institutes of health. but in contrast to the physics of nuclear energy and the claims of neo-classical economics, the knowledge of a pandemic requires detailed and nuanced empirical observation of the specificities of the situation. as said above, this kind of knowledge only becameand still becomes-gradually available. furthermore, this knowledge is then liable to somewhat different interpretations by epidemiology, virology, modelling, and public health. at the moment of writing, one can say that there has been a considerable, even though in some settings slow, process of convergence of knowledge-based policy recommendations over the first few months of the pandemic. this convergence may even be understood, optimistically, as an indicator of solidarity across borders, or some understanding of a common problem and the need to act in common. but such convergence is not yet assured for the further course of the pandemic and the measures for "deescalation." this is so because, second, the already plural set of bio-medical expertise, broadly understood, meets countervailing expertise from the social sciences-economics, sociology, political science, psychology-as soon as policy decisions need to be taken. this is not to say that truly scholarly knowledge from these disciplines was present at the beginning, not at all. but politicians have a kind of "practical expertise" in these matters. they have a sense of their dependence on the mood in circles of society: business circles, the media, social movements, and others, varying with the political parties. this "knowledge" tells them what they can do and not do. from this observation, two questions arise, one asking about the decisions regarding the past two months and one asking about the decisions to be taken during the next, say, half a year. the striking answer to the first question is that politicians have done what they knew could not be done, namely ordering what is now called a "lockdown" of economy and society. the two societies that have long (though in recent years much less) been seen as the standard-bearers of liberalism, the united kingdom and the united states, toyed for some time with taking another route, led by governments that incarnate the doubt about institutional collective action that has become more widespread across the past three decades in general (more surprisingly, and probably for somewhat different reasons, sweden did so as well). this initial divergence permits us to speculate about what would have happened if this laissez aller had become the dominant attitude. clearly, many more people would have died, and at some point "herd immunity" would possibly have been reached-from all we know now: very little and after many victims. the pandemic would have been described as a natural catastrophe, like a giant earthquake or a tsunami. the governments would have regretted the "human losses" but argued that there was nothing that could be done about them-or at least nothing that could reasonably be done, given that different concerns had to be balanced. such an attitude was not as widely off the mark as it seems in the current moment, since concerns about restrictions of civil liberties and human rights have been and keep being voiced in many countries. we will know better only much later, but it is possible that only the emerging concise view of the who at the core of a well-networked global epistemic community in health studies prevented this option from being pursued and forced initially deviating governments to fall in line. carrying the speculation one step further, it is likely that we would talk very differently about covid-19 if that road had been taken. the pandemic would have been placed in the line, sketched above, that leads from the "spanish flu" to more recent spreads of viruses and just be compared in quantitative terms: number of infections and deaths, spatial diffusion, time until development of a vaccine or a treatment. there would have been some debate about social consequences, such as the sudden loss of the older generation, comparable with the debate about hiv/aids and changes in sexual behaviour. this would have been a "crisis," to be sure, but one that would have been cognitively domesticated by analysing it as something that had already happened before, only in describably different form. if so, then it is the extended "lockdown" that marks the difference, because of the sudden and radical halt to most economic, social, and cultural activities. it is the reason why we talk about covid-19 as potentially leading to a radical social transformation in a way in which we did not do about any of the other diseases mentioned above, except in some limited respects for hiv/aids. this halt, though, is nothing like an earthquake or a tsunami. it has been decided by governments and implemented by public administration, even supported by the deployment of the states' monopoly of legitimate violence. at times, the current situation is compared to a war. but recent experience of extended warfare, in particular the two world wars of the twentieth century, meant the total mobilization of society for the purpose of winning the war. currently, some segments of society are extremely highly mobilized, most importantly health workers, but most of society has been forced into de-mobilization. this is what is unprecedented and appears to us as a harbinger of radical change. since the financial crisis of 2008, critical political sociology has re-focused its attention on the relation between capitalism and democracy. one influential interpretation holds that governments today have to address two constituencies: the people in the traditional sense of the citizenry, expressing itself through elections and opinion polls, on the one hand, and on the other hand, the global markets, granting or withdrawing credibility and, as an immediate consequence, resources to indebted states (e.g., streeck 2013) . when there is tension between the interests of the constituencies, so the argument goes, the market constituency tends to prevail. currently, though, governments appear to act against the interests of both of these constituencies: they have wiped out the profit-making opportunities of big business and the earnings of small business and selfemployed workers; they have forced workers into unemployment, most drastically those in informal work situations; they have closed down the consumption and leisure activities that were considered sacrosanct because they kept people content (for an early attempt of analysing the dynamics of financial-crisis management, see tooze 2020). pre-covid-19 political sociology is at a loss to explain such government action. at first sight, one plausible way to close the explanatory gap is to underline that these measures are temporary, that they are taken in an emergency, that everything will return to "normal" once the emergency is over. but this leads us to the second question, the one about the decisions that will be taken in the near future. in parallel to the mathematical modelling of the course of the pandemic, economic modellers shoot figures about the expected decline in economic growth and its duration. however, in this situation even more than before, rather than being based on sound knowledge and technique, these predictions are best seen as attempts to imagine futures in the hope that the imagination will guide action in such a way as to make the future less uncertain than it actually is (beckert 2016) . it cannot be ruled out that, some time from now, something like a return to "normality" will occur. the adjustments of institutions and practices may turn out to be small compared to some of the expectation and imagination that the current exceptionality has generated. at the current moment, however, uncertainty and lack of knowledge prevail. and it is under this angle that the entire crisis is most fruitfully analysed. in many countries, governments have recently been criticized for having reacted late and insufficiently to the emergence of covid-19. while such criticism is more valid in some cases than others (and what follows should not be read as exempting everyone from responsibility), it is very often based on a problematic use of temporality. it is argued that some piece of information had been available early but that the action that was the adequate response to the information was taken with a considerable delay. it is overlooked that it was only with hindsight that the information was seen as requiring a certain action, not at the moment it first emerged. the criticism assumes, on the one hand, a timeless certainty of knowledge. by implication, it also assumes a fundamental stability of the world, in which an occurrence in the present can only be a repetition, with at best minor and insignificant alteration, of an occurrence in the past. and on the other hand, it assumes an unquestioned hierarchy in the application of knowledge, namely to be effected by the state. in other words, the criticism operates with a kind of vulgar platonism, a timehonoured desire of human beings to have everything known and under control. the first assumption holds that the knowledge required for action is in principle available; and that actors who do not avail themselves of the required knowledge are at fault. but this is in denial of exactly that which many of us experience, namely the occurrence of something unprecedented, and thus the lack of actionadequate knowledge. in the light of uncertain knowledge, and furthermore of a knowledge base that was only evolving over time, politicians have hesitatedproblematically so but also understandably. for purposes of action, the novelty does not have to be absolute to be problematic. virologists are unlikely to see covid-19 as radically different from all other viruses, and even sociologists do not need to abandon all of the concepts they developed for social transformations. we only need to be ready to accept that the novelty of the current situation is such that the knowledge-at-hand is insufficient to adequately understand it; that this situation is not one that can be easily subsumed under the concepts we are used to employ. therefore, it is more important at the moment to observe closely, to try to describe, to look for possible comparisons, probably not any single one that explains everything, but many partial comparisons. and this requires time. but if our scholarly knowledge is not sufficient for fully and immediately understanding the covid-19induced situation we are in, we also have to accept that the situation is similar for those who have responsibility to act. it is, furthermore, made much more difficult by the fact that the adequacy of an action often depends on whether it was made in time. the question of adequacy in time leads to the second assumption, the one of state capacity. in this regard, the virus encountered our societies on the wrong foot. the idea that the aggregate of uncoordinated individual actions would on its own bring about desirable outcomes has been ever more widely accepted for decades, in as different areas as unregulated market exchange, the "non-governmental" workings of "civil society," and the clip-form of communicative exchange in global social networks. in some such cases, like a stock exchange movement, a crowd-funding initiative, or a social-network clip "going viral," this kind of "collective" action can today be extremely fast, can take the form of a "social avalanche" (borch 2019) . with more such phenomena, though, the doubts about the presupposed desirability of the outcomes also increase. in contrast to those phenomena, co-ordinated collective action, based on problem-oriented communication and sedimented in purpose-guided institutions, has been systematically discredited for over three decades. many of its sites have been weakened and dismantled, in some cases as concretely as in the authority and resource endowment of public-health institutions. such institutions were supposed to be slow both in receiving new information and knowledge and in acting efficiently on the basis of such information. ironically, such recent criticism of bureaucratic states mirrors the timehonoured objections to pluralistic democratic deliberation, supposed to be incapable to confront any urgencies. however, we have no reason to believe that action based on multiple advice and plural deliberation is necessarily slower than either so-called "self-regulation" or hierarchic technocratic action (flaig 2013) . there is no reason at all to glorify currently leading politicians. most often, their reasons for acting tend to be considerably less than noble: getting re-elected; not offending their main allies in society; having something plausible to communicate in the short term. they are not necessarily oriented towards, as their "vocation" (weber 1994 (weber [1919 ) should be, the common good or the benefit of society at large. but watching them these days, we see that they do not even know how to pursue their lessthan-noble objectives: their re-election prospects are highly uncertain; they have acted against the immediate interests of their clientele; they are at a loss of communicating anything very convincing. as said above, they all claim that what they do is "science-based," but they say so merely to provide a justification that they would otherwise lack. there is hardly an indication of a rising technocracy and/or of a new form of authoritarian control. suddenly, critics expect this systematically disabled state to get everything right, and immediately. what we observe, though, is rather the evidence of lack of control and even of the illusion of control that politicians are used to advertise because it comes with their office. today, politicians are weak in the face of both, the pandemic and the criticism of how they are handling it. clearly, they do not have the tools at hand that they would have had before austerity politics and the discrediting of collective institutional action. and having lost those (or rather: thrown them away), they also now face human and civil rights-based criticism for wanting to increase the monitoring of behaviour; business criticism for destroying a functioning economy; social criticism for disregarding the fate of those who are less well off; and more. rather than orienting our social-science analyses towards sorting out which criticism is most justified, and to determine "whose side we're on," it seems to me we should grant to those responsible for action that they encounter the same uncertainty as everyone else in the face of a situation that in crucial respects is unprecedented. the difference between "them," the politicians, and "us," the scholars, but also between politicians in office and those in opposition, is that that the former need to act in time-and with regard to covid-19 indeed with considerable urgency. social scientists, most of the time, are exempted from that obligation. as social scientists, though, their obligation would be to elaborate a knowledge of society, economy, and politics that takes uncertainty and temporality better into account to understand the conditions for action in time. such knowledge will always be difficult to achieve but we can at least briefly spell out what, for want of better terms, can be called an ontological attitude and a methodological maxim. with regard to the former, one should abandon the notion that social phenomena repeat themselves. this is not even true of viruses, as covid-19 in relation to other coronaviruses shows, and much less so for social phenomena. rather than looking for regularity and equilibria, as much social science does, it is often more useful to focus on moments of imbalance, asymmetry, dispute, which is when more of the social world and its dynamics reveals itself (see, e.g., boltanski 1990) . this attitude has consequences for the pursuit of two of the most common activities of the social sciences, namely trying to derive the present from the past and predicting the future. as to the latter, as mentioned above, a key technique is mathematical modelling, developing with great speed and considerable variety. its practitioners are mostly well aware of the uncertainty they are dealing with. but they rarely convey this in public and, at least as importantly, they try to reduce uncertainty mostly by feeding in more data and improving technique. thus, remedial action with regard to past errors is again done by forward-looking. more effort may need to be devoted to review past modelling exercises and the way their-social, not just mathematicalstatistical-assumptions may have created or exacerbated erroneous predictions. 1 the future is not merely an extrapolation of the present, as the present is not an extrapolation of the past. but in contrast to the future, the past has for us the advantage that something about it is known with some degree of certainty, notwithstanding all ongoing dispute in the theory and philosophy of history. we have to learn to relate to the past in such a way as to grasp the possibly common conditions for action without limiting our current possibilities to the existing range of past outcomes. with a specific issue in mind, such as covid-19 today, the first question concerns the identification of a comparable situation. this is neither the plague, because the social configuration was very different, nor sars, because the behaviour of the virus was very different. my intuition is that a covid-19oriented historical-comparative sociology could fruitfully look at the first world war and the 1918-1920 pandemic. a century ago, societies were not so different from present ones that an attempt at comparison would find too little to hold on to. this is the minimum condition for a fruitful comparison. furthermore, those societies had undergone a major social transformation in the decades before 1914, one that today is sometimes called a first globalization. the dynamics of this transformation led towards catastrophe; and when the virus emerged, the catastrophe of the first world war had already happened. today, covid-19 may have emerged just in time for us to avert catastrophe-a future catastrophe that does not yet have a name but several candidates of which climate change is arguably the front-runner. my apologies for having turned a conclusion into a new opening. my excuse is that maybe this is just what we need to do. imagined futures: fictional expectations and capitalist dynamics social avalanche: crowds, cities, and financial markets l'amour et la justice comme compétence to act with good advice: greek tragedy and the democratic public sphere. in the greek polis and the invention of democracy: a politico-cultural transformation and its interpretations buying time: the delayed crisis of democratic capitalism how coronavirus almost brought down the global financial system. the guardian publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-011906-ek7joi0m authors: throuvala, melina a.; griffiths, mark d.; rennoldson, mike; kuss, daria j. title: mind over matter: testing the efficacy of an online randomized controlled trial to reduce distraction from smartphone use date: 2020-07-05 journal: int j environ res public health doi: 10.3390/ijerph17134842 sha: doc_id: 11906 cord_uid: ek7joi0m evidence suggests a growing call for the prevention of excessive smartphone and social media use and the ensuing distraction that arises affecting academic achievement and productivity. a ten-day online randomized controlled trial with the use of smartphone apps, engaging participants in mindfulness exercises, self-monitoring and mood tracking, was implemented amongst uk university students (n = 143). participants were asked to complete online preand post-intervention assessments. results indicated high effect sizes in reduction of smartphone distraction and improvement scores on a number of self-reported secondary psychological outcomes. the intervention was not effective in reducing habitual behaviours, nomophobia, or time spent on social media. mediation analyses demonstrated that: (i) emotional self-awareness but not mindful attention mediated the relationship between intervention effects and smartphone distraction, and (ii) online vigilance mediated the relationship between smartphone distraction and problematic social media use. the present study provides preliminary evidence of the efficacy of an intervention for decreased smartphone distraction and highlights psychological processes involved in this emergent phenomenon in the smartphone literature. online interventions may serve as complementary strategies to reduce distraction levels and promote insight into online engagement. more research is required to elucidate the mechanisms of digital distraction and assess its implications in problematic use. attentional focus is one of the most fundamental resources and a key to successful and high-order work [1] . in the attention economy [2] , multiple online and offline activities compete for an alternative share of attention [3] . this trend is expected to grow in the face of increasing communication complexity and information overload [4] , which is becoming even more prevalent partially due to the vast online accessibility, immediacy and convenience of smartphones, acting as a major motivational pull for engagement [5] and prompting constant multitasking and frequent attentional loss [6] . there are currently more than 3.5 billion smartphone users [7] and smartphone use is an emergent area of research [8] [9] [10] . emerging evidence on cognitive function has shown that smartphone availability and daily interruptions compete with higher-level cognitive processes creating a cognitive interference effect [11] [12] [13] [14] [15] , associated with poorer cognitive functioning [16] [17] [18] [19] , performance impairments in daily life [20] and potential supplanting of analytical thinking skills by "offloading thinking to the device" [21] (p. 473). in spite of such initial evidence, there are cognitive correlates within the digital wellbeing apps or mhapps (apps that track an individual's behaviour, i.e., time spent online, or that aid cognitive, emotional and/or behavioural wellbeing) [96] have been suggested as supporting self-awareness and self-regulation [97] and utilized in mental healthcare given their functionality, accessibility, higher adherence rates, real-time assessment, low-cost and for their intervention potential [98, 99] . the literature suggests that evidence-based apps may be efficacious in raising self-awareness, mental health literacy and wellbeing, self-efficacy, and ability to cope [96, [100] [101] [102] . online psychological interventions are becoming more prominent in the digital age [103] , rendering numerous positive health outcomes [102, [104] [105] [106] [107] [108] , complementing service provision and recognized by governmental health institutions (e.g., national institute for health and care excellence (nice) in the uk) [109] . however, more research is required to determine the comparative effectiveness of these therapies and their components [110] in improving mental health and wellbeing and rigorous objective evaluation beyond their developers is required. to date, there have been a small number of internet-based interventions associated with device use in university settings. distraction is not considered a dysfunctional construct by itself, but has been implicated in emotion regulation, adhd, and other disorders [111] [112] [113] , and has been minimally examined in the context of the digital environment with no evidence to date as to strategies that could ameliorate its occurrence [114] . therefore, the aim of the present study was to test the preliminary efficacy of an online intervention based on cognitive behavioural principles (i.e., self-monitoring, mood tracking, and mindfulness) to reduce distraction and related psychological outcomes (i.e., stress) among university students. given: (i) young adults are keen users of smartphone apps, with increased vulnerability to self-regulation and technology use [74] , (ii) the high stakes for academic achievement, and (iii) the similarity in processes observed between gambling addiction and social media overuse [115] , the strategies of mindfulness, activity monitoring, and mood tracking utilized in gambling harm-reduction [86, 116, 117] are employed in the present study. these strategies were delivered and facilitated through the use of smartphone mhapps and were tested for their efficacy in reducing levels of distraction and related psychological outcomes and their role in inducing changes in wellbeing [118] [119] [120] . the following hypotheses were formulated: hypothesis 1 (h1). compared to the control condition at follow-up, students receiving the intervention would report: (i) lower rates of smartphone distraction, smartphone and social media use duration, impulsivity, stress, problematic social media use, fomo and nomo and (ii) higher levels of mindful attention, emotional self-awareness, and self-efficacy. hypothesis 2 (h2). at follow-up, high distractors (hds) compared to low distractors (lds) (based on a median-split analysis) would show a greater reduction in distraction and significant improvement in outcomes. hypothesis 3 (h3). the intervention will mediate the relationship between (i) mindful attention and smartphone distraction, and (ii) emotional awareness and smartphone distraction. additionally, online vigilance will mediate the relationship between smartphone distraction and problematic social media use. to the authors' knowledge and given the novelty of the construct of smartphone distraction, this is the first study to examine a preliminary online randomized controlled trial via mhapps for the reduction of smartphone distraction. the present study fills a gap in the smartphone literature by assessing the efficacy of engaging with behaviour change strategies (i.e., mindfulness, self-monitoring, and mood-tracking) used successfully in gambling harm prevention for the reduction of distraction. the present study tested the efficacy of a ten-day online app-delivered randomized controlled trial (rct) based on cognitive-behavioural principles to reduce distraction (primary outcome) and a number of secondary psychological outcomes: self-awareness, mindful attention, fomo, anxiety, and depression among university students. rcts are considered the gold standard in intervention effectiveness despite limitations addressed by scholars [121, 122] , primarily for the lack of external validity or methodological choices [123] . a pragmatic psychosocial intervention with an rct design was chosen [124] . the duration of the intervention was set given a pragmatic consideration of the free use period of one of the apps (headspace) and, secondly, due to the preliminary nature of this investigation. consolidated standards of reporting trials (consort) guidelines were followed in the protocol and the procedures and reporting of the intervention [125] . the intervention involved the active engagement for the period of ten consecutive days with three smartphone apps serving three different functions: to assess smartphone and social media use, conduct mindfulness sessions with an emphasis on eliminating distraction, and track mood and assess its impact on distraction, stress, self-regulation, and other measures. interaction with apps was encouraged to: (i) raise emotional awareness of common mood states, such as feeling down, worried, or stressed through mindfulness, (ii) guide basic smartphone monitoring, focusing skills, and awareness, and (iii) provide insight through mood tracking (table 1) . to further support active engagement with these intervention components, eligible participants were asked to keep a daily online activity log for the duration of the intervention (i.e., the number of screen-unlocks and the time of day and number of minutes for which the smartphone was used, usefulness of apps, etc.), to aid time perception of daily activities, raise awareness levels, and help increase the accuracy of self-reporting and adherence to the intervention [126, 127] . promoting self-awareness of media use and understanding of own behaviour was a key target of the intervention in order to curb distraction. the study was reviewed and approved (no. 2018/226) by the research team's university ethics committee. daily reminders and messages via blogging were sent as a reminder to maintain routine and reflect on levels of activity [126, 137] . participants were recruited using convenience and snowball sampling techniques. after gaining institutional ethical approval, the study was advertised to students through the research credit scheme, in university lectures and labs, and to the public through social media as an online intervention to assess the reduction of smartphone distraction. this experimental intervention demanded a significant time involvement and offering incentives increased the chances of participation and completion of the full ten-day intervention. in return for participation, students were offered either research credits or entry in a prize draw (£50 gift cards). participants were included in the study based on two screening criteria: regular smartphone and social media usage. only those affirming both and granting consent were able to continue with participation. following the completion of the survey, participants were allocated to one of the two conditions (intervention [ig] or control [cg] ) and further instructions for participation in the intervention were provided depending on the allocation condition. after initially providing age and gender demographics, participants responded to survey items regarding habitual smartphone and social media behaviour (estimates of duration of use), smartphone distraction severity, trait self-regulation, trait mindfulness and other psychological constructs (detailed in "materials"). the survey took approximately 25 min to complete. a total of 261 participants were recruited who participated in the baseline assessment. of these, 155 were undergraduate psychology students in the uk (59.3%). the sample comprised 47 males (18%) and 214 females (82%), with an age range of 18 to 32 years (m = 20.72, sd = 3.12). figure 1 depicts the flow of participants through the study procedures. after the baseline assessment, during the intervention period two individuals of the intervention group withdrew from the study and were not considered in the analysis. from the 259 remaining participants, seven were removed due to providing 90% incomplete data. the final sample considered at baseline was 252 participants (intention to treat (itt) group) and included 123 participants in the intervention group and 129 in the control group. participants who completed both assessments were considered in the per-protocol analysis (pp) (n = 143, 56% of the original sample), with 72 participants comprising the ig and 71 participants the cg. between the two groups, as standardising can easily distort judgements of the magnitude of an effect (due to changes to the sample sd but not the population sd, which may bias the estimate of the effect size measure, such as cohen's d) [178] . as cohen's d has been reported in other rct and pre-post intervention studies, cohen's d was estimated [179] . finally, because the sample sizes of the two groups were unequal, type iii sums of squares were used for the ancova. to test the third hypothesis and the hypothesized psychological mechanisms underlying the intervention results, three different mediation analyses were performed across the chosen psychological constructs using spss statistics (version 25) and process (model 4; [180] [181] [182] [183] ), using a non-parametric resampling method bootstrap with 5000 bootstrapped samples and bias-corrected 95% confidence intervals, to probe conditional indirect effects for the variables examined. these analyses were performed on the itt sample in post-intervention results. the survey consisted of sociodemographic and usage data (questions related specifically to smartphone and social media use [hours per day]). the demographic questions and user-related questions had open responses (i.e., "how many hours per day do you use social media?"). the following scales were used for the psychological measures of the study: the smartphone distraction scale [138] is a newly developed scale comprising of 16 likert-type items. the scale comprises four factors: attention impulsiveness, online vigilance, emotion regulation, and multitasking. scores range from 1 (almost never) to 5 (almost always) with higher scores representing a greater degree of distraction. individual items on the test were summed to give composite scores. sample items included in the scale are the following: "i get distracted by my phone notifications", and "i constantly check my phone to see who liked my recent post while doing important tasks". the scale has demonstrated good psychometric properties [138] and excellent reliability in the present study with a cronbach's alpha of 0.90 for time 1 (t1) and 0.88 for time 2 (t2). the mindful attention awareness scale (maas) [139] is a 15-item assessment tool that assesses the dispositional tendency of participants to be mindful in everyday life and has been validated among young people, university students and community samples [139, 140] . item statements reflect experience of mindfulness, mindlessness in general and specific daily situations and are distributed across a range of cognitive, emotional, physical, interpersonal, and general domains. response options are based on a six-point likert scale from 1 (almost always) to 6 (almost never). scores were averaged across the 15 items to obtain an overall mindfulness score with higher scores reflecting higher levels of dispositional mindfulness. sample items include "i could be experiencing some emotion and not be aware of it until sometime later" and "i find it difficult to stay focused on what's happening in the present" and exhibited a high degree of internal consistency in the present study with a cronbach's alpha of 0.92 for t1 and 0.93 for t2. the emotional self-awareness scale (esas) [92] was used to assess esa and comprises five variables: recognition, identification, communication, contextualization, and decision making. the scale consists of 32 items (e.g., "i usually know why i feel the way i do") rated from 0 (strongly disagree) to 4 (strongly agree). the total esa score ranged from 0 to 128, and sub-scale items are combined to produce a composite score with higher scores indicating higher esa. the esas has presented reasonable internal consistency (cronbach's alpha = 0.72, 0.69, and 0.76 for pre-test, post-test and six-week follow-up) [92] . the scale has demonstrated good validity in prior studies [92, 101] and adequate internal consistency in the present study (cronbach's alpha of 0.87 for t1 and 0.86 for t2). the perceived stress scale (pss) [141] is one of the most widely used scales to assess perceived stress and the degree of unpredictability, uncontrollability, and burden in various situations. the scale used was the 10-item version rated from 0 (never) to 4 (very often) with sample items such as "in the last month, how often have you felt that you were unable to control the important things in your life?", and "in the last month, how often have you felt that you were on top of things?" scores are obtained by summing the items, with the higher score indicating more perceived stress. the scale possesses good psychometric properties [142] and its internal consistency in the present study was 0.86 for t1 and 0.83 for t2. the seven-item generalized anxiety disorder scale (gad-7) [143] is a brief clinical measure that assesses for the presence and severity of generalized anxiety disorder (gad). the self-report scale asks how often during the last two weeks individuals experienced symptoms of gad. total scores range from 0-21 with cut-off scores of 5, 10, and 15 being indicative of mild, moderate, and severe anxiety, respectively. increasing scores on the gad-7 are strongly associated with greater functional impairment in real-world settings. sample items are rated from 0 (not at all) to 3 (nearly every day) and sample items include: "feeling nervous, anxious or on edge" and "trouble relaxing". the scale has been widely used and considered a valid and reliable screening tool in previous research, presenting good reliability, factorial and concurrent validity [144, 145] , and demonstrated excellent internal consistency in the present study (α = 0.93 t1 and α = 0.90 for t2). the self-report behavioural automaticity index (srbai) [146] was used to assess habitual strength. the four-item scale was used to assess the degree of automaticity and contained items such as: "using social media on my smartphone is something . . . i do automatically" and "i start doing before i realize i'm doing it". participants indicate their agreement with each item on a likert scale ranging from 1 (does not apply at all) to 7 (fully applies). scores were averaged across items to obtain an overall habit score, with higher scores indicating stronger habitual smartphone use behaviour. the scale has been reported as psychometrically sound in previous studies with good reliability, convergent and predictive validity [146, 147] and demonstrated good internal consistency in the present study with a cronbach's alpha of 0.87 (t1) and 0.89 (t2). the generalized self-efficacy scale (gse) [148] is a widely used psychometric instrument comprising ten items that assess perceived self-efficacy ("i can always manage to solve difficult problems if i try hard enough."). items are rated on a four-point scale ranging from 1 (not at all true) to 4 (exactly true). the gse has demonstrated satisfactory internal consistency and validity across studies [149, 150] . cronbach's alpha in the present study was 0.90 (t1) and 0.88 (t2). the online vigilance scale (ovs) [46] is a 12-item likert scale which assesses a relatively new construct in the internet-related literature, referring to individuals' cognitive orientation towards online content, expressed as cognitive salience, reactivity to online cues and active monitoring of online activity. sample items include "my thoughts often drift to online content" and "i constantly monitor what is happening online". scale items are rated on a four-point likert scale from 1 (does not apply at all) to 4 (fully applies). higher mean scores indicate a higher degree of online vigilance. the scale has evidenced sound construct and nomological validity and high internal consistency [46, 49, 78] . the cronbach's alpha in the present study was 0.89 (t1) and 0.87 (t2). the eight-item barratt impulsiveness scale-alternative version (bis-8) [151] is a psychometrically improved abbreviated version of the 11-item bis scale [151] presenting good construct and concurrent validity in young populations [152, 153] . the scale assesses impulsive behaviour and poor self-inhibition and uses a four-point likert scale from 1 (do not agree) to 4 (agree very much). sample items include: "i do things without thinking" and "i act on the spur of the moment". cronbach's alpha coefficient in the present study was 0.85 (t1) and 0.86 (t2). the deficient self-regulation measure [154] is a seven-item scale assessing deficient self-regulation in videogame playing adapted for unregulated internet use [155] . the scale is rated on a seven-point likert scale from 1 (almost never) to 7 (almost always) and has demonstrated sound psychometric properties [154] . the scale was adapted for smartphone use with sample items such as "i would go out of my way to satisfy my urges to use social media" and "i have to keep using social media more and more to get my thrill". the original scale and its adaptation has presented satisfactory psychometric properties [154, 155] . the cronbach's alpha coefficient in the present study was 0.89 (t1) and 0.87 (t2). the bergen social media addiction scale (bsmas) [115, [156] [157] [158] ] is a six-item self-report scale for assessing social media addiction severity based on the framework of the components model of addiction (salience, mood modification, tolerance, withdrawal, conflict, and relapse) [159] . each item examines the experience of using social media over the past year and is rated on a five-point likert scale from 1 (very rarely) to 5 (very often), producing a composite score ranging from 6 to 30. higher bsmas scores indicate greater risk of social media addiction severity. a sample question from the bsmas is "how often during the last year have you used social media so much that it has had a negative impact on your job/studies?" a cut-off score over 19 indicates problematic social media use [160] . the bsmas has presented sound psychometric properties [115, [156] [157] [158] with high internal consistency (α = 0.82) [161] . the cronbach's alpha in the present study was 0.91 (t1) and 0.87 (t2). the fear of missing out scale (fomos) [162] includes ten items and asks participants to evaluate the extent to which they experience symptoms of fomo. the scale is rated on a seven-point likert scale from 1 (not at all true) to 5 (extremely true of me). the statements include: "i fear others have more rewarding experiences than me... i get anxious when i don't know what my friends are up to...it bothers me when i miss an opportunity to meet up with friends...". a total score was calculated by averaging the scores, with higher mean scores indicating a greater level of fomo. this instrument has demonstrated good construct validity [162, 163] , and good internal consistency with cronbach's alphas of α = 0.93 [164] and 0.87 [64] with α = 0.87 in the present study. the nomophobia questionnaire (nmp-q) [165] comprises 20 items rated using a seven-point likert scale from 1 (strongly disagree) to 7 (strongly agree). total scores are calculated by summing up responses to each item, resulting in a nomophobia score ranging from 20 to 140, with higher scores corresponding to greater nomophobia severity. nmp-q scores are interpreted in the following way: 20 = absence of nomophobia; 21-59 = mild level of nomophobia; 60-99 = moderate level of nomophobia; and 100+ = severe nomophobia. the scale has demonstrated good psychometric properties [165, 166] with cronbach's alphas of 0.94 [165] and 0.95 [167] . in the present study, internal consistency was: 0.89 for (t1) and 0.88 for (t2) respectively. the intervention initially involved the search and identification of appropriate mobile apps (in both the apple itunes store and the android google play store) for daily self-monitoring of social media activity for mindfulness practices and mood tracking. the apps needed to be freely available in order to be accessible by the participants. due to time limitations, the development of an app that would encompass all three features (mindfulness of distraction, self-monitoring, and mood-tracking) was deemed adequate for the study given the ample availability of well-designed products offering these services. the following three freely available smartphone lifestyle apps were utilized: (i) antisocial (screen time): to self-monitor screen time/social media use and for voluntary self-exclusion (block app after time limit is reached), (ii) headspace (mindfulness): brief mindfulness sessions, (iii) pacifica (mood tracking): the app encouraged monitoring and tracking an individual's emotional state at various times during the day to enhance awareness. at the outset of the study, participants were directed to an information statement followed by the digital provision of informed consent before responding to the questions. at the end of the survey, they were automatically assigned through the automatic randomization procedure used by the online survey platform qualtrics to either an intervention or a control group. therefore, the intervention was double-blind (to participants and investigators). participants assigned to the ig were asked to download the apps onto their smartphones and to actively engage with all three apps daily for 10 days, which was the maximum free period offered by one of these apps. participants were encouraged to engage with mindfulness/focusing exercises to track their emotional state during the day and monitor patterns in their wellbeing as well as report daily on smartphone usage rates. thereafter, participants received daily notifications via email for the duration of the intervention to remind them to provide online reports about their own social media usage rates, apps accessed, checking frequency, potential self-restriction from use, and satisfaction with the intervention. this process was used to motivate engagement with the apps and accountability. efficacy was evaluated by having a cg condition where participants did not engage in any app use and only completed assessments on the first and tenth day. the target of the intervention was to induce a more mindful state, raise awareness of media and smartphone use, enhance self-regulation and therefore reduce distractions and time spent on smartphones and indirectly on social media by using these apps. the sample size for the rct was determined a priori using g*power v.3 software for the expected increased effectiveness of the intervention compared to control on the primary outcome distraction at post-assessment (t2). empirical reviews [168] have suggested a median standardised target effect size of 0.30 (interquartile range: 0.20-0.38), with the median standardised observed effect size 0.11 (iqr 0.05-0.29). the present study was a low-threshold intervention for a non-clinical population, so a mean effect of d = 0.30 was expected. with a power of 1-ß = 0.8, and a significance level of α = 0.05, the sample size was calculated to be n = 95 participants per group to find between-and within-group effects. to account for attrition rates in online interventions and control for both type i and ii error rates, n = 125 participants per group were targeted for recruitment [169] . all data were analysed through spss v.25 (chicago, il, usa). preliminary data analyses included examining the data for data entry errors, normality testing, outliers, and missing data. seven cases were treated with listwise deletion due to a very high percentage of incomplete data at baseline, resulting in a final sample size of 252. for the rest of the dataset, little's missing completely at random (mcar) test showed that data were missing completely at random (p = 0.449). multiple imputation was used to complete the dataset for the baseline analysis and for the non-completers from post-intervention assessment based on patterns of missingness. the data were also checked to ensure that all assumptions for the outlined statistical analyses were satisfied. the kolmogorov-smirnov test was used to evaluate the normal distribution of the variables, and skewness and kurtosis values were examined. for both assessments, all self-report data were normally distributed. assumptions of t-tests included normality, homogeneity of variance, and independence of observations. violations of the assumption of homogeneity of variance were tested using levene's test of equality of variances [170] . descriptive statistics were conducted to summarize the demographic characteristics of the sample as well as scores for the self-reported and performance-based measures of interest (i.e., stress). pearson's correlations examined bivariate relationships between smartphone distraction and psychological variables, and frequency of smartphone and social media use (presented in table 3 ). while allocation randomisation aimed to reduce any differences between the groups at baseline, a series of independent sample t-tests for the continuous variables and chi-square tests for the categorical variables (gender, ethnicity and education and relationship status) were conducted to analyse group mean differences and compare the baseline and post-intervention outcomes for the control and intervention groups. these were also applied at post-intervention outcomes for both the control and the intervention group. a decrease from the baseline to the post-intervention assessment was hypothesised for the primary outcomes of smartphone distraction, stress, anxiety, deficient self-regulation, fomo and nomo and an increase was hypothesized for mindful attention, self-awareness and self-efficacy. following the descriptive analysis, data from the baseline and post-intervention assessments were analysed to test each of the hypotheses provided to inform the assessment of the intervention efficacy. two approaches to analysis were adopted. first, to isolate any effect of the intervention, a per-protocol (pp) analysis was conducted to maintain the baseline equivalence of the intervention group produced by random allocation [171] . however, given the limitations to this first analysis approach and to minimise biases resulting from noncompliance, non-adherence, attrition or withdrawal [172, 173] , analysis was performed also on an intention-to-treat (itt) basis [172] . however, these results were not reported in the present study. the effects of the intervention were assessed with an analysis of covariance (ancova), with a minimum significance level at p < 0.05. ancova was chosen given that it is quite robust with regard to violations of normality, with minimal effects on significance or power [174, 175] with any differences between the groups at baseline, for the various assessments being used as covariates in the model and considered artefacts of the randomisation [176] . co-varying for baseline scores supported the analysis in two ways. first, while randomisation aimed to reduce any pre-intervention differences between the groups, residual random differences may have occurred. accounting for such differences isolated the effect of the intervention. partial eta-squared were used as measures of strength of association [177] . to better understand the effect size of the intervention, it has been recommended to use the differences in adjusted means (standardized mean difference effect sizes) between the two groups, as standardising can easily distort judgements of the magnitude of an effect (due to changes to the sample sd but not the population sd, which may bias the estimate of the effect size measure, such as cohen's d) [178] . as cohen's d has been reported in other rct and pre-post intervention studies, cohen's d was estimated [179] . finally, because the sample sizes of the two groups were unequal, type iii sums of squares were used for the ancova. to test the third hypothesis and the hypothesized psychological mechanisms underlying the intervention results, three different mediation analyses were performed across the chosen psychological constructs using spss statistics (version 25) and process (model 4; [180] [181] [182] [183] ), using a non-parametric resampling method bootstrap with 5000 bootstrapped samples and bias-corrected 95% confidence intervals, to probe conditional indirect effects for the variables examined. these analyses were performed on the itt sample in post-intervention results. the t-test results for the pre-test scores found no significant differences between the groups, indicating independence. the post-test scores were significantly lower in the intervention group. for the smartphone distraction scale, the mean pre-test score was 58.06 (sd = 7.69) for the intervention group and 59.72 (sd = 8.08) for the control group. the mean post-test score was 39.70 (sd = 17.67) for the intervention and 58.78 (sd = 17.47) for the control group, respectively. the pre-test score mean was not significantly different between groups (t = −0.70, ns), but the post-test score mean was significantly lower for the intervention group than for the comparison group (t = −6.69, p < 0.001). the pattern was similar in the results for the other variables except for nomo, habitual behaviour, and social media use per day. table 2 provides a summary of the baseline t-test and chi-square outcomes and internal consistency for each scale at each measurement period. all scales demonstrated good internal consistency for the sample considered. a series of bivariate pearson's r correlation analyses was conducted to examine the results obtained amongst sds and the secondary outcomes (table 3) . smartphone distraction correlated significantly with problematic social media use (r(252) = 0.63, p < 0.01), anxiety (r (252) = 0.46, p < 0.01), online vigilance (r (252) = 0.51, p < 0.01), automaticity (r (252) = 0.57, p < 0.01), impulsivity (r(252) = 0.45, p < 0.01), deficient self-regulation (r(252) = 0.33, p < 0.01), smartphone use/day (r(252) = 0.31, p < 0.01), p < 0.01), fomo (r(252) = 0.28, p < 0.01) and nomo (r(252) = 0.51, p < 0.01). however, smartphone distraction correlated negatively with two variables: mindful attention (r(252) = −0.52, p < 0.01) and self-awareness (r(252) = −0.34, p < 0.01). to test h1 and assess the effect of the intervention on smartphone distraction, two separate ancovas were conducted. first, to isolate any effect of the intervention, a per-protocol analysis was conducted. as depicted in table 4 online vigilance (r (252) = 0.51, p < 0.01), automaticity (r (252) = 0.57, p < 0.01), impulsivity (r(252) = 0.45, p < 0.01), deficient self-regulation (r(252) = 0.33, p < 0.01), smartphone use/day (r(252) = 0.31, p < 0.01), p < 0.01), fomo (r(252) = 0.28, p < 0.01) and nomo (r(252) = 0.51, p < 0.01). however, smartphone distraction correlated negatively with two variables: mindful attention (r(252) = −0.52, p < 0.01) and self-awareness (r(252) = −0.34, p < 0.01). to test h1 and assess the effect of the intervention on smartphone distraction, two separate ancovas were conducted. first, to isolate any effect of the intervention, a per-protocol analysis was conducted. as depicted in table 4 ancova analyses for the secondary outcomes were also tested across both pp and itt samples. specifically, for the pp sample, main effects of the experimental group on post-intervention outcomes after controlling for baseline scores were found for self-awareness (f(1, 140) in order to evaluate the effects of the intervention in the intervention group based on level of distraction and to assess whether the effects were consistent in the intervention group independent of degree of distraction, participants were classed into two categories of high distractors vs. low distractors depending on perceived distraction level. a median-split analysis with high vs. low distractor levels was determined by scores above vs. below the median and these were separately analysed inside the intervention group. therefore, a two-way mixed anova with time (pre-test and post-test) as within-factor and distraction severity (high and low distraction) as between-factor was performed to investigate the impact of the intervention (time) and degree of distraction (high vs. low) as assessed at baseline on distraction levels at post-intervention. this analysis was conducted only for the dependent variable for which the interactions were found to be significant. results more specifically for mediation 1, the intervention group was the proposed independent variable in these analyses, mindfulness was the proposed mediator, and smartphone distraction was the outcome variable. for mediation 2, stress was the proposed independent variable in these analyses, online vigilance was the proposed mediator, and smartphone distraction was the outcome variable. for mediation 3, smartphone distraction was the predictor, social media addiction was the outcome and online vigilance was the mediator. analysed variables included the t1 scores on the constructs examined as covariates to account for pre-intervention performance. for mediation 1, it was hypothesized that mindful attention would mediate the relationship between the intervention and smartphone distraction ( table 5) . no mediation effect was found for mindful attention on the variables. however, a main effect of the intervention on smartphone distraction (path a: b = −0.67, t = −8.23, p < 0.001) was found, but no main effect of mindful attention on smartphone distraction (path b; b = 1.16, t = 0.67, ns). table 5 . mediation effects of mindful attention and emotional self-awareness on intervention effects and smartphone distraction and of online vigilance on smartphone distraction and social media addiction (n = 252). for mediation 2, it was hypothesized that self-awareness would mediate the relationship between the intervention and smartphone distraction (table 5 ). an indirect effect was found on self-awareness on the variables (a × b: b = −2.02, bca ci = [−3.10, −1.59]), indicating mediation. the intervention significantly predicted self-awareness (path a; b = −6.78, t = −4.32, p < 0.001) and self-awareness significantly predicted lower levels of smartphone distraction (path b; b = 0.30, t = 4.02, p < 0.001). for mediation 3, it was hypothesized that online vigilance would mediate the relationship between distraction and social media addiction (table 5 ). an indirect effect was found on self-awareness on the variables (a × b: b = 0.02, bca ci = [0.01, 0.03]), indicating mediation. the intervention significantly predicted self-awareness (path a; b = −0.01, t = −3.32, p < 0.001) and self-awareness significantly predicted lower levels of smartphone distraction (path b; b = 1.66, t = 4.02, p < 0.001). the present study tested the efficacy of an online intervention employing an integrative set of strategies-consisting of mindfulness, self-monitoring and mood tracking-in assisting young adults to decrease levels of smartphone distraction and improve on a variety of secondary psychological outcomes, such as mindful attention, emotional awareness, stress and anxiety, and perceived self-efficacy, as well as to reduce stress, anxiety, deficient self-regulation, problematic social media use and smartphone-related psychological outcomes (i.e., online vigilance, fomo and nomo). results of the present study provided support for the online intervention effectiveness in impacting these outcomes. findings suggested that students receiving the intervention reported a significant reduction in the primary outcome of smartphone distraction, unlike students in the control group who reported a non-significant reduction in smartphone distraction. in terms of the secondary outcomes, participants in the intervention condition experienced a significant increase in self-awareness, mindful attention, and self-efficacy, and a significant decrease in smartphone use/day, impulsivity, stress, anxiety, deficient self-regulation, fomo, and problematic use. no significant results were found for social media use per day, habitual/automated use and nomo. according to the findings of the present intervention, it appears likely that practising mindfulness and monitoring mood and smartphone activity could lead to a desired behavioural change towards less distraction and less perceived stress with carry-over effects in self-awareness and self-efficacy, similar to interventions for other mental health problems [83, 85, 87, 91, 93, 184, 185] . these findings are consistent with the growing body of research indicating that mindfulness and self-monitoring are effective strategies to increase self-awareness and reduce stress [84] [85] [86] [87] [88] [89] [90] 186] . mindful attention could enhance awareness of individual media behaviour by: (i) raising understanding and awareness of disruptive media multitasking activities (i.e., predictors, patterns and effects), and (ii) raising awareness of different strategies for coping with digital distraction and of which strategies are most effective. second, self-monitoring could help in developing an understanding of media habits and time spent on smartphone and social media activities and could curb perceived excess smartphone interaction, consistent with other study findings [92, 101, 187, 188] . therefore, strategies employing increased mindfulness practice and self-monitoring could aid attentional capacity and self-awareness, which is considered a necessary condition in the behaviour change process of risky behaviours [189, 190] . third, mood tracking could enhance awareness of triggers of negative mood and ensuing negative emotional states acting as drivers for distraction. it appears that the same technologies which may impact negatively on young people may be used to leverage smartphone use [100] and deflect psychological distress if evidence-based behaviour change strategies are applied. intervention strategies such as mindfulness and self-monitoring may encourage increased self-awareness and thus help reduce distraction levels and increase mindful attention. the intervention was also successful in reducing secondary outcomes, such as stress levels and fomo, and it had a positive effect on emotion regulation and loss of control levels. distraction appears to be associated with higher access to social media content and is mediated by online vigilance. salience of smartphone-mediated social interactions (i.e., the salience dimension of online vigilance) has been found to be negatively related to affective wellbeing [49] . it has been reported that emotional dysregulation mediates the relationship between psychological distress and problematic smartphone use [191] . higher self-regulation online has been identified as a moderator between need to belong and problematic social media use in young people [192] and emotion dysregulation as a mediator between insecure attachment and addiction [193] . although distraction is an emotion regulation strategy with a protective function against emotionally distressing states [111] and dysphoric mood [194] , or is used for adaptive coping [195, 196] , deficits in attentional control, such as distraction, may also be implicated in stress, anxiety or other affective disorders [197] and in generalized anxiety disorder with core cognitive symptoms related to excessive thoughts and deficits associated with increased perseverative worry [198] . therefore, higher mindful attention and monitoring of mood may have influenced the reduction of distraction and the enhancement of emotional control. mediation analyses were also performed to understand the relationships between intervention effects on smartphone distraction via two mediators, mindful attention and self-awareness, and of online vigilance on the relationship between distraction and social media addiction. mediation effects were significant for the relationship among intervention effects and distraction via self-awareness, and for distraction and problematic social media use via online vigilance, indicating that self-awareness could be a potential behaviour strategy to mitigate distraction levels. however, the relationship among intervention effects and distraction was not significant via mindful attention as a mediator. therefore, in the present study it appeared that despite its statistically significant increase, mindful attention was not a mediating factor for distraction in the intervention. mindful attention could potentially be the vehicle to increasing emotional self-awareness [93, 184, 199] , prompting more controlled smartphone interactions. on the contrary, online vigilance was found to be a mechanism associated with smartphone distraction and problematic social media use, given the strong preoccupation with the content prompted even by the mere presence of smartphones, confirming previous findings [200] . therefore, despite its protective function, distraction may concurrently serve as a gateway to increased smartphone engagement and time spent on devices. time spent alone is not a defining factor and it has been argued instead that the interaction of content, context and time spent, as well as the meaning attached to these interactions, may determine the level of problematic media use [5, 201] . within smartphone use, distraction is a salient behaviour with evidence that distraction and mind-wandering are associated with online vigilance, which via reduced mindfulness may be associated with decreased wellbeing [78] . furthermore, inattention symptoms have been implicated in risk for smartphone addiction and problematic smartphone use [202] . therefore, handling distraction, which has neural correlates [203] , may be the means to resisting cue reactivity, implicated in smartphone addiction, in reduced cognitive performance [113] or in obsessive-compulsive symptoms [204] . further research is required to assess these cognitive and emotive dimensions of smartphone distraction and its effects on engagement in line with current trends [205] . however, it has been proposed that the construct of distraction extends beyond the debate on smartphone addiction by considering the role of the smartphone in coping with negative emotions and addressing preference for online vs. offline communications [206] . research is still conflicted in relation to the cognitive function of distraction. experimental smartphone research has provided initial evidence that social apps compared to non-social apps on smartphones do not capture attention despite their perceived high reward value [207, 208] , but other studies support a high interference effect [209] . therefore, more research is required to elucidate the mechanisms of digital distraction and delineate how digital technologies, individual choices, and contexts affect individuals' attention spans and attentional loss, as well as mental health conditions, such as adhd and anxiety and overall psychological wellbeing [210] . the present rct assessed the effectiveness of the impact of the use of mindfulness, self-monitoring, and mood tracking delivered through interaction with smartphone apps in reducing distraction arising from recreational smartphone use and social media use. the findings suggest that engaging with the aforementioned practices was effective in reducing distraction levels, stress, anxiety, deficient self-regulation, impulsivity and smartphone-related psychological outcomes, and improving mindful attention and emotional self-awareness and self-efficacy. some limitations need to be taken into consideration. first, a convenience sample of university students was used, which hinders the generalizability of the findings to other groups (i.e., older adults or children). however, this population was considered of primary interest for the study because university students are digital natives liable to experience negative academic consequences due to vulnerability to problematic smartphone use [211] . the effect sizes found in this rct were medium to large for the variables examined, exceeding the expected range for low-intensity, non-clinical interventions [212] . however, as a result of the main recruitment protocol, the intervention may have attracted participants who had an interest in the outcomes and a potential self-assessed vulnerability. therefore, the voluntary, self-selected nature of participation could have introduced a significant degree of participant response and confirmation bias [213] , resulting in the medium to high effect sizes. additionally, the high drop-out rates, consistent with other online rcts [214] , could have significantly affected the strength of the findings [215] , and the use of a passive control group might have led to an overestimation of the effects [216] . due to the use of market-available apps, actual adherence and engagement with the intervention was not accounted for, nor were reasons for dropout [217] . therefore, the findings should be treated with caution and replicated in future designs. future studies should systematically address response bias and include methods in the rct to improve the accuracy of self-reported data [218, 219] . combining self-report with behavioural data [220] , ecological momentary sampling [221] , psycho-informatics and digital phenotyping, the provision of a digital footprint for prognostic, diagnostic and intervention purposes [222] , could enhance the ecological validity of the study. equally, incorporating the measurement of brain activity using magnetic resonance imaging (mri) in interventions could greatly enhance accuracy of assessment of prevention efforts and understanding of the role of neurobiology in behaviour [223, 224] . the impact of the intervention on gender was not examined because this university student sample consisted mainly of female participants. considering the gender differences reported in smartphone use [48, 225] and in attention processes [226] , future studies should explore its effect, which could have significant implications for the intervention and prevention of attention failures and poor student outcomes [227] . additionally, the study design did not manage to provide a longer intervention period due to the lack of freely available apps for participants to use and did not include a second follow-up period to track maintenance of long-term effects, as is customary in rcts, or the use of qualitative process evaluation for a critical understanding of impact of the intervention components [228] . finally, social, economic and family conditions as well as other issues, which are critical to young people's psycho-emotional states and sense of identity, were not accounted for in the present study [229, 230] . despite these limitations, the study provides initial evidence for efficacy of strategies in curbing smartphone distraction and adds to the limited body of knowledge of cognitive-emotive processes in smartphone and social media use [205] . it also contributed to the still limited knowledge on interventions in smartphone distraction and constitutes a simple, first-step, low key intervention programme, which may be practised by individuals seeking support for attentional difficulties on a self-help basis or within a stepped-care clinical framework for prevention purposes [96] . experiencing distraction from smartphones and social media content, interferes with high-level cognitive processes and has productivity and emotional implications (i.e., stress) in various contexts and situations [51, [231] [232] [233] [234] , being further compromised by digital triggers and the structural design of smartphones prompting salience and reactivity [235] . these results have clinical implications as low-intensity interventions may prevent small scale emotional problems from developing into clinical disorders and can reduce incidences of mental health problems [236, 237] . practitioners may also find value in using mindfulness and monitoring practices as an adjunct to therapy for problematic use of smartphones. it may be of high value for academic institutions to build specific university-based programmes on maintaining balanced technology use, tackling unregulated and promoting positive smartphone use, or guiding students towards suitable methods to address attention problems more effectively [238, 239] . apps may also be utilized by schools for students that are faced with attentional/excessive use difficulties and in assisting young people to become aware of their emotions in preparation for learning more adaptive coping strategies. distraction is an emergent phenomenon in the digital era considering that the boundaries between work and recreation are increasingly blurred with both domains arguably dependent on the use of digital media [240] . more research on attentional processes within smartphone use could aid the understanding of these processes and impacts experienced across different age groups. psychological low-cost interventions may be effective in addressing precursors of problematic behaviours and enhancing wellbeing dimensions. the aim of the present study was to assess the efficacy of an rct combining evidence-based cognitive-behavioural strategies to reduce distraction from smartphone use, increase mindful attention, emotional self-awareness and self-efficacy and reduce stress, anxiety, deficient self-regulation and smartphone related psychological outcomes (i.e., online vigilance, fomo and nomo). second, it tested the mediating effect of mindful attention and self-awareness of the intervention on distraction, and of online vigilance on the relationship between distraction and social media addiction. findings suggested that students receiving the intervention reported a significant reduction in the primary outcome of smartphone distraction, whereas students in the control group reported a non-significant reduction in smartphone distraction. in terms of the secondary outcomes, participants in the intervention condition experienced a significant increase in self-awareness, mindful attention and self-efficacy and a significant decrease in smartphone use/day, impulsivity, stress and anxiety levels, fomo, deficient self-regulation and problematic social media use. no significant results were found for duration of social media use/day, habitual use and nomo. mediation effects of the intervention were also observed on distraction and problematic social media use via the mediators of emotional self-awareness and online vigilance in mitigating distraction levels. mindful attention was not found to be a mediating process for reducing distraction in the intervention. research on digital distraction is still scarce, yet there is increasing interest in cognitive impacts within digital environments. more evidence is required to assess the nature of attention failures and difficulties occurring both in normative and excessive online use. this evidence would allow an understanding of the prevalence and the nature of these difficulties, as well as their integration in intervention media literacy and risk prevention programmes, enhancing wellbeing, productivity and academic performance. the authors declare no conflict of interest. the forgotten frontier of attention cognition in the 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dimensions, interventions, and policy a. ehealth literacy among college students: a systematicreview with implications for ehealth education how to strengthen patient-centredness in caring for people with multimorbidity in europe? policy brief 22 icare4eu consortium understanding the determinants of digital distraction: an automatic thinking behavior perspective this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-156291-vnc1iay1 authors: marchiori, massimo title: covid-19 and the social distancing paradox: dangers and solutions date: 2020-05-26 journal: nan doi: nan sha: doc_id: 156291 cord_uid: vnc1iay1 background: without proven effect treatments and vaccines, social distancing is the key protection factor against covid-19. social distancing alone should have been enough to protect again the virus, yet things have gone very differently, with a big mismatch between theory and practice. what are the reasons? a big problem is that there is no actual social distancing data, and the corresponding people behavior in a pandemic is unknown. we collect the world-first dataset on social distancing during the covid-19 outbreak, so to see for the first time how people really implement social distancing, identify dangers of the current situation, and find solutions against this and future pandemics. methods: using a sensor-based social distancing belt we collected social distance data from people in italy for over two months during the most critical covid-19 outbreak. additionally, we investigated if and how wearing various personal protection equipment, like masks, influences social distancing. results: without masks, people adopt a counter-intuitively dangerous strategy, a paradox that could explain the relative lack of effectiveness of social distancing. using masks radically changes the situation, breaking the paradoxical behavior and leading to a safe social distance behavior. in shortage of masks, diy (do it yourself) masks can also be used: even without filtering protection, they provide social distancing protection. goggles should be recommended for general use, as they give an extra powerful safety boost. generic public health policies and media campaigns do not work well on social distancing: explicit focus on the behavioral problems of necessary mobility are needed. the recent covid-19 pandemic has caught many governments off-guard, not only for the rapid initial spread of the virus, but more importantly for the unexpected growth of the contagion, even in presence of safety protocols. one might wonder what are in fact the main reasons for such situation. on the one hand, we have various recommendations issued by the world health organization (who) and by local authorities to limit the spreading of the virus: such measures have grown tighter with the diffusion of the contagion. on the other hand, we have the companion power of prediction models that should have also given precise indications in this battle against the virus. both of these actions, theory and practice combined, should have provided for a rapid containment of the virus and a quick return to a normal life. in reality, things have gone in a very different way. the strict recommendations progressively enforced by authorities to limit sociality, most notably lock-down and social distancing, have in fact proved surprisingly ineffective when compared to their theoretical impact. a sufficiently large social distancing should alone be a formidable protection measure 1;2;3 , but this has not been the case, as shown by the contagion growth data in many countries. alongside, the mathematical models that should have offered guidance against the virus have faced big difficulties to provide precise predictions and consequent fine insights on how to shape the best containment strategy 4;5 . why is it so? regarding public health measures, obviously there has been some mismatch between theory and practice, between the dictated recommendations and the actual behavior of the people. this mismatch can also explain the difficulties encountered in designing models, given that precise data are essential to understand the logic governing the spreading of the virus, whereas so far we have been dealing with very limited datasets collected a posteriori. for instance, covid-19 data collected and used in italy both by government and local authorities to make decisions, and by researchers to build predictive models, are accessible in a github repository 6 containing classic a posteriori data like for example the number of people infected, hospitalized or dead in regions and provinces. these kinds of data are certainly essential and helpful, but they do not provide direct insights on the actual causes of the development. what we miss is precise data on the key behavior of people during the infection, so to understand the underlying mechanics, build causal models with very low error margins, and guide effective public health policies. in this research we tackle this problem by addressing the key component of social distancing. for the first time, we collect real data on social distancing in a pandemic situation, analyze the actual shape of social distancing as performed by people, identify a paradoxical default behavior of social distancing that can explain the dangerous spread of covid-19, and provide corresponding functional actions that can be taken to help against this and future pandemics. starting from extensive experience in sensor-based equipment and smart city solutions (for instance in city environments 7;8;9;10 , shopping malls 11;12 , garbage collection 13;14 and more 15 ), we have designed and built a sensor-equipped social distancing belt, a special belt augmented with hidden sensor boxes allowing to measure social distances. the sensor boxes are concealed so to appear as normal belt pouches, therefore allowing for discrete and unnoticed operation. a social distancing box relies on a hardware core composed by an atmega 328p compatible micro-controller, custom wired and endowed with real time clock (rtc) capabilities via a ds1338 chip, microsd card module for storage, and an ultrasonic distance sensor hy-srf05 operating at 40khz. main power is provided by 20000mah rechargeable power banks, whereas a common 3v cr2032 coin cell battery powers the rtc component. in order to avoid spurious readings, and rule out cases like for instance couples, parents with children, people with dogs and so on (all cases that obviously alter the social distancing behavior and available room) the system is in standby and social distancing measures can be activated and deactivated via an on/off switch. temporal reasoning programmed in the micro-controller deals with cases of people quickly passing one by another (local minima in the social distance curve are extracted, using threshold values), so freeing the operator from dealing with continuous on/off cycles: during normal operation the switch is used only to rule out the unwanted cases (or optionally to save energy when no person is nearby). as said before, the whole assembly is concealed so no wiring or other electronic material actually shows up, so externally the apparatus looks like a normal belt with some pouches. using the belt, we have proceeded to collect social distance information in the venice metropolitan area (italy) during the most critical period of the covid-19 pandemic: data collection has taken place uninterruptedly for a period of over 2 months, from february 24 to distribution histogram of social distancing in 163cm sidewalks. µ is the average social distance, max is the maximum distance obtainable when staying within the sidewalk. april 29, 2020. even during the lock-down periods, people are still allowed to go out for essential purposes and consequent necessary mobility, like going shopping for food. in italy for instance using public transportation has been actively discouraged, asking people to walk instead. so, we have targeted focus points where social distancing is crucially important, and where data can be continuously collected even during the worst periods of a pandemic, like pedestrian sidewalks and food shops. in this first preprint we present the result collected by monitoring sidewalks. in order to see what happens in various situations we have selected sidewalks of different widths: 163cm, 175cm and 222cm. the belt operator always stays on one side of the sidewalk, maximizing the distance from another person. all the selected sidewalks also allow to temporarily step out (being parallel to a green area or to a bicycle path): this way we can measure if the pressure of social distancing in the pandemic makes people gain further distance when approaching someone. in fact, in 167cm and 175cm sidewalks the only way to get the recommended minimum distance of 1 meter is to step out (or alternatively to slide sideways 16 ). for every chosen sidewalk we study social distancing in five different cases: 1) unmasked case: the operator does not wear a mask 2) masked case: the operator wears a surgical mask 3) diy-masked case: the operator wears a diy (do it yourself) mask 4) goggles masked case: like the second (masked) case, with the operator additionally wearing gog-gles 5) goggles diy-masked case: like the third (diymasked) case, again with the operator additionally wearing goggles. the first case allows to determine the default behavior of people in a pandemic. the second and third case allows to check whether visual factors (wearing a mask) affect social distancing. given the shortage of protective masks experienced in many countries, we also test diy (do it yourself) masks, stressing their visual component: the mask has practically no protection value but it is purposely rough (made up by a piece of baking paper), so to be visually very noticeable as a bad home-made patch. the last two cases allow to verify whether goggles for eye protection (equipment not actually included in recommended public guidelines) further changes common social distancing behavior during a pandemic. for the sake of readability, in this preprint we include graphics for the 163cm case, granted that the 175cm and 222cm cases exhibit the same behaviour. the unmasked case figure 1 shows the histogram distribution of social distances, helping to identify what kind of pattern people follow. the plot shows also the average social distance µ (in this case, 29.4cm) and the available max space (maximum social distance available while staying on the sidewalk). we can see that in this case all people spatially distribute within the maximum width (so, not stepping out of the sidewalk). the first important fact to notice is that the average social distance behavior does not work as we would expect during such a threatening pandemic. a safe social distance strategy would dictate people to use all the space at their disposal, therefore maximizing distance and having a distribution strongly skewed towards the max. instead, what happens is a completely paradoxical situation: not only people do not use this strategy, but actually follow an anomalous normal-like distribution which is skewed more towards the other person in the sidewalk (or in fact, towards the central area of the sidewalk). so, surprisingly, people tend to stay closer to another passing person rather than stay far away. this highly dangerous behavior is also consistent among different widths (175cm and 222cm). this paradoxical behavior implies that requiring social distancing alone not only does not work well for sidewalks but actually maintains very dangerous proximity situations. favoring walks instead of public transportation therefore does not automatically produce a safer social environment. the results of the second scenario (operator wearing a mask) are shown in the left panel of figure 2 for 163cm sidewalks. the introduction of a mask provokes a radical change of social distancing, making it grow (the average passes from 29.4cm to 58.42cm) and also modifying the overall distribution. whereas in the unmasked case we had a distribution skewed towards the operator, in this scenario the paradox disappears, and the peak is instead farther away. last but not least, we can observe an interesting phenomenon: the distribution actually extends beyond the max limit, passing from 58.8cm of the unmasked case to 119.5cm. this behavior is consistent in all the other sidewalks (175cm and 222cm). ) shows what happens when wearing a diy mask (163cm sidewalks). the situation is in all similar to the masked case: the distribution is again skewed in the same asymmetrical way, with people distancing beyond the sidewalk max width. the only notable difference is the average distance and overall width of the distribution, which grows even more than in the masked case: average grows to 69.02cm and the whole distribution extends up to over 150cm of social distance. again, this behavior is consistent among differently sized sidewalks (175cm and 222cm) . ) shows what happens in 163cm sidewalks when we add goggles to masks. we can see that the effect is similar to what happened with diy masks: the distribution skews further to bigger social distances. in fact, this extra distance boost is bigger than what obtained with a diy mask, as the average social distance grows to 79.79cm. again, the effect is consistent along all sidewalks (175cm and 222cm). the last case is the combination of goggles and diy masks, shown in figure 3 (right panel) for 163cm sidewalks. the effect is similar to the goggles masked case: adding goggles provides an extra social distance boost. interestingly, this boost is cumulatively added on top of that coming from the diy mask. in the 163cm case the average social distance grows to 92.39cm and similar boosts are obtained for all the other sidewalks (175cm and 222cm). alongside the spread of the virus, the italian government issued a series of law decrees progressively setting more and more restrictions. on the 30th of january 2020 who declared covid-19 an international health emergency. the situation in italy apparently remained good until late february when, given the outbreak of the virus, the italian government reacted with some law decrees stating safety rules for the population. in parallel with the subsequent growth of the infection, the government (in a paradigmatic strategy of incremental national interventions followed by many other states) reacted with further decrees, progressively restricting social movements, aggregation places and workplaces. among the various national decrees issued to prevent covid-19, we can mark three main dates (dubbed n1, n2, n3 for later reference): • n1 (march 1): first social distancing enforcement 17 (dividing italy into "red", "yellow" and "red" zones). this measure implemented for the veneto region a partial lockdown (schools closed, 1-meter social distancing in restaurants and bars) • n2 (march 8): partial lockdown extended to all italy, 1-meter social distancing recommended also outdoors 18 • n3 (march 11): full lockdown 19 , only essential movements allowed. additionally, on march 9 the government also launched a continuative massive media campaign dubbed #iorestoacasa ("#istayathome"), using celebrities from various fields to promote the public health recommendations by asking people to stay at home 20 . the veneto region has been an even more interesting case given that, besides national laws, the regional government has introduced unique additional safety measures. the most notable regional ordinances are three, setting additional public health rules in the following dates (dubbed r1, r2, r3): the outcome of all these laws has been relatively disappointing: government restrictions and media outreach did not substantially change the situation, leading to a pandemic that has kept the whole italian country stalled for months. we now analyze how all these various health policies impacted social distancing. figure 4 shows the temporal evolution of social distancing during the pandemic, allowing to see the effects of national decrees (n1, n2, n3), the media campaign (m) and regional ordinances (r1, r2, r3). as we can see, there has been no noticeable difference: social distancing behavior over time has shown remarkable consistency. for instance, checking on the effect of the media campaign we find that in the unmasked case the average social distancing changed only by -1.8cm from the week before to the next week. similar small differences also occurred in the masked (+3.6cm), diy-masked (+1.6cm), goggles masked (+0.9cm) and goggles diymasked (+0.7cm) cases. all these small differences are compatible with normal data fluctuations, as substantiated by the kolmogorov-smirnov test: social distancing continues to follow the same distributions even after the campaign (the p-values for the five cases are 0.59, 0.82, 0.70, 0.93, 0.85 respectively). the same situation occurs for all the other (national and regional) public health enforcements in all the other sidewalk cases (175cm and 222cm). the common behavior of social distancing exhibits a paradoxical and very dangerous behavior, which could explain the relative inefficiency of social distancing alone to disable the virus spreading. the essence of this paradox probably lies in the intrinsic social nature of our human collective, that social component that makes us aggregate and live in communities, so favoring social versus anti-social behavior. this built-in behavior is likely hard to alter, especially in everyday situations like walking: consequently, this counter-intuitive behavior of social distancing in the unmasked case is very dangerous and it should be subject of special attention, being a critical risk factor even in quarantine, due to necessary mobility (people have to go out at least to grab food). limiting transportation mobility, like done in italy, can in fact aggravate this problem. even worst, this risky social behavior has been resilient to enforcement and media campaigns, thus also explaining the inefficiency of many public health measures against covid-19. a key strategy to get rid of the paradox and its danger is to try to de-activate the built-in social rules of people, by triggering an explicit counter-effect mechanism and so turning unconscious social behavior into conscious anti-social behavior. this safety trigger can be activated via visual stimuli that remind of the danger of social proximity, making people change their common dangerous behavior and implement a safer social distancing strategy. wearing a mask instead triggers this sort of repulsive effect, "pushing farther" people and the skew of the distribution, changing their common behavior so to gain social distance (even by stepping out of sidewalks). the distance increases with patched diy masks, confirming the effect of a visual stimulus. goggles act as "social distance boosters", again consistently with the hypothesis that a visual stimulus signaling danger makes people more sensible to safety and increases social distancing protection. the good news is that the effectiveness of this booster seems also consistent with time. consequently, a number of actions can be suggested to help against the virus: wearing masks. in the initial onset of the contagion, masks were not recommended in italy but only to infected persons. similar recommendations have been given by many other countries 24;25;26;27 . given that masks lead people to implement social distancing in a safe way and also provide an overall distance boost, usage of masks should be in fact be always recommended to everyone in spite of their protection effectiveness 28 and fitting troubles 29 . mask shortage and diy. one of the biggest problems many infected nations have been facing is availability of masks for all the population 30;31;32 , given also their disposable nature. lacking proper masks, diy ones can profitably be used: even with no filtering protection, they provide social distancing protection. so, diy masks can help a lot in all those situations where proper filtering masks are lacking or in shortage. and even when masks are available, adding a diy mask on top still gives some extra protection. goggles. goggles are currently not recommended protection equipment for the population, but they should, given they provide a significant additional boost to social distance. social distancing, media and education. suggesting or imposing social distancing, via media campaigns or laws, does not work so well on social distancing itself and leads to paradoxically dangerous situations. therefore, public health campaigns should not focus only on limiting mobility, asking people to stay at home and providing generic social distancing rules, but also explicitly focus on the key aspects and behavioral problems of necessary mobility and of the dangerous paradox lying within our social nature. the analyzed social distancing behavior can be also used to obtain more precise prediction models (and so, better countermeasures): social distancing cannot be assumed as given, dictated by law or media, it's much more complex and also depends heavily on a so far comparison of the daily average social distancing among all the five scenarios from february 24 to april 29, 2020 (163cm sidewalks). n1, n2 n3 mark the national decrees, r1, r2, r3 the regional ordinances and m the start of the national media campaign. the unmasked case stops with r3 because of the obligation to wear masks outside. neglected human factor, thus deserving specific attention leading to a real social distancing science. last but not least, the findings are not only local to the ongoing covid-19 pandemics but are of general interest in future pandemic situations, given the general nature of the social distancing paradox, and the visual nature of social distancing boosters. simulation suggests that rapid activation of social distancing can arrest epidemic development due to a novel strain of influenza effectiveness of workplace social distancing measures in reducing influenza transmission: a systematic review mathematical assessment of the impact of nonpharmaceutical interventions on curtailing the 2019 novel coronavirus special report: the simulations driving the world's response to covid-19 caution warranted: using the institute for health metrics and evaluation model for predicting the course of the covid-19 pandemic prime minister, deparment of civil protection fix me up: smart pathways status detection mind your step: monitoring pedestrian sidewalks safe cycle: infrastructural control for bikers health zone monitoring: a passive approach the paradox of the shopping mall: costumers flows and market efficiency back to the bazaar: destructuring the data mall the smart cheap city: efficient waste management on a budget bins with eyes: towards a more efficient urban ecosystem happy cows, happy milk: smart cows and quality factors pedestrian planning and design italian prime minister decree law italian prime minister decree law italian prime minister decree law italian ministry of health, #iorestoacasa: fallo anche tu! (#istayathome: you do it too!) veneto region ordinance n veneto region ordinance n veneto region ordinance n advice on the use of masks in the community, during home care and in healthcare settings in the context of the novel coronavirus (2019-ncov) outbreak: interim guidance mass masking in the covid-19 epidemic: people need guidance personal protective equipment: questions and answers rational use of face masks in the covid-19 pandemic face masks for the public during the covid-19 crisis the importance of fit-testing particulate filtering facepiece respirators! shortage of personal protective equipment endangering health workers worldwide are uk doctors getting sufficient protective equipment against covid-19 faqs on shortages of surgical masks and gowns during the covid-19 pandemic key: cord-024871-emfk3gdg authors: piperagkas, grigorios; angarita, rafael; issarny, valérie title: social participation network: linking things, services and people to support participatory processes date: 2020-04-29 journal: advanced information systems engineering workshops doi: 10.1007/978-3-030-49165-9_10 sha: doc_id: 24871 cord_uid: emfk3gdg digital technologies have impacted almost every aspect of our society, including how people participate in activities that matter to them. indeed, digital participation allows people to be involved in different societal activities at an unprecedented scale through the use of information and communication technologies (ict). still, enabling participation at scale requires making it seamless for people to: interact with a variety of software platforms, get information from connected physical objects and software services, and communicate and collaborate with their peers. toward this objective, this paper introduces and formalizes the concept of social participation network, which captures the diverse participation relationships – between people, digital services and connected things – supporting participatory processes. the paper further presents the early design of an associated online service to support the creation and management of social participation networks. the design advocates the instantiation of social participation networks within distinct participation contexts—spanning, e.g., private institutions, neighbor communities, and governmental institutions—so that the participants’ information and contributions to participation remain isolated and private within the given context. an increasing number of institutions and self-organized communities have been promoting the use of information and communication technologies (ict) to improve the participation of people in community-wide processes as diverse as, e.g., online education, neighborhood projects, or public consultation. such digitally-powered participation, known as digital participation [24] , has led to the emergence of various participatory practices that empower people at scale. illustrative examples include: crowd-sourcing/-funding [14] , participatory budgeting [15] , peer to peer sharing in communities [26] , open government data access & analysis [25] , participatory urban planning [6] , and public consultations [21] . as the "ladder of participation" illustrates [4] , there exist different levels of involvement of the community in participatory processes, from non-participatory to citizen control, through to, e.g., informing, consultation and partnership. still, independent of the target level of participation, enabling digital participation requires making it seamless for people to connect and interact with the relevant community of people but also of digital entities (see fig. 1 ). indeed, the "community" of digital entities is essential to support the implementation of participatory processes in the digital world and even in the physical world by way of the iot. toward that direction, this paper introduces the concept of social participation network, which captures the various entities that may potentially engage in a given digital participatory process, while abstracting the underlying heterogeneity. in what follows, we first walk through illustrative examples of participation that have flourished in the digital society over the last ten years, from the government-led top-down to the people-led bottom-up approaches (sect. 2). then, using a dedicated ontology, we define the digital entities and relations among them that a social participation network characterizes (sect. 3). we also introduce the rules that govern the emergence of relationships among the participating entities within a network to enhance the associated participatory process, while enforcing privacy and security guarantees to participants. we then present the early design of an online service -introducing its architecture and component technologies -supporting the implementation of participatory processes based on the proposed concept of social participation network (sect. 4). finally, we conclude with a summary of our contribution and the research challenges ahead of us (sect. 5). the development of participatory technologies has been drastic over the last ten years, as it builds upon the development of ict and their increasing widespread adoption by the masses. we may classify the related participatory initiatives according to who is leading them: government, people or both. open government promotes governmental transparency and accountability, so as to reduce democratic malfunctioning incidents. open data is among the pioneer implementation of open government in today's digital era. still, there exist various implementations of the concept [16] , which differ according to the level of participation, from the citizen being a mere consumer to an actor, of the government actions. accordingly, a number of software tools support the open data movement, from the management of data to engaging developers in the creation of new applications as open government data as a service illustrates [20] . the proper organization of the exposed data is in particular essential to avoid misinterpretations and requires appropriate visualization tools. still in the direction of leveraging digital technologies for opening up government knowledge and practices, agencies have applied crowdsourcing to foster civic participation at a massive scale for top-down politics, reform discussion and e-voting. examples are many and include: the constitution reform in iceland [17] , open ministry in finland [8] and open innovation strategies [7] . according to aitamurto [1] , crowdsourcing with co-creation constitutes the main method for realizing participatory democracy. the analysis of practices and associated digital tools supporting the "open government" approach shows that they ignore too often the fundamental principles of effective deliberation, participation and collaboration, and focus mainly on transparency and information [13] . people-led initiatives fostering actions at the community level tend to overcome the shortcomings. people-led community actions: social media are a tool of choice for communities of people to organize themselves. this includes using well-established online social networks (osns) for political discussion and online deliberation [12] . existing studies of this specific use of osns further suggest the design of osn services dedicated to political organization and action. this is to foster online interactions that have shown to play a crucial role in the formation of a movement, where politics is obvious to everyday life, in contrast to formal settings [9] . the emergence of specialized community social media sustains well the analysis. the associated software applications then serve connecting the residents of a given local community via an exclusive portal, further implementing strong features for building trust and safety among users. it is worth stressing that the society's digitization allows for people-led actions at a large scale. the web-based we europeans 1 civic consultation is one such illustration. the consultation, run between february and march 2019, allowed european citizens to offer solutions on concrete steps to be taken to reinvent europe. the initiative collected 30,000 proposals and 1,7 million votes. the top 10 proposals of each country were then translated in all the european languages, so that european citizens could vote in a second round to identify the top 10 proposals at the european level. finally, the political parties of every country were able to take a stand on these proposals and share their position via the we europeans web application. hybrid urban-scale actions: the most common form of people participation is urban-centric. with the development of computing in urban environments and of the smart city vision, participatory platforms have been gaining momentum. these platforms and associated applications ease and organize the interactions of the connected people among them and/or with local authorities and agencies. they also promote collective actions. urban computing is at the heart of the development of urban applications. as defined in [28] , urban computing is a process of acquisition, integration, and analysis of big and heterogeneous data generated by diverse sources in urban spaces, such as sensors, devices, vehicles, buildings, and humans, to tackle major issues that cities face. the supporting software platforms then cope with: sensing and data collection, analyzing the data, and combining the physical with the virtual environments (i.e., social networking and sensor data integration). as such, the software solutions involve a large diversity of systems, spanning: mobile computing, cyber-physical, and artificial intelligence, to name a few. the widespread adoption of smartphones and further development of the iot, allow collecting data that address multiple domains of the smart cities -mobility, health, utilities, etc. -and offer a unique opportunity for participatory applications. this includes accommodating political expression and participation. fostering massive participation then becomes the target in the deployment of applications in the wild [23] , while the abundance and complexity of applications ultimately lead to lessen the interactions with people and among them. however, development in the area of civic technologies (aka civic tech) aims at offering platforms easing participatory processes at scale although introducing proprietary technologies that limit their adoption. the previous section illustrates the key role of cyber-physical-social systems (cpss) in the realization of digital participatory processes: people not solely need to network together, they also need the digital tools to collaborate, get access to the relevant information and (co-)create. we argue that the specific participatory cpss must be structured around the paradigm of social participation network that manages the connection of people, actions and digital entities according to their relevance to the focus of the participation. the paradigm of social participation network builds upon the well known one of osn and of the more recent social iot [5] . the latter aims at integrating social networking concepts into the internet of things (iot). that is, the social iot creates social network graphs of people and things, in which the relations with things derive from the things' ownership and physical properties. the distinctive feature of a social participation network is then to specifically manage participatory links among people and digital entities so as to enable: -people to connect with other people who share similar interests within a given group, thereby enabling the social character of participation. -people to discover the participatory actions in which they are interested and may engage in online and/or offline. -digital entities -associated with the participants and/or the actions -to discover and connect with each other, thereby automating supporting actions (e.g., information sharing). the structure of a social participation network underlying a participatory process evolves as the participants come and go, and their contributions and interests change over the course of the process. we formalize the entities and relations of social participation networks using an ontology. this provides us with a formal foundation to: discover new participatory relationships using inference engines, verify the network consistency, compose social participation networks, and build participatory platforms and services by creating instances of the ontology classes. there already exist ontologies that establish participation concepts. for instance, [10] defines the concepts and relations of traditional participatory scenarios such as persons, organizations, causes and supporters. another example is [19] that focuses on digital paricipation, thereby addressing the specification of both supporting software platforms and democratic processes and projects. our ontology differs in that it includes not only human participants but also iot devices and software services, which are essential to the implementation of digital participation. figure 2 outlines the social participation network ontology. it is composed of three main classes: -actor : actor has the subclasses human and cyber. cyber has two subclasses: thing and service. things can be connected sensors, actuators and appliances, and also more powerful devices such as mobile phones. services are cloud services, web services, apis, databases, etc. -theme: themes are topics representing subjects of interest such as parks, security and climate change, just to mention some examples. -action: actions represent concrete projects aiming at doing something; for example, rethinking a particular park in the city, improving the security of a particular street, or reducing carbon emissions around schools. in the following, we denote with lowercase letters h, c, t and a, the instances of the classes human, cyber, t heme and action, respectively. the ontology also introduces two types of relations: -explicit relations are defined based on the declared behavior of actors. a base explicit relation is hasinterestin with which a human can relate to a theme. actions and cybers may also relate to themes through the isabout and relatesto relations. humans can relate to other humans through the relations collaborateswith, meaning the humans participate in the same action. -implicit relations characterize inferred relations. they derive from the explicit ones and their labels add the prefix may (e.g., mayhaveinterestin) as the relationships are inferred by the system as opposed to being explicitly specified. in the last years, several initiatives have emerged to build rule-based systems for the social iot where rules automate the formation of social links between iot devices and allow the inference of new relations. examples of such systems are diverse (see [22] for a survey) and include, e.g., university & car pooling, and trust management & smart building. in a way similar to these works, this section introduces rules associated with the management of "participatory links", although it focuses only on the case of creation. we first define the invariant properties of any social participation network for which the two following rules 1 and 2 must always hold. ∀h ∈ human, ∃t ∈ t heme : h hasinterestin −−−−−−−−−→ t the dynamics of social participation networks results from the occurrence of events (e.g., see table 1 ) as the two next rules specify. ∃h ∈ human, ∃t ∈ t heme : showsinterestin(h, t) : h hasinterestin −−−−−−−−−→ t ∃h ∈ human, ∃t ∈ t heme, ∃c ∈ cyber : and, the link mayhaveinterestin is created between that human and all the actions that relate to that theme: ∃h ∈ human, ∃t ∈ t heme, ∃a ∈ action : finally, if two humans are interested in the same theme, the link maycollabo-ratewith is created between them: ∃h ∈ human, ∃a ∈ action : engagesin(h, a) : following, if two users engage in the same action, then the link collaborateswith is created between them. the rules we presented in this section are an early formalization of the social participation network paradigm. while the paradigm builds on those of social network and social iot, it goes further by addressing the necessary connection among people and cyber entities within participatory processes. we are currently analyzing the rich literature on digital participation in order to discover the core set of rules for participation. however, we do not pretend to introduce a fixed set, other rules can be added during the design phase of a participatory process to meet specific needs. in addition, although we have not presented rules associated with the removal of links, they are similar to those presented in this section. the social participation network paradigm paves the way for the design of an associated participatory osns (online social network service), through which people may connect and collaborate together as well as with relevant cyberentities to engage in participatory processes. one key feature of the participatory osns is to provide interoperability across the heterogeneous cyber entities, including the diverse online communication services people use (from email to popular osnses). we have previously introduced the social middleware solution to address such interoperability requirements [2] . in particular, social middleware leverages the universal social network bus [3] which mediates interaction across online communication technologies to overcome the platform lock-in. participatory osns architecture: building on the above contributions and state-of-the-art technology building blocks, fig. 3 depicts the architecture design of a participatory osns. the architecture includes the event handler service as a node.js (www.nodejs.org) and express (www.expressjs.com) application. actors, in a given participatory context, then trigger events such as engagesin and showsinterestin, which are published to a message broker such as rabbitmq (www.rabbitmq.com) (see publish event in fig. 3 ). the event handler service consumes events from the message broker (see consume event in fig. 3 ), which it evaluates using the rule engine and knowledge base containing the social participation network rules we presented in sect. 3.2 (see event evaluation in fig. 3 ). the rules are stored in a mongodb (www.mongodb.com) database as json documents. if the event evaluation triggers an operation, the social participation network graph structure is updated accordingly (see operation in fig. 3) , where we leverage the graph-oriented database neo4j (www.neo4j.com), to store the social participation network graph. finally, actors receive an updated version of the social participation network graph that concerns them (see publish update and consume update in fig. 3 ). participatory technologies such as the proposed dedicated osns can support a wide range of activities. however, the possibility of gathering unprecedented amount of information can endanger the privacy of people. this is a threat that participatory technologies share with the more global paradigm of smart cities [18] and, in general, with any online activity [11] . a base requirement is for any participatory service/platform to enforce the isolation of the diverse participation contexts (e.g., consultation within an enterprise, participatory budgeting campaign, neighborhood co-creation initiatives, ...). figure 4 illustrates the isolation of participatory processes. the social participation network graph and its associated data hosted by a town hall is distinct and isolated from the one hosted by a group of neighbors and by a private institution. the town hall hosts two instances for two participatory contexts, which can have different participants and relations among them. the main goal is to protect information such as who are the participants, their personal and private data and their participation contributions. this example shows the two main levels of participatory process isolation: 1. service provider-level : the isolation is at the level of the party -or consortiuminterested in setting up the participatory process. the interested parties act as service providers, as they host an osns for the participation instance -or are responsible for finding an appropriate host-. 2. participatory context-level : the isolation is at the level of participants contributions and interactions. all information remains isolated among different participatory contexts even within the same service provider. we have introduced and formalized the paradigm of social participation network to capture the diverse participation relationships -between people, digital services and connected things -supporting participatory processes. in a nutshell, the introduced relationships allow automating the finding of: potential collaborators by commonality of interests, participatory actions, and relevant information coming from digital services. we have presented an early formalization of the rules allowing the creation and management of a social participation network together with the architecture design of an associated participatory online social network service. moreover, we recommend the instantiation of social participation networks within distinct participation contexts-spanning, e.g., private institutions, neighbor communities, and governmental institutions-to protect personal data and privacy given the diverse, and maybe sensitive, participatory contexts. the work we presented here is preliminary and there are still open questions regarding the conceptualisation and implementation of social participation networks. as part of our ongoing and future work, we are developing key technical aspects of our architecture design, such as the integration of heterogeneous iot devices and software services, as part of the extension of the universal social network bus [3] . we are also studying the definition of additional social participation network rules to automatically learn and adapt the embedded participatory links. we also plan to evaluate our work both by simulations of participatory contexts and by running small real use cases. finally, it is crucial to address key challenges facing digital participation, such as the digital divide since not everyone has internet access and/or is digital literate, and improving the level of engagement by supporting the right participation incentives. crowdsourcing for democracy: a new era in policy-making social middleware for civic engagement universal social network bus a ladder of citizen participation the social internet of things (siot)-when social networks meet the internet of things: concept, architecture and network characterization participatory urban planning in brazil from open data to open innovation strategies: creating e-services using open government data does crowdsourcing legislation increase political legitimacy? the case of avoin ministeriö in finland a pool of dreams: facebook, politics and the emergence of a social movement social participation ontology: community documentation, enhancements and use examples where is online privacy going? glob social media as a catalyst for online deliberation? exploring the affordances of facebook and youtube for political expression open government and democracy: a research review crowdsourcing development: from funding to reporting engineering software assemblies for participatory democracy: the participatory budgeting use case open government data: a stage model inclusive constitution-making: the icelandic experiment the pursuit of citizens' privacy: a privacy-aware smart city is possible an ontology for next generation e-participation initiatives open government data as a service (godaas): big data platform for mobile app developers the european commission's online consultations: a success story? social internet of things (siot): foundations, thrust areas, systematic review and future directions urban computing in the wild: a survey on large scale participation and citizen engagement with ubiquitous computing, cyber physical systems, and internet of things digital participation open government data using peer-to-peer technology for knowledge sharing in communities of practices webvowl editor: device-independent visual ontology modeling urban computing: concepts, methodologies, and applications key: cord-005385-hswyus24 authors: baehr, peter; gordon, daniel title: on the edge of solidarity: the burqa and public life date: 2012-08-21 journal: society doi: 10.1007/s12115-012-9584-2 sha: doc_id: 5385 cord_uid: hswyus24 dislike among european publics for the islamic full veil and the desire to ban it are often ascribed to nativist "islamophobia." this article questions that assumption. it argues that, in political terms, the wearing of the burqa and niqab is inconsistent with western norms of equality, the backbone of the citizenship ideal; and that, in social terms, the full veil erects a partition to interpersonal understanding and reciprocity. while the constitutional duty to protect religious freedom is a good argument in favor of tolerating the full veil, the practice of wearing it is at the edge of solidarity and injurious to the democratic public sphere. a matter of simple ignorance, or, far worse, evidence of rampant islamophobia. the obvious remedy is not to ban the burqa and niqab (henceforth n/b) but to enlighten the ignorant. puncturing double standards is a good place to start. the american philosopher martha nussbaum puts it this way: it gets very cold in chicago-as, indeed, in many parts of europe. along the streets we walk, hats pulled down over ears and brows, scarves wound tightly around noses and mouths. no problem of either transparency or security is thought to exist, nor are we forbidden to enter public buildings so insulated. moreover, many beloved and trusted professionals cover their faces all year round: surgeons, dentists, (american) football players, skiers and skaters. what inspires fear and mistrust in europe, clearly, is not covering per se, but muslim covering. 3 these analogies fail. pulling a scarf over one's mouth in the dead of winter is an expedient to deal with a temporary situation. once one is in the company of others inside a building, however, the scarf or hat is removed. the same is true for champion skiers or football players who are interviewed after their competition and who relish public attention. dentists and surgeons wear masks for reasons of hygiene that are deemed beneficial to professional and client alike. in contrast, the n/b is not a remedy for a particular occasion; it is a permanent social impediment in all four seasons. and far from having beneficial reciprocity in mind it is a stark expression of separateness. nussbaum's views are typical of those who believe that the full-face veil is not a problem in its own right. if the problem bears no rational relationship to the n/b itself, then it follows that the real problem is in the eye of the beholder. that is in good measure true, as we will show, but not for the reason nussbaum adduces: the fear that often goes by the name islamophobia. sociologists, of all people, should be skeptical of this question begging term. is durkheim forgotten? do we intend, in all seriousness, to explain social currents in terms of individual or aggregate phobias? doubtless, some people view the n/ b as an emblem of unwelcome immigration. doubtless, some people fear muslims for no good reason. but other peopleincluding some leaders of international human rights organizations; some leftist and green politicians; and some prominent muslim intellectuals-share none of these attributes yet still favor banning full veils. those who spoke in 2010 to the french national assembly's information committee on the burqa in favor of a ban included (anri 2010): -sihem habchi, the president of ni putes ni soumises (neither whores nor submissives, a feminist organization founded in 2002) -abdennour bidar, a philosopher and commentator on the koran -andré gerin, a member of the french communist party -patrick gaubert, the president of the ligue internationale contre le racisme et l'antisémitisme (international league against racism and antisemitism) nussbaum also believes, as many do, that n/b-wearing is at root a matter of conscience, a right that demands protection. but conscience cannot be assumed to be the universal motive or defense of covering. muslim women cover for many reasons: piety, pride, tradition, political ideology, and family pressure. oppositional excitement is another factor. as one of eva chi's tunisian subjects confided, "the forbidden is desirable, and the more the government controls the veil, the more it is tempting to challenge it" (2010: 44). besides, in many societies and sub-societies, failure to cover is a mode of deviance that can be and is severely punished. the same is true sometimes even in the west, where in the most dramatic cases facial exposure, the wearing of make up, and the dating of western boys has culminated in planned, orchestrated murder by the shamed family, so called "honor killing" (chesler 2009 (chesler , 2010 husseini 2009; wikan 2008) . one only has to observe women -muslim and infidel both-on international flights to tehran, kabul or karachi donning scarves on entry, and removing them on exit, to appreciate the full weight of customary expectations in covering practices. nussbaum, to be sure, deplores pressures on women to conform. she simply wishes that women who choose to veil be left alone to do so in peace and dignity. yet her sympathy towards traditional practices is one sided. privileging the conscience of the covered over established western norms places the whole burden of adaptation on to the host population. it shifts the requirement to respect tradition on to everyone but the n/b wearer. western conventions of clothing and salutation can be ignored as superficial or coercive. it also bears emphasis that post-colonial writers (nussbaum is not among them), who see the west as "an imaginary formation" (al-saji 2010: 878), fail to note a telling irony of their position: that the fiercest fighters for colonial liberation were adamant about the "uniqueness," "national originality," and "national vocation" of their own cultures. "cultural destruction" was an evil to be resisted. local traditions were at the heart of national identity. anti-colonial radicals, unlike their post-colonial successors, were no cultural relativists. 4 this article seeks to identify features of n/b antipathy that polemics and special pleading routinely obscure. two dimensions are paramount. politically, n/b wearing is by western standards an uncitizenly posture that undermines the twin practices of civic equality and reciprocity. sociologically, n/b wearing impedes cross-cultural understanding, social interaction and, a fortiori, social solidarity beyond the domestic unit. together these political and sociological features suggest that the n/b, whatever the various intentions of its wearer-religious devotion, identity statement, life-style choice, generational revoltmarks a person as a political and social outsider within a western environment. three caveats preface the argument advanced below. first, our focus on the n/b is exclusively on its public appearance on the street, in public buildings such as schools, hospitals and offices, in parliaments and so forth. the garb is typically removed in domestic, familial settings. second, we say nothing of substance about the hijab (headscarf) or the iranian chador, both of which reveal the face without serious impediment. in france and belgium, the issue of the full veil has been formulated as a problem separate from the problem of the headscarf. speaking to the french national assembly (anri: 592), the sociologist nilüfer göle, whose book the forbidden modern (1997) elicited sympathy for the headscarf, described the full veil contrastingly as "a regression or, at least, a very radical will to rupture with reciprocity and exchange." the third caveat is that our comments refer exclusively to n/b wearing in western societies where it is an unorthodox attire confronting folkways and sentiments different from those in, notably, the middle east. there, and in western enclaves where middle eastern people are in the majority, matters are entirely different; the n/b is an accustomed presence of everyday life. as such it mostly prompts no comment or curiosity. in its native milieu, full-face covering is acknowledged but little noticed, whereas discarding it would drastically increase the visibility of the woman who did so. vision, as we now turn to see, is influenced by powerful cultural traditions. 5 citizenship in western democratic regimes is based on ideals of equality. 6 whereas other spheres of life are particularistic, asymmetric or exclusive-the family of which one is a member, religious confession, how much money one makes, how good looking, clever, socially adept or athletic one is, and so forth-modern citizenship confers on adults in a political jurisdiction the same rights (for instance, to vote) and obligations (such as tax payment) irrespective of rank, class, gender, religion, ethnicity and family (weber [1917 (weber [ ] 1994 . 7 to be sure, the prerequisites of citizenship in western societies are heterogeneous (brubaker 1992; caldwell 2009: 148-154) . and it is evident that many people who reside in a country, such as immigrants, are not afforded full political protection and rights of participation. our concern in the present argument, however, is mainly with the norm of equality as a conceptual basis of citizenship. that this is an idealized picture of the modern constitutional polity need not detain us so long as the aspirational link between equality and democratic citizenship is accepted. idealization is, in any case, an important part of citizenship; it enables citizens to demand that states lives up to their ideals. more immediately pertinent is that citizenship equality is, in fundamental ways, integrally related in western traditions to citizens being visible to one another. this expectation is registered in theories of moral judgment (consider the role played by the "spectator" in adam smith and kant's theories of judgment) and in some of our most potent democratic terms and metaphors: enlightenment, openness, transparency, illumination, recognition, social legibility, accountability, "publicity" and, not least, public, to which we return in the next paragraph. the echo of biblical revelation and ancient greek thought in these notions is audible. for the eighteenth century philosophes, enlightenment substituted holy writ with "the great book of nature, open for all mankind to read." the heavenly city of the philosophes was a city of light surpassing in its rational luminosity even the splendor of the sun king (becker ([1932] 1964: 51, 105-6) 105-6). negating these images are opacity, the dark ages, the dark arts, dark times, heart of darkness, artifice, living in the closet, a shadowy realm, a troglodyte world (paul fussell's depiction of world war i trench warfare), cavelike illusion, stygian gloom, moral blindness, the id, concealment, inscrutability, subterfuge, murkiness, obscurantism, and backroom deals-notions which imply various states of ignorance, menace and deceit. in sharp contrast, liberals trumpet the virtue of the open society and liberalized marxists idealize the translucent speech-situation. socialists and radicals extol debunking, the heir of rousseau's ([1750 rousseau's ([ ] 1993 crusade to remove the "deceitful veil of politeness" which conceals "fear, coldness, reserve, hate, and fraud". true, prominent french intellectuals of the last century sought to demote vision's status in the pantheon of sensibility (jay 1994) , while conservatives still remain attached to the "decent drapery of life" (burke [1790 (burke [ ] 1999 ). yet these perspectives have done little to impede the centrality of seeing within the western, apollonian political aesthetic. invented in the ancient greek world, the concept of "public" has assumed since its birth a host of connotations: common property and the common good; a realm in which free and equal men are able to deliberate on and decide political affairs; a place of discourse rather than labor; the primacy of law over arbitrary rule; a domain in which the ruler is considered to be a kind of custodian or guardian of the commonweal rather than a seigneur or lord; a region in which citizens may find distinction and glory; an area accessible to the many; a vehicle of composite opinion; a community pursuing a joint purpose (habermas [1962 (habermas [ ] 1999 oakeshott 1975: 149, 207, 218.) each of these meanings has, in turn, taken on its own inflections; for instance, robert nisbet's (1982: 249-50 ) distinction between public opinion ("the sturdy filter of long-shared values and traditions") and popular opinion (the transient froth of mood and fashion). of special relevance for our enquiry is that by the mid-sixteenth century, public added to its modern meanings the sense of activities and events that are "manifest and open to general observation" (sennett [1974 (sennett [ ] 1992 . in the public sphere, unlike domesticity, we demand to see what is going on, we expect honest dealing, disclosure; hiding is an affront to that stipulation. hannah arendt (1958: 50-3) claimed that the word public evokes two "interrelated phenomena". first: everything that appears in public can be seen and heard by everybody and has the widest possible publicity. for us, appearance-something that is being seen and heard by others as well as by ourselvesconstitutes reality. compared with the reality which comes from being seen and heard, even the greatest forces of intimate life-the passions of the heart, the thoughts of the mind, the delights of the senses-lead an uncertain, shadowy kind of existence unless and until they are transformed, deprivatized and deindividualized, as it were, into a shape to fit them for public appearance…the presence of others who see what we see and hear what we hear assures us of the reality of the world and ourselves… the second referent of public is "the world itself, in so far as it is common to all of us and distinguished from our privately owned place in it." the world, in arendt's usage, comprises not the terrestrial globe or earth on which we stand and from which we derive our physical sustenance, but the sphere of created things that join and separate us, the sphere of human "affairs which go on among those who inhabit the man-made world together." this formulation suggests what is discordant about the n/ b's existence in the western political space. while for its bearer the n/b may be understood as a badge of tradition and piety, from the standpoint of a constitutional pluralist citizenry it is a mode of concealment incompatible with public recognition in which visibility of face is central. the n/b denudes facial and, to a degree, vocal recognition, debilities to which we shall return in a more sociological context later. it standardizes human features and hence contributes to the very stereotyping that n/b wearers themselves deplore. faces and voices are all different, evidence of human plurality. the n/b literally effaces these variations, with the partial exception of the eyes that may sometimes be seen. the n/b also symbolically ruptures the bond of citizenship reciprocity because while its wearer can see her real or potential interlocutor, can take advantage of the visibility of others, non-wearers are denied such access. the integral importance of reciprocity to "public reason" and, its corollary, deliberative democracy, is a leitmotif of john rawls's later work. rawls says that the role "of the criterion of reciprocity…is to specify the nature of the political relation in a constitutional democratic regime as one of civic friendship" (rawls 1999: 137) . in arendtian terms, n/b apparel is an obstruction to "appearance"-"something that is seen and heard by everybody and has the widest possible publicity." to this line of reasoning at least four objections can be anticipated. n/b-clad persons, it might be protested, do appear in public; they simply appear in a different way to those uncovered. that is true. indeed one might add that concealment of the face and other parts of the body is by no means the same as general inconspicuousness. on the contrary, in western societies the n/b wearer is more eyecatching than the non-wearer of it, more subject to the stare or, conversely, more prone to evoke the embarrassment that greets attire that is deemed bizarre or inappropriate. some (notably al-saji 2010: 886), sympathetic to veiling, claim that it is western attitudes themselves that are responsible for a bizarre combination of the seen and the unseen. hence "while the veil is hypervisible as an oppressive and repressive barrier [according to its critics], muslim women 'behind the veil' are not merely invisible to the western gaze, but are made invisible as subjects" by not being respected. yet uncitizenly comportment is not about appearance as such. it is about a precise type of appearance that, concealing the face, impedes mutual openness and repels interaction as equals. frantz fanon ([1959 fanon ([ ] 1965 , describing what he called the "phenomenology of encounters" between the colonized veiled woman and the colonist, amplifies the point: the woman who sees without being seen frustrates the colonizer. there is no reciprocity. she does not yield herself, does not give herself, does not offer herself. the algerian has an attitude toward the algerian woman which is on the whole clear. he does not see her. there is even a permanent intention not to perceive the feminine profile, not to pay attention to women… [in contrast, the] european faced with an algerian woman wants to see. fanon cheered on this lack of reciprocity, enjoying the aggravation it caused the powerful. the colonized woman seeks to frustrate the will of the colonial man. that is not our current situation. the colonial was an interloper, unwelcome in a foreign land, bending and breaking customs so that his will be done. today, in western societies, muslim citizens are afforded equal rights in law, which is to say they are accorded the same rights as non-muslims. yet one group still veils while another is visible. denial of reciprocity to occupiers of colonial societies is extended to citizens of post-colonial ones. a second objection to the argument that hiding the face is uncitizenly might run as follows. users of the internet are often obscured from view and no one assumes that their being invisible is uncitizenly. indeed, under some definitions of politics, the internet might be considered the quintessentially modern medium of political life: informing the public of political events, orchestrating voting, requesting or inciting people to participate in demonstrations, directing attention to abuses of rule, mobilizing citizens for collective action. search engines like google ever more assume traditional government functions. its engineers claim that the company's predictions of flu epidemics and employment trends are already more accurate than those of the centers for disease control and the bureau of labor statistics. better predictions of "crime, terrorism and political unrest" may be in the offing, prompting one journalist to predict in turn that the "line between google and government is destined to blur." 8 even so, the political effectiveness of the internet, especially in comparison with face-to-face encounters, is more dubious, or at least more complex, than it first appears. to those who claim that digital networks act "as a massive positive supply shock to the cost and spread of information, to the ease and range of public speech by citizens, and to the speed and scale of group coordination" (shirky 2011: 154) , others reply with considerable skepticism. the above statement may be true, they say, but "weak ties" rarely lead to "high-risk activism." the latter entails not only personal contact and hard graft in actually building a movement but also organizational hierarchy, even in the most democratic initiatives. loose networks are no substitute for the "precision and discipline" afforded by such centralized groups as the naacp during the civil rights' struggles of the 1950s and 1960s. "facebook activism succeeds not by motivating people to make a real sacrifice but by motivating them to do the things that people do when they are not motivated enough to make a real sacrifice"-for instance, giving on average nine cents a piece to the facebook save darfur coalition (gladwell 2010: 1-6) . this important debate is not, however, central to the n/b issues raised here and for a plain reason. in western societies the internet is an ancillary to public display not a substitute for it, a tool to expand communication, rather than an obstacle to constrict it. computer webcams are employed between interactants and in web chat rooms; interviews of foreign job applicants conducted via skype grow daily in popularity. and it is no coincidence that the world's most prominent social networking site is called facebook. moreover, where internet use takes place without face recognition (as with email or instant messaging) it typically does so reciprocally: both users are in the same position and hence issues of visibility imbalance and citizen asymmetry do not arise. a third objection to the claim that n/b attire in public places is uncitizenly turns the tables on the authors: it draws on the graeco-roman tradition itself, the origins of western notions of citizenship. in that tradition, being a public person was considered a kind of theatricality in which an agent adopts a persona, a mask. hobbes ([1651] 1996: 111-2) , before noting that "persona in latine signifies the disguise, or outward appearance of a man, counterfeited on the stage; and sometimes more particularly that part of it, which disguiseth the face, as a mask or vizard," observed: a person, is he, whose words or actions are considered, either as his own, or as representing the words or actions of an other man, or of any other things to whom they are attributed, whether truly or by fiction. when they are considered as his owne, then he is called a naturall person. and when they are considered as representing the words and actions of an other, then he is a feigned or artificiall person (hobbes's emphasis) the persona was and is, however, a metaphorical mask, not one of cloth. in hobbes' political theory, it was a means of expanding modes of public representation whereas the n/ b is a symbol of religious belonging and, in french parlance, a claustral "folding in" (repli communautaire) or a "closing off" (enfermement) (bowen 2007: 156. 177 ). in antiquity, the function of persona was not to conceal public visibility but precisely to do the opposite: to shine the light of the polis on the political actor, to dramatize the fact that the individual had entered the public stage and that, as such, had left the private world of intimacy so as to consort freely with his peers and deliberate on political affairs. the political persona was, then, an addition to, or rather a rupture with, private life, not a replication or extension of it, a vehicle of distinction, not a mantle contrived to expunge from public view the unique personality of the woman beneath its folds. 9 politics, in western traditions, entails a split within the being that engages in it, the construction of a second self: as an equal of others who are familial strangers bound together by the common tie of citizenship; a self able to cooperate with these strangers, to "see" things from multiple points of view and be seen seeing. more generally, the western political tradition is notable for its pronounced binary structure: oikos and polis, dominium and res publica, lordship and office, king and crown, natural persons and artificial persons 8 christopher caldwell, "government by search engine," financial times, oct. 15, 2010, http://www.ft.com/cms/s/0/a62be1dc-d897-11df-8e05-00144feabdc0.html#axzz1k1hbrfpp 9 arendt 1963: 106-9. (louglin 2003: 6, 21, 45, 55-7, 76-9) . superimposed on these bifurcations are other contrasts that impute to religion, and religious institutions, a separate sphere of engagement to that of the political: god and caesar, piety and justice, sacerdotium and regnum, church and state, soul and city, revelation and reason, sin and crime (scruton 2003:1-6, 23, 134-139) . the nb, however, is not a fictive mask designed to open up its wearer to the public recognition of peers acting in concert or in conflict; it is a carapace projected into the public space, a material mask that signals exclusivity, an emblem of segmental occlusion, of what durkheim ([1893 durkheim ([ ] 1997 , discussing the primacy of resemblance in tribal societies, called the politico-familial. as a badge of similitude, the n/b smacks of mechanical solidarity. nor is the n/ b artificial or dualistic. on the contrary, it signifies sharia's total claim on the individual in all her activities, the type of claim that the public-private distinction expressly repudiates. it transpires that the classical concept of the mask and the n/b have nothing substantively in common. finally, it might be objected that our argument about the uncitizenly nature of the n/b rests on an unduly restrictive notion of citizenship. after all, the meaning and practice of citizenship has expanded greatly over the past two centuries. citizenship today involves social and cultural dimensions, not simply political and juridical ones. it straddles a wide array of contents, types, conditions and arrangements (susen 2010) . that being the case it is strained to place, as this article does, such a burden on the political idea of equality and reciprocity to the exclusion of all other citizenship elements. yet while a political community of equals, obligated to one another, is no longer a sufficient aspect of citizenship in the west, it is nonetheless a necessary aspect of it. moreover, an inflationary conception of citizenship is not without major problems or incongruities, as a number of theorists recognize. simon susen (op. cit.: 273) , for instance, insists that the "extension of civil, political and social citizenship to a potentially infinite number of different forms …leads to the relativistic impoverishment" of "contemporary accounts of the political". for if any social group can claim citizenship on the basis of its own definition, the concept degenerates into a "mere identity game". richard bellamy (2008: 51, 98-9) agrees. citizenship, he says, is ever more defined as a series of global human rights. and these putative rights are constantly growing. a survey conducted by the polling organization globescan for the bbc, on a population of 27,000 adults in 26 countries, found that four in five respondents believe that internet access is a "fundamental right." 10 the "absence of a political dimension," however, suggests a "somewhat second-rate account of what being a citizen involves". and why is that? because the "idea of a political community of equals … lies at the heart of citizenship." bellamy (2008:114) also remarks that "citizenship involves a degree of solidarity and reciprocity between citizens" and that such citizens "need to see each other as equal partners within a collective enterprise." if that is true, the n/b is a negation of citizenship. disguising the face, and avoiding contact with the kafir, disables citizens from "seeing" each other as free and equal partners. we have been discussing the ways in which n/b effacement breeches norms of political equality and reciprocity, the backbone of the citizenship ideal. n/b wearing is further accompanied by a social impairment: the partition it erects to interpersonal understanding and solidarity. making sense of the conduct of others in face-to-face, real-time encounters requires us to pay attention to more than disembodied words. unlike reading a book, which is a cognitive, reflective endeavor, albeit informed by past experience and learned competences, inter-personal understanding draws on immediate, spontaneous and practical aspects of the interaction-situation itself. these aspects are both cognitive and somatic: emotional signals emitted by the face, the voice, and the body in general. as erving goffman (1963:34-5) remarks, "bodily idiom … is a conventionalized discourse. we must see that it is, in addition, a normative one." he adds ([1955] 1967: 33) : during direct personal contacts…unique informational conditions prevail and the significance of face becomes especially clear. the human tendency to use signs and symbols means that evidence of social worth and of mutual evaluations will be conveyed by very minor things, and these things will be witnessed, as will the fact that they have been witnessed. an unguarded glance, a momentary change in tone of voice, an ecological position taken or not taken, can drench a talk with judgmental significance. humans in their social transactions, goffman reminds us, are constantly engaged in "face work," a semiotic traffic in which proper deference is given and where the appropriate demeanor is supposed to be maintained. "good" demeanor "is what is required of an actor if he is to be transformed into someone who can be relied upon to maintain himself as an interactant, poised for communication and to act so that others do not endanger themselves by presenting themselves as interactants to him" (ibid: 77). probably the single most important sign-vehicle that humans possess, the chief corporeal building block of solidarity in situational encounters, is the face. people who look away when we are talking to them, scanning the perimeter, are apparently preoccupied with other matters; they are indicating a kind of inattentiveness that, in our culture, translates to distraction or rudeness. our response to their alienation is alienation of our own. more generally, signals of emotions-such as sadness, anger, surprise, fear, disgust, contempt, and happiness-have facial correlates that convey various kinds of information about their bearer. 11 what makes people angry, for instance, differs to some degree among persons and cultures; but the looks of anger are universal, and spontaneously understood, part of our evolutionary hard wiring and manifested in muscular movements that differ both in intensity (ranging from irritation to fury) and type (sullen anger, resentful anger, indignant anger and cold anger) (ekman 2003: 58) . even when we seek to manage or hide our emotions, it is common for them to leak out through facial signs, bodily gestures and tone, volume and pitch of voice. accordingly people who look at us can, with a fair bit of reliability, tell how we are feeling unless we suppress our expressions (ibid: 54-55) or hide them as the n/b does. (botox and other similar treatments, by giving the face a stony and shiny appearance, also reduce expressive capacity and viewer reception.) even if we can see the eyes of the facially covered, as with the niqab, we may not be able to see the frame that gives their glance meaning: the forehead, the eyebrows, the mouth and the cheeks that, in various combinations of muscular movement or fixity, impart emotional information to the viewer. when people have difficulty understanding one another, this does not mean that fellow feeling between them is impossible. non-muslims, or the habitually uncovered in any society, are likely to feel sympathy for the woman in a crowded airport whose outfit must, in many circumstances, make her hotter, more confined and generally more uncomfortable than she would otherwise be divested of a niqab. or so we are inclined to think. the truth is that we do not know for sure and, out of a sense of propriety, would not wish to enquire. adam smith notes that much of our sympathy for others is not an accurate reflection of how they feel but how we imagine we would feel if we shared their situation. to illustrate this point, he ([1759] 1976: 12-13) gives a consoling example: we sympathize even with the dead, and overlooking what is of real importance in their situation, that awful futurity which awaits them, we are chiefly affected by those circumstances which strike our senses, but can have no influence on their happiness. it is miserable, we think, to be deprived of the light of the sun; to be shut out of life and conversation; to be laid in the cold grave, a prey to corruption and the reptiles of the earth; to be no more thought of in this world, but to be obliterated, in a little time, from the affections, and almost from the memory, of their dearest friends and relations…. the happiness of the dead, however, most assuredly, is affected by none of these circumstances; nor is the thought of these things which can never disturb the profound security of their repose. time and again, smith reminds us that moral imagination is mediated by vision: seeing, gazing, looking on, looking upon, (his words) objects that, thereby, excites us to feel compassion, revulsion and a host of other emotions. the connection, he says, between the way we feel about a person's plight, and that person's situation, is our witnessing the former, and our "foresight" (again smith's term) into the implications of the latter. it follows that our ability to judge with confidence a person's situation is greatly limited if our seeing, gazing, looking on and looking upon, let alone our foresight, is obstructed. whether georg simmel recalled smith's comments on this matter is unknown. but he offers an intriguing gloss on them in the remark that of "the special sense-organs the eye has a uniquely sociological function. the union and interaction of individuals is based upon mutual glances. this is perhaps the most direct and purest reciprocity which exists anywhere." 12 to return to our example of the n/b clad woman in the crowded airport: sympathy may turn to pity and indignation on her behalf if we believe that her dress is a sign of oppression. or we may feel incredulity and confusion. when people "turn off" their emotional lights, they appear blank and lifeless. covering the face turns off emotional lights in the most direct and comprehensive way imaginable. its consequences for fellow feeling and the interaction it enables in western societies are significant. to understand with greater precision why this is so, it is useful to identify three kinds of attachment among strangers: political solidarity, social sympathy, and social solidarity. these modes are ideal-types that in reality are intermingled to a greater or lesser extent. the point of sketching them is to discern whether, and to what extent, they can be extended to sartorially sequestered persons. political solidarity is an action or series of actions derived from an obligation: the duty, as we believe it to be, to support those who share similar political or quasi-political values to our own. socialists are happy to stand by other socialists who are embattled, whereas they are happy to see an abundance of liberals and conservatives in total disarray; and vice versa. political solidarity is hence a union of like with like and it is confined to that likeness. we feel political solidarity for groups to the extent they embody beliefs that we consider vital-say, of fairness or dignity-or because their predicament reveals dangers to which we could ourselves one day be exposed. people committed to constitutional pluralism, for instance, believe that all non-violent groups of citizens that obey the law are entitled to rights of participation. when british and west european trade unionists supported the polish trade union and political organization solidarity, during the 1980s, they did so out of the conviction that workers should support one another when oppressed by the state (or employers). while political solidarity is limited to like supporting like, confined to helping people as citizens or protocitizens of a certain persuasion (e.g. liberals not fascists, political prisoners not political jailors, workers not employers), social sympathy is potentially boundless and, where it is not simply emotional, rests on the altruistic principle of assisting individuals as fellow human beings, irrespective of their political and other views. social sympathy is boundless because the suffering that prompts it is endless. and unlike political solidarity, social sympathy is deaf to political antagonisms, credentials and alliances. social sympathy is especially sensitive to individuals rather than groups; and the individuals for whom sympathy tends to be strongest are children. while political solidarity is principally a matter of adult responsibilities, nothing is more likely to trigger social sympathy than the sight of a bedraggled orphan, a crying stray, an emaciated child, or a young face ravaged by the horror of war. it is for good reason that humanitarian aid agencies use such images as their prime advertising tool. social sympathy, often shading into pity, is more affective, more immediate, less detached and less conceptual than political solidarity (arendt 1963: 88-89) . and while political solidarity flags a boundary or marker of exclusion (not everyone is our ally but only those who share our convictions), social sympathy is infinitely extendable. the sense of justice that inspires social sympathy is based not on the requirements of political similarity but on the fulfillment of personal charity, common decency and elite philanthropy. those to whom we tender political solidarity are comrades and political equals, real or imaginary; those who provoke social sympathy are the abandoned with whom we have nothing in common aside from our humanity. neither political solidarity nor social sympathy requires physical proximity. nor do they require symmetry and reciprocity. a and b may strike up an alliance to assist one another, generating a vitality that neither party possesses by itself. just as often, however, the solidarity afforded by a to b is never reciprocated by b (south african trade unions under apartheid; political prisoners in china and cuba) because a, being safe and secure, has no need of reciprocation, and because b lacks the resources ever to "repay". similarly, the gifts of social sympathy are unlikely ever to occasion gifts in return because their recipients are simply too poor, too powerless and too geographically distant to give anything back. the weak are neither expected nor in a position to shore up the strong. in sharp contrast, social solidarity derives principally from face-to-face encounters and it requires reciprocity and mutual respect for its very existence. sociology 101 still teaches introductory students to think of social solidarity as the socialization of norms and values that, where successful, permeate the reflexes of human beings, coordinating their behavior, and committing them to common moral standards. or solidarity is said to arise from increasing differentiation, the modern division of labor, whereby we become dependent on a manifold of people and services that provide conditions of our existence that we are incapable of providing for ourselves. these textbook descriptions are not so much wrong as imprecisely stated or at least stated in such a way as to mean something different from social solidarity as the term is used here. drawing on the durkheimian model, we can say that social solidarity is a mode of cohesion based on mutual recognition of worth and classificatory congruence. in turn, these properties emerge out of situations of a special type, namely those that enact interaction rituals in natural settings. these rituals, more often spontaneously slipped into than deliberately choreographed, are ever present in social relations and help create a common mood centered on common foci of attention. the more intense the attention, the more concentrated the intersubjective awareness of the ritual participants of their common bond; as awareness increases, so too, does the entrainment of the actors as they fall into a common rhythm of interactions, and share the "emotional energy" they generate (durkheim [1912 (durkheim [ ] 1995 and especially collins 2004) . human rituals require co-presence. they may span the smallest encounter between two people-a greeting at the office, a joking relationship with a colleague, a marriage proposal-or larger units such as a sports event or a political demonstration; during a major crisis, a whole city may briefly be caught up in the same set of rituals. in each case, those in contact with one another expect, and themselves cultivate, a demeanor of respect for the situation and its participants so as to allow the interaction to proceed smoothly. and ubiquitously, interaction rituals take place within boundaries of recognition that delineate outsiders in the very act of soliciting the chosen few and affirming their status. those boundaries are marked by totems such as wedding rings, flags, holy buildings, songs, coins, slogans and other representations of exclusiveness that remind ritual interactants of past deeds and past promises and arouse commitments to the interactant unit. despoilment of these totems, or betrayals of the rituals of group intimacy they signify, cause anger and aggression. as a local event, a bounded interaction among subjects who give each other face and by so doing find unity in their social commerce, social solidarity is thus also the occasion of conflict between those granted respect and those denied it, between those in the "pocket of solidarity," and those outside it, between those allowed access to the enclave of valued transactions and those denied admittance as pariahs or inferiors . in this context, one sees the difficulty of social solidarity emerging spontaneously for and with n/b clad women. 13 if is true that "eye-to-eye looks…play a special role in the communication life of the community, ritually establishing an avowed openness to verbal statements" (goffman 1963: 92) , then it is also true that n/b, as a materialized collective representation, is an avowal of closure to familial strangers, a sharp boundary. the covered woman's eyes may well be visible, but covering itself is a disincentive towards meeting the eyes; a glance must be especially furtive if is not to push "civil inattention" too far and become offensive. in goffman's (1963: 38, 92-3) lexicon, the n/b is an "involvement shield." as with all such shields, the result is a dilution of both "richness of information flow" and "facilitation of feedback" (ibid: 17). more generally, the inability to see potential interlocutors is a major impediment to drawing "emotional energy" from them. the sociological irony is that a garb that signifies the danger of contamination-the male gaze-may itself be deemed dangerous by strangers because it represents tribal notions of exclusiveness as contrasted to pluralist notions of far-flung reciprocity. along these lines, stefaan van hecke, a member of the belgian ecolo-green! party, stated in the chamber of deputies that his party had supported the headscarf but that the burqa "goes too far in our eyes" because it is "a wall that permits no communication." he was immediately supported by georges dallemagne of the democratic humanist center party. "it [the burqa] represents to us a rupture with the fundamental principle of our society which holds that communication, even of a minimal kind, among the members of society implies the possibility of seeing the face of the other" (crb2 2010: 23-25). notice, however, that it is not public covering as such that creates alienation; it is the meaning that the covering conveys, together with its permanence. cities that experience particularly dangerous epidemic diseases such as the sars outbreak in hong kong in 2003 witnessed omnipresent mask wearing. but "efface work" (baehr 2008: 159-167) in the hong kong case shows that while mask wearing was a signal of repulsion ("don't get too close to me") it acted also as a signal of common courtesy: less a prophylactic against catching the virus than a symbol of deference for the sensibilities of others, expressing the desire not to infect them. in this case distance served the purpose of reciprocity; it was a demeanor that flagged respect. mask wearing in these conditions was temporary; it was a response to crisis. it was also ubiquitous, rather than being exclusive to one group. when sars retreated, the masks were discarded. the n/b is entirely different. it is a permanent marker of a separation deemed normal. it is not irrational for muslims to wear the n/b where it is appropriate for a certain kind of life. nor is it irrational for such covering to provoke indignation in another ritual order with diverging norms of appropriateness. however, "diversity" consciousness-the idealization of multiculturalismfinds such legitimate and rational incommensurability hard to handle. if two ritual orders are in collision, one of them must be phobic. we know which one that is. this article's exploration of the n/b's appearance in the west is limited in many obvious ways. it represents neither the experiences of covered women in western lands nor offers an ethnography of covering practices and native responses to them-for instance, videotaped behavior of people in supermarkets, airports and streets. both tasks are valuable; the latter, in particular, would be able to test, qualify and refute some of the claims made above. equally this article offers no divination of public opinion polls (the pew survey referenced at the beginning of this article did not ask people why they support a burqa ban), nor does it argue on the basis of survey data or interviews conducted by the authors. we offer something else: an enquiry into the political and social frameworks that, even in the absence of hatefulness and prejudice towards muslims, make the n/b profoundly dissonant with western traditions. these traditions are no less weighty by being historically "constructed". they are the real frameworks, or shards of frameworks, within which people make sense of the world. as we have stressed, our principal concern is with what the n/b controversy reveals about western structures of thought and feeling rather than what is says about muslim women. another limitation of the foregoing is that it offers no definite public policy advice to governments regarding prohibition, no attempt at adjudication to parties involved in the dispute. this is not a debate on which a sociologist can deliver authoritative judgment. it is a matter of political argument, moral choice and, almost inevitably, conflict. nor can sociologists ignore legal traditions that play a major role in defining the rationality or irrationality of a ban. for french ultra-secularists, banning the n/b makes sense in 13 we are also unlikely to extend political solidarity to those whose idea of politics is so very different from our own. we are just as unlikely to feel social sympathy for people who are happy to be as they are, if they are indeed happy, or who do not request our aid. light of france's republican tradition and civil religion. it also makes sense given france's tradition of regarding the public space as a controlled sphere in which egalitarian mannerisms and citizenly gestures are not merely a polite choice but a civic duty, a necessity, backed in constitutional law by the doctrine of "public order" (gordon 2008: 47, 52-53, 63 note 53; baehr and gordon 2013; anri 2010: 556-558) . for most americans, by contrast, prohibition is largely unthinkable because a) it contradicts the first amendment of the constitution protecting "the free exercise" of religion; b) americans fear government regulation more than they do cultural diversity; and c) the american idea of "religion" is more generic and inclusive than that of the french. americans rush, in cross-religious solidarity, to faiths that are embattled, believing that infringement on the liberty of one confession is potentially a threat to them all (gordon 2008:48-51) . both the structure of american jurisprudence and american popular culture work against a burqa ban. logic and universal morality (moralität), on which philosophers and theologians pronounce, is different from situated ethicality (sittlichkeit) with which historians and sociologists are concerned. 14 underpinning that ethicality are legal systems and popular conceptions of constitutional freedom. if the burqa controversy reveals more about what is important to western traditions than it does about muslim women, it also raises vital questions. these are questions about the rights of groups to organize their own collective life; questions about the responsibilities of the state to protect individuals within groups who are oppressed by them; questions about the indispensable nature of basic forms of citizenly, face-to-face comportment in a democracy; and questions about whether the state can legitimately require citizens to be communicative and reciprocal with each other, or whether the minima of transparency are a matter of choice. the burqa is at the edge of solidarity. it may be deemed a symbolic harm to democracy, or as a basic civil right. but the burqa controversy is certainly more than an expression of islamophobia. it is a predicament requiring us to articulate our democratic conceptions with uncustomary precision. and no matter which policy we choose, to ban or not to ban, it requires us to recognize the antimonies of democratic existence, and to sacrifice some goods for the sake of protecting others. the racialization of muslim veils: a philosophical analysis rapport d'information au nom de la mission d'information sur la pratique du port du voile integral sur le territoire nationale the human condition on revolution reflections on little rock from the headscarf to the burqa: the role of social theorists in shaping laws against the veil caesarism, charisma and fate: historical sources and modern resonances in the work of max weber the heavenly city of the eighteenth-century philosophers citizenship. a very short introduction why the french don't like headscarves. islam, the state and public space citizenship and nationhood in france and germany reflections on the 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co-editor of the journal historical reflections key: cord-274009-ew4diub5 authors: emerson, kerstin gerst title: coping with being cooped up: social distancing during covid-19 among 60+ in the united states date: 2020-06-29 journal: rev panam salud publica doi: 10.26633/rpsp.2020.81 sha: doc_id: 274009 cord_uid: ew4diub5 objectives. this study examined the impact of sheltering in place and social distancing among adults aged 60 and older during the 2020 outbreak of covid-19 in the united states. methods. using convenience sampling respondents were asked to complete a web-administered survey to explore impact of social distancing on loneliness, stress, and behavioral changes. the analytic sample consisted of 833 responses of persons aged 60 and older. results. a large portion reported being stressed (36%), and/or being lonely (42.5%). nearly 1/3 stated that their sense of loneliness increased during the time of social distancing. respondents reported engaging in more solitary activity (and fewer in-person activities), using email and text messages more than usual, and spending more time on computers/tablet than usual. approximately 2/3 reported using more social media than usual. these differed significantly by younger (age 60-70) and older (71+) respondents. additionally, changes in physical activity, drinking, recreational drug use and sleeping pattern changes differed by age. conclusions. social distancing has significant consequences on loneliness and health behaviors among adults in the united states, many of which differ by age group. results have implications for continued shelter in place practices, but also for any older adult that may be homebound for other reasons. the worldwide spread of covid-19 has created a pandemic unlike any seen in a century, and it is disproportionately affecting older adults (1) . global data, including those from the united states, consistently show higher death rates among older adults and those with underlying conditions (2) . to curb disease transmission and risk of infection, the us began recommending restrictions of social interactions for these most vulnerable populations. specifically, on march 5, 2020, the centers for disease control (cdc) warned that older adults were particularly vulnerable to the covid-19 and encouraged older adults to take extra precautions (2) . recommended precautions included social distancing and sheltering in place. social distancing is a public health practice to reduce disease transmission by preventing people with an illness from coming into close contact with non-infected people (3) . similarly, sheltering in place is aimed at reducing transmission rates by remaining at home except for essential travel. adhering to these recommendations means many older adults in the us have been at home with minimal outside contact for an extended period of time. little is known about how this extended period of sheltering in place has impacted older adults. however, researchers are concerned that current public health safety measures pose a risk of loneliness, even among those that are living with other family members (1) . social interaction is integral to human well-being, and the impact of not having ones social needs met (aka loneliness) can be wide ranging. loneliness has been connected to both morbidity and mortality (4, 5) . loneliness can be a particularly important concern for older adults, who may have additional risk factors, such as physical and cognitive impairment, death of loved ones, and decreases in economic resources (6, 7) . sheltering in place and social distancing may be adding additional risk factors for loneliness as older adults lose many potential outlets for social interaction, such as going to religious services, seeing friends and family, shopping, and group exercise classes. while data on the impact of social distancing for covid-19 is not yet available, research on prior quarantining events suggests that one unintended consequence of such measures is psychological distress. most recently, research on the impact of mandated quarantine during the severe acute respiratory syndrome (sars) outbreak in canada showed a high level of psychological distress among respondents (8) . the purpose of this study was to explore how adults aged 60 and older in the us are coping with social distancing and sheltering in place during the covid-19 pandemic. specifically, the survey hoped to answer two main questions: 1) what have been the effects of social distancing on adults aged 60 and older, and 2) what have been behavioral and social communication changes since social distancing started? the answers can shed light on challenges experienced by those social distancing, and can guide potential public health interventions strategies. survey instrument. we conducted a web-based survey in qualtrics, which consisted of 28 questions. a web-based format was chosen due to budget and time constraints; it was important to reach those practicing social distancing during the event to avoid recall bias (8) . the survey was open for two weeks, beginning on march 30 th and concluding on april 12 th , 2020. the sampling of the survey was a convenience sample, with links sent out on social media and gerontology listservs. only persons aged 60 and older were asked to respond. each respondent was asked to forward the survey on to other persons aged 60 and older. the study was approved by the university of georgia institutional review board (irb# 00002133). analytic sample. 922 persons initiated the survey, but only 843 (91.4%) completed the survey. an additional 10 responses were not included in the analytic sample because they did not provide their age or because they were not in the united states. the final sample size was 833 respondents living in the us, aged 60 and older. variables. the survey collected socio-demographic data, including age (top-coded at 85), sex (male, female, other), race (white, black/african american, american indian/alaska native, asian, native hawaiian/pacific islander, other), ethnicity (hispanic or latino as defined by the us census (14)), employment status (part-time, full-time, not employed), and household size (continuous). additionally, respondents were asked to estimate how many people they continue to be in contact with in person, but outside of the home (no one else, 1, 2-3, 4 or more). respondents were also asked about the type of home they live in (apartment, house, nursing home, assisted living, other). loneliness was determined by asking respondents: "since you started socially distancing, have you felt lonely?" (yes, most of the day/yes, some of the day/no, never). for analyses all respondents who answered most or some were coded as lonely. respondents were then asked a follow up loneliness question: "do you feel more, less, or the same level of loneliness compared to the time before you were socially distancing?". stress was measured by self-report response to the prompt: "stress means a situation in which a person feels tense, restless, nervous or anxious or is unable to sleep at night because their mind is troubled all the time. do you feel this kind of stress these days?" (answer choices were a 5-point likert scale). for analyses the five answer choices were collapsed into three groups (1=a great deal/a lot, 2=moderate amount, 3-a little/not at all). relationships was determined by the question: "do you feel like you have close relationships that bring you emotional security and well-being?" (answer choices were yes, definitely/yes, somewhat/no, not at all). self-rated health was measured by a 5-point likert scale ranging from poor to excellent. finally, respondents were asked to choose all that apply from a range of behavioral and communication changes since beginning social distancing. these included doing more or less: sleeping, engaging in physical activity, smoking, drinking alcohol, using recreational drugs, eating, solitary activities, engaging in in-person activities, making/receiving phone calls, using social media, emailing, ending/receiving text messages, and spending time on the computer/tablet/phone. analyses. data are presented in descriptive format. means were calculated to summarize continuous variables. for categorical variables, group proportions were calculated. to explore differences by age, the results were divided into younger (ages 60-70) and older (ages 71+). because sample cell sizes were small, all statistical comparisons by age are conducted using fisher's exact test. stress, loneliness, and relationship responses were examined by whether respondents lived alone, using pearson chi-square tests. a p-value of < 0.05 was considered to be significant for all analyses. all analyses were conducted using spss v21. description of the sample. the sample age range was 60 to 85+(top-coded), with 62.8% in the younger (aged 60-70) category (table 1) . a majority (80.5%) of the sample was female, white (96%), and not hispanic (97.9%). race/ethnicity did not differ by age of respondents, though the younger age group was significantly more likely to be female (84.3%) compared to the older age group (74.1%). who is social distancing and what does their household look like? the average number of days spent practicing social distancing for this sample was 16.95 (range 2-65 days, sd 5.8). this did not differ significantly by age. for context, the survey opened 25 days after the official cdc recommendations were published for older adults and ended 39 days after the recommendations. about 85% of survey respondents lived in a house, 8.6% lived in an apartment, and 5.7% lived in other locations, such as condos, or townhomes. a majority of respondents were living either with one other person (64.3%) or living alone (21.3%). approximately two-thirds (67.7%) of respondents were not employed, although this differed significantly by age. the older age group had higher rates (86.7%) or not working, compared to 56.5% of younger age group. of those that were employed, 28-30% usually work from home and continue to work from home (across both age groups). among the older respondents 48.6% usually worked outside the home, but were now working from home because of covid-19, compared to 61.6% of the younger group. what social contacts do people have? more than half (51.2%) of respondents saw no one else outside their household, 15.3% saw only one person, 21.9% saw 2-3 people, and 11.6% saw four or more people. most (94.5%) respondents spoke with someone on the phone at least once a day, and 56.4% spoke to someone using video calling (e.g. facetime/skype) at least once a day. video calls were significantly more common among the younger respondents, with nearly 53.8% of older respondents saying the never used video calls, compared to 37.6% of younger respondents. nearly all respondents (98.8%) reported having at least some close relationships that bring them emotional security and well-being. how are people feeling? respondents rated their health fairly highly, with 94.4% rating their health as good, very good, or excellent. approximately 43% of respondents reported feeling lonely some or most days. for about two-thirds (65.6%) of the respondents their level of loneliness had not changed, though 30.9% stated that they are more lonely now compared to before they were socially distancing. about 3.5% felt less lonely. over one-third (36.9%) of the sample reported being moderately to a great deal stressed. this differed significantly by age. older respondents reported higher rates of being only a little or not at all stressed out (74.2%) compared to younger respondents (56.5%). analyses stratified by living alone. some health measured differed significantly by whether or not respondents lived alone ( table 2 ). those living alone had much higher rates of current loneliness (59.3%) compared to those that lived with others (38.4%). those living alone were also significantly more likely to report that their loneliness had increased since social distancing (42.4%) compared those living with others (27.9%). those living alone were less likely to report having a close relationship that brings them emotional security and well-being, where 3.6% said they didn't have this at all, and 20.4% said they had it somewhat. this was compared to 0.0% for not at all and 12.7% for somewhat among those living with others. stress, having close relationships, and physical health did not differ significantly by living alone. table 3 . health behaviors. sleep patterns were impacted for a little over 1/3 of the sample, with 27.1% reporting more sleep than usual, and 15.8% reporting less sleep. younger respondents were significantly more likely to report sleeping less. physical activity levels changed as well, in both directions. about one-quarter (24.6%) of respondents engaged in more physical activity, while 37.3% engaged in less physical activity than usual. younger respondents were significantly more likely to increase their physical activity, whereas older respondents were significantly more likely to decrease their physical activity. alcohol intake increased for 12.2% of the sample, but decreased for 4.4% of the sample. increase in alcohol consumption was significantly higher for the younger age group (14.9%) compared to younger respondents (7.7%). smoking and recreational drug use both had smaller changes, with 1.3% smoking more than usual and 1.1% smoking less than usual, and 1.4% taking more recreational drugs and 1.0% taking fewer drugs. less use of recreational drugs than usual was significantly more common among older adults, though sample sizes are small. since social distancing, over one-third (35.4%) of respondents report eating more than usual, and 11.1% ate less than usual. this differed significantly by age, where younger people were more likely to report eating more, and older respondents were more likely to report eating less. a majority of respondents (56.4%) engaged in more solitary activities, and 1.2% engaged in fewer of those activities. a larger proportion of older respondents reported engaging in solitary activities (61.6%) compared to younger respondents (53.3%). while some (1.1%) have engaged in more in-person activities than usual, more (48.4%) report less in person activities. communication. among respondents, 4.6% make/receive fewer phone call, 1.3% use social media less, 3.1% email less, 1.9% send/receive fewer text messages, and 0.5% spend less time on their computer/tablets/or phones. however, for a much larger group of respondents, each of these styles of communication increased. among respondents, 45.3% make/receive more phone calls, 66.3% use social media more, 40.2% email more than usual, 60.6% send/receive more text messages, and 67.2% spend more time on their computer/tablet/or phones than usual. several of these communication styles different significantly by age. the younger respondents were significantly more likely to increase their social media use compared to older respondents (73.2 vs. 54.5%, respectively). younger respondents also indicated an increased use of text messages (64.2%) compared to older respondents (54.5%) alternatively, the older respondent group reported increased use of email (44.2% vs. 37.9%). while social distancing is not a new phenomenon (13) , it was never as sustained in the us or as prevalent as it has been since the covid-19 outbreak. while the cdc provided guidance for older adults and adults with high-risk conditions, for most people the process of sheltering in place and social distancing is asking them to create a new normal with little to no precedent to lean on. one potential concern is the higher risk of loneliness as we decrease social contacts. this may be particularly concerning for older adults, who have more risk factors for loneliness. the goal of this survey was to see how people aged 60 and older are doing given the recommendations to practice social distancing. the survey results showed that some respondents are adjusting well and not feeling lonely or stressed. however, a significant portion of adults reported experiencing at least some distress. over a third (36%) of respondents reported feeling moderate to a great deal of stress during this time. those over age 70 were less likely to report stress, however. this stress and age pattern follows previous data showing decreases in stress by age (9) . it is not clear from this cross-sectional data if this age pattern is a cohort effect (reflecting history and life experiences born around the same time) or a difference in individuals' circumstances. additionally, a large portion of respondents (43%) noted being lonely. loneliness rates did not differ significantly by (10) , suggesting that this sample had relatively high rates. rates of loneliness were significantly higher among those living alone (59.4%). however, even those living with others had relatively high rates of loneliness (41.7%). this supports previous research that simply living with others does not erase the risk of loneliness (11) . perhaps most notable is that many respondents (31%) stated that their sense of loneliness increased during the time of social distancing. this suggests that social distancing practices are having an impact on a portion of those aged 60 and older. respondents who lived alone were more likely to report an increase in loneliness. this indicates that those living alone are a particularly vulnerable group to increased loneliness during periods of quarantine. not surprisingly, a large portion of respondents reported engaging in more solitary activity (and fewer in-person activities). respondents also reported using email and text messages more than usual and spending more time on computers/tablet than usual. two-thirds of respondents reported using more social media than usual. some of these behaviors differed significantly by age. for the older age group, adults they were more likely to engage in less physical activity, and to eat less. while participating in less physical activity is probably not a healthy behavior, it is unclear whether eating less is healthy or not. this likely depends on the individual's weight and health, as well as in the nutritional changes made with eating less. unlike their younger counterparts (aged 60-70), older respondents were not drinking more alcohol (in fact, they were more likely to report lower alcohol intake, though this difference was only marginally significant). more older adults reported less recreational drug use (though this was a very small response rate). younger respondents were more likely to report sleeping less. while there is no one clear overall pattern by age, the data suggest that those in the younger age category may be engaging in less healthy behaviors during covid-19. in this sample, younger people are more stressed, drinking more alcohol, sleeping less, and eating more. they are, however, engaging in more physical activity, which for many is assumed to be a healthy behavior. communication also differed by age. while both age groups reported using social media more than usual, those in the younger age group reported this much more often than those aged 70 and older (73% vs. 55%, respectively). the younger group also used texts more often. those in the older age category reported more email use instead. this suggest that intervention and public health communication strategies may need to differ by age category. these results have implications for continued shelter in place practices, but also for how to intervene with any population of older adults that may be homebound for any number of reasons (e.g. health issues, transportation). the high level of engagement with social media suggests that for all groups social media can play an important role in interventions. this is especially the case for those aged 60-70. doing media-based interventions through platforms such as facebook live may be an effective way to reach this population. interventions could include social activities, live exercise activities, or social media public health messaging campaigns. on the other hand, those in the older age category were more likely to use the phone and email. it may be better to target interventions through phone or email for this population. examples include connecting people to hotline/ warmline services such as the institute on aging's friendship line, which provides free telephone support for older adults that are lonely (12). while interventions should certainly be targeted to those living alone, it is important not to ignore those that are living with others. these data show that those living with others are still vulnerable to loneliness. this study had some limitations. the survey was a convenience sample of a relatively small number of adults compared to the total number of adults that are actively practicing social distancing in the us. in fact, since the survey was online, a specific subset of adults were likely not reached with this survey. this includes, but is not limited to, rural elders with limited internet access. it is also possible that a self-selection effect may have occurred (8) , where those who either felt the greatest or the least effects of social distancing chose to complete the survey. therefore, the results are not generalizable and should be interpreted with caution. additionally, the survey was fielded in the first 2-3 weeks of the social distancing, which likely only captures the immediate impact of social distancing. future research should explore the impact of a longer duration of social distancing. in conclusion, this survey provides a first glimpse into the lives of adults aged 60 and older living through the unprecedented public health situation caused by the covid-19 pandemic. the results can increase awareness of potential stress, loneliness and health behavior changes for public health officials, as well as point towards the communication methods that may be most effective for interventions. managing mental health issues among elderly during covid-19 pandemic people who are higher risk for severe illness what is social distancing? social relationships and mortality risk: a meta-analytic review loneliness: a sourcebook of current theory, research and therapy. perspectives on loneliness loneliness as a public health issue: the impact of loneliness on health care utilization among older adults older adult loneliness: myths and realities sars control and psychological effects of quarantine don't worry, be 80: worry and stress decline with age loneliness and health in old er adults: a mini-review and synthesis social isolation, loneliness, and living alone: identifying the risks for public health social distancing in the times of coronavirus pandemic about hispanic origin disclaimer. authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the rpsp/pajph and/or paho. objetivos. evaluar el impacto de la indicaciã³n de quedarse en casa y el distanciamiento social en los adultos de 60 aã±os o mã¡s durante el brote de covid-19 en los estados unidos en 2020. mã©todos. utilizando un muestreo de conveniencia, se solicitã³ a los destinatarios que completaran una encuesta administrada por internet para explorar el impacto del distanciamiento social respecto de la soledad, el estrã©s y los cambios de comportamiento. la muestra analizada consistiã³ en 833 respuestas de personas de 60 aã±os o mã¡s.resultados. una proporciã³n importante de la muestra informã³ experimentar estrã©s (36%) o soledad (42,5%). en alrededor de un tercio de los casos se informã³ que la sensaciã³n de soledad aumentã³ durante el perã­odo de distanciamiento social. los encuestados informaron que realizaban mã¡s actividades solitarias y menos actividades presenciales, utilizaban el correo electrã³nico y los mensajes de texto mã¡s de lo habitual y pasaban mã¡s tiempo que lo habitual con sus computadoras o tabletas. aproximadamente dos tercios de las personas que respondieron informaron que utilizaban las redes sociales mã¡s que lo habitual. se observaron diferencias significativa entre los encuestados mã¡s jã³venes (60-70 aã±os) y los mayores (>71). los cambios en la actividad fã­sica, el consumo de alcohol y de drogas recreativas y los cambios en los patrones de sueã±o tambiã©n difirieron segãºn la edad. conclusiones. el distanciamiento social tiene consecuencias significativas respecto de la soledad y los comportamientos que afectan a la salud en los adultos mayores de los estados unidos, muchas de los cuales varã­an segãºn el grupo etario. los resultados tienen implicaciones respecto de la indicaciã³n sostenida de quedarse en casa, asã­ como para otros adultos mayores que deban estar confinados a su hogar por razones distintas a la pandemia. key: cord-273918-knlc3bxh authors: holmes, emily a; o'connor, rory c; perry, v hugh; tracey, irene; wessely, simon; arseneault, louise; ballard, clive; christensen, helen; cohen silver, roxane; everall, ian; ford, tamsin; john, ann; kabir, thomas; king, kate; madan, ira; michie, susan; przybylski, andrew k; shafran, roz; sweeney, angela; worthman, carol m; yardley, lucy; cowan, katherine; cope, claire; hotopf, matthew; bullmore, ed title: multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science date: 2020-04-15 journal: lancet psychiatry doi: 10.1016/s2215-0366(20)30168-1 sha: doc_id: 273918 cord_uid: knlc3bxh the coronavirus disease 2019 (covid-19) pandemic is having a profound effect on all aspects of society, including mental health and physical health. we explore the psychological, social, and neuroscientific effects of covid-19 and set out the immediate priorities and longer-term strategies for mental health science research. these priorities were informed by surveys of the public and an expert panel convened by the uk academy of medical sciences and the mental health research charity, mq: transforming mental health, in the first weeks of the pandemic in the uk in march, 2020. we urge uk research funding agencies to work with researchers, people with lived experience, and others to establish a high level coordination group to ensure that these research priorities are addressed, and to allow new ones to be identified over time. the need to maintain high-quality research standards is imperative. international collaboration and a global perspective will be beneficial. an immediate priority is collecting high-quality data on the mental health effects of the covid-19 pandemic across the whole population and vulnerable groups, and on brain function, cognition, and mental health of patients with covid-19. there is an urgent need for research to address how mental health consequences for vulnerable groups can be mitigated under pandemic conditions, and on the impact of repeated media consumption and health messaging around covid-19. discovery, evaluation, and refinement of mechanistically driven interventions to address the psychological, social, and neuroscientific aspects of the pandemic are required. rising to this challenge will require integration across disciplines and sectors, and should be done together with people with lived experience. new funding will be required to meet these priorities, and it can be efficiently leveraged by the uk's world-leading infrastructure. this position paper provides a strategy that may be both adapted for, and integrated with, research efforts in other countries. it is already evident that the direct and indirect psychological and social effects of the coronavirus disease 2019 (covid19) pandemic are pervasive and could affect mental health now and in the future. the pandemic is occurring against the backdrop of increased prevalence of mental health issues in the uk in recent years in some groups. 1,2 furthermore, severe acute respiratory syndrome coronavirus 2 (sars-cov-2), the virus that causes covid-19, might infect the brain or trigger immune responses that have additional adverse effects on brain function and mental health in patients with research funders and researchers must deploy resources to understand the psychological, social, and neuroscientific effects of the covid-19 pandemic. mob ilisation now will allow us to apply the learnings gained to any future periods of increased infection and lockdown, which will be particularly important for front-line workers and for vulnerable groups, and to future pandemics. we propose a framework for the prioritisation and coordination of essential, policy-relevant psychological, social, and neuroscientific research, to ensure that any investment is efficiently targeted to the crucial mental health science questions as the pandemic unfolds. we use the term mental health sciences to reflect the many different disciplines, including, but not limited to, psychology, psychiatry, clinical medicine, behavioural and social sciences, and neuroscience, that will need to work together in a multidisciplinary fashion together with people with lived experience of mental health issues or covid-19 to address these research priorities. the uk has powerful advantages in mounting a successful response to the pandemic, including strong existing research infrastructure and expertise, but the research community must act rapidly and collaboratively if it is to deal with the growing threats to mental health. a fragmented research response, characterised by smallscale and localised initiatives, will not yield the clear insights necessary to guide policy makers or the public. rigorous scientific and ethical review of protocols and results remains the cornerstone of safeguarding patients and upholding research standards. deploying a mental health science perspective 3 to the pandemic will also inform population-level behaviour change initiatives aimed at reducing the spread of the virus. international comparisons will be especially helpful in this regard. in this position paper, we explore the psychological, social, and neuroscientific effects of covid-19 and set out clear immediate priorities and longer-term strategies for each of these aspects. we also surveyed the public and people with lived experience of mental ill-health (panel 1). the general population survey, done by ipsos mori, 4 revealed widespread concerns about the effect of social isolation or social distancing on wellbeing; increased anxiety, depression, stress, and other negative feelings; and concern about the practical implications of the pandemic response, including financial difficulties. the prospect of becoming physically unwell with covid-19 ranked lower than these issues related to the social and psychological response to the pandemic. the mq: transforming mental health stakeholder survey of people with lived experience of a mental health issue likewise highlighted general concerns about social isolation and increased feelings of anxiety and depression. more specifically, stakeholders frequently expressed concerns about exacerbation of pre-existing mental health issues, greater difficulty in accessing mental health support and services under pandemic conditions, and the effect of covid-19 on the mental health of family members, especially children and older people. both surveys are reported online. 4 these findings, combined with the published scientific literature, informed the development of our research priorities. the surveys represent a snapshot of the current situation, but they will need to be repeated more rigorously over the course of the pandemic, and the research priorities reviewed. in this section, we focus on the psychological processes and effects in individual people related to covid-19, such as cognition, emotion, and behaviour, that affect mental health (table 1) . although a rise in symptoms of anxiety and coping responses to stress are expected during these extraordinary circumstances, there is a risk that prevalence of clinically relevant numbers of people with anxiety, depression, and engaging in harmful behaviours (such as suicide and selfharm) will increase. of note, however, is that a rise in suicide is not inevitable, especially with national mitigation efforts. 17 the potential fallout of an economic downturn on mental health is likely to be profound on those directly affected and their caregivers. the severe acute respiratory syndrome epidemic in 2003 was associated with a 30% increase in suicide in those aged 65 years and older; around 50% of recovered patients remained anxious; and 29% of health-care workers experienced probable emotional distress. [18] [19] [20] patients who survived severe and life-threatening illness were at risk of post-traumatic stress disorder and depression. 19, 20 many of the anticipated consequences of quarantine 14 and associated social and physical distancing measures are themselves key risk factors for mental health issues. these include suicide and self-harm, alcohol and substance misuse, gambling, domestic and child abuse, and psychosocial risks (such as social disconnection, lack of meaning or anomie, entrapment, cyberbullying, feeling a burden, financial stress, bereavement, loss, unemployment, homelessness, and relationship breakdown). [21] [22] [23] a major adverse consequence of the covid-19 pandemic is likely to be increased social isolation and loneliness (as reflected in our surveys), 4 which are strongly associated with anxiety, depression, self-harm, and suicide attempts across the lifespan. 24, 25 tracking loneliness and intervening early are important priorities. crucially, reducing sustained feelings of loneliness and promoting belongingness are candidate mechanisms to protect against suicide, self-harm, and emotional this position paper summarises the priorities put forward by an interdisciplinary group of 24 world-leading experts, including people with lived experience of a mental health issue, from across the bio-psycho-social spectrum of expertise in mental health science in march and april, 2020. the experts were convened by the uk academy of medical sciences and the mental health research charity, mq: transforming mental health. members participated in an individual capacity, not as representatives of their organisations. a coordinating group of seven experts met daily over a period of two weeks to develop the research priorities, informed by input from the expert advisory group. given the need to develop the research priorities rapidly to inform immediate funding priorities, extended evidence gathering and consultation was not possible. however, we are confident that the wide breadth of expertise on the expert group and their leading roles in their respective fields provide a wide-ranging and comprehensive view of the mental health and neuroscience research priorities now; priorities which should be reviewed and should evolve with the pandemic. lived experience of a mental health issue was incorporated by four mechanisms. first, three representatives with lived experience provided input as part of the expert advisory group. second, an online survey collected data on people's two biggest concerns about the mental health and wellbeing implications of the coronavirus disease 2019 (covid19) pandemic and the coping strategies used by patients. the survey was promoted via email to mq's supporter network and via social media. in total, 2198 people completed the survey, submitting 4350 concerns about the mental health effects of the covid-19 pandemic and 1987 responses about what has helped to maintain mental health and wellbeing during the pandemic. a thematic analysis of the full dataset was done. third, two questions were asked on ipsos mori's online omnibus survey to collect data on people's concerns about the effect of covid-19 on mental wellbeing and what is helping people's mental wellbeing at this time. in total, 1099 interviews were completed with adults aged between 16 and 75 years from across england, wales, and scotland. quotas were set and data were weighted to the offline population to ensure a nationally representative sample by gender, age, and region. statistical analysis was done and any subgroup differences included are statistically significant at a 95% confidence interval unless stated otherwise. a summary report of the findings of both surveys and further methodological details can be found online. 4 the ipsos mori tabular data can be found on its website. 5 finally, the manuscript was peer-reviewed by a reviewer with lived experience of a mental health issue. we acknowledge the limitations of our surveys, including the representativeness of the mq sample, the short timescale for input, and the representativeness of online populations. we also acknowledge the restricted evidence gathering and opportunity for wider consultation of people with lived experience. however, combined, these four mechanisms of collecting input from people with lived experience provide important insight into people's concerns about the effect of covid-19 on mental health and coping strategies within the very short timeframe. problems. 26, 27 social isolation and loneliness are distinct and might represent different risk pathways. to inform management of covid-19, it is vital to understand the socioeconomic effect of the policies used to manage the pandemic, which will inevitably have serious effects on mental health by increasing unemployment, financial insecurity, and poverty. 28, 29 involvement of people with lived experience and rapid qualitative research with diverse people and communities will help to identify ways in which this negative effect might be alleviated. achieving the right balance between infection control and mitigation of these negative socioeconomic effects must be considered. 30 the immediate research priorities are to monitor and report rates of anxiety, depression, self-harm, suicide, and other mental health issues both to understand mechanisms and crucially to inform interventions. this should be adopted across the general population and vulnerable groups, including front-line workers. monitoring must go beyond nhs record linkage to capture the real incidence in the community, because self-harm might become more hidden. we must harness existing datasets and ongoing longitudinal studies, and establish new cohorts with new ways of recording including detailed psychological factors. 26, 31 techniques assessing moment to moment changes in psychological risk factors should be embraced. given the unique circumstances of covid-19, data will be vital to determine causal mechanisms associated with poor mental health, 31,32 including loneliness and entrapment. to optimise effectiveness of psychological treatments, they need to be mechanistically informedthat is, targeting factors which are both causally associated with poor mental health and modifiable by an intervention. 31 a one-size-fits-all response will not suffice because the effectiveness of interventions can vary across groups. 26, [33] [34] [35] [36] digital psychological interventions that are mechanistically informed, alongside better understanding of the buffering effects of social relationships during stressful events, are required in the long term. the digital response is crucial, [37] [38] [39] not only because of social isolation measures but also because less than a third of people who die by suicide have been in contact with mental health services in the 12 months before death. 40 digital interventions for anxiety, depression, self-harm, and suicide include information provision, connectivity and triage, automated and blended therapeutic interventions (such as apps and online programmes), telephone calls and messages to reach those with poorer digital resources (digital poverty), 41 suicide risk assessments, chatlines and forums, and technologies that can be used to monitor risk either passively or actively. the digital landscape extends beyond apps and requires an evidence base. artificial intelligence-driven adaptive trials could help to evaluate effectiveness, while digital phenotyping could be helpful to ascertain early warning signs for mental ill-health. 42 looking beyond digital interventions (as not everyone has access to them), and ascertaining what other mechanistically based psychological interventions are effective and for whom is important. 31, 43 risks and buffers for loneliness should be a focal target in interventions to protect wellbeing. the longer-term consequences of covid-19 for the younger and older generations (and other groups at high risk, including workers, those with existing mental health conditions, and caregivers) are also unknown and must be a priority. how do individuals build optimal structures for a mentally healthy life that works for them in the wake of covid-19 and social and physical distancing? the optimal structure of a mentally healthy life for individuals in the wake of covid-19 needs to be mapped out. structure will vary as a function of background and individual circumstances. changes in sleep and lifestyle behaviours influence our mental health and stress response. understanding the effective, individualised ways of coping in such a situation is of paramount importance. [44] [45] [46] the social and personal resources (eg, seeing family and getting sufficient sleep) available to individuals can be important resiliencerelated factors for mitigating mental health difficulties under particularly stressful circumstances. 47 we need what is the effect of covid-19 on risk of anxiety, depression, and other outcomes, such as self-harm and suicide? improve monitoring and reporting of the rates of anxiety, depression, self-harm, suicide, and other mental health issues; determine the efficacy of mechanistically based digital and non-digital interventions and evaluate optimal model(s) of implementation determine the mechanisms (eg, entrapment and loneliness) that explain the rates of anxiety, depression, self-harm, and suicide; understand the role of psychological factors in buffering the effect of social context on mental health issues; ascertain the longer-term consequences on wellbeing of covid-19 for the young and older generations (and vulnerable groups) what is the optimal structure for a mentally healthy life in the wake of covid-19 and social or physical distancing? determine what psychological support is available to help front-line medical and health-care staff and their families; understand the psychological (eg, coping), physiological (eg, sleep and nutrition), and structural (eg, work rotas and daily routines) factors that protect or adversely affect mental health the immediate research priorities are to understand how front-line health and social care staff and their families can be supported to optimise coping strategies to mitigate symptoms of stress, and facilitate the imple mentation of preventive interventions in the future. 14,48 during the covid-19 pandemic, it is important that health and social care workers are supported to stay in work, the health, personal, social, and economic benefits of which are vast. personalised psychological approaches are likely to be a key component to address complex mental health conditions, coping mechanisms, and prevention. 31 given the association between sleep disturbance and mental health, 49 and the effect of sleep disturbance on the risk of suicide, 50 research on mitigating the effect of such changes on mental health and stress response is required. the longer-term strategic research programmes are to develop novel interventions to protect mental wellbeing, including those based on positive mechanistically based components (ie, causal, modifiable factors), such as altruism and prosocial behaviour. this could include increased opportunities to elicit community support, 51, 52 exercise, 53 social activities, 54 training in assertiveness and conflict resolution, 55 and group interventions that provide support through peers. 56 the inclusion of altruism in uk government health messages has likely had a positive effect on wellbeing compared with compulsory orders to stay at home. 14 key research questions include "what positive mechanistically based psychological interventions can be developed for mental wellbeing derived from theories of altruism and prosocial behaviour?" and "what can be learned from the large-scale roll-out of volunteer-based psychological interventions that will optimise the benefits to individuals and society?" working from home, loss of employment, and social and physical distancing have abruptly interrupted many social opportunities important to physical and psychological health. it is important to research the mental health dimension of online life and investigate how changes in engagement with gaming and online platforms might inform interventions aimed at improving mental health. we must rapidly learn from successful existing strategies to maintain and build social resources and resilience and promote good mental health in specific populations moving forward. population-level factors, such as the effect of social distancing measures (more recently being redescribed as physical distancing) 57 and other necessary public health measures, affect mental health within a syndemics approach (table 2) . by syndemics we mean intersecting global trends among demographics (eg, ageing, rising inequality) and health conditions (eg, chronic diseases and obesity) that yield resultant comorbidities. these longer-term strategic programmes what are the mental health consequences of the covid-19 lockdown and social isolation for vulnerable groups, and how can these be mitigated under pandemic conditions? determine the best ways of signposting and delivering mental health services for vulnerable groups, including online clinics and community support; identify and evaluate outreach methods to support those at risk of abuse within the home; ascertain which evidence-based interventions can be rapidly repurposed at scale for the covid-19 pandemic, and identify intervention gaps requiring bespoke remotely delivered interventions to boost wellbeing and reduce mental health issues; swiftly provide interventions to promote mental wellbeing in front-line health-care workers exposed to stress and trauma that can be delivered now and at scale on the basis of the intervention gaps identified, design bespoke approaches for population-level interventions targeted at the prevention and treatment of mental health symptoms (eg, anxiety) and at boosting coping and resilience (eg, exercise); develop innovative novel universal interventions on new mechanistically based targets from experimental and social sciences (eg, for loneliness consider befriending) that can help mental health; assess the effectiveness of arts-based and life-skills based interventions and other generative activities including exercise outdoors what is the effect of repeated media consumption about covid-19 in traditional and social media on mental health, and how can wellbeing be promoted? understand the role of repeated media consumption in amplifying distress and anxiety, and optimal patterns of consumption for wellbeing; develop strategies to prevent over-exposure to anxiety-provoking media, including how to encourage diverse populations to stay informed by authoritative sources they trust; mitigate and manage the effect of viewing distressing footage inform evidence-based media policy around pandemic reporting (eg, clearly identify authoritative sources, encourage companies to correct disinformation, and policies on traumatic footage); mitigate individuals' risk of misinformation (eg, improve health literacy and critical thinking skills and minimise sharing of misinformation); understand and harness positive uses of traditional media, online gaming, and social media platforms what are the best methods for promoting successful adherence to behavioural advice about covid-19 while enabling mental wellbeing and minimising distress? understand how health messaging can optimise behaviour change, and reduce unintended mental health issues; track perceptions of and responses to public health messages to allow iterative improvements, informed by mental health science synthesise evidence base of lessons learned for future pandemics, tailored to specific groups as required; motivate and enable people to prepare psychologically and plan practically for possible future scenarios; understand the facilitators and barriers for activities that promote good mental health, such as exercise; promote people's care and concern for others, fostering collective solidarity and altruism covid-19=coronavirus disease 2019. interacting health effects and societal forces that fuel them combine to form syndemics, or complex knots of health determinants. 58 research priorities around covid-19 require us to embrace complexity by deploying multidimensional perspectives. what are the mental health consequences of the covid-19 lockdown and social isolation for vulnerable groups, and how can these be mitigated under pandemic conditions? we do not yet know the acute or long-term con sequences of the covid-19 lockdown and social isolation on mental health. although worries and uncertainties about a pandemic are common, for some they can cause undue distress and impairment to social and occupational functioning. 14,59,60 across society, a sense of loss can stem from losing direct social contacts, and also range from loss of loved ones, to loss of employment, educational opportunities, recreation, freedoms, and supports. existing evidence suggests some measures taken to control the pandemic might have a disproportionate effect on those most vulnerable (panel 2). vulnerable groups include those with pre-existing mental or physical health issues (including those with severe mental illnesses), recovered individuals, and those who become mentally unwell (eg, in response to anxiety and loneliness surrounding the pandemic; panel 2). 14,61,62 therefore, loss of access to mental health support, alongside loss of positive activities, might increase vulnerability during covid-19 lockdown. increased feelings of anxiety and depression in response to the outbreak have been highlighted already. 63 health workers who come in close contact with the virus and are exposed to traumatic events, such as death and dying, while making highly challenging decisions, are particularly at risk of stress responses. 15 the pandemic intersects with rising mental health issues in childhood and adolescence. 2, 64, 65 ascertaining and mitigating the effects of school closures for youth seeking care is urgent and essential, given that school is often the first place children and adolescents seek help, 64,66 as is considering vulnerabilities, such as special educational needs and developmental disorders, and finding therapeutic levers. 67 for the older population, promoting good mental health is important during self-isolation, which can be compounded by lifestyle restrictions, exacerbated loneliness, comorbidities (such as dementia), and feelings of worry and guilt for using resources. 68 there is an acute need to identify, in consultation with people with lived experience, remotely delivered interventions that support those at risk of abuse. 69, 70 the immediate research priorities are to reduce mental health issues and support wellbeing in vulnerable groups in particular. a coordinating mechanism for pandemic mental health interventions is required for the agile identification of interventions that can be repurposed, alongside the identification of intervention gaps that will require bespoke de novo design, and the evaluation and roll-out of remotely delivered interventions. by the term intervention, we mean interventions of all sorts that make a difference to mental health, including populationlevel policy, occupational guidelines, and psychological interventions. we need to gather high-quality data rapidly to ascertain the effects of lockdown and social isolation over time. innovative research is needed to establish ways to mitigate and manage mental health risks and inform interventions under pandemic conditions. research to support vulnerable groups needs to consider cross-cutting themes (such as the physical absence of schools and clinics) to create methods to provide connectivity and support; promote rapid innovation in mental although the whole population is affected by the coronavirus disease 2019 pandemic, specific sections of the population will experience it differently. children, young people, and families will be affected by school closures. they might also be affected by exposure to substance misuse, gambling, domestic violence and child maltreatment, absence of free school meals, accommodation issues and overcrowding, parental employment, and change and disruption of social networks. older adults and those with multimorbidities might be particularly affected by issues including isolation, loneliness, end of life care, and bereavement, which may be exacerbated by the so-called digital divide. people with existing mental health issues, including those with severe mental illnesses, might be particularly affected by relapse, disruptions to services, isolation, the possible exacerbation of symptoms in response to pandemic-related information and behaviours, and changes in mental health law. front-line health-care workers might be affected by fears of contamination, moral injury, disruption of normal supportive structures, work stress, and retention issues. people with learning difficulties and neurodevelopmental disorders might be affected by changes and disruption to support and routines, isolation, and loneliness. society might experience increased social cohesion and communitarianism, but also be negatively affected by increased health inequalities, increased food bank use, increased race-based attacks, and other trauma. rural communities might also be affected differently to urban communities. socially excluded groups, including prisoners, the homeless, and refugees, might require a tailored response. people on low incomes face job and financial insecurity, cramped housing, and poor access to the internet and technology. health services that can be remotely signposted and delivered (including online clinics and community support); identify and evaluate means to support those at risk of abuse within the home (eg, online outreach); and swiftly provide interventions to promote mental wellbeing in front-line health workers. by identifying cross-cutting research themes, interventions to help specific vulnerable populations should be leveraged to help other vulnerable groups. with regard to the longer-term priorities, health services research must reliably and iteratively inform remotely delivered mental health resources, such as digital clinics, to efficiently manage mental health issues in an adaptive and flexible manner. 71 this requires a coordinating mechanism to prioritise and streamline efforts, working with service users to optimise signposting and delivery and define therapeutic targets that matter from a user perspective (eg, loss, loneliness). such a mechanism requires a range of disciplines, including psychology, digital science, and social sciences. 31, 72 international collaboration will ensure the necessary research skills and expertise. research should harness internet-based social media and gaming using existing platforms and be cognisant of the so-called digital divide, which leaves 15% of britons without internet access. 73 research for population-level interventions will require rapid evolution of approaches, starting with testing whether existing digital interventions can be repurposed, such as physical activity, sleep, and stress management programmes, as well as targeted approaches for the prevention and treatment of established mental health symptoms (eg, anxiety and worry). 31, 74 tailoring of such universal interventions will need to be informed by exper imental and social science (eg, for loneliness, befriending, and physical activity). 75, 76 the effectiveness of arts-based interventions also needs to be assessed 77 as do other generative activities that boost positive coping and resilience throughout society, from community-based activities, to life-skills classes, to exercising outdoors. 4 the effectiveness of all interventions requires rigorous evaluation and implementation to avoid recommending a plethora of apps with no evidence base. 78 interventions at the population level should be repurposed, developed, and tested in a virtuous loop to create the necessary evidence base. what is the effect of repeated media consumption about covid-19 through traditional media and social media on mental health, and how can wellbeing be promoted? people seek trusted information via the media, which can provide swift, critical guidance regarding the pandemic. media consumption can be adaptive and positive for mental health. however, reports of infectious diseases often use risk-elevating messages, which can amplify public anxiety. 79 social media can be a source of rapidly disseminated misinformation, 80 amplifying perceptions of risk. 81 repeated media exposure to information about an infectious disease particularly can exacerbate stress responses, amplify worry, and impair functioning. 82 anxiety and uncertainty can drive additional media consumption and further distress, creating a cycle that can be difficult to break. 83 media-fuelled distress can promote behaviours that negatively affect the health-care system (eg, visits to emergency departments and hoarding of face masks), with downstream mental and physical health consequences. 84 the immediate research priority is to better understand the role of repeated media consumption around covid-19 in amplifying distress and mental ill-health in various groups, and the optimal patterns of consumption to promote wellbeing. research is needed to inform future approaches, including strategies to help individuals to stay informed by authoritative sources, prevent overexposure to media, and mitigate and help manage the effect of viewing images with traumatic content. longer-term research priorities should inform evidencebased guidelines for media around pandemic reporting (eg, clearly identifying authoritative sources, limiting graphic footage, and encouraging social media companies to flag or correct disinformation and rumours). research should also help to develop strategies to mitigate an individual's risk of exposure to misinformation and amplification of anxiety by minimising sharing of misinformation, and promoting strategies for managing the emotional consequences. adaptive and positive uses of traditional media and social media, such as influencers, should be understood and harnessed. understanding the effect of pandemic media on various vulnerable groups is essential. behavioural change-such as the three personal protective behaviours of handwashing, not touching the t-zone of the face, and tissue use, and social or physical distancing required to control the pandemicnecessitates ensuring people know what to do, are motivated to do it, and have the skills and opportunity to enact the changed behaviours. 85, 86 messaging is key for good knowledge, 86 but public health messaging needs to draw on behavioural science if it is to be effective and avoid unintended consequences. we know that the more concerned people are in pandemics, the more likely they are to adhere to advice. 59 however, increasing concern experienced by the public might heighten distress, which could undermine adherence or exacerbate existing mental health issues. anxiety can be fuelled by uncertainty and by fears of risk of harm to self or others. for example, feelings of paranoia 87 can be heavily influenced by anxiety, and symptoms of obsessive compulsive disorder 88 can be associated with fear of contagion and rigid handwashing. 89 increasing people's confidence and clarity in what they need to do fosters position paper adherence to health behaviours, 90 and can help people to manage psychological distress. immediate research on covid-19 health messaging is urgently required to both optimise health behaviour change and to reduce unintended mental health issues, which will be required in the event of a second wave of infection. research should prioritise message content, format, and delivery modes and behavioural change alongside risk communication, and consider how this might need to vary for diverse groups. a virtuous cycle that tracks perceptions of and responses to public health messages during this pandemic will enable iterative improvements. it must be informed by mental health science 3 to close the knowledge-to-implementation gap (eg, between effective behaviour messages and maladaptive consequences). longer-term research priorities are to create an evidence base of lessons learned to plan for future pandemics-that is, detailing how to foster a rapid and coordinated response regarding health messaging from governments 91 and simultaneously to develop effective systems embedded in communities to reach out and access the most vulnerable groups in our society, including how to motivate and enable people to prepare psychologically and plan practically for possible future scenarios, and how to promote people's care and concern for others, fostering a sense of collective solidarity and altruism. the optimal messaging should be tailored (including digitally) to different social groups to connect diverse segments of the population to appropriate mental health information resources. almost nothing is known with certainty about the effect of sars-cov-2 infection on the human nervous system. sars-cov-2 is a zoonotic virus and a review from 2005 suggested that about half of zoonotic virus epidemics have been caused by neurotropic viruses that invade the cns. 92 the closely related coronaviruses responsible for the severe acute respiratory syndrome epidemic in 2003 and the so-called middle east respiratory syndrome in 2012 are biologically neurotropic and clinically neurotoxic, causing mental health and neurological disorders. [93] [94] [95] sars-cov-2 has a similar receptor-binding domain structure to sars-cov and probably shares its neurotropism and neurotoxicity (panel 3). 96 neurological symptoms of covid-19 infection are common, diverse, and often severe. in a retrospective study of 214 patients in wuhan, china 36% had cns symptoms or disorders and the subgroup of 88 patients with severe respiratory disease had significantly increased frequency of cns problems (45%). 97 the problems reported include dizziness, head ache, loss of smell (anosmia), loss of taste (ageusia), muscle pain and weakness, impaired consciousness, and cerebrovascular complications. similar reports have begun to emerge from italy. 98 some of these acute neurological presentations could reflect systemic aspects of infection, such as disseminated intravascular coagulation causing strokes or intense inflammation and hypoxia causing delirium. sars-cov-2 infection of the brain could be a contributor to the core medical syndrome of respiratory distress and failure in patients with covid-19. 99 viral infection of the lung alveoli is the immediate cause of severe acute respiratory syndrome; but viral infection of key brainstem nuclei could disrupt the normal rhythms and homoeostatic control of respiration. this idea needs to be tested rapidly 99 because if brainstem infection does contribute to the severity of sars and the need for treatment in an intensive care unit, it could be directly relevant to the immediate covid-19 crisis in the nhs and other health-care systems. in the longer term, it is possible that sars-cov-2 will have persistent direct neurotoxic effects and immunemediated neurotoxic effects on the brain. the spanish flu epidemic of 1918-19 was linked to a spike in incidence of post-encephalitic parkinsonism. 100 currently, it is not known if sars-cov-2 infection could cause mental health or neurodegenerative disorders immediately or years after the acute respiratory phase of covid-19 has passed, but action is needed now to build the research capacity to test these potentially important biological causes of covid-19-related mental illness. immediate actions include the development of a neuropsychological database of covid-19 cases to bring together standardised, longitudinally repeated data at scale both from the clinic for those needing hospital facilities for sars-cov-2-infected tissue handling need to be expanded to examine human brain tissue post mortem, which is crucial to understanding the neurotropic and neurotoxic properties of the virus. facilities equipped to safely handle human (or animal) brain tissue infected with sars-cov-2 are currently very few in number. we recommend building pathology and molecular neuroscience networks to enable brain and other tissue to be collected at autopsy and examined for viral infection and damage. this will require protocols for tissue collection and examination in appropriate laboratory facilities to protect researchers and other staff at all times. the longer-term research priorities are to understand the mechanisms by which sars-cov-2 might enter the brain. there are two conceivable pathways: neuronal or vascular. 101 the neuronal pathway, used by other coronaviruses, 102,103 is to invade a specialist sensory receptor in peripheral tissue, travel by the axonal transport systems to the brainstem, and propagate between neurons by transsynaptic mechanisms. it is not known whether sars-cov-2 can follow the same path to infect the human brain or whether it invades nerve cells by hijacking angiotensin converting enzyme 2 (ace2), 104-106 despite neurons expressing low amounts of the protein, as described in a preprint 107 and two other published studies. 108, 109 alternatively, sars-cov-2 might invade the brain from the blood, if circulating particles of the virus were transported across the blood-brain barrier by binding to ace2 receptors expressed by endothelial cells, 109 or if infected leucocytes could carry the virus with them as they migrate into the tissues as part of the immune response to infection. 110 better understanding of how the intense systemic immune response to sars-cov-2 infection affects mental health and neurological symptoms, 97, 111, 112 and of the mechanisms of immune clearance of sars-cov-2, is also needed. 113, 114 post-infectious fatigue and depressive syndromes have been associated with other epidemics, and it seems possible that the same will be true of the covid-19 pandemic. longitudinal studies, especially if commenced before or soon after the start of the current pandemic, will be crucial in establishing the often complex biological pathways between infection and mental health outcomes. [115] [116] [117] candidate biomarkers need to be evaluated to measure the effects of sars-cov-2 infection on the human brain and brainstem in living patients, including structural and functional mri, diffusion-weighted mri, quantitative cerebral blood flow imaging, and magnetic resonance spectroscopy. the 7 tesla mri technique has sufficient spatial resolution to measure functional connectivity between subcortical structures that constitute networks for respiratory control and distress. 118 other methods could include sampling cerebrospinal fluid or use of pet to measure brain inflammation; patient self-reporting or behavioural testing of smell, taste, and other cranial or vagal sensory functions; electrophysiological methods to measure brainstem function; and computerised tests of cognitive and emotional processing. informed by greater understanding of the effects of viral infection on the nervous system and by more accurate biomarkers of brain function in patients with covid-19, interventions need to be developed to interrupt or prevent the adverse biological effects of sars-cov-2 on brain function and mental health. potential drug targets include putative mechanisms for neuronal invasion, interneuronal propagation, and immune clearance of sars-cov-2. biological and clinical validation of these or other targets would enable experimental medicine studies or early clinical trials of repurposed drugs. for example, the ace2 inhibitors already licensed for treatment of hypertension, and a licensed drug for reflux oesophagitis, camostat mesylate, that blocks the serine protease tmprss2 119 (which operates with ace2 to facilitate viral entry into cells) have already been advocated as repurposable drugs. there are many other potential candidates for drug repurposing described in a preprint, 120 which could be a faster route to effective treatment for cns infection than development of entirely new drugs or vaccines. partnerships between researchers in academia and industry will be vital. many of the immediate priorities are for surveillance of general and specific populations for effects of sars-cov-2 infection on health, ranging from health behaviours, psychological symptoms, neuropsychiatric disorders, and mortality, including, but not limited to, suicide. the other immediate priority is to assemble cohorts to determine longer-term outcomes and provide a resource for nesting intervention studies, and a resource of interventions to monitor their effectiveness. we recommend three main routes. for each of these routes, there is a need to coordinate existing research infrastructure through shared protocols, research measures, and data assets, and to uphold the highest standards of scientific and ethical review. we urge the mental health science community to combine agility in initiating new or adapting existing research with collective scrutiny and collaboration. first, administrative data assets principally derived from existing electronic health records, with systems in place to interrogate these for research purposes, provide a means of identifying health effects at scale. 123 for general hospital settings, which provides near realtime information from health records (eg, to provide feedback on neurological consequences of severe covid-19). these systems should be linked between mental health services, acute medical services, and community health services to identify patterns and trends both in clinical populations and in individuals with confirmed or suspected covid-19. second, surveillance through recruitment platforms and existing cohorts has the benefit of embedding research on covid-19 into studies where participants' mental or cognitive health has previously been ascertained. existing cohorts or data platforms that can be rapidly deployed for covid-19 research are likely to be particularly valuable. examples include the national institute for health research national bioresource, a platform that already includes clinical and genetic data on participants, and could be deployed for rapid characterisation of mental health and neurological symptoms. uk biobank has successfully done a webbased mental health survey of 160 000 individuals, and the ongoing neuroimaging studies of 100 000 individuals with some repeat imaging, provide an ideal opportunity to image the effect of sars-cov-2 infection on the brain and the brainstem via a before-and-after imaging comparison. third, novel population-based studies on mental health and covid-19 should be established, using appropriate epidemiologically robust survey methodology for both the whole population and specific groups of particular interest (eg, children and young people, front-line staff in health and social care, and people who have survived severe . priority should be given to assembling representive populations using explicit sampling frames. finally, many other disciplines will be establishing similar studies and it is vital that the ascertainment of mental health should be embedded wherever possible. whether using established or new cohorts, priority should be given to methods that can ascertain covid-19 status, symptoms, and behaviours in as close to real-time as possible, providing a dynamic picture of change in illness status, social circumstances, and behaviours. questions regarding covid-19 and mental health symptoms and social stressors can readily be disseminated through smartphones. passive data from smartphones can also give high temporal resolution to behaviours related to the pandemic. cohorts should gain permissions for the linkage of records, including serological status, when mass testing becomes available, and consent for recruitment into nested substudies, including randomised trials of interventions. patient and public involvement in research is a critical underpinning component to research. given that the entire population has lived experience of the covid-19 pandemic, researchers will need to be particularly mindful of consulting and collaborating with patient and public groups that reflect the diverse groups being studied when developing protocols, conducting research, and interpreting results (panel 4). multidisciplinary mental health science research must be central to the international response to the covid-19 researchers must continue to describe the patient group or population and the research question under study. a priori research questions are crucial. sample size, sources of bias, participant characteristics (including sex, age, and ethnicity), and study design need to be carefully considered and must be appropriate to the research questions. research on human participants should maintain high standards of ethical practice, including seeking research ethics committee approval. 124 committees now have fast-track procedures to expedite study start up. ethical considerations for doing coronavirus disease 2019 (covid-19)-related research have been published. 125, 126 vulnerable groups researchers should recognise the capacity of the pandemic to exacerbate health inequalities within populations, particularly affecting people with established mental health issues (including severe mental illnesses) and physical disability. those with precarious or no employment or housing, or other forms of social inequality, such as digital poverty, 41 should also be considered. researchers should continue to engage and involve patients, people with lived experience, the public, and service providers in their work by mutually setting research questions, testing the acceptability of protocols and questionnaires, and interpreting results. researchers should ensure that they discuss their research findings with participants. there is an obvious need for researchers to use and share full study protocols and measures, where possible. this will facilitate comparisons between data and projects. the urgency of the research effort should be a strong driver for the principles of open science, reproducibility, and data sharing. the ready availability of analysis code and data is essential to verifying findings. broad adoption of the registered reports publication model, 127 including rapid peer review of study protocols before data collection, will help to minimise waste and ensure conclusions are empirically sound. the challenge of the covid-19 pandemic requires imaginative collaborations between disciplines, including, but not limited to, psychology, psychiatry, neuroscience, virology, intensive care medicine, and respiratory medicine. previous experience with epidemics has shown the "essential role that the humanities and social sciences play in information, reduction of fear and stigma, prevention, screening, treatment adherence, and control policies". 128 where possible, research protocols should be deployed at scale harnessing existing research infrastructures, including the clinical research networks, biomedical research centres, mental health translational research collaboration, mq data science group, charities, service user groups, and professional bodies. to avoid waste and protect against participant fatigue, it is essential that there is national coordination across research groups. international collaboration and a global perspective would also be beneficial. pandemic, given the potential effects on individual and population mental health, and its potential effect on the brain function of some of those affected by the disease. there are important immediate insights to be gained, which could provide evidence-based guidance on responding to this pandemic and on how to promote mental health and wellbeing, and safeguard the brain, should future waves of infection emerge (panel 5). the research priorities across the social, psychological, and neuroscientific aspects of this pandemic should be coordinated at a national and international level. we urge uk research funding agencies to work with researchers, people with lived experience, and others to establish a high-level coordination group to ensure that the mental health science research priorities are addressed swiftly, and that a firm evidence base is established for long-term studies. we need rigorous, peer-reviewed, ethically approved research codeveloped with people with lived experience that can be translated into effective interventions, rather than the current uncoordinated approach with a plethora of underpowered studies and surveys. the immediate priority is the collection of high-quality data on the mental health and psychological effects of the covid-19 pandemic across the whole population and in specific vulnerable groups, and on brain function, cognition, and mental health for patients with covid-19 at all clinical stages of infection and illness. these datasets must be brought together under a national data portal for rapid access and use. there is an urgent need for the discovery, evaluation, and refinement of mechanistically driven interventions to address the psychological, social, and neuroscientific aspects of this pandemic. this includes bespoke psychological interventions to boost wellbeing and minimise mental health risks across society, including in vulnerable groups, and experimental medicine studies to validate clinical biomarkers and repurpose new treatments for the potentially neurotoxic effects of the virus. there is an urgent need for research to address the effect of repeated pandemic-related media consumption and to optimise health messaging around covid-19. rising to this challenge will require integration across disciplines and sectors, including industry and health and social care. new funding will be required to meet these priorities, and it can be efficiently leveraged by the uk's worldleading neuroscience and mental health research infrastructure. the uk must connect with international funders and researchers to support a global response to the mental health and neurological challenges of this pandemic. in these challenging times, mental health science should be harnessed to serve society and benefit both mental and physical health in the long term. eb, eah, mh, rco'c, vhp, it, and sw contributed to the literature review, conceptualisation, design and interpretation of surveys, and writing and editing of the manuscript as part of the core advisory group. cc contributed to and coordinated the writing and editing of the manuscript. kc analysed the qualitative data gathered via the stakeholder survey. la, cb, hc, rcs, ie, tf, aj, im, sm, akp, rs, cmw, and ly contributed to the drafting and formulation of the manuscript as part of the expert advisory group. tk, kk, and as contributed to the drafting and formulation of the manuscript as part of the expert advisory group and by including lived-experience expertise. all authors approved the final version for submission. cb reports grants and personal fees from acadia and lundbeck; personal fees from roche, otsuka, biogen, eli lilly, novo nordisk, aarp, and exciva; and grants from synexus, outside the submitted work. eah reports serving on the board of trustees of the charity mq: transforming mental health and as chair of the research committee, but receives no remuneration for these roles. eah receives royalties from books and occasional fees for workshops and invited addresses; receives occasional consultancy fees from the swedish agency for health technology assessment and assessment of social services; and reports grants from the oak foundation, the lupina foundation, and the swedish research council. rco'c is a member of the national institute of health and care excellence's guideline development group for the management of selfharm; is co-chair of the academic advisory group to the scottish government's national suicide prevention leadership group; receives royalties from books, and occasional fees for workshops and invited addresses; and reports grants from medical research foundation, the mindstep foundation, chief scientist office, medical research council, nhs health scotland, scottish government, and national institute for health research (nihr). kk has received meeting attendance payments from the department of health and social care, nhs england and nhs improvement, and the royal college of psychiatry (rcpsych) over the last year for service user representative work, and payment for a training session she facilitated for rcpsych; and received a pass and accommodation for the rcpsych annual conference in 2019. akp reports financial support from uk taxpayers, the uk's economic and social research council, the british academy, the diana award, the john fell fund, the leverhulme trust, barnardo's uk, and the huo family foundation in the past five years. as part of science communication and policy outreach activities; and served in an unpaid advisory capacity to the organization for economic co-operation and development, facebook, google, and the parentzone. it is a trustee of 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hospital ethical and legal challenges posed by severe acute respiratory syndrome: implications for the control of severe infectious disease threats key ethical questions for research during the covid-19 pandemic rapid policy briefing: ethical considerations in responding to the covid-19 pandemic what's next for registered reports? toward a global health approach: lessons from the hiv and ebola epidemics we are grateful to all staff at the academy of medical sciences and mq: transforming mental health for their work in coordinating and supporting this project's secretariat and communications. special thanks to rachel quinn, nick hillier, helen munn, neil balmer, angeliki yiangou, fern brookes, holly rogers, claire bithell, naomi clarke, melanie etherton, tom livermore, dylan williams, and daisy armitage. we also extend our sincere thanks to katie white, carolin oetzmann, valeria de angel, and sumithra velupillai at king's college london, and norman freshney from norman freshney consulting, for their tremendous efforts in data analysis, and beau gamble at uppsala university and seonaid cleare at university of glasgow for their support with referencing. we are also grateful to the team at ipsos mori for their work on the online omnibus. special thanks also to everyone who participated in the mq: transforming mental health and ipsos mori surveys for sharing their views and personal experiences during challenging times-we are hugely grateful to them for their openness and honesty about mental health and wellbeing. we are grateful to peter jones from the university of cambridge and a member of the mq: transforming mental health board of trustees for comments on an earlier draft. key: cord-275028-u6s0gr31 authors: karos, kai; mcparland, joanna l.; bunzli, samantha; devan, hem; hirsh, adam; kapos, flavia p.; keogh, edmund; moore, david; tracy, lincoln m.; ashton-james, claire e. title: the social threats of covid-19 for people with chronic pain date: 2020-07-13 journal: pain doi: 10.1097/j.pain.0000000000002004 sha: doc_id: 275028 cord_uid: u6s0gr31 nan the covid-19 (sars-cov-2) pandemic has changed the social environment in which people live and work, as well as the social systems they rely on. 39, 88 to contain the spread of coronavirus and to prepare for a dramatic increase in demand for limited hospital/medical facilities and resources, societies have enforced physical distancing measures. consequently, there have been limitations on the use of public transportation, public spaces, and work, education, and recreational facilities. furthermore, access to vital, but nonurgent, healthcare services (including pain management services) has been restricted. these changes have affected the way people connect with each other, manage their health and wellbeing, and fulfil their social roles. for some, these changes may present opportunities (eg, increased time with family, normalisation of flexible working, and reduced demand for travel). for others, however, these social changes can also represent significant threats to health and wellbeing. the negative impact of social changes prompted by the covid-19 crisis may disproportionately affect individuals living with longterm painful conditions. living with chronic pain can threaten an individuals' fundamental social needs for autonomy (agency or independence), belonging (social connection), and justice (fairness). in turn, for some, experiencing heightened social threat can maintain and exacerbate chronic pain. 48 in this review, we draw attention to the potential for social and systemic changes associated with attempts to contain the spread of covid-19 to precipitate, maintain, and exacerbate pain by increasing the social threats faced by individuals with chronic pain ( ½f1 fig. 1 ). we also suggest strategies for mitigating the social impact of covid-19 on those living with chronic pain, for instance by learning from the resilience demonstrated by people in pain who have found ways to deal with social threat. finally, we suggest several time-critical, high-impact research questions for further investigation (fig. 1 ). one of the most immediate effects of the pandemic on our social lives is the introduction of physical distancing measures and restriction of travel. it is well known that spontaneous social interactions with others and participation in social roles can build and maintain a generalised sense of trust in others (social capital), promote feelings of wellbeing, 76 provide protection from the harmful effects of stress, 95 promote social connectedness, and reduce pain sensitivity. 91 conversely, social isolation is associated with loneliness, higher levels of depression and anxiety, poorer health behaviours, poorer sleep, higher blood pressure, poorer immune function, and pain. 40, 42 chronic pain conditions place individuals at an increased risk of social isolation, smaller social network size, and reduced social role functioning, 37, 38, 78 all of which have negative implications for pain interference and pain intensity over time. 7, 31, 47 indeed, disruption to social roles and relationships is one of the most distressing aspects of living with chronic pain. 81 physical distance from others and reduced participation in work and social activities can cause people to feel lonely or socially distanced from others, 73 and there are concerns that the covid-19 pandemic will lead to a steep rise in the prevalence of loneliness. 5, 22, 35, 39 people living with chronic pain, who may have entered the pandemic with fewer social resources than others, may be particularly vulnerable to feelings of loneliness and social disconnection at this time. unless individuals have the ability and means to maintain meaningful connections with others despite physical distancing measures, being physically isolated from others threatens to exacerbate pain and associated disability. the paradox of covid-19 is that being physically isolated from one's community can mean living in closer proximity to one's household members. people living with chronic pain conditions may benefit from more frequent contact with family members because closer proximity offers more opportunity to improve social bonds. however, enforced close-proximity living could also bring challenges to autonomy and independence. although social support can help buffer against pain, 14, 15, 18, 56 an increase in solicitous behaviours in such close proximity might unintentionally contribute to the chronicity of pain. 34, 43, 72 for example, in households where a child is in pain, increased social proximity could lead to increased exposure to protective parental behaviours and reductions in child autonomy and activity. conversely, family members could become desensitised to the pain of others, or even become avoidant, risking further isolation for individuals living with pain. those living with pain may experience increased feelings of guilt in response to increased support, especially if they perceive themselves to be a burden. 50, 75 alternatively, fear of rejection could lead to masking pain from others in shared living spaces, preventing individuals with pain from asking for help to meet their needs. 13, 65 there is also a risk that for people living with chronic pain, living in close proximity and enclosed environments could increase exposure to interpersonal conflict, 63, 69 which is known to amplify pain ® pain and disability. 11, 26, 36, 61 for some, covid-19 has brought about increased risks of conflict among household members, as they deal with the stresses associated with unexpected financial pressures, job insecurity, and unemployment. 21 many people are struggling to juggle multiple social roles and responsibilitiessupporting children with schoolwork, working from home, and parenting-leading to emotional exhaustion. women, in particular, are likely to carry a greater social burden and greater responsibility for childcare during covid-19. 1,92 critically, domestic abuse has increased during the covid-19 lockdown, 10 which has also been shown to contribute to chronic pain. 2,60 1.3. reduced access to high-quality pain management covid-19 potentially poses a significant challenge for patients seeking to access pain management. although pain management is a fundamental right, 23 the health system responses to mitigate the impact of covid-19 may significantly affect access for patients with complex medical conditions (eg, people with comorbid mental health conditions and addiction) and widen existing inequities in relation to pain management for socially disadvantaged populations. 90 for some people with chronic pain, the pandemic might bring life stressors that result in pain flare-ups, and increase the need for pain services. 77 furthermore, individual pain experiences may not be considered as immediately important when compared to the need to treat lifethreatening symptoms associated with covid-19, 12 leading to less help-seeking and psychological distress. pain management during this pandemic for clinicians involves balancing access to care with minimising safety risk from exposure to covid-19 for vulnerable patients and clinicians themselves. 79 cancelled elective surgeries, closure of pain management services, and redeployment of clinicians to other areas of care all result in limited access to high-quality care. consequently, the increased burden on healthcare workers may result in a greater focus on biomedical management (eg, opioid prescribing), rather than psychological and interdisciplinary treatment approaches. although this may be deemed necessary in the context of the pandemic due to heightened needs from patients for pain relief, clinicians and patients may not agree on opioid prescription/deprescription. 66 in addition, the individual assessment required to address the risks and benefits of opioid use and the monitoring of its use 85 may be complicated by a lack of access to face-to-face pain services. in the absence of the availability of face-to-face contact, telehealth is increasingly being recommended as a first line of care for patients, 19 including those with chronic pain. 29 the rapid transition to telehealth in response to physical distancing regulations allows people to access high-quality care without travelling, potentially increasing patient access to care. it also opens up new opportunities and enables us to think about new ways of delivering pain management. however, this mode of delivery may be particularly challenging for vulnerable groups due to poor health status and low technological literacy. 71 even when services are delivered through telehealth, the fear of sharing confidential information from home and juggling multiple social responsibilities, particularly for women, pose further barriers to engaging in high-quality care. 64 in the context of delivery, practical challenges in conducting multidisciplinary treatment through telehealth 77 may lead to a prioritising of individual over multidisciplinary approaches. this is despite evidence that care delivered through telehealth can be as effective as face-to-face care for people experiencing pain conditions. 55 covid-19 is exacerbating existing social injustices and inequalities. extreme events such as terrorist attacks and natural disasters 32, 44, 96 are known to undermine the fundamental belief that the world is just, stable, orderly, and predictable, 52 with ramifications for perceived life control, future prospects, and wellbeing. 67, 86 this is particularly relevant to chronic pain because commitment to the belief in a just world can buffer against its adverse effects. 57 a pandemic-initiated violation of just-world beliefs could exacerbate perceived injustices associated with pain. 16 for example, physical distancing policies could further increase social isolation and potentially worsen perceived injustices, 80 while disrupting social networks that are sources of justice and support 74 may heighten perceptions of invalidation among those with pain, driven by the sense that one does not matter to others. 17 variation in the effect of covid-19 illustrates social inequalities around pain, and health care more generally. there are known individual differences in pain associated with social identities, including sex, ethnicity, and age. 6, 33 there are also social inequalities and biases, which can affect pain burden 25 and access to pain care. 24, 82 structural and individual biases towards minority and marginalized groups that are heightened by uncertainty, stress, and fear 49 are likely to be exacerbated by covid-19. discrimination experienced by marginalized groups can affect peripheral and central processes, including immune functioning, 20,28,83 thus compounding the negative effects associated with the stigmatization of chronic pain. 26 those living in poorer and/or more remote communities have higher rates of chronic pain and comorbidities 60, 62 and limited access to health care, which can lead to greater unmanaged pain and disability. 3, 4 reduced access to health care, higher costs, and language might form additional barriers to pain management in these communities (eg, refugees). for example, disabling chronic pain can be more prevalent in indigenous populations, who are also less likely to access support services. 3, 4, 8 travel restrictions imposed to limit the spread of covid-19 into remote communities are likely to disrupt the provision of nonessential services, further limiting access to pain care. socioeconomic disadvantage also increases vulnerability to disease, including covid-19, through many potential pathways including lower social support, 89 overcrowding, poorer sanitation, neighbourhood, and housing conditions, and poorer health behaviours (eg, smoking, diet, alcohol consumption, and reduced exercise). 9, 70 furthermore, although people from lower socioeconomic backgrounds are overrepresented in "essential" employment sectors, which have been largely spared from covid-19-related redundancies, many of these employees are now facing longer working hours under more demanding conditions. all these factors could not only lead to increased risk of exposure to covid-19, but also, if left untreated, exacerbate other conditions, including chronic pain. in short, covid-19 has disproportionately affected socially disadvantaged groups, and the ensuing global economic fallout could magnify these inequalities in pain further. 90 the concern is that the most economically disadvantaged will be most likely to be exposed to the hazard, most susceptible to harm from it, and most likely to experience negative outcomes from it. 88 the wide range of social threats that covid-19 brings to those in pain means that no one response will address all these issues. however, by identifying such threats, we can start to think of more month 2020 · volume 00 · number 00 www.painjournalonline.com 3 focused and targeted approaches. for example, just as some treatments have moved online, it may also be possible to mitigate some of the impacts of physical distancing and social isolation using technology. social media platforms, due to their wide reach and penetration, can help disseminate key information about covid-19, providing virtual support to enhance social connectedness. 58 people with pain already report using digital peersupport groups to connect with similar others and derive benefits from feeling validated and heard. 59 online peer-support could potentially be used to help reduce felt social distance while maintaining physical distance. increasing digital social connectedness might afford people with chronic pain more social contact and accessibility than is possible face-to-face because it does not require physical mobility. however, we also need to ensure that the use of social platforms is beneficial, and do not increase risk (eg, due to the exposure to poor-quality health information that reinforces disability or propagating unproven and potentially harmful approaches). 27 even so, the pandemic has provided an opportunity to understand how social media might be better used as a tool to develop a sense of community and reduce isolation. online technology can be used to facilitate the delivery of healthcare interventions, under the guidance of healthcare professionals. for example, cognitive behavioural therapies for loneliness delivered online can decrease loneliness and improve mental wellbeing. 45, 46 online pain management programs seem to hold promise, 29 particularly when patients have contact with healthcare providers, albeit remotely. 54 online resources can disseminate pain education, and online training programs on pain self-management can be developed for healthcare professionals, those with pain, and their close others. 30, 41, 84 however, these novel digital interventions might not be accessible for all and may even put up new barriers to those who require them the most (eg, socially disconnected individuals with limited digital literacy). we also need to think beyond technology. the covid-19 pandemic served to highlight the upstream social determinants of health, many of affect chronic pain directly. historic social inequalities and unequal access to resources shape individuallevel risk factors, which in turn produce and perpetuate health disparities. 53 these structural problems require structural solutions 51, 93 with the aim to improve population health, for instance by bolstering social welfare systems, public health funding, and improved global cooperation. 68, 87, 94 at the local level, online technologies could mitigate the social threat of existing social inequalities and injustices, providing access to relatively inexpensive, location-independent treatment, and social connection. coupled with systemic interventions such as increased government funding to telehealth services, reducing the costs and barriers to internet access, and making computers and mobile devices available to those who otherwise might not have access to them can further reduce these disparities. 97 the current pandemic has exacerbated existing sources of social threat for people with chronic pain. to prevent a population-level increase in the severity and impact of chronic pain, it is critical to devote scientific attention to the assessment, mitigation, and prevention of sources of social threat for people with chronic pain. table 1 outlines several high-impact areas for research to this end. crucially, covid-19 should not only be regarded as a challenge but also as a unique opportunity for researchers and clinicians to develop new ways to deliver social support and pain management, as well as understand the impact of social adjustment among individuals with chronic pain. the authors have no conflicts of interest to report. priorities for research on social factors resulting from the covid-19 pandemic. the social consequences of the pandemic for people with chronic pain. a. assess nature and cohesion of family and wider social support networks and emotional connectedness of people with chronic pain during physical distancing. b. assess how minority and marginalised groups with chronic pain are accessing pain support during the pandemic, identifying possible facilitators and barriers. c. assess different forms of social threat for people with chronic pain such as loneliness, experiences of injustice, victimization, and invalidation. d. examine the effects of social distancing measures in the workplace, and on job prospects after the covid-19 pandemic for employees with chronic pain. 2. fundamental research on biological, psychological, and/or social working mechanisms on the bidirectional relationship between social factors and pain. a. assess the immediate and long-term effects of physical distancing on relevant pain outcomes and pain management strategies. b. investigate whether pain-related stigma, discrimination, social isolation, or perceptions of injustice increase vulnerability to covid-19 infection or affect risk-related behaviour. c. investigate the role of social learning in times of uncertainty and the effect on pain behaviour. 3. clinical and fundamental research on digital social support for chronic pain. a. study the potential limitations (eg, less physical activity, lower quality of social relationships) and strengths (eg, lower threshold for engagement) of digital social support compared to face-to-face social support on pain outcomes. b. conduct theory-based studies on mediators that influence the effectiveness of online social support for chronic pain complaints. 4 . clinical research on the effectiveness of digital pain management interventions for chronic pain. a. clinical trials comparing the effectiveness of digital vs face-to-face interventions. b. research on the quality of social relationships, communication and trust between professionals delivering online interventions and chronic pain patients. c. identify barriers and facilitators for access to online treatments, especially for marginalized populations with chronic pain. research into possible individual resilience mechanisms (eg, increased social cohesions, revaluation of values and priorities, increased uptake of online pain management) buffering against the effects of the pandemic on chronic pain. 6 . systemic research on the effects of multilevel social determinants of health on chronic pain and policies to address them (eg, labour relations, income inequality, neighbourhood deprivation, racism, sexism, ageism, access to health care, etc.), to strengthen population resilience to the impact of heightened social threats on chronic pain. a. research into integrated methods of intervention or analysis (eg, dynamic systems modelling) across micro (ie, families, partnerships), meso (ie, community, city, organizations), and macro (ie, nations, 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earthquake physical distancing and emotional closeness amidst covid-19 key: cord-194766-binlxvvc authors: kokubun, keisuke title: social capital may mediate the relationship between social distance and covid-19 prevalence date: 2020-07-20 journal: nan doi: nan sha: doc_id: 194766 cord_uid: binlxvvc the threat of the new coronavirus (covid-19) is increasing. regarding the difference in the infection rate observed in each region, in addition to studies seeking the cause due to differences in the social distance (population density), there is an increasing trend toward studies seeking the cause due to differences in social capital. however, studies have not yet been conducted on whether social capital could influence the infection rate even if it controls the effect of population density. therefore, in this paper, we analyzed the relationship between infection rate, population density, and social capital using statistical data for each prefecture. statistical analysis showed that social capital not only correlates with infection rates and population densities but still has a negative correlation with infection rates controlling for the effects of population density. besides, controlling the relationship between variables by mean age showed that social capital had a greater correlation with infection rate than population density. in other words, social capital mediates the correlation between population density and infection rates. this means that social distance alone is not enough to deter coronavirus infection, and social capital needs to be recharged. the threat of the new coronavirus , which was discovered in wuhan, china in december 2019 and spread worldwide, is affecting the lives of many people without stopping. japan is no exception, although it is often reported that its virus death rate is mysteriously low (wingfield-hayes, 2020) . the number of infected people, which had subsided in june 2020, started increasing again in july. hirata et al. (2020) showed that the infection rate tends to be high in large cities such as tokyo and that the reason for this is the high population density of these large cities, and then stated that population density can be used as a proxy variable for social distance. however, coronal infections cannot be prevented by social distances alone. in fact, in addition to securing social distance by refraining from going out, time lag, remote work, etc., the government is implementing anti-quarantine actions such as wearing a mask, encouraging hand and finger disinfection, and refraining from loud conversations as a basic policy for countermeasures against coronavirus infectious diseases, which has been strongly sought by the public (cabinet secretariat, 2020). among some possible options, many researchers are paying attention to social capital as a factor that promotes these quarantine actions. social capital is the sharing of values, acceptance of norms, unity, and trust through reciprocity, and is said to play an important role in solving problems through interaction and cooperation (coleman, 1988; fukuyama, 1995; putnam, 2000) . previous research has also shown that social capital is effective in solving public health challenges (asri & wiliyanarti, 2017; house, landis, & umberson, 1988; pretty, 2003) . for example, some studies show that the high level of social capital (trust and human connection to the government, reciprocity, reciprocity, and solidarity) influenced the practice of preventive actions such as vaccination, washing hands, and wearing a mask during the h1n1 outbreak in 2009 (chuang et al., 2015; ronnerstrand, 2013 ; see also the review by pitas & ehmer, 2020) . in connection with the coronal disaster this time, studies that analyzed gps information in the united states showed that residents in counties with high social capital were more cooperative in going out regulations (borgonovi & andrieu, 2020) and reduced the increase of coronavirus infection (varshney & socher, 2020) . a study in italy also showed that areas with high social capital tended to have low outing rates and low corona mortality (bartscher et al., 2020) . in a related study, research in the field of human resource management based on a questionnaire survey shows that social capital (reciprocal support between company support and employee organizational commitment) enhanced employees' willingness to cooperate in the workplace corona countermeasures (kokubun, ino, & ishimura, 2020) . why does social capital have this effect? this is because social capital encourages information sharing and removes the uncertainty of choice (chung, nam, & koo, 2016; li, ye, & sheu, 2014; six et al., 2015) , also encourages collective action and deters the occurrence of the free-rider problem (koutsou, partalidou, & ragkos, 2014; mosse, 2006; ostrom, 2000; pretty, 2003) . regarding the former, kawachi & berkman (2000) argue that social capital helps promote the dissemination of health-related information and prevents unhealthy conduct. regarding the latter, an empirical study conducted in china after covid-19 showed that social capital was successful in the prevention of epidemics such as refraining from going out and wearing masks (yang & ren, 2020) . the latter, that is, the mechanism by which social capital restrains free riders, is also supported by game theory research. generally speaking, for people to take coordinated actions in the relationships with others continuously, it is necessary to expect that long-term benefits of collaborating will surpass the short-term benefits of opportunistic actions, therefore, to promote cooperative actions by increasing the benefits of cooperation and lowering the benefits of opportunism, it is necessary to have a mechanism in which a person who refuses cooperation receives "tippling" from another person (axelrod, 1984) . for reference, japan's murahachibu (making people who do not follow the rules of the village out of line) is wisdom based on such a mechanism. as mentioned above, more and more studies tend to show that social capital leads not only to epidemics prevention up to now but also to the promotion of quarantine action and deterrence of infection in this time of corona. however, to the best of my knowledge, no studies have shown that even if the effects of population density (social distance) are removed, there is a negative correlation between high social capital and coronavirus infection rates. therefore, in this study, i would like to address this issue using crosssectional data at the local government level in japan. the relationship between population density and infection rate is shown in hirata et al. (2020). a study in china also confirmed a positive correlation between population density and infection rates before the lockdown (wang et al., 2020) . these researchers point out increased opportunities for human contact (smaller social distances) associated with high population densities as a reason for the correlation. in support, some studies have directly investigated the effects of social distance. for instance, a previous study based on the results of an independent online survey showed that the number of infected people from january to march this year tended to be smaller in prefectures with less face-to-face communication, use of public transportation, and fewer meals outsides (shoji et al., 2020) . therefore, the following hypothesis is derived. h1: there is a positive correlation between population density and infection rate. previous studies have shown that social capital helps promote public health (asri, nuntaboot, and wiliyanarti, 2017; chuang et al., 2015; house et al. 1988; pitas & ehmer, 2020; ronnerstrand, 2013; pretty 2003) . besides, more and more studies at this time of corona eruption show that social capital encourages cooperation against coronavirus measures (kokubun, ino, & ishimura, 2020; yang & ren, 2020) and control infections. (bartscher et al., 2020; varshney & socher, 2020) . therefore, the following hypothesis is derived. h2: there is a negative correlation between social capital and the infection rate. small cities are more likely to form social links than large cities (putnam, 1995) . according to one theory, the basic services provided by the government in large cities are not provided in small cities with a low population density, which means that the unity and turnaround of residents to maintain alternative services will be required (browne, 2001) . in support, several studies have found a negative effect of population density on social interaction (brueckner & largey, 2008; dempsey et al., 2011) . therefore, many studies have shown that densely populated and large cities have lower social capital (andrews, 2009; eriksson & rataj, 2019; rupasingha et al., 2006; veenstra, 2002) . therefore, the following hypothesis is derived. h3: there is a negative correlation between population density and social capital. furthermore, we would like to examine whether social capital correlates with the infection rate even if population density is included as a variable. the result of one empirical study recently conducted in japan shows that the higher the population density, the greater the impact of trust with the surrounding people on health (sato et al., 2018) . this suggests that population density alone is not enough to predict people's health and that social capital acts as an intermediary between population density and health. further, given that population density is not a variable that captures all social distances, and that social capital is involved in the prevention of various types of epidemics, as shown above, population density and social capital are thought to affect the infection rate complementing each other. therefore, the following hypothesis will be established. h4: social capital partially mediates the relationship between population density and infection rates. the population density used in this paper is merely an indicator of one aspect of social distance, in which the population is concentrated in a certain area. even in densely populated areas, it is not impossible for people's efforts to reduce contact with each other. for example, a us study using mobile gps location data showed that the normative element of social capital correlated with social distance measured by the length of time at home (bai, jin, & wan, 2020) . further, infection risk will depend to a large extent on each person's social capital following norms and disciplines such as remote work, hand washing, and disinfection. therefore, the following hypothesis is derived. h5: social capital fully mediates the relationship between population density and infection rates (social capital has a greater correlation with infection rate than population density). for the coronavirus infection rate, the cumulative number of infected people per 1 million population by july 3, 2020, calculated by sapporo medical university (2020), was used. for the population density, the "population density per 1 km 2 of habitable area" for 2018 recorded in the statistics bureau (2020) was used. both the infection rate and population density were log-transformed and used for the analysis. for social capital, we used the "social capital comprehensive index" recorded in the cabinet office (2003). this index is calculated from the response of 3,878 people to a questionnaire survey consisting of 10 questions about "friendship/interaction", "trust" and "social participation", combining the figures in other two comprehensive statistics about "volunteer activity participation rate" and "community donation amount per person". it is standardized by the formula "(prefecture value-average value)/standard deviation". this index is used because it is one of the most comprehensive measures of social capital in japan, and it consists of both subjective information (questionnaire survey) and objective information (external source), increasing objectivity and reducing the common method bias. also, as a strength not found on other similar scales, empirical studies have shown that this index correlates with lower unemployment and crime rates, higher fertility rates, higher life expectancy, and higher new start-up rates (cabinet office, 2003) . also, the average age for 2015 was obtained from the statistics bureau (2017) for use as a control variable. "communications and exchanges", "trust", "social participation", "volunteer activity rate", and "community solicitation amount per capita". furthermore, the results of the path analysis shown in fig. 4 indicate that the correlation between social capital and infection rate remains even when population density is controlled, that is, social capital partially mediates the relationship between population density and infection rate. this supports h4. furthermore, figure 5 shows the results of a model including age as a control. here, population density makes the path of infection rates insignificant, indicating that social capital mediates the relationship between population density and infection rates completely. this indicates that social capital influences the infection rate more than population density, and it can be said to support h5. the results in this paper show that the negative correlation between social capital and infection rates is still statistically significant in controlling population density. it can be said that social capital partially mediates the relationship between population density and infection rates. to put it another way, securing social distance is not enough to prevent infection, and it is essential to foster social capital based on solidarity, trust, and adherence to norms. also, age-controlled models show that social capital influences infection rates more than population density. as shown in figures 1-2 , hokkaido is a good example of this. low population density should lead to low infection rates but shows high infection rates due to low social capital. this can be said to be the result of supporting the argument by kitayama et al. (2006) , which states that the culture of the pioneering spirit inherited in hokkaido is based on individualism and empirical research by yamawaki (2012) (portes, 1998) . furthermore, it has often been pointed out that such exclusivity hinders the internationalization of japanese organizations (keeley, 2001) especially in acquiring and motivating high-class or diverse human resources (kokubun, 2018; kokubun and yasui, 2020) . everything has its pros and cons. it may also be said that the reason why the prevention of epidemics in japan, especially in local cities, looks more successful than some other countries so far is that the good aspects of the japanese as an inakamono (rural person) works. cultivating a spirit that is open to others while at the same time strengthening unity is the right way to manage crises in a global society. the national, local governments, schools, and workplaces must work in tandem to achieve this goal. in this paper, we have shown by cross-section analysis using prefecture-level data in japan that social capital plays an important role in addition to the social distance in preventing infection in this coronal epidemic. this finding can be utilized not only for the measures for the second wave of coronavirus expected shortly but also for the preventive measures for various infectious disease viruses in the future. in this paper, we used population density as a proxy variable for social distance, following hirata et al. (2020) . however, in the real world, a kind of social distance that cannot be supplemented by population density is practiced, such as avoiding congestion due to staggered hours. further, the magnitude of these efforts has been shown in previous studies to be influenced by social capital. therefore, the difference in the definition of social distance does not seem to significantly change the main conclusion of this paper. rather, the larger limit would be the small size of the sample. if the infection rate, social capital, and social distance data with smaller units can be obtained from local governments, it is considered significant to verify the reproducibility of the results in this paper in future research. the threat of the new coronavirus (covid-19) is increasing. regarding the difference in the infection rate observed in each region, in addition to studies seeking the cause due to differences in the social distance (population density), there is an increasing trend toward 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obligation, public leadership, and collective action for epidemic prevention and control: evidence from the corona virus disease 2019 (covid-19) emergency key: cord-252870-52fjx7s4 authors: xie, kefan; liang, benbu; dulebenets, maxim a.; mei, yanlan title: the impact of risk perception on social distancing during the covid-19 pandemic in china date: 2020-08-27 journal: int j environ res public health doi: 10.3390/ijerph17176256 sha: doc_id: 252870 cord_uid: 52fjx7s4 social distancing is one of the most recommended policies worldwide to reduce diffusion risk during the covid-19 pandemic. based on a risk management perspective, this study explores the mechanism of the risk perception effect on social distancing in order to improve individual physical distancing behavior. the data for this study were collected from 317 chinese residents in may 2020 using an internet-based survey. a structural equation model (sem) and hierarchical linear regression (hlr) analyses were conducted to examine all the considered research hypotheses. the results show that risk perception significantly affects perceived understanding and social distancing behaviors in a positive way. perceived understanding has a significant positive correlation with social distancing behaviors and plays a mediating role in the relationship between risk perception and social distancing behaviors. furthermore, safety climate positively predicts social distancing behaviors but lessens the positive correlation between risk perception and social distancing. hence, these findings suggest effective management guidelines for successful implementation of the social distancing policies during the covid-19 pandemic by emphasizing the critical role of risk perception, perceived understanding, and safety climate. as the number of global coronavirus cases explodes rapidly, threatening millions of lives, the covid-19 pandemic has become the fastest spreading, most extensive, and most challenging public health emergency worldwide since world war ii [1] . compared to seasonal influenza, this coronavirus appears to be more contagious and transmits much faster. for example, the basic reproduction rate r 0 for seasonal influenza is approximately 1.28, while for covid-19, this value comprises 3.3 on average [2] [3] [4] . with no efficacious treatments and vaccines available yet, social distancing measures are still one of the common approaches to reduce the rate of infection. moreover, for the foreseeable multiple waves of the pandemic, covid-19 prevention will continue to rely on physical distancing behaviors until safe vaccines or effective pharmacological interventions become accessible. accordingly, social distancing has been implemented by authorities across the globe to prevent diffusion of the disease. facing this global pandemic, even each government has issued advice about mobility restriction, the definition of social distancing, and distancing rules. however, the guidance documents differ social distancing has received increasing attention in numerous studies over recent decades, especially since the covid-19 outbreaks. in order to explore critical points and network patterns of these prior research studies, a co-word analysis was conducted. the literature keywords present the relationship between the study subjects and a concentration of the research content [18] . hence, the application of a co-word analysis on the existing literature can provide generic knowledge and network patterns in the studies on social distancing. an integrated search was conducted given the topic of social distancing, such as "physical distancing", "social isolation", "lockdown", etc. subsequently, 978 related papers published from 1 january 2000 through 28 june 2020 were retrieved using the web of science core database. then, using citespace software, which is designed as a tool for progressive knowledge domain visualization [19] , the co-occurrence matrix of keywords was calculated and visualized, as shown in figure 1 . the size of the keywords presents the frequency of co-occurrence and the connection shows the significance of co-occurrence [20] . based on the co-word analysis, the major research focus and inner bibliometric characteristics of social distancing were concluded from four perspectives, such as how social distancing affects the pandemic, the additional effects and challenges caused by social distancing, modeling and simulation of social distancing, and influencing factors. most of the previous studies [21] confirmed that social distancing has positive effects on the pandemic slowdown while several studies [22] seem not to confirm this. some studies believe that social distancing cuts off the transmission path of the virus, thereby reducing r 0 [23] . moreover, different mathematical models and simulations have displayed a good correlation with the data showed in biomedical studies, which offered a high level of evidence for the impact of social distancing measures to contain the pandemic [24, 25] . for example, based on simple stochastic simulations, cano et al. [26] evaluated the efficiency of social distancing measures to tackle the covid-19 pandemic. okuonghae and omame [27] found if at least 55% of the population would implement social distancing measures, the pandemic will eventually disappear according to the numerical simulations of the model. nevertheless, a systematic review and meta-analysis demonstrated that the social distancing regulation showed a non-significant protective effect, which can be caused by the persisting knowledge gaps in disparate population groups [22] . although various cohort studies and modeling simulations have found that the social distance regulations can effectively prevent the spread of the pandemic, the additional effects and challenges caused by social distancing cannot be ignored. for instance, anxiety associated with social distancing may have a long-term effect on mental health [28] and social inequality. furthermore, loneliness pandemics are arising from physical isolation as well [29] . as a form of reduced movement and face-to-face connections between people, social distancing has changed residents' conventional health behaviors, which may lead to increasing obesity, accidental pregnancies, and other health risks [30, 31] . a national survey carried out in italy demonstrated that individual needs shifted towards the three bottom levels of the maslow's pyramid (i.e., belongingness and love needs, safety needs, and physiological needs) due to the social isolation [32] . compared with the impact of social distancing, more previous studies focused on its influencing factors. first, at the national and cultural dimension levels, akim and ayivodji [33] concluded that certain economic and fiscal interventions were associated with higher compliance with social distancing. huynh [5] found that countries with higher "uncertainty avoidance index" indicate a lower proportion of public gatherings. likewise and moon [34] explored the role of cultural orientations and showed that vertical collectivism predicted stronger compliance with social distancing norms. then, at the level of public society, aldarhami et al. [35] conducted a survey indicating that the high level of public awareness affects social distancing implementation. besides, public health authorities and experts alike pointed out that mass media and information played an important role in developing public awareness and constructing social distancing behaviors among social populations [36] . lastly, from the perspective of individual behaviors and psychological factors, oconnell et al. [1] reported that more antisocial individuals may pose a health risk to the public and engage in fewer social distancing regulations. based on a cross-sectional online survey, yanti et al. [37] identified that the respondents who had sufficient knowledge and a good attitude would positively comply with safety behaviors, such as keeping a physical distance from others and wearing face masks in public places. although the evidence unambiguously supported that implementing the social distancing regulations has a crucial effect on restraining the pandemic [38] , recent studies found that mobility restrictions do not lead to an expected reduction of coronavirus cases [8, 39] . previous literature has conducted various analyses regarding the different factors motivating social distancing behaviors. however, facing the current enormous gap between the method and the existing practice, limited research has paid attention to the key factors from the perspective of risk management. because of the significant role that individuals and public awareness play in compliance with social distancing, this study focuses on the mechanism of the risk perception effect on social distancing. individual's perceived understanding and safety climate are also examined to identify their effectiveness in the relationship between risk perception and social distancing. based on a quantitative online survey with a sample size of 317 participants from china over the period of may 2020, we built the structural equation model (sem) and conducted hierarchical linear regression (hlr) analysis to examine how the selected moderators influence social distancing behavior. the remainder of the paper is organized as follows. section 2 will review the risk perception theories and develop several hypotheses with the conceptual framework. section 3 describes the research methodology, data collection, and measurement of latent variables. then, we analyze the data and examine hypotheses (section 4) and finally, discuss the implications and limitations of our findings (section 5) as well as draw the main conclusions (section 6). risk exists objectively, but distinct people will take different behavioral decisions when they perceive risk differently [40] . hence, even many medical experts stressed the importance of maintaining physical distancing amid the covid-19 pandemic and people's risk perception still colors beliefs about facts. the concept of risk perception differs among different disciplines [41] . in this study, risk perception in the context of the pandemic is defined as the psychological processes of subjective assessment of the probability of being infected by the coronavirus, an individual's perceived health risk, and available protective measures [42, 43] . compared to the concept of risk perception in other fields, the health risk perception and the severity caused by the consequences of subsequent behavioral decisions are the most prominent features. empirical evidence has indicated that health risk perception may significantly affect people's self-protective behaviors and increase negative consequences of health risks [44] . dionne et al. [45] found that risk perception associated with medical activities was a critical predictor of the epidemic prevention behaviors. accordingly, as reported, underestimation of the pandemic knowledge and health risks could lead to decreasing implementation of social distancing. most previous research focused on identifying influencing factors for people's health risk perception as risk perception largely determines whether individuals would take protective measures during the pandemic. also, there are various factors that reduce the substantial deviation between the actual objective risk and subjective feelings. perceived understanding is just one of the crucial factors that refers to situational awareness for the adoption of healthcare protections when facing the pandemic [46] . according to the theory of planned behavior, only when people realize that they are in a health risk or even death risk will they have the situational awareness to take further healthcare protections. effective and timely perceived understanding will greatly promote people to translate risk perception into actual actions [47] . perceived understanding plays a vital role in the adoption of healthcare behaviors. therefore, the following four hypotheses were developed, considering the findings from previous studies. perceived understanding about the covid-19 pandemic plays a mediating role between risk perception and social distancing behavior. facing huge economic pressure and public opinion, many companies and organizations gradually re-opened. at the same time, these institutions require their employees to implement the social distancing policies strictly. similarly, when people go out to eat, shop, and entertain, many public places remind people to maintain a physical distance. regardless of whether it is a social organization or a public place, this kind of a reminder message released through information media has virtually created a safe climate to require people to take necessary measures and reduce the spread of the virus. generally, the safety climate refers to individuals' perception of safety regulations, procedures, and behaviors in the workplace [48] . from the perspective of pandemic prevention and control, the safety climate relates to a consensus created by the work environment which will promote people consciously or unconsciously to take the appropriate safety measures. namely, safety climate reflects common awareness among employees on the importance of organizational safety issues [49] . numerous observations and studies attest to the relationship between safety climate and protective behavior. bosak et al. [50] found that a good safety climate was negatively related to people's risk behaviors. moreover, another study showed that safety climate completely mediated the effect of risk perception on safety management [49] . however, few studies focused on the influence of safety climate on people's self-protection behavior during the pandemic. taking protective measures, such as social distancing, wearing face masks, and other self-prevention behaviors, are instrumental to avoid the spread of the infection. an organization with a good safety climate can carry out relevant safety training and drills, so as to suppress the potential risk tendency and promote their employees' safety behaviors. therefore, if the working environment can strengthen the education and publicity of pandemic knowledge, people are more willing to take correct protective measures, such as maintaining a social distance. additionally, koetke et al. [51] also pointed out that safety climate (trust in science) played a moderating role in the relationship between conservative and social distancing intentions. to conclude, based on the above literature reviews, the conceptual framework of this study is illustrated in figure 2 . our last two hypotheses read as follows: according to the 44th china statistical report on internet development, which was announced by the china internet network information center (cnnic), in 2019, there were 854 million internet users in china. several studies exploring some physical or psychological influencing mechanisms, such as risk perception, showed no significant difference between internet users and non-users [52] . therefore, online questionnaires were randomly collected from internet users through wenjuan.com. a total of 317 completed responses were received with an effective rate of 94.63%, after excluding suspected unreal answers completed in less than 60 s. additionally, participants were first directed to review and provide their consent using an online informed consent form, which was pre-approved by a panel of experts and the institutional review board, before answering the survey questionnaire. the data collection was anonymously conducted throughout may 2020. the female participants constituted 48.3% of the sample, while 51.7% of the sample were male participants. among the respondents, most of them were young people, 31.9% belonged to the age group of 18-24 years, while 40.7% belonged to the age group of 25-39 years. a total of 84.5% of the participants had a college degree or above and only 6% had a lower level education than high school. out of the total sample, 48.6% reported to be living in rural areas and 51.4% lived in urban communities. it should be noticed that there were 15.14% of the participants living in hubei province, which used to be the epicenter of the covid-19 pandemic in china. the initial questionnaire contained 22 questions to measure these 4 latent variables, including risk perception-rp (7 items), perceived understanding-pu (4 items), social distancing-sd (5 items), and safety climate-sc (6 items). all the measurement items were prepared based on the review of related literature and methods (table 2) . for example, initial items for rp were generated following previous questionnaires conducted by dionne et al. [45] and kim et al. [53] . measurement items of pu were compiled based on the infectious disease-specific health literacy scale [54] and the study by qazi et al. [46] . the sc instrument statements were taken from the literature review and previously completed research [51, 55, 56] . based on the studies of swami et al. [57] and gudi et al. [58] , initial measurement questions of sd were developed. additionally, to ensure the validity of the draft questionnaire, the original survey instrument statements were revised based on the suggestions from a panel of experts, including 5 professionals of risk management, 5 public health specialists, and 5 community managers. then, necessary modifications were made by simplifying, rewording, and replacing several items after 15 experts reviewed the survey structure, wording, and item allocation. according to the expert panel's feedback, the item-level content validity index (i-cvi) of the 18 items were all greater than 0.78 and the scale-level cvi (s-cvi) is 0.97 (>0.90), indicating an excellent validity of this scale (see supplementary materials ). an initial survey with 22 items was first pilot tested among a randomly selected sample of 100 internet users. after conducting cognitive interviews with the pilot sample participants and analyzing the reliability and correlations, 4 measurement items (rp5, rp6, rp7, and sd5) with a item-to-total correlation below 0.5 were removed. finally, a formal questionnaire containing 18 items was developed. the response scale for all the survey items was a 5-point likert scale with categories ranging from 1 = "strongly disagree" to 5 = "strongly agree". all of the items were phrased positively, so that a higher score represented stronger agreement. table 2 displays an overview of the scale and questionnaire items. avoid contact with individuals who have influenza. avoid traveling within or between cities/local regions. avoid using public transport due to covid-19. avoid going to crowded places due to covid-19. * safety climate the government is concerned about the health of people. koetke et al. [51] ; neal et al. [55] ; wu et al. [56] sc2 i trust the covid-19 information provided by the government. there is a clearly stated set of goals or objectives for covid-19 prevention. people consciously follow the pandemic prevention regulations. being able to provide necessary personal protective equipment for workers during the pandemic. offering to workers as much safety instruction and training as needed during the pandemic. note: * items removed from the initial questionnaire. descriptive statistics and correlation analyses of the latent variables were first examined. then, the exploratory factor analysis (efa) and the confirmatory factor analysis (cfa) were conducted to verify the unidimensionality and reliability of the measurement items. the sem can be applied to control for measurement errors as well as to use parameters to identify interdependencies [2, 50] . hence, this approach is appropriate to test the hypotheses by conducting the path analyses. in addition, to examine the moderating effect, hlr was carried out to verify hypotheses h5 and h6. amos version 24.0 software was applied for cfa and sem (hypotheses h1-h4) . the remaining analyses, e.g., efa and hlr (hypotheses h5 and h6) , were done using spss 22.0. (ibm, armonk, ny, usa) the means, standard deviations (s.d.), and inter-correlations of all the measures are contained in table 3 . there are significant positive correlations between the four variables. rp has significant positive correlations with sd and pu, suggesting a partial support for hypotheses h1 and h2, respectively. moreover, both pu and sc showed a significant positive correlation with sd, indicating that hypotheses h3 and h5 were partially supported as well. reliability can be formally defined as the proportion of observed score variance, which is attributable to the true score variance. there exist several approaches to evaluate the reliability of a measuring item and internal consistency is the most widely used method in research with a cross-sectional design. the cronbach's alpha (î±) can be used to estimate the internal consistency [59] . a standard value for cronbach's alpha is 0.70 or above, which indicates strong internal consistency of adopted scales [60] . table 4 indicates that all four latent variables have good reliability (cronbach's î± > 0.7), suggesting that the measurement items are appropriate indicators of their respective constructs. the validity analysis is used to examine the accuracy of the measurement instrument, namely the validity of the scale. the validity analysis mainly includes the content validity and the construct validity, of which the content validity has been supported by the expert panel's recommendations and pre-tests, while the construct validity requires a combination of efa and cfa. first, the kaiser-meyer-olkin (kmo) test value was 0.888. in addition, the result of the bartlett test (ï� 2 = 3135.94, df = 153, p < 0.001) was large and significant. hence, the data shown in table 4 were suitable for cfa. then, the measurement items identified four factors that exactly correspond to four latent variables. these four factors explained 66.41% of the total variance. similarly, the cfa results confirmed the four-factor model. in this study, the goodness-of-fit statistics were found to be x 2/ df = 2. (1) and (2): where î» i and ï� 2 e i represent the regression weight (factor loading) and measure variance estimate of the measurement item i, respectively, and k is the number of measurement items. cr and ave are other effective measures to evaluate the construct validity. correspondingly, according to jobson [61] , the acceptable value of cr is 0.7 and above, while ave should be 0.5 and above. table 4 demonstrates that most of the values of cr and ave met the standards, suggesting an acceptable goodness-of-fit for the further sem analysis. based on the conceptual framework, the sem analysis was conducted to explore the relationship between rp, sd, and pu (as the mediator). the hypothesized model shown in figure 3 was first examined. table 5 summarizes the fit indices of the model, which indicates an excellent goodness-of-fit for the data based on the majority of indices. in this model, several path analyses were developed to test hypotheses h1, h2, and h3. as shown in table 6 , rp has significant positive relationships with pu (î² = 0.296, c.r. = 4.435, p < 0.001) and sd (î² = 0.238, c.r. = 4.421, p < 0.001). likewise, pu plays a significant positive role on sd (î² = 0.581, c.r. = 8.426, p < 0.001) as well. thus, it implies that hypotheses h1, h2, and h3 are supported. bias-corrected (bc) and percentile (pc) bootstrapping approaches were carried out to verify the mediating effect of pu. previous studies have found that bootstrapping was a proper method that can provide a robust test of mediating hypotheses [62] . accordingly, the significant effect of risk perception on social distancing could be assessed through perceived understanding by using the bootstrapping of 5000 sub-samples. as can be seen from table 7 , the values of the lower and upper limits (95% bc and pc bootstrap confidence intervals) for the indirect effect (î² = 0.100) were all greater than zero. moreover, the value of z (indirect effect/standard error) equals 2.5 (>1.96). subsequently, similar to an indirect effect, it was found that there were no zero values between the lower and upper limits (95% bc and pc bootstrap confidence intervals) for the direct effect (î² = 0.138, z = 3.45). therefore, perceived understanding partially mediates the positive effects of risk perception on social distancing. in other words, perceived understanding did not completely offset the effect of risk perception, which partially explains the social distancing. in summary, these results confirmed hypothesis h4. hypothesis h6 predicted that safety climate positively moderates the impact of risk perception on social distancing. to test the moderation effects, the hlr analysis was conducted. model 1 serves as a baseline with independent variables rp and sc. then, model 2 incorporated additional variables rpã�sc. table 8 presents the significant interaction effects of the two-way interaction effect between rp and sc on sd (model 2, rpã�sc, î² = â��0.242, p < 0.001). as shown in table 8 , while risk perception is positively associated with social distancing regardless of the value of safety climate, the safety climate further reduces the positive effect. thus, hypothesis h6 is partially supported. additionally, whether sc is in model 1 (î² = 0.566, p < 0.001) or model 2 (î² = 0.4689, p < 0.001), it presents a statistically significant positive relationship with sd, which further supports hypothesis h5. note: *** p < 0.001. vif represents variance inflation factor (vif = 1/tolerance), vif < 5 (acceptable). this study has continued to demonstrate that social distancing behaviors play a critical role in preventing the diffusion of the covid-19 pandemic. in identifying influencing factors that lead to social distancing, previous studies have highlighted risk perception as a leading indicator of protective behaviors [42, 44, 45] . people should be encouraged to promote risk perception in order to identify and rectify infection risks and health issues related to unprotected behaviors during the covid-19 pandemic. however, limited research has examined whether different risk perception of individuals affects their interpretation of the social distancing regulations in an equivalent manner. by investigating the measurement scales of risk perception, perceived understanding, safety climate, and social distancing across populations of internet users in china, this study addressed the mechanism of the risk perception effect on social distancing to improve individuals' physical distancing behaviors. this study provided evidence that risk perception and perceived understanding can significantly affect people's social distancing behaviors during the covid-19 pandemic. the results of the path analysis supported hypotheses h1, h2, and h3. it is evident from figure 3 , tables 5 and 6 that the path coefficients are significant and the overall hypothesized model has a good fit for the investigation. these findings are in line with aldarhami et al. [35] , zhong et al. [63] , and machida et al. [64] . a key principle of social distancing behavior is that risk perception is a critical condition for protective action. the results support the finding that higher risk perception motivates people to comply with social distancing. only by enhancing risk perception can people truly remain vigilant against the pandemic and take protective measures. therefore, when the government implements social distancing and other prevention measures, it must take into account the public risk perception and improve public environmental awareness through various means, such as social media, press conferences, standard therapy, and guidelines for the outbreak response. in particular, it is necessary to rectify pandemic rumors to prevent incorrect information that can potentially reduce public risk perception. besides, we confirmed a dual effect of perceived understanding on social distancing. first, perceived understanding was found to predict social distancing directly. these results are consistent with other studies [1, 46] which have shown that increased perceived understanding can encourage people to gain more knowledge about the pandemic and health risks, so that they would engage more in the social distancing regulations. then, we identified that perceived understanding as a factor showed an incomplete mediating effect on the relationship between risk perception and social distancing. previous literature regarding perceived understanding shows that it affects the social distancing behaviors related to the sources of information [46] . on the other hand, our results confirm an indirect positive effect of risk perception on social distancing through perceived understanding. hence, with the help of the authority of medical experts, we should promptly popularize scientific knowledge of the pandemic and prevention measures among communities to enhance public perceived understanding. in addition, the increase in risk perception can promote public desire to understand the pandemic and pay more attention to their own health risks. the authorities should improve pandemic information release channels. moreover, we identified that a positive perception of safety climate (î² = 0.566, p < 0.001) would promote adherence to social distancing and that this effect would be stronger than the risk perception (î² = 0.165, p < 0.001). this finding concurs with the study conducted by kouabenan et al. [49] . the achievement of a consensus on a safe climate requires the joint efforts of the organization and society. first, workplaces such as shops, cafeterias, office spaces, and public transit systems have to strengthen pandemic prevention and control drills. then, it is necessary to support community propaganda and scientific knowledge popularization and gather the individual consensus on self-protective behaviors. it is also strongly recommended to wear a face mask, keep a 2 m physical distance between workers, and use sanitary measures in public venues. finally, we demonstrated that safety climate, risk perception, and social distancing are the interacting factors, supporting our hypothesis that a moderating effect of safety climate on the relationship between risk perception and social distancing exists, as found in kouabenan et al. [49] , bosak et al. [50] , and koetke et al. [51] (see hypothesis h6). however, we did not find that safety climate increased the degree to which the risk perception positively affects social distancing. as shown in figure 4 , risk perception was positively related to social distancing under the conditions of a high safety climate as well as under the conditions of a low safety climate. more importantly, we found that safety climate is a factor that lessens the positive correlation between risk perception and social distancing. this moderating effect improves our understanding of the contexts in which risk perception affects social distancing. yet, as described by kouabenan et al. [49] , the safety climate was viewed as the key factor because it completely mediated the effect of perceived risk on safety behavior. one potential explanation for this difference of findings is the complex content of safety climate measurement items, because it actually includes three clauses. compared to the previous studies, we regarded the safety climate as the whole of social consciousness. the overall promotion of social protection awareness will replace the role of risk perception and may lead to compliance with social distancing through the public herd effect. therefore, while focusing on the importance of risk perception, we cannot ignore the positive incentives for social distancing brought by a good safety climate. in addition to enhancing employees' consensus on pandemic prevention, qualified organizations can physically isolate workspaces and public venues in time and space. for example, people should avoid going out for mass gatherings (lunches, shopping, traveling, education, leisure, etc.). then, for management commitment, they should physically divide the restaurant space, office space, and other public areas to ensure that people have sufficient isolation distance. flexible work scheduling, online office hours, and e-learning are encouraged for implementation. conclusively, application of innovating social distance management technologies (e.g., technologies that are based on an emerging range of ict technologies [65] like bluetooth, radio frequency identification, cloud mobile, and others) can assist with achieving an accurate measurement of the physical distance between individuals and momentarily reminding people to maintain a social distance as needed. in public venues, such as dining areas, using multimedia, posters, and ground stickers with social distancing reminders can create a good safety climate. although substantial efforts were put into this study to ensure the reliability and validity of the results, a few limitations still exist, which might be explored in further research. first, our sample does consist of chinese internet users but may not have all the attributes that perfectly match the characteristics of the current chinese population. without collecting data from other regions and having a representative sample, the generalizability of our findings is limited to a certain extent. a cross-regional, more representative study with a bigger sample size could be used in future studies in order to improve accuracy and generalizability of the results. second, we measured all the latent variables with a simple one-dimensional factor by using a cross-sectional design. the results could neither exclude the possibility of reverse causation nor prove the exact cause-and-effect relationships from a cross-sectional survey design. hence, further study could be extended by collecting longitudinal data through multiple rounds of experiments. furthermore, several previous studies measured risk perception from a multi-dimensional perspective. therefore, it would be meaningful to present risk perception as a multi-dimension construct, developing a multi-item scale to promote reliability and validity. moreover, this study takes into consideration risk perception that creates social distancing for the adoption of risk management. some other factors, like knowledge and beliefs of the covid-19 pandemic, mask-wearing, self-awareness in prevention of covid-19, number of confirmed covid-19 cases in a given region, death rate in a given region, and percentage of elderly population in a given region, can also be included in further research. finally, we considered the mediating and moderating effects of perceived understanding and safety climate. as contingent factors, these effects may interact with other factors, shifting the results conducted in the present study. besides, several control variables that are associated with population demographics, such as gender, age, and education level, did not show a significant impact on the relationships among these latent variables. this subject, however, is worth exploring in further research. this study investigated the impact of risk perception on social distancing during the covid-19 pandemic. based on the data collected from an online survey among 317 participants in china throughout may 2020, our analyses indicate that positive changes in social distancing behaviors are associated with increased risk perception, perceived understanding, and safety climate. the individual's perceived understanding partly plays a positive mediating role in the relationship between risk perception and social distancing behaviors. furthermore, the safety climate plays a negative role in the relationship between risk perception and social distancing because the safety climate seems to mitigate the effects of risk perception on social distance. hence, effective health promotion strategies directed at developing or increasing positive risk perception, 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korea study on the development of an infectious disease-specific health literacy scale in the chinese population the impact of organizational climate on safety climate and individual behavior core dimensions of the construction safety climate for a standardized safety-climate measurement analytic thinking, rejection of coronavirus (covid-19) conspiracy theories, and compliance with mandated social-distancing: direct and indirect relationships in a nationally representative sample of adults in the united kingdom knowledge and beliefs towards universal safety precautions during the coronavirus disease (covid-19) pandemic among the indian public: a web-based cross-sectional survey coefficient alpha and the internal structure of tests introduction to psychometric theory applied multivariate data analysis: volume ii categorical and multivariate methods testing mediation and suppression effects of latent variables: bootstrapping with structural equation models knowledge, attitudes, and practices towards covid-19 among chinese residents during the rapid rise period of the covid-19 outbreak: a quick online cross-sectional survey adoption of personal protective measures by ordinary citizens during the covid-19 outbreak in japan social distancing 2.0 with privacy-preserving contact tracing to avoid a second wave of covid-19 the authors declare no conflict of interest. key: cord-282966-ew8lwmsn authors: haddow, george d.; haddow, kim s. title: communicating during a public health crisis date: 2014-07-22 journal: disaster communications in a changing media world doi: 10.1016/b978-0-12-407868-0.00011-2 sha: doc_id: 282966 cord_uid: ew8lwmsn “communicating during a public health crisis,” examines how communicating to the public and media during a public health or safety emergency is different. in a serious crisis, all affected people take in information differently, process information differently and act on information differently. this chapter incorporates the centers for disease control and prevention’s (cdc) best advice for communicating during a public health crisis, including infectious disease outbreaks, bioterrorism, chemical emergencies, natural disasters, nuclear accidents and radiation releases and explosions. this chapter also explores the growing role of social media that is now being used for a variety of traditional and new purposes from distress calls to disease surveillance. social media is now a part of the public health communications toolbox. from the cdc down to local departments of health, public health, and safety officials are using social media to push out vital and useful information to the public and to monitor and respond to public comments. but social media is also being used for a broader range of public health purposes-from collecting data to track the spread of diseases to sending calls for help-and the public health system is still figuring out how to adapt. "the use of social media has proven a valuable asset for adaptation and improvisation related to the public health and medical consequences of disasters. these tools are especially valuable for saving lives during a disaster's impact phase and especially during its immediate aftermath, when traditional disaster management capabilities are not available…. the need remains for fusion of social media into existing institutional programs for crisis informatics and disaster-risk management" (keim and noji, 2011) . the center for disease control and prevention is actively using social media, but social media use by public health agencies is still considered to be in the "early adoption stage" (thackeray et al., 2012) . even though the majority of state health departments (60%) report using at least one social media application, they are "using social media as a channel to distribute information rather than capitalizing on the interactivity available to create conversations and engage with the audience" (thackeray et al., 2012) . according to a 2012 report on the use of social media by state health departments, 86.7 percent of the state health departments reported they had a twitter account, 56 percent a facebook account, and 43 percent a youtube channel; but, "on average, state health departments made one post per day on social media sites, and this was primarily to distribute information; there was very little interaction with audiences. shds have few followers or friends on their social media sites. the most common topics for posts and tweets related to staying healthy and diseases and conditions" (thackeray et al., 2012) . the report recommends, "because social media use is becoming so pervasive, it seems prudent for state health departments to strategically consider how to use it to their advantage. to maximize social media's potential, public health agencies should communicating during a public health crisis chapter eleven develop a plan for incorporating it within their overall communication strategy. the agency must identify what audience they are trying to reach, how that audience uses social media, what goals and objectives are most appropriate, and which social media applications fit best with the identified goals and objectives" (thackeray et al., 2012) . there are examples of health departments and associations using social media to augment their communications efforts: • in shelby county, tennessee, the health department is using twitter to increase its media coverage. they tweet out their press releases which are retweeted by reporters-expanding the department's public reach. • in philadelphia, the department of hiv planning uses twitter to increase participation in their community workshops. they tweet out the meeting's content to people in the large nine-county area they serve and use twitter to "extend the conversation beyond the room." • the american public health association (@publichealth) took advantage of the 2013 super bowl to promote related health messages using the #superbowl hashtag. they tweeted about healthy snacks, drinking and driving, and flu vaccination. when the half-hour blackout hit, they took advantage of the unexpected opportunity with the tweet in figure 11 .1, which was widely retweeted. at the 2013 annual meeting for the national association of county and city heath officials (naccho), additional examples of health departments' use of social media were highlighted (new public health, 2013): • the kansas city health department uses twitter and facebook to push information on extreme heat safety during the summertime. the messages and reports of suspected or confirmed heat-related deaths resulted in coverage of health department activities and partnerships on national news channels including the weather channel and cnn. the boston health commission used social media to promote its youth media campaign on sugary beverages. the campaign received close to 30,000 views, and close to 23,000 clicks on their facebook ads. • in contra costa, california, a recent campaign included a podcast by the public health director that was promoted on twitter and facebook. parts of the podcast were picked up by local radio which allowed the public health department to most accurately get their message across. the cdc, which has been a pioneer in the integration of social media tools into public health communications, including their multichannel "zombie"-themed emergency preparedness public education campaign (cdc, 2012) , has developed and is distributing a social media toolkit for health communicators. the cdc's "socialmediaworks" toolkit was designed to help "health communicators integrate social media strategies and technologies into their communication plans." the kit features tools to develop a better social media strategy, learn how social media tools work, plan, implement, and manage all in one place including "calendar and dashboard features that allow you to schedule and manage your social media initiative," and hosts a community forum to enable health professionals to "engage with colleagues on social media strategy, share lessons learned, and learn what works" (cdc, 2013). in a new england journal of medicine article, "integrating social media into emergency-preparedness efforts," the reason given by the three authors to the pervasiveness of social media is "it makes sense to explicitly consider the best way of leveraging these communication channels before, during, and after disasters…. engaging with and using emerging social media may well place the emergency-management community, including medical and public health professionals, in a better position to respond to disasters" (merchant et al., 2011) . specifically, they suggest: • actively using networking sites such as facebook to help individuals, communities, and agencies share emergency plans and establish emergency networks. web-based "buddy" systems, for example, might have allowed more at-risk people to receive medical attention and social services during the 1995 chicago heat wave, when hundreds of people died of heat-related illness. • linking the public with day-to-day, real-time information about how their community's health care system is functioning. for example, emergency room and clinic waiting times are already available in some areas of the country through mobile-phone applications, billboard really simple syndication (rss) feeds, or hospital tweets. monitoring this important information through the same social channels during an actual disaster may help responders verify whether facilities are overloaded and determine which ones can offer needed medical care. • using location-based service applications (such as foursquare and loopt) and global positioning system (gps) software to allow people to "check in" to a specific location and share information about their immediate surroundings. with an additional click, perhaps off-duty nurses or paramedics who check in at a venue could also broadcast their professional background and willingness to help in the event of a nearby emergency. • increasing the use of social media during recovery. the extensive reach of social networks allows people who are recovering from disasters to rapidly connect with needed resources. tweets and photographs linked to timelines and interactive maps can tell a cohesive story about a recovering community's capabilities and vulnerabilities in real-time. "organizations such as ushahidi have helped with recovery in haiti by matching volunteer health care providers with distressed areas. social media have been used in new ways to connect responders and people directly affected by such disasters as the deepwater horizon oil spill, flash floods in australia, and the earthquake in new zealand with medical and mental health services" (merchant et al., 2011) . in late 2002, there was a strange increase in emergency room visits in guangdong province in china for acute respiratory illness and a number of local news and internet reports about a respiratory disease affecting healthcare workers. several long weeks later, the government announced the cause was severe acute respiratory syndrome, or sars. according to dr. john brownstein, one of the developers of healthmap, an online platform that mines informal sources for disease outbreak monitoring, "if this data had been harvested properly and promptly, this early epidemic intelligence collected online could have helped contain what became a global pandemic" (brownstein, 2011) . "we are now in an era where epidemic intelligence flows not only through government hierarchies but also through informal channels, ranging from press reports to blogs to chat rooms to analyses of web searches. collectively, these sources provide a view of global health that is fundamentally different from that yielded by disease reporting in traditional public health infrastructures," dr. brownstein explained. "they also provide a process that dramatically reduces the time required to recognize outbreaks" (brownstein, 2011) . more recently, the explosion of online news and social media has brought a new era of disease surveillance. today, the websites healthmap.org and outbreaks near me deliver real-time intelligence on a broad range of emerging infectious diseases for a diverse audience, which includes local health departments, governments, clinicians, and international travelers. healthmap.org states they "bring together disparate data sources, including online news aggregators, eyewitness reports, expert-curated discussions and validated official reports, to achieve a unified and comprehensive view of the current global state of infectious diseases and their effect on human and animal health. through an automated process that updates 24/7/365, the system monitors, organizes, integrates, filters, visualizes and disseminates online information about emerging diseases in nine languages, early detection of global public health threats" (healthmap.org, 2013) . healthmap is part of a growing landscape of government and nongovernment organizations mining internet and social data to determine the spread of viruses and the rate of infection. some organizations are also asking the public to self-report how they are feeling, according to kim stephens, the lead blogger of idisaster 2.0, who outlines several tools being used to aggregate data to fight the flu and other diseases. google flu trends is a site that provides geographically based information about the spread of the influenza virus. their data is aggregated from the search terms people are using versus self-reporting. in fact, the graph of the tracked searches (see below) related to the flu compared to the actual reported cases of the virus is so close that they almost overlap. google explains how this works: we have found a close relationship between how many people search for flu-related topics and how many people actually have flu symptoms. of course, not every person who searches for "flu" is actually sick, but a pattern emerges when all the flu-related search queries are added together. we compared our query counts with traditional flu surveillance systems and found that many search queries tend to be popular exactly when flu season is happening. by counting how often we see these search queries, we can estimate how much flu is circulating in different countries and regions around the world. google's results have been published in the journal nature (stephens, 2013) . mappyhealth is another tool that tracks keywords related to health but instead of using data from searches in google, this system uses the twitter data stream. their stated reason for the site: "it is hypothesized that social data could be a predictor to outbreaks of disease. we track disease terms and associated qualifiers to present these social trends." although this blog post is focused on influenza, the mappyhealth site tracks 27 different categories of illness (stephens, 2013) . flunearyou is a tool that allows the public to participate in tracking the spread of flu by filling out a survey each week. the survey is quite simple and asks the respondent if they have had any symptoms during the past week and whether or not they have had the flu shot either this year or last year. respondents can include family members and the questions are asked about each person individually. this user-contributed data is then aggregated and displayed on a map with pins that are either green for no symptoms, yellow for some, and red for "at least one person with influenza-like" symptoms. the pins are clickable and display the number of users in that zipcode that have reported their condition, but no personal information whatsoever. the number of participants in the state is displayed (1294 in massachusetts) as well as locations and addresses where people can get vaccinated. links to local public health agencies are also provided. people can also sign up to receive location-based disease alerts via email. social sharing of the site and its content is encouraged by the addition of prominently placed social media buttons (stephens, 2013) . consumer-oriented applications also are being developed such as sickweather, which tracks social media posts that reference illnesses and displays trends by location. sickweather also shows illness patterns over time and allows members to report their illness directly and share information with friends through social networks (newcomer, 2013) . the department of homeland security (dhs) is also mining social media for biosurveillance. dhs is testing whether scanning social media sites to collect and analyze health-related data could help identify infectious disease outbreaks, bioterrorism or other public health and national security risks. the 1-year biosurveillance pilot involves automatically scanning social media sites, such as facebook and twitter, to collect and analyze health-related data in real-time (sternstein, 2012) . the social media data analytics technology will "watch for trends," such as whether new or unusual clusters of symptoms in various geographic regions are being reported on social networking sites. the project is the latest in a series of dhs data analysis efforts for biosurveillance. for example, dhs is already analyzing data that is collected by the cdc from public health departments nationwide. also, it is collecting and analyzing air samples in several cities for signs of bioterrorist chemicals, such as anthrax (sternstein, 2012) . news organizations are providing the public with information about the effects of the influenza virus and some are also using social media to increase public awareness. at the height of the 2013 flu season a #fluchat was sponsored by @usatodayhealth. "health based twitter chats offer the public the opportunity to post questions that are addressed by healthcare professionals or researchers. the cdc, for instance, has conducted many chats on a wide variety of topics. watching the questions that are posted in these chats offers local public health organizations an opportunity to "hear" the concerns of the public. knowing this information can help with message formulation and coordination" (stephens, 2013) . here are a few questions posted to the #fluchat: @usatodayhealth how long after the flu shot are you actually prevented from getting the flu? #fluchat-taylor yarbrough (@sellorelse) january 10, 2013 @usatodayhealth what % of americans have gotten the flu each of the last 10 years?-bob (@sgt1917) january 10, 2013 (stephens, 2013) finally, a trend that will once again change the way public health and safety agencies and organizations operate during disasters-the increased use of facebook and twitter to call for help or rescue. more and more people are turning to social media as their first choice of communications during a crisis. public polling by the red cross in 2011 and 2012 documents the public's large and growing expectation that disaster officials monitor social media sites and respond quickly to distress calls on facebook, twitter, and other platforms. according to red cross surveys: • 80 percent expect emergency responders to monitor social sites-and to respond promptly for calls for help. • 20 percent would try an online channel to get help if unable to reach emergency medical services (ems). • at least a third of the public expects help to arrive in less than an hour if they posted a request for help on a social media website-and more than three out of four (76%) expect help within 3 hours-up from 68 percent in 2011 (american red cross, 2012). clearly meeting this challenge and responding to these expectations must be a priority for the public health and safety community. communicating to the public and media during a public health or safety emergency is different in several aspects than other disaster communications. in a serious crisis, all affected people take in information differently, process information differently, and act on information differently. in recognition of those differences, the cdc has published its own, highly recommended "crises and emergency risk communications manual." highlights from the 2012 edition of the cdc manual follow below. the purpose of an official response to a public health crisis is to efficiently and effectively reduce and prevent illness, injury, and death, and return individuals and communities to normal as quickly as possible. specific hazards under cdc emergency preparedness and response include: • infectious disease outbreaks-the spread of viruses, bacteria, or other microorganisms that causes illness or death. this includes cholera, e. coli infection, pandemic flu, and other infections. • bioterrorism-the deliberate release of viruses, bacteria, or other germs (agents) used to cause illness or death, including anthrax and the plague. • chemical emergencies-the intentional or unintentional release of a chemical that could harm people's health including chlorine, mercury, nerve agents, ricin, or an oil spill. the cdc also has a role in responding to natural disasters, nuclear accidents, and radiation releases and explosions. so what is the public's response to one of these disasters? • fear, anxiety, confusion, and dread-these are emotions that need acknowledging. • hopelessness and helplessness-part of the job of a crises communicator is to help the community manage its fears and set them on a course. action helps reduce anxiety and restores a sense of control, even if it is symbolic, put up the flag, or preparatory-donate blood, or just as simple, check on an elderly neighbor. • uncertainty-people dislike uncertainty. the not-knowing can seem worse than a bad result. people can manage uncertainty if you share with them the process you are using to get answers. "i can't tell you what's causing so many people in our town to get so sick. but i can tell you what we're doing to find out…." the situation may obviously be uncertain and acting otherwise creates mistrust. • not panic-panic during a crisis is rare. contrary to what we see portrayed in the movies, we seldom act irrationally when faced with a crisis-and we seldom panic. people nearly always behave in a rational way during a crisis. in the face of the 9/11 attacks, people in lower manhattan became simultaneously resourceful and responsive. when told what to do by those in authority, people followed instructions. the panic myth is one of the most pervasive misconceptions about crises. many government leaders are concerned about causing public panic. when facing a crisis, they may mistakenly withhold information in an effort to prevent panic and protect the public-at the very time they should be sharing their concerns. conditions that are likely to create heightened anxiety and severe emotional distress are silence or conflicting messages from authorities. people are likely to be very upset when they feel: • they cannot trust what those in authority are telling them. • they have been misled or left without guidance during times of severe threat. • if authorities start hedging or hiding the bad news, they will increase the risk of creating a confused, angry, and an uncooperative public. the faster you give bad news, the better. holding back implies mistrust, guilt, or arrogance. in general, the public wants access to as much information as possible. too little information enhances the psychological stress. if information is incomplete or not present at all during a crisis, this will increase anxiety and increase a sense of powerlessness. it will also lower trust in government agencies. the cdc has found that people may receive, interpret, and act on information differently during an emergency than during a normal period. four factors that change how we process information during a crisis: 1. we simplify messages-under intense stress and possible information overload, we tend to miss the nuances or importance of health and safety messages by: • not fully hearing information, because of our inability to juggle multiple facts during a crisis. • not remembering as much of the information as we should. • confusing action messages, such as remembering which highway is blocked for safety to cope, many of us may not attempt a logical and reasoned approach to decision making. instead, we may rely on habits and long-held practices. we might also follow bad examples set by others, and engage in irrational behaviors like unfairly blaming leaders or institutions. asking people to do something that seems counterintuitive. examples include the following: • getting out of a safe car and lying in a ditch instead of outrunning a tornado. • evacuating even when the weather looks calm. changing our beliefs during a crisis or emergency may be difficult. beliefs are very strongly held and are not easily altered. see, and tend to believe what we've experienced. during crises, we want messages confirmed before taking action. you may find that you or other individuals are likely to do the following: • change television channels to see if the same warning is being repeated elsewhere. • try to call friends and family to see if others have heard the same messages. • check in on their social media networks to see what their friends and family are doing. • turn to a known and credible local leader for advice. • in cases where evacuation is recommended, we tend to watch to see if our neighbors are evacuating before we make our decision. this confirmation first-before we take action-is very common in a crisis. 4. we believe the first message-during a crisis, the speed of a response can be an important factor in reducing harm. in the absence of information, we begin to speculate and fill in the blanks. this often results in rumors. the first message to reach us may be the accepted message, even though more accurate information may follow. when new, perhaps more complete information becomes available, we compare it to the first messages we heard. therefore, messages should be simple, credible, and consistent. speed is also very important when communicating in an emergency. an effective message must: • be repeated. • come from multiple credible sources. • be specific to the emergency being experienced. • offer a positive course of action that can be executed. people should also have access to more information, through other channels, such as through websites, and old and new media. good communication can reduce stress, harmful human behavior, and prevent negative public health response outcomes. trained communicators will do the following: • reduce high levels of uncertainty. • use an effective crisis-communication plan. • be the first source for information. • express empathy and show concern. • exhibit competence and expertise. • coordinate with other response officials. • commit and remain dedicated to the response and recovery after the immediate crisis has passed. audiences receive, interpret, and evaluate messages before they take action. expect your audience to immediately judge the content of your message for speed, factual content, and trust and credibility: was the message timely without sacrificing accuracy? one of the primary dilemmas of effective crisis and emergency risk communication is to be speedy in responding but maintain accuracy even when the situation is uncertain. being first to communicate establishes your organization as the primary source of information. the public may judge how prepared your organization was for the emergency based on how fast you responded. speedy responses suggest that there is a system in place and that appropriate actions are being taken. remember that if agencies are not communicating, audiences will turn to other, less credible sources. first impressions are lasting impressions, and it's important to be accurate. responding quickly with the wrong information or poorly developed messages damages credibility. this does not necessarily mean having all the answers; it means having an early presence so the public knows that agencies are engaged and that there is a system in place to respond. research shows there are some basic elements to establishing trust and credibility through communications, and you will notice they repeat the important elements in executing a successful crisis communication plan: empathy and caring-this needs to be expressed in the first 30 seconds. according to research, being perceived as empathetic and caring increases the chances your message will be received and acted on. acknowledge fear, pain, suffering, and uncertainty. competence and expertise-the public will be listening for factually correct information, and some people will expect to hear specific recommendations for action. therefore, you should do the following: • get the facts right. • repeat the facts often, using simple nontechnical terms. • avoid providing sketchy details in the early part of the response. • ensure that all credible sources share the same facts. speak with one voice. inconsistent messages will increase anxiety, quickly undermining expert advice and credibility. honesty and openness-this does not mean releasing information prematurely. it means being transparent-admitting when you do not have all the information, telling the public you do not, and why. the perception of risk is not about numbers alone and communicators should consider the following rules for raising the public's comfort level during a crisis. these are adapted from the environmental protection agency's seven cardinal rules of risk communication. 1. accept and involve the public as a legitimate partner-two basic tenets of risk communication in a democracy are generally understood and accepted. first, people and communities have a right to participate in decisions that affect their lives, their property, and the things they value. second, the goal should be to produce an informed public that is involved, interested, reasonable, thoughtful, solution-oriented, and collaborative. you should not try to diffuse public concerns and avoid action. guidelines: • show respect for the public by involving the community early, before important decisions are made. • clarify that decisions about risks will be based not only on the magnitude of the risk but on factors of concern to the public. 2. listen to the audience-people are often more concerned about issues such as trust, credibility, control, benefits, competence, voluntariness, fairness, empathy, caring, courtesy, and compassion. they are not as interested in mortality statistics, and the details of a quantitative risk assessment. if your audience feels or perceives that they are not being heard, they cannot be expected to listen. effective risk communication is a two-way activity. guidelines: • do not make assumptions about what people know, think, or want done about risks. • listen. monitor social media and comments on your website. make an active effort to find out what people are thinking and feeling. • involve all parties who have an interest or a stake in the issue. • identify with your audience and try to put yourself in their place. • recognize people's emotions. • let people know that you understand their concerns and are addressing them. understand that audiences often have hidden agendas, symbolic meanings, and broader social, cultural, economic, or political considerations that complicate the task. accepted, the messenger must be perceived as trustworthy and credible. so the first goal must be to establish trust and credibility. short-term judgments of trust and credibility are based largely on verbal and nonverbal communications. longterm judgments are based largely on actions and performance. once made, trust and credibility judgments are resistant to change. in communicating risk information, these are your most precious assets. once lost, they are difficult to regain. guidelines: • express willingness to follow up with answers if the question cannot be answered at the time you are speaking. • make corrections if errors are made. • disclose risk information as soon as possible, emphasizing appropriate reservations about reliability. • do not minimize or exaggerate the level of risk. • lean toward sharing more information, not less, to prevent people from thinking something significant is being hidden. • discuss data uncertainties, strengths, and weaknesses, including the ones identified by other credible sources. • identify worst-case estimates and cite ranges of risk estimates when appropriate. 4. coordinate and collaborate with other credible sources-allies can be effective in helping communicate risk information. few things make risk communication more difficult than public conflicts with other credible sources. guidelines: • coordinate all communications among and within organizations. • devote effort and resources to the slow, hard work of building bridges, partnerships, and alliances with other organizations. • use credible and authoritative intermediaries. • consult with others to determine who is best able to answer questions about risk. • try to release communications jointly with other trustworthy sources, such as: -university scientists. -physicians. -local or national opinion leaders. -citizen advisory groups. -local officials. 5. meet the needs of the media-the media are primary transmitters of risk information. they play a critical role in setting agendas and in determining outcomes. the media generally have an agenda that emphasizes the more sensational aspects of a crisis. they may be interested in political implications of a risk. the media tend to simplify stories rather than reflect the complexity. guidelines: • remain open with, and accessible to, reporters. • respect their need to "feed the beast"-to provide news for an audience that is eager for information 24/7. provide information tailored to the needs of each type of media, such as sound bites, graphics, and other visual aids for television. • agree with the reporter in advance about specific topics and stick to those during the interview. • prepare a limited number of positive key messages in advance and repeat the messages several times during the interview. • provide background material on complex risk issues. • do not speculate. the cdc has produced a series of manuals, toolkits, and trainings that are helping integrate social media into the disaster communications planning and operations of public health officials at every level and are helping speed up the adaption of these tools for saving lives. • keep interviews short and follow up on stories with praise or criticism, as warranted • establish long-term trust relationships with specific editors and reporters speak clearly and with compassion-technical language and jargon are barriers to successful communication with the public. in low-trust, high-concern situations, empathy and caring carry more weight than numbers and technical facts. guidelines: • use plain language • remain sensitive to local norms, such as speech and dress strive for brevity, but respect people's needs and offer to provide more information if needed • use graphics and other pictorial material to clarify messages • personalize risk data by using anecdotes that make technical data come alive. • acknowledge and respond to emotions that people express • promise only what can be delivered • understand and convey that any illness, injury, or death is a tragedy • avoid distant, abstract, unfeeling language about deaths, injuries, and illnesses • do not discuss money-the magnitude of the problem should be in the context of the health and safety of the people-loss of property is secondary give people things to do-in an emergency, simple tasks will: • give people a sense of control • keep people motivated to stay tuned to what is happening • prepare people to take action if and when they need to do so do no harm-the odds of a negative public response increases when poor communication practices are added to a crisis situation • public power struggles, conflicts, and confusion • perception that certain groups are getting preferential treatment more americans using mobile apps in emergencies using social media for disease surveillance. cnn global public square emergent use of social media: a new age of opportunity for disaster resilience integrating social media into emergency-preparedness efforts using social media to extend the reach of local public health departments idisaster 2.0: social media and emergency management. fighting influenza with data nextgov. dhs tries monitoring social media for signs of biological attack adoption and use of social media among public health departments key: cord-017334-u1brl2bi authors: annandale, ellen title: society, differentiation and globalisation date: 2017-07-21 journal: health, culture and society doi: 10.1007/978-3-319-60786-3_2 sha: doc_id: 17334 cord_uid: u1brl2bi first, theories of globalisation and their implications for the analysis of health issues are discussed. emphasis is on: (1) globalisation as embodied, something often overlooked by sociologists working outside of the field of health and (2) health vulnerabilities that arise from the heightened mobility and connectivities that characterise globalisation, taking migration and health as an illustration. second, differentiation is considered by highlighting disparities in health vulnerability and the capacity of social groups to protect their health. this is illustrated by reference to the securitisation of health and the health consequences of violent conflict and the special vulnerabilities of children and of women. third, the influence of interconnectedness of various national healthcare systems and implications for the delivery of effective healthcare are considered. sociology was born of modernity and the conception of 'society' as a sovereign unit of analysis. since the turn of the present century this has been subject to considerable critical analysis as it has been argued, with increasing force, that the discipline has entered a 'post-societal phase' as a consequence of globalisation, challenging as a consequence sociology's basic units of analysis, namely, the nation-state (burawoy 2005 ). urry characterises this as 'a theoretical and empirical whirlpool where most of the tentative certainties that sociology has endeavoured to erect are being washed away ' (2000: 17) . the effects are several, including the search for new theoretical frameworks and associated conceptual tools which turn from the traditional emphasis on stasis, structure and social order in favour of mobility, contingency and complexity (see e.g. castells 2010; walby 2009 walby , 2015 . concurrently, theorists have re-examined the assumptions of modernity, or what it means to be modern, that shaped the discipline. as connell (2007: 14) expands, 'sociology developed in a specific location: among men of the metropolitan liberal bourgeoisie'. the so-called founding fathers of the nineteenth century, such as durkheim, marx and weber, were concerned principally with the social changes taking place as european societies modernised, processes such as socio-economic restructuring, loss of social cohesion and new forms of social inequality. consequently, the very meaning of modernity itself was eurocentric since the social was conceived as 'an internally coherent, bounded phenomenon that could be understood without any reference to external relations such as the colonial or imperial misadventures that were being undertaken at the time' (bhambra 2007: 49) . for example, durkheim's (1964 durkheim's ( [1893 ) analysis of the division of labour in society, especially his disquiet about excessive individualism and lack of social cohesion under organic solidarity, was approached overwhelmingly by reference to processes internal to a society. sociologists have questioned the constraints that this presents for an adequate understanding of social life in both the global north and the global south. but as bhambra (2007: 6) argues, while sociologists are now far more inclined to discuss modernities in the plural, these often refer back to european analysis such that 'the west is understood as the major clearing house of modernity' to the rest of the world, meaning that non-western peoples must now begin to engage their traditions with modernity in different forms of hybrid "modernities"'. as she continues, with globalisation these multiple modernities still tend to be seen as becoming global as they incorporate features of the west to local circumstances. thus, as she puts it, while there is recognition of difference, that difference does not necessarily make a difference to sociological ways of thinking. bhambra (2007) exemplifies this through the analogy of the spokes of a wheel where european modernity of the centre diffuses along the spokes of other parts of the world or countries in relation to their encounters with the west, with very little consideration given to how the spokes may relate to each other. perforce there is a tenacious northernness to sociological theory which can result in the erasure of the experience of peoples outside of the metropole-the majority of the people of world-from the foundations of social thought (connell 2007 ). this has sizeable implications for the analysis of society, differentiation and globalisation and health. the connections between 'global' and 'health' are very far from given, rather, as this chapter seeks to show, global health problems and responses are 'enabled, imagined, and performed via particular knowledges, rationalities, technologies, affects, and practices across a variety of sites, spaces, and relations' (brown et al. 2012 (brown et al. : 1183 . this means it is important not only to consider globalisation's processes and effects but also how they are theorised and the consequences that this might have for our understanding of health and healthcare in different parts of the world. this chapter is organised as follows. part 1 addresses theories of globalisation and their implications for the analysis of health issues. in particular i emphasise that globalisation is embodied, something often overlooked by sociologists working outside of the field of health (turner 2004) . emphasis is given to the health vulnerabilities that arise from the heightened mobility, and connectivities that characterise globalisation, taking migration and health as an illustration. in part 2, i turn to consider differentiation by highlighting disparities in health vulnerability and the capacity of social groups to protect their health. this is illustrated first by reference to the securitisation of health and (elbe 2010a) . a focus on the mental and physical health consequences of violent conflict then draws out the special vulnerabilities of children and of women. finally, in part 3, i reflect on neoliberalism as the dominant politico-economic policy framework driving health system change and on the increasing interconnectedness of various national health systems, and their implications for the delivery of effective healthcare. as turner emphasised over a decade ago, 'we can no longer study the treatment of disease in an exclusively national framework because the character of disease and its treatment are global ' (2004: 230) . the sociology of health needs to be global in scope and, crucially, the globalisation of health risks and of medical institutions should be added to globalisation theory as 'the first steps toward a globalisation of the body' (turner 2004: 236) . while turner underlines that the spread of global health risks and global health institutions can be thought of as a new phase of globalisation, attention in these terms is wanting in most globalisation theories. even so, they can provide a useful lens into the analysis of health in the global context. as already noted, since globalisation is envisaged as a new social order, a substantially new theoretical framework is necessary to analyse what is envisaged as a 'new unbounded social system' (connell 2007: 53) . while popular thinking tends to equate globalisation with linear diffusion of western values and ideas to the rest of the world and construe arrested globalisation as resistance to such a trend-such as in the interpretation of the rise of islamic fundamentalism as a direct response to the spread of western political and cultural values into the middle east-most social scientists maintain that globalisation has no one single logic. instead of moving in one direction, they stress that it is multi-dimensional and multi-causal. bauman (1998: 60) describes globalisation as uncontrolled, operating in what he depicts as a 'vast -foggy and slushy, impassable and untameable -"no man's land"'. similarly for beck (2000) , there is no over-riding logic or driver, such as the economic; rather globalisation is multi-causal and multi-dimensional. consequently it presents as a new form of radically uncertain modernity. according to walby, globalisation is best identified as 'a process of increased density and frequency of international interactions relative to local or national ones ' (2009: 36) . she argues that this can be grasped most effectively through the lens of complexity theory. this entails a reworking of the concept and theory of society to bring system to the fore but in a substantively different way to erstwhile approaches such as that of parsons (1951) , where social systems were construed as entities made up of parts. by contrast, walby (2015) proposes that sociology should be the study not of parts but of all of society as a set of relations. from this position, she maintains it is possible to 'address multiple regimes of inequality existing within the same territory without assuming that they must neatly map onto each other or be confined to the same borders' (walby 2015: 166) . this offers a new vocabulary with which to understand social change; that of co-emergence, non-linear processes and heterogeneity (walby 2009 ), which draws attention to features of globalisation such as heightened mobility and new forms of connectivity between people, all of which have health implications. in his theory of the networked society, castells (2010) advances that social structure is always in the making, connecting the local and the global. while mobility is crucial, of equal importance for castells is perpetual connectivity. mobility stratifies through movement and through the lack of it. for some, 'space has lost its constraining quality and is easily traversed in both its "real" and "virtual" renditions' (bauman 1998: 88) , increasingly making it possible to move around the world for employment, in search of personal health and well-being and, as discussed in part 3 of the chapter, for healthcare. conversely, there are people, such as refugees, who, for reasons such as civil war and persecution, have no choice but to move and to keep on moving. globalisation also makes visible the world of the 'locally tied' and globally many people are tied to risky communities that are damaging to their physical and mental health. (see chap. 4.) in collateral damage, bauman argues that 'the inflammable mixture of growing social inequality and the rising volume of human suffering marginalised as "collateral" is one of the most cataclysmic problems of our time' (2011). 'collateral damage' is military in origin and refers to the unplanned effects of armed intrusions. applying it to global societies, bauman conveys how the poor become collateral damage in a profitdriven, consumer-oriented society. although he does not address health and illness, it may be instructive to conceptualise those increasingly vulnerable to health inequity as a form of collateral damage. we turn to look at this now through the example of recent migration and health. the term migrant encompasses multiple forms of mobility. in broad usage, it is often taken to refer to people who move 'voluntarily' to live in another country for a year or more, such as 'economic migrants' and also 'irregular migrants' (those entering a country without required documents). by turn, 'forced migrants' comprises refuges, defined under the united nations (un) refugee convention of 1951 as those forced to flee to save their life or preserve their freedom; asylum seekers, or people seeking international protection, awaiting a decision on whether they have refugee status; and internally displaced persons (idps) forced to leave their homes to avoid armed conflict, natural or human-made disasters, or violations of human rights, but who have not crossed an international border. the un convention protects refugees, but asylum seekers and idps have few rights and hence limited protection. the relationship between migration and health is complex for the reason that migrants are a heterogeneous group. nonetheless, it can be useful to draw a general distinction between 'voluntary' and 'forced' migrants. although we need to be wary of overgeneralising, where 'voluntary' movement is concerned, research points to health selection since migrants often are healthier compared to people in their country of origin, yet it is important to recognise that migration itself can carry risks such as those of transit and adjusting to life in a new country. from his in-depth consideration, gatrell (2011) concludes that although migrants tend to be in better health than those left behind as well as than those in the new host population, these relative health advantages attenuate as immigrants adapt their behaviours, particularly their dietary and exercise behaviour, to the norms of the new community. this is borne out by huijts and kraaykamp's (2012) large-scale analysis of immigrant health in europe. based on european social survey data for 2002-2008, they analysed the health of over 19,000 immigrants from 123 different countries who had moved to 31 different european countries. basing self-assessed health on a five point scale (i.e. very bad, bad, fair, good, very good), they analysed foreign born and second generation migrants in europe with a focus on 'origin' and 'destination' effects on health. characteristics of origin were found to have a lasting influence. for example, high levels of political oppression were associated with poorer health in both first and second generation migrants. religion was found also to be influential. notably, first generation immigrants from islamic countries reported better health than those from countries where other religions predominate (all other factors being equal). the authors relate this to socialisation into positive health behaviours such as refraining from alcohol consumption and smoking, although, this did not apply to the second generation, something which they put down to the influence of culture in the destina-tion countries. overall then the health of immigrants shows a strong resemblance to the health of native inhabitants of the country of destination, but there are some lasting effects of origin countries (huijts and kraaykamp 2012) . the deregulation of wars is one of globalisation's most ominous effects. as discussed further below, most present-day war-like actions are carried out by non-state entities and consequently associated with the erosion of state sovereignty and the burgeoning frontier-land conditions of 'suprastate global space' (bauman 2007: 37) . populations who flee conflict in their homelands often find themselves as outcasts in camps where they are neither 'settled nor are they on the move; they are neither sedentary not nomadic', becoming 'undecidables' made flesh (bauman 2007: 51) . when analysing forced migration we need to think less in terms of individuals moving in a linear fashion from point a to point b and more of constructed group movement, where the journey from a to b is often protracted and involves periods of stasis in 'transit' locations such as idp and refugee camps, as well as interception stages, such as border controls. such journeys are risk-laden (zwi and alvarez-castillo 2003) . as gostin and roberts (2015: 2125) relate, 'each stage of the forced migration journey…poses health risks. individuals face armed conflict, famine, or both in their home countries causing physical illness, severe mental distress, and lifelong trauma'. the body of a 3-year old syrian refugee, aylan al-kurdi, lying on a turkish beach in september 2015 is an enduring image of the present european 'migrant crisis'. in 2016 alone, 5096 people were reported dead or missing in the mediterranean sea as they sought to escape conflict in countries such as syria and afghanistan (unhcr 2017). other health risks include injury and disability in transit and infectious diseases, such as measles, polio, cholera, tuberculosis, dysentery, and typhoid which can be rife in camps and exacerbated by food insecurity and lack of clean water. a report from unhcr (hassan et al. 2015) on the mental health and psychosocial well-being of syrians affected by armed conflict draws attention to experiences of violence, exploitation, isolation and losses such as grief for loved ones, homes and possessions. this manifests in helplessness, loss of control and anxiety as well as social withdrawal (especially amongst women and young people), fatigue, sleep problems, loss of appetite, and unexplained physical symp-toms. the authors detail that often suffering is understood as a normal part of life, not in need of medical attention. most arabic and syrian idioms of distress do not separate physical experience and mental symptoms since body and soul are linked in explanations of illness. for example, 'habat qalb or houbout el qalb, literally "falling or crumbling of the heart", corresponds to the somatic reaction of sudden fear', and 'kamatni kalbi "my heart is squeezing"…generally refers to anticipated anxiety and worry' (hassan et al. 2015: 23) . the health consequences of forced migration are a powerful illustration of the 'social suffering [that] results from what political, economic, and institutional power does to people, and reciprocally, from how these forms of power themselves influence responses to social problems' (kleinman et al. 1997: ix) . bauman (2016) argues that, from the stance of the more secure in the world, migrants embody ambient fears of precarity and of people whose lives are defined by precariousness and anxiety. the insecure are less able to evade their own vulnerabilities, including fears of loss such as of work, homes and loved ones, that are intensified by their scattered and unpinpointable nature (bauman 2016) . grove and zwi (2006) draw on 'othering theory' to account for the responses of people in destination countries of the global north to forced migrants. the process of othering marks migrants out as different to 'us' and in the process shores up feelings of normalcy. concurrently migrants are constructed as risky to 'us', as distant and strange others, as needy, as charity cases and as health services queue jumpers who create welfare overload. as grove and zwi (2006) discuss, the language used is that of burden to the neglect of the agency, resilience and skill of many migrants. the health of forced migrants is but one example of the negative health consequences of globalisation. it highlights differential health vulnerabilities and the (in)capacity of groups of people to protect their health, the focus of this section of the chapter. the concept of the 'other', referred to earlier, is a useful frame within which to approach the effects of the securitisation of health in global context. although there is a strong historical connection between health and the security of nations, such as in times of war, the notion of 'health security' is quite recent. the catalyst was the events of 9/11 in the year 2001. this occasioned the setting up of the global health security initiative, an international partnership between several countries, including canada, france, germany, italy, japan, mexico, the uk and the us, intended to supplement and strengthen their preparedness to respond to threats to global health, not only in regard to terrorism, but also pandemic infection and bio-chemical warfare. by 2007, 'health security' was high on the global agenda, as reflected in the world health organisation's annual report, a safer future (who 2007) . the report defines health security as 'the activities required, both proactive and reactive, to minimise vulnerability to acute public health events that endanger the collective health of populations living across geographical regions and international boundaries' (who 2007: ix) . this signifies a two-way relationship between health and security. first, the health of populations is seen increasingly in security terms; that is, there is a felt need to secure population health against threats. concomitantly, the security of nations is viewed in medical terms. in security and global health, elbe (2010a) proposes that the medicalisation of security has three dimensions. the first is that national security moves from being only about military capabilities and the hostile intentions of other states to the proliferation of lethal medical problems in the bodies of citizens. an instructive way to consider this, and also to track changes in ways of thinking over recent time, is to consider responses to infectious diseases such as hiv/aids and sars (severe acute respiratory syndrome). the aids epidemic (see also the discussions on aids in chaps. 3 and 4), which began over 30 years ago in the 1980s, was perhaps the first time that governments, notably the us as a superpower, began to link pandemics to national security and to worry about the possible effects of illness on us interests abroad (mcinnes and ruston 2013). several years on in 2001, then us president clinton declared aids a national security threat to the country. first, and perhaps foremost, there was concern with high hiv prevalence in the armed forces in times of war and hence the capacity to protect the nation (elbe 2010a) . with the sars epidemic of 2002, security concerns shifted from armed conflict and the stability of national states to mortality burdens and economic repercussions (elbe 2010a) . sars was traced to guangdong province in china, and thereafter it spread to hong kong, singapore and toronto. by 2003, the who was warning against all but essential travel to these countries. in hong kong, over 1200 people were subject to isolation orders. when sars spread to the middle-class private housing complex of amoy gardens in kowloon, the department of health quarantined 264 apartments (although by the time the police arrived most people had already fled). a headline in the singapore straits times of may that year emblazoned that 'sars is like singapore's 9/11'. the security threat attended very much to the economic repercussions. with sars respiratory droplets are produced when an infected person coughs or sneezes; this is largely invisible and unpredictable and hence hard to avoid. during the outbreak people began to keep away from public spaces, to minimise time spent outside home, and to wear face masks. the economic effects were predictable; with the avoidance of travel, retail sales declined and there were less business exhibitions and meetings. it was estimated that the asian region as a whole lost the equivalent of 25-30 million us dollars. the canadian government evaluated that three million dollars were lost to the country's economy in the first two weeks alone of the outbreak in toronto (elbe 2010a) . this prompted wider concern that any epidemic outbreak could wreak havoc on the world economy, further boosting the medicalisation of security. the second dimension of the medicalisation of security addressed by elbe (2010a) is the expansion of medical power and accompanying influence. at the most general level this is evident in increased involvement of medically trained persons in national security circles, most notably in the us. a key turning point was when then president clinton brought physicians into politics in relation to aids with the objective of using them in helping to defend the us population from disease. of significance here is the shift in emphasis from physicians as not only treating disease in individuals but defending against disease in populations. presently, the us homeland security hosts an office of health affairs which has a division of health threats resilience. the third and final dimension of the medicalisation of security brought to the fore by elbe (2010a) is measures to secure, or attempt to secure, population health. the main strategy of governments to protect citizens has been the stockpiling of medical countermeasures to major illness as a readiness or preparedness against future uncertainly highlighted by bauman (2016) as referred to earlier. this is exemplified by the stockpiling by several governments of the global north of the anti-viral tamiflu during the 'swine flu' (h1n1) outbreak of 2009. the differential consequences for populations of containment efforts can be illustrated by the race to secure antiviral medications and vaccines in the wake of the possible h5ni (avian flu) pandemic in the mid-2000s. as recounted by elbe (2010b) , the majority of cases and of deaths at the time were in indonesia (see also chap. 7 regarding how rural poor women in indonesia are at great risk for maternal mortality, morbidity and infant death). in 2006, the country's government stopped sharing its virus samples to who under the global influenza surveillance network because it discovered that they were being given to western pharmaceutical companies and novel vaccines offered back at unaffordable commercial rates. it is therefore important to underscore that the securitisation of health is practised through, and acts on, the bodies of populations; it is a fundamentally embodied phenomenon involving the surveillance and control of populations, their bodies and their health (see also chap. 3 for a detailed discussion on embodiment). this is now pervasive for the reason that many of the health threats referred to are unpredictable-no one predicted the outbreaks of sars in 2002 and ebola virus in 2014-2015, for example, and it is hard to know where future threats may come from and what they will mean. future health pandemics have rogue status, as depicted in the metaphor of the black swan. initially the notion of black swan was used to refer to unexpected events in financial markets, and then expanded to refer to any surprise event of major proportions. it has been evoked by the us national intelligence council (2012: 16), which advises that 'no one can predict which pathogen will be the next to start spreading to humans, or when or where such a development will occur. an easily transmissible novel respiratory pathogen that kills or incapacitates more than one percent of its victims is amongst the most disruptive events possible. such an outbreak could result in millions of people suffering or dying in every corner of the world'. uncertainly is associated with both vulnerability and the escalation of agencies of health security. while the securitisation of health might seem to the good for all individuals and all populations, it can also be divisive, highlighting our concern with differentiation. among the questions to be posed are: to what extent is the concern with 'national security' and to what extent with 'human security'? (delaet 2015) are differential health interests being served? it has been argued (davis 2008 ) that the securitisation of infectious disease prioritises the health concerns of western states. in this regard agencies such as who are not neutral actors; diseases come to be identified as a threat when western states feel threatened; after the threats wane so does the support (davis 2008) . securitisation is then state-centric and shaped by the interests of privileged populations. disease that is seen as containable within national boundaries, such as diarrheal disease and the more hidden burdens such as maternal mortality, infant mortality, hunger and traffic deaths, fails to reach the level of concern that securitised infectious diseases evoke. resources are directed away from public health actors and poverty-related health challenges in ways that do not accurately reflect the global burden of disease (delaet 2015). based on data reported at the end of 2016, there were 43 extremely violent conflicts going on in the world in 2015 (ocha 2016). as well as deaths, injuries and all the other effects of collective violence, there were 65.3 million forcibly displaced persons, including 21.3 million refugees, 3.2 million asylum seekers and 40.8 million idps (ocha 2016). most contemporary or 'new wars' involve a range of not only state but also nonstate combatants who use violence to pursue exclusionary goals, such as religious, ethnic and economic interests, as exemplified by the civil war in syria. frequently in such contexts, civilian casualty is not a side effect but an aim in itself. to give an illustration, unicef (2016) reports that two million children are living in areas largely cut off from any humanitarian assistance; 2015 saw over 1500 cases of killing and maiming of children, as well as attacks on schools and hospitals and denial of humanitarian aid to children. when considering the health effects of armed conflict analysts can be inclined to focus on fatalities from direct combat or death from fatal injuries sustained in combat, including the deliberate use of starvation as a direct weapon of war. but, there are other direct effects such as significant physical and mental health problems amongst both the armed forces and targeted and untargeted civilians-such as illness resulting from disabilities (e.g. loss of limbs) and from atrocities of war, such as rape and torture, and sexually transmitted infections. there are also indirect effects of conflict. for example, health facilities, which may not have been of the highest standard even before the onset of conflict, can be destroyed, cutting off access to essential care. moreover, disease spreads in insanitary conditions such as overcrowded refugee camps, and persons living in war-torn environments invariably suffer fear, insecurity and mental trauma (levy and sidel 2008) . the differentiation of peoples is fundamental here. in frames of war, butler (2010) counsels that wars seek to manage populations by distinguishing lives to be preserved from those that are dispensable. some lives become grievable and others not, since to be grievable a life has to matter rather than to be seen as imminently destructible. violent conflict is then one of the most radical inequalities imaginable as some deaths of some populations or groups are seen as necessary to protect the living of others. as will be discussed later, women and girls, and children in general are often differentially vulnerable. we will now take this further through two case illustrations: the health of former child soldiers and rape of women in war. the term 'former child soldier' refers to children abducted into armies and rebel forces and then returned home. there are an estimated 300,000 child soldiers in the world today, of whom, over 40 percent are girls. the participation of children under the age of 18 years in armed conflict is generally prohibited under international law, and the recruitment of children under 15 into conflict is a war crime (amnesty international 2017). coerced, enticed or abducted, children serve as combatants, porters, spies, human mine detectors and sex slaves. their health and lives are endangered. many are forced to commit atrocities such as killing or maiming a family member in order to break ties with their community and to make it harder for them to return home. a high rate of mental health problems amongst returnees is inevitable, not the least because when they return home they can experience stigma due to perceptions that they are immoral or dangerous. it is unsurprising, therefore, that former child soldiers have high incidences of post-traumatic stress disorder (ptsd), which is associated not only with their experience during war, but its aftermath. betancourt et al. (2010) researched children in sierra leone who were recruited into the national army and civilian defence during the civil war of 1991, most notably the revolutionary united front (ruf), which was responsible for brutal atrocities against civilian populations, including amputations to supress resistance, and large-scale abduction of children. the ruf forced children to commit atrocities including the murder of loved ones. many were subject to repeated rape and forced to take drugs to reduce inhibition against committing violent acts. after the war ended, programs were set up to reintegrate children into their former communities, yet this was very difficult as most faced fear and distrust and girls were seen as sexually promiscuous or defiled. betancourt et al. (2010) studied the role of stigma in mediating children's exposure to war-related events and mental health outcomes. a total of 152 former ruf child soldiers aged between 10 and 18 years were interviewed at the end of the war in 2002 and again in 2004 with a focus on family and community acceptance and psychological adjustment, especially levels of depression, anxiety and hostility. the researchers found that the large majority of the respondents were involved with the rebels by force with an average age at abduction of 11 years. in all, 44 percent of the girls and 7 percent of the boys reported being a victim of rape; 31 percent of girls and 35 percent of boys had wounded or killed either a loved one or a stranger. levels of depression were high and 79 percent felt local people acted afraid of them, and 82 percent that the local people felt threatend by them. as one child said, 'initially when i arrived [back home], people feared me. some said i was a killer. there were times when i wanted to touch or play with other kids, but their parents will shout at me. i felt bad during those early days' (quoted in betancourt et al. 2010: 24) . in conflict zones around the world, military forces use gender-based sexual violence (gbsv) to terrorise, humiliate and demoralise whole communities, including by the spread of a disease such as hiv and of sexually transmitted diseases-a clear illustration of illness as a tactic of war. here the association between the individual and the collective becomes paramount. there has been a tendency to explain rape and sexual violence as random and opportunistic acts of war, that is, outside of the wider structural context of the society concerned. yet gendered structural conditions are crucial. indeed, it is arguably because of the normalisation of women's inequality in a society where gbsv appears logical and instrumental (davis and true 2015) . though violent conflict and health is not their focus, scheper-hughes and lock's (1987) theorisation of the 'mindful body' is a valuable lens through which to evaluate gbsv. (see chap. 3 for a discussion of 'the mindful body' in the context of embodiment theory.) they draw attention to the individually experienced body-self, and also to the social body and its symbolic and representational uses, and to the body politic, or the regulation and control of bodies, for example in families and in medical systems. research examples illustrate how the individual body, social body and body politics come together to help explain rape and sexual violence in war. in their research on gbsv in south kivu, democratic republic of the congo, kelly and colleagues (2012) found that, absolutely vital though this is, rape goes far beyond individual physical and psychological trauma and becomes a societal phenomenon where isolation and shame often become as important as the attack itself. analysis of focus group data revealed that many interpreted rape as a form of destruction to the community, associated with the spread of disease, the devaluation of women and the breakdown of families. as one respondent put it, 'if you are a girl [who has been raped], your parents will start mistreating you, they can't understand that you have been forced and that it was not your fault. you will never get married. they will throw you away because you are not worth anything; you will lose all value because nobody will marry you' (quoted in kelly et al. 2012: 290) . husbands may view their wives as 'contaminated', such as by sexually transmitted infections, and also as morally contaminating since the rape of a wife can result in loss of pride and a feeling of impotence in being unable to provide support (kelly et al. 2012) . a second illustration of the power of collective structural context on individual experience comes from the serbian occupation of croatia in the early 1990s. olujic (1998) argues that to understand what happens in war we must take account of the pre-war gendered context, especially meanings of female sexuality and the codes of honour and virtue that women represent in the family, alongside the role of men in protecting this honour. as she puts it, 'women's honour reflects that of men's, which, in turn, reflects that of the nation' (olujic 1998: 38) . rape can then represent men's inability to protect women, an attack on their honour and a cause of their shame. thereby the individual bodies of women become metaphoric representations of the social body and the injury to their bodies maims the family and the community. based on fieldwork in hospitals in 'post-conflict' erbil, kurdistan, keller (2012) explored women's expression of illness through presenting symptoms such as limb paralysis, convulsions and muteness. in women's own accounts, symptoms such as these were linked to home life, to experiences that were too much to bear and to lack of support. keeler (2012) associated this with the imposition of global neoliberal agendas in the individual and social body: women's trauma narratives become (re)inscribed by their physicians as anti-modern, positioned as belonging to a 'bygone age'. thus 'hysterical women' become a counternarrative to the global prosperity trope and are medically silenced by the 'body politic' to 'expunge non-normative expressions of trauma' (keeler 2012: 140) in post-conflict modernity. this occurs by such procedures as 'pain stimulation', including saline injections, the bending back of fingers and the threat of sexual trauma as 'medical treatment'. this illustration directs our attention to the alliances between healthcare and political agendas. in the final part of the chapter, i reflect on the interconnections of healthcare systems and neoliberal political agendas. health systems can be defined as the assemblage of public and private sector institutions and actors concerned with the support of health and the amelioration of illness. even though globally many countries are grappling with common problems, such as increased health needs and demands for healthcare, alongside the rising costs of providing it, there is not one, simple international line of convergence towards a common form of health system. the reason is that health systems are shaped significantly by their centuries-old economic and political regimes. in addi-tion, they take their form from 'national logics', that is, how a society defines and deals with issues of health and illness. equally, cultural factors influence how populations respond to proposed changes to their health system as well as how those external to a country relate to it. even so, without undue risk of overgeneralisation, we can point towards a worldwide drive towards the commercialisation of health systems and, where public provision exists, such as in our case example of the uk, to the rollback of state or public provision in favour of the free market principles. thus, most health systems around the world have or are moving towards a mix of public/private provision. with this point in mind, it has been argued that health services are now as much about investor potential as access to care for patients. tritter and colleagues maintain that health systems are no longer important primarily because they ensure that people gain access to health services when in need and irrespective of their ability to pay, that epidemics are prevented or controlled [...] or that the social determinants of health are addressed as part of public policies. in the emerging context of the reform policies, health systems are important not only as providers of products and services for which people are willing to pay, but also as an investment opportunity within global financial markets. (tritter et al. 2010: 36) although they manifest in different ways across health systems, we can point to a set of three shared global influences: neoliberalism (see also the discussions on neoliberalism in chaps. 4 and 6) as the dominant politico-economic policy framework driving system change; macroeconomic policies and structural adjustment programmes (saps); and international trade agreements. as addressed elsewhere in this book, neoliberalism can be defined as a project of economic and social change based on the transfer of economic power and control from governments to private markets and the injection of market competition into areas such as education, housing and healthcare which, in many western countries at least, were once part of the welfare state (scott-samuel et al. 2014) . as discussed in chap. 4, neoliberalism is usually interpreted as a response to the period of structural crisis of the 1970s when, from mid-decade, countries such as the us and uk witnessed lower rates of financial accumulation and growth, rises in unemployment and rising inflation. neoliberal economic policies encourage financial deregulation and the opening up of trade and investment by resource-rich countries in regions where social conditions afford high returns. up to the late 1970s, the predominant approach to health improvement globally was to strengthen public health systems, especially access to primary health care. this was the position established by the who's influential alma-ata declaration of 1978 which brought about access to healthcare as a human right. the world bank (wb), the international monetary fund (imf), the world trade organisation (wto) and other agencies rebuffed this position in the 1980s as they established monetarist policies prioritising the achievement of macroeconomic stability by putting constraints on the growth of money supply and public spending. supranational agencies, such as the imf, wto and the wb, have been key players in the spread of global neoliberalism in the health field. their influence is often indirect comprising the development of trade and investment agreements negotiated at bilateral and multilateral levels and the promotion of market-friendly structures and regulatory reforms. one of the most controversial of wb policies has been the pressure upon countries of the global south to adopt saps. as a condition of receipt of foreign aid and loans, structural adjustments comprise lowering trade barriers, the selling off of state-owned assets and cutting public sector budgets and public sector workforces (rowden 2009 ). the stance of the wb is that structural adjustment stabilises economies, promotes investment and generates long-term economic growth. but it has been argued to the contrary that this leads directly to chronic underfunding of local public sector services, collapsing domestic industries in the face of cheaper imports, rural-urban migration, reduced health budgets (and less money for health workers) and the reduction of access to services by local communities. for example, it might be argued that the unpreparedness of liberia, sierra leone and guinea to deal with the ebola virus outbreak of 2014-2016 in west africa was associated with a short-term focus on economic objectives and on profitable sectors, such as minerals (iron ore, gold, bauxite and rubber) at the expense of the public sector. stubbs et al. (2017) explored the effects of imf aid conditionalities on the provision of healthcare in 16 west african countries including the gambia, liberia, nigeria and sierra leonne, between 1995 and 2014. the number of conditions put on aid over the period amounted in total to 8344 in the region. imf targets, such as budget deficit reduction, were found to crowd out or to reduce the space for investment in the health sector and aid conditions which stipulated staff layoffs or caps on public sector wages limited much-needed staff expansion of doctors and nurses. in other words, conditionalities of aid negatively impacted the provision of healthcare in the countries concerned. the third significant influence on global health systems is international trade agreements, specifically the general agreement on trade in services (gats) and the associated proliferation of bilateral agreements. gats, which came into effect in 1995, was the first set of multilateral rules governing international trade in services, such as education and healthcare, with the object of removing trade barriers. ultimately, since it aims to liberate all services, it is a potential challenge to the sovereignty of national governments over policy-making in relation to public health and the provision of health services. for example, at the time of writing in march 2017, it is not clear whether the transatlantic trade and investment partnership (t-tip) between the eu and the usa, presently in an eighth round of discussions, will exclude the uk nhs (national health service). if it does not then it could give transnational corporations the right to enter the uk market and operate without limits on their activities. for the reasons referred to earlier concerning the different histories and cultural contexts, the organisation of health systems varies considerably in different countries. the us, for example, has always been a privately reimbursed system where citizens pay for care by insurance through employment or out of pocket. by contrast, in the uk health system since the inception of the nhs in 1948 most aspects of care have been provided free of charge through taxation. the same broadly applies to the nordic countries, as well as others such as italy. in between this many countries, such as germany, japan, taiwan and france, have social insurance models whereby patients and employers pay into sick funds which contract with a range of health providers. but, to varying degrees and in different ways, almost all are moving towards a blending of public/ private elements. the uk has in many ways been at the fore in this regard, beginning with reforms of the thatcher government in the 1980s. but the approach has been espoused internationally by countries as varied as italy, singapore, india, taiwan, malaysia, the philippines and russia. fundamentally, the intent has been to introduce market mechanisms to control costs. globally, though to varying degrees, healthcare costs have been rising at significant rates. for example, healthcare expenditure as percentage of gdp rose from 4.0 percent in 1970/1 to 9.8 percent in 2014 in the uk and, for the equivalent period, from 6.4 to 16.9 percent in the us, and from 6.2 to 11.1 percent in germany (world bank 2017). in the uk and most notably england, an internal market was introduced in the early 1990s as a number of gp practices became fundholders who purchased care from hospitals and other providers on behalf of their patients (doh 1989) . the intention was that this would make them more cost conscious since they would be paying; that is, they would be deterred from referring patients too readily for tests and treatments, and that they would hold care providers, principally hospitals, to account for spending and quality of care for patients (hunter 2016) . the new labour government of 1997 broadly extended this policy, merging general practices into primary care trusts which jointly commissioned services for patients. the late 1990s into the early 2000s saw the further introduction of private providers into the nhs, for example, to run day surgery, pathology and diagnostic services (doh 1997). in 2010, the new coalition government consolidated this by the setting up of clinical commissioning groups (ccgs) which hold approximately two-thirds of the nhs budget. ccgs currently purchase care on behalf of gps for their patients. moreover, under the new 'any qualified provider' provision, care could be commissioned not only from nhs providers but also from the for-profit and the not-for-profit third sector (charities and social enterprises) (doh 2010). this overall policy remains in place at the time of writing in 2017 with recent concern focusing less visibly on structural reform and more on incapacity to meet demand-for example, in january 2017 the british red cross said that the nhs was facing a humanitarian crisis in the face of escalating demand and rising waiting lists for treatment. health, culture and society endorses the enduring conceptual legacies that have shaped and continue to shape our thinking. it seeks to understand not only where we have come from but where we are going to. this has been the focus of the current chapter as we have explored sociology's disquiet with 'society', as its erstwhile unit of analysis. while theorists of globalisation have given relatively little direct attention to matters of health, it has been suggested that the attention to international connections, mobility and new emergent forms of differentiation and inequality can be a useful point of departure for the analysis of health and healthcare. in these terms we have addressed several critical health issues of our time, such as migration and health, the securitisation of health, the health devastation wrought on civilians caught up in violent conflicts around the world, and the commercialisation of health systems. amnesty international globalization: the human consequences collateral damage: social inequalities in a global age why the world fears refugees what is globalisation? cambridge: polity past horrors, present struggles: the role of stigma in the association between war experiences and psychosocial adjustment among former child soldiers in sierra leone rethinking modernity: postcolonialism and the sociological imagination critical interventions in global health: governmentality, risk and assemblage for public sociology fames of war: when is life grievable? london southern theory securitizing infectious disease reframing conflict-related sexual and genderbased violence: bringing gender analysis back in whose interests is the securitisation of health serving? working for patients. london: stationary office the new nhs: modern, dependable. london: stationary office equality and excellence: liberating the nhs. london: stationary office the division of labour in society security and global health haggling over viruses: the downside risks of securitizing infectious disease mobilities and health forced migration: the human face of a health crisis our health and theirs: forced migration, othering, and public health culture, context and the mental health and psychosocial wellbeing of syrians: a review for mental health and psychosocial support staff working with syrians affected by armed conflict immigrants' health in europe: a crossclassified multilevel approach to examine origin country, destination country, and community effects the health debate first do no harm? female hysteria, trauma, and the (bio)logic of violence in iraq if your husband doesn't humiliate you, other people won't': gendered attitudes towards sexual violence in eastern democratic republic of congo social suffering war and public health global trends 2030: alternative worlds. a publication of the national intelligence council ocha (office for the national coordination of humanitarian affairs) embodiment of terror: gendered violence in peacetime and wartime in croatia and bosnia-herzegovina the social system the mindful body: a prolegomenon to future work in medical anthropology the impact of thatcherism on health and well-being in britain the impact of imf conditionality on government health expenditure: a crossnational analysis of 16 west african nations globalisation, markets and healthcare policy the new medical sociology. london: w. w. norton company. unhcr bureau for europe no place for children -the impacts of five years of war on syrian children and their childhoods sociology beyond societies globalization and inequalities: complexity and contested modernities world development indicators: health systems the world health report 2007 -a safer future: global public health security in the twenty-first century forced migration, globalisation, and public health; getting the big picture into focus key: cord-263321-pzmo4hja authors: roach, p.; zwiers, a.; cox, e.; fischer, k.; charlton, a.; josephson, c. b.; patten, s. b.; seitz, d.; ismail, z.; smith, e. e.; collaborators, prompt title: understanding the impact of the covid-19 pandemic on well-being and virtual care for people living with dementia and care partners living in the community date: 2020-06-05 journal: nan doi: 10.1101/2020.06.04.20122192 sha: doc_id: 263321 cord_uid: pzmo4hja the covid-19 pandemic has necessitated public health measures that have impacted the provision of care for people living with dementia and their families. additionally, the isolation that results from social distancing may be harming well-being for families, as formal and informal supports become less accessible. for those with living with dementia and experiencing agitation, social distancing may be even harder to maintain, or social distancing could potentially aggravate dementia-related neuropsychiatric symptoms. to understand the lived experience of social and physical distancing during the covid-19 pandemic in canada we remotely interviewed 21 participants who normally attend a dementia specialty clinic in calgary, alberta, during a period where essential businesses were closed and healthcare had abruptly transitioned to telemedicine. the impacts of the public health measures in response to the pandemic emerged in three main categories of experience: 1) personal; 2) health services; and 3) health status (of both person living with dementia and care partner). this in-depth understanding of the needs and experiences of the pandemic for people living with dementia suggests that innovative means are urgently needed to facilitate provision of remote medicine and also social interaction and integration. with the emergence of covid-19 (sars-cov-2) as a novel coronavirus in late 2019, a global pandemic has led to varying levels of social distancing restrictions across the world. this includes restrictions on public gatherings, the conduct of businesses, the accessibility of healthcare, and movement outside the home. the unintended consequences of these measures may included disrupted routines for people living with dementia, increased stress on care partners as they manage the demands of caring for someone living with dementia, and difficulty satisfying essential needs such as obtaining groceries and medications without the typical social and health service support, or support from personal networks. these measures have the potential to cause social isolation, which is increasingly recognized to be detrimental to overall well-being (vernooij-dassen & jeon, 2016; ward et al., 2018) well-being requires deep and meaningful human connections, health status above an expected baseline, positive interpersonal expectations, and a sense of self (feeney & collins, 2015) . maintaining well-being is a key component of person-centered dementia care (kitwood, 1997) . moreover, the rapid move to virtual care provision may influence how and when people access treatment from healthcare providers, in addition to how providers can continue to provide high quality care in new virtual settings. multiple professional organizations including alzheimer's disease international (2020) have issued emergent covid-related advice for persons with living with dementia, but so far these recommendations have been based on little evidence, rarely collected systematically.to begin building an evidence base for the impact of the covid-19 pandemic on well-being and healthcare of persons living with dementia, we conducted a qualitative study of persons living with dementia and care partners receiving community-based care at a dementia specialty clinic. a qualitative approach was used to collect rich data on lived experience that incorporated a reflexive thematic approach to content analysis. we completed remote, in depth interviews using telephone with family members or care partners, as well as the person with dementia if they wished to and were able to provide consent. in order for participants to provide detail on the changes and impacts of the pandemic on their lives it is important that these data ae collected while the pandemic is occurring and while social distancing measures are in place. likely through a community network for younger people living with dementia. the calgary cognitive neurosciences clinic operates out of two large tertiary-care sites in calgary, alberta, canada. it is the only dementia speciality clinic in southern alberta, with a catchment area of approximately 1.5 million. patients are referred by a primary care provider and assessed for cognitive impairment and dementia by a staff of nurses and either a cognitive neurologist or psychiatrist. in alberta, there is universal government funding for physician visits and diagnostic testing. prompt was established in the clinic in 2010 to investigate patient outcomes. additional details on prompt design have been published previously (sheikh et al., 2018) . all patients seen at the clinic are eligible to participate and enrol in prompt. participation includes the opportunity to provide consent to be contacted for future research. consent was obtained using qualtrics survey software (qualtrics, 2019) or explicit oral consent. due to the nature of some of the clinic populations, explicit oral consent was necessary so that participants who wanted to participate but perhaps did not have access to the internet, email, or who had disablements preventing them from using devices or computer screens could still be included. explicit oral consent provided a way to ethically include a diverse population. process consent (dewing, 2007) was used throughout the project, where all participants provided verbal assent at every research encounter (including the initial call to introduce the project and any subsequent contact including interviews) to ensure that the participants were comfortable participating at that day or time. options of telephone or zoom interviews were used as a technological tool to complete the interviews in order to adhere to social distancing mandates put in place in the province of alberta when the public state of emergency was declared on march 17, 2020. potential participants were then contacted by telephone and informed of the project, after which information sheets and consent forms were emailed or mailed to interested participants who had a minimum of 24 hours to consider the information and discuss it with family members or health providers before providing consent to participate and the interview is scheduled. this study was approved by the conjoint human research ethics board at the university of calgary (reb20-0559). in depth interviews were used as they are an appropriate way to gain a robust understanding of lived experience and allow for exploration of topics that are important to the participant, maintaining a participatory approach to working with people living with dementia and care partners. an interview guide was created asking general questions about experiences of isolation due to the pandemic and virtual health care experiences, and was tested and updated after the first two interviews to act as pilots. it was anticipated that theoretical saturation of participant experiences would be achieved after completion of 15-20 interviews and so a target of recruiting 20 participants was initially determined. in depth interviews were audio-recorded and field notes were taken during the interviews in a dedicated field journal, along with reflexive field notes written directly after the interviews. demographic data was also recorded and was available through the current registry, and information on whether the participants had contracted covid-19 or were tested for sars-cov 2 was collected by interview. to collect the planned sample size of 20 completed interviews, we contacted 45 people of whom 21 consented and completed the interview. interviews ranged in duration from 8m:33s to 34m:38s (mean length = 21m:12s) and all interviews were completed over the phone as per participant request. interviews were conducted between april 23 and may 21, 2020, with recruitment and data collection completed by kf, az and ec, all research staff with extensive experience working with people living with dementia. the interviewers were unknown to the participants at the time of interview but introduced themselves and the reason for the work at initial contact and at the time of interview. in canada, provincial governments are primarily responsible for implementing public health measures for pandemics. a timeline of provincial measures for social distancing and health system reorganization was created by review of public records of the city of calgary and government of alberta, communications from alberta health services (the single public audio recordings were transcribed verbatim using a secure professional transcribing service, and anonymized and verified by the research team. transcripts and field notes were managed using nvivo 12 (qsr international, 2018) for the qualitative analysis and data management. interviews were transcribed concurrently while data collection was still occurring so that generated themes could be discussed at subsequent interviews to achieve theoretical saturation. immersion in the qualitative data was the first step of data analysis. transcripts were read and reread while the interview recordings are replayed. a reflexive thematic analysis (braun et al., 2016; clarke et al., 2019) was used to analyse the interview and field note data. reflexive thematic analysis positions the researcher as a mechanism in the production of the analysis. this form of analysis also requires a cognizance of theoretical assumptions that centers the experience of the person living with dementia and care partner, and their experiences within the data and the analytical process. analytical thoughts and iterative analyses were captured using memos and annotations. disagreements over analyses and emergent themes were resolved via team discussion. themes and subthemes were brought back to the participants for member checking and to enhance qualitative rigor and establish trustworthiness of the data (lincoln & guba, 1985) . there were 20 dyads of persons living with dementia and care partners; in 18 cases the persons living with dementia declined to participate but the care partner participated and in one case the person living with dementia and care partner each participated on their own. diagnoses and last folstein mini mental status examination (folstein et al., 1975) scores for the persons with dementia are shown in table 1 . no participants reported a diagnosis of covid-19 for anyone living in their household; two care partner participants suspected they may have had covid-19 due to symptoms but were not tested; and a third care partner participant reported being told to isolate due to being in a high risk group of complication from covid-19. through the completion of the qualitative analysis with coding and synthesis completed by az, ec and directed by pr (principal investigator and qualitative methods expert), three overarching themes emerged from the data (see table 2 ) that clearly demonstrated the impact of the covid-19 pandemic on experiences of cognitive neuroscience patients and their care partners. the themes built on a coding tree that started with small, descriptive codes about discrete areas of day to day life and were then synthesized to larger descriptions of experience. these themes are described in more detail below and have edited only for general grammar and spelling to enhance readability. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 5, 2020. . https://doi.org/10. 1101 /2020 it was also clear that the informal support provided by the community or by family members was crucial for many people who were anxious or afraid to leave the house for essentials. those participants who had family support reinforced these messages. "the first time we did something at the superstore, we put in a pick-up order. i don't have a cell phone. i have a computer but not a cell phone. so my daughter said 'you know, you put your order in and then i'll go over and pick it up when it's ready.' she would do that for me. and we social distanced the whole time, like she'd drive up in the driveway." (participant 123; care partner) managing day to day activities many care partners reported stress around coping with day to day activities of living and some of this stress was due to no longer having the formal home care service they had been receiving before the pandemic and shut down of services. the personal impact of the pandemic and associated public health measures is closely associated to the health services impact of these same measures. participants reported feeling alone and unsupported in many cases and were largely understanding of the need for health services to focus on the pandemic response. it was also clear, however, that some degree of ongoing contact was crucial for continuing to support families living with dementia. "that's kind of what i feel is, 'you're just on your own.'…i haven't heard from anyone. i finally phoned someone the other day and 'yeah. well people in ahs [alberta health services] have been redeployed ', etc. etc ., which is just fine. so maybe it would have been all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 5, 2020. some participants did report formal service and community programming continuing to stay in contact and support families in innovative ways, and this continued contact was appreciated, even if the service level and model delivery had changed when the program had to stop in-person programming. "he goes to an adult day program on wednesdays through [program] . they have been fabulous. absolutely fabulous. they're very good. they phone to see if we need groceries or anything at all because they're willing to do it. and then tomorrow they said they were going around to all the clients and delivering baking. every day of the program we always hear from them. over the phone. yeah." (participant 111; care partner) due to the scale of immediate shift to social and physical distancing, health care providers and patients had to quickly adapt to remote delivery of care in a virtual medicine format. overall, many participants expressed that although they prefer face to face appointments with their care team, there were perceived advantages to receiving care in a remote format. these included not feeling as rushed, having options presented such as telephone vs zoom, and care partners expressed an ability to be more candid with the doctor if the person living with dementia was not participating in the call. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 5, 2020. . https://doi.org/10. 1101 /2020 conversely, care partners did also report that if the person living with dementia was in the room or wanted to be part of the call there was less opportunity for frank one on one conversations with the doctor and that this could be potentially distressing for the person living with dementia, depending on the nature of the discussion. participants also expressed some concern with technological barriers of connecting via internet and while recognizing that body language and non-verbal communication was important to the appointment, support is necessary for people who are unfamiliar with the technology to be able to fully participate in this way. participants described feeling anxiety about the pandemic in general and about needing to leave the house, both personally and perceived anxiety on the part of the person living with dementia. this highlights the need to be cognizant of increased mental health needs for cognitive clinic patients and family members in times of social and physical distancing. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 5, 2020. . https://doi.org/10.1101/2020.06.04.20122192 doi: medrxiv preprint social distancing and cognitive decline a number of participants also expressed concern that the person living with dementia was experiencing more cognitive decline since the start of the public health measures during the covid-19 pandemic. these concerns were focused around the decrease in social interaction impacting the progress and severity of cognitive decline, which was perceived as progressing more rapidly the previous two months. many care partners expressed feeling as though they could not cope on their own, with limited access to both formal and informal supports .the changes to the health systems and services provided described in the section above have effects on the amount of burnout expressed by family members and care partners. participants also worried about returning to work if the services that enabled them to do so pre-pandemic were not reinstated. this study provides early evidence of the impact of covid-19 on persons living with dementia and their care partners. these interviews identified multiple adverse consequences of the public health measures implemented to contain spread of sars-cov-2, including loss of informal caregiving, lack of access to health care, and social isolation, contributing to burn out symptoms among care partners. this validates the concerns expressed by multiple advocacy organizations (such as the alzheimer society of canada, alzheimer's association (usa), and alzheimer's disease international), which although well founded have nonetheless been based on anecdotes or speculation without data collected directly from persons living with dementia. our data were collected during a period of "lockdown" when all non-essential businesses were closed, health clinic access was mandated to be online or telephone except for emergencies, and most in-person home care services were no longer being provided. therefore, it provides a snapshot of the adverse effects of the aggressive public health efforts that were needed to "flatten the curve" to prevent health system collapse. these drastic public health measures, while being lightened in many jurisdictions, may yet be required in other countries at an earlier stage of the pandemic or in case of a second wave of viral infections in the northern hemisphere in the fall. so far, there are few data on the impact of covid-19 on dementia care even though it is well understood that older people with medical comorbidities are at much higher risk of fatal infection. in a letter in the lancet, physicians from wuhan province cited multiple barriers to good dementia care including difficulty adhering to social distancing and good hygiene, loss of services, and difficulty accessing telemedicine (wang et al., 2020) . however, no perspective from persons living with dementia or quantitative information was included. a hospital-based cohort from italy noted that patients with covid-19 infection with a history of dementia were more likely to die, and often presented with hypoactive delirium (bianchetti et al., 2020) . a all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 5, 2020. . https://doi.org/10.1101/2020.06.04.20122192 doi: medrxiv preprint quantitative survey study of community dwelling persons with mild cognitive impairment or mild dementia in spain reported overall good mental health (goodman et al., 2020) . however, that study used a quantitative survey without open-ended questions, did not include care partners, and was limited to persons with mild dementia. in contrast, this study elicited many serious concerns particularly among care partners of persons with more moderate to severe dementia. we identified multiple impacts on well-being of people living with dementia and their family members and/or care partners. though most participants understood the need for social distancing, they found it difficult both physically and emotionally. meaningful activity and social engagement are vital to the well-being and functioning of families of persons living with dementia (phinney, 2006; phinney et al., 2007; roach & drummond, 2014; roach et al., 2016) . care partners expressed concerns that cognitive decline accelerated during social distancing. this is consistent with literature finding that loneliness can be detrimental to well-being and quality of life (moyle et al., 2011) and increase the risk of mortality and morbidity (luo et al., 2012; tilvis et al., 2012) . social interaction can be beneficial for cognitive functioning (vernooij-dassen & jeon, 2016) and so it is plausible that social isolation could provoke accelerated cognitive decline and or an exacerbation of neuropsychiatric symptoms of dementia. the adverse impact of the covid-19 pandemic on mental health is increasingly recognized (armitage & nellums, 2020; holmes et al., 2020) . these mental health impacts may be compounded when care partners no longer have access to formal and informal supports that provide respite, help with hygiene, medication, day to day activities of living, and essential tasks such as shopping for groceries or collecting medications. moreover, the challenges of assisting a person living with dementia to navigate changing public spaces where physical distancing, wearing of masks, and controlled movements are necessary leads to additional stress for the care partner and greater risk for the person living with dementia. participants were understanding of these measures but at the same time expressed concern for their own ability to continue to cope on a long-term basis, and the possibility of burnout without these supports. this echoes general concern of burnout by families living with dementia in times before the covid-19 pandemic (brodaty & donkin, 2009; sörenson & conwell, 2011; takai et al., 2009) , but with these caring demands now amplified by isolation and anxiety. with the accompanying sudden shift to virtual care by almost all health care teams there was additional anxiety experienced with regards to the availability of care and how to access it. many of the stresses and anxieties identified in this study could potentially be mitigated through health system innovations. remote support for social interaction for people living with dementia and care partners should be explored. there is evidence that tablet based interventions can benefit cognition and self-perceived quality of life for people living with dementia kong, 2020) and ongoing work is being made with integrating social robots into the care of people with dementia in the community (hung et al., 2019; korchut, 2017) . rapid implementation of these innovative technological solutions may provide one strategy to increase social interaction and improve well-being in times of pandemic public health restrictions. additional evidence is needed to demonstrate what kind of interaction may be valuable for these all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 5, 2020. . https://doi.org/10. 1101 /2020 approaches, and what types support may be most facilitative of a protective effect for cognition (kim et al., 2015) . other possible remote support for people living with dementia and families include virtual social networking, including virtual dementia cafes or day programming moving to online interaction . where this is not possible, telephone check-ins may also prove to be a valuable source of support for the mental health and needs assessment for families. the more problematic question remains focused on remote approaches to care partner respite, which is difficult to navigate during times of public health restrictions. possible solutions for home care or social care workers may include scheduled home care visits incorporating walks where the formal care provider and person living with dementia maintain an appropriate social distance; meal or medication collection and delivery at a safe distance or with the appropriate personal protective equipment, and flexibility on maximum limits for dispensing medications to the reduce the number of needed trips to the pharmacy. delivering high quality telemedicine will be essential to ensuring good health during a time of social distancing. it was evident in the data that if patients and care partners are expected to connect with internet technology, clear guidance should be provided to explain how to set up and use technology that may be unfamiliar to many. the ability for a care partner to provide confidential information to a clinical care team in advance of a scheduled virtual appointment was also expressed, particularly when the care partner wished to notify the medical team of symptoms that are potentially distressing or humiliating to the patient, or could lead to conflict. to address this need, our clinic is implementing secure web-based surveys that will allow the care partner to confidentially report neurobehavioural symptoms, function, and caregiver burden, using validated scales, with separate telemedicine appointments with the care partner as necessary. this work leverages data systems employed to capture patient data in the prompt registry, demonstrating another use of clinical patient registries for meaningful patient engagement and service improvement. previous work has shown that neurological and psychiatric patient populations do not see registry participation as burdensome, but as an altruistic way to contribute to research that may or may not also provide personal benefit (lee et al., 2019) . enhancing communication and preparation for clinic appointments has been shown to improve health outcomes in non-pandemic times (entwisthle & watt, 2006; street et al., 2009) and we can reasonably extrapolate that this would be true during times of social and physical distancing, as experienced during the covid-19 pandemic. strengths of the study include that it was embedded in a prospective clinic registry which enabled us to quickly contact people living with dementia and their care partners during the covid-19 pandemic, and link their data to physician collected information on cognitive assessment and disease diagnosis. the main limitation is that the study was conducted in a single setting, a specialty outpatient dementia clinic, in an urban location with universal healthcare. it may not be wholly applicable to persons receiving care in family practices or with limited access all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 5, 2020. . https://doi.org/10. 1101 /2020 to care. in future work we will also work to include more people living with dementia in the interviews, and perhaps the necessity of remote interviewing in this study presented a barrier to communication. however, the themes that emerged from our work accord with the concerns expressed by multiple advocacy groups, expert opinion (brown et al., 2020) , and the early observations of dementia specialists in wuhan province (wang et al., 2020) ; therefore, we expect that most of the themes are universal and not idiosyncratic to our practice setting. by design, we did not include persons living with dementia who are residing in care homes or who are hospitalized in acute care; additional research is needed on these important populations. this work is limited to the impacts of the initial public health response to the covid-19 pandemic, and it will be useful to continue additional qualitative work to better understand the impact on different groups over time as the public health response evolves and society adapts to the changes. this in-depth understanding of the lived impact of decreased social engagement and healthcare access on personal well-being can inform future health and social policy and health service provision. this knowledge may be useful for future pandemics (including the possibility of a resurgence of covid-19 in the fall); extreme weather phenomenon; outbreaks of other disease or isolation in supportive living or long term care facilities; or other emergencies where social distancing/isolation/virtual care may be required. the reported increase in neuropsychiatric symptoms is also important for treatment planning and support in times of social distancing. improved and innovate approaches to remote care and virtual medicine, including flexible mental and social supports for families, and the ability to provide information to clinical care teams prior to remote medical appointments has the potential to facilitate high-quality patient care that meets the needs of families and patients. 202003). direct and in-kind funding was also provided by the brain and mental health research clinics, a part of hotchkiss brain institute (https://brainandmentalhealthclinics.ca/). adi offers advice and support during covid-19 covid-19 and the consequences of isolating the elderly clinical presentation of covid19 in dementia patients using thematic analysis in sport and exercise research family caregivers of people with dementia anticipating and mitigating the impact of the covid-19 pandemic on alzheimer's disease and related dementias thematic analysis participatory research: a method for process consent with persons who have dementia patient involvement in treatment decision-making: the case for a broader conceptual framework a new look at social support: a theoretical perspective on thriving through relationships mini-mental state: a practical guide for grading the cognitive state of patients for the clinician telehealth home support during covid-19 confinement for community-dwelling older adults with mild cognitive impairment or mild dementia: survey study using touchscreen tablets to support social connections and reduce responsive behaviours among people with dementia in care settings: a scoping review virtual special issue -using touchscreen tablets for virtual connection involving patients and families in a social robot study structural brain changes after traditional and robot-assisted multi-domain cognitive training in community-dwelling healthy elderly dementia reconsidered: the person comes first the use of free non-dementia-specific apps on ipad to conduct group communication exercises for individuals with alzheimer's disease (innovative practice) challenges for service robots-requirements of elderly adults with cognitive impairments if it helps someone, then i want to do it": perspectives of persons living with dementia on research registry participation naturalistic inquiry. newbury park: sage. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted loneliness, health, and mortality in old age: a national longitudinal study dementia and loneliness: an australian perspective family strategies for supporting involvement in meaningful activity by persons with dementia doing as much as i can do: the meaning of activity for people with dementia nvivo qualitative data analysis software nobody would say that it is alzheimer's or dementia at this age': family adjustment following a diagnosis of early-onset dementia it's nice to have something to do': early-onset dementia and maintaining purposeful activity prevalence of mild behavioral impairment in mild cognitive impairment and subjective cognitive decline, and its association with caregiver burden issues in dementia caregiving: effects on mental and physical health, intervention strategies, and research needs how does communication heal? pathways linking clinician patient communication to health outcomes the experience of burnout among home caregivers of patients with dementia: relations to depression and quality of life social isolation, social activity and loneliness as survival indicators in old age; a nationwide survey with a 7-year follow up social health and dementia: the power of human capabilities dementia care during covid-19 the lived neighbourhood: understanding how people with dementia engage with their local environment the prompt registry is funded by the katthy taylor key: cord-009604-pdctikjg authors: delacy, jack; dune, tinashe; macdonald, john j. title: the social determinants of otitis media in aboriginal children in australia: are we addressing the primary causes? a systematic content review date: 2020-04-15 journal: bmc public health doi: 10.1186/s12889-020-08570-3 sha: doc_id: 9604 cord_uid: pdctikjg background: aboriginal and torres strait islander children experience some of the highest rates of otitis media in the world. key risk factors for otitis media in aboriginal children in australia are largely social and environmental factors such as overcrowded housing, poverty and limited access to services. despite this, little is known about how to address these risk factors. a scoping content review was performed to determine the relationship between social determinants of health and otitis media in aboriginal and torres strait islander children as described by peer-reviewed and grey literature. method: search terms were established for location, population and health condition. the search terms were used to conduct a literature search using six health research databases. following the exclusion process, articles were scoped, analysed and categorised using scoping parameters and a social determinants of health framework. results: housing-related issues were the most frequently reported determinants for otitis media (56%). two articles (4%) directly investigated the impact of social determinants of health on rates of otitis media within aboriginal and torres strait islander children. the majority of the literature (68%) highlights social determinants as playing a key role in the high rates of otitis media seen in aboriginal populations in australia. there were no intervention studies targeting social determinants as a means to reduce otitis media rates among aboriginal and torres strait islander children. conclusions: this review identifies a disconnect between otitis media drivers and the focus of public health interventions within aboriginal and torres strait islander populations. despite consensus that social determinants play a key role in the high rates of otitis media in aboriginal and torres strait islander children, the majority of intervention studies within the literature are focussed on biomedical approaches such as research on vaccines and antibiotics. this review highlights the need for otitis media intervention studies to shift away from a purely biomedical model and toward investigating the underlying social determinants of health. by shifting interventions upstream, otitis media rates may decrease within aboriginal and torres strait islander children, as focus is shifted away from a treatment-focussed model and toward a more preventative model. otitis media (om) is one of the leading causes of disease among aboriginal and torres strait islander (hereafter referred to as aboriginal) children [1, 2] . om refers to inflammation and infection of the middle ear and is classified as acute om, om with effusion or chronic suppurative om [1, 3] . there are currently inadequate services to deal with ear and hearing health within aboriginal communities and high demand for services is expected to continue in coming years [4] . the world health organisation have identified om in its various forms as a major health issue for aboriginal children, despite the fact that om is preventable and treatable, and is far less common for non-aboriginal children in australia [1] . the gap in prevalence of om between aboriginal and non-aboriginal children has consistently been associated with social determinants, particularly housing-related issues [2] [3] [4] [5] [6] [7] [8] . om can impact upon educational outcomes and employability for aboriginal people who are more likely to be socially and economically disadvantaged than non-aboriginal australians [5] . key risk factors for om in aboriginal children include overcrowded housing, poor housing conditions, exposure to tobacco smoke, malnutrition, socioeconomic disadvantage and limited access to services [2] [3] [4] [5] [6] [7] [8] . aboriginal children experience om at similar rates, frequency and severity as children living in developing nations, despite the overall high standard of living in australia [9, 10] . the prevalence of om in some aboriginal communities is close to 10 times higher than the 4% identified by the world health organisation as being a serious public health problem requiring urgent attention [2] . this puts aboriginal children as one of the most at risk populations for om in the world [3, 11] . significant health gaps have persisted in aboriginal populations since the british invaded australia in 1788 [6, 10] . these health gaps are highlighted by the gap in lifeexpectancy between aboriginal and non-aboriginal australians, with aboriginal children born between 2010 and 2012 expected to live 10.05 years younger than non-aboriginal children [12] . furthermore, social and economic disadvantage have been underscored as significant contributing factors to these poor health outcomes [7] . therefore, social determinants of om in aboriginal children need to be better understood in light of evidence supporting the impact of poor housing, exposure to tobacco smoke and socioeconomic disadvantage on the prevalence and persistence of om in aboriginal children. this review aims to identify how social determinants are addressed in grey and peer-reviewed literature, regarding drivers of om and proposed interventions aimed at minimising the health burden of om among aboriginal children. this review aims to identify gaps in the literature and guide further research, policy development and service provision. given the broad nature of the research objective, a scoping content review was conducted to explore available research, to evaluate the need for further investigation, to describe key themes and to identify gaps in the literature. the framework proposed by arksey and o'malley [13] for conducting a scoping content review was adapted for this study and is detailed below. initially, the research objective was established through preliminary review of the literature and discussion between the research team. following the establishment of the research objective, the search strategy was developed by implementing inclusion and exclusion criteria, and keywords (see table 1 ). the location was limited to australia, the included literature was limited to english only and no time constraints were placed on the date of publication. the population of focus was established by two criteria: individuals of australian aboriginal identity and children aged 12 years old or younger. health condition terms related to om and ear disease. literature type included peer-reviewed and grey literature. the literature search was conducted in april 2017. keywords were established and agreed upon by the research team with the assistance of university library staff for the parameters: location, population and health condition. the selected databases were chosen upon consensus and the search was conducted independently by each research team member and the assisting librarian to limit bias. boolean operators were applied in the literature search within pubmed, proquest, scopus, informit, medline and google scholar. for the google scholar literature search, multiple searches were conducted due to search box restrictions (see table 1 ). location keywords were substituted by selecting results from australia only and each of the om-related terms were searched for separately. the population keywords were searched with boolean operators consistent with other database searches and is detailed in table 1 . the first step in selecting the literature was to exclude any duplicate papers. this was done using endnote (electronic referencing software). google scholar results were limited to the first two pages, given the large number of results yielded and time constraints for conducting the literature search. an excel spreadsheet was created to categorise the literature based on the following parameters: author, title, year, within australia, 'aboriginal-related term', 'omrelated term' and full text available. the literature was then systematically evaluated based on these criteria and included or excluded accordingly. where there was any uncertainty regarding the suitability of an article, consensus on whether to include the article(s) was reached by the research team. following selection of the included literature, two separate excel spreadsheets were created to analyse and report the results. one spreadsheet contained the peer-reviewed [14] , as shown in fig. 1 . the literature search was conducted using six specified databases and the exclusion process is detailed in fig. 2 . the search yielded 186 results, 69 duplicates were excluded and a further 19 articles were excluded based on location of the studies. 98 articles were screened by title and article type, with 47 excluded based on irrelevance of the title and one article was excluded due to the article type (unpublished thesis). following the screening process, 50 articles were included in the study. of the 50 included articles, 40 were peer-reviewed and 10 were grey literature articles. following the exclusion process, the included literature was evaluated by how om related social determinants were addressed. 34 (68%) peer-reviewed and grey articles were identified as discussing social determinants, with 17 (34%) discussing social determinants as a significant factor for driving the high rates of om and 17 (34%) articles identifying the need to address social determinants to reduce the high rates of om in aboriginal children. of the 17 articles that discuss social determinants as important for om management, 11 articles did not discuss this in detail -these articles did not provide specific recommendation or evidence for further research and policy development. for example, sparrow et al. [15] (p14) state "the key to improving chronic middle ear disease must be by addressing living standards and general health". although this type of statement is true and does acknowledge an important issue, the article does not pursue this theme further. further evaluation of the literature revealed that 16 (32%) articles did not mention social determinants at all, with four articles (8%) providing analysis of social determinants of om. these four articles presented social determinants as key priority areas for future intervention and provided supported recommendations to help address social determinants linked to om. for example, jacoby et al. [16] (p602) state "there is a need for more input by indigenous australians in developing programs, increased funding and improved access to nicotine replacement therapy". lastly, the most significant finding was that despite the majority (68%) of the literature discussing social determinants as impacting the presence of om in aboriginal children, there were no studies within the literature that proposed or investigated a social determinants-focussed intervention. in addition to the social determinants-related scoping criteria, the literature was comprehensively assessed using the 'social determinants framework for aboriginal and torres strait islander health'. [14] the social determinants of health framework identifies three key areas of health for aboriginal populations, with the literature addressing 'housing, employment, education and income' most frequently (32%) in relation to high rates of om in aboriginal children. 'community involvement, social networks and family support' were discussed by few articles (16%) and even fewer mentioned 'culture, history and connection to land' (8%). moreover, over 50% of the peer-reviewed articles (n = 22) did not address any of the three key areas of the social determinants of health framework. housing-related social determinants were reported most frequently within the literature, with 28 (56%) reports of housing related risk factors for om (18 specifically related to overcrowded housing). the next most frequently discussed social determinant was exposure to tobacco smoke, with 11 articles (22%) discussing this as a significant determinant for om. low socioeconomic status, low income and poverty (20%), access to services (18%), hygiene (16%), and education of the primary caregiver (14%) were among the most frequently mentioned determinants. other reported determinants for om were employment status and employment opportunities (12%), nutrition (12%), community involvement in service provision and planning (6%), and cultural and language differences (n = 4). sun et al. [17] (p8) explain that improved housing for aboriginal populations is desperately needed, as "overcrowding is the single most important and most consistent risk factor for upper respiratory tract carriage (presence of bacteria), and consequently, the development of om in indigenous children". it is therefore important to note, that of the 40 peerreviewed articles, only jacoby et al. [18] examined overcrowded housing and its impact on om associated bacterial carriage. jacoby et al. [18] provide thorough analysis on aspects of overcrowding, such as the number of adults, children and rooms within a household and its impact on om occurrence. more specifically, the greater the number of people, the greater the number of children and the fewer rooms within a house, the greater the risk of developing om [18] . unfortunately, this article did not identify any means to address these issues and only highlights the seriousness of the housing problems faced by many aboriginal communities. a detailed analysis was performed on what recommendations were made in the literature (i.e. review of the recommended approaches to the management of om in aboriginal children). 31 (62%) of the peer-reviewed and grey articles did not discuss social determinants in future directions at all. 23 articles (46%) primarily recommended further research into antibiotic treatment and vaccine development, and the need for greater understanding of om associated bacterial carriage. five (10%) articles presented detailed recommendations for future research and policy development intended to address social determinants to reduce the high rates of om in aboriginal children. om is one of the leading causes of preventable disease amongst aboriginal children, and has been determined by the world health organisation to be a serious public health issue requiring urgent attention [1] [2] [3] 11] . om primarily occurs during developmental years and can drastically impact upon speech and language development, which is likely to influence educational outcomes and prospective employability-precursors to potentially life-long socioeconomic disadvantage and poverty [5] . this study identifies how social determinants are addressed within grey and peer-reviewed literature, and summarises the primary determinants reported to be associated with om and management recommendations within the literature. this study highlights gaps between factors reported to be associated with om and recommended interventions within the literature. given the significance of this gap, further research aimed at understanding social determinants associated with om and identifying more effective management of the social determinants of om within aboriginal children is warranted. furthermore, the inter-related nature of the social determinants of health is emphasised throughout this paper and helps to underline the challenge that an exclusively biomedical model poses in addressing specific aetiology [19] .(p73-74) notably, a shift in approaches to manage om is desperately needed, in conjunction with further research to better understand the relationship between the social determinants of health and risk of om in aboriginal populations. this review demonstrates that there is an imbalanced research focus towards biomedical approaches in contrast to improving our understanding about how to address key social determinants contributing to high rates of om in aboriginal children. using the social determinants of health framework, this review has identified significant shortcomings within the literature and the current public health management of om in aboriginal children. the social determinants of health framework used within this study identifies three key areas of aboriginal health that are largely neglected by the available grey and peer-reviewed literature in relation to om management. although the literature mentions various social determinants that are consistent with the framework (e.g. housing, education, employment, community engagement, culture and history), none of the included articles evaluated these key areas of aboriginal health with the objective to establish effective social, environmental, political or cultural-focussed interventions for om. further, the key social determinants of om can be argued to stem from the persistent social, economic and cultural discrimination experienced by aboriginal populations. through evaluation using the social determinants of health framework, this review highlights the need to preserve aboriginal culture, strengthen aboriginal self-determination, respect and support aboriginal connection to land, empower aboriginal communities, improve education and employment opportunities for aboriginal people, and address poor housing conditions and overcrowding within aboriginal communities. importantly, one of the most significant and achievable goals should be to ensure the adoption of co-creation and a decolonised approach to ear health research, and health research more broadly, in aboriginal populations. aboriginal self-determination and services that are embedded within community are key to improving the management of om within aboriginal populations [20] . such an approach is needed to help ensure success of public health programmes and services aimed at reducing the risk of om in early life, and consequently helping to eliminate the cycle of disadvantage that contributes to social determinants driving ill-health across the life-course. measurement of such targets should be done through formal and informal consultation with community at each step of the research process. there is growing acknowledgement within the literature that the current empirical research paradigm should adopt co-creation and qualitative research methods, in conjunction with quantitative methodology, to ensure successful research and research translation within aboriginal communities [20] . furthermore, recognising aboriginal people as experts of their communities is vital to ensure successful planning, development, implementation and evaluation of health research and health approaches within aboriginal contexts. the most evident theme arising from this review was the importance of the home environment, with housingrelated determinants reported almost three times more than the next most frequently reported risk factor. despite acknowledgement of the association between housing and the prevalence of om in aboriginal children, there were no intervention studies within the reviewed literature that investigated how to effectively address the issue of housing in aboriginal populations. exposure to cigarette smoke and poor hygiene were not directly acknowledged as relating to housing within this review. however, these risk factors are likely to be influenced to some degree by the home environment, given the relatively high rates of smoking within the home in aboriginal populations [15, 16] . it is therefore evident, that addressing the home environment is fundamental to adequately manage om in aboriginal populations. moreover, further research into housing as a determinant of om and as a means for intervention is desperately needed, given the lack of information available to adequately deal with this area of aboriginal health. addressing housing issues in aboriginal communities is a complex issue, particularly when considering the importance of connection to land in contrast with the importance of the physical structure itself. it can be said that the efforts of government housing programmes have been heavily focussed on the logistics. for example, funding and physical infrastructure, with little acknowledgement of the need to develop culturally appropriate housing policies and pathways [21] . (p207) carson et al. [21] (p219) stress the lack of intervention studies that link housing to aboriginal health outcomes and the ability to develop policy is limited as a result. the lack of intervention studies is also highlighted by this review, as no intervention studies looking at social determinants and aboriginal health outcomes were identified within the literature. intervention studies are crucial for policy development and although remoteness, and political and social barriers exist for improving housing and infrastructure in aboriginal communities [21] , a shift in focus towards more culturally appropriate housing policy and provision is urgently needed. exposure to tobacco smoke is consistently reported as a key contributing factor for aboriginal children developing om. aboriginal children who are exposed to tobacco smoke in the home and who do not attend day-care have been suggested to be at greatest risk of developing om [18] . this is not to say that home-care by parents and family is problematic. however, given the relatively high rates of smoking within the home environment [18] , it is an important issue for consideration. jacoby et al. [18] suggest that children who are exposed to tobacco smoke in the home who also attend day-care may be at lower risk of developing om, presumably because the time spent at daycare means less time exposed to tobacco smoke in the home. however, day-care attendance has previously been associated with a greater risk of om, and further research may help to explain this relationship. moreover, this inconsistent research helps to highlight the evident gaps within the literature resulting from the long-standing narrow lens of the biomedical focus of the existing research. furthermore, this supports calls for further investigation into the relationship of the social determinants of health and environmental factors with om risk in aboriginal children. education and employment of the primary caregiver is cited frequently as an important determinant for aboriginal children developing om. however, no paper within the reviewed literature discussed this any further than listing it as a significant contributing factor. it is important to highlight that low-level education and lack of employment opportunities consign many aboriginal people to levels of poverty [22] . (p108) furthermore, education that excludes culture and native language has been demonstrated to adversely impact individuals by disempowering aboriginal communities and harming the cultural identity of these communities [21] . moreover, hearing loss associated with om is likely to further disengage children within the classroom, and this is compounded by lack of engagement due to hearing loss being misconstrued as misbehaviour. it is therefore clear, that aboriginal children face significant barriers within the classroom and highlights the need for culturally appropriate schooling, accompanied by approaches to reduce rates of om and hearing loss. notably, there were no papers identified within this review that comprehensively evaluated the impact of om across the life-course, including the impact of om on speech, language and early childhood development, which may impact educational outcomes and long-term social and emotional wellbeing. aboriginal community involvement is an area that requires greater emphasis and encouragement from public health promoters, policy makers and service providers. programmes such as the 'healthy ears, happy kids', [9] 'aboriginal otitis media project' [23] , 'hearing, ear health and language services' ('heals') [24] and 'deadly kids, deadly futures' [25] help to draw attention from government and non-government organisations towards the seriousness of the burden of om in aboriginal communities. 'heals' and 'deadly kids, deadly futures' have helped to demonstrate priority areas for the public health management of om in aboriginal communities, in addition to recommendations about key research considerations when working with aboriginal communities. priorities include working towards improved coordination, access and delivery of services, enhancing capacity building within communities, and aboriginal control of research activities and translation [24, 25] . furthermore, these programmes have helped to educate and empower aboriginal communities and health workers to manage om more effectively in a culturally safe way [9, 23, 24] . given the historical marginalisation, neglect and subjugation of aboriginal populations, empowering aboriginal communities to manage health services, develop and implement research, and provide recommendations is essential to overcome issues of mistrust, and consequently, improve cultural access to essential services. importantly, 'deadly kids, deadly futures', which was not identified by the systematic literature search, provides a 'social determinants model of ear and hearing health' that highlights relevant social determinants of ear health for aboriginal children [25] . this model may be useful to guide future research, policy development and the development of services. however, research focussing on how to best target these social determinants is lacking. therefore, further work is needed to advance these programmes and identify how to effectively target the underlying social determinants of om in aboriginal children. despite the lack of research about how to effectively target the social determinants of om, there is a growing body of research regarding diversifying health approaches to better address social determinants of health more broadly. the term 'integrated models of care' has emerged within the literature, which describes the integration of biomedical services with non-medical community services (e.g. housing, employment and food insecurity services) to provide a more comprehensive approach to target underlying risk factors for ill-health [26] . using a similar approach, it is recommended that tools to screen for social determinants associated with om are developed. this will assist health workers to identify and target important social, environmental and cultural risk factors associated with om [27, 28] . information obtained through this type of screening may provide health workers with relevant information to refer at-risk children to community services, in conjunction with traditional medical management, to help alleviate factors placing a child at heightened risk. this process has been referred to as 'social prescribing' and aims to broaden the often-narrow focus of biomedical intervention alone [28] . therefore, it is recommended that future research looks at 'integrated models of care' and 'social prescribing', and how they can be incorporated into primary care management of om and ear disease. additionally, service coordination is key for successful navigation of healthcare systems and referral pathways, which are often complex. by integrating a wider variety of services in the primary care of om, such as housing or employment services, the need for coordination is particularly important to support the implementation of such models [24, 28] . while this review presented a comprehensive analysis of both peer-reviewed and grey literature, this study excluded unpublished masters and doctoral theses. despite this, findings by vickers and smith [29] following review of the cochrane library, found only one of 878 systematic reviews included data from theses that could have significantly altered the conclusions of the 878 reviews. moreover, there is limited benefit of including theses in systematic reviews, as they rarely influence the conclusions, and retrieving and analysing unpublished dissertations involves considerable time and effort [29] . the timeframe of this project also limited the number of selected databases and consequently the number of papers that were included within the study. however, 50 articles still provides comprehensive scope of the literature to enable thorough analysis, detailed explanation and well supported recommendations. using google scholar presented limitations in search function, as search box options within the database meant that a modified search was needed to fulfil the specified search strategy and to remain consistent with searches performed on the other selected databases. there is overwhelming consensus within the reviewed literature that aboriginal children experience disproportionately high rates of om when compared to non-aboriginal children. the high rates of om are linked to poor housing conditions, overcrowded housing, exposure to tobacco smoke, education, and overall social and economic disadvantage. furthermore, there is disparity between reported risk factors of om and current interventions aimed at reducing the burden of om in aboriginal populations. current interventions are primary focussed on biomedical approaches such as investigating vaccines and antibiotics. although vaccines and antibiotics are essential to the provision of high-quality clinical care for om, a broader public health lens is required to address the underlying social factors reported to be driving the gap in om rates between aboriginal and non-aboriginal children. it is important to mention that the aboriginal understanding of health includes "body, mind, spirit, land, environment, custom, socioeconomic status, family and community" [10] . (p417) this understanding of health significantly differs from mainstream models of health, which typically involves the pursuit to merely limit ill-health within individuals without considering the context of their lives [10] . therefore, policy and services founded upon this restricted understanding of health is likely to be restrictive in its ability to address the much more holistic aboriginal understanding of health, which includes how people live, work and interact with their environment, and the importance of community for the individual. in accordance with this notion, engaging communities in research design and implementation is fundamental to shift the current research paradigm. understanding the context of aboriginal lives is key for successful research and meaningful translation of research. further research into how social determinants contribute to om and what interventions may be beneficial to address om associated social determinants in aboriginal children is needed. intervention studies to evaluate the benefit of culturally suitable, accessible and safe housing on rates of om in aboriginal communities is vital. lastly, development of an aboriginal ear health framework is recommended. development of a comprehensive ear health framework requires further research, although should include information about social determinants of health screening, social prescribing, and coordinating the complex network of health and community services that may help to address underlying social determinants of om. research evaluating the association between social determinants of health and risk of om in aboriginal children what is known about health and hearing? in: australian indigenous healthinfonet review of ear health and hearing among indigenous australian household number associated with middle ear disease in urban indigenous health service: a cross-sectional study australian institute of health and welfare. ear and hearing health of indigenous children in the northern territory australian institute of health and welfare. ear disease in aboriginal and torres strait islander children otitis media in indigenous australian children: review of epidemiology and risk factors gaps in indigenous disadvantage not closing: a cencus cohort study of social determinants of health in australia, canada and new zealand from longtitudal analysis of ear infection and hearing impairment: findings from 6-year prospective cohorts of australian chidlren healthy ears, happy kids: a new approach to aboriginal child ear health in nsw health equity and the social determinants of health in australia the spectrum and management of otitis media in australian indigenous and nonindigenous children: a national study australian institute of health and welfare. the health and welfare of australia's aboriginal and torres strait islander peoples 2015 scoping studies: towards a methodological framework department of health and ageing. summary of aboriginal and torres strait islander health status do tissue spears used to clear ear canal pus improve hearing? a case series study of hearing in remote australian aboriginal children with chronic suppurative otitis media before and after dry mopping with tissue spears the effect of passive smoking on the risk of otitis media in aboriginal and non-aboriginal children in the kalgoorlie? boulder region of western australia association between early bacterial carriage and otitis media in aboriginal and non-aboriginal children in a semi-arid area of western australia: a cohort study crowding and other strong predictors of upper respiratory tract carriage of otitis media-related bacteria in australian aboriginal and non-aboriginal children environments for health: a salutogenic approach building trust and sharing power for co-creation in aboriginal health research: a stakeholder interview study social determinants of indigenous health. crows nest: allen & unwin australia indigenous australians and health: the wombat in the room ear infection ten times more likely in aboriginal children a case study of enhanced clinical care enabled by aboriginal health research: the hearing, ear health and language services (heals) project deadly futures: queensland's aboriginal and torres strait islander child ear health framework addressing social determinants of health: challenges and opportunities in a value-based model screening and referral for low-income families' socal determinants of health by us pediatricians social prescribing incorporating data from dissertations in systematic reviews publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations authors' contributions all authors have read and approved the final manuscript. jd: protocol development, literature search, data collection, data collation, data analysis, interpretation of results and was the major contributor to writing the manuscript. td: protocol development, literature search, interpretation of results, reporting of results and contributed to writing the manuscript. jm: literature search, interpretations of results, reporting of results and contributed to writing the manuscript. not applicable. data are available through the corresponding author.ethics approval and consent to participate not applicable. not applicable. the authors declare that they have no competing interests. key: cord-018947-d4im0p9e authors: helbing, dirk title: challenges in economics date: 2012-02-10 journal: social self-organization doi: 10.1007/978-3-642-24004-1_16 sha: doc_id: 18947 cord_uid: d4im0p9e in the same way as the hilbert program was a response to the foundational crisis of mathematics [1], this article tries to formulate a research program for the socio-economic sciences. the aim of this contribution is to stimulate research in order to close serious knowledge gaps in mainstream economics that the recent financial and economic crisis has revealed. by identifying weak points of conventional approaches in economics, we identify the scientific problems which need to be addressed. we expect that solving these questions will bring scientists in a position to give better decision support and policy advice. we also indicate, what kinds of insights can be contributed by scientists from other research fields such as physics, biology, computer and social science. in order to make a quick progress and gain a systemic understanding of the whole interconnected socio-economic-environmental system, using the data, information and computer systems available today and in the near future, we suggest a multi-disciplinary collaboration as most promising research approach. static where the world was dynamic, it assumed competitive markets where few existed, it assumed rationality when we knew full well that economic agents were not rational . . . economics had no way of dealing with changing tastes and technology . . . econometrics was equally plagued with intractable problems: economic observations are never randomly drawn and seldom independent, the number of excluded variables is always unmanageably large, the degrees of freedom unacceptably small, the stability of significance tests seldom unequivocably established, the errors in measurement too large to yield meaningful results . . . " [5] . in the following, we will try to identify the scientific challenges that must be addressed to come up with better theories in the near future. this comprises practical challenges, i.e. the real-life problems that must be faced (see sect. 16 .2), and fundamental challenges, i.e. the methodological advances that are required to solve these problems (see sect. 16.3) . after this, we will discuss, which contribution can be made by related scientific disciplines such as econophysics and the social sciences. the intention of this contribution is constructive. it tries to stimulate a fruitful scientific exchange, in order to find the best way out of the crisis. according to our perception, the economic challenges we are currently facing can only be mastered by large-scale, multi-disciplinary efforts and by innovative approaches [6] . we fully recognize the large variety of non-mainstream approaches that has been developed by "heterodox economists". however, the research traditions in economics seem to be so powerful that these are not paid much attention to. besides, there is no agreement on which of the alternative modeling approaches would be the most promising ones, i.e. the heterogeneity of alternatives is one of the problems, which slows down their success. this situation clearly implies institutional challenges as well, but these go beyond the scope of this contribution and will therefore be addressed in the future. since decades, if not since hundreds of years, the world is facing a number of recurrent socio-economic problems, which are obviously hard to solve. before addressing related fundamental scientific challenges in economics, we will therefore point out practical challenges one needs to pay attention to. this basically requires to classify the multitude of problems into packages of interrelated problems. probably, such classification attempts are subjective to a certain extent. at least, the list presented below differs from the one elaborated by lomborg et al. [7] , who identified the following top ten problems: air pollution, security/conflict, disease control, education, climate change, hunger/malnutrition, water sanitation, barriers to migration and trade, transnational terrorism and, finally, women and development. the following (non-ranked) list, in contrast, is more focused on socio-economic factors rather than resource and engineering issues, and it is more oriented at the roots of problems rather than their symptoms: 1. demographic change of the population structure (change of birth rate, migration, integration. . . ) 2. financial and economic (in)stability (government debts, taxation, and inflation/ deflation; sustainability of social benefit systems; consumption and investment behavior. . . ) 3. social, economic and political participation and inclusion (of people of different gender, age, health, education, income, religion, culture, language, preferences; reduction of unemployment. . . ) 4. balance of power in a multi-polar world (between different countries and economic centers; also between individual and collective rights, political and company power; avoidance of monopolies; formation of coalitions; protection of pluralism, individual freedoms, minorities. . . ) 5. collective social behavior and opinion dynamics (abrupt changes in consumer behavior; social contagion, extremism, hooliganism, changing values; breakdown of cooperation, trust, compliance, solidarity. . . ) 6. security and peace (organized crime, terrorism, social unrest, independence movements, conflict, war. . . ) 7. institutional design (intellectual property rights; over-regulation; corruption; balance between global and local, central and decentral control. . . ) 8. sustainable use of resources and environment (consumption habits, travel behavior, sustainable and efficient use of energy and other resources, participation in recycling efforts, environmental protection. . . ) 9. information management (cyber risks, misuse of sensitive data, espionage, violation of privacy; data deluge, spam; education and inheritance of culture. . . ) 10 . public health (food safety; spreading of epidemics [flu, sars, h1n1, hiv], obesity, smoking, or unhealthy diets. . . ) some of these challenges are interdependent. in the following, we will try to identify the fundamental theoretical challenges that need to be addressed in order to understand the above practical problems and to draw conclusions regarding possible solutions. the most difficult part of scientific research is often not to find the right answer. the problem is to ask the right questions. in this context it can be a problem that people are trained to think in certain ways. it is not easy to leave these ways and see the problem from a new angle, thereby revealing a previously unnoticed solution. three factors contribute to this: 1. we may overlook the relevant facts because we have not learned to see them, i.e. we do not pay attention to them. the issue is known from internalized norms, which prevent people from considering possible alternatives. 2. we know the stylized facts, but may not have the right tools at hand to interpret them. it is often difficult to make sense of patterns detected in data. turning data into knowledge is quite challenging. 3. we know the stylized facts and can interpret them, but may not take them seriously enough, as we underestimate their implications. this may result from misjudgements or from herding effects, i.e. from a tendency to follow traditions and majority opinions. in fact, most of the issues discussed below have been pointed out before, but it seems that this did not have an effect on mainstream economics so far or on what decision-makers know about economics. this is probably because mainstream theory has become a norm [8] , and alternative approaches are sanctioned as norm-deviant behavior [9, 10] . as we will try to explain, the following fundamental issues are not just a matter of approximations (which often lead to the right understanding, but wrong numbers). rather they concern fundamental errors in the sense that certain conclusions following from them are seriously misleading. as the recent financial crisis has demonstrated, such errors can be very costly. however, it is not trivial to see what dramatic consequences factors such as dynamics, spatial interactions, randomness, non-linearity, network effects, differentiation and heterogeneity, irreversibility or irrationality can have. despite of criticisms by several nobel prize winners such as reinhard selten (1994), joseph stiglitz and george akerlof (2001) , or daniel kahneman (2002) , the paradigm of the homo economicus, i.e. of the "perfect egoist", is still the dominating approach in economics. it assumes that people would have quasi-infinite memory and processing capacities and would determine the best one among all possible alternative behaviors by strategic thinking (systematic utility optimization), and would implement it into practice without mistakes. the nobel prize winner of 1976, milton friedman, supported the hypothesis of homo economicus by the following argument: "irrational agents will lose money and will be driven out of the market by rational agents" [11] . more recently, robert e. lucas jr., the nobel prize winner of 1995, used the rationality hypothesis to narrow down the class of empirically relevant equilibria [12] . the rational agent hypothesis is very charming, as its implications are clear and it is possible to derive beautiful and powerful economic theorems and theories from it. the best way to illustrate homo economicus is maybe a company that is run by using optimization methods from operation research, applying supercomputers. another example are professional chess players, who are trying to anticipate the possible future moves of their opponents. obviously, in both examples, the future course of actions can not be fully predicted, even if there are no random effects and mistakes. it is, therefore, no wonder that people have repeatedly expressed doubts regarding the realism of the rational agent approach [13, 14] . bertrand russell, for example, claimed: "most people would rather die than think". while this seems to be a rather extreme opinion, the following scientific arguments must be taken seriously: 1. human cognitive capacities are bounded [16, 17] . already phone calls or conversations can reduce people's attention to events in the environment a lot. also, the abilities to memorize facts and to perform complicated logical analyses are clearly limited. 2. in case of np-hard optimization problems, even supercomputers are facing limits, i.e. optimization jobs cannot be performed in real-time anymore. therefore, approximations or simplifications such as the application of heuristics may be necessary. in fact, psychologists have identified a number of heuristics, which people use when making decisions [18] . 3. people perform strategic thinking mainly in important new situations. in normal, everyday situation, however, they seem to pursue a satisficing rather than optimizing strategy [17] . meeting a certain aspiration level rather than finding the optimal strategy can save time and energy spent on problem solving. in many situation, people even seem to perform routine choices [14] , for example, when evading other pedestrians in counterflows. 4. there is a long list of cognitive biases which question rational behavior [19] . for example, individuals are favorable of taking small risks (which are preceived as "chances", as the participation in lotteries shows), but they avoid large risks [20] . furthermore, non-exponential temporal discounting may lead to paradoxical behaviors [21] and requires one to rethink, how future expectations must be modeled. 5. most individuals have a tendency towards other-regarding behavior and fairness [22, 23] . for example, the dictator game [24] and other experiments [25] show that people tend to share, even if there is no reason for this. leaving a tip for the waiter in a restaurant that people visit only once is a typical example (particularly in countries where tipping is not common) [26] . such behavior has often been interpreted as sign of social norms. while social norms can certainly change the payoff structure, it has been found that the overall payoffs resulting from them do not need to create a user or system optimum [27] [28] [29] . this suggests that behavioral choices may be irrational in the sense of non-optimal. a typical example is the existence of unfavorable norms, which are supported by people although nobody likes them [30] . 6. certain optimization problems can have an infinite number of local optima or nash equilibria, which makes it impossible to decide what is the best strategy [31] . 7. convergence towards the optimal solution may require such a huge amount of time that the folk theorem becomes useless. this can make it practically impossible to play the best response strategy [32] . 8. the optimal strategy may be deterministically chaotic, i.e. sensitive to arbitrarily small details of the initial condition, which makes the dynamic solution unpredictable on the long run ("butterfly effect") [33, 34] . this fundamental limit of predictability also implies a limit of control-two circumstances that are even more true for non-deterministic systems with a certain degree of randomness. in conclusion, although the rational agent paradigm (the paradigm of homo economicus) is theoretically powerful and appealing, there are a number of empirical and theoretical facts, which suggest deficiencies. in fact, most methods used in financial trading (such as technical analysis) are not well compatible with the rational agent approach. even if an optimal solution exists, it may be undecidable for practical reasons or for theoretical ones [35, 36] . this is also relevant for the following challenges, as boundedly rational agents may react inefficently and with delays, which questions the efficient market hypothesis, the equilibrium paradigm, and other fundamental concepts, calling for the consideration of spatial, network, and time-dependencies, heterogeneity and correlations etc. it will be shown that these points can have dramatic implications regarding the predictions of economic models. the efficient market hypothesis (emh) was first developed by eugene fama [37] in his ph.d. thesis and rapidly spread among leading economists, who used it as an argument to promote laissez-faire policies. the emh states that current prices reflect all publicly available information and (in its stronger formulation) that prices instantly change to reflect new public information. the idea of self-regulating markets goes back to adam smith [38] , who believed that "the free market, while appearing chaotic and unrestrained, is actually guided to produce the right amount and variety of goods by a so-called "invisible hand"." furthermore, "by pursuing his own interest, [the individual] frequently promotes that of the society more effectually than when he intends to promote it" [39] . for this reason, adam smith is often considered to be the father of free market economics. curiously enough, however, he also wrote a book on "the theory of moral sentiments" [40] . "his goal in writing the work was to explain the source of mankind's ability to form moral judgements, in spite of man's natural inclinations towards self-interest. smith proposes a theory of sympathy, in which the act of observing others makes people aware of themselves and the morality of their own behavior . . . [and] seek the approval of the "impartial spectator" as a result of a natural desire to have outside observers sympathize with them" [38] . such a reputation-based concept would be considered today as indirect reciprocity [41] . of course, there are criticisms of the efficient market hypothesis [42] , and the nobel prize winner of 2001, joseph stiglitz, even believes that "there is not invisible hand" [43] . the following list gives a number of empirical and theoretical arguments questioning the efficient market hypothesis: 1. examples of market failures are well-known and can result, for example, in cases of monopolies or oligopolies, if there is not enough liquidity or if information symmetry is not given. 2. while the concept of the "invisible hand" assumes something like an optimal self-organization [44] , it is well-known that this requires certain conditions, such as symmetrical interactions. in general, however, self-organization does not necessarily imply system-optimal solutions. stop-and-go traffic [45] or crowd disasters [46] are two obvious examples for systems, in which individuals competitively try to reach individually optimal outcomes, but where the optimal solution is dynamically unstable. 3. the limited processing capacity of boundedly rational individuals implies potential delays in their responses to sensorial inputs, which can cause such instabilities [47] . for example, a delayed adaptation in production systems may contribute to the occurrence of business cycles [48] . the same applies to the labor market of specially skilled people, which cannot adjust on short time scales. even without delayed reactions, however, the competitive optimization of individuals can lead to suboptimal individual results, as the "tragedy of the commons" in public goods dilemmas demonstrates [49, 50] . 4. bubbles and crashes, or more generally, extreme events in financial markets should not occur, if the efficient market hypothesis was correct (see next subsection). 5. collective social behavior such as "herding effects" as well as deviations of human behavior from what is expected from rational agents can lead to such bubbles and crashes [51] , or can further increase their size through feedback effects [52] . cyclical feedbacks leading to oscillations are also known from the beer game [53] or from business cycles [48] . the efficient market paradigm implies the equilibrium paradigm. this becomes clear, if we split it up into its underlying hypotheses: 1. the market can be in equilibrium, i.e. there exists an equilibrium. 2. there is one and only one equilibrium. 3. the equilibrium is stable, i.e. any deviations from the equilibrium due to "fluctuations" or "perturbations" tend to disappear eventually. 4. the relaxation to the equilibrium occurs at an infinite rate. note that, in order to act like an "invisible hand", the stable equilibrium (nash equilibrium) furthermore needs to be a system optimum, i.e. to maximize the average utility. this is true for coordination games, when interactions are well-mixed and exploration behavior as well as transaction costs can be neglected [54] . however, it is not fulfilled by so-called social dilemmas [49] . let us discuss the evidence for the validity of the above hypotheses one by one: 1. a market is a system of extremely many dynamically coupled variables. theoretically, it is not obvious that such a system would have a stationary solution. for example, the system could behave periodic, quasi-periodic, chaotic, or turbulent [81-83, 85-87, 94] . in all these cases, there would be no convergence to a stationary solution. 2. if a stationary solution exists, it is not clear that there are no further stationary solutions. if many variables are non-linearly coupled, the phenomenon of multistability can easily occur [55] . that is, the solution to which the system converges may not only depend on the model parameters, but also on the initial condition, history, or perturbation size. such facts are known as path-dependencies or hysteresis effects and are usually visualized by so-called phase diagrams [56] . 3. in systems of non-linearly interacting variables, the existence of a stationary solution does not necessarily imply that it is stable, i.e. that the system will converge to this solution. for example, the stationary solution could be a focal point with orbiting solutions (as for the classical lotka-volterra equations [57] ), or it could be unstable and give rise to a limit cycle [58] or a chaotic solution [33] , for example (see also item 1). in fact, experimental results suggest that volatility clusters in financial markets may be a result of over-reactions to deviations from the fundamental value [59] . 4. an infinite relaxation rate is rather unusual, as most decisions and related implemenations take time [15, 60] . the points listed in the beginning of this subsection are also questioned by empirical evidence. in this connection, one may mention the existence of business cycles [48] or unstable orders and deliveries observed in the experimental beer game [53] . moreover, bubbles and crashes have been found in financial market games [61] . today, there seems to be more evidence against than for the equilibrium paradigm. in the past, however, most economists assumed that bubbles and crashes would not exist (and many of them still do). the following quotes are quite typical for this kind of thinking (from [62] ): in 2004, the federal reserve chairman of the u.s., alan greenspan, stated that the rise in house values was "not enough in our judgment to raise major concerns". in july 2005 when asked about the possibility of a housing bubble and the potential for this to lead to a recession in the future, the present u.s. federal reserve chairman ben bernanke (then chairman of the council of economic advisors) said: "it's a pretty unlikely possibility. we've never had a decline in housing prices on a nationwide basis. so, what i think is more likely is that house prices will slow, maybe stabilize, might slow consumption spending a bit. i don't think it's going to drive the economy too far from it's full path though." as late as may 2007 bernanke stated that the federal reserve "do not expect significant spillovers from the subprime market to the rest of the economy". according to the classical interpretation, sudden changes in stock prices result from new information, e.g. from innovations ("technological shocks"). the dynamics in such systems has, for example, been described by the method of comparative statics (i.e. a series of snapshots). here, the system is assumed to be in equilibrium in each moment, but the equilibrium changes adiabatically (i.e. without delay), as the system parameters change (e.g. through new facts). such a treatment of system dynamics, however, has certain deficiencies: 1. the approach cannot explain changes in or of the system, such as phase transitions ("systemic shifts"), when the system is at a critical point ("tipping point"). 2. it does not allow one to understand innovations and other changes as results of an endogeneous system dynamics. 3. it cannot describe effects of delays or instabilities, such as overshooting, self-organization, emergence, systemic breakdowns or extreme events (see sect. 16.3.4). 4. it does not allow one to study effects of different time scales. for example, when there are fast autocatalytic (self-reinfocing) effects and slow inhibitory effects, this may lead to pattern formation phenomena in space and time [63, 64] . the formation of settlements, where people agglomerate in space, may serve as an example [65, 66] . 5. it ignores long-term correlations such as memory effects. 6. it neglects frictional effects, which are often proportional to change ("speed") and occur in most complex systems. without friction, however, it is difficult to understand entropy and other path-dependent effects, in particular irreversibility (i.e. the fact that the system may not be able to get back to the previous state) [67] . for example, the unemployment rate has the property that it does not go back to the previous level in most countries after a business cycle [68] . comparative statics is, of course, not the only method used in economics to describe the dynamics of the system under consideration. as in physics and other fields, one may use a linear approximation around a stationary solution to study the response of the system to fluctuations or perturbations [69] . such a linear stability analysis allows one to study, whether the system will return to the stationary solution (which is the case for a stable [nash] equilibrium) or not (which implies that the system will eventually be driven into a new state or regime). in fact, the great majority of statistical analyses use linear models to fit empirical data (also when they do not involve time-dependencies). it is know, however, that linear models have special features, which are not representative for the rich variety of possible functional dependencies, dynamics, and outcomes. therefore, the neglection of non-linearity has serious consequences: 1. as it was mentioned before, phenomena like multiple equilibria, chaos or turbulence cannot be understood by linear models. the same is true for selforganization phenomena or emergence. additionally, in non-linearly coupled systems, usually "more is different", i.e. the system may change its behavior fundamentally as it grows beyond a certain size. furthermore, the system is often hard to predict and difficult to control (see sect. 16.3.8). 2. linear modeling tends to overlook that a strong coupling of variables, which would show a normally distributed behavior in separation, often leads to fat tail distributions (such as "power laws") [70, 71] . this implies that extreme events are much more frequent than expected according to a gaussian distribution. for example, when additive noise is replaced by multiplicative noise, a number of surprising phenomena may result, including noise-induced transitions [72] or directed random walks ("ratchet effects") [73] . 3. phenomena such as catastrophes [74] or phase transition ("system shifts") [75] cannot be well understood within a linear modeling framework. the same applies to the phenomenon of "self-organized criticality" [79] (where the system drives itself to a critical state, typically with power-law characteristics) or cascading effects, which can result from network interactions (overcritically challenged network nodes or links) [77, 78] . it should be added that the relevance of network effects resulting from the on-going globalization is often underestimated. for example, "the stock market crash of 1987, began with a small drop in prices which triggered an avalanche of sell orders in computerized trading programs, causing a further price decline that triggered more automatic sales." [80] therefore, while linear models have the advantage of being analytically solvable, they are often unrealistic. studying non-linear behavior, in contrast, often requires numerical computational approaches. it is likely that most of today's unsolved economic puzzles cannot be well understood through linear models, no matter how complicated they may be (in terms of the number of variables and parameters) [81] [82] [83] [84] [85] [86] [87] [88] [89] [90] [91] [92] [93] [94] . the following list mentions some areas, where the importance of non-linear interdependencies is most likely underestimated: â�¢ collective opinions, such as trends, fashions, or herding effects. â�¢ the success of new (and old) technologies, products, etc. â�¢ cultural or opinion shifts, e.g. regarding nuclear power, genetically manipulated food, etc. â�¢ the "fitness" or competitiveness of a product, value, quality perceptions, etc. â�¢ the respect for copyrights. â�¢ social capital (trust, cooperation, compliance, solidarity, . . . ). â�¢ booms and recessions, bubbles and crashes. â�¢ bank panics. â�¢ community, cluster, or group formation. â�¢ relationships between different countries, including war (or trade war) and peace. another common simplification in economic modeling is the representative agent approach, which is known in physics as mean field approximation. within this framework, time-dependencies and non-linear dependencies are often considered, but it is assumed that the interaction with other agents (e.g. of one company with all the other companies) can be treated as if this agent would interact with an average agent, the "representative agent". let us illustrate this with the example of the public goods dilemma. here, everyone can decide whether to make an individual contribution to the public good or not. the sum of all contributions is multiplied by a synergy factor, reflecting the benefit of cooperation, and the resulting value is equally shared among all people. the prediction of the representative agent approach is that, due to the selfishness of agents, a "tragedy of the commons" would result [49] . according to this, everybody should free-ride, i.e. nobody should make a contribution to the public good and nobody would gain anything. however, if everybody would contribute, everybody could multiply his or her contribution by the synergy factor. this example is particularly relevant as society is facing a lot of public goods problems and would not work without cooperation. everything from the creation of public infrastructures (streets, theaters, universities, libraries, schools, the world wide web, wikipedia etc.) over the use of environmental resources (water, forests, air, etc.) or of social benefit systems (such as a public health insurance), maybe even the creation and maintainance of a commonly shared language and culture are public goods problems (although the last examples are often viewed as coordination problems). even the process of creating public goods is a public good [95] . while it is a well-known problem that people tend to make unfair contributions to public goods or try to get a bigger share of them, individuals cooperate much more than one would expect according to the representative agent approach. if they would not, society could simply not exist. in economics, one tries to solve the problem by introducing taxes (i.e. another incentive structure) or a "shadow of the future" (i.e. a strategic optimization over infinite time horizons in accordance with the rational agent approach) [96, 97] . both comes down to changing the payoff structure in a way that transforms the public good problem into another one that does not constitute a social dilemma [98] . however, there are other solutions of the problem. when the realm of the mean-field approximation underlying the representative agent approach is left and spatial or network interactions or the heterogeneity among agents are considered, a miracle occurs: cooperation can survive or even thrive through correlations and co-evolutionary effects [99] [100] [101] . a similar result is found for the public goods game with costly punishment. here, the representative agent model predicts that individuals avoid to invest into punishment, so that punishment efforts eventually disappear (and, as a consequence, cooperation as well). however, this "second-order free-rider problem" is naturally resolved and cooperation can spread, if one discards the mean-field approximation and considers the fact that interactions take place in space or social networks [56] . societies can overcome the tragedy of the commons even without transforming the incentive structure through taxes. for example, social norms as well as group dynamical and reputation effects can do so [102] . the representative agent approach implies just the opposite conclusion and cannot well explain the mechanisms on which society is built. it is worth pointing out that the relevance of public goods dilemmas is probably underestimated in economics. partially related to adam smith's belief in an "invisible hand", one often assumes underlying coordination games and that they would automatically create a harmony between an individually and system optimal state in the course of time [54] . however, running a stable financial system and economy is most likely a public goods problem. considering unemployment, recessions always go along with a breakdown of solidarity and cooperation. efficient production clearly requires mutual cooperation (as the counter-example of countries with many strikes illustrates). the failure of the interbank market when banks stop lending to each other, is a good example for the breakdown of both, trust and cooperation. we must be aware that there are many other systems that would not work anymore, if people would lose their trust: electronic banking, e-mail and internet use, facebook, ebusiness and egovernance, for example. money itself would not work without trust, as bank panics and hyperinflation scenarios show. similarly, cheating customers by selling low-quality products or selling products at overrated prices, or by manipulating their choices by advertisements rather than informing them objectively and when they want, may create profits on the short run, but it affects the trust of customers (and their willingness to invest). the failure of the immunization campaign during the swine flu pandemics may serve as an example. furthermore, people would probably spend more money, if the products of competing companies were better compatible with each other. therefore, on the long run, more cooperation among companies and with the customers would pay off and create additional value. besides providing a misleading picture of how cooperation comes about, there are a number of other deficiencies of the representative agent approach, which are listed below: 1. correlations between variables are neglected, which is acceptable only for "well-mixing" systems. according to what is known from critical phenomena in physics, this approximation is valid only, when the interactions take place in high-dimensional spaces or if the system elements are well connected. (however, as the example of the public goods dilemma showed, this case does not necessarily have beneficial consequences. well-mixed interactions could rather cause a breakdown of social or economic institutions, and it is conceivable that this played a role in the recent financial crisis.) 2. percolation phenomena, describing how far an idea, innovation, technology, or (computer) virus spreads through a social or business network, are not well reproduced, as they depend on details of the network structure, not just on the average node degree [103] . 3. the heterogeneity of agents is ignored. for this reason, factors underlying economic exchange, perturbations, or systemic robustness [104] cannot be well described. moreover, as socio-economic differentiation and specialization imply heterogeneity, they cannot be understood as emergent phenomena within a representative agent approach. finally, it is not possible to grasp innovation without the consideration of variability. in fact, according to evolutionary theory, the innovation rate would be zero, if the variability was zero [105] . furthermore, in order to explain innovation in modern societies, schumpeter introduced the concept of the "political entrepreneur" [106] , an extra-ordinarily gifted person capable of creating disruptive change and innovation. such an extraordinary individual can, by definition, not be modeled by a "representative agent". one of the most important drawbacks of the representative agent approach is that it cannot explain the fundamental fact of economic exchange, since it requires one to assume a heterogeneity in resources or production costs, or to consider a variation in the value of goods among individuals. ken arrow, nobel prize winner in 1972, formulated this point as follows [107] : "one of the things that microeconomics teaches you is that individuals are not alike. there is heterogeneity, and probably the most important heterogeneity here is heterogeneity of expectations. if we didn't have heterogeneity, there would be no trade." we close this section by mentioning that economic approaches, which go beyond the representative agent approach, can be found in refs. [108, 109] . another deficiency of economic theory that needs to be mentioned is the lack of a link between micro-and macroeconomics. neoclassical economics implicitly assumes that individuals make their decisions in isolation, using only the information received from static market signals. within this oversimplified framework, macro-aggregates are just projections of some representative agent behavior, instead of the outcome of complex interactions with asymmetric information among a myriad of heterogeneous agents. in principle, it should be understandable how the macroeconomic dynamics results from the microscopic decisions and interactions on the level of producers and consumers [81, 110] (as it was possible in the past to derive micro-macro links for other systems with a complex dynamical behavior such as interactive vehicle traffic [111] ). it should also be comprehensible how the macroscopic level (the aggregate econonomic situation) feeds back on the microscopic level (the behavior of consumers and producers), and to understand the economy as a complex, adaptive, self-organizing system [112, 113] . concepts from evolutionary theory [114] and ecology [115] appear to be particularly promising [116] . this, however, requires a recognition of the importance of heterogeneity for the system (see the the previous subsection). the lack of ecological thinking implies not only that the sensitive network interdependencies between the various agents in an economic system (as well as minority solutions) are not properly valued. it also causes deficiencies in the development and implementation of a sustainable economic approach based on recycling and renewable resources. today, forestry science is probably the best developed scientific discipline concerning sustainability concepts [117] . economic growth to maintain social welfare is a serious misconception. from other scientific disciplines, it is well known that stable pattern formation is also possible for a constant (and potentially sustainable) inflow of energy [69, 118] . one of the great achievements of economics is that it has developed a multitude of methods to use scarce resources efficiently. a conventional approach to this is optimization. in principle, there is nothing wrong about this approach. nevertheless, there are a number of problems with the way it is usually applied: 1. one can only optimize for one goal at a time, while usually, one needs to meet several objectives. this is mostly addressed by weighting the different goals (objectives), by executing a hierarchy of optimization steps (through ranking and prioritization), or by applying a satisficing strategy (requiring a minimum performance for each goal) [119, 120] . however, when different optimization goals are in conflict with each other (such as maximizing the throughput and minimizing the queue length in a production system), a sophisticated timedependent strategy may be needed [121] . high profit? best customer satisfaction? large throughput? competitive advantage? resilience? [122] in fact, the choice of the optimization function is arbitrary to a certain extent and, therefore, the result of optimization may vary largely. goal selection requires strategic decisions, which may involve normative or moral factors (as in politics). in fact, one can often observe that, in the course of time, different goal functions are chosen. moreover, note that the maximization of certain objectives such as resilience or "fitness" depends not only on factors that are under the control of a company. resilience and "fitness" are functions of the whole system, in particularly, they also depend on the competitors and the strategies chosen by them. 3. the best solution may be the combination of two bad solutions and may, therefore, be overlooked. in other words, there are "evolutionary dead ends", so that gradual optimization may not work. (this problem can be partially overcome by the application of evolutionary mechanisms [120] ). 4. in certain systems (such as many transport, logistic, or production systems), optimization tends to drive the system towards instability, since the point of maximum efficiency is often in the neighborhood or even identical with the point of breakdown of performance. such breakdowns in capacity or performance can result from inefficiencies due to dynamic interaction effects. for example, when traffic flow reaches its maximum capacity, sooner or later it breaks down. as a consequence, the road capacity tends to drop during the time period where it is most urgently needed, namely during the rush hour [45, 123] . 5 . optimization often eliminates reduncancies in the system and, thereby, increases the vulnerability to perturbations, i.e. it decreases robustness and resilience. 6. optimization tends to eliminate heterogeneity in the system [80] , while heterogeneity frequently supports adaptability and resilience. 7. optimization is often performed with centralized concepts (e.g. by using supercomputers that process information collected all over the system). such centralized systems are vulnerable to disturbances or failures of the central control unit. they are also sensitive to information overload, wrong selection of control parameters, and delays in adaptive feedback control. in contrast, decentralized control (with a certain degree of autonomy of local control units) may perform better, when the system is complex and composed of many heterogeneous elements, when the optimization problem is np hard, the degree of fluctuations is large, and predictability is restricted to short time periods [77, 124] . under such conditions, decentralized control strategies can perform well by adaptation to the actual local conditions, while being robust to perturbations. urban traffic light control is a good example for this [121, 125] . 8. further on, today's concept of quality control appears to be awkward. it leads to a never-ending contest, requiring people and organizations to fulfil permanently increasing standards. this leads to over-emphasizing measured performance criteria, while non-measured success factors are neglected. the engagement into non-rewarded activities is discouraged, and innovation may be suppressed (e.g. when evaluating scientists by means of their h-index, which requires them to focus on a big research field that generates many citations in a short time). while so-called "beauty contests" are considered to produce the best results, they will eventually absorb more and more resources for this contest, while less and less time remains for the work that is actually to be performed, when the contest is won. besides, a large number of competitors have to waste considerable resources for these contests which, of course, have to be paid by someone. in this way, private and public sectors (from physicians over hospitals, administrations, up to schools and universities) are aching under the evaluationrelated administrative load, while little time remains to perform the work that the corresponding experts have been trained for. it seems naã¯ve to believe that this would not waste resources. rather than making use of individual strengths, which are highly heterogeneous, today's way of evaluating performance enforces a large degree of conformity. there are also some problems with parameter fitting, a method based on optimization as well. in this case, the goal function is typically an error function or a likelihood function. not only are calibration methods often "blindly" applied in practice (by people who are not experts in statistics), which can lead to overfitting (the fitting of meaningless "noise"), to the neglection of collinearities (implying largely variable parameter values), or to inaccurate and problematic parameter determinations (when the data set is insufficient in size, for example, when large portfolios are to be optimized [126] ). as estimates for past data are not necessarily indicative for the future, making predictions with interpolation approaches can be quite problematic (see also sect. 16.3.3 for the challenge of time dependence). moreover, classical calibration methods do not reveal inappropriate model specifications (e.g. linear ones, when non-linear models would be needed, or unsuitable choices of model variables). finally, they do not identify unknown unknowns (i.e. relevant explanatory variables, which have been overlooked in the modeling process). managing economic systems is a particular challenge, not only for the reasons discussed in the previous section. as large economic systems belong to the class of complex systems, they are hard or even impossible to manage with classical control approaches [76, 77] . complex systems are characterized by a large number of system elements (e.g. individuals, companies, countries, . . . ), which have non-linear or network interactions causing mutual dependencies and responses. such systems tend to behave dynamic rather than static and probabilistic rather than deterministic. they usually show a rich, hardly predictable, and sometimes paradoxical system behavior. therefore, they challenge our way of thinking [127] , and their controllability is often overestimated (which is sometimes paraphrased as "illusion of control") [80, 128, 129] . in particular, causes and effects are typically not proportional to each other, which makes it difficult to predict the impact of a control attempt. a complex system may be unresponsive to a control attempt, or the latter may lead to unexpected, large changes in the system behavior (so-called "phase transitions", "regime shifts", or "catastrophes") [75] . the unresponsiveness is known as principle of le chatelier or goodhart's law [130] , according to which a complex system tends to counteract external control attempts. however, regime shifts can occur, when the system gets close to so-called "critical points" (also known as "tipping points"). examples are sudden changes in public opinion (e.g. from pro to anti-war mood, from a smoking tolerance to a public smoking ban, or from buying energy-hungry sport utilities vehicles (suvs) to buying environmentally-friendly cars). particularly in case of network interactions, big changes may have small, no, or unexpected effects. feedback loops, unwanted side effects, and circuli vitiosi are quite typical. delays may cause unstable system behavior (such as bull-whip effects) [53] , and over-critical perturbations can create cascading failures [78] . systemic breakdowns (such as large-scale blackouts, bankruptcy cascades, etc.) are often a result of such domino or avalanche effects [77] , and their probability of occurrence as well as their resulting damage are usually underestimated. further examples are epidemic spreading phenomena or disasters with an impact on the socio-economic system. a more detailed discussion is given in refs. [76, 77] . other factors contributing to the difficulty to manage economic systems are the large heterogeneity of system elements and the considerable level of randomness as well as the possibility of a chaotic or turbulent dynamics (see sect. 16.3.4) . furthermore, the agents in economic systems are responsive to information, which can create self-fulfilling or self-destroying prophecy effects. inflation may be viewed as example of such an effect. interestingly, in some cases one even does not know in advance, which of these effects will occur. it is also not obvious that the control mechanisms are well designed from a cybernetic perspective, i.e. that we have sufficient information about the system and suitable control variables to make control feasible. for example, central banks do not have terribly many options to influence the economic system. among them are performing open-market operations (to control money supply), adjustments in fractional-reserve banking (keeping only a limited deposit, while lending a large part of the assets to others), or adaptations in the discount rate (the interest rate charged to banks for borrowing short-term funds directly from a central bank). nevertheless, the central banks are asked to meet multiple goals such as: â�¢ to guarantee well-functioning and robust financial markets. â�¢ to support economic growth. â�¢ to balance between inflation and unemployment. â�¢ to keep exchange rates within reasonable limits. furthermore, the one-dimensional variable of "money" is also used to influence individual behavior via taxes (by changing behavioral incentives). it is questionable, whether money can optimally meet all these goals at the same time (see sect. 16.3.7) . we believe that a computer, good food, friendship, social status, love, fairness, and knowledge can only to a certain extent be replaced by and traded against each other. probably for this reason, social exchange comprises more than just material exchange [131] [132] [133] . it is conceivable that financial markets as well are trying to meet too many goals at the same time. this includes: â�¢ to match supply and demand. â�¢ to discover a fair price. â�¢ to raise the foreign direct investment (fdi). â�¢ to couple local economies with the international system. â�¢ to facilitate large-scale investments. â�¢ to boost development. â�¢ to share risk. â�¢ to support a robust economy, and â�¢ to create opportunities (to gamble, to become rich, etc.). therefore, it would be worth stuyding the system from a cybernetic control perspective. maybe, it would work better to separate some of these functions from each other rather than mixing them. another aspect that tends to be overlooked in mainstream economics is the relevance of psychological and social factors such as emotions, creativity, social norms, herding effects, etc. it would probably be wrong to interpret these effects just as a result of perception biases (see sect. 16.3.1) . most likely, these human factors serve certain functions such as supporting the creation of public goods [102] or collective intelligence [134, 135] . as bruno frey has pointed out, economics should be seen from a social science perspective [136] . in particular, research on happiness has revealed that there are more incentives than just financial ones that motivate people to work hard [133] . interestingly, there are quite a number of factors which promote volunteering [132] . it would also be misleading to judge emotions from the perspective of irrational behavior. they are a quite universal and a relatively energy-consuming way of signalling. therefore, they are probably more reliable than non-emotional signals. moreover, they create empathy and, consequently, stimulate mutual support and a readiness for compromises. it is quite likely that this creates a higher degree of cooperativeness in social dilemma situations and, thereby, a higher payoff on average as compared to emotionless decisions, which often have drawbacks later on. finally, there is no good theory that would allow one to assess the relevance of information in economic systems. most economic models do not consider information as an explanatory variable, although information is actually a stronger driving force of urban growth and social dynamics than energy [137] . while we have an information theory to determine the number of bits required to encode a message, we are lacking a theory, which would allow us to assess what kind of information is relevant or important, or what kind of information will change the social or economic world, or history. this may actually be largely dependent on the perception of pieces of information, and on normative or moral issues filtering or weighting information. moreover, we lack theories describing what will happen in cases of coincidence or contradiction of several pieces of information. when pieces of information interact, this can change their interpretation and, thereby, the decisions and behaviors resulting from them. that is one of the reasons why socio-economic systems are so hard to predict: "unknown unknowns", structural instabilities, and innovations cause emergent results and create a dynamics of surprise [138] . the problems discussed in the previous two sections pose interesting practical and fundamental challenges for economists, but also other disciplines interested in understanding economic systems. econophysics, for example, pursues a physical approach to economic systems, applying methods from statistical physics [81] , network theory [139, 140] , and the theory of complex systems [85, 87] . a contribution of physics appears quite natural, in fact, not only because of its tradition in detecting and modeling regularities in large data sets [141] . physics also has a lot of experience how to theoretically deal with problems such as time-dependence, fluctuations, friction, entropy, non-linearity, strong interactions, correlations, heterogeneity, and many-particle simulations (which can be easily extended towards multi-agent simulations). in fact, physics has influenced economic modeling already in the past. macroeconomic models, for example, were inspired by thermodynamics. more recent examples of relevant contributions by physicists concern models of self-organizing conventions [54] , of geographic agglomeration [65] , of innovation spreading [142] , or of financial markets [143] , to mention just a few examples. one can probably say that physicists have been among the pioneers calling for new approaches in economics [81, 87, [143] [144] [145] [146] [147] . a particularly visionary book beside wolfgang weidlich's work was the "introduction to quantitative aspects of social phenomena" by elliott w. montroll and wade w. badger, which addressed by mathematical and empirical analysis subjects as diverse as population dynamics, the arms race, speculation patterns in stock markets, congestion in vehicular traffic as well as the problems of atmospheric pollution, city growth and developing countries already in 1974 [148] . unfortunately, it is impossible in our paper to reflect the numerous contributions of the field of econophysics in any adequate way. the richness of scientific contributions is probably reflected best by the econophysics forum run by yi-cheng zhang [149] . many econophysics solutions are interesting, but so far they are not broad and mighty enough to replace the rational agent paradigm with its large body of implications and applications. nevertheless, considering the relatively small number of econophysicists, there have been many promising results. the probably largest fraction of publications in econophysics in the last years had a data-driven or computer modeling approach to financial markets [143] . but econophyics has more to offer than the analysis of financial data (such as fluctuations in stock and foreign currency exchange markets), the creation of interaction models for stock markets, or the development of risk management strategies. other scientists have focused on statistical laws underlying income and wealth distributions, nonlinear market dynamics, macroeconomic production functions and conditions for economic growth or agglomeration, sustainable economic systems, business cycles, microeconomic interaction models, network models, the growth of companies, supply and production systems, logistic and transport networks, or innovation dynamics and diffusion. an overview of subjects is given, for example, by ref. [152] and the contributions to annual spring workshop of the physics of socio-economic systems division of the dpg [153] . to the dissatisfaction of many econophysicists, the transfer of knowledge often did not work very well or, if so, has not been well recognized [150] . besides scepticism on the side of many economists with regard to novel approaches introduced by "outsiders", the limited resonance and level of interdisciplinary exchange in the past was also caused in part by econophysicists. in many cases, questions have been answered, which no economist asked, rather than addressing puzzles economists are interested in. apart from this, the econophysics work was not always presented in a way that linked it to the traditions of economics and pointed out deficiencies of existing models, highlighting the relevance of the new approach well. typical responses are: why has this model been proposed and not another one? why has this simplification been used (e.g. an ising model of interacting spins rather than a rational agent model)? why are existing models not good enough to describe the same facts? what is the relevance of the work compared to previous publications? what practical implications does the finding have? what kind of paradigm shift does the approach imply? can existing models be modified or extended in a way that solves the problem without requiring a paradigm shift? correspondingly, there have been criticisms not only by mainstream economists, but also by colleagues, who are open to new approaches [151] . therefore, we would like to suggest to study the various economic subjects from the perspective of the above-mentioned fundamental challenges, and to contrast econophysics models with traditional economic models, showing that the latter leave out important features. it is important to demonstrate what properties of economic systems cannot be understood for fundamental reasons within the mainstream framework (i.e. cannot be dealt with by additional terms within the modeling class that is conventionally used). in other words, one needs to show why a paradigm shift is unavoidable, and this requires careful argumentation. we are not claiming that this has not been done in the past, but it certainly takes an additional effort to explain the essence of the econophysics approach in the language of economics, particularly as mainstream economics may not always provide suitable terms and frameworks to do this. this is particularly important, as the number of econophysicists is small compared to the number of economists, i.e. a minority wants to convince an established majority. to be taken seriously, one must also demonstrate a solid knowledge of related previous work of economists, to prevent the stereotypical reaction that the subject of the paper has been studied already long time ago (tacitly implying that it does not require another paper or model to address what has already been looked at before). a reasonable and promising strategy to address the above fundamental and practical challenges is to set up multi-disciplinary collaborations in order to combine the best of all relevant scientific methods and knowledge. it seems plausible that this will generate better models and higher impact than working in separation, and it will stimulate scientific innovation. physicists can contribute with their experience in handling large data sets, in creating and simulating mathematical models, in developing useful approximations, in setting up laboratory experiments and measurement concepts. current research activities in economics do not seem to put enough focus on: â�¢ modeling approaches for complex systems [154] . â�¢ computational modeling of what is not analytically tractable anymore, e.g. by agent-based models [155] [156] [157] . â�¢ testable predictions and their empirical or experimental validation [164] . â�¢ managing complexity and systems engineering approaches to identify alternative ways of organizing financial markets and economic systems [91, 93, 165] , and â�¢ an advance testing of the effectiveness, efficiency, safety, and systemic impact (side effects) of innovations, before they are implemented in economic systems. this is in sharp contrast to mechanical, electrical, nuclear, chemical and medical drug engineering, for example. expanding the scope of economic thinking and paying more attention to these natural, computer and engineering science aspects will certainly help to address the theoretical and practical challenges posed by economic systems. besides physics, we anticipate that also evolutionary biology, ecology, psychology, neuroscience, and artificial intelligence will be able to make significant contributions to the understanding of the roots of economic problems and how to solve them. in conclusion, there are interesting scientific times ahead. it is a good question, whether answering the above list of fundamental challenges will sooner or later solve the practical problems as well. we think, this is a precondition, but it takes more, namely the consideration of social factors. in particular, the following questions need to be answered: 8. how do costly punishment, antisocial punishment, and discrimination come about? 9. how can the formation of social norms and conventions, social roles and socialization, conformity and integration be understood? 10. how do language and culture evolve? 11. how to comprehend the formation of group identity and group dynamics? what are the laws of coalition formation, crowd behavior, and social movements? 12. how to understand social networks, social structure, stratification, organizations and institutions? 13. how do social differentiation, specialization, inequality and segregation come about? 14. how to model deviance and crime, conflicts, violence, and wars? 15. how to understand social exchange, trading, and market dynamics? we think that, despite the large amount of research performed on these subjects, they are still not fully understood. the ultimate goal would be to formulate mathematical models, which would allow one to understand these issues as emergent phenomena based on first principles, e.g. as a result of (co-)evolutionary processes. such first principles would be the basic facts of human capabilities and the kinds of interactions resulting from them, namely: 1. birth, death, and reproduction. 2. the need of and competition for resources (such as food and water). 3. the ability to observe their environment (with different senses). 4. the capability to memorize, learn, and imitate. 5. empathy and emotions. 6. signaling and communication abilities. 7. constructive (e.g. tool-making) and destructive (e.g. fighting) abilities. 8. mobility and (limited) carrying capacity. 9. the possibility of social and economic exchange. such features can, in principle, be implemented in agent-based models [158] [159] [160] [161] [162] [163] . computer simulations of many interacting agents would allow one to study the phenomena emerging in the resulting (artificial or) model societies, and to compare them with stylized facts [163, 168, 169] . the main challenge, however, is not to program a seemingly realistic computer game. we are looking for scientific models, i.e. the underlying assumptions need to be validated, and this requires to link computer simulations with empirical and experimental research [170] , and with massive (but privacy-respecting) mining of social interaction data [141] . in the ideal case, there would also be an analytical understanding in the end, as it has been recently gained for interactive driver behavior [111] . as well as for inspiring discussions during a visioneer workshop in zurich from january 13 how to understand human decision-making? how to explain deviations from rational choice theory and the decision-theoretical paradoxes? why are people risk averse? 2. how does consciousness and self-consciousness come about? how to 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(papers in monetary economics, reserve bank of australia, 1975); for applications of le chatelier's principle to economics see also p. a. samuelson, foundations of economic analysis structures of social life: the four elementary forms of human relations understanding and assessing the motivations of volunteers: a functional approach happiness: a revolution in economics the wisdom of crowds: why the many are smarter than the few and how collective wisdom shapes business swarm intelligence. introduction and applications economics as a science of human behaviour: towards a new social science paradigm growth, innovation, scaling and the pace of life in cities uncertainty and surprise in complex systems scale-free networks: a decade and beyond economic networks: the new challenges hyperselection and innovation described by a stochastic model of technological evolution introduction to econophysics: correlations and complexity in finance minority games: interacting agents in financial markets economics needs a scientific revolution the economy needs agent-based modelling meltdown modelling introduction to quantitative aspects of social phenomena econophysics forum fifteen years of econophysics: worries, hopes and prospects worrying trends in econophysics econophysics and sociophysics: trends and perspectives aims and scope of the physics of socio-economic systems division of the german physical society pluralistic modeling of complex systems handbook of computational economics simulation modeling in organizational and management research developing theory through simulation methods understanding complex social dynamics: a plea for cellular automata based modelling platforms and methods for agent-based modeling from factors to actors: computational sociology and agent-based modeling artificial societies. multiagent systems and the micro-macro link in sociological theory generative social science: studies in agent-based computational modeling the handbook of experimental economics managing complexity: concepts, insights, applications engineering economy statistical physics of social dynamics the future of social experimenting the authors are grateful for partial financial support by the eth competence center "coping with crises in complex socio-economic systems" (ccss) through eth research grant ch1-01 08-2 and by the future and emerging technologies programme fp7-cosi-ict of the european commission through the project visioneer (grant no.: 248438). they would like to thank for feedbacks on the manuscript by kenett dror, tobias preis and gabriele tedeschi key: cord-016146-2g893c2r authors: kim, yeunbae; cha, jaehyuk title: artificial intelligence technology and social problem solving date: 2019-03-14 journal: evolutionary computing and artificial intelligence doi: 10.1007/978-981-13-6936-0_2 sha: doc_id: 16146 cord_uid: 2g893c2r modern societal issues occur in a broad spectrum with very high levels of complexity and challenges, many of which are becoming increasingly difficult to address without the aid of cutting-edge technology. to alleviate these social problems, the korean government recently announced the implementation of mega-projects to solve low employment, population aging, low birth rate and social safety net problems by utilizing ai and icbm (iot, cloud computing, big data, mobile) technologies. in this letter, we will present the views on how ai and ict technologies can be applied to ease or solve social problems by sharing examples of research results from studies of social anxiety, environmental noise, mobility of the disabled, and problems in social safety. we will also describe how all these technologies, big data, methodologies and knowledge can be combined onto an open social informatics platform. a string of breakthroughs in artificial intelligence has placed ai in increasingly visible positions in society, heralding its emergence as a viable, practical, and revolutionary technology. in recent years, we have witnessed ibm's watson win first place in the american quiz show jeopardy! and google's alphago beat the go world champion, and in the very near future, self-driving cars are expected to become a common sight on every street. such promising developments spur optimism for an exciting future produced by the integration of ai technology and human creativity. ai technology has grown remarkably over the past decade. countries around the world have invested heavily in ai technology research and development. major corporations are also applying ai technology to social problem solving; notably, ibm is actively working on their science for social good initiative. the initiative will build on the success of the company's noted ai program, watson, which has helped address healthcare, education, and environmental challenges since its development. one particularly successful project used machine learning models to better understand the spread of the zika virus. using complex data, the team developed a predictive model that identified which primate species should be targeted for zika virus surveillance and management. the results of the project are now leading new testing in the field to help prevent the spread of the disease [1] . on the other hand, investments in technology are generally mostly used for industrial and service growth, while investments for positive social impact appear to be relatively small and passive. this passive attitude seems to reflect the influence of a given nation's politics and policies rather than the absence of technology. for example, in 2017, only 4.2% of the total budget of the korean government's r&d of ict (information and communication technology) was used for social problem solving, but this investment will be increased to 45% within the next five years as the improvement of korean people's livelihoods and social problems are selected as important issues by the present government [2] . in addition, new categories within ict, including ai, are required as a key means of improving quality of life and achieving population growth in this country. in this letter, i introduce research on the informatics platform for social problem solving, specifically based on spatio-temporal data, conducted by hanyang university and cooperating institutions. this research ultimately intends to develop informatics and convergent scientific methodologies that can explain, predict and deal with diverse social problems through a transdisciplinary convergence of social sciences, data science and ai. the research focuses on social problems that involve spatio-temporal information, and applies social scientific approaches and data-analytic methods on a pilot basis to explore basic research issues and the validity of the approaches. furthermore, (1) open-source informatics using convergent-scientific methodology and models, and (2) the spatio-temporal data sets that are to be acquired in the midst of exploring social problems for potential resolution are developed. in order to examine the applicability of the models and informatics platform in addressing a variety of social problems in the public as well as in private sectors, the following social problems are identified and chosen: 1. analysis of individual characteristics with suicidal impulse 2. study on the mobility of the disabled using gps data 3. visualization of the distribution of anxiety using social network services 4. big data-based analysis of noise environment and exploration of technical and institutional solutions for its improvement 5. analysis of the response governance regarding the middle eastern respiratory syndrome (mers) the research issues in the above social problems are explored, and the validity of the convergent-scientific methodologies are tested. the feasibility for the potential resolution of the problems are also examined. the relevant data and information are stored in a knowledge base (kb), and at the same time research methods that are used in data extraction, collection, analysis and visualization are also developed. furthermore, the kb and the method database are merged into an open informatics platform in order to be used in various research projects, business activities, and policy debates. while suicide rates in oecd countries are declining, only south korea has increasing suicide rates; moreover, korea currently has the highest suicide rate among oecd countries as shown in fig. 1 . its high suicide rate is one of korea's biggest social problems, entailing the establishment of effective suicide prevention measures by understanding the causes of suicide. the goals of the research are to: (1) understand suicidal impulse by analyzing the characteristics of members of society according to suicidal impulse experience; (2) predict the likelihood of attempting suicide and analyzing the spatio-temporal quality of life; and (3) to establish a policy to help prevent suicide. the korean social survey and survey of youth health status data are used for the analysis of suicide risk groups through data mining techniques, using a predictive model based on cell propagation to overcome the limitations of existing statistics methods such as characterization or classification. in the case of the characterization technique, results indicate that there are too many features related to suicide, and that there are variables including many categorical values, making it difficult to identify the variables that affect suicide. on the other hand, the classification technique had difficulties identifying the variables that affect suicide because the number of members attempting suicide was too small. correlations between suicide impulses and individual attributes of members of society and the trends of the correlations by year are obtained. the concepts of support, confidence and density are introduced to identify risk groups of suicide attempts, and computational performance problems caused by excessive numbers of risk groups are solved by applying a convex growing method. the 2014y social survey including personal and household information of members of the society are used for analysis. the attributes include gender, age, education, marital status, level of satisfaction, disability status, occupation status, housing, and household income. the high-risk suicide cluster was identified using a small number of convexes. a convex is a set of cells, with one cell being the smallest unit of the cluster for the analysis, and a density is the ratio of the number of non-empty cells to the total number of cells in convex c [3] . figure 2 shows that the highest suicidal risk group c1 is composed of members with low income and education level. it was identified that level of satisfaction with life has the highest impact on suicidal impulse, followed in order of impact by disability, marital status, housing, household income, occupation status, gender, age and level of education. the results showed that women and young people tend to have more suicidal impulse. new prediction models with other machine learning methods and the establishment of mitigation policies are still in development. subjective analyses of change of wellbeing, social exclusion, and characteristics of spatio-temporal analysis will also be explored in the future. mobility rights are closely related to quality of life as a part of social rights. therefore social efforts are needed to guarantee mobility rights to both the physically and mentally disabled. the goal of the study is to suggest a policy for the extension of mobility rights of the disabled. in order to achieve this, travel patterns and sociodemographic characteristics of the physically impaired with low levels of mobility are studied. the study focused on individuals with physical impairments as the initial test group as a means to eventually gain insight into the mobility of the wider disabled population. conventional studies on mobility measurement obtained data from travel diaries, interviews, and questionnaire surveys. a few studies used geo-location tracking gps data. gps data is collected via mobile device and used to analyze the mobility patterns (distance, speed, frequency of outings) by using regression analysis, and to search for methods to extend mobility. a new metrics for mobility with a new indicator (travel range) was developed, and the way mobility impacts the quality of life of the disabled has been verified [4] . about 100 people with physical disabilities participated and collected more than 100,000 geo-location data over a month using an open mobile application called traccar. their trajectories are visualized based on the gps data as shown in fig. 3 . the use of location data explained mobility status better than the conventional questionnaire survey method. the questionnaire surveyed mainly the frequency of outings over a certain period and number of complaints about these outings. gps data enabled researchers to conduct empirical observations on distance and range of travel. it was found that the disabled preferred bus routes that visit diverse locations over the shortest route. age and monthly income are negatively associated with a disabled individual's mobility. based on the research results, the following has been suggested: (1) development of new bus routes for the disabled and (2) recommendation of a new location for the current welfare center that would enable a greater range of travel. further study on travel patterns by using indoor positioning technology and cctv image data will be deployed. many social issues including political polarization, competition in private education, increases in suicide rate, youth unemployment, low birth rate, and hate crime have anxiety as their background. the increase of social anxiety can intensify competition and conflict, which can interfere with social solidarity and cause a decrease in social trust. existing social science research mainly focused on grasping public opinion through questionnaires, and ignored the role of emotions. the internet and social media were used to access emotional traits since they provide a platform not only for the active exchange of information, but also for the sharing and diffusion of emotional responses. if such emotional responses on the internet and geo-locations can be captured in realtime through machine learning, their spatio-temporal distribution could be visualized in order to observe their current status and changes by geographical region. a visualization system was built to map the regional and temporal distribution of anxiety psychology by combining spatio-temporal information using sns (twitter) with sentiment analysis. a twitter message collecting crawler was also developed to build a dictionary and tweet corpus. based on these, an automatic classification system of anxiety-related messages was developed for the first time in korea by applying machine learning to visualize the nationwide distribution of anxiety (see fig. 4 ) [5] . an average of 5,500 tweets with place_id are collected using open api twitter4j. to date, about 820,000 units of data have been collected. a naïve bayes classifier was used for anxiety identification. an accuracy of 84.8% was obtained by using 1,750 and 70,830 anxiety and non-anxiety tweets as training data respectively, and 585 and 23,610 anxiety and non-anxiety tweets as testing data, respectively. the system indicated the existence of regional disparities in anxiety emotions. it was found that twitter users who reside in politicized regions have a lower degree of disclosure about their residing areas. this can be interpreted as the act of avoiding situations where the individual and the political position of the region coincide. as anxiety is not a permanent characteristic of an individual, it can change depending on the time and situation, making it difficult to measure by questionnaire survey at any given time. the twitter-based system can compensate for the limitations of such a survey method because it can continuously classify accumulated tweet text data and provide a temporal visualization of anxiety distribution at a given time within a desired visual scale (by ward, city, province and nationwide) as shown in fig. 5 . environmental issues are a major social concern in our age, and interest has been increasing not only in the consequences of pollution but also in the effects of general environmental aesthetics on quality of life. there is much active effort to improve the visual environment, but not nearly as much interest has been given to improve the auditory environment. until now, policies on the auditory environment have remained passive countermeasures to simply quantified acoustic qualities (e.g., volume in db) in specific places such as construction sites, railroads, highways, and residential areas. they lack a comprehensive study of contextual correlations, such as the physical properties of sound, the environmental factors in time and space, and the human emotional response of noise perception. the goal of this study is to provide a cognitive-based, human-friendly solution to improve noise problems. in order to achieve this, the study aimed to (1) develop a tool for collecting sound data and converting into a sound database, and (2) build spatiotemporal features and a management platform for indoor and outdoor noise sources. first, pilot experiments were conducted to predict the indicators that measure emotional reactions by developing a handheld device application for data collection. three separate free-walking experiments and in-depth interviews were conducted with 78 subjects at international airport lobbies and outdoor environments. through the experiment, the behavior patterns of the subjects in various acoustic environments were analyzed, and indicators of emotional reactions were identified. it was determined that the psychological state and the personal environment of the subject are important indicators of the perception of the auditory environment. in order to take into account both the psychological state of the subject and the physical properties of the external sound stimulus, an omnidirectional microphone is used to record the entire acoustic environment. 118 subjects with smartphones with the built-in application walked for an hour in downtown seoul for data collection. on the app, after entering the prerequisite information, subjects pressed 'good' or 'bad' whenever they heard a sound that caught their attention. pressing the button would record the sound for 15 s, and subjects were additionally asked to answer a series of questions about the physical characteristics of the specific location and the characteristics of the auditory environment. during the one-hour experiment, about 600 sound environment reports were accumulated, with one subject reporting the sound characteristics from an average of 5 different places. unlike previous studies, the subjects' paths were not pre-determined, and the position, sound and emotional response of the subject are collected simultaneously. the paths can be displayed to analyze the relations of the soundscapes to the paths (fig. 6) . the study helped to build a positive auditory environment for specific places, to provide policy data for noise regulation and positive auditory environments, to identify the contexts and areas that are alienated from the auditory environment, and to extend the social meaning of "noise" within the study of sound. respiratory syndrome (mers) the development and spread of new infectious diseases are increasing due to the expansion of international exchange. as can be seen from the mers outbreak in korea in 2015, epidemics have profound social and economic impacts. it is imperative to establish an effective shelter and rapid response system (rrs) for infectious diseases control. the goal of the study is to compare the official response system with the actual response system in order to understand the institutional mechanism of the epidemic response system, and to find effective policy alternatives through the collaboration of policy scholars and data scientists. web-based newspaper articles were analyzed to compare the official crisis response system designed to operate in outbreaks to the actual crisis response. an automatic news article crawling tool was developed, and 53,415 mers-related articles were collected, clustered and stored in the database (fig. 7) . in order to manage and search for news articles related to mers from the article database, a curation tool was developed. this tool is able to extract information into triplet graphs (subjects/verbs/objects) from the articles by applying natural language processing techniques. a basic dictionary for the analysis of the infectious disease response system was created based on the extracted triplet information. the information extracted by the curation tool is massive and complex, which limits the ability to correctly understand and interpret information. a tool for visualizing information at a specific time with a network graph was developed and utilized to facilitate analysis and visualization of the networks (fig. 8 ). all tools are integrated into a single platform to maximize the efficiency of the process. as for the official crisis response manual in case of an infectious disease, social network analysis indicated that while the national security bureau (nsb) and public health centers play as large a role as the center for disease control (cdc) in crisis management, the analysis of the news articles showed that the nsb was in fact rarely mentioned. it was found that the cdc and central disaster response headquarters, the official government organizations that deal with infectious diseases, as well as the central mers management countermeasures & support headquarters, a temporarily established organization, were not playing an important role in response to the mers outbreak. on the other hand, the ministry of health and welfare, medical institutions, and local governments all have played a central role in responding to mers. this means that the structure and characteristics of the command & control and communication in the official response system seems to have a decisive influence on the cooperative response in a real crisis response. these results provided concrete information on the role of each respondent and the communication system that previous studies based on interviews and surveys have not found. much research based on machine learning has been criticized for giving more importance on method itself from the start rather than focusing on data reliability. this study is based on a kb in which policy researchers manually analyze news articles and prepare basic data by tagging them. this way, it provides a basis for improving the reliability of results when executing text mining work through machine learning. by using text mining techniques and social network analysis, it is possible to get a comprehensive view of social problems such as the occurrence of infectious diseases by examining the structure and characteristics of the response system from a holistic perspective of the entire system. with the results of this study, new policies for infectious disease control are suggested in the following directions: (1) strengthen cooperation networks in early response systems of infectious diseases; (2) develop new, effective and efficient management plans of cooperative networks; and (3) create new research to cover other diseases such as avian influenza and sars [6] . an ever-present obstacle in the traditional social sciences when addressing social issues are the difficulties of obtaining evidences from massive data for hypothesis and theory verification. data science and ai can ease such difficulties and support social science by discovering hidden contexts and new patterns of social phenomena via low-cost analyses of large data. on the other hand, knowledge and patterns derived by machine learning from a large data set with noise often lack validity. although data-driven inductive methods are effective for finding patterns and correlations, there is a clear limitation to discovering causal relationships. social science can help data science and ai by interpreting social phenomena through humanistic literacy and social-scientific thought to verify theoretical validity, and identifying causal relationships through deductive and qualitative approaches. this is why we need convergent-scientific approaches for social problem solving. convergent approaches offer the new possibility of building an informatics platform that can interpret, predict and solve various social problems through the combination of social science and data science. in all 5 pilot studies, the convergent-scientific approaches are found valid and sound. most of the research agendas involved the real-time collection and development of spatio-temporal databases in a real-time manner, and analytic visualization of the results. such visualization promises new possibilities in data interpretation. the data sets and tools for data collection, analysis and visualization are integrated onto an informatics platform so that they can be used in future research projects and policy debates. the research was the first transdisciplinary attempt to converge social sciences and data sciences in korea. this approach will offer a breakthrough in predicting, preventing and addressing future social problems. the research methodology, as a trailblazer, will offer new ground for a research field of a transdisciplinary nature converging data sciences, ai and social sciences. the data, information, knowledge, methodologies, and techniques will all be combined onto an open informatics platform. the platform will be maintained on an open-source basis so that it can be used as a hub for various academic research projects, business activities, and policy debates (see fig. 9 ). the open informatics platform is planned to be expanded to incorporate citizen sensing, in which people's observations and views are shared via mobile devices and internet services in the future [7] . in the area of social problem solving, fundamental problems have complex political, social and economic aspects that have their roots in human nature. both technical and social approaches are essential for tackling social problem solving. in fact, it is the fig. 9 . structure of informatics platform integrated, orchestrated marriage between the two that would bring us closer to effective social problem management. we need to first study and carefully define the indicators specific to a given social problem or domain. there are many qualitative indicators that cannot be directly and explicitly measured such as social emotions, basic human needs and rights, and life fulfillment [8] . if the results of machine learning are difficult to measure or include combinations of results that are difficult to define, that particular social problem may not be suitable for machine learning. therefore, there is a need for new social methods and algorithms that can accurately collect and identify the measurable indicators from opinions of social demanders. recently, mit has developed a device to quantitatively measure social signals. the small, lightweight wearable device contains sensors that record the people's behaviors (physical activity, gestures, and the amount of variation in speech prosody, etc.) [9] . machine learning technologies working on already existing data sets are relatively inexpensive compared to conventional million-dollar social programs since machine learning tools can be easily extended. however, they can introduce bias and errors depending on the data content used to train machine learning models or can also be misinterpreted. human experts are always needed to recognize and correct erroneous outputs and interpretations in order to prevent prejudices [10] . in the development of ai applications, a great amount of time and resources are required to sort, identify and refine data to provide massive data for training. for instance, machine learning models need to learn millions of photos to recognize specific animals or faces, but human intelligence is able to recognize visual cues by looking at only a few photos. perhaps it is time to develop a new ai framework which can infer and recognize objects based on small amounts of data, such as transfer learning [11] , generate lacking data (gan), or integrate traditional ai technologies, such as symbolic ai and statistical machine learning into new frameworks. machine learning is excellent in predicting, but many social problem solutions do not depend on predictions. the organic ways solutions to specific problems actually unfold according to new policies and programs can be more practical and worth studying than building a cure-all machine learning algorithm. while the evolution of ai is progressing at a stunning rate, there are still challenges to solving social problems. further research on the integration of social science and ai is required. a world in which artificial intelligence actually makes policy decisions is still hard to imagine. considering the current limitations and capabilities of ai, ai should primarily be used as a decision aid. ibm: science for social good -applying ai, cloud and deep science toward new societal challenges analyzing suicide-ideation survey to identify high-risk groups: a data mining approach mobility among people with physical impairment: a study using geo-location tracking data sns data visualization for analyzing spatial-temporal distribution of social anxiety application of network analysis into emergency response: focusing on the 2015 outbreak of the middle-eastern respiratory syndrome in korea a platform for citizen sensing in sentient cities chapter 52: the sociology of social indicators to signal is human a guide to solving social problems with machine learning how transferable are features in deep neural networks? in: advances in neural information processing systems 27 (nips 2014). nips foundation acknowledgements. this work was supported by the national research foundation of korea (nrf) grant funded by the korean government (msit 1 ) (no. 2018r1a5a7059549). key: cord-034437-lore5krk authors: de kervenoael, ronan; schwob, alexandre; manson, inci toral; ratana, chatlada title: business-to-business and self-governance practice in the digital knowledge economy: learning from pharmaceutical e-detailing in thailand date: 2020-10-30 journal: asian bus manage doi: 10.1057/s41291-020-00141-z sha: doc_id: 34437 cord_uid: lore5krk this study investigates self-governance within business-to-business (b2b) in the digital knowledge economy. to do so, we elicit the engagement of healthcare professionals (hcps) and medical science liaisons (msls) with “for-profit social media technology” (fpsmt) in e-detailing. using data from 23 in-depth interviews with hcps (physicians and pharmacists) and msls in thailand, we show that e-detailing fosters self-governance as a practice. the data identify how fpsmt, as privatized social media managed by large firms, represents a tool for self-governance that is articulated by expert professionals along three cognitive frames: aspiration, regulation, and responsibilisation. through fpsmt, professionals in highly regulated b2b ecosystems engage in self-governance practice to develop pooled views that are influenced by personal and collective rules. the perspective on self-governance as a practice that is offered allows to understand how b2b network governance rely on professionals’ engagement to foster aspirations for the collective agenda, beyond the narrow pursuit of sales’ objectives. self-governance delineates the process whereby one is "having control over oneself, to act in a way that is relevant to one's own profession, to know who you are and, therefore, behave in the way your profession expects" (mctaggart et al. 2017, p. 90 ). despite widespread research on self-governance in political sciences and management literature, there is a scarcity of studies addressing the forms self-governance takes to face the needs of asian' firms within the digital knowledge economy (wang et al. 2016) . within today's hyperconnected economies, self-governance is so far depicted as accomplished through knowledge work that has often been equated to self-branding (gandini 2016; grénman et al. 2019) . in this research, we propose an enlarged view on self-governance that establishes how individuals demonstrate their sense of professionalism while appreciating existing governance structures that prevail in inter-firm relationships (chelariu and sangtani 2009) . this view allows to approach self-governance as a practice occurring in today's digitized environments that fuel innovation in settings where relationships are very tightly organized, as is the case in business-to-business (b2b) relationships (fox and ward 2008; olakivi and niska 2017) . in this paper, we investigate the unfolding of self-governance practice within the digital knowledge economy by examining the b2b case of pharmaceutical e-detailing in thailand. e-detailing represents the main access point leveraged by medtech firms via their medical science liaisons (msls) to engage healthcare professionals (hcps). it helps to manage access to information including sales content, on multiples devices, making new product information (e.g., drugs, delivery mechanisms, test studies, etc.) interactive and updated in real time. importantly, because of its strategic importance, e-detailing is strictly regulated revealing, how hcps' engagement with smt meets both novel and often conflicting expectations stemming from social media platforms owned by private large pharmaceutical brands that we call 'for-profit social media technology' (fpsmt). we analyze self-governance practice through twenty-three in-depth semi-structured interviews with msls and hcps (including pharmacists and physicians) as key users of e-detailing systems. the data show how hcps and msls are engaged with fpsmt, indicating that such technology requires them to develop their own sense of professionalism while appreciating how to comply with governance structures that concern both public (patients, governments, ngos) and private stakeholders. the findings show that digitized self-governance supports asian firms' innovation management by enabling expert professionals to articulate collaborative behaviors and the pursuit of sales objectives with the management of their own reputation. set in the framework of these broad challenges, we pursue two main objectives: (1) to address in b2b how hcps make sense of their current situations when cognising, drawing on, and leveraging their engagement with fpsmt in e-detailing; and (2) to identify the main drivers and manifestations of self-governance in practice that occur through b2b market-actors' engagement with fpsmt. to accomplish this, we adopt an approach based on framing and sensemaking that sheds light on the ambiguities and paradoxes that technology implies. we show how hcps and msls are empowered to unravel smt's unsettled structures and take actions, while at the same time, leaving scope for dissonance and situational improvisation (goffman 1974; mazmanian 2013; orlikowski and gash 1994) . we then consider the theoretical contributions by revealing insights on how self-governance operates in b2b and as a practice beyond discrete experiences or desirable states for expert individuals (gautam 2017; gandini 2016) . self-governance is found to be a fundamental resource to invigorate network governance in the digital knowledge economy. subsequently, learning from pharmaceutical e-detailing in thailand, we show how for managers, self-governance transforms organizations and management practices by supporting an innovative and socially negotiated view on technologized networks. for-profit smt for b2b market-actors' engagement in the digital knowledge economy a wide set of theories (e.g., diffusion of innovation, technology acceptance and value-added models) has been mobilized in the literature to investigate how different b2b market-actors comprehend smts, which are developed, codified, and retained to seize socially generated values that enhance knowledge management processes and help organizations compete (pascucci et al. 2018; golden 2011) . in a professional context, employees' knowledge sharing via smt is an investment in social relationships and represents individual market actor's experiential know-how (work, actions, and sociality-based practices [marwick and hargittai 2019] ) shared during social interactions (panahi et al. 2016) . real time information diffusion through shared learning experiences carries specific expectations about with whom it can be shared and what an increasingly freelance workforce can legally convey (marwick and hargittai, 2019; wegner and mozzato 2019) . in b2b, most intranets or smts are a single firm's property and strictly controlled within that firm; thus, proposing a specific knowledge partaking culture (gandini 2016; north and kumta 2018) . smts facilitate knowledge retention and monitor market-actors' internalization of company values and culture, including appropriate communication and respect of the legislation so that expert knowledge is not lost (ammirato et al. 2019) . in b2b, researchers have analyzed the changing characteristics of smt and the novel types of behavior they generate (buratti et al. 2018; siamagka et al. 2015) . macro-issues with smt have mainly related to technical hurdles (moncrief et al. 2015) , underusage and unidirectionality of tools (järvinen et al. 2012) , dissemination issues (ammirato et al. 2019) , sales performance and marketing content creation (huotari et al. 2015) , firm brand-building strategy (cawsey and rowley 2016) . at meso-and micro-levels, b2b studies have investigated smt adoption and management's understanding (sivalingam 2010) ; managers' sensemaking (rooderkerk and pauwels 2016) ; influences on business practices, sales and branding; training requirements; employee management communication (edosomwan et al. 2011 ); and individual professionals' self-branding (gandini 2016) . at this point, as smts experience hyper-growth and hype continues in b2b, the boundaries businesses establish between their employees and outside market-actors are becoming increasingly blurred, precluding the non-engagement of the latter as a viable stance (leek et al. 2016; razmerita et al. 2016) . fpsmt opposes the traditional understanding of smt as allowing any individual or group to leverage and share experiences to all without specific organizational oversight or steering capacity, thus encouraging many firms and parties to capture the potential benefits. indeed, different from the models used in e-commerce platforms (e.g., amazon), p2p (e.g., ebay) or the circular economy (e.g., gumtree), fpsmt is specifically designed to allow only selected individuals, professional groups or experts to interact and share knowledge and information. this leads to appropriation and monetisation of their ideas and data and, in effect, provides better decision support services to develop novel sales tactics, products and marketing strategies for a specific private firm (schor 2016) . within the health ecosystem, fpsmts are commonly used to cultivate corporate profiles, encourage pharmacy careers, and support over the counter (otc) brands' profiles and innovation along brand communities' properties. this importantly refocuses fpsmts on specific diseases, molecule resistance, and future innovation (unmetric.com 2019) . fpsmt privatize profits for the social media provider and socialize expenses and losses when supporting healthcare professionals (hcps) involved in knowledge sharing on b2b platforms, thus calling upon hcps to be attentive to violations of personal-professional boundaries including safeguarding accountability and trustworthiness of data storage (see hipaa rules 1 ). consequently, b2b market-actors' activities on fpsmt encourage and problematise independent individuals' social engagement in the value creation process. this engagement operates in knowledge networks and requires professionals to question and monitor the linkages between themselves and their chosen networks. as a social process, self-governance between heterogenous professionals becomes central to understanding what makes individual actions meaningful, responsible, and sustainable (de kervenoael et al. 2015) . smt usage thus reflects preferred conduct when relating to professional peers in this new labor market (edosomwan et al. 2011) . the literature underlines that smt allows individuals to work for themselves in securing employment because it is a supporting tool that emanates from the socialization process at work (gandini 2016) . within these conditions, establishing the relationships between smts and expert market-actors' engagement is difficult because economic performance levels and heightened perceptions of (legal) risk characterize the decision process (swani et al. 2017 ). on the one hand, b2b actors' engagements are encouraged, echoing the sharing economy model, which facilitates knowledge work on digitized platforms, and promotes professionals' open asset sharing, requiring outward-oriented self-development where gains/losses are often intangible and hard to measure (grondys 2019) . on the other hand, engagement in knowledge sharing depends on specific organisations' strategies (e.g., promoting corporate brands and specific selected products and hard-sell approaches) and how market-actors are affiliated with, professionals' embeddedness in pre-existing social networks (endowment effect). market-actors' engagement thus goes along with the presence of various sets of governance procedures reflecting a wider range of social values that oscillate between progressive goals and genuine cooperation to "business as usual" that combines play and work (schor 2016) . the novel recombination of knowledge and its outcomes suggests innovative behavior and becomes tangible at the individual market actor level. when learning from smts, individuals become aware of their own expert value and capacity to understand others' perspectives, "functioning as intermediaries that transform social relationships into value" (gandini 2016, p. 125) . this allows individuals to make sense of multiple demands (e.g., economic, legal or, in our case, health) placed on market-actors by the digital knowledge economy's modes of innovation, characterized on a continuum between e-topia and dystopia and questioning whether smts can promote social change (lomborg 2017) . the necessary competencies identified in smt literature are in formal areas, such as sales style and customer relationship management (ammirato et al. 2019) or telemarketing (moncrief et al. 2015) , and less formal areas, including networking, problem-solving skills, and leadership capabilities (wathne and fjeldstad 2019)-but all aim at driving socio-economic growth (north and kumta 2018) . in this context, digital transformation and smts as becoming increasingly more complex to manage (swani et al. 2017 ) and stressed rapidly evolving transformative capability building is needed among highly skilled and specialized professionals (baptista et al. 2017 ; van den berg and verhoeven 2017). b2b professionals' concerns for private and collective agenda that are present on daily usage of fpsmt calls for an understanding of their engagement in the value creation processes based on collaborative and competitive modes of conduct and how the structuring and uncertain outcomes of the latter have consequences on network governance (wegner and mozzato 2019). knowledge work can be defined as actions market-actors take to solve problems whereby not only the state or large institutionalized actors regulate behavior (i.e., going across public-private boundaries of the classical liberal movement). often, many actors operate in networks across multiple mechanisms (legal, market, and social) to foster a continuous exchange process to tackle specific complex issues for which local expertise becomes important (esmark and triantafillou 2009; parker 2007) . both convergent and divergent reasoning on what is active interaction on smt is required to cope with today's complex and dynamic knowledge economy management beyond the meso-level theories traditionally considered in governance research (burchell et al. 1991; north and kumta 2018) . as strategic assemblages, smt engagement influences how market-actors critically sense and act within specific professional domains to create a coherent knowledge framework. in support, network governance is designed to capture decentralized decision-making systems where actors are connected by ties and share power and information reflecting their practices and world views. within network governance, an actor's participation is based on recognition and trust and how both affect and are affected by the behavior of other actors (davies 2000) . studies on knowledge work in networked technologies underline the importance of positive coping together with positive computing design (clarke 2018 ), but these have often bracketed in their focus network settings in which the exercise of power, authority, and influence for "getting things done" (stoker 1998, p. 24) have to be operant. in interorganisational literature, network governance represents the knowledge used for the network's overall functioning (provan and kenis 2008; stoker 2006; . three modes of governance (shared, lead-organization, and network administrative organization) shape critical factors of broadly defined network effectiveness (i.e., outcomes not achievable by individual organizations) (mandell 1994) . within the process, three main tensions are identified: efficiency vs. inclusiveness, internal vs. external legitimacy, and flexibility vs. stability. thus, information sharing processes' communal, social nature implies a self-governance capacity embedded within a range of heterogeneous market-actors who draw potential benefits from socio-technological uncertainties and opportunities (lipshitz and strauss 1997; stieglitz et al. 2018) . within organizational ecosystems, smt communities of practice address day-today knowledge work characteristics, such as role modeling, mentoring, experiential learning, and reflection; provide developmental support that complements/enriches market-actors' existing work lives; and facilitate human/social and material (smts) agencies' intermingling (kilduff and tsai 2003; lakshman and rai 2019) . these are non-linear articulations of multiple individuals' and collective's decisions of how to gradually move information in its physical form (in our case, patient data) to digital platforms. in other words, we move beyond debates whereby governments or firms' management coerce individual self-governance through legislation or threats of regulation, leaving little room for discretion and deviation (gupta and lad 1983) or firms observing agreed standards, such as interoperability and certification, to be profitable (king and lenox 2000) . while doing this, we follow work in the area of legal innovations (see levillain and segrestin 2019 regarding 'profit with purpose corporations'). we particularly recognize firms' accountability when steering the collective. a constituency's role within a network calls for understanding individuals' self-governance as a form of their accountability to themselves. governance is no longer based on a business ethics form whereby powerful firms direct smaller suppliers; rather, it is built on every market-actor's daily activities. unlike broader governance arrangements involving governments (local or national), regulatory bodies, and supranational organizations that strongly influence the decision-making process, individual (non-heterogenous) actors employ selfgovernance at the micro level, deciding resource allocations amid an external environment's more limited influence (ojo and mellouli 2018) . self-governance, from a narrow perspective, is outlined as having control of one's own affairs and managing processes along ethical and socially responsible lines without coercion by punitive regulations (gandini 2016; gautam 2017) . it has been growingly investigated in management and marketing literature showing that individuals. self-governance, as a tenet of b2b expertise sharing, implies actors act in both private and public decision-making spheres (sørensen and triantafillou 2013). network governance can thus be applied to self-governance whereby market-actors selfmonitor their thinking and learning processes (lajoie et al. 2013) , form relationships with others (maclaren 2009) , and encourage autonomy (oshana 2005) and reflection on action (wickramasinghe 2010 ) and create new loci of power but caution against networks' negative effects, such as overbearing control and relational pressures (smt trolls, polarized views, digital bullies) (broniatowski et al. 2018 ). the study positioning, within self-governance and distributed innovation practices, reflects a framing situation on e-detailing in which smts and associated ecosystems can be considered as conceptual tools (gal and berente 2008) . e-detailing is the main access point leveraged by medtech firms via their medical science liaisons (msls-previously sale rep) to engage hcps. it digitizes access to sales marketing content, mainly on mobile devices, making new product information (e.g., drugs, delivery mechanisms, test studies, etc.) interactive and updated in real time. it allows instantaneous data collection and tracking, generating a tailored high-quality experience for hcps. e-detailing can facilitate awareness of specific products, but at the same time, it can create blind spots when data monetisation emerges from privatized access and strategy (as with fpsmt) and prevent a reasonable assessment of the global picture needed in therapy. e-detailing engagement and management encapsulates both promises and dilemma calling specifically for an investigation on self-governance accomplished by expert professionals who have to work on a daily basis to shape appropriate conditions for emerging actions along the problematized principles of legitimacy, efficiency, democracy, and accountability (hennart 2015; li 2003; wedeman 2011) .the leading pharmaceutical firm's (e.g., the smt platform provider) position orchestrates the market-actors' endeavors, collective actions and network conditions for specific purposes. framing embodies and structures the professionals' choices and reveals how they process information and it resources and interact with peers (orlikowski and gash 1994) . beyond framing's technological interpretation, it incorporates the dynamic progress, uncertainties and inconsistencies smts represent (van burg et al. 2013) . framing, or frame creation, and sensemaking are considered complementary processes for understanding how market-actors can negotiate smts as a structuring context in which they are voluntarily embedded. goffman (1974) viewed frames as abstractions that allow the configuration or structure of information meaning. the active process of seeking, processing and integrating information is labeled sensemaking (wilson and wilson 2013) . frames allow multiple (at times, contradictory) interpretations of shared smt resources to become compatible and strengthen the voicing of tension (positive and negative) and encourage unusual solution searches. through combined framing and sensemaking, we can understand and articulate how market-actors draw on formal and informal resources others create (caughron et al. 2013) to impose a sense of control and decorum on themselves in a given ecosystem. at the field level, framing allows interdependent market-actors to adopt uncommon answers to complex issues according to their beliefs (cornelissen and werner 2014) . in highly regulated b2b ecosystems, sensemaking requires individuals to recognize the abstract resources they need and the organizational constraints they face. as a first step, this requires seeking, noting, and integrating new and often counterintuitive information that challenges one's original beliefs and attitudes (weick et al. 2005) . then, sensemaking demands interaction and information sharing to capture the crowd's wisdom and guard against unintended data disclosures (surowiecki 2005) . in sum, one can use framing and sensemaking to appraise market-actors' social relationship investment and engagement processes. understanding this ambiguous refocusing process and how multiple actors' selfgovernance is practiced forms this study's core (nalini et al. 2017 ). e-detailing, like all technologised practices, requires understanding not only technology acceptance (abdekhoda et al. 2014) but also this acceptance's underlying meanings, including how health information management is negotiated within networks (ehteshami 2017) . at stake here, along with market pressures and innovations, is the understanding of how some platforms set up by facilitating private firms require the engagement of hcps and their genuine willingness to positively contribute to the collective agenda that in essence raises drugs status away from a commodity to a valued innovation. overview following yin's (2015) and eisenhardt's (1989) guidelines, we present a case study on e-detailing in the pharmaceutical industry to theorize self-governance as a practice based on b2b actors engagement with fpsmt in highly regulated contexts that has far-reaching implications for other industries such as banking, insurance or power generation. case studies are recommended for unfolding events bounded by a specific time, multiple actors, and tasks (i.e., "a program, an event, an activity, a process, or one or more individuals" (creswell and creswell 2017, p. 15) . a qualitative research approach was used to collect and analyze the data (miles and huberman 1994) . the unit of analysis in this study is represented by three types of healthcare professionals, namely pharmaceutical salesforce called medical science liaisons (msls), physicians and pharmacists, representing the key current active market-actors engaged with fpsmt on one particular global pharmaceutical firm e-detailing platform. we apply established conventions of qualitative data analysis involving (1) categorization, abstraction, comparison integration, and abstraction searching for patterns in the data and why those characteristics are there towards consolidated meaning, and (2) interpretation, along essence-capturing of the essential elements of the stories connections (spiggle 1994; ng and hase 2008) . our interpretative analysis draws on 23 in-depth interviews conducted in thailand, an emerging asian market chosen because of the diverse and urgent healthcare issues it faces. deloitte estimated health care spending in thailand would reach $18.7 billion in 2018, growing by 8% between 2014 and 2018. this was higher than malaysia's 4%, indonesia's 3.1%, myanmar's 1.8%, and the philippines' 4.4% and was on par with singapore (oxford business group 2020). in thailand, more than 70% of the population receive free health care under universal health coverage, and the country is rapidly becoming a competitive destination for medical tourism. moreover, private hospitals are raising funds and expanding overseas (oxford business group 2020). thailand has received recognition for its quality healthcare services, placing sixth (67.99/100) in ceoworld's 2019 health care index out of 89 countries (ireland 2019) . of the various subsets (all out of 100), thailand received a score of 92.58 for its healthcare infrastructure, 17.37 for professionals' competence, 96.22 for healthcare cost, 67.51 for medicine availability, and 89.91 for government readiness (bangkok post 2019). thus, e-detailing strategies seem to contribute to raising the somewhat lower scores for professional competence through thailand's government establishing proactive policy strategies, making it the medical hub of asia. moreover, one key challenge the thai healthcare system faces is to advance the capturing of accurate health data from different stakeholders to better plan and control spending. in data rich healthcare, e-detailing, if properly overseen, could foster sustainability of public healthcare expenditure (khidhir 2019) . one of this study's authors had full access to msls at a global pharmaceutical firm in thailand. this allowed direct observation of daily services practices from its headquarters during video calls and face-to-face visits with hcps. this access provided a solid foundation to observe individual practices, and meaningful interactions. an initial pilot study was carried out through three interviews. a semi-structured guide was created cycling between the pilot study and the literature (davis and eisenhardt 2011) . interviewing follows purposeful sampling (teddlie and yu 2007) . interviews were recorded with the interviewees' consent; when required, one of the researchers carried out translations, with pilot study respondents crosschecked for validity. subsequently, an interview request was sent to 36 hcps if they had at least 15 interactions on the e-detailing platform (internal data); however, 13 of those declined participation for various reasons. for those that agreed, they were contacted via email and the generic topic was explained, along assurances of confidentiality and that ethical guidelines of the interviewing researcher's university would be followed. therefore, we conducted a series of 23 in-depth interviews (face to face or via video links) with six physicians, seven pharmacists, and 10 msls (from a single global pharmaceutical firm) (see the appendix). respondents were from either public or private hospitals and had, on average, eight years of experience and were, on average, 32 years old; this was deemed appropriate to reflect and manage the complexity of the analytic task. all interviews were analyzed using the criterion of information saturation and redundancy (lincoln and guba 1985) . detailed notes were taken of specific examples shown by the hcps (including screen shots of specific information on the e-detailing platform), photos of older leaflets, photos of how files were organized at the individual level, photos of it equipment available, and displays of any drug or pharmaceutical firm names, if available. the aim of the interviews was for deep understanding of the interactions at stake in the e-detailing service, including the demands the informants perceived were put upon them (mccracken 1988) . twelve interview questions were divided into three parts: (a) how hcps engage, or not, with fpsmt; (b) how hcps change, or not, their work practices to echo the concepts of technological framing; and (c) how sensemaking engage hcps towards self-governance (järvinen et al. 2012; kianto et al. 2016; siamagka et al. 2015) . moving from general to more-specific questions, we asked about hcps day-to-day experiences with e-detailing, including their experiences on pharmaceutical "x" e-detailing platform; approaches and managing the acquisition, creation, sharing, and retention of information; how those issues affect accomplishing their work (i.e., relevance of knowledge, effective process of knowledge evaluation and knowledge protection ability; evolvement of the fpsmt process with other professional actors (e.g., mutually beneficial decision-making process; better understanding of other market-actors' views regarding dispute resolution; daily practices and opportunities with "x" smt and any restrictions or challenges they faced). content soundness was ensured by linking the semi-structured interview questions to the theoretical framework and through unpacking the framing and sensemaking processes in which market-actors' engagement in fpsmt becomes effective and self-governance is practiced. the protocol was reviewed by three experts within the global firm and was pre-tested by a representative of each profession, each of whom had more than 5-years' experience in healthcare. (after piloting, hospital managers and policymakers were not interviewed because they represented a more accounting-based view and were not directly involved in daily smt activities.) to analyze the data, the authors systematically read the transcripts to search for ideas, patterns, common ground, and opposition within the respondents' answers. the analysis procedure included four steps: (a) researchers independently coded the practices identified through the interview transcripts and notes into preliminary working categories of informant-centric terms using nvivo version 10 to generate first-order themes; (b) shifting between the data and the literature (santos and eisenhardt 2009), second-order themes (corbin and strauss 1990) were developed; (c) the second-order themes were refined by cycling between theory and the field data (davis and eisenhardt 2011); at the end of this stage, three frames (aspiration, regulation and responsibilisation) were formed, and a framework was developed to demonstrate the relations among these concepts (see fig. 1 ). initially we used open coding that generated a large number of open codes including for example: 'assertiveness to fit in', 'technology commitment and professional image', 'tenability and accuracy', and 'e-detailing access and manipulation focuses'. leveraging these multiple open codes, we mapped the mosaic of narratives without imposing a pre-imposed perspective (yin 2015) . the data revealed more details, and comparing the hcps led to pattern and commonality recognition, such as respondents' underlining matters associated with information trust, it-mediated information types (videos, graphs, photos), 'technological savviness', 'discussion modes standardisation' and 'information benchmarking and comparability'. by merging these materials, a higherlevel classification, 'expansion of content trustfulness' emerged. from that, we axial coded to identify central phenomenon (davis and eisenhardt 2011) and introduced additional search regarding specific positive and negatives examples about the challenges and opportunities faced on e-detailing to saturate the emerging higher-level classifications. following colliander and wien (2013) , the authors discussed the findings and resolved disagreements (ng and hase 2008; spiggle 1994) . in the last step, we theorized on these higher-level categories along the attributes highlighted in the literature review, leading to developing our three frames. the findings reveal that hcps (pharmacists, physicians and msls) identify and seize opportunities offered on fpsmt in ways that disclose different reflective states through which along micro-practices self-governance practice is accomplished (see fig. 1 ). the conceptual figure describes how market-actors develop a sense of purpose and appreciate the extent to which fpsmt continuously affects their own initiatives and development. as a reflective state, self-governance, through the questioning centered on each frame, encourages purposeful actions that ultimately foster active quests for relevance. the double-headed arrows in our framework represent the quests (i.e., self-governance practice as projects), which are often only partially resolved, leading market-actors to move to another frame. the three intertwined cognitive frames are labeled aspiration, regulation, and responsibilisation frames. the granularity of fpsmt is found to support market-actors' abilities to manoevre within multiple levels of competing rationalities, which then delineates the instantiation of self-governance practice. in each frame, we characterize the key micropractices, understood as individual activities abstracted from their specific context or time of application to appreciate how a phenomenon (here, self-governance) is instantiated. when being framed, these establish a teleoaffective structure toward self-governance as an integrative practice (rouleau 2005) . micro-practices are understood as individual activities that have been abstracted from their specific context or time of application to appreciate how a phenomenon (here self-governance) is instantiated (rouleau 2005) . the respondents first revealed healthcare professionals rely on smt to generate strong aspirations. still, this aspiration frame relates both the humbling experiences and doubts about seizing control over one's career trajectories, competencies and effectiveness the development of fpsmt generates. under this frame, respondents appeared to be critical towards fpsmt's present usage (i.e., current rules and obligations are considered problematic). the following quote from respondent i illustrates that cognition triggers a readiness to be critical on the current state of fpsmt. however, both respondents i and b pointed towards novel micro-practices that encourage the development of social agilities based on interactive, dynamic communication and trust in self-governance purposes. respondent i (pharmacist): i found fascinating that the detailed video showing how available drug molecules can deliver to targeted organs. it is very clearly explained and also encouraged me to understand it better, maybe from another perspective and in greater detail. it encouraged me to discuss, share and comment [on] the video with others to create further value. respondent b (physician): i can update to the new guideline of treatment and get the knowledge from the most famous professor's experience, all shared on one sm platform. i can adapt that information to use with my patients. i questioned myself. this application helped my hospital to save time and cost. it is real progress for all. these market-actors displayed an obvious enthusiasm for smt functionalities that change and strengthen network members, hence, positively enhancing their self-presentations. for most hcps, technology-mediated interactions are related to the willingness to deepen content quality, which is directly linked to the inseparability of hardware, software and resource creation that facilitate the "professional social game." this frame supports the affordances of technological tools that articulate both individual and collective aspirations, including developing capacities to confront change. hcps feel empowered by fpsmt they can use to answer multiple questions about the directionality and prescription of what is then a prescriptive disseminating tool. with professional fpsmt usage, hcps must adopt a higher level of vigilance and prudence compared to private smt usage. the aspiration frame reflects what the mastery or obligations related to fpsmt (demands and expected outcomes) calls for in terms of smt's scope and how to engage with it (e.g., assessment, conformity or deviation) when considering higher-order interests and flow of experiences. through this reflective process, the aspirational values that individuals share on fpsmt are not suppressed by the personal risks these technologies epitomize; on the contrary, they are embraced towards innovation. however, respondent h voiced an awareness of the danger that may come from adverse event cases. i used e-detailing smts […] to provide information to doctors, but often needed to smooth the discussion because of internet signal issues and legal requirements…. if a salesperson is not familiar with e-detailing or ipad technology, he will not use it naturally, the knowledge of technology itself is an issue. this can cause professional image damages. but it is getting better, and everybody can see that! the aspiration frame subsequently involves making sense of the contradictions included in fpsmt's daily usage. this is akin to imposing a constant oversight reflecting "perceived absolute" demands (e.g., respect of the legal framework) beyond the innovative mindset that encourages active actors to make sense of direct interactions. overall, the aspirational frame allows market-actors to work on professional sustainability and the development of content accuracy, and it even asserts specific firm's technological savviness, as respondent h explained: slides presentation and sponsorship must be approved by [country level organisation] medical first and the legal guys [within the firm]. slide presentation cannot have [a] trade name appearing because we are not doing business only but [must] focus on education and needs for information. then we need to be very clear among ourselves on what we say how we interpret what is written. otherwise, our jobs could be at risk. this forces all of us to reflect on what and how we want to use the material and how physicians will interpret and react to what is said. although this quote reveals a fearful side of communication and misuse of privilege, respondents accentuate a possible set of reasoned usage that, as a group, they feel exposes the learning scope on fpsmt. here, aspiration expresses the social nature of networks grounded in experience-based reassurance. in the regulation frame, respondents elaborated on the corollary of the relative empowerment described in the aspiration frame. in this frame, market-actors are better equipped to appraise their need for regulation for both formal and informal communication and sharing rules. as such, smt is perceived as not appropriately or sufficiently scrutinized (towards correcting errors or incorrect information), especially when mutual support could clearly lead to richer, more valuable outcomes. going beyond stereotyping, substantial concerns exist about the security of smt (including privacy issues) and about the (de)legitimisation of legal issues, as evidenced in respondent p's remarks. in my opinion, there are many concerns… perhaps, confidentiality concerns, security network, accuracy and reliability of the information should be made clear when using digital media. it is about "patient's rights" because if users took a photo of a patient or shared a patient's opd card on the platform or sent to others without erasing/blurring the patient's name/face, it would be illegal and violate the patient's rights. it is about accuracy concerns. to get rapid feedback on things[,] because if pharma marketers publish any mistakes, despite all the checks; or incorrect information, danger can spread very quickly, and the problem will be very hard to solve, smts seem to have a tendency not to let information even false [information] be erased. indeed, respondents developed various dispositions and sensibilities towards fpsmt guidelines and status beyond the blanket notice-and-consent model. most respondents discussed the necessity of instigating, fostering and achieving protocols that do not curb communication, so that knowledge diffusion occurs, as respondent n shows. it surely supports pharmaceutical marketing but also innovation. we need it. i always search for medicine information on the doc. they share, but often i am not able to find much beyond normal information on traditional leaflets. thus, i think that if pharmaceutical companies upload more information about their medicines or delivery mechanisms on their platform, we will conveniently access that essential information, will participate [in feedback, reviews] and use the drug, if appropriate, in our work. caught by the regulation frame, market-actors' self-governance practices tend to touch on both legal requirements and social communication expectations, demonstrating a need to further externalize fpsmt social evaluation across a broader set of actors. this frame allows market-actors to shape suitable strategies and, concurrently, be considered valued and trusted pioneers. still, when actors engage in and challenge complex sociotechnical values, they recognize the unequally distributed risk to an individual's reputation. this encourages them to scrutinize specific market-actors', like the government's, initiatives, as respondent k mentioned. generally, rather than describing inertia, the regulation frame calls and relies on the other two frames (aspiration and responsibilisation) to shape market-actors' selfgovernance directionality and prescriptions towards fully exploiting what fpsmt can bestow on them. thai regulation has many particular rules about digital communication. therefore, maybe one isn't brave enough to be the digital marketing leader among the pharmaceutical industry in thailand. we are not all equal according to the government policies [,] you know. but we all need a voice, and we know stuff; the society needs it. this frame provides further evidence that market-actors work along an enquiring continuum and are thus aware of fpsmt usage's transformative and far-reaching implications on healthcare. this frame calls market-actors to problematise their engagement, which allows more socially valuable networked e-detailing practices, as respondent h noted. all actors may resist [smt] change. in my opinion, sometimes it is too quick to change [,] but it is required to keep up with innovation and encourage improvement. i am familiar with the existing e-detailing, but all the time[,] i have to re-learn through physicians' comments and views. value must be developed together. the data illustrate that reflections are open on the exclusive charters and conditions in which healthcare professionals operate. respondent a illustrates the thin line between grounding privileged communication and the carelessness of actions on fpsmt. within the responsibilisation frame, time (or the lack of it) is a precious resource for all market-actors and is a central mechanism in fostering (or not) robust interactions. as such, respondent a's quotation illustrates timely contextual actions' saliency, revealing market-actors must operate in symbiosis with the dynamic environment. this attempt to reach unification through fpsmt's use is portrayed as depending on responsible, collaborative learning as an impetus for communication that creates knowledge flows beyond facts. digital media absolutely support marketing of pharmaceutical companies. they do not only benefit them but also benefit patients because it is a necessary condition to share information in modern medicine. pharma firms use digital media such as media graph and e-detailing to create contents, spot patterns and gain best physicians' attention, but nothing is straightforward. the next quote from respondent q illustrates concerns that responsibilization must transpire across all market-actors (not only privileged ones) who adjust their behaviors and performance accordingly while recognizing that more traditional and differently codified offline practices (here, conferences) must be combined with the emerging new systems. : i cannot answer how much a webcast can influence a specific doctor's belief and behavior. i think this is the salesperson's responsibility to follow up again and again maybe face to face or at a conference as we are creating behaviors. i find out information, with statistics from the platform after the webcast is finished about the actions taken or not taken. it is about developing comfortable communication. it is not one system or another. taken together, the three frames and sensemaking processes represent three pairs of binoculars b2b market-actors leverage in interpreting the unsettled communication on fpsmt within the healthcare ecosystem. these allow them to sustainably shape actions and engage in the digital knowledge work economy. the paper sets out to investigate how self-governance practice allows professionals in the digital knowledge economy to leverage smt within highly regulated b2b environments while actively engaging in continuous knowledge work. specifically, we show empirically how, in the case of healthcare in thailand, such engagements operate in e-detailing. in doing so, self-governance practice is found to be generated through hcps and msls' reliance on cognitive framing. it allows hcps and msls to strengthen their position within fpsmt mediated practices. in the context of the highly regulated b2b healthcare social media ecosystem, the data emphasize how through the interdependence of three specific frames, self-governance operates as a practice leading to: (a) aspiration related to the benefits of being trusted, (b) regulation in ways that allow to appreciate formal and informal rules and (c) responsibilisation representing smt's context internalization for daily usage and viable engagement in e-detailing practices. the three frames are akin to a process accentuating every market-actor's voice, richness, and role in open strategisation and organizing practice, in effect bringing professionals together (whittington et al. 2011) . fpsmt for self-governance underlies a range of possibilities for expert professionals related to where and how to positively contribute to the healthcare ecosystem beyond contingencies related to the here and now (i.e., complacency) (broniatowski et al. 2018) . it illustrates how distinct professional actors legitimize or delegitimise emerging digital practices (e.g., knowledge re-use, distributed leadership) by voicing opinions, expressing empathy, or relying on daily tactics. collectively, the frames explain how engagement with privatized smt incorporates information sharing through sensemaking in knowledge economies. this leads individuals to a more organized sense of self-governance (burchell et al. 1991 ) and ways to cope with the inventive features of networks in a digital era. while analyzing the healthcare sector in thailand, this research contributes to the management literature by bringing a novel understanding of self-governance in the digital economy in two main ways. first, we give account of how selfgovernance operates in b2b contexts. second, by delving into a cognitive framing approach, we bring to the fore a novel understanding of how self-governance for professional actors in the digital economy unfolds as a practice. over the last decade, self-governance has primarily contributed to significant research in political sciences (ostrom et al. 1992; sørensen and triantafillou 2013) , management (gautam 2017; johnson et al. 2020; park 2020) , and marketing (gandini 2016; grénman et al. 2019) . in doing so, it has largely ignored the forms self-governance take in digitized b2b contexts whereby the sense of professionalism is underpinned by the extensive set of tightly organized relationships and networked imperatives that are reflected in day-to-day managerial work (fox and ward 2008; chelariu and sangtani 2009; olakivi and niska 2017; macheridis and paulsson 2019) . this study bridges this gap by proposing a view on self-governance that accommodates the increasing development of smt within and between firms and the often conflicting expectations expert professionals face when being engaged in exchanges that advance both private and public interests (wegner and mozzato 2019). we show how self-governance as a digitized practice unfolds in situated practices through which professionals negotiate stakes related to personal aspirations, responsibilities, and regulatory concerns. as such, we offer an understanding of self-governance as a practice that places professionals as major actors on both private and public agenda who demonstrates a sense of professionalism by going beyond self-interests (gandini 2016; gautam 2017) . the data show that b2b market-actors are often encouraged to step into new roles they might initially find unfamiliar and that have to be established to meet collective needs. dispersed expert professionals are critical sources of knowledge, interpretation, and elucidation. they shape complex social codes, rules, and technologies, including smt, towards developing original, often unprecedented solutions with far-reaching effects on different dimensions of the corporate innovation process, reputation, and control beyond the narrow pursuit of sales' objectives (wider et al. 2018) . hcps are now extensively embedded in their ecosystems, where different types of sustainable solutions can coexist, and where a wider array of expert professionals are able to keep momentum to influence the decision-making process. beyond the healthcare sector and asia, this research underlines that expert professionals' engagements via self-governance conjointly serve professionals individually, the collective agenda, and specific business dimensions (e.g., perception of products and service quality). self-governance becomes here a central resource for network governance. we thus contribute to network governance research by showing the conjoint roles of innovative governance structures (e.g., fpsmt) and professional engagement in the shaping of effective network governance. we specifically underline the worth of a practice-based view on self-governance to articulate the collaborative and competitive modes of conduct that prevail in network governance explicitly in highly regulated contexts (wegner and mozzato 2019) . considering that this study has been conducted within a single country, its findings provide avenues for further research. given the rapid development of e-detailing and b2b social media in asia, a longitudinal approach may capture the ever-changing nature of situated practices related to self-governance. it would be also important to enhance the understanding of the roles played by various information technologies in self-governance practices. future studies comparing managerial stances across organizational departments in b2b can add to the understanding of self-governance and network governance by exploring various countries and types of industries including the less regulated ones. following the same logic, studies can investigate self-governance as a resource through which professionals negotiate governmental regulations in the case of non-mature marketplaces (e.g., second-hand goods or promotion of alternative lifestyle). finally, to provide a more balanced view on how expert professionals draw on self-governance within networks, future research could determine how self-governance via social media platforms operates along various professional positions from trainees to ceos. in relation to this, we call for specific research on self-governance that investigates professional actors whose actions on privatized social platforms led to negative consequences for them (e.g., job loss). for managers, our research shows that innovative governance structures in the digital economy, such as fpsmt, are powerful in developing expert professionals' confidence and autonomy. professionals are indeed found to be going beyond what is strictly regulated and develop knowledge structures favoring innovations. under these conditions, firm strategies can mobilize expert professionals to balance the voices of influential groups (e.g., scientific committees, lobby groups etc.). our research echoes managers' challenges reflected in demand-side activities related to economies of scale or network effects when attempting to foster more inclusivity to forge a navigable path to collective welfare and innovation (swani et al. 2017) . consequently, this study shows that on privatized and public smt, b2b professionals are expected to go beyond mere views of information towards contributions to knowledge production. in sum, each professional is called to reflect on his/her active steering participation (e.g., boycotts, resistance, compliance etc.) to influence network-level changes (coyle 2017 ). the findings suggest that self-governance and privatized social media technologies (e.g., fpsmt) are at the core of a broader and deeper debate regarding professionals, firm and collective accountability, and the ways they question the value of globalized wealth sharing and associated impacts on business models. in the pharmaceutical sector, executive boards and leading ceos will need to appreciate the worth of collective ways that foster innovation within more inclusive service orientated approaches. e-detailing now departs from push marketing strategies as it does not lock in actors and fosters individuals' openness to alternative solutions (ehteshami 2017; kwak and chang 2016; nalini et al. 2017) . along shifting regulations, key stakes for b2b firms are to enact relevant performance indicators (e.g., number of views, number of document downloads etc.) and associated rewards for mlss. the study shows the relevance for firms in emerging market conditions to facilitate the understanding of how e-detailing technology operates (e.g., tracking and adjustments of data in real time, regulatory constraints and prevailing netiquette). spotting problematic behaviors allows firms to limit the occurrence of adverse events by taking early corrective actions, which in turn could limit the perceived intrusiveness of governments' interventions. coming to the case of e-detailing in thailand, it is essential to underline that hcps' possible non-engagement may endanger the country's healthcare system (oxford business group n.d). indeed, the findings underline that the local public and private hospital management is welcoming digital access to support modern medicine. at stake here is the welcoming of individual expert professionals' voices that contribute to bring medical solutions in all parts of the country and allow medicine sales to fit better with demand. conveying local information appears here as being essential to strengthen healthcare system's responsiveness and be less vulnerable to unanticipated events such as pandemic (e.g., or natural disasters. this implies that the thai government develops a robust healthcare system by documenting all the processes and harnessing data to support expert professionals' reskilling and upskilling capacities (bangkok post 2019). conflict of interest on behalf of all authors, the corresponding author states that there is no conflict of interest. information technology acceptance in health 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different americans changed behaviors before and after major covid-19 policy announcements date: 2020-06-08 journal: nan doi: 10.1101/2020.06.04.20119131 sha: doc_id: 270828 cord_uid: h9tgkboe background: as states reopen in may 2020, the united states is still trying to curb the spread of the covid-19 pandemic. to appropriately design policies and anticipate behavioral change, it is important to understand how different americans' social distancing behavior shifts in relation to policy announcements according to individual characteristics, and community vulnerability. methods: this cross-sectional study used unacast's social distancing data from february 24th may 10th, 2020 to study how social distancing changed before and after: 1) the world health organization's declaration of a global pandemic, 2) white house announcement of "opening up america again" (ouaa) guidelines, and 3) the week of april 27 when several states reopened. to measure intention to social distance, we assessed the difference between weekday and weekend behavior as more individuals have more control over weekend leisure time. to investigate social distancing's sensitivity to different population characteristics, we compared social distancing time-series data across county vulnerability as measured by the covid-19 community vulnerability index (ccvi) which defines vulnerability across socioeconomic, household composition, minority status, epidemiological, and healthcare-system related factors. we also compared social distancing across population groupings by race, 2016 presidential election voting choice, and employment sectors. results: movement reduced significantly throughout march reaching peak reduction on april 12th (-56.1%) prior the enactment of any reopening policies. shifts in social distancing began after major announcements but prior to specific applied policies: following the who declaration, national social distancing significantly increased on weekdays and weekends (-18.6% and -41.3% decline in mobility, respectively). social distancing significantly declined on weekdays and weekends after ouaa guidelines (i.e. before state reopening) (+1.1% and +5.3% increase in mobility, respectively) with additional significant decline after state reopening (+10.0% and +20.9% increase in mobility, respectively). social distancing was significantly greater on weekends than weekdays throughout march, however, the trend reversed by early may with significantly less social distancing on weekends, suggesting a shift in intent to social distance during leisure time. in general, vulnerable counties social distanced less than non-vulnerable counties, and had a greater difference between weekday and weekend behavior until state reopening. this may be driven by structural barriers that vulnerable communities face, such as higher rates of employment in particular sectors. at all time periods studied, the average black individual in the us social distanced significantly more than the average white individual, and the average 2016 clinton voter social distanced significantly more than the average 2016 trump voter. social distancing behavior differed across industries with three clusters of employment sectors. conclusion: both signaling of a policy change and implementation of a policy are important factors that seem to influence social distancing. behaviors shifted with national announcements prior to mandates, though social distancing further declined nationwide as the first states reopened. the variation in behavioral drivers including vulnerability, race, political affiliation, and employment industry demonstrates the need for targeted policy messaging and interventions tailored to address specific barriers for improved social distancing and mitigation. introduction those staying home (klein et al., 2020) . these in-week variations suggest that social distancing behavior on weekdays and weekends should be analyzed separately (rather than looking at a week overall) to better understand shifts in behavior over time and as an indicator of social distancing intent. to date, however, the relationship between weekdays and weekends has not been explored in detail. individual and community characteristics influence social distancing uptake as well. social distancing behavior can be influenced by monetary loss (bodas & peleg, 2020) , political affiliation of individuals and policymakers (adolph, amano, bang-jensen, fullman, & wilkerson, 2020; allcott et al., 2020; andersen, 2020; painter & qiu, 2020) , and poverty (wright, sonin, driscoll, & wilson, 2020) . research has shown that different population segments vary in their beliefs and behaviors around social distancing: the segment practicing the least social distancing has low risk perception and low self-efficacy, and is more likely to be male and republican (charles et al., 2020) . employees who work in industries that require face-to-face communication or physical proximity with other workers may also be affected differently by social distancing policies (koren & pető, 2020) . in addition to these individual characteristics, research has shown that certain geographic communities are better equipped to respond to disasters than others, which suggests that there may also be differences in social distancing uptake based on community vulnerability (flanagan, gregory, hallisey, heitgerd, & lewis, 2011) . vulnerable communities may face disproportionate socioeconomic costs, such as job loss and income reductions, as a result of social distancing that make the practice less accessible or more burdensome (fairchild, gostin, & bayer, 2020; flanagan et al., 2011; hutchins, fiscella, levine, ompad, & mcdonald, 2009; lewnard & lo, 2020) . while existing research identifies several individual factors that influence social distancing behavior, there is no comprehensive assessment that characterizes social distancing across these factors. as states continue to reopen across the nation, it is essential for national and state policymakers to understand local social distancing behavior to guide their responses to the continued spread of the virus. examining this heterogeneity in how communities respond to shifting policies and how these responses vary by community and individual characteristics may help policymakers better balance trade-offs, such as between the economic benefits of reopening and the continued need for social distancing, as well as determine what messaging to use in their policy announcements. this case study leverages large-scale, near real-time mobility data to explore national social distancing trends over time, as well as how these changes differ across population subgroups. our analysis uses a covid-19 community vulnerability index (ccvi) to explore the relationships between social distancing and the factors that make a community less able to cope with the impact of the pandemic (surgo foundation, 2020a) . we address four questions: first, how much are americans social distancing and how has this changed over time? second, how has mobility increased or decreased in the weeks following key policy announcements? third, as most business-related activities are conducted during weekdays, what is the difference in mobility levels between weekends versus weekdays and how has this difference changed over time? fourth, how do these temporal trends in social distancing differ across population subgroups, including vulnerability, political affiliation, race, and employment sector? results have important implications for policymakers' continued adaptation of social distancing and other measures to fight covid-19. near real-time social distancing data were gathered at the county level from unacast's analysis of mobile phone location data (unacast, 2020) . data were collected from over 2,500 mobile phone applications, from february 24th to may 10 th , 2020, inclusive. social distancing is reflected as a percentage change in the distance travelled when compared to pre-pandemic averages (for any given day of the week, the prepandemic average is defined by unacast as the average distance traveled on the four same days of the week between february 10th and march 8th 2020, inclusive). a negative number represents more social distancing, and a positive number less social distancing. for example, if individuals in a county average 10 miles of travel on the four wednesdays in pre-pandemic days, but only average 8 miles on a wednesday during the pandemic, a -20% measurement is recorded as the mobility decline, i.e., degree of social distancing, for the county on that date. national policy announcements were selected based on their prevalence in news coverage of national covid-19 timelines. announcements that featured in multiple timelines were selected as indicating major shifts in the pandemic discourse. effective dates of state reopening policies were tracked over time from the kaiser family foundation and national governors association resources and confirmed with local government documentation of signed executive orders (kaiser family foundation, 2020; national governors association, 2020) . to understand how social distancing might be sensitive to vulnerability within the context of the coronavirus pandemic, we used the covid-19 community vulnerability index (ccvi, to be published) to identify communities that have a limited ability to delay and mitigate the health, economic, and social impacts of a pandemic. recognized by the cdc, the index builds on the cdc's own social vulnerability index (svi) (flanagan et al., 2011) . the ccvi's 34 indicators are grouped into 6 core themes that reflect a community's vulnerability to the covid-19 pandemic: the four existing themes from the svi including socioeconomic status, household composition and disability, minority status and language, and housing type and transportation; and two themes specific to covid-19epidemiological factors, and healthcaresystem factors. data are available online at the covid-19 community vulnerability index (ccvi) along with a detailed methodology (ccvi methodology) (surgo foundation, 2020a , 2020b . the ccvi and its component thematic scores are on a percentile scale, and we grouped counties into least vulnerable (x < 0.33), moderately vulnerable (0.33 <= x < 0.67), or most vulnerable (x >= 0.67), where x is either the county's aggregate ccvi score or any of its component thematic scores. data on race were sourced from the us census bureau's 2018 american community survey (us census bureau, 2018) . for each county, the census bureau estimated the number of residents who identify with one or more race categories, including american indian or alaska native, asian, black, native hawaiian or other pacific islander, or white. hispanic or latino origin was not included because the census bureau classifies this separately as ethnicity rather than race. for simplicity, only census categories "black alone" (labeled "black" in our analysis) and "white alone" (labeled "white") were analyzed; other racial groups were excluded because of their low prevalence in the population relative to other races. to measure political affiliation, voting data from the 2016 presidential election were sourced from the mit election data and science lab (mit election data and science lab, 2018) . the data set includes vote counts for the republican nominee, donald trump, and for the democratic nominee, hillary clinton, for each county in the us. the exception is alaska, which reported counts by districts at the time of the election and not by county-equivalent borough boundaries. boroughs without corresponding district reports were excluded from the mit data set and the current analysis. employment-sector data were sourced from the us bureau of labor statistics' quarterly census of employment and wages, which tracks employment numbers per job sector (us bureau of labor statistics, 2019). to account for seasonality, we used march 2019 data to approximate employment in each sector in the months prior to the pandemic. the total number of employees employed by private establishments was aggregated into 20 employment sectors (2-digit sector code level, as defined by the north american industry classification system) per county. to simplify our analysis, we did not include government employees, which also led to the exclusion of the public administration sector. confirmed cases and death counts were sourced from the johns hopkins university center for systems science and engineering, which collects and reports covid-19 data for each us county (dong, du, & gardner, 2020) . because counties occasionally switch reporting formats, reported cumulative counts may decrease at times. we rectify this by enforcing the cumulative counts to be monotonically increasing to only report peak cumulative countsif the cumulative count is less than the previous day, the data is replaced with the previous day's count. all data are publicly available, other than social distancing data obtained through unacast's data for good initiative. all data sets are deidentified. we received unacast's deidentified social distancing data already aggregated at the level of counties, which cannot be traced to individuals. unacast has an explicit privacy and consent policy (https://www.unacast.com/opt-out) stating that mobile phone users have opt-in consent for the collection of location data from mobile devices. since the current study is a secondary analysis of existing, deidentified datasets obtained at the county-level, it did not require irb approval. surgo foundation approved the study. we analyzed national social distancing data as time series for time periods before and after specific events, weekdays and weekends, and population groupings. for analysis without population groupings, social distancing was aggregated at the national level by computing the weighted mean from the county social distancing data, based on county population. the full analyses were conducted for all us counties at the national level. the dates of key national announcements were graphed with social distancing along . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june 8, 2020 . . https://doi.org/10.1101 with covid cases and deaths per population from february 24th to may 10th, 2020 (last day of social distancing data availability). we characterized how much social distancing was achieved by different population groupings across community vulnerability, race, 2016 presidential election voters, and employment sector. characteristics were selected based on a review of existing evidence on potential influences on social distancing compliance (adolph et al., 2020; allcott et al., 2020; andersen, 2020; bodas & peleg, 2020; charles et al., 2020; fairchild et al., 2020; flanagan et al., 2011; hutchins et al., 2009; koren & pető, 2020; lewnard & lo, 2020; painter & qiu, 2020; wright et al., 2020) . the groupings were made along the following dimensions, and mean social distancing was computed as described below: 1. overall vulnerability to cope with covid-19: we assessed social distancing of the most vulnerable, moderately vulnerable, and least vulnerable counties according to the ccvi to compare social distancing by vulnerability level. there is one ccvi score per county, so we computed the mean at the national level by weighting each county's social distancing by its respective population. 2. thematic vulnerability to covid-10: the ccvi divides overall vulnerability into six component themes: 1) socioeconomic factors, 2) household composition and disability, 3) minority status and language, 4) housing and transportation, 5) epidemiological factors, and 6) healthcare-system factors. for each of these component themes, we assessed social distancing of the most vulnerable, moderately vulnerable, and least vulnerable counties, aggregated at the national level. there is one score per thematic vulnerability per county, so we computed the mean at the national level by weighting each county's social distancing by its respective population. 3. community racial make-up: we estimated how much social distancing was done by black and white americans. the census bureau provides the estimated sub-population by race in a county. we computed the mean social distancing by race at the national level by weighting each county's social distancing by its respective population estimates per race. 4. political affiliation: we estimated how much social distancing was conducted by populations that voted for donald trump or hillary clinton in the 2016 presidential election. we repeated the same process used for the racial analysis to compute the weighted mean social distancing per voting group. 5. employment sectors: we estimated how much social distancing was observed in aggregate by 20 employment sectors. we did this by computing social distancing for individual employment sectors at the national level, by weighting county social distancing by each sector's employment level (i.e., number of jobs) in the county. for each population grouping listed above, we analyzed three key events: (1) the world health organization (who) declaration of a global pandemic on march 11th, 2020, (2) the release of president trump's national guidelines for reopening ("opening up america again"abbreviated ouaa) on april 16th, and (3) the time period (including effective date) of states' first relaxation of social distancing . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 8, 2020. . https://doi.org/10.1101/2020.06.04.20119131 doi: medrxiv preprint policies. for each event, we selected a "before" and "after" period for comparison, defined as the first full week before and the first full week after the event of interest. for events 1 and 2, these are the immediate full weeks (monday-sunday) before and after the event, without overlapping with the week of the event. for event 3, because the first states to reopen did so during the weeks overlapping with the ouaa release period, to avoid overlap in comparison periods, we compared the week following ouaa with the last available full week of mobility data (the week of may 10th at the time of analysis). during this time period, 16 states relaxed restrictions (and an additional 10 did so in the weeks prior), making it a reasonable proxy for comparing movements before and after state reopenings (appendix table 1 ). table 1 lists the dates for the periods of interest. we evaluated weekday and weekend trends separately because social distancing graphs show clear differences in weekday and weekend movement, likely because most business activities are conducted during weekdays, even after closure announcements. the percentage change in movement (i.e. social distancing) was averaged for weekdays (monday to friday) and for weekends (saturday and sunday). the percentage change in social distancing during each time period (table 1 ) was calculated by comparing the average social distancing on weekdays before and after each event, and similarly for weekends. in addition, for each week used for the before-and-after event comparisons, the difference in weekday and weekend social distancing was assessed by calculating the percentage change in social distancing on the average weekday (monday to friday) compared with weekend (saturday and sunday) for the time periods listed in table 1 . for categorical analyses, for both 1) comparisons between periods before and after key events, and 2) differences between weekdays and weekends, the magnitude of the percentage change in social distancing was compared across the five dimensions outlined. since interaction effects are expected between population groupings, for each event a repeated measure, type iii analysis of variance (anova), was conducted to assess the interaction effects on social distancing of (1) before vs after key events, (2) weekend vs weekdays, and (3) categories within the population grouping. where interaction effects are identified with an alpha value of 0.05, we conducted post-hoc analyses using paired, weighted, two-tailed student t-tests, to determine whether there was a significant change in the amount of social distancing before and after the event in interest, between . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 8, 2020. . https://doi.org/10. 1101 weekdays and weekends in the same seven-day period, or between population grouping categories within each time period. we examined social distancing as observed for each employment sector. to further classify variations in social distancing among different sectors, we used k-mean clustering, an unsupervised classification algorithm, to group employment sectors into three clusters on a given day based on how close (or far away) the sectors' social distance measures were to each other on that day. we then tallied how many times a sector was classified in each cluster and assigned the sector to the cluster with the highest frequency. nationally there was an overall decrease in mobility (i.e. an increase in social distancing) corresponding with the beginning of the covid-19 pandemic in the us in early march ( figure 1 ). throughout march, mobility declined, indicating that social distancing was increasing with the number of confirmed cases. however, the magnitude of the decline in mobility peaked nationally on april 12th, with 56.1% less mobility recorded than prior to the pandemic. following this peak, social distancing decreased, despite a continued increase in new cases. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 8, 2020. . https://doi.org/10.1101/2020.06.04.20119131 doi: medrxiv preprint *the lines represent weekday or weekend averages. the shaded area represents the 95% confidence intervals, however, they may be too small to be seen. during the week of march 16th, following the who declaration of a covid-19 pandemic on march 11th and president trump's declaration of a national emergency on march 13th, national social distancing significantly increased both on weekdayswith a 18.6% decline in mobility (p>0.01) compared with the week of march 2ndand weekendswith a 41.3% decline (p>0.01) ( table 2 ). this increase in social distancing occurred before the cdc announced specific social distancing guidelines on march 16th. in the week beginning april 20th, after the white house had released the ouaa guidelines, individuals socially distanced significantly less on weekdays (1.1%, p>0.01 less social distancing) and on the weekends (5.3%, p>0.01 less) than during the week prior to the week of the guideline release. this decline (i.e., increase in mobility) occurred before any states officially relaxed social distancing policies, which were not implemented until the week of april 27th. following the first state reopenings, during the . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 8, 2020. . https://doi.org/10.1101/2020.06.04.20119131 doi: medrxiv preprint week of may 4th, national social distancing significantly declined further, with 10.0% (p>0.01) less social distancing on weekdays and 20.9% (p>0.01) less on weekends, compared with the week prior to relaxed social distancing mandates. this trend was observed regardless of reopening date (appendix figure 1 ). negative numbers represent a decrease in mobility, i.e. more social distancing than before; positive numbers represent an increase in mobility, i.e. less social distancing than before. in the week of march 2nd, prior to the march 11th who pandemic announcement, there was a significant small-magnitude difference between weekday and weekend social distancing: national social distancing was 0.9% (p>0.01) greater on weekdays than on weekends (table 3) . by the week of march 16th, following the pandemic announcement, 21.8% (p>0.01) more social distancing occurred on weekends compared with weekdays. throughout april, social distancing remained higher on weekends than weekdays, although the magnitude of the disparity declined from early to late april, being 11.7% and 7.5% for the weeks of april 6th and 20th, respectively. however, by the week of may 4th, the first week following state reopening, the trend reversed: national social distancing was now 3.4% (p>0.01) greater on weekdays than weekends. negative numbers represent less mobility, i.e., more social distancing, on weekends than weekdays; positive numbers represent more mobility, i.e., less social distancing, on weekends than weekdays. week (ns) , not significant . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 8, 2020. . https://doi.org/10.1101/2020.06.04.20119131 doi: medrxiv preprint vulnerable counties practiced significantly less social distancing than non-vulnerable counties at all time periods studied ( figure 2 ). on april 12th, all three vulnerability groups reached peak social distancing; the decrease in mobility was greatest for least-vulnerable counties (58.4%, 95% ci [57.8%, 59.0%]), significantly less so for moderately vulnerable counties (55.5%, 95% ci [55.0%, 56.1%]), and even less so in the most-vulnerable counties (55.0%, 95% ci [54.3%, 55.8%]). the difference in peak social distancing between moderately vulnerable and most-vulnerable counties is not significant. nationally, all three vulnerability groups followed the same trends in making significant changes in social distancing after key announcements and state reopenings (table 4 ). however, the magnitude of change differed by vulnerability. the interaction effects of vulnerability on the change in social distancing before and after all three key events were significant (f(2,3046)=87.8, p<0.01), (f(2,3046)=38.0, p<0.01), (f(2,3046)=34.4, p<0.01). while most-vulnerable counties increased social distancing on weekdays and weekends following the who pandemic declaration, with decreases in mobility of 14.4% and 36.9% (p<0.01), respectively, they social distanced less than least-vulnerable counties, where mobility decreased by 21.8% and 42.7% (p<0.01), respectively. likewise, although social distancing declined generally following the ouaa announcement on march 16th, least-vulnerable counties saw less of a decline on both weekdays and weekends (mobility increased by 0.6% and 4.5%, p<0.01 respectively) than mostvulnerable counties (mobility increased by 1.8% and 7.1%, p<0.01 respectively). following state reopenings, most-vulnerable counties experienced a greater decline in social distancing on weekdays and weekends (11% and 20.8% more mobility, p<0.01) compared with least-vulnerable counties (9.1% and 20.2%, p<0.01). national trends in the differences between weekday and weekend social distancing were similar for all vulnerability groups with significant interaction effects for all time periods (f(2,3046)=36.8, p<0.01), (f(2,3046)=67.9, p<0.01), (f(2,3046)=65.7, p<0.01). however, most-vulnerable counties had a greater disparity between weekday and weekend behavior. this trend disappeared in the week after reopenings, with most-vulnerable counties having a smaller magnitude in weekday and weekend differences compared with moderately and least-vulnerable counties (table 5 ). . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 8, 2020. . https://doi.org/10.1101/2020.06.04.20119131 doi: medrxiv preprint *the lines represent weekday or weekend averages. the shaded area represents the 95% confidence intervals. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 8, 2020. . https://doi.org/10.1101/2020.06.04.20119131 doi: medrxiv preprint the level of social distancing differed by types of vulnerability across socioeconomic, demographic, and household composition factors but the difference was more nuanced on epidemiological, health system factors the relationship between the six themes that compose the ccvi and social distancing varied by vulnerability type. socioeconomic vulnerability ( figure 3a ) and household composition vulnerability ( figure 3b ) followed the same pattern as overall vulnerability: counties that were most vulnerable based on these themes social-distanced significantly less than less-vulnerable counties at all time points studied. the same was true for housing and transport vulnerability ( figure 2c ) and healthcare-system vulnerability (with the exception of the weekends before and after the who announcement) (figure 2d ), but the magnitude of differences between vulnerability categories are smaller. for epidemiological vulnerability (figure 3e) , the difference in social distancing was only significant during the time period around the who announcement (f(2,3047)=11.7, p<0.01) and the weekdays (f(2,3047)=.57, p=0.55), but not for the weekends before and after the ouaa guidelines release. by the weeks before and after state reopenings, there was no significant difference in social distancing by epidemiological vulnerability level ( figure 3e ). for minority status and language vulnerability the pattern was generally reversed: counties that are more vulnerable based on this theme social distanced more ( figure 3f ). this interaction effect was significant at all time points (f(2,3047)=179,p<0.01), (f(2,3047)=107.6, p<0.01), (f(2,3047)=13.87, p<0.01). socioeconomic vulnerability, household composition vulnerability, housing and transport vulnerability, and health-system factor vulnerability (with the exception of weekends after state reopenings) all follow the same overall vulnerability trends in the differences in magnitude, significance, and direction of change in social distancing during each time period (table 6 ). for both weekdays and weekends, most-vulnerable counties in these themes increased social distancing less than less-vulnerable counties following the who announcement, and reduced social distancing more than them following the ouaa guidelines and state reopenings. epidemiologically vulnerable counties increased their social distancing less than counties with low epidemiological vulnerability following the who pandemic announcement, but there was no significant difference in the changes in social distancing by vulnerability for the other time periods for this theme. counties vulnerable by minority status and language followed an opposite trend: mostvulnerable counties in this theme increased social distancing more after the who pandemic announcement than less-vulnerable counties, and decreased social distancing less following the ouaa guidelines and state reopenings. the only exception was on weekends after state reopenings, where mostvulnerable counties in this theme decreased social distancing more than less-vulnerable counties. there is heterogeneity by theme for within week differences between weekday and weekend social distancing behavior over time (table 7) . . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 8, 2020. . https://doi.org/10.1101/2020.06.04.20119131 doi: medrxiv preprint . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 8, 2020. . https://doi.org/10.1101/2020.06.04.20119131 doi: medrxiv preprint using social distancing data weighted by county population of race, we estimated that the average black individual in the us social distanced significantly more than the average white individual at all time periods studied (figure 4) . the maximum level of social distancing reached on april 12th was greater for black americans (58.8% versus 56%). for both black and white americans, the change in weekday and weekend average social distancing matched national trends, with increased social distancing following the who announcement and decreased social distancing after the ouaa announcement and state reopenings ( table 8 ). the interaction effects of race on the change in social distancing before and after all three key events were significant (f(1, 6098) = 27.6, p<0.01); f(1, 6098) = 25.5, p<0.01); f(1, 6098) = 4.0, p<0.01)). the differences in weekday and weekend social distancing trends were similar, with little difference in the magnitude between black and white individuals over time ( table 9 ). the interaction effects of race on the difference in weekday and weekend social distancing were not significant for the weeks before and after the who announcement (week 1, week 2) and after states reopened (week 5), but were significant for the weeks before and after the ouaa announcement (week 3, week 4) (f(1, 6098) = 9.7, p<0.01). . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 8, 2020. . https://doi.org/10.1101/2020.06.04.20119131 doi: medrxiv preprint 1.4* 0.9* -22.6* -21.6* -12.4* -11.8* -7.9* -7.5* 3.6* 3.3* *significant at p<0.05; otherwise (ns) , not significant the average trump voter (based on 2016 presidential election voting) social distanced significantly less than the average clinton voter at all time periods studied ( figure 5 ). on april 12th, the maximum social distance achieved was greater for clinton voters (58.6%) than for trump voters (55.0%). although overall social distancing rates differed by voting behavior, the change in weekday and weekend average social distancing again matched national trends for both groups, with increased social distancing following the who announcement and decreased social distancing after the ouaa announcement and state reopenings (table 10 ). the interaction effects of 2016 presidential voting on the change in social distancing before and after all three key events were significant (f(1, 6072) = 228.5, p<0.01), (f(1, 6072) = 274.8, p<0.01), (f(1, 6072) = 61.9, p<0.01). clinton voters on average increased social distancing by a greater magnitude following the who announcement, and decreased by a smaller magnitude following the ouaa guidelines and state reopenings. for both voter groups, social distancing matched national trends, with less social distancing on weekends early on and following state reopening, and more social . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 8, 2020. . https://doi.org/10.1101/2020.06.04.20119131 doi: medrxiv preprint distancing on the weekends in between (table 11 ). the interaction effects of voter group on the difference in weekday and weekend social distancing were significant for the weeks before and after the who announcement (week 1, week 2) (f(1, 6072) = 22.7, p<0.01) and ouaa announcement (week 3, week 4) (f(1, 6072) = 38.0, p<0.01), however, were not significant after states reopened (week 5). negative numbers represent a decrease in mobility, i.e. more social distancing than before; positive numbers represent an increase in mobility, i.e. less social distancing than before. (ns) , not significant . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 8, 2020 . . https://doi.org/10.1101 we computed the amount of social distancing by each employment sector. for clarity we pooled the social distance average for each sector and clustered based on social distancing level (table 12) . transportation and warehousing . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 8, 2020. we used k-means clustering to analyze differences in how various employment sectors social distanced on each day, and tallied the frequency. all sectors consistently (>60 days out of 77 available) classified into the same clusters, suggesting a systematic difference in the mobility patterns for employees in different sectors ( figure 6, table 13 ). in particular, employees in sectors that closed early in the pandemic (education services), or sectors that we can reasonably assume can work remotely (information, real estate and rental and leasing, professional scientific and technical services, management of companies and enterprises, finance and insurance) or have a high degree of freelance work (arts, entertainment and recreation) clustered as social distancing the most. sectors that often require on-site physical presence (construction, manufacturing, utilities, transportation and warehousing, administrative and support, and waste management and remediation services) or customer-facing work (retail trades, wholesale trades, accommodation and food services, health care and social assistance) social distanced less. two employment sectors requiring on-site manual labor (agriculture, forestry, fishing, and hunting; and mining, and quarrying, and oil and gas extraction) social distanced the least. the interaction effects of employment sector clusters on the change in social distancing before and after all three key events were significant (f(2,8560)=138.1, p<0.01), (f(2,8560)=61.2, p<0.01), (f(2,8560)=42.2, p<0.01) ( table 14) . the interaction effects of employment sector clusters on the difference in social distancing between weekdays and weekends for all three key events were not significant for who pandemic declaration (f(2,8560)=1.52, p=0.219), but were significant for the two later events (f(2,8560)=30.8, p<0.01), (f(2,8560)=15.7, p<0.01) (table 15 ). . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 8, 2020. . https://doi.org/10.1101/2020.06.04.20119131 doi: medrxiv preprint . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 8, 2020 . . https://doi.org/10.1101 until a vaccine is widely available, social distancing in some form will continue to be one of the only effective approaches for preventing the spread of the coronavirus. despite its importance, social distancing practice remains sensitive to shifts in announcements, policy enactments, and individual and community-level characteristics. using mobility data as a proxy for social distancing, we found that social distancing in the us increased significantly throughout march and peaked on the sunday (april 12) before the us government announced the ouaa guidelines. after the peak, despite continued growth in the total number of new cases, we observed significant declines in social distancing nationallyinitially in the absence of guidance and policies permitting movement, but with additional significant declines following the ouaa announcement and the relaxation of individual state policies restricting movement. interestingly, we found that shifts in social distancing began prior to specific policy enactments (whether to restrict or to relax movements), suggesting that people may shift behavior in anticipation of policy changes. we also observe that social distancing was much greater on weekends than weekdays throughout march, suggesting weekday activities (presumably employment-related) were still limiting how much people could social distance. by early may this gap disappeared and reversed, with even less social distancing on weekends than weekdays. this suggests a fundamental shift in how much caution individuals were choosing to exercise in their free time. these findings have important implications for the future of the pandemic response. first, social distancing behaviors change over time, regardless of specific policy mandates. the observed decline in social distancing prior to any policies allowing increased movement could be due to individual social distancing fatigue leading to reduced precautions in behavior, or to public discussion of predicted reopening policies triggering preemptive behavior change. during outbreaks, protective behaviors can be influenced by news coverage on the current reported severity (andersen, 2020; fenichel, kuminoff, & chowell, 2013; wong & sam, 2010) or mismatched expectations between individual perception and actual policy mandates (i.e. policies lasted longer than expected) (briscese, lacetera, macis, & tonin, 2020) . while this analysis cannot show what caused the decline in social distancing, the fact that individuals change their behaviors before policies are enacted suggests the need to keep a close pulse on social distancing behaviors so that policy can appropriately respond to behavioror, more importantly, accurately anticipate it, to enforce social distancing as needed. research suggests that risk perception and community norms are key predictors of social distancing behavior (charles et al., 2020) . mitigating the negative costs of social distancing (e.g., providing monetary compensation for lost income) (bodas & peleg, 2020; wright et al., 2020) or targeting risk communication to those who may feel less impacted (e.g., wealthy individuals) can improve social distancing compliance (bodas & peleg, 2020) . responding to observed changes in behavior requires policy, messaging, and communication that will appeal to these behavioral drivers and consider expectations of social distancing compliance. second, policy signaling can influence behavior. although social distancing declined prior to reopening decisions, there remains an observed relationship between national policy announcements and shifts in . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 8, 2020. . https://doi.org/10.1101/2020.06.04.20119131 doi: medrxiv preprint behavior. social distancing did not significantly increase until the week following the declaration of the pandemic by the who and the national emergency declaration by the white house (and this preceded the release of social distancing guidelines by the cdc). social distancing significantly declined nationally following the release of the ouaa guidelines and after the first state reopenings. this suggests that individuals will adjust their behavior in response to national policy announcements, even when these do not include specific mandates or relaxations of mandates. before announcing changes to come, public officials must recognize that individuals may shift their behavior because of the mere announcement itself, even if the policy does not suggest doing so. third, the shifting difference between weekend and weekday social distancing hints at the potential influence of employment barriers to distancing, as well as changes in social distancing intent over time. that for the initial 1.5 months of the pandemic social distancing was higher on the weekends, when individuals have more leisure time, suggests that it was structural barriers, such as requirements to perform essential work, or lack of paid sick leave, that led to lower levels of social distancing on weekdays. in future waves of the pandemic, it will be important to build in more opportunities for weekday social distancing, such as expanding work from home opportunities and allowing for paid sick leave across sectors, as well as building out protective measures for those who must work. the recent shift to less weekend social distancing implies that in later months of the pandemic, individuals may be travelling more during their free time, adding additional evidence that intent to social distance is declining. this is a key signal for policymakers: while social distancing has declined overall as states have reopened, this appears not only a product of people returning to work, but of people choosing to be more active on their weekends. differences emerge in social distancing among subgroups of the us population. more vulnerable counties, as measured by the ccvi, social distance less than less vulnerable counties, particularly counties that are poorer, have more households with elderly, young, and disabled members, those with limited transport access and crowded living arrangements, and those with less healthcare-system resources. more vulnerable counties also tend to have a greater within-week difference in weekday vs. weekend social distancing, but after reopening, this difference shrinks. in contrast, after reopening, less vulnerable counties have a greater within-week disparity, suggesting they experienced a disproportionate decline in voluntary weekend social distancing. the four vulnerability themes that differ the most in rates of social distancing suggest that vulnerable counties encounter structural barriers to social distancing, especially during weekdays. these may include lower-paying jobs in essential services that do not allow work from home, and a need to travel greater distances to get to employment. findings are similar to existing research indicating that poverty reduces social distancing compliance (wright et al., 2020) . economic barriers to social distancing must be addressed to enable better social distancing in these communities. recognizing that these barriers will likely persist, it is also important to prioritize other interventions to combat the spread of covid-19 in these communities, such as ensuring safe work environments and adequate and accessible personal protective equipment. while in general those that are more vulnerable social distance less, the exception to this trend is counties that are more vulnerable in minority status and language, who consistently social distance more than communities that are less vulnerable in this regard. we conducted additional analysis on the relationship between race and social distancing by weighting social distancing data directly with subpopulation . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 8, 2020. . https://doi.org/10.1101/2020.06.04.20119131 doi: medrxiv preprint estimates of county racial breakdown. we again found that black americans social distance more than white americans. taken together, the results suggest that there are influences that we have not accounted for that contribute to demographic differences in social distancing behavior, such as differences in urban/rural settings, preferred information sources, risk perception, and community social norms. in addition to community (i.e., vulnerability) and demographic (i.e., race) differences that may influence social distancing, there also appear to be differences based on the beliefs people hold. clinton voters social distance more on average than trump voters, similar to findings of previous research (allcott et al., 2020; andersen, 2020; painter & qiu, 2020) . past research suggests democrats have high perceptions of the risk and severity of covid-19 and attach greater perceived importance to social distancing (allcott et al., 2020) . partisan differences may also be driven by perceived credibility of politicians and messaging (allcott et al., 2020; andersen, 2020; painter & qiu, 2020) . combined with the findings on vulnerability, this ideological divide in social distancing behaviors suggests that there is a need for more targeted messaging around social distancing tailored to the specific barriers an individual faces. messages should come from diverse messengers, as crisis communication shows the most effective messaging comes from sources an individual feels a connection with, which will vary by the population targeted (heath, lee, & ni, 2009 ). while some americans may face structural barriers that prevent them from social distancing, such as jobs in essential services, others may be doing because of beliefs such as lower risk perception about the value of social distancing or different perceived community norms (allcott et al., 2020; charles et al., 2020) . for these individuals, messaging should focus on the value of social distancing in keeping them and their communities safe. lastly, we look at different employment sectors. employees in sectors that typically require less customer-facing interaction, such as information and professional services, and sectors that are currently shut down, such as educational services, social distance more. by contrast, employees in sectors such as manufacturing, retail, and accommodation and food services social distance less throughout. the lowest social distancing group is those in agricultural sectors and mining. this aligns with research showing that social distancing's impact on employment productivity also varies by industry and geographic location, requiring different levels of compensation to offset losses for continued business operation (koren & pető, 2020) . in addition to laws focused on job security, income replacement, and business relief (koren & pető, 2020; rothstein & talbott, 2007) , policymakers need to consider additional workplace protection measures such as masks with continued reopening, especially for sectors unable to maintain some level of social distancing. this is critical given that risk of transmission can also vary by industry; work-related transmission contributed substantially to the early growth in covid-19 cases throughout asia (lan, wei, hsu, christiani, & kales, 2020) . this analysis has several limitations. the most apparent is that many vulnerability dimensions and population characteristics are confounded. second, because policy effects are likely cumulative, it is difficult to tease out individual policy effects. the selected national announcements may also not have any causal relationship with the observed shifts in social distancing behavior and may not reflect the true first shift in increasing or decreasing social distancing behavior. however, observational data show a clear large difference in the magnitude of social distancing before and after these time periods, in line with broad changes in the national discourse, suggesting a certain relationship. lastly, we have not attempted to fully capture the perceptual drivers and other potential signals such as news, misinformation . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june 8, 2020. . https://doi.org/10.1101/2020.06.04.20119131 doi: medrxiv preprint campaigns, and social norms. the reported results are therefore only observational in nature and cannot quantify the true causal effects of policies on social distancing behavior. however, our findings show that different communities respond in social distancing differently. more research and analysis is needed to understand how different policy approaches to restrictions and relaxation impact progress along the epidemic curve, and to identify which drivers, such as policy type or trust in government, are to be found in the causal pathway. research is also needed to explore the causal relationship between specific policies and behaviors as well as how the described trends vary at the state level and in response to state and local policy shifts. the social distancing rates based on unacast's mobility measurement assume that the population studied uses smartphones with such apps activated. therefore, it may not model a representative sample of the movement of all individuals in a county. however, the data are considered a reasonable proxy for social distancing given the high levels of smartphone penetration in the us, and that measures are calculated based on distance traveled rather than location. social distancing measures modeled from location data also make behavioral assumptions that may not be universal (e.g., all individuals having one "home" location throughout the pandemic, rather than relocating to family homes or other locations) (walle, 2020) . the definition of prepandemic baseline was determined by unacast without our input; however, we believe unacast has made a reasonable choice. interpretation of analyses may be limited by the availability of samples and their granularity. for example, vulnerability is ranked per county relative to all other counties at a national level, resulting in a heterogeneous distribution of low, moderate, and highly vulnerable counties from the perspective of the country. here we have presented analysis at the national level but similar analyses were also performed (not shown). in a single state, though, there may be very few or even no low-vulnerability counties. this results in greater uncertainty of how representative a social distance estimate may be for finer geographical levels. both race and political-affiliation data were aggregated as a per-category populationweighted average of county social distancing behavior. this requires an assumption that individual social distancing behaviors in these groupings follow that of a normal distribution (and similar to the county average). while future analysis is needed to identify the specific factors that cause individuals to shift their social distancing behavior, our observational analysis of social distancing changes over time suggests that that behavior may be sensitive to both policies themselves, anticipation of policies to come, as well as individual and community-level characteristics that can make an individual more or less likely to social distance. to curb the spread of the virus, these factors must be acknowledged and addressed in future policies. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june 8, 2020. . https://doi.org/10.1101/2020.06.04.20119131 doi: medrxiv preprint pandemic politics: timing state-level social distancing responses to covid-19. medrxiv polarization and public health: partisan differences in social distancing during the coronavirus pandemic early evidence on social distancing in response to covid-19 in the united states self-isolation compliance in the covid-19 era influenced by compensation: findings from a recent survey in israel compliance with covid-19 social-distancing measures in italy: the role of expectations and duration social distancing increasing uptake of social distancing during covid-19: behavioral drivers and barriers among us population segments strong social distancing measures in the united states reduced the covid-19 growth rate when do shelter-in-place orders fight covid-19 best? policy heterogeneity across states and adoption time the effect of nonpharmaceutical interventions on covid-19 cases, deaths and demand for hospital services in the uk: a modelling study. medrxiv an interactive web-based dashboard to track covid-19 in real time vexing, veiled, and inequitable: social distancing and the "rights" divide in the age of covid-19 adaptive human behavior in epidemiological models skip the trip: air travelers' behavioral responses to pandemic influenza imperial college covid-19 response team, who collaborating centre for infectious disease modelling, mrc centre for global infectious disease analysis, abdul latif jameel institute for disease and emergency analytics a social vulnerability index for disaster management estimating the number of infections and the impact of non-pharmaceutical interventions on covid-19 in 11 european countries. department of infectious disease epidemiology -imperial college london, department of mathematics -imperial college london, who collaborating centre for infectious disease modelling, mrc centre for global infectious disease analysis, abdul latif jameel institute for disease and emergency analytics -imperial college london did california's shelter-in-place order work? early coronavirus-related public health effects tracking public and private responses to the covid-19 epidemic: evidence from state and local government actions crisis and risk approaches to emergency management planning and communication: the role of similarity and sensitivity protection of racial/ethnic minority populations during an influenza pandemic state data and policy actions to address coronavirus assessing changes in commuting and individual mobility in major metropolitan areas in the united states during the covid-19 outbreak. northeastern university. network science institute business disruptions from social distancing work-related covid-19 transmission in six asian countries/areas: a follow-up study timing of community mitigation and changes in reported covid-19 and community mobility -four scientific and ethical basis for social-distancing interventions against covid-19. the lancet. infectious diseases state/territorial resource pages and other select state actions political beliefs affect compliance with covid-19 social distancing orders changes in subway ridership in response to covid-19 in seoul differential effects of intervention timing on covid-19 spread in the united states. medrxiv encouraging compliance with quarantine: a proposal to provide job security and income replacement the covid-19 community vulnerability index (ccvi) covid-19 community vulnerability index (ccvi) methodology the benefits and costs of using social distancing to flatten the curve for covid-19 quarterly census of employment and wages the unacast social distancing scoreboard temporal changes in psychobehavioral responses during the 2009 h1n1 influenza pandemic poverty and economic dislocation reduce compliance with covid-19 shelter-in-place protocols we thank unacast and its data for good initiative for providing the social distancing data for humanitarian efforts and global health causes. key: cord-011924-7ofjjwqo authors: ul hassan rashid, muhammad abo; abbasi, saif-ur-rehman saif; manzoor, malik maliha title: socio-religious prognosticators of psychosocial burden of beta thalassemia major date: 2020-07-21 journal: j relig health doi: 10.1007/s10943-020-01069-6 sha: doc_id: 11924 cord_uid: 7ofjjwqo the study investigates the socio-religious factors in the propagation of genetically inherited disease of beta thalassemia. the disorder which reportedly has a significant protraction through repeated cousin marriages results in the social maladjustment of the parents of the sick children due to constant depression, anxiety, and weak social interaction and may lead to social isolation as well. this research aims to find out the significant effect of socio-religious trends on psychosocial burden of beta thalassemia major among cousin and non-cousin couples in the province of punjab in pakistan. it takes a sample of 932 parents of sick children, among whom 735 were married with cousins and 197 with non-cousins, for data collection. the findings reveal that inadequate knowledge of the disease, insufficient or misdirected social support, stigmatization, and marriage breakups caused by the disease, superstitions, and misinterpretations of religion and the subsequent practices accordingly as significant predictors of psychosocial burden of beta thalassemia major among non-cousins and cousin couples. additionally, it also finds patriarchy as only significant predictors of outcome variable among cousin couples. thalassemia is a serious public health problem across the world, particularly in developing countries. this disease has various forms. two among these forms, which are termed as alpha and beta, are most common (mettananda et al. 2015) . moreover, in either of these two forms of thalassemia, hemoglobin, which carries oxygen to all the cells in a human body, is affected (greenburg 2009 ). studies show the propagation of beta thalassemia major to be a serious threat to the middle-and low-income countries across the world (khalid et al. 2019) . the disease imposes intensive psychosocial burden on parents and children. researches find that parents and children with beta thalassemia major experience a significant psychological maladjustment (joshi and vashist 2018; mettananda et al. 2019) . however, most of these researches (lomas 1998; mcewen and wills 2017; moghavvemi et al. 2017) have been conducted in biomedical sciences, and thus, they have focused on biological aspects of this disease and its epidemiological postures rather than exploring any social, cultural, and religious factors associated with it (hossain et al. 2017; smith and praetorius 2019) . lack of education and awareness about thalassemia is a major non-biomedical factor, which leads families to face serious social, economic, and psychological problems (ebrahim et al. 2019) . researches (piel and weatherall 2014; radke et al. 2019) found that lack of knowledge about the disease, health facilities such as medicalization and counseling, and associated psychological and cultural issues impede the maintenance of healthcare. therefore, awareness and attitude towards screening practices for the treatment of disease depend upon the level of awareness and education of the families concerned about the disease (thiyagarajan et al. 2019 ) because without appropriate knowledge of the causes of the disease, preventions and remedies remain ineffective. moreover, without adequate relevant knowledge and understanding, one fails to differentiate between thalassemia major, thalassemia minor and the carriers of this disease as well. additionally, inheritance patterns are also difficult to be discerned without due knowledge and understanding of the disease. the failure in discerning these inheritance patterns causes an immense physical as well as social impact in the form of disorder(s) on affected patients and their families (zaheer et al. 2015 ). an adequate knowledge and awareness at public level coupled with a trained general social attitude towards these issues of thalassemia have proved an important measure against the propagation of thalassemia since ancient times (politis et al. 1991) . the attitude of a family, especially in traditional societies particularly in rural areas, is mainly determined by social, cultural and religious factors (furnham 2015; tokur-kesgin et al. 2019 ). these factors shape the living patterns and life styles of the inhabitants in such communities. therefore, individuals in such communities cope with the challenges of thalassemia under prevalent social attitudes practices. any innovate strategy adopted at individual level may come into conflict with the local interpretations and practices of religion (chong et al. 2019) . moreover, like many other chronic illnesses, patients of thalassemia and their families required meticulous support from relatives, health professionals and from rest of the community members to manage their psychological and social maladjustment. studies (patel et al. 2019) reflect that a family is believed to be the primary and most important source of social support for patients and their parents to mitigate the psychological and social burden caused by thalassemia. patients of thalassemia are required medical as well as social support from their families, medical professionals and other community members for their social adjustment. similarly, preventions against thalassemia also need moral, social and medical support to the affected children and their families. moreover, the effective management and social support also largely depends upon general knowledge about the disease; therefore, the general population of any area needs at least relevant basic awareness and education (kelsey 2015) . studies (cremonini et al. 2009; katz et al. 2017; nutini and bell 2019) emphasize that the cultural and religious factors are major variables that determine an individual's choices and decisions about his life. hence, these factors significantly shape people's choices and preferences of medication and treatment of beta thalassemia major (adly and ebeid 2015) . although termination of pregnancy is an acceptable way in islam and muslim community can follow the certain instructions, that are very clear in fatwa (before 120 days of gestation, a fetus can be terminated in case of having any chronic illness, that might cause death or any other serious complication for mother or new born) (iqbal et al. 2019) . having clear religious instructions, nobody can blame the true spirit of any religion including islam, for the treatment of any chronic disease. these are only myths and synthesis that blame religious true spirit and retain individuals to choose scientific ways to handle such chronic ailments (alkali et al. 2015) . parents and family members of those children who are suffering with beta thalassemia major face acute depression and anxiety (kermansaravi et al. 2018) . such feelings originated from the perception that beta thalassemia major is a life sacking disease may ultimately result in a general pessimism about life in the suffering children and their families as well (mohamadian et al. 2018) . moreover, this pessimistic attitude is also significantly aggravated by stigmatization developed about beta thalassemia major (moudi et al. 2019) . beta thalassemia major also creates the feelings of denial, withdrawal and lack of acceptance of the consequences of disease, among parents and families of thalassemic children (chan et al. 2017) . the disease creates emotional and psychological trepidation among parents of sick children because of its ominous repercussions. moreover, psychological impact of this disease immensely mars the recreational and aesthetic aspects of life of the affected children and significantly disrupts educational activities such as school timings (khanna et al. 2015) . in the same way, beta thalassemia major has also a negative impact on sexual and physical growth of sick children because of abnormal hormonal growth and lack of healthy diet, along with iron overload due to excessive blood transfusion (khanna et al. 2015) . after the dominant criticism on the existing biomedical model in twenty-first century, the literature drew attention of health experts and medical scientists to integrate social causes for the prevention of this disease of beta thalassemia major. social narratives highlighted the cultural, religious, communal and familial practices, which shape the health of any individual and the practices to avoid any health issue. these social perceptions included health and hygiene, marriage practices, and psychological aspects. others focused on medicines and clinical experiments, which were dominant in earlier model. the social model included the social and cultural aspects that shape the maintenance or disruption of health. it viewed health in connection with the continuous process of individual, cultural and social practices (fried et al. 2004) . from weberian explanation of life chances and choices (cockerham et al. 1993 ) to sick role of (parsons 1951) , health and illness have been conceptualized differently across the world (larson 1999) . moreover, the universal agreement on the definition of health still remains unsettled (zautra et al. 2010 ) because the social and cultural practices and understandings are not identical. the social model interprets biological mechanisms in terms of social causes. it explains being healthy and unhealthy on the basis of social explanations. the model contextualizes health as an amalgamation of social factors including socioeconomic status, cultural practices, sanitation and hygiene. the proponents of this social model (anastasiou and kauffman 2011; ghaemi 2009 ) emphasize that the understanding of health and illness depends on the understanding of social aspects including poverty, awareness, parental practices, ethnic and cultural practices and religious beliefs which, they think, largely determines medical realities. this social model considers mental and psychological factors equally important because, accordingly to this model, these factors significantly prove not only as the consequences of any disease but its causes as well (kawachi and berkman 2001) . in the context of thalassemia generally and beta thalassemia major particularly, the theoretical orientations incorporated by many researchers (fibach et al. 2012; auger and pennell 2016) are highly influenced by biomedical model of health and illness. although the disease prompts due to biological abnormalities of human globin and transmits from parents to their children but there are numerous social factors which contribute to the prevalence of thalassemia along with the outcomes such as psychological abnormalities and physical disabilities (messina et al. 2008) . social model of health and illness which aims to denote the attention of researchers and policy makers towards the social causes and practices of any biological disorder or epidemic, encompasses social factors including socioeconomic status, cultural practices, sanitation and hygiene to determine the state of being healthy or not (rashid and abbasi 2020) . the prevalence of thalassemia highly depends upon consanguineous marriages, traditional/religious beliefs and practices for the management and treatment of disease (platania et al. 2017) . the effective mitigation of the disease can be acquired by addressing social, cultural and religious beliefs and practices across the world and especially in rural and traditional communities of pakistan, india, bangladesh, saudi arabia, iran and iraq and among many other countries which are facing increasing rate of beta thalassemia major. the study focuses on the province of punjab in pakistan. it collected data for its analysis from 3 different blood transfusion centers which are jamila sultana foundation, fatimid foundation and sundas foundation. the participants were 932 parents of children suffering from beta thalassemia major. this data was selected with the help of taro yamane (1973:258) formula, which is commonly used in social sciences to calculate sample sizes (eckhardt and ermann 1977; songkram et al. 2015; yamane 1973 ). the formula is explained below: n sample size; n total population; e margin of error. the total population of this study was 5597 patients which is denoted by n , while e is known as margin of the error and commonly used as .05. the margin of error used in this study was .03 which is less than the common maximum range. the sample size, which is denoted by n , was 932, which was finally selected by planned methodology of this study. the study population consisted of the parents of those children who were suffering from beta thalassemia major. the selection of the respondents was based on the following criteria by applying random sampling method: 1. parents of the patients were selected from the province of punjab in pakistan. 2. all these were the parents of those children who were diagnosed as the patients of beta thalassemia major. 3. all these parents of only those children, who were not suffering from any other genetic disorder. 4. parents of those children, who were not suffering from any other illness data was collected by using interview schedule as a tool which comprised demographic variables, independent factors (parental knowledge of disease, social and religious factors) and dependent variable (psychosocial burden of beta thalassemia major). parental knowledge of beta thalassemia major comprised 16 items. it was used as a computed variable in the both models. the variable was measured by using 5 likert scale. social factors of beta thalassemia major were based on 10 items, though significant predictors of psychosocial burden among non-cousin couples (m9) were only four social factors (marriage breakups, beliefs in unnatural forces, stigmatization, and social support). however, psychosocial burden among cousin couples (m10) was predicted by five social factors (patriarchy was a fifth factor). the study employed three religious predictors (religious restrictions regarding termination of pregnancy, beliefs regarding prevention and encouragement of consanguineous marriages) in both models, out of eight items. to measure the psychosocial burden of thalassemia on patient's parents an interview schedule "psychosocial burden of thalassemia" by canatan et al. (2003) was adapted. this interview schedule consisted of total 16 items to measure the burden (psychosocial) on patient's parent. the items of were rated on 5 likert scale (sa = strongly agree, a = agree, u = undecided, d = disagree, sd = strongly disagree). however, the variable in model was employed as a computed variable. the reliability of the interview schedule, used for the measurement of dependent variable was .8051, which was measured using cronbach alpha. the statements used for the measurement of dependent variable along with the values are given in table 1 . the data of present study was collected with the permission of competent authorities of thalassemia foundations. the parents of sick children were also ensured that their personal information would not be sold or revealed for any commercial purpose. they were briefed about the nature of the study for which they were surveyed. moreover, their written consent was also obtained to ensure the ethical practices of public health. socioeconomic status includes age, education, monthly family income and expenditures (baker 2014). the present study measured the ages (now and at the time of their marriages) of mother(s) and father(s) along with their education, monthly income and expenditures of entire family including the particular expenditures for the treatment of beta thalassemia major. descriptive statistics are tabulated in table 2 . the data reveals that average age is 36 and 33 years of father(s) and mother(s) of the children suffering from beta thalassemia major respectively. the average age at the time of marriages has also been recorded in the table 2 (father's age = 24 and mother's age = 21). the study showed the average, minimum and maximum educational level of both parents. it also revealed that majority of the parents (father, n = 150 and mother, n = 168) were uneducated, while the highest educational level of father's was ms/m. phil degree (n = 1). overall, as the education level of mothers was found higher than that of fathers because 21 mothers had 16 years education. the average monthly income of respondent's was 29482 pkr (approximately 182 usd), while the expenditures were 22633 pkr (approximately 139 usd). the study also found that the difference between income and expenditures of a family was due to the disease of a child because the parents were averagely spending 5336 (approximately 33 usd). moreover, due to cultural practices, especially endogamy, in pakistan, majority of the respondents (78.9%) were married with cousins, while only (21.1%) were married out of their families. these findings agree with those reflected in the study of (khan et al. 2015) , which show that out of 180 respondents, 133 (74%) of the respondents were married with their cousins and that due to this higher rate of cousin marriages, beta thalassemia major was alarmingly propagating. another study (ishaq et al. 2012 ) also found as many as 81.7% cousin marriages among its respondents. table 3 reveals the data of predictors of psychosocial burden of beta thalassemia major in non-cousin couples (respondents). using stepwise (forwards method) multiple linear regression technique, the final model (m9) figured out eight significant predictors of outcome variable (psychosocial burden). data reveals that 39.4% variation of outcome variable has been explained by the eight significant predictors (r 2 = .394). furthermore, parental knowledge of beta thalassemia major, social support and religious encouragement regarding cousin marriages were significantly negative predictors of psychosocial burden of beta thalassemia major in non-cousin couples ( data enclosed in table 4 reveals the predictors of psychosocial burden of beta thalassemia major among cousin couples (respondents). using stepwise (forwards method) multiple linear regression technique, the final model (m10) figured out nine significant predictors of outcome variable (psychosocial burden). data shows that 32.6% variation of psychosocial burden of beta thalassemia major, among cousin couples has been explained by these nine predictors. furthermore, parental knowledge regarding beta thalassemia major ( the previous studies conducted by (alswaidi et al. 2012; memish and saeedi 2011) focused on social and religious factors which propagate beta thalassemia major and caused serious economic, social and psychological burden on parents of sick children (prasomsuk et al. 2007 ). it has also been intensively studied that cousin marriages are the major reasons of beta thalassemia major (ayub et al. 2017; faizan-ul-haq et al. 2016) . the researchers (ishfaq et al. 2015; muhammad et al. 2017) kept their focus rigorously to study consanguinities and beta thalassemia major but none of them figured out the effect of social, cultural and religious factors on psychosocial burden of beta thalassemia major on cousins and non-cousin couples distinctively. the study found that role of patriarchy is a significant factor among cousin couples. this role of patriarchy was found to be positively affecting the psychosocial burden of beta thalassemia major among cousin couples. the study also revealed that parental knowledge of disease has a significant effect on psychosocial burden of beta thalassemia major among both cousin and non-cousins couples. the effective management and prevention of thalassemia requires comprehensive understanding and knowledge about beta thalassemia major (elewa and elkattan 2017; rund and rachmilewitz 2005) . the lack of knowledge and awareness regarding causes and management of beta thalassemia major, not only aggravates the disease but has a strong impact on social and psychological adjustment of parents of sick children (abu shosha and al kalaldeh 2018). parental maladjustment due to continuous stress and social pressure imposes a negative effect on their quality of life (mettananda et al. 2019; tomaj et al. 2016) and social adjustment (inamdar et al. 2015) . strong emphasize on endogamy and cultural practices for marriages restrain couples and families to follow precise management practices for the treatment of beta thalassemia major (bener et al. 2019 ) and they avoid pre/postnatal diagnosis and genetic screening methods (antonarakis 2019). as a result, the genetic abnormality (beta thalassemia major) prompts over the large scale across the world. it has been generally estimated that, every year 50 thousand to 1 lack children, living in the low and middle income countries die because of this chronic genetic aliment (beta thalassemia major), however, an estimated population of 7% in the entire world is the carrier of hemoglobin disorder in the form of beta thalassemia major (arif et al. 2008) . lack of social support has also been seen to be a significant factor, which increases psychosocial burden of the disease (palanisamy et al. 2017) . like many other chronic illnesses, patients of thalassemia and their families required meticulous support from relatives, health professionals and from rest of the community members to manage their psychological and social maladjustment. it has been investigated by researchers (patel et al. 2019 ) that family is believed to be the primary and most important source of social support for patients and their parents to mitigate the psychological and social burden caused by thalassemia. patients of thalassemia are required medical as well as social support from their families, medical professionals and other community members for their social adjustment and confrontation against thalassemia requires moral, social and medical support to the children and their families. the effective management and social support also required general knowledge about the disease, so the general population of any area required to gain at least the basic (kelsey 2015) . in many rural areas of pakistan, due to traditional cultural practices, blind religious believes, ignorance and pressure from family and society, parents of thalassemic child face many problems in the treatment of their sick child (aziz et al. 2012 ) along with their social adjustment (shaligram et al. 2007) . beside medical and professional support, these people required awareness, acceptance, recognition and removal of social pressure to manage the disease and knob these decisive circumstances (roy and chatterjee 2007) . social support and strong ties among communities have positive impact on children's health, development and wellbeing (palanisamy et al. 2017) . in case of thalassemia these strong ties and enriched social support is very helpful to manage thalassemia very effectively and which can be seen among rural communities of pakistan but parents of thalassemic children are facing stigmatization and social isolation because of lack of education and awareness of causes and propagation of thalassemia (hussein et al. 2018) . a range of psychological and social maladjustment have been premeditated among the parents of thalassemic children, that includes; social isolation, stigmatization, anxiety and depression (mufti et al. 2015) . the accentuate on reducing social and psychological burden requires effective parental knowledge for the management and prevention of thalassemia (maheen et al. 2015) , strong social support (messina et al. 2008) , elimination of social stigma (pouraboli 2019) and patriarchy (raffa 2019) , along with the awareness of religious believes (punaglom et al. 2019 ). the present study was conducted at selected centers of blood transfusion in punjab province covering only the registered patients, which limits the scope of study in terms of territorial coverage. the future studies may cover other provinces and patients of beta thalassemia minor for comparative analysis. conflict of interest the undersigned with the consent of all the authors, declare that they have no conflict of interest for submission and publication of this manuscript in "journal of religion and health''. the 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overview of health sociology the experiences of adolescents with thalassemia in west bengal psychological problems and quality of life in children with thalassemia college students' knowledge about sickle cell disease e-learning system to enhance cognitive skills for learners in higher education assessing the role of family well-being on the quality of life of indian children with thalassemia a determinant for family planning attitudes and practices of men: marriage features the effects of group play therapy on self-concept among 7 to 11 year-old children suffering from thalassemia major statistics: an introductory analysis knowledge, attitude and practices with relevance to thalassemia a new definition of health for people and communities. handbook of adult resilience publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-264479-s20oacr9 authors: bern-klug, mercedes; beaulieu, elise title: covid-19 highlights the need for trained social workers in nursing homes date: 2020-05-25 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.05.049 sha: doc_id: 264479 cord_uid: s20oacr9 nan core features of psychosocial care in a crisis include access to information and emotional support 2 . this editorial provides examples of how nursing home social workers are adapting the way they connect with residents and families during the pandemic and concludes with suggestions. some of the information comes from experiences shared by nursing home social workers who have participated in weekly online support sessions initiated in april by the national nursing home social work network https://clas.uiowa.edu/socialwork/nursing-home/national-nursing-home-social-work-network .these weekly support sessions provide an anonymous space for social services staff around the country to share experiences and ideas about coping with covid-19 challenges. the editorial also highlights the needs for trained social workers in nursing homes. one of the first topics to surface during the online support sessions was the shortage of personal protective equipment (ppe). many nursing homes around the country still struggle to get enough ppe for the nursing staff who provide hands-on care. in nursing homes experiencing ppe shortages, the lack of equipment means activities and social services staff cannot safely enter resident rooms. much of the psychosocial care provided to these residents now occurs over the phone, computer, or through direct care staff. in nursing homes where ppe is available, training on how to use it safely may not be. this leaves untrained activities and social service staff with a false sense of security and vulnerable to catching and spreading the virus. in some nursing homes, staff members are expected to re-use the ppe. in others, there is not enough ppe for families who want to visit dying loved ones. some hospice workers are arriving at nursing homes to provide services to residents but lack their own ppe. the ppe shortage endangers the physical health of residents and staff and damages emotional health as well. during our weekly online support sessions, social workers shared they are as deeply concerned about bringing covid-19 home to their families as they are about bringing covid to the nursing home. in part because of the lack of ppe, social workers are spending more time on the phone and on the internet communicating with residents. some of these contacts can happen directly between the social worker and the resident. other contacts must be facilitated by busy nursing staff who have access to ppe. cooperation, coordination and collaboration among staff can improve care provided to residents and enhances communication with concerned family members. while a core function of the social work role has always been to anticipate, assess and address resident psychosocial needs, social workers have also been key liaisons between the family and the facility. during a pandemic, that connection is more important than ever, and often occurs over the phone. engaging in this level of conversation with anxious family members requires skill. not all nursing homes have a staff person skilled in delivering bad news, listening to distraught families, and helping to identify and affirm family resilience. the federal government requires only nursing homes with more than 120 beds to hire one fte social services staff member, and that person does not have to hold a degree or license in social work 3 . the unrealistic staffto-resident ratio and the disregard of professional standards has been a problem for decades. the inadequacy of this lax regulatory stance toward the credentials of the key onsite professional responsible for psychosocial care is even more apparent during a crisis when residents, families and staff are simultaneously and chronically in distress. nursing homes are being inundated with phone calls from families concerned about their loved one contracting covid and about the impact of social isolation. families have a lot of questions. some questions have no answers. families wonder why the nurse hasn't called them back in two days and why no one picks up the phone. suspicion brews. families hold themselves responsible for being there for their loved one 4 . this sense of responsibility is heightened during a crisis. families want their mother/brother/sister to know they are not forgotten and have not been abandoned. the nursing staff to provide resident care. one social worker disclosed that while some families use these phone calls to vent their anger, others ask how they can help; she followed up with "…and then a large box of home-made masks appears later in the week." what else are social workers doing during these phone calls? a social worker engages constructively and compassionately with families by using skills acquired as part of a social work education, including: active listening, crisis management, anger deescalation, situation stabilization, emotion processing, problem solving, decision-making support, boundary setting assistance, advance care planning, transitions of care discussions, validation of family connectiveness, role playing, role affirmation, clarifying, reflecting, interpreting, reassuring, and meaning-making 5, 6 . social workers also advocate on behalf of residents and families, provide information on a wide range of topics including health insurance, resident rights, and how to connect with the local foodbank. social workers with a reasonably sized case load can be expected to provide more frequent and comprehensive support to families compared with social workers with large caseloads. even before the pandemic, the most qualified and these conversations can be difficult when the resident and family member disagree on appropriate goals of care for residents. they can also be difficult when residents are not cognitively capable of participating and family members disagree among themselves. sometimes these conversations are difficult because they reflect the mistrust that is present in the larger social context of racism, ageism, and ableism. for example, during a phone conversation with an african american daughter one social worker was asked, "are you saying the same thing to whites?" these delicate conversations call for expertise and compassion. during our online support sessions, social workers discuss the fine line they walk daily between reassuring family members and not over promising. by keeping family expectations realistic today, disappointment can be diminished tomorrow. for example, many families would like the staff to help them connect daily by phone or computer with their loved one. most nursing homes don't have the staff capacity for that, even if they have a spare laptop or tablet. from the family's perspective it doesn't seem to be asking much for a ten-minute daily face-time session, yet from the staff perspective it requires much more than ten minutes to organize, prepare and safely deliver a phone or internet session. many nursing home policies and procedures developed pre-covid are inadequate during covid, including some end-of-life policies. in most nursing homes, the only family members now allowed to visit are those whose relative is actively dying. even then, the number of family members is limited. some family members tell social workers they are afraid to enter the nursing home for fear they will catch covid and are equally afraid they will never forgive themselves if they don't visit in-person to say goodbye. social workers can help people sort out their feelings, understand ppe options, gain the information they need to weigh the risks, and reach a decision they can live with. in nursing homes with multiple covid deaths, social workers leave work with a pit in their stomach from the phone conversations with family members to discuss what to do with the decedent's body and their belongings. most nursing homes do not have an on-sight morgue and many lack sufficient storage space for decedents' possessions. a strong social work presence has always been necessary in nursing homes; the pandemic underscores the need. after the pandemic, the need will continue. because we are working with people in physically, emotionally and socially vulnerable circumstances, many of whom are approaching the last chapter of their life, we know that psychosocial concerns will be ever-present. if we are serious about improving the quality of care and the quality of life in nursing homes, we must be serious about psychosocial care. we need to be concerned with fractures of bones yes of course, but we also need to address a resident's fractured broken heart. we need to do all we can to prevent wounds on the skin, yes of course and we also need to prevent wounds on the soul 7 . this pandemic has exposed many ways the country can better support nursing homes and nursing homes can better care for residents and families. including degreed and licensed social workers as part of the core team is a basic way to provide psychosocial care in nursing homes and enhance resident quality of life. • securing ppe for staff is necessary but not sufficient. training must be provided to all staff. a good source is: https://www.cdc.gov/coronavirus/2019ncov/hcp/using-ppe.html • develop and communicate a protocol for securing ppe and training for family members who come to visit residents who are approaching the end of life. • let residents and families know what format (social media, newsletters, phone calls) and frequency of communication they can expect from the facility. clear, consistent, truthful information from a trusted source is an important factor to help individuals and organizations adapt. • squash rumors and build a sense of inclusion by keeping all staff updated and informed. encourage questions. • have a mechanism for staff who are in touch with families to relay concerns and compliments back to the whole staff. • consider hosting "drop-in" online support sessions for family members. if staff are not available to coordinate, hire a local mental health provider or enlist a trained volunteer. • regularly recognize the hard work of staff in concrete ways. • maintain a "nurturing environment" which provides the necessary resources, security, and support to facilitate individual and organizational adaptation. adaptation is key to resilience 1 . resilience as effective functional capacity: an ecological-stress model psychosocial crisis management: the unexplored intersection of crisis leadership and psychosocial support. risk, hazards, & crisis in public policy code title 42 section 13951. requirements for, and assuring quality of care in, skilled nursing facilities family members' responsibilities to nursing home residents standards for social work services in long-term care facilities psychosocial assessment of nursing home residents via mds 3.0: recommendations for social service training, staffing, and roles in interdisciplinary care transforming palliative care in nursing homes: the social work role key: cord-017349-eu1gvjlx authors: koh, howard k.; cadigan, rebecca o. title: disaster preparedness and social capital date: 2008 journal: social capital and health doi: 10.1007/978-0-387-71311-3_13 sha: doc_id: 17349 cord_uid: eu1gvjlx the first decade of the 21st century has pushed the field of disaster preparedness to the forefront of public health. in a few short years, the world has witnessed the far–ranging ramifications of 9/11 and anthrax (2001), sars (2003), the indian ocean tsunami (2004), hurricane katrina (2005) and the looming threat of pandemic influenza. societies everywhere are responding to these developments with new policies that commit added resources for protection against future disasters. to date, literature relevant to social capital has focused largely on the value of existing social capital in disaster mitigation and recovery. for example, among environmental scientists, there is growing interest in the role of social capital and global climate change (adger, 2001; pelling & high, 2005) . in light of the causal link between global climate change and the increasing incidence of natural disasters such as hurricanes, tsunamis and floods, researchers have identified social capital as an important tool in disaster mitigation. for example, semenza, et al. (1996) found that during the 1995 heat wave in chicago, in addition to location (i.e., living on the top floor of building) and access to air conditioning, variables related to social contact and networks were also strong predictors of mortality. specifically, the authors found that individuals who participated in church or social groups had a significantly lower risk of death during the heat wave. it is clear from these findings that social networks and social capital are important tools in community coping with stresses, and serve to mitigate adverse outcomes of disasters and other events associated with climate change. similarly, existing social capital has served as a vital instrument in the recovery and rebuilding efforts following numerous natural disasters. nakagawa and shaw (2004) hypothesized that differing rates of post-disaster recovery following major earthquakes in kobe, japan and gujarat, india could be attributed to disparate levels of existing social capital in the two cities. in the immediate aftermath of the 1995 kobe earthquake, neighborhood groups (previously formed in the 1960s to protest polluting factories) quickly reconvened to assist with school evacuation, establish community kitchens, and help protect against looting. these actions accelerated response efforts and served to initiate rebuilding. following hurricane katrina in 2005, a number of observers (garreau, 2005; turner & zedlewski, 2006 ) attributed many of the barriers to rebuilding new orleans to the previously documented low social capital there (putnam, 2000) . nevertheless, exceptions were notable. for example, within a matter of weeks, select tight-knit groups such as the vietnamese enclave in east new orleans were already engaged in rebuilding efforts (hauser, 2005; shaftel, 2006) . many of the 20,000 vietnamese in new orleans had previously emigrated to the u.s. in the 1970-1980s and have since maintained strong social and cultural networks. using a church as headquarters, the vietnamese residents of east new orleans formed neighborhood teams to rebuild, repair, and decontaminate houses, prepare meals for families visiting to check on their property, and drive one another to work, church, and temporary housing. for the preparedness and response phases of preparedness, much of the current efforts are focusing on the process of creating new social capital. one poignant illustration is the dramatic volunteer convergence on new york city following the terrorist attacks on september 11th, 2001, documented to include over 15,000 individuals within two and a half weeks. a qualitative study conducted by lowe and fothergill (2003) found that the primary motivation for volunteering was a need "to contribute something positive and find something meaningful in the midst of a disaster characterized by cruelty and terror" (p. 298). the authors characterized the impact of such spontaneous volunteerism on both the community and the volunteers themselves, i.e., affecting both groups and individuals. one volunteer described the work as "honoring our commitment to the american public" (p. 303), implying a broad national community. individual impact was noted when "the volunteers found that by working with new groups of people. . . . . they experienced a sense of solidarity with different community members" (p. 303). in another example outside of the united states, an estimated 2 million volunteers responded to assist with search and rescue, medical aid, transportation, and provision of shelter following the 1985 earthquake in mexico city (dynes & quarantelli, 1990) . a major benefit of preparedness planning would be to strengthen local public health infrastructure which has been traditionally fragmented and severely underfunded. over a few short years, nascent efforts on preparedness have broadened the initial focus on training federal and state government leaders to include local officials and indeed all members of society. lessons from sars and hurricane katrina have underscored the message that every person has an opportunity and responsibility to protect themselves, their families and their communities. as a result, in the world of public health, emergency preparedness training now extends deeply to the local level with respect to planning, communication and training. in many parts of the united states, efforts have focused attention to regionalization of local public health, surge capacity planning, vulnerable populations, risk communication, and training through exercises and drills. all these efforts have the potential to boost local public health infrastructure and build a legacy of social capital and social networks in local communities. the remainder of this chapter will explain in greater detail how such preparedness efforts apply to dimensions of social capital at the local level, particularly with respect to pandemic influenza preparedness. the threat of pandemic influenza has sparked heightened planning worldwide. the world health organization (who) urges that each country and community develop and regularly update a pandemic preparedness plan. who guidance centers on issues such as surveillance, communications and prioritization of scarce resources. as of december 2005, 40 countries have completed such plans (uscher-pines, omer, barnett, burke & balicer, 2006) . the united states unveiled its national pandemic influenza plan in november, 2005, addressing areas such as domestic and international surveillance, vaccine development and production, antiviral therapeutics, communications and state/local preparedness. moreover, each of the 50 states has developed and publicized plans, as summarized on www.pandemicflu.gov. all nations understand the importance of priority setting in preparedness planning, although such plans currently vary by rationale of prioritization of antiviral agents, vaccines and other scarce resources (uscher-pines, omer, barnett, burke, & balicer, 2006) . as "all preparedness is local" however, such plans can only come alive through full engagement at the local level. both bonding and bridging social capital apply throughout such plans. 13.4.1.1. local/regional planning the current fragmented status of local public health in the united states has left few cities or towns (aside from the major metropolitan areas) capable of responding on their own. for the most part, local health departments lack the personnel, resources or capacity to respond to mass casualties without the support of surrounding communities. to address this challenge, many states have turned to regionalization of resources and services to build emergency preparedness capacity at the local level. a study of state public health preparedness programs conducted in fall, 2004 by the association of state and territorial health officials (astho) found that most states tended to subdivide their organizations into regions for preparedness purposes, with more than half of such regions created post-9/11 (beitsch et al., 2006) . massachusetts, nebraska, illinois, kansas and the northern capital region (greater metropolitan washington dc) are among the states that have done so. for example, massachusetts, a state of 6.3 m, traditionally had a highly decentralized local public health system with 351 autonomous cities and towns. nevertheless, after 9/11 the state reorganized into seven emergency preparedness regions and 15 subregions (koh, elqura, judge, & stoto, 2008) . in another example, the primarily rural state of nebraska of 1.7 m people has developed 16 regions in efforts to improve capacity. preliminary qualitative information suggests that regionalization has built social capital for groups and individuals. the national association of county and city health officials (naccho) notes that regionalization has promoted coordination (of local public health and partners in public safety and emergency medical services), standardization (of resources and emergency plans) and centralization of local emergency response capability (bashir, lafronza, fraser, brown, & cope, 2003; hajat, brown, & fraser, 2001) . in so doing, improved collective efficacy can be realized. analyses have noted that regionalization has served as a foundation for sharing resources, coordinating planning, conducting trainings and improving capacity. for example, in massachusetts, regionalization led to emergency local capacity essential for pandemics and mass casualties, such as establishment of 24/7 emergency on-call capacity for all local public health officials in the state (when none previously existed) and mutual aid agreements for over 60% of local public health departments (compared to none previously). in fact, in the few short years of its existence, regionalization has facilitated the efficient organization of hepatitis a immunization clinics in the face of food borne outbreaks, and coordination of seasonal flu vaccine distribution during the shortages of the 2004-2005 season (koh, shei, judge et al., 2006) . such examples reflect enhanced social capital within groups (e.g., nurses and allied health professionals) and bridging between groups (local health groups and state public health officials). most notably, regionalization has fostered communication and connections between multiple groups: public health and public safety, interested parties in neighboring towns, local and state leaders, and volunteers across the state. multiple parties that rarely worked together prior to 9/11 are now meeting regularly to plan joint responses and clarify roles and responsibilities. planning for pandemics and mass casualties requires ramping up the current national health care system to care for thousands of extra ill patients. building surge capacity in this way can generate bonding and bridging capital, mobilizing and unifying a vast array of societal resources. based on past pandemics, the u.s. department of health and human services (dhhs) has modeled its pandemic planning on scenarios ranging from moderate (such as the 1957 and 1968 pandemics) to severe (such as the 1918 pandemic). current models project as many as 90 m cases nationally, 50% of cases requiring outpatient medical care, and up to 9.9 m requiring hospitalization (hamburg et al., 2005) . the u.s. centers for disease control and prevention (cdc) has developed the software program flusurge, which provides hospital administrators and public health officials local estimates of the surge in demand for hospital-based services during the next influenza pandemic. the challenge of surge capacity remains enormous, as national trends over the past several decades reflect declining, not increasing, capacity. with this daunting backdrop, the united states is working toward increasing surge capacity, explicitly defined by the u.s. agency for healthcare research and quality (2004a) as "a health care system's ability to expand quickly beyond normal services to meet an increased demand for medical care in the event of bioterrorism or other large-scale public health emergencies" (p. 1). the u.s. health resources and services administration (hrsa) has offered surge capacity benchmarks with respect to staff, space and supplies, as shown in table 13 .1 (agency for healthcare research and quality, 2004b) . building staff can be viewed as an exercise in creating bonding capital, i.e., within the community of health care providers. additional personnel needed for deployment in a crisis would include, in addition to physicians (approximately 800,000 in the u.s.) and nurses (approximately 2.2 m in the u.s.), veterinarians, pharmacists, mental health professionals and a host of other allied health professionals. such providers would not only administer direct care to those who are sick but could also aid with mass prophylaxis efforts to the many more who may be exposed or at risk. to augment this national network, communities across the u.s. are engaging volunteers in emergency response. with respect to space, all hospitals have been charged by hrsa and other organizations to identify additional beds for use in pandemics and emergencies. in addition to staffed beds (beds that are licensed, staffed, and physically available), all acute care hospitals are ascertaining surge capacity by identifying other beds that: are licensed but not staffed, can be made available within 24 hours (by discharging patients and canceling elective procedures) or within 72 hours (through use of non-traditional locations such as hospital cafeterias, chapels, etc.). in the event that hospital capacity is still overwhelmed, professionals across the country are currently identifying other health care facilities such as community health centers (koh, shei, bataringaya et al., 2006) or even non-medical sites such schools, gymnasiums, armories, and convention centers. considerations for such facilities include dimensions such as bed capacity, sanitary facilities, food services, and security. the shortage of medical supplies has also prompted bridging outside the medical world to other parts of government and society to generate sufficient resources. many have argued that preparing for pandemic influenza first entails mastering the proper coordination of national vaccination efforts for annual seasonal influenza, which yearly leads to 36,000 deaths and 200,000 hospitalizations (thompson, shay, & weintraub, 2003 . in particular, the fragmented nature of the national seasonal influenza vaccine supply became starkly apparent during 2004-2005, when a national low of 61 m doses led to prioritization of risk groups for immunization for the first time. production for 2006-2007 is now estimated to reach a high of 115 -120m doses, however (fauci, 2006) . shortages of antibiotics and antiviral agents may require interaction with the federal strategic national stockpile (sns), managed by the cdc and dhhs. the sns contains prepackaged pharmaceutical agents that can be deployed to states at the governor's request. all states have prepared preliminary plans for the receipt and management of stockpile materials, and many have initiated planning for emergency dispensing at the local level. acquiring such resources and even determining the resources needed are a tremendous source of activity and controversy. one area involves personal protective equipment (ppe) where, for example, experts differ about recommendations regarding proper use of surgical masks, n 95 respirators and other equipment (institute of medicine board on health sciences policy, 2006). additionally, ventilators represent a critical limiting physical resource. there are approximately 105,000 ventilators in the u.s., with as many as 80,000 in use at any given time for medical care; and more that 100,000 required during a typical influenza season (osterholm, 2005) . in the event of a pandemic, the number of patients requiring mechanical ventilation would likely exceed this capacity in excess of 500% (hamburg et al., 2005) . all disasters expose disparities. as mentioned previously, hurricane katrina has been a recent disaster that has graphically highlighted vulnerabilities of special populations, the varying levels of social capital within those populations, and the need to ensure equity in preparedness. a survey revealed that 38% of those who did not evacuate before hurricane katrina were either physically unable to do so or had to care for someone who was physically unable to leave. 52% of evacuees reported having no health insurance coverage at the time of the hurricane (brodie, weltzien, altman, blendon, & benson, 2006) . national groups have redoubled efforts to address the needs of special populations, defined by the cdc (2006) as "groups whose needs are not fully addressed by traditional service providers or who feel they cannot comfortably or safely access and use the standard resources offered in disaster preparedness, relief, and recovery" (p. 4). they include, but are not limited to: 1) those who are physically or mentally disabled (blind, deaf, hard-of-hearing, cognitive disorders, mobility limitations); 2) limited or non-english speaking; 3) geographically or culturally isolated; 4) medically or chemically dependent; 5) homeless; 6) frail/elderly and children. such groups would need to bridge to resources currently not available to them. issues of trust in, and trustworthiness of, authorities charged to protect them further complicate this issue. planning for special populations has increased recently. such planning may differ dramatically for densely populated urban settings as opposed to more sparsely populated rural settings; each community with its own profile of risks and assets. examples of special populations planning include evacuation planning for elderly immobile populations in nursing homes, targeted risk communication strategies for non-english speaking populations, and coordination of services for people who are homeless, homebound, or medically or chemically dependent. such populations are particularly vulnerable to broader social forces affecting their communities. overcoming social isolation in these instances remains a daunting societal challenge. in a time of crisis, all members of society expect and deserve accurate information that is conveyed simply, clearly, and in a timely fashion. such information is critical not only for all to understand roles and responsibilities in times of crisis but also for how and when to access resources. in this regard, the who, cdc and other organizations have afforded considerable attention and resources to upgrading media plans, training of communicators, and message preparation and delivery. to a great extent, the responsibility for such risk communication will fall on government public health authorities through broad use of the media. this presents special challenges in the u.s., where recent surveys show that less than 50% of the general public trust government public health authorities "a lot" as a source of useful and accurate information about an outbreak, compared to significantly higher levels in other parts of the world, such as taiwan, hong kong and singapore . in particular, it is unclear exactly how much the public understands the concept of "pandemic influenza" and how it differs from the term "avian influenza". also, there are many other subtleties in communicating relevant information to the public and the press. for example, the uncertain efficacy of antiviral agents for pandemic influenza may not be well known. in chapter 12 of this book, viswanath explores the information disparities affecting populations in society. building public awareness now through regular communication can enhance trust and confidence in advance of any future pandemic. in preparing for a disaster, professionals and the public need continuous education and training. groups such as the federally funded academic centers for public health preparedness have been charged with exploring many such educational avenues, including face-to-face teaching, train-the-trainer initiatives (orfaly et al., 2005) , distance learning initiatives (moore, perlow, judge, & koh, 2006) and other modalities. recently, the public health community has moved aggressively into exercises and drills as a favored educational modality (cadigan, biddinger, & koh, 2006) . mounting a rapid, coordinated, integrated local response to mass casualty events such as pandemic influenza necessitates tight collaboration among a host of participants, including emergency management, public health, law enforcement, fire, emergency medical services, health care providers, public works, municipal government, and community-based organizations. exercises, defined as any event beyond the planning process that gathers people to test or improve preparedness (u.s. department of homeland security, 2004) , both teach and test such coordination for individuals and organizations. involving representatives from multiple agencies to exercise together in a regular fashion facilitates an iterative cycle of developing plans, training personnel, testing preparedness, and improving plans even further to clarify specific roles and responsibilities. both bonding and bridging capital can be enhanced in this way. for example, tabletop exercises are often organized around multiple tables, with each table representing one local municipality. key government officials from across various agencies work together at each table, while being forced to interact with other towns/tables as well as state agencies. resources can be enhanced by building bonding capital within each professional group, each agency, each town, as well as bridging capital across agencies, communities and between local and state officials. furthermore, since public health disasters are critical but rare, exercises serve the vital function of testing plans in a concrete and memorable fashion. use of local tailored scenarios provides exercise participants with a sense of urgency as well as concrete opportunities to understand the complex coordination involved in local emergency response. furthermore, respondents can test their understanding of the national incident management system and the incident command system. such active, experiential learning appears to have greater educational impact than more conventional, didactic lectures, particularly for rare events (streichert et al., 2005) . these exercises build social networks of responders. qualitative studies suggest that exercises improve communications with colleagues from other agencies, force participants to address inadequacies in communications systems and protocols, and promote strategies to ensure presentation of consistent messages. by convening with local/regional partners, participants realize potential opportunities to increase capacity by sharing resources with neighboring communities. bringing together participants from a range of disciplines enhances opportunity to learn about the unique services, skills, and expertise offered by others. an ongoing area of research is to quantify these outcomes in a standardized way that demonstrates enhanced preparedness. while we offer our ideas here on the ramifications of social capital on evolving public health preparedness work, much of this information is qualitative and/or preliminary. many observations noted here need verification and validation. furthermore, the intense current focus on community disaster preparedness is still relatively new. academic investigation should verify and extend these concepts, offer more quantitative assessments of social capital as applied to disasters, demonstrate their utility through more rigorous analyses, and ascertain whether initial societal changes found in qualitative studies will be enduring and sustained. moreover, we have presented concepts of social capital as being overwhelmingly positive in their nature when in fact research in other areas has documented possible negative ramifications noted elsewhere in this book. nevertheless, much of the current work regarding public health preparedness can enhance social capital through stabilization and growth of the current fragile public health infrastructure, i.e., workforce capacity and competency, information and data systems, and organizational capacity (cdc, 2001) . disaster planning has undoubtedly revived and accelerated community discussions about societal planning, obligations, and expectations in a time of crisis. regionalization of local health has generated new local capacity. attention to special populations has renewed emphasis on commitments to equity and raises key questions about obligations of community members to one another. efforts to enroll volunteers through mrc and other initiatives have revitalized discussions on expectations of service in a community. attention to surge capacity, resource shortages and the prospect of alternate sites of care during a mass casualty event has raised explicit discussions about obligations and expectations. agencies have advanced bridging in the common mission of protecting the public. inherent in all planning has been the importance of trust building, particularly in information sharing and risk communication. moreover, such investments may well be helping to build a more cohesive, integrated, prepared national and global community where all understand their interdependence in the midst of a crisis. in a time of social isolation where many are "bowling alone", disaster preparedness efforts may serve as a force that reverses this trend and contributes to a legacy of stronger local public health and a more revitalized society for the future. tyndall centre for climate change research -working paper no surge capacity-education and training for a qualified workforce optimizing surge capacity-regional efforts in bioterrorism readiness local and state collaboration for effective 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hospitalizations in the united states mortality associated with influenza and respiratory syncytial virus in the united states after katrina: rebuilding opportunity and equity in new orleans priority setting for pandemic influenza: an analysis of national preparedness plans public health workbook to define, locate, and reach special, vulnerable, and at-risk populations in an emergency public health's infrastructure: a status report homeland security exercise and evaluation program, volume i: overview and doctrine avian influenza frequently asked questions key: cord-024640-04goxwsx authors: oates, sarah title: the easy weaponization of social media: why profit has trumped security for u.s. companies date: 2020-05-11 journal: digi war doi: 10.1057/s42984-020-00012-z sha: doc_id: 24640 cord_uid: 04goxwsx american-based social media companies have become active players in digital war, both by accident of design and a subsequent failure to address the threat due to concerns over profits. discussions about the negative role of social media in society generally address the myriad problems wrought by social media, including electoral manipulation, foreign disinformation, trolling, and deepfakes, as unfortunate side effects of a democratizing technology. this article argues that the design of social media fosters information warfare. with its current composition and lack of regulation, social media platforms such as facebook and twitter are active agents of disinformation, their destructive force in society outweighing their contributions to democracy. while this is not by deliberate design, the twin forces of capitalism and a lack of regulation of the world’s largest social media platforms have led to a situation in which social media are a key component of information war around the globe. this means that scholarly discussions should shift away from questions of ethics or actions (or lack thereof) on the part of social media companies to a frank focus on the security risk posed to democracy by social media. this article departs from the usual discussion of the role of social media in society by comparing its value to its destructive elements. the problem with trying to "balance" both the benefits of social media such as its challenge to censorship and ability to aggregate social movements against destructive elements such as disinformation and the loss of privacy suggests we can somehow offset one side against the other. but if social media are making a country vulnerable to a key component of modern warfare, that really cannot be "balanced" even by the ability of social media to give voice to those often ignored by the mainstream media or to allow citizens to find affinity groups online. it's like saying that we can find a "balance" for discussing other national security issues, such as the idea that while an enemy might have superior weapons, at least our nation spent more on social welfare over the past decade. it might be true, but it won't help you win the war when the tanks roll over your borders. as executives in silicon valley bristle at these ideas, let us first consider the nature of modern war and why information has become a key element of contemporary conflict. it is not so much that we need to understand the digital aspect of modern warfare; rather we need to see that digital warfare is a new way of understanding war in the digital age. digital war is the central, rather than peripheral, issue. according to the federation of american scientists, digital war is "a subset of what we call information war, involves non-physical attacks on information, information processes, and information infrastructure that compromise, alter, damage, disrupt, or destroy information and/or delay, confuse, deceive, and disrupt information processing and decision making." 1 one of the most useful frames to consider information war is as the "fifth dimension" of warfare, joining land, sea, air, and space as spheres of battle (franz 1996) . information war is more precise than the notion of "cyber war" (hunker 2010) . indeed, the two concepts of "digital war" and "cyber war" are often conflated, given that "cyber" capabilities could be much broader than information operations and could embrace such tactics as dedicated denial of service (ddos) attacks to bring down servers, the takeover of critical infrastructure via online or local malware, or even drone attacks that are programmed from afar. that kind of conflation is actually not useful, in that it reduces information to a subset of a broader phenomenon and underplays the critical role of information in conflict. while it is disruptive for a country to lose access to the internet due to an attack on a server, this does not have the same insidious danger as subversive propaganda. cutting off access is an obvious act of war that has a clear solution. infiltrating a media system, especially social media, in order to sow seeds of distrust in a way that undermines political institutions is a far more insidious and corrosive act of aggression against a society. this discussion is focused on information war as it is carried out on social media, the battle for hearts and minds, as the most recent, critical development in modern warfare. social media play a very important part in that war and social media are a critical part of both attack and defense in modern warfare. indeed, information operations not only augment, but they often presage or even essentially replace conventional warfare. while the most publicized attack on democracy has been through attempted russian influence in the u.s. elections, countries in europe also have uncovered sustained anti-democracy campaigns by russians in countries ranging from estonia to the united kingdom. while the u.s. and other countries are aware of the threats and are responding, this article argues that it is difficult to have a robust response when u.s. social media companies are key distribution nodes of foreign disinformation. the ways in which narratives about coronavirus have become part of information warfare should sound a particularly ominous warning to democracies. a combination of fear, a large degree of unknown about the virus, as well as the rapid shifts in the evolution of the epidemic highlight how quickly disinformation can travel through social media at vulnerable moments. while national governments and major media outlets also are struggling with covering and framing the outbreak, social media platforms allow for authoritarian communication campaigns to widen and deepen the gaps between citizens and countries just when those connections are most desperately needed to combat an international health crisis. an example of this has been the attempt by authoritarian states (including china) to hint or even outright claim that the virus originated in a laboratory in the united states. now that it is impossible for social media companies to ignore the rising evidence of the central role of social media in inculcating conflict, they have defaulted to two key arguments in their defense: freedom of speech and the idea that the problem is limited to a fundamental misuse of their platforms. a core point emphasized by social media supporters was that the platforms were also vehicles for positive social change, such as in the arab spring, although the platforms showed very little ability or desire to adapt their programs to a range of national laws or norms. a 2008 article called "doing just business or just doing business" highlighted the problem: if internet companies choose to do business in china, for example, they must abide by china's censorship rules. in the case of the yahoo! email service, this meant turning over personal information on hong kong dissidents (dann and haddow 2008) . dann and haddow argued that the companies had violated their ethical standards, in that it was reasonable to surmise that turning over the information would have adverse consequences for their users. this ethical discussion, which took place before the current global reach of u.s. social media companies, now seems touchingly quaint. dann and haddow describe a world in which the main concerns were about privacy, censorship, and state surveillance, notably whether a country could compel an internet service provider to hand over personal information on its users. there was also disquiet about search engines being compliant with information filtering and collection regimes in non-free states. social media companies still face these challenges, but they pale in the face of the ability of states to weaponize social media for both domestic and international use. in particular, the way that social media companies organize users into affinity groups (for example, by friending on facebook or via hashtags on twitter) makes it remarkably easy to find ways to manipulate these groups. when you add on the way that social media companies sell audiences to advertisers by identifying key markers via user activity (friends, posts, clicks, likes, shares, etc.), you have the ability to manipulate both domestic and foreign audiences as never before. while there has been outrage over cambridge analytica, the same capacity to identify and manipulate social media users still lies at the heart of the social media business model. and there is little sustained outrage over that. social media companies would (and do) argue that it's unfair to blame the nature of social media itself if it winds up as the fifth dimension of warfare. siva vaidhyanathan disagrees: in his 2018 book antisocial media, vaidhyanathan asserts that the entire design of social media makes it the perfect carrier for disinformation and that social media companies do little to counter this. indeed, the arguments by mark zuckerberg and other social media officials are at best misinformed and, at worst, disingenuous. given the evidence of the weaponization of social media and the particular lack of foreign citizens to have any right of redress against u.s. companies, 2 it is clear that unregulated and mostly unresponsive dominant media platforms are choosing not to fundamentally change their business model. indeed, shareholders in facebook, twitter, and similar companies would not wish for greater policing of their platforms. the central element of the social media business model is the argument that social media companies are platforms, not providers, of information. this is protected by section 230 of the u.s. communication decency act, which states that "no provider or user of an interactive computer service shall be treated as the publisher or speaker of any information provided by another information content provider." this sounds a little circular but it means that the blame lies with the source of any problematic content, not the platform that provides the content. this has functioned as a get-out-of-jail-free card for facebook and other internet providers if someone, for example, harasses or bullies or even threatens an individual or group. at the same time, section 230 has been hailed by internet advocates as protection of free speech, which is true, but also (inadvertently) creates a great opportunity for proponents of disinformation. 3 section 230 is a very liberal interpretation of u.s. law, which is quite protective of free speech to the point that even hate speech is permissible in the united states. this has created some friction in the united states, but the truly dangerous aspect isn't entirely domestic. it creates opportunities for digital war in two ways. first, it leaves the "digital borders" for disinformation more or less open for foreign states (this is aside from the problems of domestic disinformation). at the same time, as facebook became the dominant social media platform around the world, citizens in other countries find themselves in the same dilemma. while citizens and their leaders discover they need to use the u.s.-based platform in order to communicate and even govern, at the same time social media platforms such as facebook foster disinformation. they have introduced a communications system with a powerful virus of disinformation. this is exacerbated by the fact that facebook also owns whatsapp and instagram, which carry the same problems. a u.s. freedom of speech model has set up a system through which disinformation flourishes and undermines democracy in countries worldwide. it is not that social media companies are unaware or even naive about the way in which their platforms are used for disinformation. rather, there are strong economic incentives for keeping the current laissez-faire 'platform' model. there are three key parts to the model: the needs of the advertisers are primary over those of the users; there is almost no vetting of the identity of who is posting; and content is virtually unmoderated. when content is moderated, it is automated as much as possible and this, so far, has been fairly ineffective. ignoring the role of social media as the fifth dimension of war is lucrative, especially for facebook. according to facebook's 2019 annual report, 4 the company had revenue of $70.7 billion and earned $18.5 billion. despite all the bad press about facebook in the wake of the 2016 russian election interference scandal, daily active users still increased by nine percent to 1.66 billion by the end of 2019. the number of employees at facebook surged as well in 2019, with the company reporting 44,942 workers at the end of 2019, an increase of 26 percent in a single year. overall, the company estimated that on average about 2.5 billion people used facebook at least every month by end of 2019, an increase of eight percent in a single year. the company describes itself in the press release in this way: "founded in 2004, facebook's mission is to give people the power to build community and bring the world closer together. people use facebook's apps and technologies to connect with friends and family, find communities and grow businesses." the self-description highlights the deliberate self-deception: while facebook does provide the services listed, it also furnishes an excellent way to spread malicious disinformation and propaganda to both domestic and foreign audiences. if we want to return to the question of business ethics, one could argue that facebook (and other social media companies) are continuing with a 'hands off' business model to keep costs down and profits up. and it's working. in the five years ended on december 31, 2019 (before the global financial shock from covid-19), facebook stock increased in value by about 163 percent, while the nasdaq index was up about 87 percent over the same period. 5 allowing free access to the platform keeps revenue up and costs down. this raises the question of whether social media could change so that there would be a better balance between the benefits and the drawbacks for society, notably the weaponization of social media to promote foreign disinformation. the real problem is that the users are not the financial priority of facebook or almost any social media site. rather, the advertisers are the key customers being served by the platform. in addition, the investors (in the form of shareholders) also rank far above the users in terms of company priorities. almost any move made to protect the platform and its users from being used in digital war would adversely affect service to the advertisers and the shareholders. as the currency of social media platforms such as facebook is in the number of users, you should keep barriers to entry as low as possible. although facebook is slightly harder to join than twitter, it's still relatively easy to create fake accounts. 6 changing a system in which artificial intelligence is overwhelmingly used to detect fake accounts would be expensive and cumbersome, but still possible (not least by having better ai). but there is a deeper problem. as the value of social media companies is based to a large degree on the number of users, it is not in the interest of the companies (or their shareholders) in either identifying fake accounts or in discouraging them in general. while social media companies may publicly condemn fake accounts and occasionally purge some, in reality fake accounts prop up their business model. content moderation is a more complex issue for social media companies. on the one hand, better content moderation would make a more pleasant experience for a user seeking to avoid extreme speech, pornography, trolling, or what could be considered culturally inappropriate elements of the public sphere (or inappropriate for a particular age or group). social media companies do moderate their content to screen out child pornography, extreme violence, etc., although even this is quite difficult. yet, emotionally charged subject matter drives engagement (celis et al. 2019 ). this dovetails with the need to attract consumers to the site so that they can be marketed to advertisers. thus, a quiet, calm public sphere is not the best for their business model. it's true that it would be much more expensive for social media companies to moderate either content or users in a more forceful and efficient way. but as with fake users, outrageous content also helps the bottom line. so it's a lose-lose for social media companies to police their users and their content, as it would be far more costly and actually might reduce engagement. so their reluctance to do so is more than financial or logistical. moderation works directly against their core economic interests as companies. 7 if the economics of social media make it illogical for the platforms to change, how can we inculcate a shift in how social media works? if we stick to a dialogue that compares the benefits of social media to the problems of social media, we are unlikely to drive change. however, if citizens and policymakers alike can be made aware of the critical role of u.s. social media companies in supporting information operations by foreign states, then change is more likely. this means making the central role of information warfare in modern conflict much more visible and compelling. this will take a significant shift in thinking for citizens, democratic leaders, and social media companies alike: in the american laissez-faire freedom of speech model, it is assumed that misinformation and even disinformation are just part of the marketplace of ideas. however, this is a misconception in a world in which information is deployed into highly engaged, yet highly segregated, communities of voters who are essentially walled off from fact-based journalism and information. in the united states, russia and other foreign entities are able to deploy weapons of mass persuasion directly on vulnerable citizens, with both the vulnerabilities and the deployment system provided to a large degree by social media companies. this vulnerability also came into clearer view during the coronavirus epidemic, as propaganda released for financial and political gain added to the global 'infodemic.' in order to fully understand the role of social media companies in warfare, we need to return to the concept of the fifth dimension of war, i.e. information warfare. it is added to the first four dimensions of land, sea, air, and space. information warfare is, of course, not a new phenomenon but it is radically changed and augmented by the digital sphere. in particular, the advent and wide adoption of social media around the globe gave a unique and unprecedented opportunity for countries to carry out information operations on the citizens of other states. the design of social media allows foreign influence operations to identify key groups, infiltrate them, and manipulate them. in 2016, russians were particularly interested in using wedge issues as ways to polarize and manipulate u.s. citizens and could be effective at doing this with trump supporters via social media (jamieson 2018) . in other words, the design of social media companies is no longer an issue of pros and cons. according to analysts such as vaidhayanathan, facebook's entire design creates the perfect operating theater for information warfare. with social media in its current state, this type of activity cannot be detected or curtailed in a reasonable way because it is embedded in the very nature of social media. it is so easy to pose as another, to gain trust, to polarize, and even convince people to change behavior that american corporations such as facebook create a low-cost weapon for foreign enemies. thus, american corporate ingenuity and business logic created a weapon that is deployed against americans themselves. this again brings up the problem of tradeoffs. americans are now accustomed to the affordances of social media, including the idea that it is "free" to the user. in point of fact, user activity is harvested and sold to advertisers, so users are working for the social media companies in exchange for access. few users, however, either realize or are particularly perturbed by that tradeoff. we could compare this to the rise of the automobile as a mode of transport. initially, cars were seen as independent luxury items and there were few rules to govern their use. the early automobile age was accompanied by chaos and a high rate of accidents. over time, governments took over regulation of the roads and-to a large degree-of car safety through the introduction of seat belts, anti-locking brakes, airbags, and other features. yet, almost 40,000 americans die in car accidents every year and tens of thousands more are injured. 8 so americans do accept tradeoffs. but there has never been a national discussion about the security tradeoffs in social media. what is the level of safety that is necessary? how can we start a national conversation about this? why is it a mistake to leave this in the hands of companies? how can we maintain a robust online sphere, but keep it much safer? are citizens willing to pay for this, either directly or through government support? if the nature of the problem is framed as one of national security, can u.s. regulation work? regulating social media is enormously difficult and that's just in the united states, which has the advantage of being the headquarters of large western social media companies. much of this is due to excessive cyber-optimism in the united states, in particular as an echo of the origins of the internet as a research and educational tool outside of the commercial realm. although that aspect of the internet has been long overshadowed by the commercial web, there is no comprehensive set of laws to specifically regulate the internet. nor is there any public consensus on social media regulation, although just over half of americans now believe that major tech companies should be more heavily regulated. 9 but according to the pew research center, republicans feel that tech companies might already interfere with content too much: 85 percent of republicans suspect that tech companies censor political viewpoints. can americans be convinced that social media regulation is a security issue? we can turn to the issue of terrorism as a shift in thinking from civilian to defense issues. prior to 9/11, the idea that u.s. citizens would go through body and luggage searches for all domestic flights would have been laughable. yet, americans and visitors now go through searches not only at airports, but in a wide range of other public spaces. while this is framed as a defense against foreign attacks, americans face significant threats from domestic terrorism. here is a silver lining to how illuminating the capabilities of social media as a tool for foreign actors to wage disinformation war against u.s. citizens is useful. american democracy also faces significant online domestic threats, from anti-vaxxers to hate groups to disinformation attacks on political opponents. politically, though, there is no will to frame social media as a key part of that problem; rather, the general narrative is that disinformation is an unfortunate side effect of the social media we cannot live without. to change this attitude on the part of americans and u.s. social media companies, it will take a radical shift in understanding how social media has opened up a new and (so far) asymmetric battlefield for enemies of the american state. american perception of conflict and security shifted radically with 9/11. the threat of social media is much less visible and woven not only into the generally opaque nature of social media as people pose, pretend, and market themselves. it also comes at a time when the u.s. government is particularly weak as the political sphere is deeply split over the trump administration's actions. that being said, americans do seem to be waking up both to the threat and the lack of protection from social media companies. while russian interference is seen through a strictly partisan lens, chinese interference creates a much more unified response. nor have social media executives won themselves much praise for their disingenuous performance at congressional hearings. as the coronavirus pandemic has led to heightened awareness of both the importance and vulnerability of trustworthy information, this could be a watershed moment in understanding and valuing the communication ecosystem. youtube chief executive susan wojcicki said that the virus had been "an acceleration of our digital lives" and noted that it caused the platform to speed up changes to direct users to authoritative information. 10 it is particularly relevant to consider how youtube addressed health disinformation in the coronavirus pandemic, in that a study by the oxford internet institute found that the platform had emerged as a "major purveyor of health and wellbeing information" (marchal et al. 2020, p. 1) . the washington post column that quoted wojcicki speculated that health disinformation was taken more seriously than political disinformation by social media platforms. the relative affordances of social media companies might baffle and confuse many americans, but security threats never baffle or confuse americans for long. all it will take is some relatively unified political leadership that can highlight this threat and americans may indeed be ready for significant changes to the current social media model. just as americans pay a security tax for every airline flight, they may be willing to endorse a model of social media that is forced to take responsibility for its users and content. this will likely mean much more stringent government regulation and a change from section 230. while this is disappointing for liberal concepts of free speech, free speech cannot work in a system in which it is weaponized by foreign adversaries. controlling polarization in personalization: an algorithmic framework just doing business or doing just business: google, microsoft, yahoo! and the business of censoring china's internet ks: school of advanced military studies, united states army command and general staff college cyber war and cyber power: issues for nato doctrine cyberwar: how russian hackers and trolls helped elect a president: what we don't, can't, and do know coronavirus news and information on youtube: a content analysis of popular search terms antisocial media: how facebook disconnects us and undermines democracy key: cord-308249-es948mux authors: dokuka, sofia; valeeva, diliara; yudkevich, maria title: how academic achievement spreads: the role of distinct social networks in academic performance diffusion date: 2020-07-27 journal: plos one doi: 10.1371/journal.pone.0236737 sha: doc_id: 308249 cord_uid: es948mux behavior diffusion through social networks is a key social process. it may be guided by various factors such as network topology, type of propagated behavior, and the strength of network connections. in this paper, we claim that the type of social interactions is also an important ingredient of behavioral diffusion. we examine the spread of academic achievements of first-year undergraduate students through friendship and study assistance networks, applying stochastic actor-oriented modeling. we show that informal social connections transmit performance while instrumental connections do not. the results highlight the importance of friendship in educational environments and contribute to debates on the behavior spread in social networks. social environment has a significant impact on individual decisions and behavior [1] [2] [3] . people tend to assimilate the behavior, social norms, and habits of their friends and peers. it is empirically shown that social interactions play a key role in the spread of innovations [4] , health-related behavior [5, 6] , alcohol consumption and smoking [7, 8] , delinquent behavior [9, 10] , happiness [11] , political views [12, 13] , cultural tastes [14] , academic performance [15] [16] [17] [18] [19] . although there is an extensive body of research showing that a large proportion of social practices disseminates across social networks [3] , the question of what types of social contacts cause the spread of specific behavior remains open [1, 20] . in this paper, we analyze the diffusion of academic performance across different types of student social networks. while these social networks are extensively studied in the literature [15] [16] [17] [18] 21, 22] , there is a lack of agreement on whether social networks are effective channels for the academic performance spread [16, 18, 23] . and if they are, what types of networks serve the best for the propagation of the academic-related behavior? we analyze the spread of academic achievements within two different social networks of first-year undergraduate students. we test two mechanisms of academic performance diffusion in the student social networks. first, we analyze the academic performance spread through the friendship network, which can be considered as a network of informal social a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 interactions. second, we study the academic performance spread in the study assistance network which is aimed at study-related information and knowledge transmission, and serves for problem-solving [24] . we apply stochastic actor-oriented model (saom) for joint modeling of networks and behavior dynamics [25] . we model the evolution of two social systems. in the first model, we analyze the coevolution of friendship network and academic achievements. in the second model, we study the coevolution of study assistance network and academic achievements. both models are controlled with a variety of structural and behavioral properties such as a tendency to form mutual ties and befriend similar others. results show that academic performance spreads through friendship connections, while the study assistance ties do not cause the performance transfer. social networks are the pathways for the behavior transmission. this process may be guided by various factors, including the network topology [26] , type of propagated behavior, nature of social contacts, and other features of the social environment. the majority of recent studies on this topic are concentrated on the structural properties of the networks that drive the behavior diffusion processes. for example, it was experimentally shown that short average path length and high clustering cause a faster behavior spread [27] that can be explained by the formation of the dense network communities with the fast information and behavior exchange within these cohesive groups. in [28] it was demonstrated that there are differences in spreading processes initiated by well-connected actors, or hubs, and by actors with a few social connections. hubs are effective in information propagation due to the high number of connections, while actors with a few ties are more efficient in spreading messages that are controversial or costly. the probability of behavior adoption by an individual is also highly correlated with the number of social contacts that directly influence this individual [29] . the influence by many peers, or so-called "complex contagion", results in faster and easier behavior adoption, rather than the influence by one person, or "simple contagion" [26] . the efficacy of social contagion is often associated with the type of propagated behavior. centola and macy outline the danger of considering the social contagion studies in the 'whatever to be diffused' way [30] . for example, the adoption of information is much less risky, costly, and time-consuming, rather than the adoption of health-related behavior, sports habits, and academic achievements. the nature of social ties is also a significant factor for behavior transmission. social connections are traditionally divided into "weak" and "strong" ties, and they exhibit completely different spreading patterns [31] . strong ties are formed within the dense network communities such as family or friends, while weak ties, according to granovetter's definition, emerge during the whole life and represent people who are marginally included in the network of contacts, such as old college friends or colleagues [31] . empirical literature shows that both types of relationships can serve as channels for the diffusion of behavior or information [1, 20] . but weak ties are important instruments for information propagation, while strong ties are more successful in costly behavior transmission. although the vast array of theoretical and empirical studies improved our understanding of the behavior transmission processes, there is still an open question regarding the differences of the behavior spread in networks of different natures. social ties can vary both in the level of their strength and intensity, as we outlined above, and in their origins. networks can be based on friendship, romantics, advice seeking, social support, and many other relationships. despite the huge variance in the social network types, the majority of the research on social diffusion is concentrated on the networks of friendship ties. however, the relationships of distinct nature can result in completely different behavior transmission processes. in this paper, we consider the transmission of academic performance within student social networks. this process attracts the attention of researchers since the publication of the famous "coleman report" [21] . this report showed that students tend to obtain similar grades as their peers, classmates, and friends, and this effect remains strong after controlling for a variety of socio-economic and cognitive variables. further empirical studies demonstrated the presence of this effect in various case studies. for example, it was shown that student grade point average (gpa) increases if her dormmate is in the highest 25th gpa percentile [32] . in [15] , mba students tend to assimilate the grades of their friends and advisers. it was also demonstrated that this social influence is associated with the personal characteristics of students and the nature of their social connections. for instance, lower-achieving students are more influenced by their peers [33, 34] , the diffusion of academic performance is stronger among women than men [35] , can be related to the race of a peer [36, 37] , and is stronger from close peers such as friends [38] . at the same time, online communication networks do not serve as effective channels for performance transmission. students tend to segregate in online networks based on their performance and this prevents the diffusion of achievements through online ties [18, 19] . summarizing, the majority of studies demonstrate that social networks are effective channels for the performance diffusion. it was shown that achievements spread well within friendship networks, while other types of ties (e.g. online relationships) do not serve as channels for the performance transmission. in this paper, we examine the diffusion of academic achievements in two distinct social networks: friendship and study assistance. we demonstrate that, despite the significant overlap in these networks, they exhibit different patterns of behavior transmission. we analyze the longitudinal data on friendship and study assistance networks and gpa of a first-year student cohort of the economics department in one of the leading russian universities in 2013-2014 academic year. in this university, students are randomly assigned by the administration to different study groups of up to 30 students. lectures are usually delivered to all the cohort simultaneously while seminar classes are delivered to each study group separately. in the first year, most of the courses are obligatory. therefore, students have a limited possibility to form networks with students from other groups, programs, or year cohorts. the academic year consists of four modules of two or three months. at the end of each module, students take final tests and exams. the grading system is at a 10-point scale where a higher score indicates a higher level of academic achievement. the course grade is the weighted average of midterm and final exams, homework, essays, and other academic activities during the course. the sample consists of 31% males and 69% females. the data for this study was gathered from two sources: the longitudinal student questionnaire survey (3 waves during the first academic year: october 2013, february 2014, and june 2014) and the university administrative database. in total, our dataset consists of 117 students that took part in at least two surveys with up to 700 connections between them in total. the detailed over-time aspect of the networks gives us a rich dataset of links of diverse nature. the sample can be considered representative to student cohorts in selective universities. in the questionnaire survey, we ask students about their connections within their cohort. the questions were formulated in the following way: 1. please indicate the classmates with whom you spend most of your time together; 2. please indicate the classmates whom you ask for help with your studies. the role of distinct social networks in academic performance diffusion. there were no limitations in the number of nominations. additionally, students were asked to indicate those classmates whom they knew before the admission to the university. we also gather information about students' study-group affiliation from the administrative database. in total, we have four different network types: friendship, study assistance, knowing each other before studies, and being in the same study group. from an administrative database of the university, we gather data about student performance (grade point average, or gpa at the end of the first year) that is measured on a scale from 0 to 10. we transform the data on performance from continuous to categorical scale and distinguish four performance groups based on the grading system of the university: high performing students (their gpa is equal or higher than 8), medium high performing students (with gpa from 6 to 8), medium low performing students (with gpa from 4 to 6) and low performing students (with gpa lower than 4). it is important to mention that the information about individual student grades is publicly available in this university. this is common in some russian universities but very different from educational systems in the european union and the us. in russian universities, grades are often publicly announced by teachers to the class. in the studied university, final grades are additionally published online on the university website. this creates a specific case when students know about the grades of each other and can coordinate their social connections depending on this information. individuals who did not participate in the questionnaire survey were excluded from the analysis (14 individuals, 10.7% of the sample). these missing data were not treated in a special way. we followed the recommendations (40) , suggesting that 'up to 10% missing data will usually not give many difficulties or distortions, provided missingness is indeed non-informative'. data collection procedures are described in the "data collection" section in s1 file. the descriptive statistics of the sample are presented in the si ("case description" section and tables 1-3 in s1 file). the network visualizations are presented in figs 1-6. standard statistical techniques such as regression models are not applicable for the analysis of social networks due to the interdependence of network observations [39] . therefore, we apply a stochastic actor-oriented model (saom) that allows to reveal the coevolution of network properties and behavior of actors [25, 40] . this dynamic model is widely used for studying the joint evolution of social networks, actor attributes, and separating the processes of social selection and social influence. in total, we estimate two models: the first model estimates the coevolution of friendship network and academic performance, the second one estimates the coevolution of study assistance network and academic performance. the saom's underlying principles are the following. firstly, network and behavior changes are modeled as markov processes which means that the network state at time t depends only on the (t-1) network state. secondly, saom is grounded on the methodological approach of structural individualism. it is assumed that all actors are fully informed about the network structure and attributes of all other network participants. thirdly, time moves continuously and all the macro-changes of the network structure are modeled as a result of the sequence of the corresponding micro-changes. this means that an actor, at each point in time, can either change one of the outgoing ties or modify his or her behavior. the last principle is crucial for the separation of the social selection and social influence processes. there are four sub-components of the coevolution of network and behavior: network rate function, network objective function, behavior rate function, and behavior objective function [25, 40] . the rate functions represent the expected frequencies per unit of time with which actors get an opportunity to make network and/or behavioral micro-changes (40) . the objective functions are the primary determinants of the probabilities of changes. the probabilities of the network and/or behavior change are higher if the values of the objective functions for the network/behavior are higher [25, 40] . the objective functions for the network (eq 1) and behavior change (eq 2) are calculated as a linear combination of a set of components called effects: where s ki (x) are the analytical functions (also called effects) that describe the network tendencies (40) ; β kz s ki z (x, z) are functions that depend on the behavior of the focal actor i, but also on the behavior of his or her network partners and a network position [22] ; β k and β k z are statistical parameters that show the significance of the effects. saom coefficients are interpreted as logistic regression coefficients. parameters are unstandardized, therefore, the estimates for different parameters are not directly comparable. during the modeling, saom allows the inclusion of endogenous and exogenous covariates. as endogenous variables, we include in our models network density, reciprocity, popularity, activity, transitivity, 3-cycles, transitive reciprocated triplets, and betweenness [40] . density and reciprocity show the tendency of students to form any ties and to form mutual ties. transitivity, 3-cycles, transitive reciprocated triplets, and betweenness measure a propensity of students to form triadic connections with their peers. popularity and activity are included to control the tendency of actors to receive many ties from others and to nominate a large number of actors. to control for social selection, we include the selection effect based on academic achievement. it shows whether students with similar levels of academic achievements tend to form connections with each other. we also controlled for the tendency of students with high grades to increase their popularity and activity over time. to test the presence of social influence, we include the effect of performance assimilation. it shows whether students tend to assimilate the academic achievement levels of their peers. in addition, we controlled for the propensity of students with high levels of popularity and activity to change their academic performance. in the model construction we follow the general network modeling requirements necessary for saom [40] . the role of distinct social networks in academic performance diffusion. all research protocols were approved by the hse (higher school of economics) committee on interuniversity surveys and ethical assess of empirical research. all human subjects gave their informed verbal consent prior to their participation in this research, and adequate steps were taken to protect participants' confidentiality. table 1 presents the modeling results of two separate models. in the first, we model the coevolution of friendship network and academic performance. in the second one, we model the coevolution of study assistance network and academic performance. social influence [effect 24] is positive and significant in the friendship social network. this means that the academic performance of students tends to become similar to the performance of their friends. in other words, academic achievements diffuse through friendship ties. in the study assistance network, however, social influence is not present. this indicates that students the role of distinct social networks in academic performance diffusion. do not assimilate the performance of their study assistants; this network channel does not propagate the spread of academic achievements. positive indegree effect [effect 25] suggests that students who are often asked for help increase their performance over time. the non-significant estimates of the linear and quadratic shape parameters [effects 22 and 23] for friendship indicate that the influence of peers sufficiently explains the performance dynamics [15] . the negative effect of the quadratic shape parameter [effects 23] for the study assistance network shows the convergence of the academic performance to unimodal distribution [15] . the effect of performance selection [effect 19] is positive for the study assistance network. it suggests that students with similar levels of academic achievements tend to ask each other for help. the effect of social selection in the friendship network is not significant. this means that students do not have a preference to befriend students with similar academic achievements. positive estimates for the performance of alter [effect 17] in both social networks suggest that individuals with high performance are popular in friendship and study assistance networks. positive effect for the performance of ego [effect 18] for friendship network shows that high performing students tend to create friendship connections. the role of distinct social networks in academic performance diffusion. we find the presence of gender homophily [effect 16] in both friendship and study assistance social networks. students tend to create friendship and study assistance connections with individuals with the same gender. positive effect of ego for males [effect 15] in the friendship network suggests that males tend to nominate more friends. the network control effects [effects 3, 4, 7, 8, 9, and 10] that were included in the models show expected signs and significance scores, as in most student social networks [25] shows that transitivity is less important for friendship ties when reciprocity is present (and vice versa) [41] . the combination of negative betweenness [effect 10] and positive transitivity [effect 7] in both networks demonstrate that individuals do not seek for brokerage positions and do not want to connect peers from different network communities and study groups. positive activity effect [effect 6] in friendship network indicates that students with many ties tend to create new friendship relationships. positive effect of popularity [effect 5] in study assistance network suggests that individuals ask for help those students, who are often asked for help by others. in friendship network this effect is negative, which means that students do not tend to befriend popular individuals, i.e. those who already have a lot of friends. in both networks rate parameters are larger in the first period rather than in the second, indicating that the tie formation stabilizes over time. the modeling results also show that students tend to create friendship and study assistance ties with individuals they knew before the enrollment [effect 11] and individuals from the same study group [effect 12]. also, students tend to create friendship connections with their study assistants [effect 13.1] and they seek for study assistance from their friends [effect 13.2]. we conducted the time heterogeneity test for both network models [40] . this test is used to examine whether the parameter values β k of the objective function are constant over the the role of distinct social networks in academic performance diffusion. periods of observation. we find the time heterogeneity in models. in both networks, parameters such as betweenness, acquaintance before enrollment, popularity and activity of the high performing individuals are heterogeneous. in the friendship network, there is also time heterogeneity for gender of alter and ego, performance social selection and influence. in the study significance codes ��� p < 0.001 �� p < 0.01 � p < 0.05. the models converged according to the t-ratios for convergence and the overall maximum convergence ratio criteria suggested in (40) . goodness of fit is adequate for all models. https://doi.org/10.1371/journal.pone.0236737.t001 the role of distinct social networks in academic performance diffusion. assistance network, we find time heterogeneity for studying in the same group, gender of ego, and performance of ego. the cases of previous acquaintance or being in the same study group can be explained by the nature of these types of ties. for instance, the acquaintance before enrollment can play a significant role at the beginning of studies, while after several months' students will tend to expand their networks and will not seek connections with individuals they knew before studies. the same explanation can be used for the case of being in the same study group. at the beginning of studies, students will form ties within their study groups but later they will tend to expand their network and form ties with other group members. differences in time heterogeneity of academic achievements may be related to the decreased statistical power of these effects between different models. the effects of academic performance on network evolution processes may be understood in details by considering all the performance-related effects simultaneously [40] . in table 2 , we present log-odds for the performance selection within different achievement groups. the higher the estimate, the higher the probability of a study assistance tie formation between students from different performance groups. table 2 shows that there is a significant tendency toward selection of high-performing individuals as study assistants, and this tendency is present among all groups of students. similarly, in table 3 we present precise estimates for the social influence process for all achievement groups. each row of the table corresponds to a given average behavior of the friends of an ego. values in the row show the relative 'attractiveness' of the different potential values of ego's behavior. maximum diagonal value indicates that for each value of the average friends' behavior the actor 'prefers' to have the same behavior as all these friends (40) . this shows that individuals tend to assimilate their friends' performance. in this paper we explore the academic performance diffusion through two social networks of different natures: friendship and study assistance. we empirically confirm that educational the role of distinct social networks in academic performance diffusion. outcomes of students are diffused in different ways within friendship and study assistance networks. ties in the friendship network transmit academic achievements, while ties in the study assistance network do not. the absence of the social influence process along the presence of social selection in the study assistance network may suggest the presence of social segregation based on performance [19] . this can be related to the high competitiveness of the university environment under the study. we expect that some students are highly motivated to receive higher grades and prefer to invest time and effort in their high academic results rather than help their less academically successful peers. our findings demonstrate that the efficacy of academic achievements diffusion is determined by the nature of the social network. it was established that social integration in the classroom is positively associated with the higher academic performance of students [17, 19] . here we claim that it is extremely important to integrate individuals specifically in the network of informal friendship interactions and motivate them to create connections with higher-performing students. these findings support the idea that the nature of social relationships is crucial for the transmission of specific types of information and behavior in social networks. close friendship relationships serve as effective channels for the spread of various complex behaviors, including very costly behavior types such as health behavior [1] . academic performance is one of the examples of these behavior types that are not easily transmittable. in contrast, the instrumental study assistance ties do not produce the propagation of academic achievements from successful students to their lower-performing peers. to sum up, we show that costly and complex behavior (such as academic achievement) diffuses more effectively in the network of strong close connections such as friendship. these findings contribute to the current debates on behavior propagation in social networks and propose new insights on factors that impact the success of behavior transmission. this study has several limitations. first, we analyze social networks of first-year students. this time frame, when students start their educational path at an undergraduate level, receives a lot of attention in the literature [17, 19, 42] due to the fast speed of social tie formation. at the same time, it would be beneficial to investigate the diffusion of academic achievements through social networks along the full period of studies. second, we examine only two types of social relations, however, the spectrum of social ties that can serve as channels of the performance diffusion is much wider. it is a potential avenue for future studies to estimate the efficacy of other types of social networks such as cooperation, competition, romantic relationships, and negative ties on the process of academic achievement diffusion. the data on some of these networks is difficult to collect (e.g., negative relationships) due to the high sensitivity of studied relationships but these types of ties can be nevertheless significant for behavior transmission. in the time of the covid-19 pandemic and after it, it is also extremely important to examine the effect of online networks on academic performance transmission because online interaction remains the only communication channel for students. our empirical findings have several policy implications. academic achievements are one of the key components of financial success and individual well-being [43, 44] , that makes the performance increase is one of the main goals of the educational system. however individual achievements are quite stable and largely driven by heritable factors [45] which make interventions aimed at the academic performance growth highly complex and difficult to implement. one of the possible mechanisms of performance increase is social influence, as we show in this paper. teachers can pay additional attention to the development of informal friendship relationships between students with various performance levels during classes. it can be reached by group work assignments, in which group membership is defined by the teachers and is not based on the personal preferences of students. long-term group assignments such as working on a research project together can stimulate students from different achievement groups to develop friendship ties with each other. the creation of recreation and open spaces within the university building can also give additional options for students with distinct performance to meet, interact, and form friendship ties. the combination of these actions would help students to build and sustain their informal networks, which, in turn, serve as key channels of the academic performance diffusion and lead to a positive behavior change. supporting information s1 file. 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laato, samuli; talukder, shamim; sutinen, erkki title: misinformation sharing and social media fatigue during covid-19: an affordance and cognitive load perspective date: 2020-07-12 journal: technol forecast soc change doi: 10.1016/j.techfore.2020.120201 sha: doc_id: 254191 cord_uid: 5cxv9l3c social media plays a significant role during pandemics such as covid-19, as it enables people to share news as well as personal experiences and viewpoints with one another in real-time, globally. building off the affordance lens and cognitive load theory, we investigate how motivational factors and personal attributes influence social media fatigue and the sharing of unverified information during the covid-19 pandemic. accordingly, we develop a model which we analyse using the structural equation modelling and neural network techniques with data collected from young adults in bangladesh (n = 433). the results show that people, who are driven by self-promotion and entertainment, and those suffering from deficient self-regulation, are more likely to share unverified information. exploration and religiosity correlated negatively with the sharing of unverified information. however, exploration also increased social media fatigue. our findings indicate that the different use purposes of social media introduce problematic consequences, in particular, increased misinformation sharing. covid-19 was not only a global pandemic but according to the director of who, also an "infodemic", highlighting dire issues arising from the abundance of misinformation and fake news circulating about covid-19 (laato et al., 2020a) . in response to the infodemic, a significant number of resources were directed to curb the spread of misinformation; to ensure the availability of reliable information about covid-19 to the public (zarocostas, 2020) . among the adverse effects observed during the infodemic were messages of inefficient government (mahase, 2020) and individual-level (vaezi, and javanmard, 2020) responses. another concerning observation was health issues such as cyberchondria or increased anxiety (farooq et al., 2020) . previous work has highlighted social media to play a crucial role in the spread of misinformation (allcott and gentzkow, 2017) which calls into question what the platforms could do to prevent the spread of fake news (figueira and oliveira, 2017) . consequently, the three main research areas concerning fake news are divided into (1) the (technical) prevention of the spread of fake news; (2) the impacts of misinformation; and (3) the relationship between misinformation and population health (laato et al., 2020a) . to support these three areas of concern, human behaviour related to social media use and misinformation sharing needs to be understood. users of social media platforms such as facebook reported to be driven by several motivators such as a wish for entertainment, wish to stay informed and the desire to know the social activities of friends (kietzmann et al., 2011; quan-haase and young, 2010) . recent studies have also pointed out that social network sites are often used for selfpromotion and exhibitionism purposes (islam et al., 2019) . as such, social network sites differ from instant messaging, which is more personal, less self-promoting, more direct and driven by a wish to maintain and develop relationships (quan-haase and young, 2010) . modern social media platforms such as facebook offer multiple ways in which people can interact, including social activities, instant messaging, photo sharing, video streaming and sharing of news and articles. the social media ecosystems can cause or reinforce the stratification of people into social sub-groups characterised by having a similar mind (guerra et al., 2013) . this is the result of individuals' own choices due to psychological tendencies as well as ai-based recommendation systems that aim to provide users content they are likely to enjoy (spohr, 2017) . the lack of critique on thoughts and the amplification of radical ideas by the virtual echo-chambers created by social media have been claimed to contribute to increased dissemination of misinformation (barberá et al., t during covid-19, clear communication of the severity of the situation and recommended health measures was needed to ensure people took correct action and did not suffer from unnecessary anxiety (farooq et al., 2020) . the abundance of unclear, ambiguous and inaccurate information during covid-19 led to information overload and accelerated health anxiety (cyberchondria) as well as misinformation sharing (laato et al., 2020a) . as social media amplifies the spread of news, and people read news through links shared on social media (allcott and gentzkow, 2017; thompson et al., 2019; ku et al., 2019) , understanding the role that social media plays on the sharing of misinformation is essential. in this setting, social media fatigue (smf) and its connection to misinformation sharing may reveal further insights into human behaviour on social media and the antecedents of the spread of misinformation. thus, our research aims to observe this relationship as well as personal attributes and motivational factors connected to the two constructs via the theoretical frameworks of affordances (norman, 1988) and cognitive load theory (clt) (sweller, 2011) . with our paper, we expand the existing literature on misinformation sharing by connecting it to the affordances of social media and smf. the study context of covid-19 enables us to study our research model at a time when people were faced with a potentially lifethreatening disease that had severe consequences also on the economy. the rest of this study is structured as follows. in the background section, we review the extant literature on misinformation sharing as well as smf. we then present our theoretical foundation before moving on to forming the hypotheses for our research model. the methods and results follow the hypothesis section. in the discussion section, we go through our key findings, theoretical and practical implications of our results, as well as limitations and future work. via the internet and social media, individuals have access to an ever-increasing quantity of information. however, the availability of information has not reportedly correlated with individuals' increased knowledge (pentina and tarafdar, 2014) . while information is available, it might not be clearly structured, organised or even accessed. previous studies have given four primary reasons for this: (1) a proportion of the available information is misinformation; (2) much of the available information is irrelevant; (3) information entropy: information is poorly organised and presented; and (4) information overload, there is simply too much information for humans to make sense of (pentina and tarafdar, 2014; laato et al., 2020a) . the use of a few trusted online sources has been recommended in the literature (farooq et al., 2020; misra and stokols, 2012; zarocostas, 2020) . this becomes especially important in situations such as the covid-19 pandemic where the novelty, rapid development and unpredictability of the situation can give rise to not only misinformation but poorly structured and presented information as well. resolving these issues is essential to manage and communicate with individuals about the situation and boost their intrinsic motivation to adapt to recommended health measures (farooq et al., 2020) . social media can be regarded as the amplifier of news articles, both real and fake (allcott and gentzkow, 2017) . in 2019, the most popular social media platform facebook had over 1.5 billion registered users, 62% of which use the platform for keeping up with news (thompson et al., 2019) . allcott and gentzkow (2017) observed that during the 2016 us elections, roughly one-sixth of the population regarded social media as their primary news source. however, a recent study on adolescents' online behaviour showed a third considered social media as their primary news source, surpassing all other sources (ku et al., 2019) . besides, studies often separate online websites from social media as a news source (allcott and gentzkow, 2017; ku et al., 2019) , however, website news stories are typically disseminated and shared onwards specifically via social media. consequently, social media is particularly susceptible to be used as a platform for fake news dissemination. almost half (42%) of people sharing news reported having, at least at some point, shared misinformation (chadwick and vaccari, 2019) . there have been reports of bots being used to increase the visibility of fake news (howard et al., 2017; wang et al., 2018) , as well as attempts to algorithmically detect fake news (del vicario et al., 2016) . while bot networks spreading this news can be detected and stopped, algorithms cannot, in many cases, distinguish fake news from real news (del vicario et al., 2016) . as such, attempts to algorithmically detect and sensor fake news articles from social media would result in a large number of false positives and false negatives, contributing to censorship that would still leave some room open for fake news to be displayed. however, humans can also make mistakes in identifying fake news, on purpose or unintentionally (vicario et al., 2019) . previous studies have identified various intrinsic predictors for fake news sharing such as (1) smf; (2) fomo; (3) inexperience using the internet; (4) lack of information verification skills; (5) laziness; (6) information overload; and (7) online trust (laato et al., 2020a; khan and idris, 2019; talwar et al., 2019) . also, people are heavily impacted by confirmation bias, meaning they are more likely to believe information when it aligns with their pre-existing views regardless whether the information is reliable or not vicario et al., 2019) . in the context of pandemics, physical proximity, and perceived severity of the situation have been shown to increase information sharing in general (huang et al., 2015) . on the other hand, a recent study during covid-19 found perceived severity not to increase the intention to share unverified information (laato et al., 2020a) . nevertheless, we maintain that rapidly emerging new situations, coupled with a large quantity of ill-structured information may contribute to increased fake news sharing (huang et al., 2015) . in addition to ensuring the availability of accurate and well-structured information and directing people towards it, there have been several other recent suggestions in the academic literature on how to mitigate the negative impacts of fake news and stop humans from spreading them (nekmat, 2020) . recent studies have shown users to be more critical towards online news if they have reasons to suspect that the quality of the news is low . nudging people to pay attention to the source(s) of the news they are reading, increases their criticality towards the information and makes them less likely to share fake news onward nekmat, 2020) . these findings show promise in how social media platforms could influence peoples' news sharing and reading behaviour. another recent article proposed the use of crowdsourcing to fact-checking news as well as confirming their authenticity (pennycook and rand, 2019) . in a way, crowdsourcing of news articles is already in place. wikipedia, for example, can be regarded as a crowdsourced database of information. however, news articles need to be produced and disseminated rapidly, which means that measures for detecting fake news also need to be quick. the problem in general with currently available suggestions for curbing the spreading of misinformation is that there begins to be a trade-off. while the number of fake news shared can be minimised, other negative consequences can begin to emerge, such as the users' limited freedom (del vicario et al., 2016) . smf has several, sometimes conflicting definitions (xiao and mou, 2019) such as "persistent impulses to back away from social media due to information and communication overload" (bright et al., 2015) and "a subjective and self-evaluated feeling of tiredness from social media usage" . the definition of bright et al. (2015) relates fatigue to cognitive overload. however, it simultaneously reduces the concept of fatigue to the two components of information and communication overload. on the other hand, the definition of lee et al. (2016) is broader, but as a downside provides little theoretical guidance for understanding the factors which lead to smf. one argument for using the definition of lee et al. (2016) is that previous studies have identified several factors contributing to smf besides information and communication overload (bright et al., 2015) such as depression (cao et al., 2019) . according to piper et al. (1989) , fatigue can be acute or chronic. acute fatigue is temporary, normal and short while chronic fatigue is more permanent (aaronson et al., 1999) . in this study, we understand smf based on the above provided definitions (bright et al., 2015; lee et al., 2016) to be a temporary, however systematically triggered, state of fatigue caused by social media use. previous studies have shown compulsive social media use to be one of the primary predictors of smf, and have further demonstrated that it can lead to anxiety and depression (dhir et al., 2018) . another study conceptualised anxiety and depression as the antecedents of fatigue instead, adding a third impacting factor, cyberbullying as a predictor (cao et al., 2019) . this highlights an issue in the previous literature of smf where there seems to be a lack of a clear theoretical framework explaining what are the antecedents and what are the consequences of smf. furthermore, some studies have provided models studying the relationships between seemingly random factors and smf, resulting in a list of factors predicting it. for example, dhir et al. (2019) showed privacy concerns, self-disclosure, parental encouragement and parental worry to increase smf. furthermore, xiao and mou (2019) reviewed the literature on what causes smf and found 23 relevant quantitative studies, which gave a plethora of reasons that cause smf. these included fear of missing out (fomo), privacy concerns, technology-related factors, social media users' attitudes and personality, social overload, cognitive overload, anxiety, excessive use, cyberbullying, depression, destruction, parental influence, ubiquitous connectivity, shame, social comparison and complexity among many others (xiao and mou, 2019) . two main theories have been suggested to make sense of what causes smf: the cognitive load theory (clt) (bright et al., 2015; islam et al., 2018) and the stressor-strain-outcome model (xiao and mou, 2019) . both theories share the similarity of modelling smf as the dependant variable and theorising factors influencing it. according to clt, smf can be predicted by information overload, communication overload, system feature overload, social overload, and connection overload (islam et al., 2018) . there are also moderating factors present, as islam et al. (2018) identified multitasking computer self-efficacy to attenuate the effect of information overload. the presence of attenuating factors, as well as other factors, has also been discussed in studies using the stressor-strain-outcome theory (xiao and mou, 2019; whelan et al., 2020b) . this theory has been used to look at how social media characteristics give rise to stressors, such as privacy invasion and invasion of life, which then lead to smf (xiao and mou, 2019) . from this brief look into social media fatigue, we draw three key points. first, the quantity and quality of available information have a significant impact on developing smf (bright et al., 2015; pentina and tarafdar, 2014) . second, the social media platform, the user and the interaction between the two all need to be understood to explain smf and its behavioural impacts. finally, clt (sweller, 2011) and stressorstrain-outcome (xiao and mou, 2019) offer promising theoretical frameworks for understanding smf (bright et al., 2015; islam et al., 2018) . for the current study, we adopt the affordance lens for understanding how social media users interact with the platform during the covid-19 pandemic. for understanding smf and sharing unverified information, we also draw from clt (sweller, 2011) . in this section, we present these two theoretical approaches by connecting them to the topic of our study. the term affordance was introduced by the psychologist james gibson (1966) , who conceptualised the term to describe the potential actions that an actor can make in a specific situation. in the context of a door handle, it has the logical affordance of being used to open a door. the door handle may be used in other ways as well, such as rubbing the back or being used as a clothing stand. gibson (1977) stated that affordances are independent of the actors' ability to recognise them. norman (1988) thought this expansion to the concept of affordance was unnecessary, and re-defined affordances to be only those actions, which an individual realises to exist. in doing so, affordances were tied to the objectives, values, thoughts and capabilities of individuals (norman, 1988) . not all scholars agreed on norman's conceptualisation of the term, and this gave birth to two schools of thought, one supporting norman's definition and the other following that of gibson. in this study, we adopt the definition of norman (1988) and divide affordances into (1) technical affordances, the opportunities that the technology provides in general, in our case, social media platforms; (2) individual affordances, the opportunities given to the individual; and (3) contextual affordances, the opportunities provided by the context, in our case, the covid-19 pandemic. with technical affordances, our particular focus is on those technical features that afford social media users to read and share news and information. the platforms provide affordances to explore content as well as an opportunity for individuals to promote themselves or their ideologies or simply have fun. therefore, when looking at the individual affordances, we are concerned with personality factors (i.e. capabilities). religious people might, for example, use social media to share religious news and posts. in contrast, people with low levels of self-regulation may bombard their social media network with content they have given little thought to. with regards to contextual affordances, the covid-19 pandemic gave birth to a new situation with countless news emerging relating to the disease, policies, recommended health measures and various others. accordingly, users were provided contextual affordances to share and comment on this news. the two most significant benefits of using the affordance perspective for social media research: (1) it can provide new perspectives into how social media shapes its users' interactions; and (2) it can help understand how the users' inner needs can shape and regulate social media usage . accordingly, social media affordances are concerned with human-computer interaction and can help understand this relationship. as such, affordances can help understand and then minimise the spread of misinformation. on the other hand, one of the primary outcomes that prior literature highlights from social media use is smf (whelan et al., 2020b) . in order to understand how fatigue is developed, we now turn to clt. clt postulates that the human working memory has a limited capacity, which may be overloaded if presented with too much information (sweller, 2011) . the evolutionary reaction to such situations is to back away and retreat to safer ground (sweller, 2011) . as an example, imagine our ancestors living in a jungle. there is an obvious benefit from tending to go out and explore, such as finding food and resources. however, exploration also leads to unknown territory and situations where humans can no longer predict what will happen next, thus, making the situation potentially perilous. accordingly, retreating to a familiar environment away from potential peril has been a beneficial thing to do. this evolutionary mechanism still affects human behaviour today and is at play, especially when acquiring new knowledge (panksepp, 2013; sweller, 2011) ; also referred to as the human comfort zone. vygotsky theorises that learning happens right outside this zone, the so-called zone of proximal development (shabani et al., 2010) . using vygotsky's zone of proximal development and clt, information overload can be conceptualised to occur when individuals are overwhelmed with too much novel information or are taken too far away a.k.m.n. islam, et al. technological forecasting & social change 159 (2020) 120201 from their comfort zone. accordingly, information overload leads to impulses to step away from the new knowledge, back to the zone of proximal development (shabani et al., 2010) . consequently, in the case of information overload due to new knowledge and information coming from social media, smf emerges (bright et al., 2015) . cognitive load is conceptualised to constitute an intrinsic, extraneous and germane load (sweller, 2010) . the extraneous load has been investigated more often (mutlu-bayraktar et al., 2019) , and in the broader concept of human-computer interaction (hci), refers to the environmental stimuli to which the human brain reacts. intrinsic cognitive load, on the other hand, is the load resulting from processing this information and is affected by the individuals' psychological state of mind as well as their prior knowledge (sweller, 2011) . accordingly, well-structured information and prior expertise of the learner can both reduce intrinsic cognitive load (hollender et al., 2010) . germane load is a subconscious load that results from the working memory transferring information to long-term memory into so-called schemas. the three types of cognitive loads have been theorised to be linked so that reduced load of one kind releases cognitive capacity for the others (paas et al., 2003) . originally introduced as a theory for instructional science, clt has recently been integrated with hci (hollender et al., 2010) , and has been widely successful in explaining human online behaviour such as retention in online courses (mutlu-bayraktar et al., 2019) and the effects of social media use on learning (lau, 2017) . as a theory of learning, clt can also be used to understand how humans acquire knowledge through news articles. accordingly, it is relevant in the ongoing research about fake news and misinformation, especially during times when humans need to absorb new information rapidly and change their behaviour, such as the covid-19 pandemic (laato et al., 2020a) . more specifically, we look at factors, which may affect the intrinsic cognitive load (xiao and mou, 2019) of social media users. xiao and mou (2019) in their literature review found the following intrinsic cognitive load factors to be meaningful in this context: fear of missing out (fomo), privacy concerns, anxiety, and depression. they also revealed extrinsic cognitive load factors such as parental influence, cyberbullying, complexity, technology-related factors, and social overload to be relevant (xiao and mou, 2019) . in order to contribute to this body of literature, we propose that five key factors are yet to be taken into account with regards to intrinsic cognitive load factors (which are also aligned with the affordance perspective as discussed earlier) influencing smf. these are: (1) self-promotion; (2) entertainment; (3) religiosity; (4) deficient self-regulation (ds-r); and (5) exploration. accordingly, we place these as our independent variables and hypothesise relationships to both smf and sharing unverified information. in the next section, we will hypothesise the relationships in further detail. people have an inherent need to belong by seeking approval and recognition from others (zhou, 2011) . social media are a place where this need may be fulfiled via obtaining approval for self in forms of favourable comments and likes. studies have found that people tend to follow different strategies to enhance their image on social media (islam et al., 2019) . for example, people may share information (even private information) on social media to seek relatedness and approval from others (nesi and prinstein, 2015) . using the affordance lens (norman, 1988) , social media can be seen to provide social affordances. with these affordances, social media users actively create and maintain their self-image. islam et al. (2019) conceptualised it as self-promotion and showed it to lead to both subjective vitality and addiction. the relationship between self-promotion and addiction indirectly suggests that in the long run, social media use driven by self-promotion increases fatigue (dhir et al., 2018) . furthermore, when people use social media for self-promotion purposes, they need to actively balance between what to share and what not to in order to maintain a positive image of themselves. this may be increasingly difficult under situations such as the covid-19 pandemic where it is not easy to conceptualise which piece of information is relevant and trustworthy. this creates additional cognitive load, which in turn can lead to smf (whelan et al., 2020b) . thus, we hypothesise the following. h1. self-promotion increases social media fatigue. self-promotion on social media has been linked to narcissism (moon et al., 2016) , but is most primarily driven by a wish to stay connected (kietzmann et al., 2011) . perhaps surprisingly, focusing on others on social media has been found to have negative impacts on psychological wellbeing, whereas focusing on self-image has positive outcomes (vogel and rose, 2016) . the way social comparison on social media decreases wellbeing is that people tend to share only their best aspects online, hiding the negative, thus giving a falsified image to which to compare to (vogel et al., 2014) . thompson et al. (2019) showed status-seeking, which is closely related to self-promotion, to have a significant positive correlation with the intention to share news and information. similar findings have also been shown in previous studies (lee and ma, 2012) . in the context of intra-organisational social media platforms, the primary motivation for sharing information is helping people (vuori and okkonen, 2012) . prior research also suggests that social media users gain social capital through communicating and self-promoting themselves in social media (de zúñiga et al., 2017) . by drawing on the affordance lens, islam et al. (2019) discussed that social media provides the affordances to self-promote and gain social capital by creating an overly positivistic image of the self that appeals to other people. when the individuals' reputation is on the line, they are no longer under the influence of the online disinhibition effect (suler, 2004) and are more mindful of what they are sharing. this may lead them to double-check information sources before sharing news articles. during the covid-19 pandemic, the sharing of reliable information was being emphasised by the media and even social media platforms. thus, we theorise that individuals driven by self-promotion are extra mindful not to share misinformation on covid-19, as that may end up ridiculing them in the case the news they shared was fake. thus, we hypothesise the following. h2. self-promotion decreases the sharing of unverified information. social media has been characterised as a hedonic information system, meaning social media use is driven at least partially by factors such as enjoyment, fun, and entertainment (quan-haase and young, 2010; turel and serenko, 2012; mäntymäki and islam, 2016) . the wish for fun or entertainment materialises, for example, by enjoying funny stories shared to the user's network and making fun of celebrities and political figures (rieger and klimmt, 2019) . while people wishing to inform and help others are concerned with the validity and reliability of the information they share (vuori and okkonen, 2012) , people wishing to have fun may not feel a similar obligation. using the affordance lens (norman, 1988) , we model social media as a multimodal venue, meaning it can be used for entertainment, but also as a place to share and read information. during the covid-19 pandemic, a proportion of information sharing and social media activity was driven by a wish to have fun, often caused by humour as a coping mechanism in stressful situations (chiodo et al., 2020; lee and ma, 2012) , or because humour can be a way to make sense of new information. a study observing covid-19 related tweets on twitter found roughly 6.1% to be written in a humorous tone (kouzy et al., 2020) . while humour itself is a good thing, striving for entertainment as a goal is not concerned with the validity of the shared information as long as the content is funny. accordingly, it is feasible to predict that using social media for entertainment leads to increased sharing of unverified information. thus, we hypothesise the following. h3. entertainment increases the sharing of unverified information. a.k.m.n. islam, et al. technological forecasting & social change 159 (2020) 120201 entertainment can be a way for people to blow off steam after a long workday, and as such, it can be characterised by emotional release, escapism and anxiety relief (lee and ma, 2012) . in particular, emotional release and anxiety relief act as ways to reduce stress and fatigue. by drawing on clt (sweller, 2011) , we argue that entertaining information may provide less cognitive load, as fun and entertainment may relax our mind, and thereby reduce our cognitive load. while social media use can be characterised by several drivers (thompson et al., 2019) , the entertainment aspect of it can be regarded to reduce fatigue. during the covid-19 pandemic, several tweets and social media posts containing humour emerged (kouzy et al., 2020) . some of the content may be regarded unsuitable and being in bad taste, such as the "covid-19 is a boomer-remover" meme (brooke and jackson, 2020) . on the other hand, joking even with such grave topics can be regarded to be a form of coping with the ongoing situation, trying to find humour and lighter sides of it. entertainment or comedy is often political but maybe also otherwise incorrect, possibly even as information. the information that a comedy often provides only serve the goal of provoking and making people think, and as such, is not concerned at all with being accurate. because entertainment can thus be characterised as mindless escapism, anxiety relief and emotional release (lee and ma, 2012) , we propose the following hypothesis. h4. entertainment decreases social media fatigue. exploration has been defined as "appetitive strivings for novelty and challenge" (kashdan et al., 2004) . in the context of social media use, exploration refers to individuals' desire to go through the information, glance at novel topics and engage with new content. as such, it is linked to curiosity and courage, but also a more precise need to dig into available information (kashdan et al., 2004) . exploration as a concept is also related to novelty-seeking, which is a personality trait that varies between people. most typically, novelty-seeking is classified from low to high, meaning all people possess novelty-seeking to some degree (bardo et al., 1996) . the most important brain chemical for regulating exploration and novelty-seeking is dopamine (dulawa et al., 1999) . exploration may also be understood via clt (sweller, 2011) in that reduced cognitive load leads to increased exploration, as the primal neurofunctional seeking system activates (panksepp, 2013) . while exploration itself may lead to seeing increased quantities of information, the seeking of this information is voluntary and under the regulation of the user (panksepp, 2013) . building off clt (sweller, 2011) , the trait of exploration functions when people are not overloaded by information and have the cognitive capacity to seek more. while information overload has been found to increase the sharing of unverified information (laato et al., 2020a) , the lack of experiencing information overload, therefore, reduces unverified information sharing. as exploration and tertiary level information overload are regulated by the same primal seeking system (sweller, 2011; panksepp, 2013) , we conclude that exploration is associated with the ability to process information. in practice, this manifests in the ability to process new information as well as seek verification for news. exploration should thus have a negative impact on unverified information sharing. therefore, we hypothesise the following. h5. exploration decreases the sharing of unverified information. as exploration is connected to a primal desire to seek new content (kashdan et al., 2004) , it may manifest as increased use of social media. social media, on the other hand, is addictive (islam et al., 2019) . through addiction, exploration may impact fatigue in two ways: (1) social media users do not have sufficient time to take care of their duties related to work or family, which may increase their cognitive load. in turn, this may increase fatigue; (2) social media users are exposed to a large quantity of information, which can cause information overload, which in turn, leads to fatigue (islam et al., 2018) . during the covid-19 pandemic, as people were more at home due to government-issued limitations on movement and several workplaces closing down (farooq et al., 2020) , people had more time on their hands to explore and use social media (laato et al., 2020a) . furthermore, the novelty of the pandemic situation brought a plethora of information to social media, opening new doors for exploration. these circumstances may contribute to increased smf via increased social media use. accordingly, we hypothesise the following. h6. exploration increases social media fatigue. the positive effects of faith and religiosity have been controversial topics in academia in the current millennium with famous works having been published arguing against (hitchens, 2008) and for (mcgrath, 2013) the usefulness of religion. the complexity of religion can understand the broad spectrum of conceptualisations of religion as a phenomenon. religion has several levels: cognitive, affective, pragmatic and social. religion can serve, at all these levels, an individual, a social group, a broader community -and the community might be a religious community or a profane community using religion as an organising, constitutive or power structure -or a nation. thus, religion can define identity in its diverse forms, for example as a cognitively expressed confession of the vital dogma of one's faith, or one belongs to a group of believers that share the same faith. therefore, also the usefulness of religion has diverse interpretations, depending on the expected function and role of a given religion. should it serve an individual, their psychological integrity, sense of belongingness, meaning of life, or should religiosity support a religious community and the enforcement of the law in society? following khalaf et al. (2014) , we define religiosity as an intrinsic motivation to practise religion. the complexity of religiosity has consequences to the concepts of information, knowledge and truth, and their verifiability, thus, it may be understood through the clt (sweller, 2011) . religious people might be more sensitive to information that would refer to divine intervention; a thing that is hard to verify. at the same time, religious truth is very often unverified per se. the confirmation bias that may result from having strong religious viewpoints could cause an increase in sharing information that is regarded by the public as misinformation . accordingly, religiosity could be linked to the sharing of unverified information. thus, we hypothesise the following. h7. religiosity increases the sharing of unverified information. campbell (2012) emphasises the role of community for the expression of and living out personal faith. instead of broadcasting or streaming religious events, called "online religion", she emphasises the transformation of religion by technology, i.e., "religion online". social media provides affordances for religion online and offers a platform for synchronised and asynchronous communication. it enables religious people to interact even amidst pandemics where meeting in real life is discouraged. religious people can form online communities on social media, where they primarily share the news that is written from the viewpoint of their religion. being able to read the information that is built on a shared core belief system can reduce cognitive load and make reading news less stressful (sweller, 2011) . this may decrease smf. additionally, religiosity is often associated with discipline and weekly (or daily) routines such as prayers. this may ward against overconsumption of social media, which has been identified as the primary cause for smf (dhir et al., 2018) . this may have been particularly relevant during covid-19 where recommended social isolation measures caused people to spend an increasing amount of time at home and gave them more time to overload on social media content (laato et al., 2020a) . taking these two points together, we propose the following hypothesis. h8. religiosity decreases social media fatigue. people suffering from ds-r have trouble regulating their actions. as such, they are more susceptible to acting based on impulses or habits a.k.m.n. islam, et al. technological forecasting & social change 159 (2020) 120201 rather than planned behaviour and cognition . because of this, ds-r is connected to (1) irresponsible, and sub-optimal behaviour; and (2) decreased psychological wellbeing; (3) internet addiction (laato et al., 2020a; larose et al., 2003; lee and perry, 2004) amongst other harmful things. because ds-r leads to internet addiction (larose et al., 2003) , it can also contribute to increased social media usage. the covid-19 pandemic forced people off their routines to adopt health measures such as social isolation (laato et al., 2020b) and in many cases, remote working (barbieri et al., 2020) . covid-19 also caused significant unemployment (coibion et al., 2020) . the lack of routines hit people with poor self-regulation hard, as they have no compulsory or agreed activities guiding their time use. with social media platforms, providing hedonistic instant gratification (mäntymäki and islam, 2016) , we propose that the covid-19 pandemic may have amplified the effects of ds-r and even increased experiencing ds-r. the likely increase in social media use during covid-19 because of ds-r can contribute to smf via two mechanisms: (1) more time spent on social media leads to higher cognitive load in terms of information and communication overload; (2) more time spent on social media takes time away from other more meaningful activities. furthermore, the lack of regulation on behaviour will increase the probability of sharing news articles even when one really should not. accordingly, we propose two hypotheses. h9. deficient self-regulation increases the sharing of unverified information. h10. deficient self-regulation increases social media fatigue. as our last relationship, we investigate the connection between smf and the sharing of unverified information. conceptualising smf to be driven by communication and information overload (bright et al., 2015) we can use clt to understand this relationship. people experiencing communication and information overload have less cognitive resources at their disposal, which hinders their ability to verify the information they encounter. furthermore, the positive impact of smf on fake news sharing has been empirically demonstrated in previous work (talwar et al., 2019) . however, on the other hand, smf also leads people away from social media and its active use. these two phenomena may counter each other to an extent. however, talwar et al. (2019) argue that fatigued social media users do not disengage from using social media, but instead change their behaviour. using the clt, we predict this change of behaviour to be in accordance with reducing cognitive load. accordingly, it is highly possible that fatigued users do not go through extra trouble such as verifying the sources of information they encounter, which in turn may lead to an increase in sharing unverified information. thus, we postulate our final hypothesis. the overall proposed research model is displayed in fig. 1 . the five independent variables: (1) self-promotion; (2) entertainment; (3) religiosity; (4) ds-r; and (5) exploration are all shown connections to both smf and sharing unverified information. the direct relationship between smf and unverified information sharing is also visible. next, we present our methodology and study context for testing the proposed model. our study concentrates on social media users from bangladesh in april 2020, during which the covid-19 pandemic was causing severe restrictions and limitations on citizens' lives and mobility . bangladesh is a country in south asia, which has a population of approximately 160 million people. around 62% of the people have access to the internet, and around 20% use social media. 1 the most popular social media platforms are facebook and youtube, followed by reddit, instagram, twitter and tiktok. the covid-19 pandemic arrived in bangladesh officially on march 8th when the first three cases were reported. this caused governments to take action placing infected areas into quarantine and enforcing it by law. 2 furthermore, the government closed all educational institutes and public services and advised citizens to stay home and avoid social contact, i.e. adopt personal voluntary health measures. we collected data from bangladeshi social media users during april 2020 through an online survey drafted using an online survey software called webropol. we adapted validated scales from prior literature for all constructs in our theorised model. after drafting the initial questionnaire, three researchers were asked to carefully look through the survey and the items to ensure they were grammatically correct and made sense in the current study context. according to received suggestions, we made changes to improve the understandability of the items and fixed a few grammar errors. after that, we asked 9 bangladeshi social media users to comment on the overall final questionnaire in terms of how easy or difficult the questions were to understand and respond to. we received a few minor suggestions at this stage, which were taken into account. the final survey items and their source are listed in appendix 1. before presenting the respondents with the items to measure unverified information sharing, we described the following to clarify the context: "via the following questions, we ask you about your information sharing on social media (e.g. facebook, twitter, linkedin instagram) during the covid-19 pandemic". similarly, before asking about smf, self-promotion, ds-r, and entertainment, we explained the following: "via the following questions, we ask you about your use of social media (e.g. facebook, twitter, linkedin, instagram) during the last two weeks". we posted the survey link to two major covid-19 related facebook groups, which both had more than 10,000 members. furthermore, we asked students and alumni of a major private university in bangladesh to respond to the survey. the survey was opened 1305 times, 565 started responding, and 435 respondents completed the survey in full and submitted their responses. we removed two responses due to missing data. therefore, 433 responses were used to test our research model. out of the respondents, 62% were male, 37% were female, and 1% were other or preferred not to tell. the most popular social media platforms among the respondents were facebook (94%), youtube (79%) and instagram (69%) followed by snapchat, linkedin, twitter, reddit and tiktok. the majority of respondents were young, aged 18-25 (83,45%), followed by the age groups of 26-35 (14,25%), 36-50 (1,84%) and 51-64 (0,23%). the proposed research model was tested via a two-staged analysis approach. at the first stage, pls-sem technique was utilised to confirm the reliability, the validity of the constructs and test the causal relationships between the constructs. we followed this analysis with a neural network (nn) based approach. pls-sem is an analysis technique for evaluating relations between various independent and dependant 1 internet world stats usage and population statistics, https://www. internetworldstats.com/stats3.htm#asia, (accessed on april 24th 2020). 2 corona info bd, iedcr. https://corona.gov.bd/ (accessed on april 23rd, 2020). a.k.m.n. islam, et al. technological forecasting & social change 159 (2020) 120201 variables and is commonly used for understanding relationships between constructs in cross-sectional data. however, pls-sem cannot examine the non-linear relationships between constructs. to address this issue, we supplemented the pls-sem analysis with the nn approach. to summarise, pls-sem was used to evaluate the hypotheses shown in fig. 1 , while in the second stage, the nn was used to validate the findings of the pls-sem results, and also to prioritise predictors based on their relative importance in influencing smf and unverified information sharing. before moving to use the pls-sem and nn as analysis techniques, we tested multivariate assumptions and the validity and reliability of our data following the guidelines of wong et al. (2016) and fornell and larker (1981) . we first conducted several statistical tests to ensure that our data fulfils the multivariate assumptions for further statistical analysis (wong et al., 2016) . to ensure normality, at first, we tested our data for skewness and kurtosis in spss. all values were within −2.58 to + 2.58, and therefore, we conclude that the data is normally distributed. next, we tested the linearity of the associations between constructs. the test results (see appendix 2) showed that the predictor and target construct have a combination of linear and non-linear relationships. due to the existence of non-linear relationships, the nn approach is necessary to complement the pls-sem results (chong 2013) . third, the values of variance inflation factor (vif) were calculated (hair et al., 2010) . all values were less than 3, which is a widely accepted vif threshold (o'brien, 2007) . it was, therefore concluded that there was no question of multicollinearity with the data (tan et al., 2014) . finally, scatter plots were generated to ensure homoscedasticity (white, 1980; ooi et al., 2018) . we looked at the regression standardised residuals of all our relationships and found them to be equally distanced from the regression line. it was therefore assumed that the presumption of homoscedasticity was fulfiled. before continuing to test our model results using the sem technique, we checked the validity and reliability of our data. to this end, first, we verified the internal consistencies and convergent validity of the data. the thresholds recommended by fornell and larker (1981) were selected, meaning each item loading was to be above 0.7, construct composite reliability (cr) was to be above 0.8. the average variance extracted (ave) had to be above 0.5. as shown in appendix 1, all items (except three religiosity items) had loadings higher than 0.7. we removed those three items that did not match the criterion. furthermore, we ensured that crs were above 0.8, and aves were above 0.5 (fornell and larker, 1981) . next, we verified the discriminant validity of our data by using the correlation matrix and square roots of aves. table 1 shows the correlation matrix. from this table, we see that the inter-construct correlations were less than the diagonally presented square roots of the aves. furthermore, we verified the loadings and cross-loadings and observed that the loadings were consistently higher than cross-loadings. these tests ensured that we achieved sufficient discriminant validity. common method bias (cmb) is a problem in studies that use selfreported survey data. it refers to the variance caused by the survey method (podsakoff et al., 2003) . to address this issue, we conducted harman's single factor test (harman 1976) . the findings of our analysis islam, et al. technological forecasting & social change 159 (2020) 120201 showed that 31.39% of the total variation was due to a single construct, which is well below the required 50% (podsakoff et al., 2003) . we revalidated cmb with other methods, owing to increasing disagreements with the validity of harman's single-factor test (lowry and gaskin 2014) . following the guidelines of liang et al. (2007) , we proceeded to conduct the common method factor test. we did this using the smartpls software by re-using all our items to create a common method factor. we then calculated the variances for each item as explained by the created common method factor and our actual factors in the pls model. the average variance explained by the method factor delivered the average of 0.01 and the average variance explained by the assigned factors gave the average of 0.48. as the method variance was minimal (0.01), we concluded that common method bias was not an issue for our operationalisation and data. machine learning methods producing a neural network have been used to support pls-sem analysis (chan and chong, 2012; chong, 2013; talukder et al., 2020) . the main advantage of supplementing sem with a neural network-based analysis is that it is capable of addressing non-linearity in data (chong, 2013) . some studies have also reported that even with relatively small amounts of data 100<n<500 the predictive accuracy of neural network analysis can be better than sem (sharma et al., 2016) . in this study, we created two anns using the feedback propagation multilayer perceptron (mlp) analysis, which has been successfully used in recent studies to supplement pls-sem analysis results (e.g. khayer et al., 2020; talukder et al., 2020) . for building the anns, we used the spss 23.0 software package with the neural network add-on module. accordingly, we decomposed the sem model ( fig. 1) into two sub-models (appendix 3.1 & 3.2) to prepare the model for ann analysis. model a (see appendix 3.1) has five input layers, and each layer is represented by factors namely self-promotion, entertainment, exploration, religiosity, and dsr and one output layer presented by smf. model b (see appendix 3.2) has six input layers representing independent variables, namely, self-promotion, entertainment, exploration, religiosity, dsr, smf, and unverified information sharing representing the output layer. the average cross-validated rmse (root mean square of error) for the training and testing model was obtained by using a 10-fold crossvalidation algorithm (chong 2013) . the architecture of the network was such that we used 80% of the data to train the neural network, and the remaining 20% was used to test the trained model in terms of its predictive accuracy. we analysed both model a and b (see appendix 4). for model a, our analysis showed the average rmse for the training to be 0.196 and for the testing 0.217. we did the same test for model b, and the resulting rmse for training was 0.207 and for testing was 0.255. the results of the pls-sem analysis are displayed in fig. 2 . selfpromotion (beta = 0.00, t = 0.25) had a non-significant effect on smf, therefore, h1 was not supported. in contrast to h2, we observed that self-promotion (beta = 0.17, t = 3.51) had a positive influence on unverified information sharing. h3 was supported, as entertainment (beta = 0.12, t = 2.82) had a positive effect on unverified information sharing. h4 was also supported as entertainment (beta = −0.10, t = 1.98) had a significant negative impact on smf. exploration (beta = −0.22, t = 4.66) had a negative impact on unverified information sharing and a positive effect on smf (beta = 0.22, t = 4.15). therefore, both h5 and h6 were supported. religiosity (beta = −0.08, t = 1.97) had a significant negative effect on unverified information sharing. therefore, h7 was supported. however, h8 was not supported, as it (beta = 0.00, t = 0.06) had a non-significant effect on smf. h9 and h10 were both supported as deficient self-regulation (beta = 0.23, t = 4.14) had a significant effect on unverified information sharing and smf (beta = 0.48, t = 10.72). finally, h11 was also supported as smf (beta = 0.08, t = 1.98) had a significant effect on unverified information sharing. in summary, seven hypotheses were supported out of 11 hypothesised relationships. the average importance and average normalised importance of each input variable in predicting unverified information sharing and smf are depicted in tables 2 and 3. from table 2 , ds-r is the most critical predictor followed by exploration, self-promotion, religiosity, smf, and entertainment in predicting unverified information sharing. it can be observed from table 3 that dsr is the most critical predictor followed by exploration and entertainment in predicting smf. this section compares the findings of the pls-sem analysis and the neural network analysis (see tables 2 and 3 ). table 2 shows that there are some significant differences regarding the importance of individual predictors among pls-sem and neural network results in predicting unverified information sharing. for example, exploration was the second most important predictor in the pls-sem model, whereas in the nn model, self-promotion was the second most important. such differences in the results of two different methods highlight the advantage of using a machine learning technique such as the neural network (chong 2013) . the results provide practitioners with further insights into the relative importance of predictors in describing unverified information sharing. however, we did not notice any differences when predicting smf (see table 3 ). we summarise our key findings as follows. we found that smf, self-promotion, entertainment, exploration, ds-r, and religiosity all predicted unverified covid-19 information sharing on social media. among these constructs, particularly ds-r, exploration and self-promotion, had the most substantial effects. the impact of ds-r and self-promotion was positive, whereas the effect of exploration was negative. it was interesting to observe that all other factors had marginal influences on unverified information sharing. therefore, our paper identified additional factors that impact covid-19 misinformation sharing than what have been previously found by laato et al. (2020a) . in particular, laato et al. (2020a) found that information related factors (online information trust and information overload) are the main factors. in contrast, we found that ds-r, exploration, and selfpromotion are the most critical factors that drive unverified information sharing. we also note that ds-r and self-promotion have often been linked to negative consequences such as addiction (islam et al., 2019) and even reluctance to adopt recommended health measured during covid-19 (laato et al., 2020b) . our findings corroborate these findings and show that these factors may also lead to misinformation sharing. it was interesting to observe that the relative importance of the predictors varied between pls-sem and nn models. as we detected some non-linearity in our data, we think that the nn model provides a more accurate view of our results. among the predictors of smf, we observe ds-r to be the strongest predictor followed by exploration. entertainment has a marginal negative impact on smf, which implies that sharing entertaining information helps users deal with smf to some extent. based on prior a.k.m.n. islam, et al. technological forecasting & social change 159 (2020) 120201 literature (e.g., lee et al., 2016; xiao and mou, 2019) , perhaps the two most important factors that lead to smf are information and communication overload. these two factors are also included in the definition of smf by bright et al. (2015) . in contrast to these studies, our paper identified additional factors (particularly personal attributes) such as ds-r and exploration as the most important predictors of smf. these findings were supported in the current study by both pls-sem and nn approaches. our paper contributes to the literature on misinformation by identifying several factors that affect unverified information sharing. we contribute to the prior literature by identifying the positive effects of smf, self-promotion, ds-r and entertainment on unverified information sharing. we also show that exploration and religiosity had negative effects on unverified information sharing. with these novel findings, we extend the literature on misinformation sharing (e.g. chadwick and vaccari, 2019; del vicario et al., 2016; dhir et al., 2018; laato et al., 2020a; nekmat, 2020) . we observe that exploration and religiosity have a negative influence on unverified information sharing. this implies that these two constructs can be thought of coping strategies of individuals that help them to refrain from sharing unverified information on social media. to the best of our knowledge, these two relationships are never investigated in prior literature on misinformation sharing. ds-r has been linked with poor academic performance and cognitive overload in prior literature . also, we show that it may be a significant reason why people share unverified information about covid-19. smf has been linked with fake news sharing by talwar et al. (2019) . in this sense, our paper reinforces their findings by showing smf led to unverified information sharing also during the covid-19 infodemic. the impact of self-promotion has been suggested to have dual consequences (e.g. islam et al., 2019) . this implies that self-promotion may lead to both positive consequences like psychological wellbeing and negative consequences like social media addiction. our study adds to this body of research by showing that selfpromotion may also promote unverified information sharing on social media. it may be that entertainment, memes or sarcastic political news or information may be shared more often than others. in this regard, we show that false news on covid-19 is partially propagated on social media due to the entertainment aspect of the news or information. our finding that entertainment increases sharing fake news contradicts previous studies, which have shown no relationship between intention to share news and entertainment (lee and ma, 2012; thompson et al., 2019) . our paper contributes to the smf literature (whelan et al., 2020b; xiao and mou, 2019) in general by identifying additional predictors. prior literature found information overload, communication overload, and social overload to be the key factors leading to smf (whelan et al., 2020b) . therefore, our results contribute to this body of literature by showing that ds-r, entertainment and exploration are additional significant predictors of smf. we note that while ds-r and exploration had positive effects, sharing entertaining news or information related to covid-19 had negative effects on fatigue, meaning that it helped reduce smf. the effect of exploration is particularly interesting as it has a .k.m.n. islam, et al. technological forecasting & social change 159 (2020) 120201 positive effect on smf, but a negative effect on unverified information sharing. this implies that although exploration as a coping strategy refrains users from sharing unverified information, it may increase users' cognitive load and subsequently increase fatigue. previous studies on smf were found to be disjointed (bright et al., 2015; cao et al., 2019; dhir et al., 2018 dhir et al., , 2019 xiao and mou, 2019) in terms of used theory, causal relationships and even the definition of smf. in this work, we adopted clt an overarching theory to explain smf as proposed by also earlier work (bright et al., 2015; islam et al., 2018) . we contribute to current smf literature by showing that clt may be useful in bringing clarity to particularly causality issues presented in previous work (e.g. cao et al., 2019; dhir et al., 2018 and dhir et al., 2019) . clt can also be a theory, which unites our findings to the plethora of previous work on smf (xiao and mou, 2019) . furthermore, by using clt and the affordance lens, we expanded on the relationship between smf and fake news sharing, which was brought up by talwar et al. (2019) . we demonstrated the complexity of this relationship by showing the impacts of five related independent variables on both. from a methodological point of view, we have combined the pls-sem and nn based approaches and shown that the importance of the factors in predicting the dependant variables may vary. therefore, our study highlights the importance of combining multiple methodological approaches and as such, echo the recommendations of prior literature (chong 2013; khayer et al., 2020; talukder et al., 2020) . the dissemination of unverified information has been showcased as a significant challenge during the covid-19 pandemic (laato et al., 2020a) . the role of social media in this process is exemplified by its increased use during covid-19, as, for example, a recent report shows that the use of facebook hit record levels during the pandemic. 3 our findings can help bring clarity to this situation, providing knowledge that can help designers, social media platform developers and policymakers who wish to combat the spread of fake news in social media. in this regard, based on our findings, we propose four suggestions related to social media affordances which can curb the spreading of misinformation: • encourage exploration by, for example, providing social media affordances for looking up news sources and highlighting them, as suggested by previous studies nekmat, 2020) . however, at the same time, we note that this may also lead to smf. therefore, the service providers need to understand the delicate balance when they design tools and services that scaffold exploration. • provide social media users support for regulating behaviour. ds-r was a significant predictor of unverified information sharing. it was ranked as the most critical predictor in both pls and ann analysis. following the nudge approach , displaying users their screen time could provide awareness of how long they have been using their device, and may consequently lead to more regulated behaviour with regards to social media. however, future work on this topic is needed. • we highlight a need for socio-cultural change in handling information on social media. for example, we suggest that social media users refrain from sharing unverified information just to improve their self-image or for entertainment. they need to consider that fake news can destroy their positive image. furthermore, we also think that social media users should retract or delete their posts immediately in case they identify that the information they have shared is fake. in addition to these three points, other strategies have been identified in previous work, which seem highly relevant. one of them is information overload and information entropy, which have risen from previous work using clt to understand misinformation sharing (e.g. farooq et al., 2020; laato et al., 2020a) . information overload is also highly relevant for smf . guarding against information overload, people free cognitive capacity for better-conceptualising information and making sense of it, which can reduce fake news sharing (laato et al., 2020a; sweller, 2011) . several fake news reports emerged during covid-19, some of which caused people to take unwanted action such as destroying 5 g cellular network towers . our findings can be used to devise intervention strategies for curbing the spread of misinformation and consequently enable people to behave more optimally and harmoniously during situations such as covid-19. we found several constructs connected to social media use which increase the sharing of misinformation. previous work nekmat, 2020) suggest that nudging people to pay attention to news sources is one way to reduce the spread of misinformation. while these are effective, our findings highlight another route for addressing the situation by focusing on social media use habits. most importantly, we argue that impulsive action should be avoided as our results show smf and factors leading to it, such as ds-r correlate positively with misinformation sharing. furthermore, we found that social media is being used for much more than information sharing, including self-promotion and entertainment, which in turn increased the sharing of unverified information during the covid-19 pandemic. this calls into question whether it is wise for social media to mix a variety of use purposes such as entertainment and self-promotion with information sharing. as a personal solution to avoid spreading fake news, besides being sceptical about the information on social media, we suggest reducing the time spent on social media and reading news from more rigorous and trustworthy sources. our study has theoretical as well as methodological limitations, which deserve to be disclosed and discussed. first, using clt as an overarching theory might be regarded limiting even though it has been adopted in previous studies on social media (e.g. bright et al., 2015; islam et al., 2018) . the main concern is that clt is still primarily a theory of instructional science (sweller, 2011) . even though it has been adopted, used widely in hci (hollender et al., 2010) and also shown promise to explain not only learning but also acquiring knowledge from news articles; other theories might be more useful for conceptualising smf and fake news sharing. additionally, we chose factors by looking at previous studies and noticing gaps in prior literature. accordingly, our results with regards to fake news sharing, as well as smf, need to be understood as complementary to prior studies (e.g. dhir et al., 2018; islam et al., 2019; laato et al., 2020a; talwar et al., 2019; and xiao and mou, 2019) and not as a full model explaining all possible factors. we encourage future research into smf and fake news sharing to focus on uniting currently disjointed findings. with regards to data collection, we collected cross-sectional responses from bangladeshi social media users during the covid-19 pandemic in april 2020. while we ensured the validity and reliability of our data, some geographical, cultural and contextual specificity may be introduced in the outcome. furthermore, the results did not take into account any possible change over time, as the structural model was tested solely on cross-sectional data. to combat these issues, we used a multi-method approach analysing the data with pls-sem and an ann. while the rank of importance on smf was the same on both analysis, with regards to fake news sharing, we saw some difference. thus, our results encourage future research to adopt multi-method approaches when possible to ensure the reliability of the results. due to collecting data primarily among young adults, our results may contain some bias. furthermore, our sample consisted of muslims, and the religiosity measure might be different for other religions. these limitations may be addressed in future work by comparative studies. we also note that the early stages of the covid-19 pandemic may have introduced factors that were not accounted for in the current study. these include factors such as internal fears or panic disorder. therefore, future research may take these factors into account in modelling smf and misinformation sharing. future work on this domain should focus on the theory of smf, as we found discrepancies among previous studies, in particular with regards to the causality of relationships (e.g. cao et al., 2019; dhir et al., 2019) . we also encourage research into the impacts of intervention strategies, which aim to reduce fake news sharing. here we identified three practical avenues: (1) encouraging exploration and directing social media users' attention towards news sources; (2) encouraging users' self-regulation in social media use; and (3) scaffolding a socio-cultural change towards the sharing of fake news as being something to be ashamed of. our results further demonstrated that the various use purposes of social media have an impact on fake news sharing. in particular, people driven by entertainment, for example, do not seem to be equally concerned about the reliability of the information they share on social media. we encourage further research into the different use purposes of social media (entertainment, self-promotion, information sharing) and their impact on the sharing of misinformation. appendix 1. measurement items, loadings. religiosity ( defining and measuring fatigue covid-19 and the 5g conspiracy theory: social network analysis of twitter data social media and fake news in the 2016 election social media, political polarization, and political disinformation: a review of the scientific literature italian workers at risk during the covid-19 epidemic psychobiology of novelty seeking and drug seeking behavior too much facebook? an exploratory examination of social media fatigue older people and covid-19: isolation, risk and ageism 2012. digital religion: understanding religious practice in new media worlds. routledge the 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sem-neural network approach why do people share fake news? associations between the dark side of social media use and fake news sharing behavior predicting the drivers of behavioral intention to use mobile learning: a hybrid sem-neural networks approach determinants of news sharing behavior on social media the benefits and dangers of enjoyment with social networking websites infodemic and risk communication in the era of cov-19 polarization and fake news: early warning of potential misinformation targets social comparison, social media, and self-esteem self-reflection and interpersonal connection: making the most of self-presentation on social media knowledge sharing motivational factors of using an intraorganizational social media platform is this the era of misinformation yet: combining social bots and fake news to deceive the masses applying the sobc paradigm to explain how social media overload affects academic performance is boredom proneness related to social media overload and fatigue? a stress-strain-outcome approach a heteroskedasticity-consistent covariance matrix estimator and a direct test for heteroskedasticity can mobile tv be a new revolution in the television industry? social media fatigue-technological antecedents and the moderating roles of personality traits: the case of wechat how to fight an infodemic understanding online community user participation: a social influence perspective key: cord-033481-3kxi7fd9 authors: baker, joseph o; martí, gerardo; braunstein, ruth; whitehead, andrew l; yukich, grace title: religion in the age of social distancing: how covid-19 presents new directions for research date: 2020-09-16 journal: sociol relig doi: 10.1093/socrel/sraa039 sha: doc_id: 33481 cord_uid: 3kxi7fd9 in this brief note written during a global pandemic, we consider some of the important ways this historical moment is altering the religious landscape, aiming our investigative lens at how religious institutions, congregations, and individuals are affected by the social changes produced by covid-19. this unprecedented time prompts scholars of religion to reflect on how to strategically approach the study of religion in the time of “social distancing,” as well as moving forward. particularly important considerations include developing heuristic, innovative approaches for revealing ongoing changes to religion, as well as how religion continues to structure social life across a wide range of contexts, from the most intimate and personal to the most public and global. although our note can only be indicative rather than exhaustive, we do suggest that the initial groundwork for reconsiderations might productively focus on several key analytical themes, including: epidemiology, ideology, religious practice, religious organizations and institutions, as well as epistemology and methodology. in offering these considerations as a starting point, we remain aware (and hopeful) that inventive and unanticipated approaches will also emerge. as we write this, the world remains mired in a global pandemic, with the rates of infection from a novel coronavirus continuing to rise. covid-19 is still a new and inadequately understood upper respiratory infectious disease, with a rate of mortality that is high enough to have killed over 500,000 people to date globally. with delays in testing in some locations and insufficient knowledge, official estimates are still being corrected; nevertheless, the spike of known infections in march of 2020 moved national governments around the world to close businesses, places of worship, and schools-essentially, any arena where people gathered in substantial numbers. by the end of april, the united states alone had reported over one million cases of covid-19, and by the end of may, amidst the accumulation of infections, mortality in the united states reached a grim milestone of 100,000 deaths. by the time this paper is published, infections and deaths in the united states and elsewhere will not just be higher. they will be significantly higher. in this brief note, we consider some of the ways that the global pandemic is altering the religious landscape, aiming our investigative lens to how religious institutions, congregations, and individuals are responding to the social changes wrought by . where should our analytical attention be focused? the ongoing coronavirus pandemic, the related public health measures taken to mitigate the spread of the disease, and the varied public responses to the virus have far-reaching social implications. religious institutions, communities, practices, beliefs, and identities present a particularly rich area for social scientific study, especially given the centrality of face-to-face and intimate gatherings typically associated with nearly all religious practices and traditions. further, the death and mourning wrought by a pandemic would typically result in an increase in face-to-face gatherings and religious rituals; but given the need for social distancing and the necessity of adapting interaction to these constraints, the pandemic is triggering an increased need for religious traditions while at the same time significantly altering the expressions of those traditions. how religious institutions manage death and mourning-two of the social moments religious leaders and institutions are most central to during normal times-is a strategic location for viewing some of the ongoing changes to religion. in this we can see how the "demand" for religious ritual, comfort, and support is presumably increased by the pandemic, while simultaneously the "available supply" of religion (in the form it is expected) is drastically decreased. so too the changes to levels of existential risk and the associated patterns of social engagement brought about by the pandemic offer social scientists numerous opportunities to explore important theoretical and practical questions regarding how conditions of change and uncertainty relate to private religious beliefs and practices. while the health risks of debilitation and death draw immediate attention, controversy rages on about how to handle the threat of covid-19. among the most basic points of dispute is the economy. the segregation of health issues into doctors' offices and hospitals, the relative isolation of severe illnesses, and the fact that the majority of people are either asymptomatic or as yet unaffected by the virus have prompted much attention on the economic impact of local, state, and federal governmental responses to the pandemic. for months, the slowing of the economy due to the sanctions on in-person gatherings and mandates to shelterin-place has resulted in millions of people being financially affected by closings, furloughs, and layoffs, with sharp increases in unemployment. immense pressure exists to "re-open the economy" out of a desperation to keep businesses running and to re-hire workers, with the use of "phases" to indicate the types of activities that could result (i.e., 1: bare essentials of food, health, and utilities; 2: limits on room capacity and enforced social distancing; 3: continued sanitization and expansion of social boundaries). the wearing of masks has been strongly encouraged, although selectively enforced and inconsistently modeled by political leaders. and mainstream news and various social media sources often add to polarization and obfuscation about re-opening the economy, resulting in decidedly split judgments on which experts are valid, which solutions are viable, and which practices are needed to address the pandemic. likewise, calls to re-open the economy have been interwoven with demands to re-open churches, and restrictions on in-person gatherings that have limited religious services have been opposed as limiting "essential" social services, and hence as an infringement of religious liberty. the pandemic raises a number of important analytical considerations for researchers, from intra-individual and interactive, to larger organizational and cross-national implications. at a minimum, religion scholars will want to pay attention to how religious professionals have altered their leadership to accommodate social distancing, switching to a largely remote working environment. while the social spaces of many congregational leaders are shrinking considerably, other religious professionals have been called upon to play expanded roles. for instance, chaplains "usually do [their] work quietly, around the margins. but with the pandemic, their work has moved to the center of the american religious experience" (cadge 2020) . however, perhaps a broader re-imagining is possible in this moment. just as the circumstances surrounding the pandemic have caused many people to rethink such systemic issues as racial inequality, health care provision, and the role of education in a thriving society, the mandated "pause" might allow religion scholars the time and space to more thoroughly revamp the study of religion in the twenty-first century, and to develop innovative approaches to understanding how religion continues to shape people's lives (see figure 1 ). one critical way religious institutions and individuals will be central to analyses of the pandemic is as an "independent variable" (smilde and may 2015) , including as a vector of disease transmission (conger et al. 2020 ). multiple instances have been documented of religious gatherings operating as "superspreading events," including cases in washington (hamner et al. 2020) , oregon (cline 2020), california (bizjak et al. 2020) , arkansas , and west virginia (nazaryan 2020) in the u.s. religious gatherings have also been identified as important sites of virus transmission in germany (boston 2020) and south korea (shin et al. 2020) . while most congregations followed state orders to close, some resisted such orders, staying open and risking arrest. still others innovated by developing "drive-in" church services that likely still posed some dangers to the health of attendees. the centrality of intensive interactive rituals for producing the communal benefits of religion (e.g., social support, emotional catharsis, perceived healing) ensures that there will be persistent tension between many religious groups' desire for in-person gatherings and the social distancing requirements necessary to limit the spread of covid-19. to the extent that religious individuals and their related groups believe in-person collective experiences are essential to their religiosity, social identity, and well-being, they may continue in-person gathering to the limits of (or even beyond) social distancing policies. at the same time, social connections among members within congregations may lead to the urging of doctor visits, care for symptoms as they emerge, and practical assistance for medical bills, making congregational participation a potentially important factor in treating and overcoming disease (see benjamins et al. 2011) . a central consideration on this topic is the extent to which different religious traditions and worldviews emphasize particular orientations, such as individualistic versus collectivist orientations, care for the vulnerable, and neoliberal economics. sorting out the different ways that religion relates to the spread of disease and care for the sick stands as an opportunity for researchers in the field of religion and health to contribute to the wider body of knowledge about the pandemic. although religion is never truly an "independent variable" because of its historical and ongoing relationship to other facets of social life, particularly race/ethnicity, social class, and gender (wilde 2018) , it is nonetheless critical to investigate and document how religion influences behavioral patterns that are directly related to disease transmission and mitigation. likewise, in the case of the united states, the reciprocal and intensifying relationship between religion and partisanship ensures that (margolis 2018) , to the extent that public policies and actions toward covid-19 are politicized, religion is a critical consideration for a full understanding of social distancing actions (or inactions). religion will also likely be assessed as a complex system of beliefs that are shared and contested. a key consideration here is religion and science, for which a number of issues are immediately notable for both quantitative and qualitative study. central among these are whether and how religious identity, beliefs, and practices relate to behaviors undertaken (or avoided) in response to social distancing requirements, such as avoiding gatherings, vaccine hesitancy, or wearing face masks, to name but a few. for example, wearing masks has become figure 1. topics for researchers of religion to consider in relation to the covid-19 pandemic. a strong point of contention, with some insisting that masks are ineffective and unnecessary (as long as one has enough faith and courage). those who refuse to wear masks include many who believe mask wearing bows to the dictate of "the state," and therefore restricts a person's god-given freedom. coupled with this, many believe that mask wearing bows to the dictates of science, which is viewed as unreliable, especially in contrast to the strength of one's own spiritual devotion for providing unseen, and therefore miraculous, protection. already, there is evidence emerging that religious views are consequentially connected to following (or ignoring) such social distancing practices (hill et al., forthcoming; perry et al., forthcoming) . notably, these patterns fall along distinctively gendered lines in relation to religion (smothers et al., forthcoming) . at least four dimensions of religiosity are worth exploring in regard to their connection to social distancing behaviors: (1) certainty of beliefs, (2) perceptions of invulnerability, (3) collectivist versus individualist orientations, and (4) the centrality and intensity of collective rituals. certainty and exclusivity of an ideological framework can relate to the distrust of authority from other institutions, such as science or medicine ). an important contextual consideration is the extent to which these aspects of religion are connected to social dynamics of race (see yukich and edgell 2020), and how the differential racial impact of the pandemic may therefore be connected to religiosity in ways that differ along racial and ethnic lines. another important contextual consideration, at least in the united states., is the increasing politicization about views about science and religion (o'brien and noy, forthcoming). further, public opinion about the pandemic and social policies for mitigation cannot be fully understood without consideration of multiple aspects of religiosity and worldview. 1 approaching religion in the pandemic from a different angle, the responses of clergy and religious elites to the hardship of the pandemic provide ample opportunity for systematic studies of multiple dimensions of ideology, including theodicy, the relation of particular religious traditions to scientific authority, and in some cases claims and experiences of miraculous healing. the analysis of official rhetoric and communications offers an opportunity to look at how representatives of different traditions frame suffering and death in the face of widespread injustice and tragedy. in the sense that theodicy provides a crucial window into the larger ideology of traditions (berger 1967), comparative and in-depth qualitative analyses hold much promise for revealing important connections between religious groups, their practices and experiences, and their larger cultural environments. beyond religious elites, popular assessments of rumors about what is true also warrant focused attention from researchers. weber's ((1922 weber's (( ) 1993 interest in different forms of authority, including charismatic authority, places questions about the social construction of "truth" squarely in the realm of sociology of religion. religion scholars might, for example, examine the proliferation, consumption, and spread of conspiracy theories about the pandemic. although not necessarily related to formal religion (although sometimes they are), conspiracy theories contain a number of quasi-religious elements (bader et al. 2020; robertson 2016) , and social scientists studying religion can assist with evaluating the relative diffusion, as well as the patterns and consequences, of conspiracy theories. conspiratorial beliefs about the pandemic have already been spliced into existing conspiracy subcultures, such as the ones spun by alex jones or the anonymous online denizens of qanon (frenkel et al. 2020) . importantly, acceptance of conspiracy theories has consequences for political behavior (oliver and wood 2014a) , health behaviors such as vaccine resistance (oliver and wood 2014b) , and general social well-being, including trust in other people and the purchasing of firearms out of fear (bader et al. 2020 ). scholars of religion should not overlook this aspect of the pandemic, but rather contribute positively to this area of research. 1 it is worth noting that secularity will also be related to social distancing attitudes and behaviors, and should be studied accordingly. we are focusing here on aspects of religion, but secular attitudes and identities should be considered from a similar perspective. religion will also continue to be analyzed as a set of emerging and established practices (ammerman 2020; wuthnow 2020) . thinking about religion as the object of analysis and its role in disease transmission, a clear and consequential way that the pandemic has changed religion is the suspension of in-person religious gatherings, and the corresponding need to engage in "socially distanced" forms of interactive religious services and rituals. religious groups have used a wide range of technological innovations to fill the void left by in-person gatherings, from teleconferenced seders to drive-in church services broadcast on radio stations, and increasingly in video chat memorial services. how long such mediated substitutions are necessary for interactive rituals remains an open question depending on groups' locations, orientations toward social distancing measures, and congregants' levels of fear and reticence about interactions in public spaces. even when congregations do return to face-to-face gatherings, there may be changes to interaction rituals, particularly those involving physical contact, singing, and ingestion. five possible implications of these changes can be seen in: (1) the privatization of religiosity; (2) asynchronous consumption of and participation in religious services; (3) a shifting of conditions in the religious environment to favor groups that are already technologically advanced and adequately staffed to facilitate technologically-mediated religious innovation and distribution; (4) religious organizations and their civic engagement with the local community; and (5) conflicts between religious groups and local, state, and federal governments regarding social gatherings. a notable consequence of the pandemic may be further advancing the preexisting processes toward the privatization of religiosity (e.g., chaves 2017; houtman and aupers 2007). even for those continuing to participate in their religious communities remotely via mediated interaction, a qualitative shift toward the privatization of religious practice necessarily occurs. the long-term consequences of these shifts will depend on the extent and length of social distancing requirements, as well as whether and how people reintegrate physical co-presence within religious communities after social distancing requirements are reduced. while we can reasonably expect an acceleration of pre-existing trends toward religious privatization as a result of the covid-19 pandemic, the degree and expressions of this privatization remain to be seen and documented. the pandemic may also accelerate trends associated with secularization. to the extent that religious participation is habit based and interrupted by social distancing, it may facilitate the exit of some from active religious participation. so rather than a v-shaped pattern in religious participation after the easing of social distancing, returns to religious practice may well not reach their pre-pandemic levels. undoubtedly, some of this will be a transition to the privatization of religion, but some will also likely simply be declining levels of religiosity. generating adequate measures to map the extent of privatization versus secularization will be a key consideration for researchers. a related consequence is the increasing production and consumption of religious services and rituals via asynchronous communication. a primary example of this trend is the vast reduction of the annual hajj to mecca in 2020, the first time this pillar of islam has been curtailed since the mid-1800s (hubbard and walsh 2020) . more generally, by removing the physical co-presence of group services, music, and rites, a foundational element of the positive affect produced by efficacious interactive rituals is removed (collins 2005) . in essence, the durkheim ((1912 durkheim (( ) 1995 pathway to collective effervescence is substantially and negatively altered. while not all emotion is removed, an important shift has taken place that removes groups' abilities to generate shared rhythm and mood (on the positive side of generating group cohesion), and severely reduces or removes groups' abilities to police participation and norms (on the negative side of the social dynamics that create group cohesion) (see draper 2019; wellman et al. 2020) . so, while individuals may passively consume religious interactions or individually engage in rites and sacraments, the longer-term aspects of group cohesion and the accompanying social identities it generates are imperiled. beyond the experience of worship itself, the ability to mobilize and recruit volunteers for the practical needs of religiously motivated ministries, as well as generating financial contributions, are also challenged when members are deprived of the opportunity to interact face-to-face. encouraging use of digital platforms for charitable giving will also become much more important. notably, this places particular challenges on poorer individuals and religious congregations, where members' access to electronic forms of capital transfer may be limited. as charitable giving is re-directed from in-person to remote, organizations with a larger cache of financial resources have considerable advantages for long-term survival and success by virtue of their ability to weather potential downturns in financial giving, although the challenge of fundraising is a constant concern, even for seemingly stable organizations mulder and martí 2020) . related to the shift toward mediated communication for interactive rituals, groups and organizations that already emphasized the use of such technologies before the imposition of social distancing requirements have a clear competitive advantage for the maintenance of their organizations compared to groups who were more heavily reliant on face-to-face interactions. streaming services, both live and recorded, have become more common recently, and many congregations had already invested in the equipment and personnel to provide access to their services remotely. regarding communal rituals such as weddings, technology has been used to allow small in-person gatherings while providing remote participation for broader networks of family and friends. similarly, in relation to bereavement and death, online options have opened to conduct funeral services that allow involvement and interaction through video. organizations' access to capital resources will affect their ability to upgrade communication technologies to substitute for face-to-face gatherings during periods of social distancing. the pandemic also provides an opportunity to examine the role of religious organizations in social support for communities' members. for both the medical and economic hardships wrought by the pandemic and related social distancing measures, religious groups and individuals are playing important roles for formal and informal social support. for example, we know that religious congregations have been important sources of immediate assistance, from food pantries to supplemental funds to assist with costs associated with housing, medicine, and transportation. the changing landscape for religious nonprofits and local social service provisions organized through congregations are key domains for changes in the dynamics of formal social support. for informal social support, the provisions put in place by denominational organizations and local congregations to care for members during times of physical and financial hardship warrant explicit attention from researchers. conversely, the limitations placed on faith-based organizing and political engagement by social distancing should also be carefully documented. for instance, in light of a surge of protests connected to the "black lives matter" movement spurred on by the death of george floyd on may 25th, 2020, there is evidence that the lull in congregational activity allowed logistical space for church leaders to redirect their energies toward mobilizing their ministries to participate in protests that publicly advocate against racial injustice. thus, an intriguing and unintended consequence of closed church services may have been allowing for the expansion of community and civic engagement beyond sanctuaries (see beyerlein and ryan 2018) . finally, at an institutional level, there are a number of opportunities for examining interesting and consequential issues involving the intersection of religion and law. thousands of religious groups received forgivable loans of up to 10 million dollars through the paycheck protection program, which was part of a 669-billion-dollar economic stimulus package; support that some groups have strongly criticized. the u.s. roman catholic church alone gained at least $1.4 billion in this taxpayer-backed aid (and may have even exceeded $3.5 billion; see dunklin and rezendes 2020) . early reports also raised questions as to whether different religious groups were equally likely to receive support. the urge to re-start worship services given the pragmatic issues of accepting donations and the mobilization of volunteers for all sorts of ministries and services accomplished through the congregation have prompted aggressive calls for religious exemptions for church gatherings. on one end, some churches have insisted on a drive-in church option to ensure proper distancing and provide access to services for those without the technological means to access services remotely. on the other end, most churches who insist on continuing to meet physically have stated their intent to sanitize sanctuaries, provide masks, and generously space seating. some churches have sued their state governments, insisting that congregations are "essential businesses" and citing "religious liberty." indeed, there appears to be a resonance between those who agitate for re-opening the churches and those who agitate for re-opening the economy-a christian libertarian affinity that insists open churches and businesses are what is needed to keep america strong (see martí 2020a martí , 2020b . whether and how religious organizations, groups, and individuals are restricted from particular practices in order to limit the spread of disease necessarily raises points of tension about the legal parameters of religious freedom. accordingly, there will likely be waves of court cases across national, state, and local contexts dealing with issues related to social distancing and the rights of religious expression. some of these issues have already been taken up by high courts, such as the south bay united pentecostal church v. newsom (2020) case, where the supreme court of the united states denied injunctive relief to a church in california that did not want to follow social distancing restrictions on public gatherings. soon after, churches in california filed suit in federal court challenging the governor's ban on singing in houses of worship (calvary chapel of ukiah et al. v. newsom et al.) . many other similar cases will undoubtedly follow, and documenting how and why the legal boundaries surrounding religious freedom are remade in the ongoing and eventually post-pandemic landscape provides ample opportunity for meaningful study (see bennett 2017; wenger 2017) . a final consideration for social scientists studying religion during and after the covid-19 pandemic concerns methodology, and to an extent, the broader epistemology undergirding the study of religion. methodologically, many of the most vital tools available for studying religion, particularly those that are qualitative in orientation, are restricted by the need for social distancing. ethnographic, observational, and interview methods are all severely constrained by the reduction of in-person gatherings and the limitations on face-to-face interaction. of course, these are the precisely the methods that are needed to document the ongoing changes to structure and meaning of religion. consequently, researchers must be innovative in their use of digital technologies for the application of qualitative analyses, including but not limited to the use of online archives, digital ethnography, and alternative interview formats. in addition, the use of unobtrusive measures may become especially important as we seek to examine materials without the ability to observe as much in situ (see webb et al. 2000) . beyond the need to be methodologically innovative and resourceful, the changes to the social contexts of religion that we have detailed above also raise important epistemological and theoretical considerations for the sociology of religion. as religious adherents' definitions of worship and ritual life undergo reconsideration and change, researchers should pursue these emerging epistemologies by creatively tracking them. cutting-edge work in the field, such as the focus on "lived religion" (ammerman 2014; mcguire 2008 mcguire , 2016 , has already raised many of these questions. now, however, such considerations about the meaning of religion in the contemporary world-and how we should approach it as researchers and theorists-can no longer be ignored. rather than being prescriptive, this note is intended as an encouragement to our colleagues. given that covid-19 emerged as a public health crisis only a few months ago, sociologists of religion are only beginning to grapple with the many unanticipated and unseen dynamics of this global phenomenon. these happenings were playing out as most social scientists were also moving their professional lives into quarantine, taking on new roles, getting trained in social distancing practices, and managing the radical uncertainty of their work and home lives. as the circumstances of the pandemic normalize, as acceptable risks and potential vaccines emerge, and as the ability to secure analytical focus returns, there is no doubt that clever, insightful, and not-yet-fully apparent means of analyzing and revealing profound structural patterns will emerge. even as we are mournful of the suffering and tragedy the world continues to endure, we are hopeful that the creative and capable researchers who comprise our field will find ways to add their voices to the emergent understanding of how the world has changed in light of covid-19, and perhaps better prepare us for the many unknowns of our collective future. our discussion here is neither comprehensive nor exhaustive, and no one can foresee all the ways that religion will influence and in turn be affected by the ongoing pandemic. we anticipate that the list of topics brought into new relief by the ongoing pandemic will grow ever-larger over time. still, we hope the considerations we have outlined are the beginning of productive dialog in the field. sacred stories, spiritual tribes: finding religion in everyday life fear itself: the causes and consequences of fear in america crusading for moral authority: christian nationalism and opposition to science religion and preventive service use: do congregational support and religious beliefs explain the relationship between attendance and utilization? defending faith: the politics of the christian conservative legal movement religious resistance to trump: progressive faith and the women's march on chicago 71 infected with coronavirus at sacramento church. congregation tells county 'leave us alone more than 100 in germany found to be infected with coronavirus after church's services the rise of the chaplains american religion: contemporary trends 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translated by ephraim fischoff high on god: how megachurches won the heart of america religious freedom: the contested history of an american ideal complex religion: interrogating assumptions of independence in the study of religion what happens when we practice religion? textures of devotion in everyday life religion is raced: understanding american religion in the twenty-first century key: cord-126132-5k415xvj authors: swain, v. das; kwon, h.; saket, b.; morshed, m. bin; tran, k.; patel, d.; tian, y.; philipose, j.; cui, y.; plotz, t.; choudhury, m. de; abowd, g. d. title: leveraging wifi network logs to infer social interactions: a case study of academic performance and student behavior date: 2020-05-22 journal: nan doi: nan sha: doc_id: 126132 cord_uid: 5k415xvj on university campuses, social interactions among students can explain their academic experiences. however, assessing these interactions with surveys fails to capture their dynamic nature. while these behaviors can be captured with client-based passive sensing, these techniques are limited in scalability. by contrast, infrastructure-based approaches can scale to a large cohort and infer social interactions based on collocation of students. this paper investigates one such approach by leveraging wifi association logs archived by a managed campus network. in their raw form, access point logs can approximate a student's location but with low spatio-temporal resolution. this paper first demonstrates that processing these logs can infer the collocation of 46 students in 34 lectures over 3 months, with a precision of 0.89 and a recall of 0.75. next, we investigate how this wifi-based coarse collocation reflects signals of social interaction. with 163 students in 54 project groups, we find that member performance shows a correlation of 0.75 with performance determined from collocation of groups through 14 weeks. additionally, this paper presents preliminary insights for other campus-centric applications of automatically inferred social interactions. finally, this paper discusses how repurposing archival wifi logs can facilitate applications for other domains like mental wellbeing and physical health. humans are social by nature; their functioning is informed and explained by behaviors that are interlinked with those of others [24] . one of the ways these behaviors manifest is when people in the same physical space take mutually-oriented actions [52] . in situated communities such as college campuses, a student's social interactions with their peers can be important to describe the academic experiences of students, such as motivation [20, 66] , absenteeism [64] , and social isolation [19] . indeed, these interactions also share a relationship with a student's academic performance [19, 20] . as a result, understanding how students socially interact can help campus stakeholders gain valuable insights to support academic outcomes and support flourishing. however, traditional survey based approaches are limited in representing these dynamic behaviors at a fine temporal and spatil grannularity, that is scalable at the community level. this motivates us to gain an objective insight into social interactions using unobtrusive and automated methods that can be practically deployed at scale. it is possible to capture social interactions through devices possessed by the user [14, 43, 44] . however, it is often impractical to gain a comprehensive picture of a large community's social behaviors because these 2 background and related work social interactions are known to be related to behavioral and psychosocial outcomes [63] . this motivates us to study how meaningful signals of social interactions can be inferred by unobtrusively sensing collocation among related individuals. particularly, this paper adopts the definition for social interactions as described by rummel [52] : "...acts, actions, or practices of two or more people mutually oriented towards each other's selves...". these interactions cannot be determined by physical distance alone [52] . people could walk through crowds without socially acting on each other. people could also be sitting quietly in a room but still socially interacting [45] . rummel's definition refers to people regulating their actions based on others sharing mutual intent, with the purpose of shaping their subjective experience [52] . although these interactions can take place digitally, this paper focuses on synchronous social interactions in the physical world, i.e., the people interacting are in proximity. the ubiquitous computing community, along with other hci researchers, has shown a keen interest in understanding wellbeing of students geographically situated on a campus [4, 12, 54, 69, 71, 72] . wellbeing describes an individual's perceptions of satisfaction, fulfillment, and motivation. these experiences are characterized by phenomena like affect, stress, and performance. as an individual outcome, wellbeing strongly interacts with social support [60] . social circles-friends, family, or even work-related groups-can influence the functioning of students at higher-education institutes. one's peer group serves multiple functions of support, such as collaboration on specific tasks or protection from external stressors, even without directly assisting the individual's tasks [8] . therefore, in order to holistically study wellbeing, it is important for the community to explore methods to identify social interactions. specifically, social support for college students has been found to moderate stressful events [57] and is linked with reduced negative affect [19] and depression [20] . therefore, the interactions of an individual with others can facilitate coping with negative events [57] . in fact, these interactions can also be indicative of greater satisfaction [19] and self-actualization [20] . in the context of student life, these factors often contribute to determining student performance. for instance, the lack of social interactions is related to absenteeism [64] , the habitual absence associated with low motivation. at the workplace, the social interactions of an individual also explain their embeddedness, which has been shown to describe the propensity to perform [66] . and more explicitly, interactions foster collaborations, which are positive for performance [3] . therefore, reduced interactions, or a complete lack of them, not only affects a student's mental health but also impact their academic outcomes. traditional methods of evaluating social interactions rely on survey instruments, but these are limited by recall and desirability biases [1, 34] . moreover, self-reports are static assessments, while social interactions are fluid and vary over time [55] . one approach to studying human phenomena by avoiding such biases is with unobtrusive sensing. these automatic methods have the promise of dynamically sensing human behavior without interfering with an individual's natural functioning and are therefore more practical for gathering reliable insights. automatically sensing social interactions have piqued the interest of the community for over a decade. according to lukowicz et al., one of the opportunities that describes socially aware computing is "methods for monitoring and analyzing social interactionsâăťin particular, with respect to long-term interactions and interactions within large communities and organizations" [38] . prior work in this space has fundamentally focused on two approaches, differentiated by the scope of the spaces and people studied. the first set of approaches have focused on studying face-to-face interactions in small spaces [14, 44] . olguín et al., used wearable badges to study how low-level interpersonal interactions are related to workplace performance [44] . although this methodology is precise, it is limited by the cost of instrumentation and by the obtrusiveness of wearing a foreign device. a known variation is to track social interactions using bluetooth sensors embedded in one's smartphone [41, 70] . however, the convenience of installing applications on an existing wearable [27, 62] or phone [10] still requires user adoption and introduces concerns of privacy violations [59] . this challenges the approach of aggregating individualized sensing to determine social interactions. the second approach has largely focused on studying city-scale "flocks" through gps based localization [14, 17, 29, 68] . while this approach scales, it is privacy-invasive because of its continuous data aggregation [35, 59] . however, gps-based localization varies in accuracy for indoor settings [31] . moreover, gaining these insights without requiring client-adoption would require resources that are not readily accessible to a campus community. campus settings require an approach that can infer interactions within buildings while not compromising individual privacy outside their perimeter. this would mitigate the adoption issues of client-side approaches and the oversight challenges of global sensing. as a result, campuses can consider harnessing data already logged through their network infrastructure without needing any active participant effort or involvement. to understand social interactions in a large community, campus stakeholders require methods that can infer such interactions in a dynamic, scalable and reliable way. this has led to some prior explorations to leverage wifi-based technologies for localization and consequently infer social interaction based on collocation. a common technique for localization with wifi is by fingerprinting or trilateration [67] . for instance, hong et al., have shown that wifi based fingerprinting can help identify ties between groups [25] . however, these works are client-side approaches. alternatively, enterprise solutions with fingerprinting and trilateration capabilities at the infrastructure-side have emerged [42, 47] . to infer location, these technologies store the received signal strength indicator (rssi) values for any client-device within a neighborhood of access points (aps). yet, a common form of wifi infrastructure deployment in university campuses [16, 71] only stores association logs describing which ap a client-device is connected to. although it is relatively coarse [39] , this parsimonious representation of location has been exploited to understand individual behavior. ware et al., have inferred student location based on network logs to assist depression screening by inferring individual dwelling behaviors (e.g., duration, entropy, and rhythms) [71] . similarly, eldaw et al., have used unsupervised methods on similar logs to understand how the pattern of student visits can explain the semantic purpose of certain campus spaces [16] . while these works trace individual dwelling patterns across campus, they do not explicitly assess if specific groups of students were interacting. this paper is motivated by these ideas to use network association logs and extend it to identifying periods when multiple individuals are collocated for meaningful social interactions. even though collocation does not necessitate verbal communication in the strict sense, it does serve a social function [45] . olson and olson have described how "spatiality" is fundamental to human collaboration even if individuals do not communicate [45] . therefore, we seek to determine if this collocation-based information can capture the signals of such collaborations or social interactions by studying the performance of project groups. although singular instances of collocation might be contaminated with spurious events of co-presence where individuals did not interact, by gleaning the right information from such data we can predict social-interaction based outcomes. for instance, prior work has shown that the network association patterns can phenotype people into behavioral groups [37] . even other infrastructure-based coarse location technologies, such as bluetooth, have been used to capture social signals like synchrony within group routines [11] . while these studies implicitly associate individuals together (e.g., distinguish students by dining hall), they do not explore explicit interactions in physical spaces sufficiently. a more direct depiction of social interactions was demonstrated by zakaria et al., who leverage a custom system integrated to the campus network infrastructure to monitor groups and subsequently predict stress [72] . however, these systems either rely on additional augmentation of the infrastructure or a "social interaction" occurs when and where individuals mutually orient themselves [52] . this happens in the physical world when two or more individuals are within proximity, or they are collocated [45] . in the scope of this paper, periods when individuals are collocated is the basic unit for which we infer social interactions. this paper seeks to answer if coarse collocation can determine meaningful social interactions. therefore, it is important to establish an automatic approach to compute these collocation sessions. as illustrated in figure 1 , this section describes a pipeline to determine collocation by leveraging wifi network association logs and an evaluation of its reliability (rq1). to build a reliable processing pipeline we need real test data that represents the students on campus. this is to ground the methodology in how the network logs actually depict the behaviors of real students. 3.1.1 sample association logs. as a testing sample, we obtained consent from 46 students at a large public university in the united states, and we then analyzed their wifi association logs. these students belonged to two sections of a group project intensive course. both sections were taught by the same instructor(s) and had attendance data for each lecture. we refer to these sections as "1a" (22 students) and "1b" (24 students) throughout the paper. the instructor for the course provided each consenting student's attendance and group label, along with the course lecture schedule. the instituteâăźs it management facility provided anonymized network log data for these students. this data was accessed at the end of the semester 1 and contains approximately 14 weeks of data, which spans 34 lectures for each section 2 . table 1 shows an ap in room 209 of building 122s. larger rooms, such as lecture halls, have multiple aps to increase coverage. in the logs, these aps are registered with different mac addresses, but associated to the same room. every entry in the log documents an snmp (simple network management protocol) update in the network. its timestamp denotes when a device associates or responds to an snmp poll request. therefore, the log itself indicates that a device is in the vicinity of an ap, but without information of the client rssi this inference has a low spatial resolution. moreover, the snmp update is irregular because it depends on the connected device's response [61] . this is erratic because of variable connectivity settings in the device agent (e.g., the wifi turns off when the screen is locked). the irregularity in log updates leads to a low temporal resolution. the low spatio-temporal resolution is what introduces "coarseness" to this data. outside of the specific association timestamps -when a device responds to a poll or switches aps because it roams -the device is invisible in the logs. because of this, it is non-trivial to determine the location of users between two raw log entries. this section describes a method to use this momentary log information of presence to determine sustained periods of mobility, dwelling, and consequentially collocation. the raw logs are coarse for assessing location because the snmp updates occur either when a device roams or when it responds to a network poll if it happens to be awake. therefore, there is no fixed interval within which a log occurs. to reliably determine if an individual is dwelling, it is important to determine where they are between two updates. specifically, our focus here is identifying when an individual is dwelling in the same room, i.e., in the proximity of the associated ap(s). for this we propose the following approach: (i) determine if an individual is mobile -since we knew the scheduled class time and location for the regular lectures of sections 1a and 1b, we examine the logs accumulated in the thirty minutes before and after figure 2 depicts the instances when a student's device is logged before, during, and after the lecture times, along with the ap that captured the update for a section 1a class held on april 5, 2019. in this analysis, we consider any entry associated with a student because less than 1% of the log entries show concurrent updates at different aps from two or more devices owned by the student. since snmp updates occur when a device roams, we measure the interval between two successive log entries from a user's devices that associate with different aps. based on the 90th quantile of these intervals (233 seconds), to determine if an individual is mobile we establish the largest interval between two successive updates from different aps. (ii) determine if an individual is dwelling in place -based on the criteria for moving, a user is considered stationary at the location of the earlier log entry when the time between two successive updates at different aps exceeds the threshold. as evident in figure 2 , the log updates before and after class times not only are at a different ap (than that of the lecture room), but they also exhibit higher update frequency in shorter intervals. therefore, we consider any time segment when the user is not mobile, to be when they are dwelling. contiguous dwelling segments where the ap does not change are combined to represent longer dwelling segments. figure 3 shows how the raw logs represented in figure 2 can depict moving and stationary time segments. (iii) filtering out disconnection periods -one confound to this method of determining dwelling time segments is that it can erroneously label time periods where a user was disconnected from the network as a period when they were dwelling. consider an individual that moves through network coverage and then exits out. when they are moving from campus out of it, this would be registered as multiple short interval updates for the changing aps till the last ap connection on campus. this will be followed by a large interval till the user returns into coverage area. this large interval needs to be distinguished from legitimate dwelling periods to avoid false positives. based on the class dwelling time, we that find the longest interval between two successive log entries of a student present each stack depicts where how many students of section 1b were found to be connected to the lecture room's ap, another ap in the same building, to the campus network, or not connected at all in class was 76 minutes. we use this heuristic as a threshold. with this, we mark any periods of dwelling as disconnected (or inactive) where the log entries are timestamped at intervals longer than the threshold. figure 4 shows that the disconnection periods identified were predominantly on weekends and before or after class times. the previous phase identifies dwelling periods for individuals. this phase identifies periods of collocation based on overlapping periods of dwelling near the same ap (or room). simply considering the overlapping dwelling segments could have breaks when one of the collocated members inadvertently switches from the corresponding ap to a different one and then returns (e.g., participant 2,034 in figure 3 ). this could occur either when they took a break or if they are in place but their device intermittently found a better connection to a different ap. since the aim of obtaining collocation segments is to infer meaningful social interactions, we consider a liberal approach to characterize collocation. this decision aligns with rummel's definition of social interactions, which admits interaction between individuals even when they are not within line of site, because behaviors can still be influenced [52] . when an individual takes a brief break from a meeting, for example, it does not signify the conclusion of social interactions. therefore, instead of dissecting the collocation periods around such short lived absences, these gaps in the segments are bridged. in particular, these gaps are characterized by: (i) common members of a group between the collocation periods adjacent to the gap; and (ii) the gap containing a collocation or dwelling segment with a subset of those members. after identifying such overlapping segments, we first find the median duration of these gaps. the median in our data for such occurrences was 11m 7s. any gaps less than this threshold are resolved by considering all members to be collocated throughout, including the break period. to quantify the reliability of this coarse localization and collocation technique, we evaluate the attendance of 46 students in 2 sections for the 34 lectures that occurred in the sample data period. each section had 3 classes a week and the two sections met in different buildings on campus. the instructors provided us with lecture-by-lecture records of each consenting student's attendance for both sections. we use this as the ground truth to evaluate the reliability of our proposed automated method. missing data. first, we would like to address the missing data problem. on certain lecture days, we did not find any entry for some students (including a 30 minute margin before or after). the red stacks in figure 5 show the number of students per lecture with no log entries for section 1b. on comparing this to the attendance records, we learn that 93% of the times a student does not appear in the logs, they are actually present. one possibility is that the student either had all their devices turned off or connected to a different network (e.g,. cellular data). every student in the sample had no wifi log entries on at least one lecture they attended (the median was five lectures). therefore, despite its pervasiveness, leveraging the managed network will still miss out on students who were actually present. this is irrespective of the technique applied or sophistication of logs as it is dependent on the client-side behavior. for such occurrences, the automated method cannot ascertain if a student was present or absent. as result, we exclude these student records (for that lecture) from further analysis. accuracy. we analyze the accuracy by considering every student who connected to the network during the lecture time for each lecture. we consider a student to be in class, if any time during class they were collocated with their peers. for the lecture illustrated in figure 3 this refers to the green segments. for every lecture this technique identifies a student to be in class, they were actually present 89% of the time-precision. we speculate, the false positives that emerge could be the result of a student missing the attendance sign-up sheet. alternatively, for every instance when the student was present, this method infers them to be collocated 75% of the time-recall. this implies the high false negatives, as shown in figure 6 . a false negative could occur when a student's device connects to a different ap on the network. figure 3 denotes these as the orange segments. a device could connect to an ap that is physically further away because the signal from their closest wifi was attenuated [31] . therefore, this uncertainty in location could lead to missing out on students that were actually present. although this might underestimate possible social interactions that took place, it motivates us to see what we can meaningfully learn from the interactions that we do detect correctly. the previous section describes how raw wifi network logs can be processed to detect the collocation of students in a lecture room. this was validated with attendance records. however, attendance only represents occupancy and not necessarily social interactions [52] . since social interactions are known to be related to several aspects of wellbeing [63] , it is important to learn if collocation-detected by repurposing network logs-can be used to infer these interactions (rq2). this section presents a case study to explore how the collocation of project teams outside scheduled lectures can represent social interactions. specifically, social interactions in teams is known to affect performance [3] . this encourages us to investigate the relationship between a group member's' performance and how they collocate with other group members (such as time invested in meetings, the regularity of group activities, and the locations of these meetings). this case study demonstrates the feasibility of leveraging raw logs for one specific application that involves social interactions-predicting the performance in project teams. in this way, it answers our research question-to what extent can wifi-based coarse collocation represent meaningful signals of social interactions? 4.1.1 participants. the participants were enrolled in an undergraduate design course for cs students. the course is offered every semester and is a two-semester sequence typically taken by students in their junior (3rd) year. students in this course are expected to work with a team of four to six students over two semesters (part 1 and part 2) on a single design project. in spring 2019, this course had four sections for part 1 and five sections for part 2. each section had an enrollment of about 40 students. in terms of course structure, part 1 involves both lectures as well as project milestones. in contrast, part 2 has fewer lectures and expects students to allocate scheduled class-times for project-related efforts. students in both parts are expected to collaborate on project work outside scheduled lectures. it is not generally known how often student teams meet outside of class, nor is it known how much those meetings impact team performance. the data used in the previous analysis was from sections of this same course but had lecture wise attendance records (section 3). recruitment. the recruitment took place in spring 2019 in collaboration with the course instructors. recruitment was carried out in april by physically advertising the study during the lectures and online outreach through the instructors. in addition, a large number of the students were recruited during the final demonstration expo that is attended by students of both parts. on enrolling, participants provided consent for the researchers to access their wifi ap log data as well as their course data. the participants were assured that this is retrospective data that is already archived and the insights of our study would not impact their course outcomes. during enrollment, participants also completed an entry survey where they reported their group id along with describing when, where, and how often they interacted with their group members face-to-face for class purposes. participants were remunerated with a $5 giftcard for enrolling. in total we received consent from 186 students ( table 2) . of these, 170 students were in the age of 18-24 years, and 16 were of age 25 and above. among these students, 59 reported female (32%) 3 . privacy. participant privacy was a key concern for the research team given the nature of data being requested. the two core streams of data, course outcomes and wifi ap logs, are both de-identified and stored in secured databases and servers which were physically located in the researchers' institute and had limited access privileges. the study and safeguards were approved by the institutional review board of the authors' institution. the course related data of the consenting students was requested from the different instructors after grading for the semester was completed. we obtained data for the remaining 186 students along with course lecture times (table 2 ). among them, 23 students did not have any other member from their group in our study and thus were dropped from this analysis. this leaves us with 163 students and 54 groups (figure 7) . final score. all instructors provided the final score of students in their section. this represents a numerical score between 0 and 100 that is incorporated into the instructor's grading scheme to assign a letter grade for the course. this final score is dominated by the project but students are assessed individually. these variations are introduced by participation as well as the instructor's subjective assessment of team feedback. this study uses this final score to represent a student's academic performance. peer evaluation. given the group project oriented nature of the course and our interest in studying social interactions in groups, students completed a fairly extensive peer-evaluation battery. this battery was completed by the students at the end of the semester and it captures their perceptions of conflict, satisfaction, and security with the team [15, 28, 65] . it can also assess behaviors like collaboration, contribution, and feedback [37] . in essence, this battery evaluates an individual's experience interacting with their team members. prior work shows that these instruments quantify aspects of social interactions that relate to performance [15, 28, 37, 65] . therefore, we use a participant's responses to these surveys as a gold-standard to predict grades. we feed these responses into a model to compare against the predictions of models trained on automatically inferred behaviors. table 3 summarizes the distribution of scores for each peer-evaluation survey instrument. specifically, the peer-evaluation battery contained the following validated survey instruments: • team conflict -conflict represents the perception of incompatible goals or beliefs between individuals that cannot be trivially reconciled. this battery contains three scales, "task conflict", "process conflict", and "relationship conflict". jehn and mannix have shown that low-levels of process and relationship conflict along with moderate levels of task conflict are optimal conditions to maximize team performance [28] . • team satisfaction -satisfaction reflects the contentment of an individual with their personal situation in terms of their expectations. van der vegt et al., have shown that team satisfaction is associated with interdependence among team members which is indicative of team performance [65] . • psychological safety -this construct captures a "shared belief held by members of a team that the team is safe for interpersonal risk taking " [15] . edmondson has shown that it is associated with both learning progress as well as team performance [15] . • team member effectiveness -this measure encompasses five dimensions: (i) contributing to the project; (ii) interacting with collaborators; (iii) monitoring progress and providing feedback; (iv) expecting quality; and (v) relevant knowledge and skills [37] . these dimensions characterize behaviors related to "team member effectiveness", which is theoretically related to team performance [37] . the wifi access point log data for consenting students was obtained from the institute's it management facility. since this data was already aggregated for maintenance and security purposes throughout the semester, we were able to retroactively obtain this information at the end of the semester. the data spans all wifi access logs by connected devices belonging to consenting students. this data is richer compared to the sample data for processing the raw logs into collocation (section 3.1.2). it includes more individuals and a larger set of aps. the data spans a time frame of 95 days between january 1 2019 and april 5 2019. on average, the time between the first log by a participant's devices and the last is approximately 90 days. figure 8 shows the distribution of connected students throughout the semester. the logs in this study include 204 unique buildings with 4,865 unique aps. we also find multiple aps to be in the same room for 803 rooms. additionally, the 204 buildings were manually categorized to best express the purpose of that space [16, 70] -for example, "academic", "dining", "green spaces", "recreation", and "residential". two researchers referred to campus resources to independently assigned categories to these buildings. only two of the building labels had a disagreement, which was resolved by a third researcher. the raw logs of the consenting students was processed with the technique described in section 3.3 to obtain periods when students in the dataset were collocated. the median time spent collocating with other students in the dataset was found to be about 70hrs. the low spatial resolution of the collocation makes it insufficient to assert from single instances if individuals were interacting during a session in which they were in proximity. however, processing multiple collocation periods over the semester can represent behaviors that indicate these social interactions. for instance, members of the same group are expected to be collocated on a regular basis at a specific type of building. therefore, it is important to engineer features that can represent these behaviors. this phase extracts relevant information at a week-level based on various behaviors labelled semantically with the help of manually annotated or retrieved data (e.g, building categories, group meeting/lecture schedules). we segregat features by "individual" and "group" in order to capture different behavioral signals. the former is meant to characterize individual behaviors which are not explicitly associated with social interactions. the latter captures the behaviors of individuals that are oriented towards their group, such as time spent collocated with other group members. the dissociation between these features is meant to distinguish the explanatory power of the group behaviors from individual ones. this helps provide discriminant validity that coarse collocation-based features indeed captures social interactions and is not confounded by an individual's general behavior, such as the time spent at academic spaces. table 4 summarizes the different features we extracted at a week level. we derive the individual features based on the lecture schedule and semantic labels for buildings. to craft the group features, we use the same information but compute them as both absolute duration and a relative percentage. the former denotes how much time a student spent collocated with their group (at least one other member). the latter describes this behavior relative to the total time spent by that group together to express what portion of time a student participated. in comparison to the individual feature, the group features are crafted to consider when the behavior occurred (1) scheduled: groups reported their regular meetings in a free-form response field during enrollment (section 4.1.1). the meeting locations reported were at a building resolution and respondents typically indicated a primary building (e.g., learning commons) along with a potential backup (e.g., library). however, teams also expressed meetings could take place at undetermined locations on campus. moreover, groups often provided multiple potential meeting times and places for a week. to accommodate all possibilities, this feature captures the collocations between group members that occurred during any of the reported periods. (2) class: this segregates collocations with group members during class times. this distinguishes itself from the attendance feature by considering periods of collocation even outside the assigned lecture room. for instance in the case of part 2 sections, the students were expected to meet among themselves during class time. and based on student reports, teams did not necessarily use all class times in a week for meetings. this feature represents this set of behaviors. (3) other: this is a catch-all bucket to capture all other ad-hoc collocations. only 4 groups in our study reported interacting with group members for non-academic reasons (e.g., "lived together"). therefore, this category can be considered to indicate impromptu interactions motivated by course milestones or other classes in which group members are together. processing. the phase processes these raw week-level features into aggregate features that describe their collocation behavior. all the raw features we extract (table 4 ) from the data are computed at a week-level for 14 weeks-5 × 14 for individual features and (9 × 2) × 14 for group features. this leads to a rather large feature space given the target variable was the final score obtained at the end of the semester. therefore, in order to reduce the feature space we calculate summary features to describe the entire semester of the individual. specifically for each feature extracted at a week level, we compute the median, the mean and the standard deviation for the study period. these are moment statistics that quantitatively depict the distribution of that feature throughout the study period. in addition to these we also compute the approximate entropy of the feature per individual [48] . this statistic is a measure of the regularity of that feature for every individual. this reduces the overall feature count to 20 and 72 for individual and group features respectively. to predict the academic scores, we build multiple models to investigate how the collocation-based features can predict the final scores in comparison to survey-based peer evaluation scores. since the final score is a continuous integer value, we estimate it using regression. social interactions are known to be related to performance within teams [19, 20] . this motivates our analysis to demonstrate the relationship between performance and collocation behaviors to explain the extent to which coarse collocation reflects meaningful signals of social interaction (rq2). m p e denotes the model trained on peer-evaluation scores (section 4.1.2) based on the self-reported survey responses provided by the instructors. this model illustrates the efficacy of peer-evaluation reports in explaining performance and serves as a benchmark because these constructs have been validated to be associated with performance [15, 28, 37, 65] . m iw f refers to the model trained on individual features and therefore is independent of the participant's group. m дw f describes the model trained only on group features based on coarse collocation and is therefore potentially representative of social interactions. on comparing these models to a specific subset of features (individual or group), it is possible to assess the discriminant validity in predicting final course scores with each subset without confounding interaction effects from other features. we evaluate all models through a 5-fold cross-validation process. to estimate the target variable (the final score), for each model described, we train with different estimators to account for variations in the data. particularly, we train a linear regressor [56] to represent linear relationships between variables and a decision tree regressor [53] for non-linear relationships. additionally, we also train a random forest regressor [36] , i.e., an ensemble method and thus more sophisticated learner. first, we compare these estimators the basis of the rmse (root mean square error) [7] of the predictions. then, to determine the predictive utility of the we measure the correlation between the predicted value and the actual values. for internal validation we compare these models to a rudimentary baseline m 0 , which always predicts the median of the target variable from the training set. the transformations are needed to solve problems with missing data and to scale the features to comparable units. both the transformations and selections take place within each fold and therefore we perform all fitting only with the training data of that fold: (1) scaling final scores by instructor -the target variable the models are trying to predict is the final score for the course. since the final score varies based on the instructor, we standardize the final scores based on the distribution of scores for each instructor in the training data. (2) impute missing data -for a few individuals certain features might have missing values. in case of peerevaluations this could be because the student did not complete a particular survey instrument. for some of the group features a project team did report their scheduled meeting times (in total seven students). we impute these missing values with the mean. (3) standardize the features -we convert all features to zero mean and unit variance [33] . (4) mutual information regression -lastly, we employ a univariate feature selection method on the basis of mutual information between the training features and the target variable [32] . the number of features selected varies from 1 to k, where k is the total number of features in the model. we select the k that minimizes the rmse. the choice of k is illustrated in figure 9 . to re-emphasize, these results will show if the collocation behaviors of students can predict their group-based performance. since team performance is linked to social interactions in physically collocated teams [45] , these results can delineate if patterns in coarse collocation can infer social interactions. this section describes the prediction results of the various models (described in section 4.3.1) to explain the explanatory power of the coarse collocation features. table 5 summarizes the results of the predictions with the best estimator for each model. the rmse of m 0 -the arbitrary regressor -establishes a baseline to determine the goodness of the models we analyze. any features that do not reduce the rmse in comparison are not noticeably better than predicting the mean of the distribution. to compare the information in the features, we select only the best estimator algorithm (based on reduced rmse) for each set of features. the rmse of m 0 was 1.075, which can be interpreted as 1.075 standard deviation away from the true value. the smallest rmse of m p e was 1.085 and that for m iw f was 1.068. for both of these input features, linear regression was the best estimator. therefore, the modeling the peer-evaluation features shows no improvement in error-reduction and the predicted results have an insignificant correlation with the actual scores. in contrast, m iw f only produces a relatively better, yet still weak correlation of 0.12. this implies that merely processing the individual dwelling behaviors is more informative than peer-evaluation responses to predict scores in a group-project intensive course. in comparison, the best rmse for m дw f is 0.748, which uses random forest (a 30% improvement). moreover, the predicted values exhibit a correlation of 0.759 with the true values. figure 10 shows the correlation between predicted and actual final scores variables. the results show that the model trained on students' collocation behaviors (m дw f ) outperforms other models in predicting their final scores, in comparison to models trained on peer-evaluation responses and individual behaviors. first, we find the collocation-based behaviors are significantly better predictors than peer-evaluation scores (m p e ). while peer evaluation scores are expected to yield better correlations [15, 28, 37, 65] , the social desirability bias in manually reporting team experiences can wash out the intricacies of actual team behavior [1, 34] . these surveys expect the participants to subjectively interpret and then transform their social interactions into scores. but these students are also aware that these scores might affect the instructor's impression of their team members and possibly their score. in contrast, m дw f incorporated multiple characteristics of the collocation behavior within groups over multiple weeks. these features are devoid of the subjective biases that plague self-report and other manual assessments of social interaction. second, we find that m дw f performs better than a model built on individual behaviors (m iw f ). note that m iw f was also found to be a better model than the peer-evaluations. this already implies that dynamic offline behaviors carry explanatory power to determine academic performance. however, given the collaboration-based nature of the course in determining the final score of an individual, m iw f falls short of m дw f . for instance the individual behaviors of attendance or dwelling in academic spaces were not comparable in explaining the final score. therefore, this result indicates that features in m дw f reflect more than dwelling around an ap. arguably, in a snapshot of time, individuals could be collocated and not socially interact with each other [52] . however, by observing these behaviors over a period of time it might reveal if certain individuals are mutually oriented when in the same physical space [45, 52] . the fact that the collocation based model (m дw f ) predicts the final score better than the dwelling only model (m iw f ) prides evidence that this data can indicate social interaction. finally, to further dissect the model and understand how the collocation-based features explain the final score, we evaluate the feature importance of the selected variables. table 6 shows the top five features in the best model, m дw f with random forest. it is notable that four of these capture relative behaviors (e.g., percentage of time students were present in group meetings). another noticeable aspect is that three of these features are based on the variance in collocations. these features essentially describe the consistency in collocation patterns (e.g., being collocated with the same group every week for a fixed period of time). however, given the importance scores it is evident that not one collocation behavior alone but analyzing a set of them together is what enables a strong prediction of performance. we demonstrate that collocation behaviors of group members predict performance better than individual behaviors and peer-evaluations. this exhibits that our method of determining collocation can be viably used to infer social interactions. the previous two sections demonstrate that infrastructure-based coarse collocation captures some important aspects of social behaviors in students, and that these measures of behavior form a good predictor for group project success. this presents new opportunities to harness archival network logs to scale analyses of social behaviors for larger groups, up to and including an entire campus. for instance, with an empirical understanding of how successful teams socially interact, instructors can tailor recommendations for project courses. this section illustrates other potential use-cases based on insights gathered from the case study. social interactions are crucial to understand the physical and mental wellbeing of an individual. the lack of social interaction, or social isolation, is linked to stress, negative affect, depression and dissatisfaction [19, 20, 57] . the presence of social interactions can uncover ties within a peer group, which can be helpful to understand individual perception and behavior. for instance, weak social ties are related to a lack of motivation to go to work or absenteeism [64] . alternatively, strong social ties can also explain peer influence and its effect on alcohol, drug and tobacco use [9] . as a result, retrospective investigations of who a student interacts with and how these interactions evolve over a period of time can provide insights for supporting student wellbeing. using the data from section 4, we develop network graphs representing the collocation between pairs of individuals in the same section, shown in figure 11 . we compute the graphs week-wise (excluding lecture times), with each edge depicting the duration of collocation between any pair of individuals. figure 11 shows the evolution of these interaction ties between participants from section 1b. every node represents a participant and the color denotes project groups. nodes that are closer illustrate individuals who spent more time collocated together. even in the first week of class, the participants are somewhat closer to their group members than others, and this becomes more pronounced in the later weeks. however, since we consider all collocations it is evident that a participant's ties are not exclusive to their group. this makes automated methods even more valuable so as to identify these informal interactions. in some cases, members of different groups might be connected through other courses or even social circles. similarly, figure 12 represents interaction ties in section 2d aggregated over the whole study period. it reveals the tight connection amongst some members of the red group. this particularly refers to participants 2006, 2009, and 2010. in comparison, two other group members are slightly further apart. this is explained by the disclosure during enrollment that these participants live together. this application is similar to what hong et al., describe as relationship maps to understand intimacy between individuals [25] . by using raw association logs for an entire campus, it presents opportunities to understand where these interactions occur and semantically labels them based on the expected purpose of collocation (e.g., residential ties for roommates, academic ties for project teams, or recreational ties for parties). note that our sample is limited to the 215 individuals that consented to the use of their network logs. more nuanced automated learning techniques can help identify social groups in a completely unsupervised way, making a compelling argument for the application to a broader cohort on campus. accordingly, stakeholders can take actions for a cohort of individuals based on noticeable anomalies in a network, such as when someone from a cohort drops out. another use case is when someone in a network is affected by an ailment-mental (e.g., violent incident) or physical (e.g., contagious disease)-the campus can react by securing the peers first. another approach to visually analyzing the segments identified by the pipeline is to observe where social interactions occur. this can be further expanded by locating the "collocation spaces", which are spots on campus where individuals gather together. figure 13 shows how the collocation changes before the midterm, during the midterm, after the midterm. while there is a slight increase in collocation period at academic spaces towards the end of the semester, it is most notable how the interactions in residential spaces change during the midterm. this excessive collocation could indicate groups working together to collaborate on midterm milestones or simply study for exams. another notable aspect is the decrease of collocation duration at fraternities and sororities. this might be related to fewer parties and gatherings during midterm exams. more importantly, this data provides evidence that social interactions vary over time at different places. by investigating how collocation varies around specific events, say an exam, it is possible to define the purpose of spaces more dynamically. furthermore, this can be extended to gain a better understanding of the purpose of social interactions itself. this would stem from knowledge of the space and community. accordingly administrators could focus on facilitating better interaction in these spaces during times of collaboration. by contrast, they could also choose to carefully regulate the use of these spaces during times of social distancing [40] . social interactions in physical spaces can lead to congestion depending on the purpose and popularity of a space. understanding where these spaces are and when congestion can occur can regulate gatherings for crowdmanagement [17, 68] and even prevent the spread of contagious diseases [40] . therefore, campus stakeholders have an interest in identifying rooms and pathways with high pedestrian concentration. not only could this help pre-determine bottle-necks for flock movement in cases of emergencies, it can also retroactively indicate which spaces were prone to congestion and inadvertent physical contact. this subsection presents some observational evidence from our data showing how sections move in and out of their class room around a lecture. as discussed in section 3.4, one of the instructors (1q) provided us with lecture-by-lecture attendance data (46 students in sections 1a and 1b). for section 1a, lectures took place three times a week from 10:10-11:00, and for section 1b, these lectures took place from 11:15-12:05. the rooms where these lectures took place were both single entry/exit. to gain a better understanding of how congested these points can get, we evaluate the arrival and exit times of the students that attend class. for entering class, we compare the earliest starting time of an individual's collocation with the designated commencement time. similarly for exiting class, we compare the latest ending time with the lecture's expected conclusion time. the median entering time is five minutes and the median exiting time is two minutes ( figure 14) . these values align with the instructors' observation of typical class behavior, i.e., students are typically tardy on entry but are on time for the exit. notably, our analysis considers the only students from the current class and not those who would occupy the same room for the next or previous lecture. however, with richer data, it is possible to understand congestion points not just for class rooms but where any social interactions occur. with these findings, stakeholders could regulate the exit of students even between different rooms to avoid crowding the pathways. these can be proactive interventions to reduce the physical interactions. this work showcases the utility of association logs recorded by managed wifi networks. these logs are archival data that can be easily scaled for every campus community member that is connected to it, if a mechanism to obtain broad informed consent can be devised. beyond the case study presented in this paper, repurposing this data to infer social interaction based on collocation behaviors can inform the design of various applications for different stakeholders. in this section, drawing upon the threads of the other applications discussed above as well as others in the existing literature, we highlight some of the real-world scenarios where this technology can be implemented on the campus. 6.1.1 academic experiences. harnessing data already collected at the infrastructure facilitates long-term analyses of social interactions in a large cohort of students. in section 4.4, we show that modeling the collocation behavior of project group members can convincingly explain their final scores. in other words, signals reflecting social interaction, and its ramifications on academic outcomes, can be captured by understanding collocation. this enables instructors to provide data-driven insights to a new cohort based on actual behaviors of successful teams. however, student experiences are not limited to the classroom. inspecting the collocation patterns inside a campus can help characterize the campus spaces in terms of their social purposes. in fact, it would be possible to trace the campus' evolving "social blueprint" and dynamically approximate the nature of social interactions based on when and where people were collocated (section 5.2). this knowledge could be used to augment the static semantic labels of places. moreover, it can help disentangle social relationships within a community. it is not uncommon for individuals to be collocated in the same space on campus. however, by studying prior collocations and its evolution, it is possible to elucidate if two students were mutually oriented to each other's actions, and thereby socially interacting [52] (section 5.1). for example, ties at the gym are different from ties through parties. processing these logs provides researchers an opportunity to understand social interactions on multiple dimensions which motivate new questions and applications. for instance, how do teams with prior ties work in comparison to teams of strangers [23] , or how different are the social interactions in a new class for a student from a marginalized community [49] . essentially, the network logs are a passive source of information to gather empirical insights of social support. and in a student's life, social support can explain performance [19, 20] , drug use [9] , and even dropping out [22, 49, 64] . 6.1.2 mental wellbeing. the applications related to academic outcomes discussed earlier have implications for a student's mental wellbeing. however, this dedicated section is to describe applications that are agnostic of student success and instead focus on supporting their mental wellbeing requirements. abundant work in psychology and sociology express the importance of receiving social support, and this coping mechanism is fundamental to leading a healthy life. this data makes it possible to evaluate the changing social interactions over time, for both positive and negative outcomes. major events on campus can impact social behaviors linked to mental wellbeing. this could either be a violent incident [5] (e.g., during a shooting) or an enforced lockdown (e.g., during a pandemic). in fact, the absence of interaction can be associated with social isolation, which in turn is related to stress, affect, and depression [19, 20, 57] . although these kinds of analyses might be hard to justify in real-time, post-hoc analysis of these trends can provide insights to support positive trends or mitigate negative ones. for example, with the use of archival data, campus health facilities can incorporate the social interaction information for screenings. ware et al. have already shown that similarly leveraging network logs to infer individual dwelling behaviors (e.g., duration, entropy and rhythms) can assist with depression screening [71] . in the same vein, social behaviors inferred by our method can be analyzed to predict community-scale mental wellbeing concerns and alert campus health facilities. this can help prepare responses following certain expected (e.g., exams) and unexpected (e.g., student death) events on campus. 6.1.3 physical health. social interactions, and the lack thereof, are important behaviors in the context of contagious diseases, something that has become very clear in 2020 with the coronavirus disease (covid19) pandemic that is affecting people globally. literature in epidemiology provides substantial evidence that social distancing helps reduce the spread of influenza [21] and coronaviruses [40] . even though wifi-based collocation is too coarse to determine physical contact at the spatial resolution of 6-10 feet, the behaviors that can be derived from it has applications for both reactive and proactive measures. in terms of the former, similar processing pipelines aid contact tracing by automatically assessing the likelihood of individuals at risk based on the amount of collocation they may have had with a known contagious set of individuals. although this can have false positives, it can still render a risk-based prioritization to help with screening during highly contagious outbreaks, such as was experienced in spring 2020, and we expect it to recur in the coming years. using sophisticated interaction networks as we demonstrate in section 5.1, campus health officials can look at historically-accumulated data to understand which students are associated with infected ones. this can be potentially extended to study multi-hop relationships with greater degrees of separation as well. alternatively, similar data can be leveraged to develop and simulate proactive measures that assist campuses in resuming and continuing safe operations during a period of contagion. by modeling prior data based on congestion and pedestrian traffic (section 5.3), it is possible to determine the specific bottlenecks on campus that should be regulated because of risk through both direct interaction and exposure to contact surfaces (e.g., door handles at exits) [6] . even simpler solutions of applications that depict occupancy of spaces (section 5.2) to students in real-time can help them adopt safer behaviors by avoiding interactions [18] . policies such as instituting one-way walkways, assigned seating in classrooms, hybrid physical-remote class attendance policies to reduce student density in classrooms or other creative measures can be tested to see how much they impact risk of exposure to an individual and an entire campus community. the use of passive sensing technologies captured in the digital infrastructure of a campus can characterize human behavior and holds exciting potential because it can be automated and scaled. this mitigates the limitations of manual sensing such as self-reports of experiences or even requiring all individuals to install and consent to passive sensing on the personal devices. however, since this paper highlights the feasibility of appropriating data archived in existing systems, it also elicits new concerns when considering practical deployments. any ubiquitous technology with the potential of large-scale passive sensing faces privacy concerns [46] . in the scope of our work, the privacy concerns can be related to both the data that is collected (coarse location) as well as what it can infer (interaction with peers) and its eventual implications [35] . from the perspective of data collected, the use of the wifi association logs is more privacy preserving in comparison to installing an application on a client device that accumulates data to a central server. such client-based applications can be perceived as invasive not only because such agents can collect sensitive data-possibly more than what the user is aware of-but also because the aggregation can be continuous and unbounded, e.g., a campus application logs locations even beyond the campus perimeter [59] . on the other hand, infrastructure-based localization is limited only to timestamps of network associations and does not elicit anxieties related to a client-side agent leaking data from other sensors. moreover, these approaches are also localized to the campus. however, automatic computation of where individuals are and who they interact with can be considered sensitive by campus students [50] . therefore, when adapting such approaches to infer interactions, stakeholders need to consider approaches like differential privacy to obfuscate sensitive data [13] . related to the privacy concerns is establishing policy around data access. this paper and prior work showcase the utility of social interactions and how it can be inferred unobtrusively. however, this involves a centralized observer that harnesses location data, and even when anonymous, this can be used to trivially identify individuals [26] . a predator can incisively connect certain dwelling patterns if they choose to, e.g., lecture rooms can reveal a schedule and potentially an individual. to protect against this, more data can be abstracted, i.e., the ap locations can be anonymized as well (while still retaining category, floor and relative information). yet, it still needs to be established which people have the privileges to query for information and what the queries can be. in fact bagdasaryan et al. have proposed a system for managing the privacy of ubiquitous computing systems that limits the use of the data itself [2] . moreover, campuses can adapt existing policies regarding access to student records to protect data related to students' social interactions on campus. finally, we also need to discuss the ethics of such inferences. since the data relies on network association logs, any individual that connects to the network effectively opts-in their data for this analysis. choosing to not connect can be considered an unfair choice that limits a student's right to self-determine [51] . although students already connect to other networks, it is important to understand their rationale in order to weigh the cost and benefits of opting-out of an institute managed network. moreover, even if a student makes that decision, the fact that they will be excluded from social interaction based insights could in itself be unethical. even though, on any given day, 90% of the students in our sample were connected to the network, the students outside coverage will be missed in applications like contact tracing and social isolation. and this missing data can have ramifications for the entire community. even for academic performance, if instructors can use this kind of data for intervening with certain groups during midterms, those that were left out lose the opportunity of improvement. consequently, this raises concerns of fairness and accountability, which need to be considered before incorporating such systems. the most apparent limitation of using these association logs to determine social interaction is its low spatiotemporal resolution. this introduces reasonable uncertainty in determining the exact location of individuals [37, 71] . even with a lack of precision, wifi-based localization does have its advantages. it can be argued that such approaches (e.g., [25] ) provide greater insight into indoor mobility and dwelling than other scalable solutions like gps [17, 29, 68 ]. yet, indoor setups present several challenges that can lead to unexpected device associations [31] . as a result, an individual could be in a room and not be associated with the physically closest ap, but rather another ap node that found a stronger signal to the client. this creates an opportunity to deal with this noise by modeling the probability of displaced connections. individual dwelling and collocation could be described as a probabilistic measure based on their pathway to the location. other pieces of information that could help calibrate the modelling is incorporating the size and configuration of rooms and neighbourhood maps of the aps. furthermore, advanced off-the-shelf methods to study archival data can be developed to make ap nodes aware of other aps visible to a client. these additional pieces of information can still be very valuable without the need of installing applications on user phones or fingerprinting the entire campus. our work shows that collocation behavior over time can indicate social interactions, even if an instance of co-presence between two individuals does not guarantee face-to-face interactions. theoretically, this falls in line with ideas of spatiality [45] -when collaborators are present near each other, they are interacting through observations and increased sense of accountability. however, it is yet to be explored if these notions of will translate to other social relationships. specifically, if the principles of spatiality can be used to identify the social groups in an unsupervised way. social interactions can explain student experiences in terms of stress, motivation and performance. one way these interactions manifest on campus is when students are physically collocated. this paper studied the feasibility of coarse collocation leveraged from wifi network logs to describe social interactions. we established the reliability of computing collocation of students in class. then we demonstrated how collocation behaviors of project team members is related to 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acceptability of using smartphone data to assess mental health der wert des privaten understanding conflict and war a survey of decision tree classifier methodology inferring mood instability on social media by leveraging ecological momentary assessments modeling dynamic identities and uncertainty in social interactions: bayesian affect control theory linear regression analysis life stress in various domains and perceived effectiveness of social support a walk on the client side: monitoring enterprise wifi networks using smartphone channel scans four billion little brothers? privacy, mobile phones, and ubiquitous data collection the relationship between social support and subjective well-being across age snmp, snmpv2, snmpv3, and rmon 1 and 2 working-relationship detection from fitbit sensor data social relationships and health: a flashpoint for health policy social support at work and its relationship to absenteeism patterns of interdependence in work teams: a two-level investigation of the relations with job and team satisfaction social embeddedness and job performance of tenured and non-tenured professionals location in ubiquitous computing crowdwatch: pedestrian safety assistance with mobile crowd sensing studentlife: assessing mental health, academic performance and behavioral trends of college students using smartphones smartgpa: how smartphones can assess and predict academic performance of college students large-scale automatic depression screening using meta-data from wifi infrastructure stressmon: scalable detection of perceived stress and depression using passive sensing of changes in work routines and group interactions key: cord-194404-q9ne5i2y authors: rostami-tabar, bahman; ali, mohammad m; hong, tao; hyndman, rob j; porter, michael d; syntetos, aris title: forecasting for social good date: 2020-09-24 journal: nan doi: nan sha: doc_id: 194404 cord_uid: q9ne5i2y forecasting plays a critical role in the development of organisational business strategies. despite a considerable body of research in the area of forecasting, the focus has largely been on the financial and economic outcomes of the forecasting process as opposed to societal benefits. our motivation in this study is to promote the latter, with a view to using the forecasting process to advance social and environmental objectives such as equality, social justice and sustainability. we refer to such forecasting practices as forecasting for social good (fsg) where the benefits to society and the environment take precedence over economic and financial outcomes. we conceptualise fsg and discuss its scope and boundaries in the context of the"doughnut theory". we present some key attributes that qualify a forecasting process as fsg: it is concerned with a real problem, it is focused on advancing social and environmental goals and prioritises these over conventional measures of economic success, and it has a broad societal impact. we also position fsg in the wider literature on forecasting and social good practices. we propose an fsg maturity framework as the means to engage academics and practitioners with research in this area. finally, we highlight that fsg: (i) cannot be distilled to a prescriptive set of guidelines, (ii) is scalable, and (iii) has the potential to make significant contributions to advancing social objectives. organisations make operational, tactical and strategic decisions every day. regardless of the sector or industry, these decisions reflect the expectations of what the future may look like. this is where forecasting can play a crucial role as an integral part of a decision-making process (hyndman and athanasopoulos, 2018) . this is well understood in areas with commercial or economic interests. forecasting and its link to business decision-making has been under research for decades (gonzález-rivera, 2016; sanders, 2016; gilliland et al., 2016; ord et al., 2017) . many important contributions have been offered in these fields (e.g., macroeconomics and the financial sector, retail industry and supply chains, energy industry and tourism (fildes and stekler, 2002; fildes et al., 2008; syntetos et al., 2009; athanasopoulos et al., 2011; hong et al., 2014) ) on how forecasting may improve organisational decision-making. however, such studies have largely sought to improve forecasting processes (and their integration with decision-making) in the presence of financial or economic motivations. on the other hand, little attention has been paid to forecasting when the emphasis is on deriving some societal benefits regardless of the financial or economic implications. in this article, we refer to such forecasting practices as forecasting for social good (fsg). while there is a growing recognition by agencies, organisations, and governments that data-driven decision-making tools, such as forecasting models, may offer significant improvements to society (iyer and power, 2014) , there is not a cohesive body of research that offers guidance towards the conceptualisation, implementation and evaluation of forecasting models for social good in practice. although some work has been done in this area (gorr and harries, 2003; nsoesie et al., 2014; van der laan et al., 2016; wicke et al., 2019; litsiou et al., 2019) , progress has been relatively slow and sporadic, both in terms of academic contributions and practical applications. this is exemplified by the fact that the development and use of forecasting models in organisations with social missions (especially in health, humanitarian operations and the third sector) is considerably under-developed. evidence (getzen, 2016; cacciolatti et al., 2017; lu et al., 2018) suggests that this may be due to a lack of awareness, skills and understanding of the value of forecasting, but the fact remains that such organisations are largely not exploiting (relevant) forecasting capabilities. further, major review papers in the areas of forecasting, as well as operations research and operations management when forecasting is explicitly considered (fildes et al., 2008; syntetos et al., 2009; boylan and syntetos, 2010; syntetos et al., 2016; makridakis et al., 2020) , do not take into account work related to fsg. the paucity of academic contributions may be due to the limited amount of existing work to build upon, or the fact that relevant work might appear in journals not frequently read by the forecasting community (soyiri and reidpath, 2013; nsoesie et al., 2014; dietze, 2017; goltsos et al., 2019) . given the background discussed above, we feel it is timely to explicitly address the definition of fsg and its positioning in the wider body of knowledge. this exercise will facilitate the discussion of both forecast implementation and evaluation issues leading to the proposition of a research agenda; it should also allow organisations to advance their social missions and benefit from the value forecasting may offer. the purpose of this paper is three-fold: • increase awareness and interest of academics and practitioners on the potential impact of fsg; • encourage interested academics and practitioners to engage in the fsg agenda; • inspire the development of new forecasting methodologies tailored for social good applications. the remainder of the article is organised as follows. section 2 defines the area of fsg, its scope and boundaries as well as its relation to (other) data-driven social good initiatives and forecasting areas. section 3 suggests a positioning framework on the basis of (i) the maturity of the forecasting process (theory) and (ii) the use of forecasting in social good (practice). it also provides an indicative agenda for further research. finally, section 4 presents a summary of our conclusions. in this section we first explain the doughnut theory used to frame our definition and scope of fsg. this theory is an alternative way of looking at growth economies. it prioritises people and the planet over economic growth, which can help us as a society thrive within the limits of our planetary boundaries (raworth, 2017) . in this paper, the theory helps to create a common understanding of the term forecasting for social good. we attempt to answer the following two questions: 1. what is meant by fsg? 2. what attributes/features make a forecasting process aligned with fsg? that is, when does a forecasting process belong to fsg and when does it not? doughnut theory was proposed by raworth (2017) and offers a framework for thinking about how we create a world in which humanity thrives. raworth states that, instead of economies that need to grow, whether or not they make us thrive, we need economies that make us thrive, whether or not they grow. the aim is to meet the needs of all people within the means of the living planet. the theory combines the concept of social foundation with that of ecological ceiling in a single framework as illustrated in figure 1 . the social foundation is derived from the social priorities described in the united nations sustainable development goals (un general assembly, 2015) . the idea is to ensure that no one is left in the hole of the doughnut below the social foundation and falls short on essentials of life ranging from food and clean water to gender equality, and everyone has a political voice and access to housing. the ecological ceiling includes nine planetary boundaries developed by environmental scientists (rockström et al., 2009 ) that represent the planets capacity of critical lifesupporting systems. in order to preserve them, humanity must live within these ecological boundaries while meeting the needs of all described in the social foundation. between the social foundation and the ecological ceiling lies a an space in which it is possible to meet the needs of all people within the means of the living planet -an ecologically safe and socially just space in which humanity can thrive. this is the space we must move into from both sides simultaneously, in ways that promote the well-being of all people and the health of the whole planet. achieving this globally calls for action on many levels, including research and its applications. the framework has been adopted in multiple academic disciplines, various countries, subregions and cities worldwide (cole et al., 2014; dearing et al., 2014; hoornweg et al., 2016; amenta and qu, 2020; bennett, 2020) . the doughnut framework allows multi-metric compasses to be elaborated for informing the decision-making process (dearing et al., 2014) . in order to promote the well-being of all people and the health of the whole planet, the decision-making process needs to support all activities that bring us into the doughnut space -an environmentally safe and socially just space -in which humanity thrives. we note that one of the main components of any decision-making process is forecasting. we define forecasting as a genuine prediction of the future, given all the information available at the time the forecast is generated, including historical data and knowledge of any future events that might impact the outcome(s) (goodwin, 2018; hyndman and athanasopoulos, 2018) . the forecasting process starts by taking inputs in the form of a problem description, data and information, then an appropriate forecasting method is identified and the inputs are processed and formulated to implement the method using a software and make the forecast, incorporating human judgement and uncertainty assessments when necessary. genuine forecasting can also take place in the absence of available data and not relying on statistical methods or using statistical software. instead, we may rely on structured management judgement including the delphi method, forecasting by analogy, surveys, scenario forecasting and other judgemental forecasting approaches. forecasting is used to help decision makers to make more informed and potentially better decisions. therefore, forecasts need to be tailored to provide answers to the questions a decision maker needs in a particular set of circumstances. in the case of fsg, we argue that the forecasting process should be determined by a decision-making process that leads a community into an ecologically safe and socially just space where it can thrive. figure 3 shows the relationship between the doughnut theory, decision-making process and the forecasting process in fsg. fsg is a forecasting process that aims to inform decisions that prioritise thriving of humanity over thriving of economies by enhancing the social foundation and ecological ceilings that impact public as a whole at both local and global levels. therefore, fsg contributes to the solutions to real problems that are primarily driven to thrive humanity by enhancing the social foundation within the planetary capacity. while profits and other growth-oriented metrics can be considered they are not given priority. now we move towards our second question i.e. what attributes make a forecasting process a fsg. we argue that to qualify for fsg, a forecasting process needs to have four attributes: (i) it is concerned with a real problem; (ii) the problem is primarily driven by thriving humanity over thriving of economies; (iii) the proposed solution enhances the social foundation and ecological ceiling; and (iv) it impacts the public as a whole. these are further discussed below. real problem: fsg emphasises the problems directly affecting people/humanity and are experienced in daily life, in contrast to the problems mostly residing in the theoretical world. while the scope of other similar initiatives such as data science for social good (paolotti and tizzoni, 2018) might be limited to real problems in sectors such as government and/or the voluntary sector, our definition of fsg is inclusive and encompasses all organisations irrespective of the industry and whether they are governmental, commercial or voluntary organisations. hence, the scope and the nature of the problems that the forecasting process is attempting to provide solutions for could range from a task in a profit-driven organisation e.g. forecasting to reduce waste, to a whole sector, e.g. forecasting for humanitarian and disaster relief operations. this is important as commercial organisations are rapidly changing in terms of how they think and position themselves when it comes to social good, and they should not be excluded in the definition (rostami-tabar, 2019). this dimension highlights an important aspect of fsg -that is the collaborative effort and continuous interaction between the problem owner and the forecaster to define the problem, design the model, evaluate and implement the solution and link it to the decision-making process. the collaborative efforts will lead to questions that are not only crucial to help humanity to thrive but also provide opportunities for innovative research. the second attribute focuses on the objectives of solving the real problems under consideration. fsgs outputs prioritise thriving of humanity over the thriving of economies. therefore, one of the key features that define fsg is whether the purpose of informing decisions -by the forecasting process-to solve the real problem, is driven primarily by social/environmental considerations or economic growth. fsg is not primarily driven by economic growth i.e. the goal is to help humanity thrive within environmental boundaries whether the economy grows or not. the is a radical change in the way we look at forecasting process. the idea is to ensure that decisions and actions informed by forecasts are helping humanity to get into the doughnut-shaped space, an ecologically safe and socially just space for humanity to thrive in. the forecasting process may also result in economic growth. however, it is within the scope of fsg if the primary focus is to improve the human and planetary condition. the third dimension of fsg relates to how the benefits of the forecasting outputs are being measured. in a traditional business forecasting scenario, the outputs or the empirical utility will be associated with the financial or economic implications. however, in the case of fsg, the forecasting process focuses on the social foundation as the primary output. forecasting should inform decisions towards enhancing social foundation while maintaining or improving the ecological ceiling simultaneously. therefore, we need indicators and metrics that allow us to measure both components. doughnuts social foundation includes twelve dimensions that are derived from internationally agreed minimum social standards described in the sustainable development goals (sdg) defined by the united nations (united nations, 2019). sdg indicators are relatively well thought through at an international level and developed/refined by hundreds of multidisciplinary experts. also, they are already being integrated into national and transnational policies as well as referenced in academia (cancedda et al., 2018; biermann et al., 2017) . doughnuts social foundation include water, food, health, education, income & work, peace and justice, political voice, social equity, gender equality, housing, networks and energy. various metrics such as nutrition, sanitation, income, access to energy, education, social support, equality, democratic quality, employment, self-reported life satisfaction and healthy life have been used in various studies to quantify social foundation (steinberger and roberts, 2010; cole et al., 2014; dearing et al., 2014; raworth, 2017; oneill et al., 2018) . the ecological ceiling consists of nine dimensions that are vital to our planets ability to sustain human life as set out by rockström et al. (2009) . beyond these boundaries lie unacceptable environmental degradation and potential tipping points in earth systems. these boundaries include ozone layer depletion, ocean acidification, nitrogen and phosphorus loading, chemical pollution, freshwater depletion, land conversion, air pollution, climate change and biodiversity loss. indicators used in various studies include phosphorus, nitrogen, ecological footprint, material footprint, co2 emissions, greenhouse gas emissions (knight and rosa, 2011; dearing et al., 2014; lamb and rao, 2015; oneill et al., 2018) . when a forecast is made to inform a decision, the penalty will arise if the forecast turns to be different from the actual value. the idea in fsg is to use amended penalty functions that integrate social foundation and ecological ceiling indicators instead of current functions based on statistical, economical and financial kpis (berk, 2011; lee, 2008) . fsg informs decisions that enhance social foundation indicators and not violate any principle measures of ecological ceiling. there is still more to be done to define new metrics for social foundation and ecological ceiling at local and global levels and this is one of the important challenges facing humanity. traditionally, forecasting publications, conferences and practices focus on methodological advances and profit driven goals. this would need a radical shift to allow researchers and practitioners to get involved in fsg research. the last dimension focuses on who benefits from the application of forecasting. fsg gives priority to both local and global levels rather than focusing only on its local beneficiaries themselves. fsg can be used at multiple scales from an individual to a nation -as a tool for transformative action that embraces social and ecological metrics, both locally and globally. organisations should ensure that these metrics are measured through the internal activities rather than external activities such as donation to a charity. fsg starts by asking this question: how can the forecasting process inform decisions that help thriving humanity whilst respecting the wellbeing of all people, and the health of the whole planet? following this question, the benefit of fsg can be assessed across four lenses that arise from combining two type of benefits (social foundation and ecological ceilling) and two scales (local and global) as depicted in figure 4 . what would be the impact of the decision informed by forecasting for the wellbeing of local people? what would be the impact of the decision informed by forecasting for the local environment? what would be the impact of the decision informed by forecasting for the wellbeing of the people worldwide? what would be the impact of the decision informed by forecasting for the health of the whole planet? ecological ceiling fsg. moreover, the forecasting process in fsg might be different compared to other areas of forecasting when it comes to its input, process and output in the next subsection we discuss the fsg process and its overlap with other data-driven social good initiatives. the unique attributes of fsg discussed in section 2 can lead to various changes throughout the forecasting process including input, process, and output from fig 2 that is discussed in this subsection. • problem: as discussed in section 2.1, the forecast problem needs to be real and primarily driven by thriving humanity over economic growth through improving social foundation within the ecological boundaries. • data and information: the data and information used in fsg projects can often be more publicly accessible than when there are commercial interests to consider (ocha, 2020). however, confidentiality may be required for privacy reasons, especially when the project involves individual-level data. for instance, individuallevel data on health, social services or even real-estate prices must be anonymised or made confidential in some way to protect individuals, but data at higher levels of aggregation can often be shared. for example, the aggregated data in healthcare have been shared by the centre for disease prevention and control (cdc, 2020) in the united states and the national health services (nhs, 2020) in the uk. additionally, we expect to observe lots of missing data, poorly recorded data, the need to combine information from various data sources and data types, and the need for the contextual knowledge of domain applications. (hyndman, 2020) . another open-source software that has been used to create forecasting tools is python. statsmodels library (seabold and perktold, 2010) in python allows for statistical forecasting and scikit-learn library (garreta and moncecchi, 2013 ) is used more for machine learning. commercial software such as oracle, sap, simul8, optima, tableau, sas, forecast pro and others might also be used in fsg given that they incorporate forecasting modules in their solutions. • method: it is important to note that fsg may or may not involve a novel statistical forecasting methodology. while in some cases societal challenges may lead to innovative research development, the application of existing methods in novel ways is also included in fsg. moreover, problems in fsg often have small datasets, or in some cases the data is not available at all or the data is incomplete and its quality is unreliable. therefore, the application of well structured qualitative approaches in such circumstances might be more appropriate. this could also lead to new forecasting methods that concentrate on incomplete and small datasets. we should also note that the importance of aligning projects with a real problem in social foundation and ecological ceiling highlights the difference between simply applying exciting forecasting methodologies to a dataset in domain applications and fsg. the latter must have a broader appreciation for the context in which forecasting method would be used in order to provide solutions that can effectively contribute toward achieving the goal. in fsg, we are not only interested in a methods forecast accuracy, but also in its reproducibility, interpretability and transparency. the absence of sufficiently documented methods and computer code underlying the study effectively may undermine their value and becomes a barrier in their use and implementation. (hyndman, 2010; boylan et al., 2015; boylan, 2016; haibe-kains et al., 2020) . another part of new methods is developing techniques to estimate model parameters with novel loss functions driven by fsg. • report: when forecasting is intended to provide social good and to prioritise the public as a whole, the results should be widely reported to maximize the benefit of the forecast. fsg is often going to be of interest to, and hence scrutinized by a wide audience. thus transparency and trust may emerge as being more important than raw predictive ability. consider the recent and current discussion of earthquake predictions in italy (benessia and de marchi, 2017) , pension dispute in higher education in the uk (wong, 2018) and the recent covid19 pandemic (shinde et al., 2020) . in some domains, forecasters can be held liable. weather forecasts are, for example, widely available on websites, apps and in other media. modern reporting tools such as rshiny and dashboard make it easy to create user-friendly web-based interfaces for reporting forecasts. example of using rshiny for fsg include the flusight network that shares real-time forecasts of influenza in the us each week, covid-19 forecast hub and modeling covid-19 (reich et al., 2019; hill et al., 2020) . while forecasts specifically designed for the desired application in social good should provide the best information, in some cases forecasts generated for other purposes can be used to provide good information for social good decision making, e.g., climate models can be used for early warning in predicting droughts that can inform humanitarian disaster relief planning (travis, 2013; coughlan de perez et al., 2015) . forecasting for social good is built on previous movements aiming at using technology to positively impact the society. one of the initial movements in that direction is the tech for social good that broadly uses digital technology to tackle societal challenges (chaudhary and murata, 2015) . another related area is green supply chain that uses a range of technologies and measures to incorporate the ethical and environmental responsibilities into the core culture of contemporary business models (min and kim, 2012; zhu and sarkis, 2004) . with the increase in data availability in the recent decade and the interest in using the power of data to tackle societal challenges, these initiatives have slowly branched out leading to data-driven initiatives for social good (cuquet et al., 2017) . data dssg is defined as applying data science to improve civic and social outcomes. the initiative was introduced to help non-profits and government organisations achieve more with their data (moore, 2019) . several other forms of engagements have since been introduced to derive insights from data in order to help solving social issues. these engagements might be found in the form of fellowships, conferences, competitions, volunteerbased projects, innovation units within large development organizations, and data scientists employed directly by smaller social change organizations. another similar initiative to dssg is aisg that focuses on the techniques usually utilised in the artificial intelligence field towards social good. dssg and aisg terms have been used interchangeably in research. pro bono or initiatives aim at connecting or/analytics professional volunteers with social good causes. volunteers donate their time and skills to help nonprofit organizations make better decisions. ssg uses data analysis, statistical and computational techniques to tackle social problems. ssg focuses mainly on problems stemming from economic inequities, like poverty, hunger, human trafficking, and unequal access to education. table 1 summarises related areas to fsg. dssg, aisg, pro bono or and ssg are broader terms that may include forecasting as a component. the need for forecasting is driven by uncertainty around the future decisions dealing with societal challenges that need to be made in the light of forecasts. fsg might differ from these movements in the following ways: 1. while dssg, aisg, pro bono and ssg initiatives are defined as domain applications, their scope might be limited to certain organisations or sectors. fsg is not defined based on domain applications, it is inclusive and does not exclude anyone; 2. fsg is still valid in the absence of data, the area of judgemental forecasting is a valuable tool in the lack of data. however, this is not the case with dssg, aisg, pro bono or and ssg; 3. our focus in fsg is narrowed down from the general data science, artificial intelligence, statistics or operations research, to the use of forecasting for social good improvement; 4. fsg acts as a compass for the way we do forecasting research and engage with the society at various scales, from an individual to an organisation level; in this section, we provide a framework that allows the forecasting community, researchers and practitioners to discuss the status of research in fsg and to discover new research opportunities where they can come together to contribute to the area of forecasting for social good. figure 6 presents a 2 × 2 matrix of research maturity (stokes, 2011; gregor and hevner, 2013) in fsg based on two dimensions: i) theory: maturity of forecasting process research and ii) practice: use of forecast for social good. in this framework the forecasting process maturity is defined from initial to mature levels, where: 1. initial: it is characterised by a lower range of topics and methodologies, with a few researchers focusing on the area. 2. mature: it is characterised by well-developed forecasting processes that have been studied over time by many researchers resulting in a body of knowledge that contains points of broad agreement. we consider four areas of development as illustrated in the fsg research maturity framework in figure 6 . we discuss each quadrant and explore some examples of research opportunities for each one. this quadrant is concerned with well established forecasting process research that is regularly used in social good. this implies that users know at least conceptually the forecasting process and how to do it. therefore, the forecasting process is applied widely across social good as a routine work. research opportunities and contribution to research might be less obvious but it is not impossible. for example, simple linear regression models are widely applied in social good practices such as medicine, emergency department and emergency medicine service to inform policies (boyle et al., 2012; kuk and varadhan, 2013) . this quadrant is related to well-defined forecasting processes that are not used widely in social good. we may face situations where the effective forecasting process is not available and used in social good, however it may exist in other areas. therefore forecasting processes can be adopted, refined or extended for a particular need of social good. it is also possible to adopt a well-defined forecasting process from one application of social good to another. projects fitting this quadrant provide a great opportunity for research contributions towards applications and possibly knowledge. a large part of research in social good might fall in this quadrant. for instance, successful use of forecasting processes in load demand could be adopted to forecasting emergency department demand as both deal with sub-daily data (rostami-tabar and ziel, 2020) . van der laan et al. (2016) employed knowledge available in intermittent demand forecasting theory to forecast humanitarian needs for medecins sans frontieres (msf-oca). this quadrant focuses on a situation where forecasts -in various forms of estimation-are used in social good, however the forecasting process is not mature. fsg practices can improve the effectiveness of the forecasting process and advance its level of maturity. there are research opportunities here towards contributing to advancing the forecasting process theory. for instance, practices in the area of energy forecasting led to the advance of the theoretical framework of probabilistic load forecasting (hong and fan, 2016) . in humanitarian and disaster relief operations, experts are using their own experience, expertise and opinion to estimate the humanitarian relief needs and make decisions accordingly. given the high level of uncertainty such as impact of disaster, its duration, the demand and supply requirement, in the humanitarian and disaster relief forecasting, it is possible that there are methods developed in handling humanitarian and disaster relief operations where multiple perspectives need to be brought together quickly, and these methods may have wider applicability in forecasting problems (altay, 2020) . hence, it is likely that fsg practice may lead to improvement and advance research maturity in the judgemental forecasting process. this quadrant concerns innovative forecasting processes that are new to social good. this will contribute to both forecasting process research maturity and the use of forecasts in social good. for instance, the development of new forecasting methodologies that is directly integrated to the decision making process and its accuracy is evaluated based on social good metrics is an important avenue. an accurate forecasting method evaluated based on statistical measures might not necessarily led to an accurate social good metric. this is because the translation between forecast errors and social good metrics might not be linear. this is a well known issue in forecasting for inventory control (syntetos et al., 2009; kourentzes et al., 2020) . another example would be identifying appropriate loss functions for social good to estimate the parameters. it is crucial to produce forecasts that are tuned to social good loss functions rather than assuming that the most accurate forecasts based on statistical measures are always best. the social good context has asymmetric and unusual losses that should be taken into account. forecasting for resource planning is a common task in the health forecasting. a loss function that can balance the over versus under capacity could be used to optimise the forecasting model parameters. finally, the limited capacity to record data in developing countries and the data quality issues related to that, especially when it is coupled with humanitarian crises is very common. in this context, other similar humanitarian disasters may have data that could be applied to a new disaster/event. therefore, developing new forecasting processes that specifically focus on small and messy datasets in social good is important. we should note that the fsg research maturity framework is not prescriptive. it can serve as a tool to help researchers and practitioners map their research to social good practices. this will help them to prioritise their research agenda, identify areas where they can contribute to social good and create opportunities to advance fsg knowledge and close the gap between theory and practice in fsg. forecasting is an integral part of organisational decision making, but its linkage to noneconomic/financial utility has been limited. better integration of forecasting with environmental and social kpis is both feasible and desirable, and relevant practices have been receiving increasing attention as a means to safeguarding and generating social good. with the support of the international institute of forecasters (iif), forecasting for social good (fsg) has recently been introduced as a self contained area of scholarship, enabling focused academic research and facilitating a constructive exchange of ideas between academia and the private and public sector (rostami-tabar, 2018 , 2020b . in this paper, we have attempted to further formalise fsg in order to increase awareness and interest of academics and practitioners on its potential impact; encourage interested academics and practitioners to engage in this important agenda; and inspire the development of new forecasting methodologies tailored for social good applications. we find the doughnut theory accommodating, towards reaching a helpful definition of fsg: it is concerned with real social problems both in terms of application and performance measurement, and emphasises society as a whole. different from other data science, statistics, and operations research initiatives that emphasise social good, fsg is not restricted to particular organisational contexts or sectors, and capitalises on the fundamental advancements that have been made in the area of judgmental forecasting, to dissociate substantive contributions from the availability of (quantitative/hard) data. mapping the maturity of research in various areas of forecasting against fsg practice allows us to identify opportunities for bridging the gap between the theory and practice of fsg. when practice lags behind theory, there is an opportunity to adopt already existing theory to advance practical applications. when theory lags behind practice, there is a need to advance forecasting research, building on the insights and lessons learned from practical applications. the forecasting community is called to invent new approaches in areas where neither sufficient knowledge nor empirical evidence have been accumulated. the fsg guidelines we present in this paper are not intended to be definitive, and we recognise that relevant work may indeed fall outside our working framework. the intention of fsg is to motivate engagement with important issues facing our world and society and allow best (forecasting) practices to emerge. that is, we hope a definition of fsg and its introduction as a self-contained area of inquiry will lead to increased appreciation of forecasting as an enabler of greater social good. qualifying what constitutes fsg should permit academics and practitioners to appreciate the opportunity cost of not engaging with its scalable agenda. there are a number of ongoing initiatives in this area (dssg, 2019; 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vincent, penny; anderson, jamie; rawstorne, patrick title: measuring well-being: trial of the neighbourhood thriving scale for social well-being among pro-social individuals date: 2020-06-10 journal: int doi: 10.1007/s42413-020-00067-6 sha: doc_id: 26596 cord_uid: 1kr5vmtf we report on a trial of the neighbourhood thriving framework (ntf), a conceptual framework from psychology and social science for measuring collective subjective social well-being. it combines the notions of feeling good and functioning effectively in a neighbourhood social environment in an indicator set of 15 conceptual dimensions. an online questionnaire was used to measure neighbourhood thriving (nt) among 212 pro-social volunteers involved in revitalising neighbourhoods in the uk city of stoke-on-trent between may and october 2018. exploratory factor analysis revealed 11 factors that made conceptual sense including three social epidemiological pathways to well-being, networks, participation and pro-social behaviours, and four criteria for flourishing societies, autonomous citizenship, safety, cohesive communities and resilience. the 11 sub-scales of nt showed satisfactory internal consistency reliability and preliminary evidence of construct validity. the sub-scales were used tentatively to examine nt among the volunteer sample, which showed the highest sub-scale score for positive regard and the lowest score for celebration. different levels of nt were observed among the community, with age and income positively associated with higher levels of nt. further validation work is needed before the nt scales can be used with confidence. validated scales offer potential benefits including: measuring nt preand -post project implementation; establishing which dimensions of nt are, and are not, working well in a community and need strengthening through further initiatives, and establishing which specific groups of people are experiencing lower levels of nt and designing projects that meet their needs. electronic supplementary material: the online version of this article (10.1007/s42413-020-00067-6) contains supplementary material, which is available to authorized users. the nff was devised by anderson. it comprised a preliminary indicator set of 14 features centred on the combined notion of social feelings and functionings at the group, not individual level, in relation to geographic or non-spatial communities. these were derived from huppert et al.'s (2006) individual well-being framework, based on current psychological theory, and developed for the european social survey (ess). it distinguishes interpersonal features (e.g. receiving help from others) from personal feelings (e.g. i feel happy). anderson introduced four additional features. the ess framework measured well-being among individuals. it evolved from developments in psychology where individual subjective well-being is conceived of as split between momentary experiences of pleasure or positive emotions (hedonic well-being) and more important, long-term and active processes of 'well-doing' (aristotle's eudaimonia) (see, e.g. keyes 2002; ryan and deci 2001; huppert and so 2013) . hedonia is theorised as a passive process of attaining the state of feeling good. eudaimonia is said to involve 'being holistically engaged, being challenged and exerting effort' (waterman 1993, cited in anderson and baldwin 2017, p. 316) , which meets needs rooted in human nature, such as the realisation of potential (waterman 1993; ryan et al. 2008, cited in anderson and baldwin 2017, p. 316) . huppert and so (2013) combined these two types of wellbeing -feeling good (hedonic well-being) and functioning effectively (eudaimonic well-being) -into an operational definition of individual mental well-being increasingly referred to as flourishing. they captured each form through an objective list of feelings and functionings. when compared with the results of a single survey question about 'life satisfaction', a traditional survey proxy for well-being, they found that the single measure lost much information and confirmed subjective well-being as a multidimensional construct (p. 839). whilst there are other indicator sets that combine hedonia and eudaimonia, they are not designed to measure neighbourhood-based flourishing, as shaped by the particular social experiences that people accrue by living in a geographically defined neighbourhood. the most widely used measures include the personally expressive activities questionnaire standard form (peaq-s) (waterman 1993) , the orientations to happiness scale (oth) (peterson et al. 2005) , the satisfaction with life scale (diener et al. 1985) , the scales of psychological well-being (ryff and keyes 1995) , and the hedonic and eudaimonic motives for activities (huta and ryan 2010) . while these scales provide general measures of hedonia and eudaimonia they do not indicate the sources of well-being and happiness and nor are they linked to neighbourhoods and local communities. with the exception of one item (positive relationships), huppert and so's scale did not address social well-beingwell-being at the group or community level, i.e. how the individual responds to experiences of the social environment which can affect their health (larson 1993; keyes 1998) . as individual local communities around the world face increasingly more frequent challenges that affect all members and put a strain on their daily social environment, (e.g. climate change, pandemics, and socio-economic crises), many people's well-being will be affected. well-being is a core component of group social resilience (zautra et al. 2008 ), a quality that communities can collectively cultivate that allows them to cope with, and respond effectively to these shock experiences. other essential components of social resilience are social capital (participation in networks for collective benefits) and social cohesion (cohesive relationships between social group/network members) (baldwin and king 2018) . whilst the individual members of a population may be feeling good and functioning effectively on an individual (personal) level, the same people might respond weakly at a communitylevel to a big challenge, (e.g. a natural disaster) (anderson and baldwin 2017) . strong communities experiencing high levels of well-being are more likely to develop the 'adaptive capacity' (berkes and ross 2013) to respond resiliently to challenges (baldwin and king 2018) . therefore, being able to measure (and maintain) a type of aggregated individual well-being that is grounded in shared social experiences (i.e. social well-being or flourishing), will be a key aspect of assessing and maintain community resilience. social health and well-being are recognised as a distinct phenomenon (e.g. larson 1993; keyes 1998; keyes et al. 2007 ) from individual psychological and emotional well-being (keyes et al. 2007, p. 100) , and physical and mental well-being (world health organization 1946 /1948 . whilst there is no widely accepted common definition, 'social health' (larson 1993, p. 287) describes the health of society and factors such as the distribution of wealth (mcdowell and newell 1987) , or the influence of social phenomena on individuals. the latter has been defined as: 'that dimension of an individual's well-being that concerns how he gets along with other people, how other people react to him, and how he interacts with social institutions and societal mores' (mcdowell and newell 1987, p. 152) . keyes (1998) proposed a conceptualisation of social well-being that situates an individual within social structures. that person evaluates their situation and personal functioning against social criteria (italicised), whereby they appraise themselves in the context of: 1) integration (relationship with community/society); 2) contribution (their social value and contribution); 3) appraise others: acceptance (trust in others); and appraise society/community: 4) actualisation (evaluation of society/communities' potential); and 5) coherence (perceived quality and organisation of society/community) (keyes et al. 2007, p. 100) . the original nff (anderson's work) built upon keyes' work, and aristotle's eudaimonia to argue that 'a well-lived life includes the quest for positive social lives, involving meaningful interaction with family, community and wider society'. going beyond individual psychological functioning, the presence of both social feelings (e.g. i feel close to my community) and social functioning (e.g. i feel supported by my community) reach beyond perceptions of one's self and represent a key part of positive social health. as public health scholars, we were also aware of the broader social epidemiology approach that situates psychological approaches to well-being within an epidemiological model of causal pathways between factors that affect human health and well-being, and health and well-being outcomes. social epidemiologists (e.g. kiwachi and kennedy 1997; berkman and glass 2000; kiwachi and berkman 2000; wilkinson and marmot 2003) charted causal pathways between the individuals' social experiences of the social environment, encompassing interactions with others within it for different purposes, and personal physical and mental health and well-being status. they explore pathways between individual and group experiences of processes described by sociological concepts such as social integration (as defined by keyes); social networks -the structures of society/community; social cohesion -the quality of individual and grouplevel relationships within networks; social capital -the ways in which networks operate to provide members with benefits; the provision of social support -a particular kind of network benefit; and individual and group-level health and well-being. both psychology and social epidemiology recognise the roles of the individual, others with whom they interact, and the social environment as determinants of social well-being (mcdowell and newell 1987, p. 152; keyes et al. 2007, p. 100; berkman and glass 2000; kiwachi and kennedy 1997) . the ntf uses proxy indicators, otherwise known as construct scales, which aim to measure the specific feelings and functionings that individuals experience at the interface between individual and social experiences. psychology focuses on the internal psychological processes that individuals experience during and through such interactions and processes during daily life. social epidemiology identifies the wider social processes and dynamics operating in broader community, societal and institutional contexts, and evinces concrete links to health and well-being. these approaches are combined in our conceptual framework. the dimensions of social well-being that we tested in this study, then, are the 14 conceptual dimensions in the nff and one additional dimension. they are described in table 1 below. we named this set of conceptual dimensions the neighbourhood thriving framework to differentiate it from other neighbourhood flourishing trials run by author anderson. each dimension was represented in our study by a set of 5-7 proxy indicatorscommonly known as 'items' in psychology questionnaires (see below). each item uses a statement for survey respondents to respond to by testing this framework on pro-social people rather than all residents of a neighbourhood, we had the following questions: 1) did pro-social volunteers' responses lead to any variations in the dimensions of well-being that emerged when exploratory factor analysis was performed? 2) to what extent did the resulting factor structure reflect the three social epidemiological pathways to well-being: networks, participation and pro-social behaviours? the neighbourhood is the geographic location of the local social environment, but within this social environment, there is a sub-network of pro-social volunteers aiming to produce reciprocity a balance between give-and-take or reciprocity in social exchange (i.e. perception of support from locals and providing help and support to them in turn) celebration two sub-features: the extent to which people feel that their local community values and actively celebrates (a) fellow members and (b) creativity engagement positive social relationships, that can be intimate or more informalas in more numerous but more superficial autonomy residents' perceptions of their influence over the local area and in shaping community life or activities, free from others people's control pro-social outcomes from their volunteer activity. each individuals' experience of volunteering occurs in social networks with fellow volunteers. equally then, 1) the volunteer network, 2) the wider social environment created through the interaction of people in neighbourhoods during voluntary activity, and 3) the prosocial activity, may all influence respondents' social well-being outcomes. accordingly, we adopted the social epidemiological emphasis (berkman and kiwachi 2000) on the social health and wellbeing effects of social networks and civic activity, identifying the three aforementioned possible causal pathways (each a sociological concept with sub-components) to an individual's positive social well-being matching the position of the volunteers in our study. social networks as non-spatialised communities are becoming more common (anderson and baldwin 2017, p.314 ) and volunteers were distributed throughout the city, although acting in neighbourhoods, conceptually, we focused away from geographic neighbourhood-based communities to communities-as-social-networks (see also berkman and glass 2000) as a sub-network within the neighbourhood. berkman and glass (2000, p. 141 -2) used a network approach to understand how the structure and function of social relations and networks influences health outcomes. they drew on the analysis of earlier anthropologists (barnes 1954; bott 1957) of the ways that networks 'cut across traditional kinship, residential and class groups' (berkman and glass 2000, p. 140) to explain the benefits that network members acquired such as jobs and political activity, and emphasises analyses of the structural qualities of the relationships among people in the network, its composition, and the type of resources that were available through it. social networks are linked to health outcomes through four sub-casual paths: through their functions in providing social support, the social influence of network members on other members, e.g. the provision of information on maintaining good health, social engagement and attachment, and the access that networks provide to resources and material goods (berkman and glass 2000, p.143) . social participation and engagement social participation and engagement is a related concept to 'network' that builds on its inherent abilities to connect people, and which is influential in social psychology, and the social and political sciences. it is described as 'a process in which individuals take part in decision making in the institutions, programs, and environments that affect them' (heller et al. 1984; florin 2000, cited in keyes et al. 2007, p. 98) . it involves people participating in a community context in social activities in networks, as shaped by local issues, the geographic location, and local 'culture, norms, values and institutions' (keyes et al. 2007, p. 98) . this describes the position of our volunteers. contributing to the community through participating and engaging with other participants has been linked to aspirations for life and well-being (keyes et al. 2007, p. 99-100) . berkman and glass (2000, p. 146-7) elaborated on an unclear pathway between social engagement and participation and positive health status. they saw participation as the face-to-face 'enactment of potential ties' in informal and formal settings where people take on social or occupation roles (e.g. as a community volunteer, as per our study, which can give them feelings of 'value, belonging and attachment'). participating in a social role within the network reinforces personal identity (berkman and glass 2000, pp.146-7) , provides company and sociability, and on the collective level, networks are a key feature of social cohesion, also a determinant of positive health status (kiwachi and kennedy 1997) . the authors found that 'contact with friends and family, and participation in voluntary activities' gives life 'a sense of coherence, meaningfulness and interdependence' (p. 147). they linked social participation and engagement indirectly via coherence and identity to improved levels of well-being, and directly various physical health outcomes. the participation and engagement aspect of volunteering could also contribute to our volunteers' social well-being. pro-social behaviours when people participate in social networks, a third pathway emerges between the actual prosocial behaviours and actions that each individual engages in, and the influence of these on their health and well-being, and that of an aggregation of their fellow community members'. ryan et al. (2008) have described the eudaimonic component of flourishing as a way of life. they reviewed a number of studies that collectively showed that people who live in a eudaimonic way are more likely to exhibit prosocial behaviour, thus benefiting themselves and other people in their wider community. individuals who undertake much social and volunteering activity have shown correlations with positive affect (the emotional component of well-being) and negative correlations with depression (larson 1993, p. 286) . in reverse, well-being itself is said to result in prosocial behaviour (huppert and so 2013, p.838) , so there is a hypothesised bidirectional pathway of influence. ryan et al. (2008) also found that 'conditions both within the family and in society more generally contribute toward strengthening versus diminishing the degree to which people live eudaimonic lives' (ryan et al. 2008, p139) . our study was able to test out this statement by exploring the extent to which stoke's social environment was associated with pro-social activity. the 14 conceptual dimensions from the original nff framework are mainly an extension of huppert et al.'s well-being frameworks for the 2006 and 2012 ess (huppert et al. 2012) . to these, author, anderson, added three further concepts: safety, participation and celebration. safety and participation were included in light of roger's (2003) substantive development of a social cohesion index and their absence from the ess model. celebration overlaps with roger's concept of creativity (community that encourages imagination and boldness) but also includes the notion of appreciation, and affection. we incorporated an additional dimension, 'affection', into the adapted neighbourhood thriving framework trial because loneliness and isolation are detrimental to mental health, and "friendliness" is a valued quality in uk communities. our aim in the present trial was to achieve sub-scales with a minimum of 3 items in each to provide reasonable reliability and validity of each sub-scale. to achieve this, baldwin and rawstorne devised 5-7 proxy indicators per dimension (subscale) in anticipation of the potential loss of proxy indicators during exploratory factor analysis (efa) and reliability analysis. where possible, proxy indicators were adapted from the ess (2006; 2012) , and existing national uk surveys, the citizenship survey (2010-11; uk data archive study no 7111), uk household uk household longitudinal study (institute for social and economic research 2014), ons social capital indicators review (foxton and jones 2011) and surveys from environmental psychology (e.g. williams and vaske 2003) and social epidemiology (e.g. cobb 1976 ). elsewhere, original proxy indicators were devised through discussion/refinement between the authors, with disagreement rare and discussed until agreement was reached. the survey questionnaire is in the appendix, and was reviewed by stoke project leads. face validity (i.e. proxy indicators appearing to measure what they are intended to measure) and content validity (i.e. proxy indicators measuring the full breadth of each construct) were built into the design of the proxy indicators measuring each sub-scale. a summary of the research process ranging from the utilisation of the neighbourhood flourishing framework through to the development of the neighbourhood thriving scale is depicted in fig. 1 . the study received ethical approval from the university research ethics committee at oxford brookes university, uk, and human research ethics committee at the university of new south wales (unsw), australia. we sought volunteers involved in pro-social/community activities at neighbourhood level, via a request circulated to public health authorities/community development organisations in uk cities/regions using our networks and online mailing list community empowerment evidence network ceen@jiscmail.ac.uk interest was received from aylesbury, sheffield, exeter and stoke-on-trent, and south wales. stoke-on-trent (hereafter known as 'stoke') (estimated population of 255,378 in 2017; 88.5% 'white' ethnicity) was selected because it is one of the most deprived cities in england -14th out of 326 local government authorities. over half the population (53%) live in areas that are among the 20% most deprived in the country (all: stoke-on-trent city council 2011). we also chose stoke as people in the city are generally disengaged on civic and organised community levels. residents demonstrate the lowest participation in volunteering (7.37% -just below the county's average) and lowest voting rate (54%) in the county (region) of staffordshire. social cohesion is challenging. just 60.8% of people say they believe people from different backgrounds get onthe national average is 76.4%. and 26.9% of people thought they could influence decisions compared to the national average of 28.9%. and 44.3% of people feel that people do not treat each other with respect, with a national average of 31.2% (staffordshire community foundation 2015). in response, stoke-on-trent city council public health department commissioned two community development projects in 2012 to reduce health inequalities through social action, each run by a separate community interest company (cic -a social business, with stated community benefit). a) my community matters (mcm) engages residents in social action in 10 neighbourhoods. in each, community development workers collaborate with residents, community groups, businesses and organisations to set up neighbourhood partnerships. they empower residents to lead community activities, to identify local assets, improve neighbourhoods and inspire further action. http://mcmstoke. org.uk/ neighbourhood flourishing framework = 14 conceptual dimensions of social well-being (within place-based neighbourhood) + 1 new conceptual dimension (affection) = neighbourhood thriving framework = 15 conceptual dimensions of social well-being each conceptual dimension represented in our questionnaire by 5-7 proxy indicators (items) * to what extent is it reflective of 3 social epidemiology pathways to social wellbeing: networks, social participation and engagement and pro-social behaviours? * = statements that represent the conceptual dimension being tested in our survey to measure social well-being that pro-social volunteers are asked to respond to international journal of community well-being b) 1000 lives network is a city-wide virtual network that was developed in response to demand from active citizens for opportunities to connect for mutual support to sustain their social action and engage others in volunteering. motivated residents, civil society and voluntary groups, and paid workers support volunteers and community groups. the network provides training in skills for community leadership, facilitates resource sharing, supports social action project start-up, and celebrates 'community champions.' by 2017, 1000 lives and mcm were in contact with a minimum of 2000 volunteers, but were unaware of how many participated in both. keen to gain a baseline measure of participants' social well-being (nf), they agreed to inform their networks about our online survey hosting the trial, and assist respondents to access it using mobile phones and computers. development of the neighbourhood thriving framework scale for social wellbeing involved several stages including: item development, piloting and revising item statements, as well as reliability and validity testing (including content validity, face validity, construct validity, and cronbach's alpha coefficient internal consistency reliability). item (proxy indicator) development occurred between december 2017 and january 2018. in the statements, we distinguished between the physical locality of a neighbourhood, and its human residents to make it clear which one we were talking about. we phrased this distinction in the questionnaire using terms taken from the two stoke initiatives: "by neighbourhood, we mean: the buildings and outdoor spaces where you live and/or work where you see local people". "by community, we mean: the people who live, work, study, volunteer, run services and businesses locally with whom you interact, other than your family". this distinction was stated before and mid-way through the 15 dimensions-based sets of statements in the online survey. the premise of our research was that volunteers conducted activities on a face-to-face basis within spatial proximity of each other, not a virtual one, hence the questionnaire did not address online activity. however, in conceptual research terms, there is no guarantee that the human residents of a physical neighbourhood will form any kind of network or social community. it is not uncommon in northern europe to find that people do not know or cooperate with their neighbours in any meaningful way. this norm may be changed significantly after the current covid 19 pandemic which is showing the importance of local cooperation and neighbourly relationships. the original nff in part sets out to measure what level of shared social experiences occur in any given neighbourhood, and how these impact on residents' social well-being. the stoke projects intended to galvanise residents to come together to work collectively on improving their neighbourhoods, and to enhance networks and feelings of social community. with this additional pro-social effort on top of the routine workings of neighbourhoods, how would this impact the final factor structure? the stoke-on-trent well-being survey questionnaire (sotwsq) was constructed for the purpose of collecting data for this trial and hosted by online platform qualtrics: https://www.qualtrics.com/uk/. respondents were guaranteed anonymity and gave their consent via an online form prior to completion. a downloadable sheet listing the contact details of the authors, community development workers from 1000 lives and mcm, and local mental health support services for respondents to ask questions or seek support should they experience any discomfort after completing the questionnaire was clearly marked beside the consent form. it was not expected that completing the questionnaire would result in adverse effects due to the gentle nature of questions, and no respondents contacted the team with questions. after responding to demographic questions, they were asked to answer 15 questions one relating to each dimensionby responding to 5-7 items per dimension by selecting an answer option for each from a 5-point likert scale, from 1) strongly agree, 2) agree, 3) neither agree nor disagree, 4) disagree, and 5) strongly disagree. the subscales are named in appendix a for reader clarity and have been re-labelled, but were not named or numbered as such in the questionnaire. some items were inverted at random to mix up the order of positive and negative statements so as to identify response bias (i.e. respondents ticking all answer options down the left-or right-hand side of the page). a full list of the scale items and their sources are provided in appendix a. we opted for a convenience sample of a minimum of 200 volunteers which was not randomised or stratified. volunteers' addresses were already known and there was no viable way of randomising their selection as relevant demographic information was unavailable. instead, the limitations of a convenience sample were accepted, and the following survey inclusion criteria were set for respondents: they should be aged 18 or over, live or work in stoke, volunteer with mcm, 1000 lives or another local community action group, and be able to complete the survey online. a pilot trial was run with the first 20 volunteers at a community meeting in stoke. they completed it on laptops (some with support worker assistance) following an introduction by authors baldwin and rawstorne, who visited. respondents provided verbal feedback on the pilot version of the survey and small changes were made to the wording of survey items for clarity, and incorporated into its final design. no items were deleted. project workers used their face-to-face contacts, email distribution lists, facebook pages, twitter, and community group webpages to inform volunteers about the survey and invite them to take part. online data collection for the full community trial took place in stoke-on-trent between may and october 2018. data collection for the pilot trial ran from late april to early may, and the community trial ran from early may to october 2018. the pilot data was not used in the final analyses, only the data from the trial. data cleaning was minimal since the instrument was administered via the qualtrics site with skips (routing) built into the programme. exploratory factor analysis (efa) using principal axis factoring with oblique rotation was performed on all 85 items, based on the responses of 212 participants who lived and/or worked in stoke-on-trent. cronbach's coefficient alpha was calculated for each factor to determine the scale internal consistency reliability as well as whether the reliability of each sub-scale could be improved by the deletion of any items. removal of items from scales was also informed by conceptual considerations. construct validity was tested in two ways: first, by correlating each sub-construct with other sub-constructs, after making predictions about the direction and strength of each association, and second by: conducting analyses between sub-constructs and other study variables that were expected to show a relationship or difference. once satisfied that the sub-constructs showed preliminary evidence of reliability and validity, we conducted further analyses of nt in stoke. many of the analyses, including those used to help describe the sample, were examined across two variables of interest: sex of participant and judgement about whether their neighbourhood had got better to live and/or work in over the preceding 2 years. a majority of the 212 participants were women (n = 144; 69%), and 66 (31%) were men (table 2) . over one-third of the sample participated in the mcm, while 50% were involved in projects other than mcm and 1000 lives (table 2 ). in answering whether their neighbourhood had got better to live and/or work in the prior 2 years, 65 people (31.4%) agreed to some extent, 56 (27.1%) were neutral, and 86 (41.5%) disagreed, thinking that their neighbourhood had got worse. the age of participants ranged from 18 to 86 with most between 35 and 64 years. most participants were living in households alone or with another adult (table 2) , mostly without children at home. three variables influenced perceptions of whether neighbourhoods had improved as a place to live/work. most people had lived and/or worked in their neighbourhood for at least 20 years (table 2) . those who had lived and/or worked in their neighbourhoods for longer than 20 years were more likely than others to think their neighbourhood had not improved in the preceding 2 years, ï� 2 (6) = 17,121, p = .002. a majority (53.3%) reported living and working in stoke (table 2) . those working in stoke were more likely than those who lived in stoke to report their neighbourhood had improved, ï� 2 (4) = 14.18, p = .007. most of the sample reported household income of less than â£52,000, while over one quarter opted not to reveal this. those who were in the highest household income group were significantly more likely than those in other income categories to believe their neighbourhood had improved, ï� 2 (6) = 12.647, p = .049 (table 2) . the exploratory factor analysis produced eleven distinct factors that made conceptual sense and accounted for 63.5% of the variance based on 65 of the 85 original items. the conceptual underpinnings of the new factors are described in table 3 below. the 11 new factors suggest three findings. firstly, there are six factors mirroring the social epidemiological pathways to well-being: networks, participation and engagement, and pro-social behaviours (included in the latter: collective positive effort, celebration, and optimism about the communitya pro-social state of mind). secondly, the factor, positive regard, mirrors an additional pathway outlined in the community psychology literature: affective attachments to community, and well-being. thirdly, the remaining four factors are all contemporary social conditions that can be deemed necessary pre-cursors to social well-being: social cohesion (cohesive societies and communities), safety, autonomous citizenship (individual autonomy safeguarded by the state), and resilience (current advents can lower resilience and well-being (e.g. deprivation, financial crises, climate change etc.) (baldwin and king 2018) . without these conditions present, positive well-being may be threatened. it is interesting to note that well-being in this scale is represented by pro-social attributes that individuals can experience in group social settings and activity, but also by the right underlying social conditions. eight more items were removed from four factors based on conceptual considerations and improvements to internal consistency reliability with their removal. the removed items and scales included: two items (par5 & par6) from the participation scale; three items (alt4, con3, con5) from the celebration scale; one item (bel6) from the social networking pathway to wellbeing scale, and; two items (alt2 & aff5) from the autonomous citizenship scale. after removal of these items, the 11 factors contained 57 of the original 85 items. with reference to anderson's original nff, two of the 11 factors resembled 'feelings' (safety; positive regard), while nine factors characterised 'functionings' (celebration, collective positive effort, optimism about the community; participation; social network pathways; social cohesion; autonomous citizenship). as shown in table 4 , internal consistency reliability, based on cronbach alpha coefficient, was sound for each of the 11 scales. the reliability coefficients were also stable for men and women, as they were for each of the three responses to the question about whether people believed their neighbourhood had improved as a place to live and/or work in the past 2 years. condition of the social environment for social well-being face validity and content validity were built into our study design by having content experts design the questions, which were reviewed by local community development practitioners. evidence of construct validity was assessed initially through the conceptually coherent factors that emerged from the efa. convergent and divergent evidence of construct validity was then assessed from the inter-scale correlations (table 5 ) as well as through the associations between each construct scale and participants answers to questions about changes in their community (table 6 ). as shown in table 5 , inter-scale correlations (pearson correlation coefficients) ranged from .19 to .77. while some scales showed similarity, a majority were not highly correlated, showing support for a lack of redundancy. the only scale for which a higher score was indicative of lower community wellbeing, low resilience, correlated negatively with all other scales, as expected. the strong associations between construct scales that we argue measure aspects of cohesiveness (e.g. social cohesion, collective positive effort, celebration, social network pathways, low resilience) provided some convergent evidence of construct validity. to compare the mean scores of each of the 11 factors, within-subjects analyses were conducted using glm. the total mean scores of each factor are reported in the total column in the left-hand side of table 6 . there was an overall difference across the factors at a multivariate level, f (10, 195) = 57.93, p < .001. pairwise comparisons showed the mean score on social cohesion was significantly (p < .05) lower than for all table 5 inter-scale correlations (n = 212) 1 1 2 3 4 5 6 7 8 9 10 11 to further assess preliminary evidence for convergent and divergent evidence of construct validity, participants scores on each construct scale were compared with the way they answered two statements about their perceptions of whether their neighbourhood had got better or worse, respectively, in the previous 2 years. for all scales we expected to see a linear relationship in scale scores across the three agree/ neutral/disagree categories for the two neighbourhood questions. those people who agreed with the statement that their neighbourhood had got better were expected to score higher on the nt scales (except for low resilience for which a higher score equates to lower nt) compared with those who disagreed with the statement. and the reverse was expected for the statement that their neighbourhood had got worse. the results shown in table 6 support the hypotheses: for all nt scales, there was a linear relationship in the expected direction with responses to both statements in each of the analyses using anova with polynomial contrasts. for the statement that their neighbourhood had got better, agreement with the statement was associated with higher nt scale scores while disagreement with the statement was associated with lower scores ( the reverse was true for the statement that the neighbourhood had got worse. agreement with the statement was associated with lower nt scale scores while disagreement with the statement was associated with higher scores (collective positive effort, f(1, 199) = 43.43, p < .001; participation, f(1, 199) = 9.83, p < .001; celebration, f(1, 199) = 28.49, p < .001; social network pathway, f(1, 199) = 24.48, p < .001; optimism about the community, f(1, 199) = 46.28, p < .001; social cohesion, f(1, 199) = 61.59, p < .001; engagement pathway, f(1, 199) = 39.92, p < .001; safety, f(1, 199) = 48.44, p < .001; autonomous citizenship, f(1, 199) = 28.30, p < .001; positive regard, f(1, 199) = 19.17, p < .001; low resilience, f(1, 199) = 26.17, p < .001). these results provide some preliminary evidence of construct validity. overall, the sample of pro-social volunteers did not endorse their neighbourhood as being a better place to live and/or work in compared with 2 years prior. anova with linear (polynomial) contrasts were used to test the relationship between the four age categories and each of the scale scores. as shown in table 7 , three of the scales showed a linear trend with age: participation, social network pathway, and engagement pathway. for each of these scales the significant trend was in the direction of neighbourhood thriving being positively (directly) related with age; older people experiencing neighbourhood thriving to a greater extent than younger people. participants who indicated their preference not to answer the question about their household income (n = 58; 27.6%) were excluded from this analysis so that an anova with linear (polynomial) contrasts could be conducted. these analyses, which included three household income categories, showed a significant trend with 9 of the 11 neighbourhood thriving scales: collective positive effort, celebration, social network pathway, optimism, social cohesion, engagement pathway, safety, autonomous citizenship, and low resilience. each significant trend was in the direction of a positive (direct) relationship between income and nt: the higher the income the greater sense and experience of nt. time lived and/or worked in stoke (analysed as three categories) were analysed against the nt scales using anova for between-subjects effects as such analyses explained the data more accurately than linear trend. scores on five of the 11 scales were associated with time lived in stoke: collective positive effort, celebration, social cohesion, safety, and autonomous citizenship. in each of these associations, except for social cohesion, those who had lived and/or worked in stoke for 10 to 19 years showed higher levels of nt compared with participants who had lived and/or worked there for less than 9 years or greater than or equal to 20 years. for social cohesion, there was greater nt among those who had lived and/or worked in stoke for 10 to 19 years compared with the people who had lived in stoke for 20 years or more. the type of presence people had in stoke (analysed as three categories: living; working; living and working in stoke) were analysed against the nt scales using anova for between-subjects effects. scores on seven of the 11 scales were associated with connection with stoke: collective positive effort, celebration, optimism, social cohesion, safety, autonomous citizenship, and low resilience. in each of these associations, those who worked in stoke only (i.e. did not live in stoke) showed higher levels of nt compared with participants living there, and those who both lived and worked in stoke. age ( missing (n = 38); 5 the last category -those who did not want to answer the question -was removed to enable linear analysis *p < .05; **p < .01; ***p < .001 international journal of community well-being our first trial of the ntf resulted in useable questionnaire data from 212 participants. exploratory factor analysis (efa) produced 11 conceptually coherent factors that were further refined through the omission of items that were not contributing conceptually or to internal consistency reliability. all scales showed satisfactory internal consistency reliability across the entire sample as well as separately for men and women and for all three responses to the question about whether participants thought their neighbourhood had improved over the previous 2 years. while face and content validity were built into the design of the scales, construct validation was limited to preliminary evidence only through inter-scale correlations and the relationships of the scales to two questions which asked participants whether they thought their neighbourhood had got better or worse, respectively, in the previous 2 years. inferring construct validity from these analyses is limited because the variables that were used to validate the scales against, were broad areas and not specific to each scale. as such, these associations are only able to confirm that the scales were associated with other factors in predictable ways. additional research is needed to validate individual scales against other known validated scales that are measuring similar constructs. until that happens and the body of evidence for construct validation builds, there must be caution in making inferences when using the scales. other validation work that is needed is in showing whether the scales can be used to predict (at least correlate with) behaviours consistent with a person's scores on each construct, and also examining whether a total nt score is predictive of behaviours. it will also be important for future studies to apply and validate the scales in populations that are comprised of people other than pro-social volunteers, particularly in random samples of local communities. until that happens, we cannot be sure of the stability of the scale structure for non pro-social populations. as such, caution should be exercised when seeking to draw conclusions from the results of administering the scale to non prosocial populations. notwithstanding the need for further validation studies, what do the new scales tell us about nt in our sample? caution is required in making any claims about levels of nt until further validation and norm scores are established. however, since all scale items were measured on a 5-point likert scale from 1 to 5, we offer some broad observations based on mean scores for the scales. with a mid-point of 3 on the 5-point likert scale, and based on higher scores for each of the scales (except for low resilience) indicating higher levels of nt, we can observe that the mean of each of the scales was equal to or above the mid-point, likely indicative of nt. the social cohesion scale was scored the lowest of all the scales which suggests many in the sample perceived social difference in their neighbourhoods as being somewhat problematic rather than as a richness to celebrate. the celebration scale was also one of the lowest scored scales, albeit above the mid-point, which suggests a relative absence of activities and events that recognise and celebrate community achievements. at the opposite end, the positive regard scale was scored highest of all the scales which indicates that people may have experienced a positive outlook towards others in their neighbourhood, perhaps because they are intimately involved in revitalisation activities. as for who appears to be experiencing the greatest levels of nt, the results indicate it is positively (linearly) associated with age and income: older people and those with higher household incomes. also, those who had lived and/or worked in stoke for 10-19 years showed higher levels of aspects of nt compared with those who had been living or working there for shorter or greater periods of time. the type of involvement was also important, with those who work in stoke showing higher levels of aspects of nt compared with those people who lived, some of whom also worked, in stoke. these results are consistent with findings from the 'ageing in place' literature (e.g. young et al. 2004 ) which often show that older residents are less likely to move from their long-term place of residence and feel attached to it, which may help explain higher levels of well-being. similarly, wealthier people are less likely to experience adverse living circumstances and associated stress, therefore demonstrate higher levels of well-being (wilkinson and marmot 2003) . those not living but just working in stoke could be hypothesised as more likely to live in pleasant surrounding rural areas. likewise, those in the middle 'length of residence' category had lived in stoke long enough to have evolved networks and experienced residential stability, but not so long as to become jaded with the deprived environment. it may surprise some readers that the sample of pro-social volunteers in this study did not confirm their neighbourhood had become a better place to live and/or work in over the previous 2 years. there are some plausible reasons for this finding. one explanation is that people who volunteer to try and improve their social environment are motivated by observing that their neighbourhoods could become more pleasant places to live and work. without that observation and viewpoint, it is unlikely people would be motivated to volunteer for such roles. as such, one may conclude that a sample of pro-social volunteers are likely to be the harshest critics of their social environments as they are the ones who observed that change was necessary and chose to act upon that realisation. this is another reason why it is important to sample from a broader cross-section of the community to gauge wider-held community perceptions of changes in the neighbourhood. since the current study did not set out to evaluate the two community development projects that were commissioned by stoke-on-trent city council public health department in 2012 to reduce health inequalities through social action, and because the current sample comprised pro-social volunteers and not a broad cross-section of the community, we are unable to ascertain the specific benefits of these programmes to their communities. however, the 11-factor nt scale that emerged from our research revealed social conditions key to social well-being in the local social environment. future community development programmes should aim to address these conditions: the first three of which can be cultivated through local action: social cohesion (through structured mixing of people from different backgrounds in collaborative activities), safety (through design efforts to transform urban environments with poor street lighting, poor traffic control, and no eyes on the street, and the targeted reduction both crime and violence, and their risk factors), and resilience (through cultivating social capital, social cohesion, well-being and the eradication of inequalities). autonomous citizenship is both a national and local benefit that individual volunteers may experience feelings of it if, during civic action, they can express themselves freely, their fears for safety are allayed, appreciation is shown for volunteers' input, and a feeling of community spirit is garnered. in this paper we have taken steps towards developing a neighbourhood thriving scale underpinned by various sub-scales. each sub-scale showed satisfactory internal consistency reliability and early signs of construct validity. more validation work is needed on these scales, particularly with non pro-social volunteers, before they can be used with confidence to measure the 11 dimensions identified in the study. when these measures were applied to a sample of pro-social community volunteers in stoke, we observed the highest scale score for positive regard and the lowest scale score for celebration. gauging levels of nt through comparison with other places will be made possible once further validation and norms are established. we also observed a positive relationship between age and income with neighbourhood thriving, suggestive that nt may not be experienced equally and to the same extent by all stoke residents. the scale may develop into a useful tool for evaluating the success of community projects when administered pre and post project implementation. it may also be useful for gauging which members of a community are experiencing low levels of nt and to tailor the design of projects at different groups of community members and their needs. conflict of interest the authors declare that they have no conflict of interest. open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. building wellbeing: neighbourhood flourishing and approaches for participatory urban design intervention social sustainability, climate resilience and community-based urban development: what about the people class and committees in a norwegian island parish community resilience: toward an integrated approach social integration, social networks, social support and 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validity and generalizability of a psychometric approach constitution of the world health organization the sense of belonging to a neighbourhood: can it be measured and is it related to health and well being in older women? community development and community resilience: an integrative approach publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-035133-znbqpwgu authors: aye, baba title: health workers on the frontline struggle for health as a social common date: 2020-11-10 journal: development (rome) doi: 10.1057/s41301-020-00271-z sha: doc_id: 35133 cord_uid: znbqpwgu through the lens of health workers’ concerns, the article interrogates the impact of the neoliberal turn of the 1980s on the loss of the ideal and pursuit of health as a social common. it highlights the great recession as a confirmation of the failure of the neoliberal project but notes that this the project continues with even greater frenzy. capturing the dynamics which inhibit the world health organization, it calls for mass mobilization to reclaim health as a social common. health workers have been the first line of humankind's defence against the rampaging incursion of the microbial world, in the shape of sars-cov-2. they have received accolades from peoples and governments alike. in many european cities, people would come out on their balconies at a designated time every evening to shout in honour of health and social care workers. governments as well, joined this chorus, without government officials batting an eye. many questions were not considered or were left unanswered as the waves of applaud came. why were health and social care workers saddled with so much work such that many were running insane shift periods? why was there a global shortage of personal protective equipment (ppe) for so long? how seriously were decision-makers taking the important need to safeguard the health of those taking care of our health in this pandemic? some of these questions have been raised in several ways in the literature in this turbulent year. this tends to be as part of attempts to understand why the pandemic happened and how can a similar situation be avoided in the future. finding answers for these questions requires our grasping the root of the problem. it is the primacy of for-profit interests in health which undermine the provision of health as the fundamental human right and social common which it is meant to be. health, including that of the health and social worker has become a commodity. tons of applauses without systemic change, ushering in a post-neoliberal world would be empty. crises like the present pandemic present opportunities for structural change. health workers are on the frontline delivering much needed care across the world. they are also on the frontline of struggle to bring about such systemic change. this article contextualizes the problem by putting neoliberal health reforms in perspective. it then looks at efforts of health workers roles in the current period, despite daunting challenges and tries to understand why the best intentions of the world health organization might not be enough to ensure the realization of its mandate. it then concludes with a return to a fundamental point made in the alma ata declaration 1 -a pressing need for a new global social compact, for health as a common to become reality. 'since the 1970s, neoliberal health and social welfare policies around the world shifted resources from the public to the private sector'. this has had adverse effect 'on the wellbeing of health and human service care workers' as well as patients (abramovitz and zelnick 2010: 97) . health workers have faced increasing work intensity and less control on the job, leaving them 'emotionally and physically depleted'. high levels of on-the-job stress and burnout became a regular feature of their lives. this ideologically-driven decline of public expenditure in healthcare; privatization of healthcare services, and; dismantling of public health infrastructures (navarro 2008: 153) , went on overdrive from the end of the 1980s as the fall of the soviet empire paved way for capitalist triumphalism of the neoliberal order, best captured with fukuyama's vision of the 'end of history' at the time (fukuyama 1989) . radical changes were made in the public sector as new public management (npm) became the norm in western countries, rolling back the welfare state of the post-world war ii order. the rights-based essence of public service delivery was eroded, in fact, if not always in words. along with privatization, cost cutting measures became engrained in the public sector in imitation of the supposedly inherent efficiency of the private sector. healthcare delivery was not spared. on the contrary health, as one of the fastest growing sectors of the economy (in an age where the value of everything was considered only as its worth in dollars or euros), was a major target of the neoliberal anti-public sector reforms. this was pushed through with a flurry of 'health reforms' which entailed marketization of healthcare delivery. the presence and influence of for-profit interests in health and social care grew exponentially. global healthcare companies, big pharmaceuticals and insurance firms grew in numbers, wealth, and influence. with the use of outsourcing, contracting out and diverse forms of public-private partnerships, they latched onto public health systems, milking it of resources. an increasing number of workers delivering health and social care in public health systems became fixedterm contract staff. as the welfare state was being rolled back in the west, the developmental-interventionist state which had been able to prioritize healthcare delivery was also being smashed in the developing world. international financial institutions played a key role in this. many countries were embroiled in debts after a series of economic setbacks in the 1970s from the oil crisis to the volcker shock. as they turned to the international monetary fund and world bank in the 1980s, they were slammed with structural adjustment programmes. and while imf loans are officially meant to help member countries tackle balance of payment problems, the conditionalities that went with these included setting caps on public sector employment. these ceilings have been identified as key impediments to hiring or retaining health sector workers, and are linked to medical "brain drain" as health workers migrate in search of better employment opportunities (kentikelenis 2017: 299) the great recession at the end of the 2000s demonstrated the failure of neoliberalism in practice. but to reassert the resultant dent of neoliberal hegemony, governments stuck even more religiously with the ideology of this failed god. instead of less, we had more neoliberalization of health and care as well as social life as a whole. fiscal discipline was pushed through with austerity measures, as governments and international finance institutions did all they could to make working-class people bear the cost of economic recovery, while bailing out corporations whose profit maximization led to the crisis. the public wage bill was either cut or had caps put on it in 130 out of 187 by 2015 (ortiz et al. 2016) . health and social workers were particularly hard hit. for example, a 2015 guardian survey showed that nhs staff were the 'most stressed public sector workers' in britain. 2 this is not surprising, as they are 'under-resourced and definitely understaffed' as one of the respondents of the survey said. and on top of that, they are underpaid. their wages were frozen for 7 years and after that, wage increases were capped at 1% for another year until 2018. the case in greece was no better. the salaries of healthcare workers were cut twice in 2010. first by 12% in january and then by another 8% in june (economou et al. 2014) . in a world where profit had become god, with productivity and 'efficiency' its trusted servants, increases in health sector wages were considered at best as a cost disease (baumol and bowen 1993). but, as the pandemic shows quite clearly, reducing the value of human labour to the economic logic of productivity does great injustice to workers concerned and our collective humanity. to roll back the commodification of health and devaluing of the labour of healthcare requires holistic root and branch radical reforms aimed at enthroning universal public healthcare. the pandemic met a global health workforce that was understaffed, underpaid, under-resourced and overstressed. but health workers rose to perform what was close to miracles, putting their lives at risk to save lives. with their lived experiences at a critical hour for humankind, they demonstrated and emphasized the social commons that health in its essence is. from the doctors and scientists in china who dared local party officials to get information out on the new coronavirus, to the indian nurses and doctors who wore diapers to save personal protective equipment which was in short supply 3 health workers demonstrated courage and self-sacrifice. marketization of healthcare prepared the ground for hospitals that felt like war zones as surges spiked in different countries. 4 like the polish cavalry charge at krojanty in 1939, ill-equipped though they have been, healthcare workers bought humankind time as much as they could, in the face of the rampaging sars-cov-2. the task was made the more difficult by a number of interrelated causes within the neoliberal paradigm which had informed health reforms over the decades. the privatization of healthcare was one of such key determinants. analysis covering 147 countries for example, that preponderance of private provision of healthcare as well as cross-cutting policies such as 'reduction in the number of hospital beds per 1000 people' result in significantly higher 'rates of covid-19 prevalence and mortality across countries' by up to 4.3% and 4.9% respectively (assa and calderon 2020: 17) . this analysis was concerned more with the direct impact of privatization and cuts in public hospitals beds on the higher risks of covid-19 prevalence and mortality. we need to also consider the indirect impact. the plummeting of public health investment in europe since 2008 contributed to increasing pre-existing health states which predisposed persons to being infected. for example, public health spending in england fell by £870 m since 2014. this might have 'caused 130,000 deaths and a rise in chronic conditions like diabetes, that incidentally also make you more likely to die from covid-19' (mackenzie 2020: 42) . as several former and serving united nations special rapporteurs point out, the pandemic exposes the catastrophic impact of privatizing vital services such as water and sanitation, and health. 5 the social and economic determinants of health are as much part of the fabric of our collective humanity which should not be left to the determination of market forces. the consequences of the reign of such corporations over our social commons, as the pandemic shows, could be disastrous. the global shortage of ppe was a stark case of an emergency within the global health emergency. but it did not just happen. it speaks to how global supply chains have evolved to best serve profit maximization as the first law of social production, which explains why governments across the world were not prepared in several other ways, when the pandemic broke out. one of the lessons from the 2002-2004 sars outbreak was that ensuring the health of health workers and preparing for surge capacity must be accorded priority, to avert the worst impact of epidemic outbreaks. and several simulation exercises which should have informed governments and the international community to look beyond the logic of on-time production to ensure consummation of these priorities. these include nhs england's exercise cygnus which showed lack of crisis preparedness of the british government for a flu pandemic. 6 the who's r&d blueprint for action to prevent epidemics' disease x in 2018 should likewise have also served as caution for stockpiling ppe. but, with for-profit interests upping policy formulation that puts people first, why keep capital expended on such essential equipment tied down before a pandemic's pandora escaped from its box? this demonstration of 'savage capitalism', as noam chomsky 7 puts it, was not just passive in terms of not having needed medical devices ready, it was also active. as chomsky informs, drawing lessons from the ebola outbreak in 2014, the obama administration entered a contract to make 'high-quality, low-cost ventilators' available for such eventualities as now befall the world was sabotaged by a corporation which bought the original smaller company contracted, because 'it was competing with their own expensive ventilators'. but while neoliberal hegemony continues to hold sway, pushing the maxim of there being no such thing as social commons, the pandemic forced the hands of several governments to take radical and far-reaching actions to safeguard the social commons, in the early months of the pandemic. these included the requisitioning of private hospitals, conversion of factories to produce needed medical devices, supplies and ppe. this was however not with the spirit of ubuntu which health workers demonstrated. these temporary measures did not necessarily amount to taking the private health facilities into public hands or their 'nationalization' 8 as sensationalized in the press. there is a pressing need to go beyond the limited and feeble demonstrations of government's turn to seeming consideration of health as a social common, and only so during emergencies like the covid-19 pandemic. founded in 1948 as part of the multilateral united nations system, the world health organization has a mandate 'to act as the directing and co-ordinating authority on international health work' towards achieving the objective of 'the attainment by all peoples of the highest possible level of health' (who 1995) . from the 1980s when the world bank delved into lending to the health sector on a large scale, this leading role of the organization has been challenged (clift 2013) . the rise of diverse global health initiatives over the last few decades have accelerated this whittling of who's real powers. and relatedly, its increasing reliance on voluntary contributions, including-indeed increasingly more-from philantrocapitalist foundations. this has severe long-term implications. these 'nonstate actors' influence has helped to consolidate the hold of private interests on the health system internationally and in countries across the world leading to; undermining of accountability mechanisms, institutional hybridization, weakening of 'public sector and government responsibility' for health and social care, fostering opacity and the illusion of a redistribution of wealth by the elite. 9 the multi-stakeholderism promoted by philantrocapitalism, and perennial failure of governments to live up to their financial and other commitments whittle the capacity of who to serve in reclaiming health as a social common. it is against this background that such laudable resolutions that would have helped safeguard the health and well-being of health workers such as the 2017 working for health: five-year plan for health employment and inclusive economic growth have failed to translate into concrete steps on the ground. the politics of the covid-19 global response echoes the need for reinstatement of the who's leading role in international health. global health initiatives such as gavi and cepi occupy more or less equal place in the access to covid-19 tools accelerator (act-accelerator), while who cannot arrest the unfurling of vaccine nationalism. the neoliberal turn of the 1980s represents a loss of the trajectory of social progress towards health as a social common. commodification and marketization of health which started with the incursion of international financial institutions at that period reflected a change in the global social and economic order to one of the most naked forms of capitalism. this laid the basis for nightmare which health workers have faced in the pandemic-overworked, underpaid and ill-protected. health works realize the need to change this situation. public services international, the global trade union federation which brings together thirty million workers across the world, about half of which are in the health and social sector has called for 'rapid changes in policies….that put people and planet over profit'. 10 this requires advocacy and lobbying of the who and countries. but even much more it requires monumental social mobilization to restructure the world as we know it, with public health for all at the heart of such this. we must remember that it took 'the combination of militant social movements and structural changes in the economy' to give birth to 'the rise of the welfare state' (abramovitz and zelnick 2010: 98) . it is also important to note that the alma ata declaration recognized the fundamental importance of economic and social development (at the time envisioned as the 'new international economic order') for the fullest attainment of health for all and reduction of health inequities to become reality. 'the post-covid-19 age will usher in a new era of social and political relations' (horton 2020: 127) . but the nature of this is not pre-defined. it could be more of the same as the post-great recession age has been. we must contest it and fight for it to be an age of health as a social common-a post-neoliberal age. double jeopardy: the impact of neoliberalism on care workers in the united states and south africa privatization and pandemic: a cross-country analysis of covid-19 rates and health-care financing structures es?id=10694 &lang=en. accessed 29 ry_analy sis_of_covid -19_rates _and_healt h-care_finan cing_struc tures performing arts, the economic dilemma: a study of problems common to theater, opera, music, and dance the role of the world health organization in the international system the impact of the financial crisis on the health system and health in greece the end of history? the covid-19 catastrophe, what's gone wrong and how to stop it happening again structural adjustment and health: a conceptual framework and evidence on pathways covid-19 the pandemic that should have never happened and how to stop the next one neoliberalism and its consequences: the world health situation since alma ata the decade of adjustment: a review of austerity trends 2010-2020 in 187 countries world health organization (who). 1995. constitution of the world health organization key: cord-270008-h0vghr2w authors: fazio, r. h.; ruisch, b. c.; moore, c. a.; granados samayoa, j. a.; boggs, s. t.; ladanyi, j. t. title: who is (not) complying with the social distancing directive and why? testing a general framework of compliance with multiple measures of social distancing date: 2020-10-27 journal: nan doi: 10.1101/2020.10.26.20219634 sha: doc_id: 270008 cord_uid: h0vghr2w a study involving over 2000 online participants tested a general framework regarding compliance with a directive in the context of the covid-19 pandemic. the study featured not only a self-report measure of social distancing but also behavioral measures -simulations that presented participants with graphical depictions mirroring multiple real-world scenarios and asked them to position themselves in relation to others in the scene. the conceptual framework highlights three essential components of a directive: (1) the source, some entity is advocating for a behavioral change; (2) the surrounding context, the directive is in response to some challenge; and (3) the target, the persons to whom the directive is addressed. belief systems relevant to each of these three components are predicted, and were found, to relate to compliance with the social distancing directive. the implications of the findings for public service campaigns encouraging people to engage in social distancing are discussed. given the current lack of a vaccine, minimizing the spread of covid-19 requires that people change their behavior. people are urged to wash their hands frequently, use hand sanitizer, disinfect surfaces, and wear masks. above all, government leaders and health experts plead with citizens to engage in social distancing -that is, deliberately increase the physical space between themselves and other people. the mantra "stay six feet away from others" has been repeated regularly. rarely has the entire population been called upon to exhibit immediate behavior change in compliance with an urgent directive. that raises an important question: who is or is not complying? understanding who chooses to practice (or not) social distancing -and why -is crucial for the design of effective public service campaigns, both now, and during the occurrence of future pandemics. whom should such campaigns target? what specific beliefs should be addressed? theory and research concerning compliance (behavioral change in response to an explicit or . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 27, 2020. ; https://doi.org/10.1101/2020. 10.26.20219634 doi: medrxiv preprint social distancing 3 implicit request) is central to social psychology. the field has acquired substantial knowledge regarding social influence tactics promoting compliance [1] , including such classic approaches as the foot-in-thedoor [2] , door-in-the-face [3] , and low-balling [4] . in addition, the impact of both descriptive and injunctive norms has been examined extensively [5, 6] . however, as some scholars have noted [7] , the field lacks a general theoretical framework about who is likely to comply with a directive, and why they might or might not. such a framework is particularly important when considering a directive calling for compliance and behavior change on a large scale, as is currently true of the social distancing directive. the major aim of the current research is to test such a theoretical framework regarding the who and why of compliance. any directive is open to interpretation and ultimately will be assessed as warranting or not warranting compliance. only if deemed justified is the directive likely to promote behavioral change. yet, one of the core principles of social psychology is that individuals construct their own reality [8] [9] [10] . such constructions influence and are influenced by the information to which individuals choose to expose themselves [11] , their exploratory behavior, and ultimately the accuracy of their understanding of reality [12, 13] . thus, any given directive will be viewed through the lens of the individual's knowledge, beliefs, and attitudes. decades of research demonstrate the pervasive influence of such factors on judgments and decisions [14] [15] [16] . such considerations raise the question of what might be regarded as the essential components of a directive. our theoretical framework highlights three: (1) the source: the entity advocating for behavioral change; (2) the surrounding context: the challenge the directive addresses; and (3) the target: the persons to whom the directive is addressed. is the source to be trusted? what does the surrounding context imply about the seriousness of the challenge? are there individual propensities that affect responsivity to the directive? thus, a complex network of beliefs will affect who chooses to . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted october 27, 2020. ; https://doi.org/10.1101/2020. 10.26.20219634 doi: medrxiv preprint social distancing 4 comply or not, and for what reasons. some individuals' belief systems will lead them to assess the directive favorably, thus promoting behavior change. others will reach less positive conclusions and, hence, fail to respond appropriately. in examining compliance, the challenge rests in how to assess social distancing. the field's dominant approach is to ask people to report the frequency with which they socially distance. however, the problems associated with self-reports of behavior have been discussed for decades. individuals may over-report their social distancing to convey a socially desirable impression to others and themselves [17] [18] [19] [20] . moreover, self-reports may be all the more problematic to the extent that they rely on retrospective memory regarding past behavior [21, 22] . even more troubling, some of the very characteristics and beliefs we predict will affect responsiveness to the directive may also influence how a person (mis)represents their social distancing on self-report measures. we thus supplemented self-reports of social distancing with an innovative, more behaviorallyoriented approach. we simulate social distancing behavior with graphical depictions mirroring realworld scenarios, asking participants to position themselves in relation to others in the scene. for example, in one scenario people view a street scene and choose whether to follow a path passing directly in front of another individual, or detour via the crosswalk. other more interactive measures allow participants to manipulate a slider to virtually "distance" themselves from an oncoming walker, or to separate individuals waiting in line. these graphical scenarios simulate real-life and require a concrete, "in-the-moment" behavioral decision. in this sense these measures are behavioral in nature. our argument regarding the value of these behavioral scenarios parallels a relevant empiricallysupported proposition regarding attitudes as predictors of behavior. attitude measures are more likely to predict behavior when they match the behavior in terms of specificity regarding the action in question and the context in which the action is performed [23, 24] . similarly, the simulated scenarios . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted october 27, 2020. ; https://doi.org/10.1101/2020. 10.26.20219634 doi: medrxiv preprint closely match real-life situations in terms of their concreteness. they offer a means, in addition to a selfreport, of indexing the extent to which individuals make decisions that accord with the principle of social distancing. this study examines the relation between social distancing and various predictor variables. to test our guiding framework regarding compliance, the predictors involve our three classes of beliefsthose regarding the source of the directive, the surrounding context posed by the challenge, and additional characteristic of the targets themselves. the primary source of the social-distancing directive is government and health officials. the latter are medical scientists or liaisons represent the scientific community. given the distinction in the literature between valuing science as means of acquiring knowledge and trusting scientists and their work [25] , we hypothesized that (a) greater belief in science and (b) greater trust in scientists would relate positively to compliance. given the highly polarized sociopolitical context and the politicization of the pandemic, assessing faith in government officials is more complex. president trump downplayed the pandemic's severity relative to state governors. accordingly, we separately assessed trust in the president's and governors' leadership regarding the pandemic, predicting that these measures may relate differently to compliance. several questions regarding assessments of the pandemic and support for social distancing were included to examine the hypothesis that greater concern about the virus and positive attitudes toward the directive would be associated with more social distancing. we tested a similar hypothesis regarding . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted october 27, 2020. two sets of target characteristics were expected to relate to individuals' receptivity to the plea to engage in social distancing: beliefs relevant to disease or views of the government and more general characteristics of the individual. perceived vulnerability to disease [26] and its concomitant disgust sensitivity [27] were expected to relate positively to social distancing. similarly, general compassion [28] and concern for others' vulnerability to the coronavirus were expected to predict distancing. given president trump's equivocal stance and the traditional emphasis that conservatives place on economic freedom, we anticipated that conservatism would be associated with less distancing. in addition, we predicted that conspiratorial ideation [29, 30] would promote minimization of covid-19's severity, and hence relate to less compliance. turning to the second set of target characteristics, we also predicted that individual differences in scientific literacy [31] would likely relate to both trust in health experts and the development of accurate knowledge regarding the coronavirus. hence, scientific literacy was expected to be associated with more distancing. additionally, a considerable literature highlights the importance of the particular news sources that individuals follow [32, 33] . we expected that reliance on more conservative news sources would relate to minimizing the threat posed by the pandemic and less distancing behavior. we recruited a sample from mechanical turk. although not representative of the u.s. population, mturk samples are considerably more diverse than the student samples used in most psychological research [34, 35] , and they perform similarly to non-mturk samples across many tasks and measures [36, 37] , including surveys on political attitudes [38] . further, our aim is not to make claims . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 27, 2020. ; https://doi.org/10.1101/2020.10.26.20219634 doi: medrxiv preprint regarding the absolute frequency of beliefs and behaviors in the population, but rather to understand how the psychological variables of interest relate to social distancing behavior. given these aims, we judged the mturk sample as appropriate for testing our hypotheses. as will become evident, both the very systematic nature of the data and their replication of some relations previously established in the literature attest further to the appropriateness of the mturk sample. past experience with mturkers led us to believe that they prefer, and respond most conscientiously, when a study is relatively short. hence, we included only our social distancing measures, survey items assessing beliefs and knowledge about the pandemic, and various demographics as the elements of a common survey that was completed by all the participants. subsets of our other predictors were included in four distinct surveys to which participants were randomly assigned. the four subsets involved: (a) source beliefs and science literacy, (b) news sources and belief in conspiracy theories, (c) compassion and concern for others vulnerability to covid-19, and (d) perceived vulnerability to disease and disgust sensitivity. we aimed for sample sizes that would clearly be large enough to obtain stable estimates of the relations with social distancing within each of our four sub-studies [39] . a total of 2,004 mturkers (us residents) participated in the common survey (903 women, 1,084 men, 17 no response; mage = 38.66, sdage = 12.33), with about 500 being randomly assigned to each sub-study. they completed the study on may 7-8, 2020, at which time some states had begun to re-open their economies. ohio state university's institutional review board approved all study procedures (irb: 2020b0129). after providing informed consent, participants completed the behavioral measures of social distancing, followed by questions regarding the pandemic, the test of covid knowledge, the . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 27, 2020. ; https://doi.org/10.1101/2020.10.26.20219634 doi: medrxiv preprint social distancing 8 unique set of predictor variables for the study to which the participant had been randomly assigned, and finally a series of demographic questions. all of the measures and the datafile are available at https://osf.io/359et/?view_only=2c83bae138984cb592ba354043b3d1dc. ten graphic scenarios comprised the behavioral measure of social distancing. examples include: (a) an image of two people approaching each other in a crosswalk. participants moved a slider that shifted the walkers from the center of the crosswalk to the distance that they would prefer. (b) an aerial image of a crowded beach for which participants were asked to "click the point on the beach where you'd be most likely to lay down your towel." the distance to the nearest person (in pixels) served as the measure of interest. (c) a graphic depicting a park for which participants used a 4-point scale to indicate whether would they definitely or probably walk via one of two paths. one path was less direct, but also more isolated relative to the many people situated on either side of the alternative path. all ten of the behavioral scenarios are described in the supplemental material and can be viewed at our demonstration website, http://psychvault.org/social-distancing-measures/. after standardizing scores from each measure, we computed the average as our index of social distancing behaviors (α = .82). questions regarding the pandemic the behavioral scenarios were followed by the common portion of the survey, including the selfreport measure of social distancing: "generally speaking, how strictly have you personally been following the "social distancing" recommendations?" and a number of questions regarding perceptions of the pandemic. participants were asked how worried they were about contracting the virus, how likely they were to do so, and how concerned they were about the spread of the virus. they also indicated whether they felt the threat of covid-19 had been "greatly exaggerated" versus "not conveyed strongly . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. to assess people's trust in different elements of the government, we used four single-item measures. specifically, participants were asked to rate the extent to which they "trust president trump to lead us effectively through the current covid-19 crisis" and separately whether they trust state governors to do so. they also indicated the extent of their general confidence in president trump and general confidence that the federal government will address the nation's problems effectively. to assess the extent to which individuals believe in the value of science as the best way to accumulate knowledge about the world, participants responded to a shortened version (the six items with the highest factor loadings) of a scale developed by farias, newheiser, kahane, & de toledo [40] . participants rated the degree to which they endorsed statements such as "science is the most efficient means of attaining truth" (α = .92). . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 27, 2020. ; https://doi.org/10.1101/2020. 10.26.20219634 doi: medrxiv preprint this variable was assessed using a shortened version (the 11 items, out of 21, with the highest corrected item-total correlations) of the scale developed by nadelson et al. [25] . participants rated their level of agreement with statements such as "we should trust the work of scientists" (α = .80). participants' understanding of basic scientific ideas was assessed using the civic scientific literacy scale [31] . this scale consists of 11 claims such as "light travels faster than sound" and "electrons are smaller than atoms" for which participants indicate agreement or disagreement (α = .59). participants completed the generic conspiracist beliefs scale [29] . they rated each of 15 items that address a variety of generic conspiracy theories, e.g., "evidence of alien contact is being concealed from the public" (α = .96). participants were presented with a list of potential news sources: cnn, fox news, msnbc, npr, national newspapers and magazines, social media, and abc, cbs, or nbc news, as well as the option "do not follow the news." they were asked to select all the sources from which they got their news in the past week. any who did not indicate that they do not follow the news were then asked to select which one of the news outlets they consider to be their primary source of news. to assess general compassion for others, we employed a subset of items of the interpersonal reactivity index [28] . specifically, we included the 14 items of the scale related to empathic concern (e.g., "when i see someone being taken advantage of, i feel kind of protective towards them") and perspective taking (e.g., "before criticizing somebody, i try to imagine how i would feel if i were in their place"). participants indicated the extent to which each statement described them (α = .87). . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 27, 2020. concern for others' vulnerability to four items assessed the extent to which participants experienced empathic concern for people who had contracted covid-19 or were vulnerable to do so. participants rated their agreement with such statements as "i feel it is my personal responsibility to keep others safe from covid-19 coronavirus" (α = .67). individuals' perceptions of their likelihood of contracting a disease or illness was assessed with the 15-item scale developed by duncan, schaller, & park [26] . participants rated the degree to which they agreed with statements such as "if an illness is 'going around' i will catch it" (α = .73). the contamination subscale (five items) from the disgust scale revised [27] was used to assess individuals' sensitivity regarding situations that have the potential for the transmission of pathogens. participants rated how disgusted they would be by various scenarios as well as their agreement with statements such as "i probably would not go to my favorite restaurant if i found out the cook had a cold" (α = .70). in addition to a number of demographic questions, participants were asked to identify their political orientation on a scale ranging from 1 (extremely liberal) to 7 (extremely conservative). the survey concluded with a brief attention check in which participants were informed that a man had seen a beautiful butterfly, and were then asked to select what he had seen: a girl, a day, a fruit, or an insect. ninety-one percent correctly chose insect. to provide a more conservative test of our hypotheses, we did not exclude participants who failed this attention check. however, none of our . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 27, 2020. ; https://doi.org/10.1101/2020.10.26.20219634 doi: medrxiv preprint conclusions or statistical results are altered to any meaningful degree if these participants are excluded from analyses. to test each of the hypotheses, we examined the multiple correlation between a given variable and our two indices of social distancing -the behavioral and the self-report measures. table 1 presents the regression data for each of our hypothesized predictor variables. table 2 displays the correlations among the variables. turning first to the source, both belief in the value of science and trust in scientists correlated positively with social distancing. as expected, these variables also correlated with assessments of the pandemic itself, including more support for the social distancing guidelines, greater concern about the spread of covid-19, stronger beliefs that the threat posed by the virus had not been exaggerated, and a view that public safety should be prioritized over economic recovery. faith in the government officials was more complex, just as we anticipated. whereas greater trust that the state governors can lead us effectively through the covid-19 crisis was positively associated with behavioral compliance, the relations were negative when participants considered either president trump specifically or the federal government more generally. more confidence in those sources was associated with less social distancing. interestingly, these relations do not appear to be a simple reflection of political orientation. although participants who more strongly identified as conservative engaged in less social distancing and expressed more trust/confidence in president trump, in each case the measures of social distancing accounted for unique variance over and above that explained by political orientation (all p's < .001). all the belief measures concerning the pandemic itself related as expected with social distancing. this was especially true of support for the social distancing guideline, worry about contracting the virus, . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 27, 2020. .071 a higher numbers reflect more social distancing behavior. b coded 0=neither watch last week, nor primary news source, 1=watched last week or primary, 2=both *p < .05; **p < .01; ***p < .001 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 27, 2020. concern about the spread of the virus, and the assessment that the threat posed by the virus had not been exaggerated. believing that relatively more emphasis should be placed on economic recovery than public safety also was associated with less social distancing. answers to our test of covid-19 knowledge also related positively to behavioral compliance. importantly, the recognition of true statements and the rejection of misinformation each correlated with social distancing (multiple r's of .234 and .260, respectively). knowledge also was associated with support for the social distancing guideline and especially with the belief that the threat posed by the coronavirus had not been exaggerated. in addition, more knowledgeable individuals expressed greater trust in scientists and less confidence in president trump. self-beliefs highlighting interpersonal compassion and concern for others' vulnerability to the virus were associated with more social distancing. these variables correlated as expected with beliefs about the pandemic. for example, more compassionate individuals were more supportive of the social distancing guideline and believed that the threat of the virus had not been exaggerated. the same was true of individuals who had expressed concern for others' vulnerability; they also were more worried that they themselves would contract the virus. the data offered a number of interesting observations regarding the extent to which respondents viewed themselves as generally vulnerable to disease. this variable was related to more social distancing, and, just as one would expect, with greater worry about contracting covid-19 and greater perceived likelihood of contracting it. disgust sensitivity correlated with perceived vulnerability to disease, replicating past findings, and also related to social distancing. stronger disgust sensitivity also was associated with greater worry about contracting covid-19 and greater likelihood of doing so. as already noted, political orientation also was relevant; more conservative individuals engaged in less physical distancing. just as expected, political ideology correlated strongly with general confidence in president trump and trust in his leadership regarding the covid-19 crisis, but not with . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 27, 2020. ; https://doi.org/10.1101/2020. 10.26.20219634 doi: medrxiv preprint trust in the state governors. more conservative individuals also reported less belief in the value of science and less trust in scientists. they also believed the threat of the coronavirus to have been exaggerated and that economic considerations needed to take priority over public safety. generally believing in conspiracy theories also was predictive of less social distancing, possibly because it promotes a less accurate view of the pandemic. indeed, such beliefs correlated strongly with scores on the test of covid-19 knowledge. conspiracy theorists also were more likely to believe that the threat posed by the coronavirus had been exaggerated. in addition to beliefs, we examined a number of other personal characteristics that seemed potentially relevant to receptivity to the directive (see the fourth section of table 1 ). female participants displayed more evidence of social distancing, as did older participants. our hypothesis regarding science literacy also received support. those who exhibited a greater understanding of a small set of basic scientific facts engaged in more social distancing. scientific literacy also related strongly to expressed trust in scientists and scores on the test of covid-19 knowledge. it also was associated with the belief that the threat posed by the virus had not been exaggerated. finally, although none of the multiple correlations were very substantial, accounting for less than 3% of the variance, a number of the news sources variables related to social distancing. whereas engagement with npr or newspapers and magazines was associated positively social distancing, greater involvement with fox news related negatively to distancing. the latter was more common for participants who endorsed a more conservative political orientation, whereas the former was associated more strongly with a more liberal perspective. parallel relations were observed with support for the social distancing guideline, valuing economic considerations more than public safety, believing that the covid-19 threat had been exaggerated, and accurate knowledge regarding covid. our primary interest was to employ the behavioral and self-report measures of social distancing . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 27, 2020. ; https://doi.org/10.1101/2020.10.26.20219634 doi: medrxiv preprint as supplemental to one another and, hence, as jointly related to each of the hypothesized predictor variables. although the two measures were related (r = .459, p < .001), the magnitude of the correlation was not so overwhelming as to suggest that they were equivalent. given this observation, it is interesting to consider how the two variables differ with respect to the unique variance for which they each accounted in the multiple regressions (table 1) . although drawing any strong inferences from the patterns evident in the table is difficult, the larger differences appear especially striking. for covid knowledge and scientific literacy, which are much more objective measures than any of the other predictor variables, the multiple correlation was driven almost entirely by the behavioral measure. indeed, the self-report failed to account for any significant unique variance. the same was true with respect to engagement with fox news, belief in conspiracy theories, and the variables reflecting trust in president trump's leadership regarding the pandemic and general confidence in him. on the other hand, for the arguably most subjective measure -support or opposition for the social distancing guideline -the self-report measure of social distancing accounted for twice the unique variance that was associated with the behavioral measure. similar patterns were evident for general compassion, concern for others' vulnerability to covid-19, and disgust sensitivity. these differences certainly suggest that behavioral and self-report measures of social distancing are not responsive to the same forces. the findings highlight the importance of individuals' beliefs as factors associated with social distancing behavior. they also support the theoretical framework of compliance that guided our selection of variables for inclusion in the study. any directive regarding behavior change will be shaped by beliefs about the directive's source, beliefs about the context surrounding the challenge to which the directive is responding, and relevant self-views and characteristics. as such, the framework is applicable to any call for behavior change aimed at the general public. when applied to the social-distancing . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 27, 2020. ; https://doi.org/10.1101/2020.10.26.20219634 doi: medrxiv preprint directive, the conceptual framework led to our focus on (a) source variables related to the government and public health officials, (b) beliefs regarding covid-19 and the severity of the threat, and (c) various self-related beliefs and target characteristics influencing receptivity to the social distancing directive. importantly, these relations were evident not only on a self-report social-distancing measure but also on a measure that relied on vivid, graphical simulations of real-life behavior. participants made concrete, "in-the-moment" decisions about actions involving different degrees of social distancing. they interactively distanced themselves from oncoming passersby and from people standing in line. they selected a position on a crowded beach. as such, the behavioral decisions closely matched the features of real-life situations. the current findings did indeed reveal some striking differences between behavioral and selfreport measures of social distancing. although the two were related, the correlation did not reach a level that suggested these were equivalent measures of the same construct. moreover, the unique variance accounted for by each measure differed markedly for a number of predictor variables. especially telling was that scores on our tests of covid knowledge and scientific literacy -the most objective of our predictor variables -related more strongly to the behavioral measures, with selfreports accounting for little or no additional variance. thus, self-reports do not cohere with behavioral decisions sufficiently to suggest they are mutually interchangeable. however, they complement one another well, as is evident by their accounting for unique variance for many predictor variables. we conclude with a brief consideration of the implications of the present findings for public service campaigns encouraging social distancing. how might compliance be promoted? the findings highlight the importance of communicating accurate knowledge and dispelling misinformation. campaigns also should promote science as the means by which we will come to understand the coronavirus, how it spreads, and how it might be contained. there is also likely value in appealing to, and heightening concern, about others' vulnerability to the coronavirus and the suffering of those . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted october 27, 2020. ; https://doi.org/10.1101/2020. 10.26.20219634 doi: medrxiv preprint infected. similarly, the results regarding perceived vulnerability to disease and compassion suggest the need to emphasize the vulnerability of people of all ages to the virus and the role that everyone, whether symptomatic or not, plays in spreading it. indeed, the data seem to call for frequent repetition of the portrayal of social distancing guidelines that white house coronavirus response coordinator dr. deborah birx offered: "this is a road map to prevent your grandmother from getting sick" [41] . maybe, most importantly, the findings highlight the importance of the plea so pointedly articulated by world health organization director-general ghebreyesus: "please don't politicize this virus" [42] . the politicizing is very evident in the present data. very different relations were observed with respect to trust in president trump versus the state governors as providing effective leadership during the covid-19 crisis. participants' political orientation, and even their exposure to more partisan news sources, related to beliefs about the severity of the civod-19 threat, support for the social distancing guideline, and social distancing behavior. obviously, a more coherent, non-partisan perspective, emphasizing reliance on scientific evidence, is essential. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted october 27, 2020. ; https://doi.org/10.1101/2020.10.26.20219634 doi: medrxiv preprint influence: science and practice compliance without pressure: the foot-in-the-door technique a reciprocalconcessions procedure for inducing compliance: the door-in-the-face technique low-ball procedure for producing compliance: commitment then cost a focus theory of normative conduct: recycling the concept of norms to reduce littering in public places crafting normative messages to protect the environment social influence and personality see what you want to see: motivational influences on visual perception on perceptual readiness accessible attitudes as tools for object appraisal: their costs and benefits selective exposure: voter information preferences and the watergate affair cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity social interaction basis of cooperators' and competitors' beliefs about others understanding attitudes and predicting social behavior variables that moderate the attitude-behavior relation: results of a longitudinal survey the mode model: attitude-behavior processes as a function of motivation and opportunity where the motivation resides and self-deception hides: how motivated cognition accomplishes self-deception social desirability bias and the validity of indirect questioning self-deception: a concept in search of a phenomenon impression management: a literature review and two component model memories of unethical actions become obfuscated over time relation of implicit theories to the construction of personal histories attitude-behavior relations: a theoretical analysis and review of empirical research international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity specificity of the attitude as a determinant of attitudebehavior congruence i just don't trust them: the development and validation of an assessment instrument to measure trust in science and scientists: trust in science and scientists perceived vulnerability to disease: development and validation of a 15-item self-report instrument the disgust scale: item analysis, factor structure, and suggestions for refinement measuring individual differences in empathy: evidence for a multidimensional approach measuring belief in conspiracy theories: the generic conspiracist beliefs scale the psychology of conspiracy theories the measurement of civic scientific literacy polarizing news? representations of threat and efficacy in leading us newspapers' coverage of climate change driving a wedge between evidence and beliefs: how online ideological news exposure promotes political misperceptions: driving a wedge between evidence and beliefs systems perspective of amazon mechanical turk for organizational research: review and recommendations international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted evaluating online labor markets for experimental research: amazon. com's mechanical turk common concerns with mturk as a participant pool: evidence and solutions are samples drawn from mechanical turk valid for research on political ideology? research & politics at what sample size do correlations stabilize? scientific faith: belief in science increases in the face of stress and existential anxiety white house coronavirus response coordinator on new guidelines please don't politicize this virus supporting information s1 supplemental material. description of the simulated behavioral measures of social distancing.. cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 27, 2020. ; https://doi.org/10.1101/2020.10.26.20219634 doi: medrxiv preprint key: cord-164718-f6rx4h3r authors: wellenius, gregory a.; espinosa, swapnil vispute valeria; fabrikant, alex; tsai, thomas c.; hennessy, jonathan; williams, brian; gadepalli, krishna; boulanger, adam; pearce, adam; kamath, chaitanya; schlosberg, arran; bendebury, catherine; stanton, charlotte; bavadekar, shailesh; pluntke, christopher; desfontaines, damien; jacobson, benjamin; armstrong, zan; gipson, bryant; wilson, royce; widdowson, andrew; chou, katherine; oplinger, andrew; shekel, tomer; jha, ashish k.; google, evgeniy gabrilovich; inc.,; view, mountain; ca,; health, department of environmental; health, boston university school of public; boston,; ma,; surgery, department of; brigham,; hospital, women's; school, harvard medical; policy, department of health; management,; health, harvard t. h. chan school of public; institute, harvard global health; cambridge, title: impacts of state-level policies on social distancing in the united states using aggregated mobility data during the covid-19 pandemic date: 2020-04-21 journal: nan doi: nan sha: doc_id: 164718 cord_uid: f6rx4h3r social distancing has emerged as the primary mitigation strategy to combat the covid-19 pandemic in the united states. however, large-scale evaluation of the public's response to social distancing campaigns has been lacking. we used anonymized and aggregated mobility data from google location history users to estimate the impact of social distancing recommendations on bulk mobility among users who have opted into this service. we found that state-of-emergency declarations resulted in approximately a 10% reduction in time spent away from places of residence. implementation of one or more social distancing policies resulted in an additional 25% reduction in mobility the following week. subsequent shelter-in-place mandates provided an additional 29% reduction. our findings provide evidence that state-wide mandates are effective in promoting social distancing within this study group. social distancing has emerged as the primary strategy for slowing the spread of the covid-19 pandemic. social distancing is expected to reduce the frequency of close contact with others and thus minimize the transmission of the sars-cov-2 coronavirus. prior experience with the 2009 h1n1 influenza and ebola suggests that social distancing is effective in reducing disease transmission. (1, 2) in china, officials engaged in an unprecedented quarantine of hubei province to contain covid-19 transmission out of the initial epicenter city of wuhan. (3) (4) (5) as the pandemic spread to new clusters of infection in the united states (u.s.) efforts at containment and then mitigation have been largely at the discretion of state and local governments, leading to a patchwork of directives to encourage social distancing. these policies have included state emergency declarations, work-from-home policies, school closures, closures of non-essential businesses and services, limits placed on large social gatherings, bans on in-restaurant service, and shelter-in-place orders. (6) to date, there is some limited data that these policies may be working. several news outlets have shown substantial drops in mobility across the nation since early march, although the ties to specific policy interventions are less clear. given the current reliance on social distancing policies to limit the spread of covid-19, systematically quantifying the impact of these policies on mobility may be helpful to public health officials. the availability of anonymized and aggregated mobility data represents a novel opportunity to quantify the effectiveness of individual social distancing interventions. (7) we used aggregated (anonymized with differential privacy) data from google users across the u.s. who have opted-in to location history (the location history feature is off by default and requires explicit opt-in). (8, 9) using these data, information on the dates of implementation of various social distancing policies (see supplemental material), and a regression discontinuity approach, we sought to: 1) quantify the average effect on mobility of declarations of states of emergency, social distancing policies, and shelter-in-place orders, and 2) gain insights into which policies are most effective in promoting social distancing. our primary outcome of interest is the relative change in the time spent away from places of residence, and also considered relative changes in the number of visits to places of work and the number of visits to: 1) grocery stores and pharmacies, 2) retail, recreation, and eateries), 3) parks, and 4) transit stops. overall, we observed three waves of state-level responses to covid-19: 1) a first wave occurring during the first two weeks of march with state of emergency declarations, 2) a second wave during the week of march 16 where a variety of specific social distancing orders were implemented, and 3) a third wave during the last two weeks of march consisting of orders for residents to shelter in place orders ( figure 1 ). the first state of emergency related to covid-19 was declared by washington state on february 29, and most recently by oklahoma and maine on march 15. many states subsequently ordered that schools close (led by louisiana and virginia on march 13, 2020), and/or placed limits on specific activities and businesses in order to promote social distancing. within a week, 48 states and washington dc had implemented at least 1 social distancing policy. in 78% of states, the first social distancing order imposed was the closure of schools. on march 16, nevada enacted orders advising residents to shelter in place, followed by california on march 19, 2020. as of april 5, 80% of states had ordered residents to shelter in place. we used the same data that was used to prepare the community mobility reports published by google (8, 9) to compute aggregated visit trends to a number of specific categories of locations (see supplemental material). trends were aggregated to the county level (including washington, dc and independent cities that are not otherwise included in county boundaries), and available daily from january 1 through march 29, 2020. within each county we applied a regression discontinuity analysis to estimate the relative change in the amount of time spent away from places of residence of location history users and the relative change in the number of visits to specific categories of locations in the week after versus before each intervention. the following results should be interpreted in light of several important limitations including that our data are limited to google users who have opted in to location history. on average across the country, a declaration of a state of emergency was associated with a 9.9% (95% confidence interval [ci]: -10.1%, -9.7%) decrease in time spent away from places of residence, 11.4% (95% ci: -11.8%, -11.0%) fewer visits to the workplace, 11.5% (-11.7%, -11.2%) fewer visits to retail outlets and recreational sites, and 9.3% fewer visits to transit stops (-9.6%, -9.0%) in the following week ( figure 2a ). these changes in mobility are noteworthy given that emergency declarations did not necessarily specifically call for increased social distancing and suggests that government messaging, news coverage, and/or actions observed in other countries could have influenced people's activities. visits to parks were also affected by emergency declarations, with a small 3.5% (95% ci: -4.4%, -2.6%) average reduction. the smaller impact of emergency declarations on visits to parks versus other venues is likely at least partly explained by the warmer weather and transition to spring during this period. on the other hand, emergency declarations coincided with a relative increase in visits to grocery stores and pharmacies of 8.2% (95% ci: 7.9%, 8.5%), consistent with news reports of individuals stocking up on dry goods, cleaning supplies, and medications at the end of february and early march in anticipation of impending social distancing orders. (10) we next examined the impact on mobility of the first social distancing policies implemented in each state. we found that on average across the country these orders resulted in additional reductions in mobility above and beyond the changes observed following emergency declarations ( figure 2b ). specifically, implementation of one or more social distancing policies resulted in a further 24.5% (95% ci: -24.7%, -24.3%) reduction in time spent away from places of residence, a further 33.0% (-33.3%, -32.8%) reduction in visits to retail and recreational outlets, and a further 27.9% (-28.3%, -27.5%) reduction in visits to work in the following week. the same pattern was evident for visits to parks, and for visits to grocery stores and pharmacies. the impacts of social distancing orders varied substantially between states ( figure 3 ). for example, implementation of social distancing policies was associated with a 36% decrease in the time spent away from places of residence in new jersey versus a 12% decrease in louisiana, but we note that differences in mobility between states may be due to a number of factors beyond social distancing policies. the median of state-specific changes in time spent away from places of residence was a decrease of 19%. states that enacted multiple social distancing measures tended to experience greater reductions in mobility. the impact of social distancing orders also varied substantially across counties within each state regardless of the average impact across the state ( supplemental table 1 ). results were consistent when considering changes in visits to work, visits to grocery stores and pharmacies, visits to retail, recreation, and eateries, visits to parks, and visits to transit stops ( supplemental figure 1 ). we next considered the impact on mobility of state-wide orders to shelter in place. among the 7 states that had issued shelter in place orders on or before march 23, we found substantial reductions in time spent away from places of residence and in visits to all categories of locations ( figure 2c ). specifically, time spent away from places of residence was 29.0% (95% ci: -29.4%, -28.5%) lower in the week following implementation of shelter in place orders versus the prior week. note that these changes are multiplicative over time as all states had already declared a state of emergency and implemented at least one social distancing policy. for comparison, we also show in figure 2c the change in mobility during the same time frame (march 23-29 versus march 14-20, 2020) among those states that had not yet issued shelter-in-place orders by march 23. however, note that comparisons between states reflect the influence of a number of factors on mobility in addition to policy differences. given that most states enacted multiple policies to encourage social distancing over a short time period, it is not possible to estimate the independent effects of individual policies. however, in secondary analyses we sought to identify the combinations of social distancing orders that were associated with greater changes in mobility ( figure these results should be interpreted in light of several important limitations. first, our source data are limited to smartphone users who have opted in to google's consumer location history feature. these data may not be representative of the population as whole, and furthermore their representativeness may vary by location. additionally, these limited data are only viewed through the lens of differential privacy algorithms, specifically designed to protect user anonymity and obscure fine detail (8) . moreover, comparisons across rather than within locations are only descriptive since these regions can differ in substantial ways besides the policy environment. second, our analyses are focused on state-level policies, whereas individual metropolitan areas and counties within a state may have implemented specific social distancing policies prior to implementation of state-level policies (see supplemental figure 4 for detailed examples from king county, wa, westchester county, ny, new york county, ny, and santa clara county, ca). third, we did not assess the impact of social distancing policies or resulting changes in mobility on published counts of confirmed covid-19 cases or deaths. although such analyses are of critical importance, they are complicated by the heterogeneous availability of testing, delays in reporting, and the inherent latency before social distancing impacts are evident in clinical outcomes, and thus beyond the scope of this report. in summary, using anonymized, aggregated, and differentially private data from google users who opted in to location history, we found that state-mandated social distancing orders were effective in decreasing time spent away from places of residence, as well as reducing visits to work, and visits to both grocery stores/pharmacies and retail/recreational locations. while the majority of states declared states of emergency by early march, the emergency declaration per se had only a modest effect on mobility. in contrast, implementation of one or more specific social distancing orders was associated with an almost 25% additional reduction in time spent away from places of residence and a 33% additional reduction in visits to retail and recreational locations. these effects were evident in every state and in virtually every county. although we were unable to estimate the independent effects of different social distancing measures due to their close temporal proximity within each state, we did observe that those states that implemented multiple such measures experienced more pronounced declines in mobility. in addition, limits on bars and restaurants appeared to be the single most effective social distancing order. we conclude that state-based orders intended to promote social distancing appear to be very effective in accomplishing the public health goals of encouraging individuals to stay at home in order to minimize the risk of covid-19 transmission. our findings not only illustrate the importance of specific social distancing orders, but also demonstrate the magnitude of change in mobility that we might expect from these policies. this information can help public health officials better calibrate and understand the extent to which social distancing can slow down the disease. the anonymized and aggregated dataset analyzed herein was the same one that was used to create the publicly-available google covid-19 community mobility reports (published at http://google.com/covid19/mobility on april 2, 2020). the data analyzed in this paper consisted of anonymized, aggregated, and differentially private counts of visits to places in different categories. the publicly available data reflects percentage ratios computed using these counts. the information on dates of policy interventions was aggregated from publicly available data as described in the supplemental material. our overall approach was to use regression discontinuity using each county's recent past as its own control to assess the impact of state declarations of emergency and targeted social distancing policies on the relative changes in the average time spent away from places of residence, the number of visits to work, and the number of visits to: 1) grocery stores and pharmacies, 2) retail stores, recreational sites, and eateries, 3) transit stops, and 4) parks. data on state social distancing policies were obtained from official documents issued by state governors and health and education officials. documents were linked from the kaiser family foundation's state data and policy actions tracker (11) and supplemented with manual searches of state public health websites. dates of policy enactment were cross-checked with the aei covid-19 action tracker (12) and the nytimes shelter in place tracker (13) . policies tracked were categorized as follows: 1) state-declared state of emergency, 2) state-mandated school closures, 3) state-mandated closing of non-essential businesses and services, 4) state-mandated limits on large gatherings, 5) state-imposed bans on in-restaurant service, and 6) state-imposed mandatory quarantines. state-mandated closing of non-essential businesses included any order closing gyms, theaters, and other businesses even if it did not extend to all non-essential businesses. limits on large gatherings referred to any ban on gatherings larger than a certain number of people, though that threshold varied between states. for states that issued additional orders reducing the size of permitted gatherings, the date of the first such order was taken. bans on in-restaurant service excluded mandatory reductions in restaurant capacity and included only those orders that prohibited any restaurant activity except pick-up and delivery. these bans often also included bars and clubs. mandatory quarantine referred to any stay-at-home or shelter-in-place order that prohibited non-essential travel away from the home for all residents. shelter-in-place orders specifically for high-risk individuals were excluded. orders that went into effect at any time after 12:00 pm were considered to begin on the following day. we obtained aggregated and anonymized data from groups of google users on mobile devices in all 50 states and washington, dc who have opted in to having their location history data stored. the anonymized dataset used for these analyses is the same as the one used to create the publicly-available google covid-19 community mobility reports (published at http://google.com/covid19/mobility on april 2, 2020). the aggregation and anonymization process applied to the initial version of google covid-19 community mobility reports has been previously described in detail. (8) the community mobility reports leverage signals such as relative frequency, time and duration of visits to calculate metrics related to places of residence and places of work of location history users as described elsewhere. (8) the anonymization process is designed to ensure that no personal data, including an individual's location, movement, or contacts, can be derived from the resulting metrics. data were aggregated to the county level (and washington, dc) and available daily from january 1 through march 29, 2020. within each county we applied a regression discontinuity analysis to estimate the relative change in time spent away from the place of residence (primary outcome) and the relative change in the number of visits to public locations (secondary outcomes) associated with: 1) declaration of a state of emergency, 2) ordering of one or more social distancing measures, and 3) orders for people to shelter-in-place. we note that less populous counties are more likely to have days with missing data for visits to one or more categories of places (e.g., pharmacies) due to privacy filtering and other technical aspects. however, we believe that missing data has negligible effects on the state and national estimates provided because: 1) state level estimates are weighted by county population, and populous counties are extremely unlikely to have any metrics which fall below the limits of detection, and 2) the (unweighted) correlations between the relative changes in the combined metrics used in this paper (e.g., grocery stores and pharmacies considered together), compared to an unbiased, but lower-coverage alternative (e.g., grocery stores only) are very high (>0.95). for each county we compared the value of each metric in the week after the date of implementation versus the 7-day period 9 to 2 days prior to the date of implementation. we included a two-day washout period prior to the implementation date given the public messaging that typically precedes implementation of these orders. given data until march 29 were available, the effects of policies enacted on or before march 23 could be evaluated. the state level estimates reflect population-weighted aggregates of the county-specific estimates. the national estimates are a simple average of the state estimates. because each county and state is compared to its recent past these estimates are causally interpretable. however, comparisons across counties or states are only descriptive since locations can differ substantially in terms of the proportion of the population opted-in to location history; the demographics of this group; the quality of the mobility data and of the google maps data about local establishments; and a number of other factors that may influence the observed changes in mobility beyond differences in the policy environment. we performed a sensitivity analysis to assess the distribution of each outcome metric under the null hypothesis of the policies having no effect. we interpret the relative change across two periods of time (period 1: january 27-february 2, 2020; period 2: february 5-11, 2020), prior to the enactment of any state-level social distancing measures, as observations under the null hypothesis. during this time there were only 5 reported cases of covid-19 in the u.s., which were isolated in washington state. although there was a small drop in time spent away from the place of residence across these pre-intervention periods, the much larger effects on mobility observed after each of the policies suggests that our observed effect during the exposure period is in fact related to the implementation of social distancing ( supplement figure 2 ). figures 2 and 3 in the main text to gain a sense of how different these effects look when the first social-distancing measures were implemented. under the null hypothesis of no policy-affect, the median observed change is slightly below -2%. however, during the first social-distancing measures, the median drop is nearly 10 times as large at -19%. for further context, all but two counties during the first social-distancing measures are below the null distribution median, and over 96% of counties are below the null distribution 2.5% percentile. a comparison between the changes in mobility during first social-distancing measures and changes in mobility under the null hypothesis for each metric is presented in supplemental tables 2.a and 2.b . our main analyses estimate the incremental mobility changes after versus before each of three waves of policy orders ( figure 2 ). however, it is also of interest to quantify the overall effect of social distancing by comparing mobility at the end versus the start of march. we define the overall effect as the change in mobility from the week before the term "social distancing" started increasing in google search (march 1-7th) to the last week available in the data (march 23-29th). we see a significant decrease in all metrics. the ordering of the magnitudes is comparable to those in figure 2b . as expected the overall magnitudes of the drops are larger than any of the incremental effects in figure 2 . table 1 : anova sum of squares decomposition of the variation in the relative change on average time spent away from places of residence across counties for the linear model with the relative pre-post difference in time spent away from the residence as the outcome and state as the only independent variable. the results show that approximately half of the variance in the outcome is explained by differences between states and the remaining variance is largely explained by differences across counties within states. figure 2 .a relative changes in national averages from january 27-february 2, 2020 to february 5-11, 2020 for all metrics of interest. the results are also shown in supplemental table 2 .a. this plot can serve as a reference point for figure 2 in the sense that these periods occurred before any orders were issued and can be interpreted as observations under the null hypothesis of no effect of policy interventions . supplemental figure 2 .b : relative changes in county averages from january 27-february 2, 2020 to february 5-11, 2020 for time spent away from the residence. counties are grouped by state to show the heterogeneity across counties and states before any orders were issued. the changes can be interpreted as observations under the null hypothesis of no policy effect because these periods occurred before any orders were issued population mobility reductions associated with travel restrictions during the ebola epidemic in sierra leone: use of mobile phone data characterizing the epidemiology of the 2009 influenza a/h1n1 pandemic in mexico the effect of human mobility and control measures on the covid-19 epidemic in china an investigation of transmission control measures during the first 50 days of the covid-19 epidemic in china effective containment explains sub-exponential growth in recent confirmed covid-19 cases in china governmental public health powers during the covid-19 pandemic: stay-at-home orders, business closures, and travel restrictions aggregated mobility data could help fight covid-19 google covid-19 community mobility reports: anonymization process description panicked shoppers empty shelves as coronavirus anxiety rises kaiser family foundation, state data and policy actions to address coronavirus covid-19 action tracker see which states and cities have told residents to stay at home supplemental figure 1 : effect of first social distancing order on visits to places of work (a) , visits to grocery stores and pharmacies (b) , visits to retail, recreation, and eateries (c) , visits to transit stops (a) and overall average national effects of social distancing orders relative to period prior to social distancing awareness we are grateful to giorgia abeltino, matthew abueg, skip addison, elizabeth adkison, maha afifi, gerald agapov, ahmet aktay, putri alam, jan antonaros, neha arora, harry askham, boris babenko, arturo bajuelos, avi bar, davi barbosa, sean barclay, pinal bavishi, sherry ben, ashish bora, aleksey boyko, michael bringle, sander bruens, figure 4 : timeline of change in average time spent away from places of residence in king county, washington (i.e. seattle area) (a), westchester county, new york (b), new york county, new york (i.e., manhattan) (c), and santa clara county, california (i.e. san jose area). colored boxes denote the declaration of a state of emergency, the implementation of the first county-level social distancing order, the implementation of the first state-level social distancing order, and county and/or state-level orders for residents to shelter in place. the height of each box corresponds to the change in average time location history users spent away from places of residence in the week before (plus a 2-day washout period) versus the week after each policy date. key: cord-030957-45tc5ksf authors: schaap, andrew; weeks, kathi; maiguascha, bice; barvosa, edwina; bassel, leah; apostolidis, paul title: the politics of precarity date: 2020-08-28 journal: contemp polit theory doi: 10.1057/s41296-020-00435-z sha: doc_id: 30957 cord_uid: 45tc5ksf nan forms that political agency and solidarity might take in response to it, and the appropriate site within which precarious social conditions can be contested and transformed, is controversial. precarity refers to a situation lacking in predictability, security or material and social welfare. importantly, this condition is socially produced by the development of post-fordist capitalism (which relies on flexible employment practices) and neoliberal forms of governance (which remove social protections) (see azmanova, 2020) . precarity entails social suffering, which is manifested in the declining mental and physical health of both working and 'out of work' people and compounded by the attribution of personal responsibility to individuals for their politically induced predicament (apostolidis, 2019, pp. 3-5) . precarity leads to social isolation as workers find themselves segregated and alienated by work processes while the capacity to sustain community is undermined (pp. 8-10). moreover, precarity leads to temporal displacement with precarious workers finding they have no time to do much else than work: they must constantly make time to find and prepare for work and, in doing so, become out of sync with the normal rhythms of social life (pp. 5-8) . precarity involves social dislocation as people are forced to relocate to adapt to precarious situations at the same time as their movements are constrained and policed (pp. 10-12). importantly, precarity is distributed unequally, with people of colour, women, low-status workers and many in the global south experiencing its most devastating effects. at the same time, however, some of its aspects penetrate all social strata. as apostolidis (2019, p. 2) puts it, 'if precarity names the special plight of the world's most virulently oppressed human beings, it also denotes a near-universal complex of unfreedom'. recognizing that anti-capitalist struggle has always been a fight for time, apostolidis (2019, p. 15 ) reflects on how this fight should be adapted to our present political conjuncture. to develop this vision of radical democratic politics, he turns to the experience of migrant day labourers to both diagnose contemporary social pathologies and envision alternative social possibilities. the research for the book is based on apostolidis's involvement in the activities of two worker centres located in seattle, washington, and portland, oregon. in addition to participating in various activities of the centres (such as staffing phones and running occupational health and safety sessions), the research team conducted 78 interviews with migrant day labourers. through interpreting the interviews, apostolidis practices a kind of political theory inspired by paulo freire, which he characterises as 'critical-popular analysis' (p. 30). by attending to the self-interpretations of the research participants, apostolidis characterises precarity and considers the possibility of its transformation in terms of four generative themes around which the book is structured. the first three themes speak to the experience of precarity: 'desperate responsibility', 'fighting for the job' and 'risk on all sides, eyes wide open'. the fourth theme envisions an anti-precarity politics in terms of a 'convivial politics'. as apostolidis acknowledges, there is an ethnographic dimension to this project since it provides a thick description of the everyday experiences and practices of migrant day labourers. however, it also entails critical-popular analysis since apostolidis aims to co-create political theory with the research participants. he does so by staging a constructive dialogue between the self-interpretations and practical insights of day labourers and the systematic and defamiliarized perspective afforded by critical theory. the fight for time not only provides insight into how some of the most vulnerable people in society experience, negotiate and resist precarity: from this social perspective, it aims to generate a wider understanding, of what agency all working (and 'out of work') people have to challenge the precaritisation of social life. as such, the book pivots on a fundamental distinction between day labour as exception and day labour as synecdoche. as kathi weeks explains below, this paradigmatic understanding of the precarity of day labouring, enables a perspectival shift from the singular experiences and ideas of migrant day labourers to the more general social condition of precarity and the possibility of its transformation. on the one hand, apostolidis considers those exceptionalising forms of precarity that dominate day labourers' lives, differentiating them from other members of society. on the other hand, however, apostolidis considers the significance of day labour as synecdoche for how precarity permeates social relations on a much broader social scale. a synecdoche is a figure of speech in which a part represents the whole. an often remarked on synecdoche in political language is that of the people, whereby the poor (those who do not participate in politics) speak in the name of the citizenry (the people as a whole). similarly, apostolidis treats day labour as synecdoche, according to which the exceptional forms of precarity experienced by labourers might make visible the precarity that increasingly conditions all social relations. in the final chapters, apostolidis explores how worker centres might also function synecdochally insofar as the purpose of association is construed not only instrumentally, as protection against the risks associated with precarity, but in terms of their constitutive potential to sustain convivial networks of political possibility for more mutually supportive, creative and pluralistic forms of solidarity than those afforded by traditional unionised spaces. it is in these spaces, which are both mundane and potentially extraordinary, that apostolidis discerns a nascent form of radical democratic politics that consists in a struggle against precarity. this entails three key elements: first, the refusal of work, i.e. the refusal to allow one's life to be consumed according to one's role as worker within capitalist social relations; second, the constitution of spaces for egalitarian social interaction that resist the imperatives of neoliberal governance, and; third, the reclamation of people's time from capitalist and state powers (p. 34) . this recuperation of time (the time robbed from people's lives, which is symptomatic of alienated labour) is fundamental to understanding how day labour might function as synecdoche both of the wider social condition of precarity and the possibility of its transformation. as apostolidis explains, 'working people are running out of time and living out of time ' (p. 8; emphasis in original) . in this context, he suggests, day labourers' socialized activities within the 'time-gaps' of the precarious work economy indicate how the 'time of everyday precarity' might be remade into 'novel, unpredictable, and politically generative temporalities ' (p. 29) . the contributors to this critical exchange engage with two key aspects of the politics of precarity. the first relates to the subject of an anti-precarity politics and the extent to which the exceptional but inevitably partial experiences of day labourers can function as a synecdoche for the precarity of all. edwina barvosa questions whether identification with precarity provides an adequate basis for an emancipatory politics, given that it may condition unreflexive modes of action. bice maiguashca suggests that an intersectional politics would require attending to multiple exceptions, each with their own set of experiences and aspirations, as the basis for a coalitional anti-precarity politics. leah bassel similarly advocates building a politics of migrant justice from the knowledge experiences that are generated by a matrix of oppression, which requires acknowledging struggles against patriarchy and racism as well as capitalist domination. in this context, she emphasises the political imperative of making settler colonialism visible in any analysis of migrant justice, including acknowledging the social position of migrants as settlers. in contrast, kathi weeks highlights how certain appropriations of the marxian category of lumpenproletariat resonate with apostolidis's synecdochal interpretation of day labour. as such, it can be interpreted as a conceptual articulation of a heterogenous -rather than a homogenizing -political subject. indeed, in his response, apostolidis clarifies that the use of the term synecdoche indicates that the perspectival shift from the experience of day labour to the general social condition of precarity is intended as a contingent act of representationrather than a reductive empirical truth. the second issue relates to the mode and site of political organizing against precarity, encapsulated in apostolidis's demand of 'workers' centres for all'. weeks emphasises the urgency of politicizing workplace death and injury, which is obscured by the managerial appropriation of discourses of health and well-being with increased productivity of workers. yet, she is concerned that workers centres might be susceptible to co-optation. moreover, she wonders whether workers centres require embodied social interaction to be effective or might also be realised in virtual spaces. bassel highlights how such anti-precarity spaces are both sustained by affective labour of women and may reproduce other forms of oppression. maiguashca wonders what the visionary pragmatism that apostolidis ascribes to day laborers has in common with the principled pragmatism that she and catherine eschle observed among feminist activists involved in the global justice movement. barvosa questions the assumption that global inequality is most effectively redressed through the mobilization of oppressed groups according to a salt-of-the-earth script. she invokes instead to an alternative keep-only-a-competency script, according to which social inequality might be more effectively reduced by the voluntary giving of the wealthy. in response, apostolidis elaborates on the benefits of the critical-popular approach he adopts in the book. while the practical focus of the fight for time supports a coalitional politics as a key mode of struggle, apostolidis highlights the limits of a 'coalitional epistemology', which would require a cumulative assemblage of particularised knowledges prior to envisioning a desirable form of mass solidarity. lois mcnay (2014) has rightly highlighted how radical democratic theory risks becoming 'socially weightless' to the extent that it treats the social world as contingent, devoid of any significance of its own and able to be reshaped in limitless ways through political action. radical democrats tend to over-estimate the agency of members of oppressed groups when they neglect the mundane experiences of social suffering, which undermine individuals' capacity to participate in politics (mcnay, 2014, pp. 11, 14-15) . as this critical exchange demonstrates, the fight for time challenges theorists of radical democracy to recognise the weight of the world while reflecting on how political agency is shaped, constrained and enabled by the conditions that it seeks to transform. moreover it challenges us to reflect on how political solidarity is possible across the differences and inequalities that are currrently being exacerbated and intensified by the social production of precarity in response to the covid-19 pandemic. andrew schaap the future of anti-precarity politics the discussion that follows is constructed around three insights gleaned from the fight for time about how to formulate an anti-precarity politics in the u.s. today. the first concerns one target for such a politics, the second its political subject, and the third considers one of its organizational sites. all three draw on apostolidis's approach to day labouring as both singular and paradigmatic, as at once an exceptional case and an exemplar of precarious work in the contemporary economy. i will begin with one of the targets of an anti-precarity politics apostolidis identifies that seems critically important today: publicizing and politicizing the incidents of work-related death and injury. this is one of the aspects of day labouring, which might be distinctive insofar as it is more hazardous than many other jobs, but is also appallingly common to precarious work under postfordism more generally. (if we include the household as a site of unwaged work as well, the rate of workplace injury and death increases dramatically.) apostolidis mentions briefly an encounter with a nurse who talked about the dangers of working intimately with bodies in need, and this certainly squares with the literature on other forms of care work, especially of home health aides (one of the fastest growing jobs in the u.s.), whose privatized places of work, and complex as well as under-regulated employment relations, can easily render workers unsafe. publicizing this issue is difficult because, as apostolidis notes, the problem of workplace death and injury is strangely absent from popular consciousness. public awareness is only occasionally peaked when massive disasters are reported: 'intervallic evocations of shock enable an overall scheme of normalization' (p. 3). the anarchist polemicist bob black, in his 1985 essay 'the abolition of work', speaks to this normalization -using his own inimitable brand of sarcasm in a bid for attention to the issue -by claiming that we have made homicide a way of life: 'we kill people in the six-figure range (at least) in order to sell big macs and cadillacs to the survivors' (black, 1996, p. 245) . in her book on emma goldman, i was struck by the effort with which ferguson (2011) attempts to make visible the violence that capital and the state used against workplace organizing in the late 19th and early 20th centuries, which was rarely reported at the time and remains largely absent from our history books. ferguson (2011, p. 22 ) even offered, to powerful effect, a visual aid in the form of a six-page list, a 'bloody ledger', of what she could find of the documented instances of violence levied by public and private armies against striking or resistant workers. for the most part, this spectacular, overt wielding of force and violence over workers by the state and capital has been replaced by brutality meted out through the tools and within the routines of the labour process, such that the perpetrators are typically less directly involved or clearly identifiable. i agree with apostolidis when he argues that anti-precarity political activism requires 'a self-conscious, strategically eclectic, affectively inventive politics of the body' (p. 145). the trick, as i see it, is how not only to publicize but also to politicize the issue of bodily harm, given how extensively the idiom of health has been rendered amenable to the logics and aims of biopolitical management. what vocabulary can be used when the seemingly most obvious and most legible candidate, the language of health, has become so tightly sutured to measures of productivity and complicit with the 'workplace wellness' programs dedicated to its restoration and maximization? although it may still be a language through which the problem of work-related death and injury can be publicized, particularly in light of the ways it is currently deployed to pathologize various modes of indiscipline, i am less certain that the individualizing and biologizing vocabulary of health can be used as a tool of work's politicization. the second aspect of the analysis that i want to consider once again draws on the day labourer as both a specific figure and an archetype of precarious work in order to think further about how to conceptualize a political subject adequate to a broad anti-precarity politics. the case of day labourer activism would seem to lend support to the proposition that the marxist category of the lumpenproletariat is once again resonant. the concept is not offered as a form of self-identification, but rather as a mechanism of conceptual articulation, particularly across lines of gender, race, and citizenship, that might serve as alternatives to the analytical and political categories of proletariat and working class. famously disparaged by marx and engels as the sub-working class, or, more precisely, a de-classed and disparate collection that includes vagabonds, former prisoners, pickpockets, brothel keepers, porters, tinkers, and beggars (marx, 1981, p. 75) , the lumpenproletariat was negatively contrasted to the upstanding 'labouring nation' exemplified by the economically and socially integrated -hence, powerful and politically reliableindustrial proletariat. (although it should be noted that marx and engels include some discards from other classes as well, including the bourgeoisie.) even the unemployed members of the industrial reserve army were posited as fully inside capitalist relations, as opposed to the surplus population relegated to the outside: that subaltern, disorganized, and politically untrustworthy non-class of people 'without a definite occupation and a stable domicile' (engels cited in draper, 1972 draper, , p. 2287 . engels included day-laborers in his list of the lumpenproletariat, and those who have since tried to reclaim and revalue the category -most notably, bakunin, fanon, and the black panthers -have added as well various modes of petty criminality, maids, sex workers, and 'the millions of black domestics and porters, nurses' aides and maintenance men, laundresses and cooks, sharecroppers, unpropertied ghetto dwellers, welfare mothers, and street hustlers' with 'no stake in industrial america' (brown, 1992, p. 136) . while i am interested in the category as a way to make particular connections among prison workers, domestic workers, day laborers, sex workers, laborers in various underground economies, and undocumented migrants, it has also been used to identify linkages among a host of precariously employed people (see, for example, bradley and lee, 2018) . indeed, refusing the original distinction between proletariat and lumpenproletariat, the latter category could serve as the general designation that links the lumpen to the proletariat through the hinge category of the precariat. engels once criticized kautsky for using the label proletariat as inclusive of what engels sought to set apart as the lumpen class; kautsky's proletariat was a 'squinty-eyed' concept because it looks in both directions, thereby blurring an important distinction (draper, 1972 (draper, , p. 2288 . perhaps today the lumpenproletariat could serve as a squinty-eyed, broad category, more adequate to a u.s. political economy where the difference between formal and informal employment, employment and unemployment, work and nonwork are breaking down. the specific advantages of this formulation of the lumpen category include its breadth. stallybrass (1990, p. 72) notes how the lumpenproletariat is often described in terms of the 'spectacle of multiplicity' it evokes in contrast to the unified sameness of the conception of the proletariat. this heterogeneous breadth would seem especially appropriate to a political economy in which, as apostolidis notes, rather than determine who exactly counts as a precarious worker, 'the better question might be: who does not belong to the vast population of the precaritised?' (apostolidis 2019, p. 4; emphasis in original) . another attraction of the concept is how marx and engels's pejorative characterization of the lumpen class betrays some of the ways that the moralized understanding of work and family -recall the description of the lumpen as lacking or marginal to the stabilizing force of both occupation and family -haunts their analyses. for this reason, some, myself included, are interested in how the lumpenproletariat can, as thoburn (2002, p. 435 ) notes, be figured as the 'class of the refusal of work'-and, i would add, the refusal of family. finally, i am interested in how it was conceived as politically unreliable in a way that seems more realistic than the tendency for some to posit some kind of special 'wokeness' to the working class, only to be disappointed when they turn out to be politically erratic, sometimes acting against what are taken to be their class interests. the third and last point of particular interest for me in apostolidis's theorizing about the politics of work today was the argument about the worker centre as a mode of labour organizing for precarious workers. in thinking about analogous organizational innovations two examples come to mind. both share some resemblances with the worker centre even if they are associated with more privileged workers. the first is what might be characterized as a dystopian version of the worker centre that goes by the label coworking. interestingly, coworking originated from below as activist projects to create spaces of community and collaboration among elements of the white-collar precariat, but as de peuter et al. (2017, p. 692) note: 'inside a decade, an innovation from below was drawn out of the margins, harnessed by capital and imprinted with corporate power relations'. today, by way of these global real estate ventures, capital can both appropriate the value waged workers create and charge them rent, just as we pay for the households where so much of our free reproductive labour is enacted. but what might seem quite distant from the worker centres apostolidis describes comes a little closer if we take seriously the contradictory (merkel, 2019) or ambivalent (de peuter et al., 2017) status of coworking, which may provide opportunities for the convivial mutualism that apostolidis finds in the worker centre while also interpellating members as entrepreneurial individuals, and which 'is animated by a tension between accommodating precarity and commoning against it' (de peuter et al., 2017, p. 689) . i am left with a question that i think might be worth pursuing: is coworking best understood as a specular image against which we can recognize the progressive potential of the worker centre, or is it a cautionary tale about its potential to be co-opted? the second comparison is to a very different model of labour organizing for precarious workers. this is a project based in new york city called wage, an acronym for working artists in the greater economy. it started in 2008 as a project committed to help artists to be remunerated for all the work they do with non-profit arts organizations and museums. their 'womanifesto' says they demand payment 'for making the world more interesting' (wage, 2020) . among other initiatives, wage's efforts involve knowledge production about various arts organizations and the contracts they make with independent artistic workers, the development of a platform that helped artists negotiate fair compensation, and a certification for which arts institutions can apply. this approach to organizing precarious workers is comparable to the model of the worker centre in the sense that each of the projects seeks at once to facilitate work and to acknowledge anti-work critical languages and agendas. one of the questions that the comparison with this project raises is whether the forms of convivial mutualism and politicization apostolidis found in the worker centre require the kind of 'embodied social interaction' (p. 34) and faceto-face encounters that platform models of organizing do not necessarily prioritize. kathi weeks in 2010, i co-authored a book with catherine eschle entitled making feminist sense of the global justice movement which sought to make visible, audible and intelligible a strand of feminist anti-capitalist activism that was being consistently ignored in the international relations and social movement literatures (eschle and maiguashca, 2010) . driven by the conviction that taking the words and deeds of the women engaged in these struggles seriously would yield not only a more intricate and complete empirical map of the movement, but also prompt a re-conceptualisation of its meaning and trajectory, we embarked on fieldwork in several countries as well as interviews with 80 activists over a period of several years. by seeking to expose the gendered power relations that marginalise women within the world social forum process, as well as in the academic literature about this movement, and by choosing to speak to and from the feminist struggles that emerged to confront them, the book was written in solidarity with feminist anticapitalist activists. paul apostolidis' book the fight for time encapsulates a very similar kind of intellectual-political project as it also seeks to capture the self-understandings of migrant day labourers in their everyday struggles, to reflect on how they resonate with contemporary critical theoretical concepts and to learn how, taken together, these empirical and conceptual insights may lead us to a renewed vision of what a left politics might look like for our age. like our book, paul's is unashamedly political in intent and, as such, it embodies a form of 'militant research', which 'activates enlivening moments of contact between the popular conceptions of day labourers and scholars attempts to describe and account for precarity in sociostructural terms' (p. 21). like our project, paul's research wants to bring what has been rendered marginal, both politically and academically, to the centre of our scholarship and theorising. and like my own work, more generally, paul's is driven by a commitment to revitalising both the theory and practice of left politics. in my contribution to this critical exchange i will draw out the points of contact between our respective approaches as well as tease out what i take to be our differences. in doing so, i aim to underline not only what is distinctive about paul's efforts, but also the shared challenges that we face as critical theory scholars attempting to chart a path for the theory and practice of a collective, transformative politics. more specifically, i want to highlight two broad lines of inquiry that emerge when undertaking this kind of politicised scholarship. the first line of inquiry seeks to open up a dialogue about the challenges that implicitly accompany the quest of constructing a critical theory that can simultaneously speak to and from 'the exception' and 'the synecdoche', or, to put it otherwise, that can light a path from the particular to the universal. the second theme concerns the role of utopian thinking in galvanising and giving direction to a radical left politics that is inclusive and that is fit for purpose in the 21st century. turning first to the task of critical theory, understood in marx's terms as the selfclarification of the wishes and struggles of the age, it is imperative that one grounds one's analysis in the practices and aspirations of a particular marginalised subject. elaborating on this point leonard (1990, p. 14) states, 'without the recognition of a class of persons who suffer oppression, conditions from which they must be freed, critical theory is nothing more than an empty intellectual enterprise'. now, while apostolidis and i agree on this, and both of us have chosen 'addressees' that are subjected to oppressive power relations that undermine their life chances and denigrate their ways of knowing and feeling, the conditions and experiences which give rise to and shape their respective ideas and practices are significantly different. indeed, despite some important overlaps, the radical politics and utopian imagination that emerge from each constituency -precarious labourers, on the one hand and feminist activists, on the other -diverge considerably. so, what are these differences, and what lessons might be drawn from this comparative analysis for those of us seeking to develop a comprehensive critical theory that seeks to move seamlessly from the exception to the synecdoche? apostolidis' chosen addressee is the migrant day labourer living precariously from day to day in a hostile environment in the us. framed as an exploited class, apostolidis' chosen subject wages his struggle for survival and dignity on the terrain of labour relations. while paul rightly recognises that day labourers, as a group, are also gendered and racialised subjects, his study remains primarily focused on the collective efforts of male labourers to resist forms of denigration and harm that mark their lives as workers and to overturn the destructive and exploitative practices of an unregulated capitalist economy, more generally. by contrast, my feminist interlocutors were relatively privileged economically in comparison to other women in their respective societies -and certainly to the day labourers of apostolidis's book. moreover, most of these women were well educated and, although many lived precarious professional lives (e.g. their ngo funding was secured year on year), the women themselves were, in the main, leading comparatively secure lives both materially and socially (they had families and belonged to social movement networks). finally, all of our activists were already politicised and involved in consciousness-raising activities (e.g. our fieldwork in brazil exposed popular education as a common practice) and, to this extent, were engaged in a form of feminist praxis that quite self-consciously and explicitly sought to transform the world they lived in. in sum, pace apostolidis' claim that precarity is a 'near universal complex of unfreedom' (p. 2), it is not the obvious starting point for conceptualising the challenges faced by these women. given these different starting points, what kind of politics emerges from each constituency, what utopian visions accompany them, and to whom are they directed? for apostolidis, an anti-precarity politics demands a 'post-work' future, one in which we all refuse to assume the responsibility for facing up to and accepting the consequences of precarity as an inevitable condition of life. instead, we are entreated to engage in a 'politics of demand' that seeks to reclaim our wages and our time ('for what we will') from predatory capitalist powers. more concretely, apostolidis outlines several attendant policies, including the introduction of a universal basic income and the creation of affective spaces of embodied social interaction, including multiple work centres. as he puts it, 'if all working people could gain access to workers centres like those that are inspiring such utopian effulgence â�¦ such a politics could well find masses of adherents and assume more fully developed form in our common precarious world' (p. 34). this is a resolutely anti-capitalist vision of a transformed world demanded by and imagined for all workers. or, to put it in fraser's (1994) terms, this is a bold call for a social politics of redistribution. turning to the feminist activists of my project, we find an alternative vision of what a better, more just future looks like. and while it is also anti-capitalist in orientation, it refuses to centralise either the realm of 'work' or 'workers' as its central axis of liberation. instead, the politics of demand that emerges from this politicised subject targets, not only capitalism as a systemic power relations but also patriarchy and racism. in this context, all three systems of power are understood as interlinked and pervasive to the extent that they cut across all social realms (economy, society, political, cultural) and are reproduced in both the public and private sphere. each however is also sui generis, and therefore, requires specific strategies to be overturned. moreover, on the affirmative side, our feminist interlocutors articulated their vision for the future in terms of two sets of demands. the first took the form of multiple proposals for policy change that seek to address context specific problems, such as violence against women, reproductive health, labour rights including the women's right to work and environmental degradation. the second was normative and universal in nature and revolved around the identification and defence of a set of ethical values -bodily integrity, equality, fulfilment of basic needs, peace and respect for the environment -that go beyond the concrete wish lists of different groups and pertain to all human beings. thus, the feminist anti-capitalist activism that i explored embodied a self-consciously intersectional politics in which demands for material redistribution and social justice were combined with equally important claims for cultural recognition. thus, here we have different struggles, different self-understandings and different visions of a progressive left politics. but if, as apostolidis suggests, 'we need a politics that merges universalist ambitions to change history, which are indispensable to structural change, with responsiveness to group differences that matter because minimizing them means leaving some people out' (2019, p. 14; emphasis in original), then how do we knit together these connected and yet distinct visions of emancipation? how do we move from the exception to synecdoche if we have multiple exceptions, each with their own sets of experiences, analyses and aspirations? after all, linking 'universal ambitions' to radical social change requires that we have a shared understanding not only of which structures of power need to be transformed/challenged the most, but also of how we go about building a common struggle. and whatever the intellectual synergies, programmatic overlaps and emotional affinities between the struggles of day labourer in the us and that of women worldwide, their utopian dreams would take us along very different, perhaps even incommensurable, paths. given this challenge, the question becomes one of deciding whether we need multiple critical theories running parallel to each other animated by different kinds of oppressions and degrees of marginality or whether we are still looking for a singular revolutionary subject, the one catalyst for change who is able to be both an exception and a universal exemplar, thereby embodying all the demands of the oppressed? this is not just a quibble about who gets to lead the charge: it is about what radical, progressive change should actually look like. as a feminist scholar seeking to find and defend space for an intersectional politics that refuses to be contained and streamlined in any way, i think it is imperative that critical theorists resist the temptation of elevating one concrete subject to that of a universal one. instead, we must engage in far more patient, painstaking ethnographic work of the kind that apostolidis has undertaken on male migrant day labourers, with a range of other addresses or marginalised subjects (e.g. the experiences of female day labourers are, as apostolidis suggests, one good place to start). it is only once these varied, complex mappings of power and resistance are drawn, with the recognition that they cannot be easily merged, that we can begin to look for connections across them and identify possible sites of bridge building which may lead to a convivial politics of the left and to the emergence of a collective dream. whatever it ends up being, my sense is that it will have to take the form of a coalitional politics, one in which sui generis struggles fight alone and together for radical change. the second theme is the role of utopian thinking in galvanising and giving direction to a radical left politics. despite being burdened by a 'relentless presentism' that does not allow them to think about, let alone strive for, a better future, it is clear that apostolidis believes that the 'demand' politics of day workers is suffused with utopian aspirations (p. 68). drawing on coles (2016), apostolidis describes their aspirations in terms of a 'visionary pragmatism' (p. 221) that combines an overt disruptive politics, that makes them visible and audible to the wider public, with more mundane, everyday practices of solidarity, mutual aid and self-government. interestingly, this view of utopian thinking as granular, incremental and cumulative, as well as eventful, unruly and confrontational, resonates very strongly with the dreams and impulses of feminist anti-capitalist activists. in fact, we deployed the notion of 'principled pragmatism' as a way of capturing their mode of action, in general and its pre-figurative orientation, in particular. for what became clear to us as researchers is that our feminist activists were concerned with articulating not only the political substance of their alternative future and the values that underpin it, but also an ethos by which this future should be brought into being. in this way, the 'principled' part of principled pragmatism sought to underline the highly ethical nature of both the goals/ends of their mode of action, as well as the means designed to achieve them. moreover, we found that this normative mode of action embodied a specific temporality, which was open ended and processual as well as nonlinear. this is, in part, due to the commitment of feminist activists to enabling women to speak and act for themselves, a project which, by its very nature, is unpredictable. it is nonlinear because its pre-figurative orientation demands that the future be lived out in the present. in this way, principled pragmatism is anchored by the imperative of getting things done in the 'here and now' of everyday life, without giving up the goal of radical change in the future. as a mode of praxis that pursues incremental, context specific change, feminist anticapitalist activism presents us with an inspiring alternative to the clichã©d dualism of reformism and revolution. the question here is whether the 'visionary pragmatism' of day workers is generalizable to other forms of contestation and, if not, in what ways it might be different from the 'principled pragmatism' of the feminist activists outlined above and what might be at stake in these differences. whatever our different starting points, what all the contributors to this exchange share is an abiding interest in generating explicitly normative, politicised scholarship or what apostolidis refers to as 'emancipatory scripts'. in other words, we all resist the path of what mcnay calls 'socially weightless' theorising, referred to by andrew schaap in his introduction to this critical exchange, opting instead to grapple with the messy world of politics, the material social conditions that hold it in place, and the suffering it engenders. to this extent, we all believe that what we write about and how we conceptualise it matters, not just intellectually, but also politically. for in the end, the stories we tell about the world and 'politics of resistance' that bubble up within it, can contribute to opening up (or closing down) the spaces of possibility for its realisation. pursuing this intuition is becoming harder, however, not only because academia continues to extol the virtues of scientific knowledge, but also because of changes in the political landscape. with 'populism' now elevated as the threat du jour, all resistance against the status quo is in danger of being discursively contained by politicians and academics alike. moreover, the increasingly trenchant calls to drop the left-right distinction in favour of other political cleavages (e.g. 'people vs elites', 'people from somewhere' vs 'people from nowhere') are making it harder to reclaim a politics for and by the left. in this context, critical theorists of all ilks need to stick together, learn from each other and engage in a form of 'epistemological coalition building'. while it may not be the only route to progressive change, as paul rightly points out, it is one worth sustaining, in my view, and critical exchanges of this sort provide one step in this direction. fighting from fear or creating collaboration across economic divides? in the fight for time paul apostolidis offers readers a powerful meditation on the problem and politics of precarity. he contends that precarity is a global problem shared by virtually all who toil in the global economy. through his study of latino day laborers in the us, apostolidis argues that day laborers present a proxy for the precarity of laborers worldwide (pp. 4-5). through his portrait of the cruel trials faced by day laborers, apostolidis wisely proposes that work centers for all, popular education practices and consciousness raising, as well as a 'demand politics' for better and safer labor conditions, fair pay, and flexible time are necessary to improve the lot of all laborers everywhere. his valuable work thus provides a vision of collective practices that might, if we are persistent and lucky, ease the plight of billions of precariously placed workers across all walks of life worldwide. along with my admiration, this book's fine and yet familiar tones raise for me two questions that i pose here in the spirit of conversation and in sharing in paul's quest for the best ways to realize global prosperity and peace that recoups the time that all human beings need to explore and express their best qualities and capacities. my first question is whether inviting widespread personal identification with precarity -as opposed to identifying with peace, justice, or other motivating concepts -is a necessary step to ignite awareness and action for economic change that recoups time for all (pp. 4-5)? a recent national public radio/harvard university poll shows that in the us, the majority of both the wealthy (62%) and the poor (75%) already share the view that extreme economic inequality is a widespread and serious problem that presents risks to everyone in the global economy (harvard, 2020) . while wealth and poverty are facts of a balance sheet, precarity is experienced as a feeling or state of mind. this is acknowledged implicitly by apostolidis in his application of lauren berlant's concept of 'cruel optimism', in which precarity is not considered as economic hardship alone, but is an 'affective syndrome' (p. 5). thus while wealth and poverty shape experience in material ways, the feeling of precarity is a choice to embrace and/or identify emotionally with a fearful state of dangerous insecurity. but is the choice to identify oneself with the feelings and fears of precarity wise or helpful? dangerous insecurities may arise for anyone, and even the comparatively well off may feel fear of sudden destitution. yet as frankl (2006) observed in man's search for meaning, the responses that we choose to a threatparticularly one's capacity to choose not to succumb to fear -is a central factor in securing human freedom under any conditions. as frankl himself exhibits, even in the life-threatening conditions of a nazi concentration camp, his humanity and true freedom could not be extracted from him because freedom lies in our capacity to choose our own responses to violent and destructive conditions, even unfathomable extremes. thus, in contrast to berlant's cruel optimism, frankl's observation is that even within the vicissitudes of illness, exposure, and hunger, those who faced the concentration camps with dignity, self-worth, and courage were far more likely to survive, and eventually escape those conditions, than those who surrendered to a mindset of fear-based terror and precarity. in short, our chosen mindsets under hardship also shape our prospects for resolution and escape from extremity for better or worse. thus, to choose to embrace affective fear and precarity may ultimately undermine the strength and survivability of the self. if fear of precarity is widely embraced, this may in turn subvert the capacity for collective action in pursuit of economic justice and the reclaimed time that all workers, as apostolidis deftly shows, so desperately need. beyond frankl's philosophy and experience, neuroscience also illuminates the possible hazards of self-identifying with a precarity mindset. in ledoux's (1996) influential work on the interface of emotion and human physiology, the emotion of fear, particularly mortal fear, triggers neurological subsystems of the body that enable rapid responses by bypassing and making temporarily inaccessible the neocortex -the brain-centers of conscious reflection -which are too slow to address risks to mortal safety. in other words, when humans are in fear, we cannot physically access our capacity for conscious reflection until our fear subsides (ledoux, 1996, p. 128) . instead, when in fear, the human body defaults to operating on autopilot through whatever neurologically encoded scripts the emergency systems of a given body happens to have for its fear responses, typically including, fight, flight or freeze. arguably, this can be seen in chapter three of the fight for time, in which paul shows day laborers -fearful of missing out on even an extractive job in their precarious conditions -inflict violent harm on one other in a 'surly wrestling match' as a car approaches (p. 118). does such fearbased reaction help? not as much as it endangers people, fosters increasing fear and dissention among laborers, and drives away would-be employers. yet this kind of scrum is not a poor conscious choice. instead it is a scripted embodied impulse that is the anticipated neurological consequence of adopting a fearful approach to experience and thereby hobbling conscious response. on this analysis, choosing a precarity mindset risks disabling physical access to conscious, thoughtful reasoning and response in fearful moments in favor of fear-based impulses and reactions that are attendant to moments of fear. these risks of identifying with precarity raise my second question. what blind spots might exist in the familiar narrative of economic reforms championed in the fight for time? the proposed path to reform invites readers to embrace work centers for all and collective action based in common experiences of deprivation that address intra-group biases and divisions along the way. this is an inherited social script that is long-treasured and often invoked. as a common social inheritance among scholars and activists alike it has been portrayed eloquently before in such powerful retellings as that of salt of the earth, the once blacklisted film narrating a famous 1951 new mexico labor strike. in this valuable and familiar approach, echoed here by paul, laborers come together to confront and overcome their mutual biases, and then pursue together demands for better wages and benefits. paul's recruitment into one work center's 'theatre of the oppressed,' intended to help workers address their biases, is an example of this longstanding approach in action (p. 29). in this script, rich capitalists appear as universally greedy and cruel hoarders whose victims, the long-suffering poor, must now muster the courage to see their commonalities within divisions of race and gender to demand a fair shake from capitalists. this story is rewarding. and it is true that workers everywhere would be better off if this familiar scenario were consistently fulfilled. yet the gains of this approach over time have been slow, sporadic, labor intensive, and often hobbled by the stubbornly persistent biases, suspicions, and enmities of many laborers -as well as owners -weaknesses to which all of humanity is still often prone. in contrast, from a chicana feminist perspective, such as that of gloria anzaldãºa, the enduring problem of economic inequality does not call only for looking within worker's groups for sources of intra-group conflict and dissention. it also calls for searching across polarized social divides -of workers and owners, of the haves and the have nots -to explore and create the conditions for peaceful resolution of economic inequality. although venerated in death, anzaldãºa was at times scorned in her lifetime for proposing that true peace and justice required people to eventually come together to work across trenchant social divides: people of color working with whites, women with men, immigrants with non-immigrants, and so on (anzaldãºa, 2002) . this anzaldãºan chicana feminist perspective urges us to not overlook the possibility of working generatively across the divides among workers and owners, a possibility in the blind spot of the salt of the earth narrative in which economic benefits must always be fought for and hard won rather than produced through collaborative vision and effort. following this traditional script, the fight for time's focus on work centers and the fight of traditional labor activism implies that attempts to collaboratively bridge the worker-owner divide may be futile, naã¯ve, or at best irrelevant. yet among the ultra-rich, practices of large-scale philanthropy are emerging which suggest that there is more transformative common ground between laborers and some owners than the traditional salt of the earth viewpoint can yet acknowledge. if so, then attending to this common ground may help remedy the lack of time, economic freedom, and financial stability needed by everyone more quickly and effectively than the fights and struggles of work centers, strikes, and direct actions have historically achieved. specifically, in recent years carnegie's (1889) assertion that successful capitalists should ideally end their financial careers by giving away all of their wealth, retaining only a personal competency -defined by carnegie as enough wealth to meet their own life needs and that of one's family -has been gaining a following. reflecting this view, in 2010 two of the world's wealthiest billionaires, bill gates and warren buffet, created an organizational structure called the giving pledge (2020), in which ultra-wealthy people across the world pledge to give away the majority, or at least half, of their wealth in their lifetime or upon their death. to date, over 210 ultra-wealthy individuals and families have made this pledge, including five of the top thirteen billionaires on earth (i.e. bill gates, warren buffet, elon musk, mark zuckerberg and mackenzie scott). in july 2020, these five pledgers command a combined total net worth of $410 billion usd (bloomberg bi, 2020), representing an estimated philanthropic giving over time of at least $205 billion usd by those five pledgers alone. if a growing number of the ultra-rich are voluntarily committed to giving away their wealth for the benefit others, then -by adopting an anzaldãºan perspective on working across economic and other social divides -it becomes valid to explore beyond the familiar salt of the earth script hailed in the fight for time. doing this would involve considering how engagement across social divides of workers and owners may help direct emerging philanthropy into social justice philanthropy that could potentially ease global financial inequities more quickly and resoundingly than the efforts of work centers and traditional labor actions have done to date. such a move could potentially recoup both time and transformative possibilities for the benefit of laborers, as well as owners, and provide sustainability benefits for the planet from a revised economy. by shining an anzaldãºan chicana feminist perspective into the blind spots of the fight for time, apostolidis's project is not abandoned, but augmented by bringing unforeseen possibilities into view. new possibilities might arise from organizing with willing and openhearted owners, rather than fighting against them as a class to retrieve the time and financial freedoms precious to all. in moving beyond the view that labor and owners are always divided (rather than only often so), it becomes possible, for example, to imagine efforts in large-scale social justice philanthropy that could, for example, provide everyone on earth with a carnegiesque financial competency. for the sake of discussion let's imagine that such a personal competency would be $2 million usd per person worldwide. with 7.7 billion people now on earth, the core funding for a $2 million dollar safety-trust for each person at present on earth would require 15.4 billion usd. that sum seems large, yet it is less than 7% of the combined minimum pledge, of the five of the 210 signatories to the giving pledge named above. of those five givers, mackenzie scott herself is committed to giving away all of her $59.5 billion, a sum that alone could handily endow a universal personal competency worldwide. thus at least in terms of core capital resources (even accounting for the illiquidity of many assets of the ultra-wealthy), a universal competency could be funded by a small fraction of the funds already pledged for giving by the world's ultra-rich. in this context, self-identifying with fearful precarity and fighting for traditional reforms through work centers and labor actions for the changes so urgently needed in the (now pandemic-stricken) world may be worthy in our traditional socially inherited script of salt of the earth-style social change. yet this accustomed approach arguably now may be less wise and expeditious than other emerging options. if so, it is worthwhile to explore the limitations of our commonplace labor-related scripts and to confront as needed our own potential blind-spots regarding the diversity among the ultra-rich that could -in an anzaldãºan manner -help us to better see new possibilities for bridging economic divides and opening ourselves to collaboratively producing transformations that can benefit all people and the planet upon which we reside together. is resolving the pain of global poverty through philanthropic giving so farfetched? it is not as implausible as so often thought. alongside the kinds of labor actions hailed in the fight for time, in recent months one us billionaire chose to pay the college debt of an entire class of morehouse college totaling over $35 million usd. another man paid the college debt of his uber driver, a single mother, thereby enabling her to finish her college degree. by chance, the latter giver is a well-off white man and the recent graduate an african american woman. meeting as strangers by chance, the two have now become friends and their story has gained popular attention. if giving to strangers in need is not merely feasible but also appealing, why is it perhaps emerging more visibly now? it may be because many humans are learning that beyond a meaningful competency, wealth does not necessarily create happiness, but that human connection and giving often do. if so, then a season of transformational giving may be on the near horizon. if these events reveal a nascent turning of the tide, there are still many obstacles on the path of philanthropic giving-for-global-prosperity. if a pathway to funding a universal competency could be created through social justice philanthropy, for instance, this would also need to involve further measures for healing the poverty-related traumas so aptly described in the fight for time. beyond a basic endowment, provisions would be needed to provide for new learning, safeguards, and other supports for recipients in order to truly solve the lingering problems of precarity. why? because those who come into sudden wealth from poverty and lack often risk experiencing poverty once again through missteps, fraud, or other hazards arising from a rapid change in economic conditions. thus even if furnished with a financial competency, in the context of hazardous grafts, frauds and other pitfalls that remain mainstays of us culture (young, 2017) , latino day laborerslike the vast majority of other workers alluded to in the fight for time -would need additional training to cultivate the skill sets and mindsets needed for living with meaningful wealth after having had little or no prior knowledge or instruction in how to hold, manage, or grow the would-be competency that could furnish them at last with time and freedom from extractive labor. is the idea of philanthropic solutions to global economic inequalities simply another example of 'cruel optimism'? by berlant's (2007, p. 33 ) definition, optimism is cruel only if the desired change is truly 'impossible or too possible and toxic'. clearly, however, changes are emerging that make meaningful large-scale social justice philanthropy possible, even if those changes are growing in the shadow of predatory economic practices. with these changes in view, it is worth asking whether paul apostolidis's fine call to 'fight' to retrieve time across all laborers might be best served by extending our willingness to also seek common cause not only among diverse workers, but also among those openhearted wealthy owners who are willing to give back their wealth to benefit the well-being of all humanity. if so, it may be worth our time not to fight for time, but instead to work collaboratively and creatively for time and wealth to become equitably available to everyone in unexpected ways. edwina barvosa whose politics? whose time? traditionally, political theory has not co-theorised. it has spoken from on high among 'male, pale, stale' companions. hence my defection from these ranks. in this dialogue with paul apostolidis' the fight for time, i would like to recognise the attempt to co-theorise. in this work some migrant day labourers' voices, described as latino, are represented through ethnographic moments. bodies, presumably cis-male, are portrayed in struggle. this day labour is proposed as 'synecdoche' -the part that stands for the whole -by which is meant precarity on the grand social scale (p. 248). thus, the collective fight for time is staged. demands include: a politics that goes beyond seeking marginal relief from overwork and instead fundamental alternatives; a repudiation of the work ethic that prescribes personal responsibility in the face of desperation; the demand to restore time as well as wages to the people; a refusal of work 'as the axial concept that constricts working people's social and political imaginaries' (p. 243). i can only respond from outside of the social and political world the book portrays. i am not latinx/latin@ (hence the unsatisfactory use of terms that are, themselves, the site of struggle), but white, cis female, and belonging to many other privileged social locations. from my vantage point i explore struggles for migrant justice and against austerity and precarity at the intersections, drawing on lessons from black feminism and indigenous scholars writing in the context of the ongoing violence of settler colonialism. i ask: whose politics? whose time? whose politics? whose knowledge counts as the basis for politics? i cannot accept proposals, as in this book, to radiate outwards from some bodies and experiences -people presented as cis-gender latino men, workers -as the part that stands as the whole, the synecdoche. this is a project of inclusion: generative themes are based primarily on these experiences, to which others must then align. this story has been told before. it is of a linear, sequential march toward 'justice'. some are at the centre, in the lead, and others need to wait their turn to then be included. add and stir. who must wait their turn? in this work, this sounds like (presumably cis) women domestic workers who are mentioned but peripheral to this study, as well as those who experience misogyny and harassment at the worker centres (pp. 87, 124, 226) that are to be the incubators of progressive alternatives and the collective fight for time. we could add here the women who founded and run the worker centres in this book, who are barely visible but are also key protagonists of anti-precarity and antideportation struggles. those who must wait also surely encompass malepresenting others who do not identify with what are referred to in the book as the 'normative' masculinities deployed in the worker centres (p. 161). what happens when the political knowledge of queer, non-conforming, differently gendered actors is parked for consideration later on? what politics is generated when these experiences and these intersections are named at the end of a book (pp. 249-250), after the contours of struggle have been determined against precaritisation 'as the array of social dynamics that structure these settings' (p. 243)? it becomes possible to call for 'workers centres for all workers'. and thus a space for the resistance of some is built on the oppression of others. theorising this as synecdoche does not name the problem or open up the space for resistance to multiple, intersecting oppressions. it does not centre as part of the theory the messy and vital struggles of workers' centres to change representation on governing boards, to reconfigure resistance to border control in recognition of the specific brutality experienced by lgbtq migrants (p. 249) and to bring into focus all forms of work (p. 250). this call, 'workers centres for all workers', chills me without scrutiny of all gender relations and all gendered labour -and i mean all, beyond gender binaries, at multiple intersections. what can the 'repudiation of work' mean without naming cis heteropatriarchal relationships of domination, in ableist and racialized capitalist systems that pervade all 'public' and 'private' realms? this book asks how various groups of workers articulate terms of their consent, how regimens and discontinuities of body-time on the job vary between different groups. but this undertaking is impossible without articulating at the same time the terms of consent to cis heteropatriarchal relations in and outside of the workplace. oppressors are not only employers. they are also other workers, community and family members, who are cis men and women embedded in hierarchies that include gender, class, race and legal status. what would it look like to build a politics for migrant justice, against austerity and precarity starting with the knowledge of experiences of a matrix of oppression (hill collins, 2000) ? this is no synecdoche. it is the challenge of forging justice at the intersections. these are not new lessons to learn and there is no way to do justice here to all the illustrations of this kind of politics in practice. from my past work, one example from france in the 1990s, may provide purchase on us-based challenges. in paris, madjiguene cissã© led movements for the regularisation of 'sans papiers' -people 'without papers'. she described the 'struggle within the struggle' by women 'sans papie`res' (the feminised version of 'sans papiers') for gender equality within the movement, as well as regularisation of immigration status. this was a struggle against patriarchy as well as the racism of the french mainstream. the knowledge that sans papie`res women imparted in the struggle meant that they were in charge of their own thought and politics but without excluding others (hill collins, 2000, p. 18) , and they did not project separatist solutions to oppression because they were sensitive to how these same systems oppress others (hill collins, 1986, p. s21) . women revitalised the movement and kept it together: 'a role of cement' (cissã© and quiminal, 2000) . cissã© explains how women kept the group together particularly when the government attempted to divide them, by offering to regularise 'good files' of some families, but not of single men. sans papie`res very firmly opposed this proposal, arguing that if single men were abandoned, they would never get their papers. migrant justice, anti-austerity and precarity politics look different when built at these intersections. the difference lies in who is present and also in what results. care and self-care are centred as 'an act of political warfare' in a system in which some were never meant to survive (lorde, 1988). self-help, self-care and selforganising are alternative, sometimes complementary spaces, and an important source of personal support, resilience, information and community, beyond whitedominated, politically raceless, misogynistic anti-austerity/precarity spaces (emejulu and bassel, 2017) . no part can stand for any whole when other spaces are unsafe and sites of violence rather than a collective fight for time. whose time? in our work exploring the activism of women of colour across europe, akwugo emejulu and i have argued that epistemic justice is about women of colour producing counter-hegemonic knowledges for and about themselves to counter the epistemic violence that defines white supremacy (emejulu and bassel, 2017, p. 30 ). epistemic justice is not a correction or adjustment to 'include' unheard voices, but a break away from destructive hierarchical binaries of european modernity. it is a break away from the 'persistent epistemic exclusion that hinders one's contribution to knowledge production' (dotson, 2014, p. 116) and renders women of colour invisible, inaudible and illegitimate to both policymakers and ostensible social movement 'allies'. epistemic justice at the intersections makes settler colonialism visible, whether in the united states of this study or so-called canada, where i grew up. this means going much further than the possibilities briefly flagged in the book: kindling a critical sense of historical time and orientation to the future that is fuelled by an awakened sense of historical injustice (pp. 216-217). it is necessary to go much further because the fight for time cannot be founded on indigenous erasure. erasure does not create a path toward solidarity 'with other colonised populations who understand their past experiences in somewhat parallel ways' (p. 217). this book discusses workers turning a day-labour corner where jobs are fought for in portland into a space of musical performance. these are important moments to explore and co-theorise. but when they are described as transforming the space into a 'site of freedom' (p. 217), indigenous struggles are erased. these performances are taking place on stolen land in what is now referred to as 'portland'. tuck and yang's (2012) key work 'decolonisation is not a metaphor' rattles the kind of settler logic that allows for this erasure. they discuss the occupy movement and argue that claiming land for the commons and asserting consensus as the rule of the commons, erases existing, prior, and future native land rights, decolonial leadership, and forms of self-government. occupation is a move towards innocence that hides behind the numerical superiority of the settler nation, which elides democracy with justice and the logic that what became property under the 1% rightfully belongs to the other 99%. in contrast to the settler labour of occupying the commons, homesteading, and possession, some scholars have begun to consider the labour of de-occupation in the undercommons, permanent fugitivity, and dispossession as possibilities for a radical black praxis â�¦ [that] includes both the refusal of acquiring property and of being property (tuck and yang, 2012, p. 28 ). the fight against precarity and for migrant justice must be reconfigured, if it is to be in solidarity with indigenous struggles. this means changing whose understanding of time and labour are at the centre of analysis. the land where this study took place is not an 'immigrant-receiving country' but a settler colony, founded on indigenous genocide, dispossession and slavery. when time is decolonised, the refusal of work is recast in relation to the refusal of the settler colonial state (simpson, 2014) and the formations of race, class, gender that it engenders. these formations, rooted in settler colonialism, shape the lives of the migrant day labourers who are 'here' because the united states was 'there' (sivandandan, n.d.) and must contend with entangled colonial legacies from different social locations. this requires a shift in vocabulary, when 'migrants' are in fact settlers. but with this comes also a shift in politics. in undoing border imperialism, walia (2013) shows how movements such as no one is illegal (noii) in what is now called canada have reconsidered their understandings of migrant justice. this has required recognizing the ways in which their actions have been premised on an understanding of sovereignty and territory that perpetuates the colonial legacy that has dispossessed and disenfranchised indigenous peoples (walia, 2013) . noii activists consequently re-centre ongoing colonialism and reconfigure understandings of land, movement, and sovereignty when claiming that 'no one is illegal'. specifically, activists have tried to consider how their calls for 'no borders' undermine indigenous struggles for title and against land loss, to reclaim land and nation. solidarity means reshaping the political agenda of noii beyond token acknowledgements, to move from a politics of 'no borders, no nation' to 'no one is illegal, canada is illegal' (fortier, 2015) . and now? i asked two questions here: whose politics? whose time? they remain unanswered. but they are a path to solidarity rather than solutions. so it goes in the messy world of politics, not political theory. leah bassel representing precarity: health, social solidarity, and the limits of coalitional epistemology in her contribution to this critical exchange, kathi weeks poses an unexpectedly timely question about how to politicise precaritisation in the form of heightened bodily risk at work. writing prior to the coronavirus outbreak, weeks echoes my observation in the book that, apart from the temporary rush of reporting when an occupational safety and health (osh) disaster strikes somewhere in the world, 'the problem of workplace death and injury is strangely absent from public consciousness'. how quickly things can change. i am writing this response in april 2020 in london, now in its fifth week of 'lockdown'. in this context, weeks's reflections prompt two questions: first, in what specific ways has the covid-19 crisis made workplace threats to life and health newly legible? second, what ramifications do state and employer responses to the pandemic have for the pressing issue of how 'to politicise the issue of bodily harm given how extensively the idiom of health has been rendered amenable to the logics and aims of biopolitical management', as weeks aptly puts it? i still see the outlines of an answer to the second question in the politics of solidarity around osh matters that day labourers have developed through worker centres. today's work-culture construes the task of sustaining the worker's health as the worker's personal responsibility, which the worker also exercises as a productivity-oriented social duty. many day labourers abet this tendency through their own themes of meeting the 'risk on all sides' by individually keeping their 'eyes wide open'. yet day labourers also demonstrate how health-related language, desires and practices can be cathected with a different figuration of social and individual conscientiousness: responsibility as autonomously collective solidarity. day labourers pose this alternative in three main ways. first, through convivial relations at worker centres, day labourers bolster one another to stand up to abusive employers, to refuse dangerous jobs and to de-throne work and income from their primacy in everyday affairs. second, day labourers contest biopolitical powerknowledge by fusing their own analyses of work-hazards to responsive practices of their own devising, as they teach one another about risky work processes, materials and employer conduct through popular education. third, day labourers are hatching visionary ideas about how distinct working populations can recognise their common stakes in ending the bodily precaritising dimensions of work, such as by organising with, not just against, their middle-class employers. in all these ways, at day labour centres, the talk of putting 'health' first mobilises a complexly social vernacular. one's 'own' health is always a concern, but the worker's understanding of 'health' does not stop with the individual. instead, this idiom positions health as stemming from social interactions that are contingent on power-differences, which are amenable to workers' collective re-formulations, which, in turn, need not be determined by the ideal of productivity. politically, these initiatives by day labourers imply that disentangling health-talk from the corporate wellness apparatus depends on autonomous action from below in tandem with cross-class organising. the role of the wizened welfare state in such efforts, however, is not clear -and that brings us back to the coronavirus. talk about 'biopolitical management'. the crisis has precipitated massive deployments of state resources to expand public health knowledge-systems and to use statistical probability calculations to foster mass populations' biological vigour and protection from disease, albeit in racially selective and gender-unequal ways. must this tidal wave of emergency mobilisation re-sediment personal responsibility and productivism as the norms that regulate occupational safety and health? or, as this surge recedes, could it leave behind institutional beachheads for fighting precarity on the level, and within the sinews, of the working body? even as the present apotheosis of biopolitics applies itself globally and to entire nations, it targets micro-practices in the workplace and affects precarity's configuration of work as a zone of bodily hazard. overall, the covid 19 crisis reduces to the point of vanishing the already quite faint and episodic awareness of how mounting osh threats have made the workplace increasingly dangerous to workers' health for decades, across occupations. the fight for time discusses how these threats principally entail work-environmental hazards, especially poor air quality as more work is done indoors, ergonomically dysfunctional work-processes, and debilitating stress due to corporate downsizing and rising job insecurity. ironically, the pandemic's sudden re-framing of the workplace as replete with health dangers focuses on the work environment. it does so, however, in terms that reproduce the moral individualism of the precaritised osh culture, while occluding the work-environmental systems that generate endemic hazards. thus the exhaled breath of a single co-worker becomes the respiratory threat, rather than the air circulation machinery in the office or warehouse. health-conscious bodily comportment means obeying the individual remonstrance to keep six feet away from any colleague rather than ensuring that the ergonomics of work-procedures avoid forcing workers to contort their bodies and overstrain their tendons. the stress of losing one's job, having work hours reduced, or fearing these things because of the virus's immediate economic effects, normalises the ongoing anxiety that is baked into precarious work-life and linked to heart disease. the hyper-individualisation of osh hazards in the covid-19 crisis and the fingering of co-workers as those who pose lethal hazards to us also clearly discourage building safer and healthier workplaces through solidarity among workers. such miscasting of fellow workers as the culprits whose irresponsible conduct explains why everyone's health is in jeopardy bedevils many day labourers' attempts to rationalise the contradiction between expectations of personal responsibility and the power-relations governing their work. the pandemic further embeds this thought-habit of precarity. meanwhile, consigning 'essential' workers in some occupations to higher risk exposures while others 'shelter at home' and assemble via zoom aggravates the difficulties of organising across class lines. in all these ways, the pandemic has made it harder to dislodge health discourses from their current ensnarement in norms of productivity and individual responsibility. yet the sheer size and weight of institutional responses to covid-19 also presents an opportunity to argue that, if states and employers can so speedily muster these titanic responses to this virus, then the capabilities are there, more obviously than ever, to tackle the endemic osh challenges that constitute the bodily mortifying facets of precarity even in 'normal' times. this will only happen, however, if working people redouble their organising efforts. and that makes the project of founding worker centres for all workers even more vital: extending the scaffolding for leadership development and autonomously collective organisationbuilding along with new ventures in state-sponsored redistribution, such as a universal basic income. bice maiguascha correctly observes that she and i share aspirations to pursue critical theory in ways informed by the ideas she cites from marx, leonard and militant research, and i am glad she sees in my book the work of a fellow traveller. for us both, this means doing theoretically evocative social research from positions of active engagement within political struggles against oppression and with the aim of contributing something tangible to those struggles. maiguascha and eschle's research with feminist anti-capitalist activists also illuminates how political agents quite different from those who occupy centre stage in my book can pinpoint 'systemic power relations', including gender, that are fundamental in their own right and need to be contested both as such and via the demands these women raise. in response to maiguashca, let me also underscore that, notwithstanding the near-exclusive focus of my fieldwork on male, latino day labourers, the fight for time affirms, explicitly and in its intellectual practice, the need to theorise politicaleconomic power and contestation in ways that attend to the complex gendered and racialised aspects of work. maiguashca allows that my book 'recognises that day labourers â�¦ are gendered and racialised subjects', but the book does more than this. it probes the masculine ideals woven into these workers' themes, explores how the racial state constitutes precarity through policing migrants, distinguishes day labourers' varied renderings of latino identity, and draws on my own supplementary field work and secondary literature to suggest how domestic workers' conceptions would likely both differ from and align with those of day labourers. maiguashca also implies that the book searches 'for a singular revolutionary subject' and anoints the day labourer as 'the one catalyst for change', but the fight for time does neither. if my statements in the book to the contrary do not suffice to show this, then it should still be apparent from the book's premise of basing a critique of capitalism on research with workers who, as weeks notes, resemble marx's disparaged and heterogeneous lumpenproletariat, rather than the traditional proletariat. i stand firmly in sympathy with the efforts of weeks and other theorists influenced by autonomism to widen and complicate the notion of 'the working class', as weeks does by training our attention on women's reproductive labour in households, and as studying day labourers does by foregrounding a liminal and ambiguously gendered realm between productive and reproductive labour. the analytical rubric that positions day labour as both exception and synecdoche in relation to precarity writ large appears to lie at the heart of what most troubles maiguascha and leah bassel. let me thus address further what this interpretive framework means, going somewhat beyond what is already in the book. the exception/synecdoche formulation is intended as a strategy of provocation: a prod to imagine how the critical language of one especially benighted group, which has done a remarkable job of building itself up politically, could shake loose new ways of construing overarching forms of power and domination. such general structures, systems and flows of power and domination exist, and they need to be named in order to be engaged politically. this does not obviate the fact that any act of naming by a situated subject is also bound to yield misnomers because of that person's or group's particularised social location. moreover, as mezzadra and neilson (2019) argue, capital itself regenerates, accumulates and dominates both through systemic processes that integrate the globe and through localised 'operations' that proliferate heterogeneities of experience, identity and activity (including work-activity). this, however, makes it imperative to theorise capital on both levels at the same time, through critical procedures that juxtapose the general and the particular, teasing out their resonances and tensions. one models the whole with the help of closely scrutinising an always-insufficient particular, then re-envisions the systemic through considering other concrete-particulars, and so forth. a synecdoche is a part that stands in for the whole, but this notion's origin in literary theory bespeaks selfawareness that this figuration is a contingent act of representation -rather than a straightforward declaration of truth. furthermore, critical-popular analysis does not simply infer the whole from a part but rather effects mutual mediations between self-expressions of the part and conceptions of general dynamics. the fight for time pursues this path by reading day labourers' themes together with allied concepts from critical and political theory about broad formations of precarity. this is certainly a different way of reaching a provisional sense of society-wide power than that preferred by maiguashca, but it has its virtues. one virtue has to do with the temporality and affectivity of collective action that seeks to confront thoroughly pervasive forms of social, political and economic power. having exhorted readers to pursue with other groups more of the finegrained ethnographic analysis that my book provides, maiguashca then cautions: it is only once these varied, complex mappings of power and resistance are drawn, with the recognition that they cannot be easily merged, that we can begin to look for connections across them and identify possible sites of bridge building which may lead to a convivial politics of the left and to the emergence of a collective dream. this statement conveys a political temporality of postponement as well as an ascetic tinge, and i question both. if capital and other systemic forms of power are perpetually in motion, always mutating, and never ceasing to employ both universalising and particularising modes of operation, then it makes little sense for theory to hold its own generalising capacities in reserve until it has amassed some critical mass of analyses of situated perspectives (and how could a non-arbitrary threshold be specified?). strategically, this appears unwise. affectively, something also seems awry with the gesture of renunciation one must make to defer the invigoration that comes from battling broad-scale domination, while also letting systemically generated suffering endure without being called out as such. the critical-popular approach, in contrast, partakes in the affective spirit of weeks's 'politics of the demand'. this means taking seriously both the re-constituting of desiring subjects in the midst of utopian struggle and the value of fighting for a 'collective dream' that is massive and radical -like 'worker centres for all workers' or 'wages for housework' -but neither totalising, nor conclusive. another virtue of the critical-popular approach to theorising the whole, in comparison to mapping specific differences and then building localised bridges, is that the former offers not just an alternative to the latter, but also a prelude to it. my book not only juxtaposes day labourers' popular themes with academic concepts to theorise precarity writ large and anti-precarity struggle, but also shows how worker centres, the day labour movement and a broader anti-precarity politics all depend on developing popular consciousness and political action-plans through molecular processes and alliance formation. the book's practical contribution to day labour centres' popular education programming, through workshops i conducted, as well as a report i wrote with additional dialogue options, further shows this project's commitment to fostering intersectional interactions of the kind that maiguashca and bassel endorse. the fight for time thus supports coalitional politics as one key mode of struggle needed to define and confront precarity. it takes issue, however, with what we might call a 'coalitional epistemology', or the idea that understanding power on the broadest levels and identifying desirable forms of mass solidarity, can only occur through the cumulative, piece-by-piece assembling of particularised knowledges into progressively larger composites. along these lines, it bears emphasis that the fight for time is one of two inaugural books in my publisher's series 'subaltern studies in latina/o politics', edited by alfonso gonzales and raymond rocco. i am honoured to have my book involved in this effort to support work that brings together latino studies and political theory. the series is also promoting research on latino/latin-american transnationalism (fã©lix, 2019) , contentious citizenship and gender among salvadorans in the us, and religion, gender and local agency in mexican shelters for central american migrants. colleagues interested in how my book contributes to more wide-ranging discussions of race, ethnicity, migration and gender, and to coalitional politics, should be aware of this context. for the most part, my responses to maiguashca, and defence of the criticalpopular method above, comprise my answer to leah bassel as well. bassel shares with maiguashca a similar orientation toward critique and political action, which bassel describes as embracing 'the challenge of forging justice at the intersections'. bassel argues, however, that rather than either encouraging consideration of other oppressed groups' experiences or incorporating such analysis into the book, the fight for time suppresses and erases such experiences. i strongly disagree. as i have explained, there are good reasons for understanding the logic of the synecdoche as evoking provisional renderings of broad power dynamics in ways that invite -rather than discourage -contestation. readers hoping to join a 'linear, sequential march toward ''justice''' will search in vain for marching orders in my book. bassel also does not mention how the book frames day labour as both exception and synecdoche in relation to precarity writ large. this dual optic makes basic to the book an appreciation for the specificity of day labourers' social experiences. it thus signals clearly that attentiveness to situated subjectivity is a sine qua nonthough not the sole legitimate basis -of critique. in this way, my book underscores how the forms of precarity thematised by day labourers reflect, for instance, their particular position in the urban construction economy and their specific vulnerability to the racialized and gendered homeland security state. this implicitly affirms the value of hearing what other groups of workers, situated distinctly, would say about precarity. at the same time, bassel's commentary neglects a different problem with which my book grapples: the need to challenge the invidious naturalisation of assumed group differences. white middle-class americans, for instance, certainly need to understand better what makes the lives of working-class migrants in the us both different and harder. but the former also need a better grasp of how their own economic, political and bodily fortunes resemble those of the latter much more closely than most would like to admit. anderson (2019) calls for 'migrantizing citizenship' as a tactic for waking britons up to how the shrill demand to save 'british jobs for british workers' has precaritised work for everyone. in a similar spirit, the fight for time appeals for precaritised workers throughout society to recognise their shared stakes in a common struggle, even while observing how the stakes are graver, and different, for some than for others. i do see it as a limitation of my research that, although it delved into the complexities of day labourers' commentaries and traced their interactions with an eclectically convened set of theoretical interlocutors, it did not include substantial fieldwork with other precaritised workers. thus, i could not critically compare such workers' generative themes with the themes spotlighted in the book. the conception of critical-popular research is in its formative stages, and maiguashca's and bassel's comments, have fuelled my interest in exploring how a future project could bring such critical moves into the heart of the inquiry. planning such work with migrant and indigenous subjects (including indigenous migrants) would offer one attractive pathway for doing this, especially given the anti-capitalist trajectories of leading critiques of settler colonialism, which prioritise spatial and temporal politics that may both align and conflict with migrant endeavours (coulthard, 2014) . in the meantime, i appreciate maiguashca's and weeks's invitations to speculate about how day labourers' themes and organisational spaces might relate to those of other groups. i see an affinity between feminist wsf activists' embrace of an 'ethos' whereby organising processes 'prefigure' radically altered social relations and the day labourers' anticipatory enactment of the 'refusal of work', -even as they desperately pursue jobs, and even though the day labour network takes no stand for such a refusal. as these lines suggest, however, day labourers pursue social change by generating transformation from within, and by virtue of acutely contradictory circumstances. i wonder whether a similar catalysis of power-fromcontradiction plays a role in the wsf activists' undertakings, or whether perhaps these women's class privileges permit a more confident sense that an ethically consistent programme of action is possible in ways that are precluded for day labourers. that said, it would be intriguing to know if the activists in maiguashca's research feel subjected to class-transcending temporal contradictions of precarity, such as the clash between oppressively continuous and jarringly discontinuous patterns of work. even if precarity does not furnish the express 'starting point' for these women's advocacy, it might still provide a basis for solidarity with the day labour movement in the broad fight against capital. barvosa asks whether encouraging people to identify with the timorous mindstate of precarity might be politically counter-productive, given how fear induces corporeal responses that shut down complex thinking, induce self-preserving automatism and impede cooperation. as the book shows, however, the emotions that pervade precarity include not just fear but also guilt, hopefulness, selfsatisfaction, resentment, boredom, numbness and compassion, and more. precisely because precarity is so emotionally plural, it both acquires compelling force and spawns opportunities from within itself for its own contestation. in addition, precarity is more than a 'state of mind'. it is also a socially and politically constituted condition that stems from the convergence of protracted welfare-state austerity with the transformation of employment norms and institutions. precarity, moreover, is a hegemonic formation that relies on working people's consent, which day labourers provide, for instance, through the individualism of their generative themes. yet precisely for this reason and because it is structured in contradiction, especially temporally, precarity can be transformed from within. as my book argues, many workers prefer to see the worker centrecommunity as just a 'workforce' and in this way 'identify emotionally with a fearful state of dangerous insecurity', as barvosa fittingly puts it. yet more day labourers respond to fear -along with confusion, rash self-confidence, impatience and loneliness -by acknowledging these tangled emotions and converting their affective energy into bonds of solidarity. as to gates and buffet, i am glad they are giving away mounds of money and have updated philanthropy's ethical framework, but relying on a programme to broaden beneficent actions does not strike me as a viable response to precarity. as azmanova (2020) argues, in ways complementary to the fight for time, the systemic roots of precarity lie in the competitive pursuit of profit, and precarity's structural foundations abide in the re-organisation of work and de-funding of the welfare state. absent a coordinated and democratic (anti-oligarchic) movement by masses of working people to tackle power on these levels, precarity will persist. the emancipatory script proposed by my book, far from simply pitting poor downtrodden workers against greedy bosses, casts working people at all levels of the economic hierarchy as potential collaborators in the fight against precarity, which must also be a struggle against gargantuan wealth -and a fight for time. paul apostolidis new directions in migration studies: towards methodological de-nationalism now let us shiftâ�¦the path of conocimientoâ�¦inner work, public acts the fight for time: migrant day laborers and the politics of precarity capitalism on edge: how fighting precarity can achieve radical change without crisis or utopia cruel optimism: on marx, loss and the senses the abolition of work a taste of power: a black woman's story 1889) the gospel of wealth. www.carnegie.org/about/our-history/gospelofwealth visionary pragmatism: radical and ecological democracy in neoliberal times red skin, white masks: rejecting the colonial 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(2020) life experiences and income inequality in the united states learning from the outsider within: the sociological significance of black feminist thought black feminist thought: knowledge, consciousness and the politics of empowerment the emotional brain: the mysterious underpinnings of emotional life critical theory as political practice the misguided search for the political freelance isn't free: co-working as a critical urban practice to cope with informality in creative labour markets the politics of operations: excavating contemporary capitalism mohawk interruptus: political life across the borders of settler states marx and heterogeneity: thinking the lumpenproletariat difference in marx: the lumpenproletariat and the proletarian unnameable decolonization is not a metaphor undoing border imperialism the a. sivandandan collection. race & class bunk: the rise of hoaxes, humbug, plagiarist, phonies, post-facts, and fake news key: cord-258915-lgee3ers authors: liddle, jennifer; pitcher, nicole; montague, kyle; hanratty, barbara; standing, holly; scharf, thomas title: connecting at local level: exploring opportunities for future design of technology to support social connections in age-friendly communities date: 2020-07-31 journal: int j environ res public health doi: 10.3390/ijerph17155544 sha: doc_id: 258915 cord_uid: lgee3ers social connectedness in later life is an important dimension of an age-friendly community, with associated implications for individual health and wellbeing. in contrast with prior efforts focusing on connections at a distance or online communities where the digital technology is the interface, we explore the design opportunities and role of technology for connectedness within a geographically local community context. we present findings from interviews with 22 older adults and a linked ideation workshop. our analysis identified shared concerns and negative perceptions around local relationships, connections and characteristics of the geographical area. however, local connectedness through technology was largely absent from day-to-day life and even perceived as contributing to disconnection. by uncovering how older adults use and perceive technology in their social lives and combining these findings with their ideas for improving local connections, we highlight the need for thoughtful consideration of the role of technology in optimising social connections within communities. our research highlights a need for design work to understand the specifics of the local context and reduce emphasis on technology as the interface between people. we introduce an amended definition—‘underpinned by a commitment to respect and social inclusion, an age-friendly community is engaged in a strategic and ongoing process to facilitate active ageing by optimising the community’s physical, social and digital environments and its supporting infrastructure’—to conceptualise our approach. we conclude by suggesting areas for future work in developing digitally connected age-friendly communities. social connectedness in later life is important for health and wellbeing. consequently, making it easy for people to develop and maintain social relationships is a fundamental ambition of 'age-friendly' communities. this local, place-based, policy approach recognises that physical and social environments are key determinants of whether people remain independent, autonomous and healthy in later life. human-computer interaction (hci) researchers are directing increasing attention towards the role of technology in shaping and supporting social relationships in later life. much of this work focuses on online communities or connecting across geographical or generational distances, where digital technology is the interface or infrastructure for connection. in addition, approaches commonly place emphasis on addressing technological inexperience, or on physical or cognitive impairment and decline. in this paper, we are interested in considering technology and connectedness in later life within a specific local context, and exploring how innovation in social connection can be age-friendly and embedded within such physical community settings. we consider older adults as a heterogeneous group, rather than a group marked by singular identities of health, cognitive status, or technological proficiency. nevertheless, our place-based approach aims to identify common values and experiences shared by people living in the same geographical area. life events such as retirement, along with experiences of building and maintaining social connections over the life course, will also have implications for how and why older adults wish to develop and sustain proximate relationships in particular ways. we suggest that considering these topics enables a deeper understanding of how to design for a digitally connected age-friendly neighbourhood, where both the design process and its outputs are age-friendly. our paper presents findings from a study comprising two phases: qualitative interviews with 22 older adults; and a linked workshop ideation process to engage interviewees in beginning to consider how connections within their local area might be enhanced over time. the contributions of our paper centre around a context-specific and bottom-up approach to designing for increased local connectedness in later life. the importance of this topic has since been emphasised by the covid-19 pandemic, heightening awareness of the need to consider ways to maintain and create social connectedness, particularly at a local level. our aim is not to design a technological output. instead, we see our approach as prioritising a crucial, and often neglected, stage in technology design, which provides important insights that would be required for any future stage of a design process that aimed to design or create an actual technology. themes that emerged from our interviews suggest that participants viewed technology as acceptable when it filled a 'gap' and did not have too many negative impacts on everyday life. our starting point for the linked workshop was to consider some of these 'gaps' in local connectedness that interview participants had described. the workshop activities were used to facilitate participants in thinking creatively about addressing specific local challenges, or 'gaps' in connectedness. in drawing together participants' ideas about spaces, processes and mechanisms that might address these local challenges, we conclude the paper with implications that offer scope for further exploration and consideration in terms of how technology might support the operationalisation of local people's ideas for improving face-to-face connections in age-friendly community settings. growing interest in what makes places 'good' to grow old in has led to an increasing focus on the 'age-friendliness' of different types of environments [1] . despite variation in emphasis between models of age-friendly environments, most approaches promote consideration of how policies, services and structures can integrate physical and social environments, supporting social engagement and connection [2] . our work adopts the following conceptual definition, with its emphasis on age-friendliness as commitment to a process rather than a standard to be reached: 'underpinned by a commitment to respect and social inclusion, an age-friendly community is engaged in a strategic and ongoing process to facilitate active ageing by optimising the community's physical and social environments and its supporting infrastructure' [3] . the adopted definition of age-friendliness shapes our research design and methods, with its emphasis on community engagement and the participation of older people in processes to optimise the environment to support social connections. we also draw on concepts from environmental gerontology, such as 'ageing in place' to understand the importance of the local area in older people's lives. an overarching premise of an age-friendly community is that it is 'friendly for all ages and not just "elder-friendly"' [1] . even so, the argument that older people are 'able to remain more independent by, and benefit from, ageing in environments to which they are accustomed' [4] makes it all the more important to consider how environments can support people 'ageing in place' to optimise their social connectedness within their local area. this has become even more apparent during the 2020 covid-19 pandemic, which has exposed the need for digital connection as an alternative to face-to-face interactions. similarly, finding new ways to connect, even with people in proximate locations, has become a greater priority. there has also been a strong emphasis on tackling the counterparts of social connectednessloneliness and isolation. warnings of the 'loneliness epidemic' and its associated public health implications are prevalent in media discourse [5] [6] [7] , and the uk government appointed the world's first minister for loneliness in 2018 [8] . accordingly, responses to the drive for increased social connection have often focused on mitigating unpleasant experiences, risks and deficits at an individual level [9] . efforts along these lines reflect and uphold persistent ageist stereotypes that fail to acknowledge the roles that older people (can) play in communities, or their potential to contribute innovative ideas or create a voice for themselves [10] [11] [12] . indeed, technology is often presented as the ideal way of solving these 'problems' faced by older adults [13] . ten bruggencate et al. draw our attention to the predominant focus on loneliness and/or isolation in studies about social technology, ageing and relationships [14] . in contrast, a growing body of work on social connectedness in later life challenges the image of older people as lonely and isolated. population ageing is leading to increasing numbers of older people, thereby increasing the number of older people in society who experience loneliness. however, loneliness affects only the minority of older people, including the oldest old [15] [16] [17] . the likelihood of reporting feeling lonely decreases with age, with younger adults (16-24 years) reporting loneliness more often than those in older age groups [18] . while older adults may have smaller social networks, they are often more involved in the community than younger adults-socialising with neighbours, participating in religious organisations and volunteering [19] . however, even if social reciprocity and meaningful interactions are desired and enacted by older people, infrastructural barriers can, and do, impede the quantity and quality of such connectedness [20] . technology offers the potential for scalable and cost-effective interventions to address barriers to connectedness. the design, or adoption, of digital technology to support social relationships in later life often results in technology being the core interface for connection between people, rather than a route to facilitating face-to-face connections by overcoming barriers. for example, online communities are promoted as presenting opportunities for older people to meet and interact with peers [21] [22] [23] [24] . in this interfacing role, technology is a bridge across distances. lindley et al. comment that much hci research related to relationships focuses on ways to maintain feelings of connectedness or express intimacy at a distance [25] . distances being bridged may be geographical, for individuals living in remote areas or wanting to connect with people with whom they share interests, friendship or familial bonds. distances may also be generational, where, despite intentions to the contrary, technology replicates asymmetrical family interactions [23, 26, 27] . growing proportions of older people are now using digital technologies. in the uk, 83% of adults aged 65-74, and 47% of adults aged 75 and over use the internet [28] . thus, the majority rather than a minority of older people are technologically connected, suggesting a need to understand more about how this diverse population uses, and feels about, technology for connecting with others. the few studies that have explored older people's attitudes towards, and perceptions about, communication and connection suggest that rich interactions are valued above lightweight connections offered by newer technologies [14, 25, 29] . again, this work primarily considers the capacity of digital technology to bridge geographical or generational distances, where more traditional technologies such as telephone and email are often preferred. thoughtful and meaningful interactions are the goal, and technology provides the interface. research methods centre around questions about how older adults use, or would choose to use, technology in their social relationships. for instance, sayago et al. report on research with 700 older people (across six studies) that examined situated technology use and the reasons why participants did, or did not, incorporate particular forms into their everyday lives [23] . in this way, technological interfaces are often in-built as fundamental foundations for designing for connection, diminishing considerations of technology in non-interfacing roles. research that has explored ways to improve geographically proximate connections has also tended to concentrate on a prominent role for technology, often studying online community networks. these include bespoke online communities for older adults, or those formed on more widely used social networking platforms. righi et al. focussed on how older people's use of social networking sites could be used to promote their involvement in both online and offline local communities [30] . while participants used, for example, facebook to find out information about the local area, most did not post or share information or send messages to others. instead, these interactions took the form of face-to-face conversations. on this basis, the authors conclude that proximity and face-to-face contacts should be kept in mind when designing online community networks. we would extend this argument further, to suggest reversing the design process. such a process would design for proximity and face-to-face contact in offline communities, with technology kept in mind in a background, less visible, role. the research described above concentrates on technology as the interface for connection between people. while the potential of technology to foster involvement in local communities has been explored, less attention has been paid to understanding and drawing on context-specific factors to develop approaches to promote connection in local areas with, rather than for, older people. this would be a fundamental approach for any community engaged in the ongoing process becoming (more) age-friendly. an effective strategy in one community will not necessarily translate to a community with different geographical, social or structural features. likewise, the attitudes of older people towards technology will vary individually and across communities and countries. in their 'manifesto for change' in age-friendly cities and communities, buffel et al. emphasise the necessity of ensuring the empowerment and recognition of older residents in order to achieve age-friendliness [31] . for these reasons, we adopted a bottom-up, place-based approach that can be responsive to local needs, preferences and resources. we recognise community as an inclusive concept, with the participation and empowerment of members (particularly older people) being fundamental to its creation and functioning [3, 32, 33] . the following sections present the methods and findings of our study. our research design (in-depth interviews followed by an ideation workshop) draws on key concepts, theories, gaps and definitions in the literature outlined above. it is a bottom-up place-based approach that focuses on local needs, preferences and resources. it prioritises the participation of older people in exploring context-specific routes to local connection that present opportunities for future design of technology. we see our participants as crucial to developing ideas to increase or improve connection. as residents within the local area, they have a wealth of knowledge and experience and are best placed to identify resources, ideas and options that can lead to context-specific routes to connection. our overall aim within this study is to begin exploring context-specific routes to local connection that do not start the design process with attempts to design technological interfaces. discovering issues or opportunities for increased connection at a community level is the first step in this process. these opportunities and 'gaps' also need to be considered alongside insights into the current practices and perceptions of older people regarding technology in their social lives. once opportunities for increasing connection have been identified, ways to address these can then be explored by older people with local expertise and knowledge. therefore, in practice, the workshop methods were designed after analysis of our interview data so that we could draw on the interview findings as the starting point for workshop activities and discussions. however, for structural clarity, the methods for both the interviews and workshop are presented first in this paper, followed by the findings from our analyses. the first phase of our study aimed to explore opportunities for designing to improve proximate social connections for older people living within a geographically identified 'community'. we also wanted to know more about how and why research participants were using technology, or not, in their social lives. qualitative interviews were an appropriate method for exploring these two topics, with their potential to elicit personal accounts that help people to 'make explicit things that have hitherto been implicit-to articulate their tacit perceptions, feelings and understandings' about their social lives and technology [34] . the study setting was an electoral ward (district) within a city in the north of england, uk, chosen for its proximity to the research team's institutional location. just over 10% of the around 13,600 people living in this geographical area are aged 60 or over (compared to 23% overall in england and wales). it is also one of the most ethnically diverse and socially deprived wards in the region [35] . following institutional ethical approval (ref. 13284), we recruited 22 older adults (15 women, 7 men) to take part in audio-recorded interviews. sixteen interviews were with individual participants and three interviews were with couples living in the same household who chose to be interviewed together. our only inclusion criterion was that participants were aged 60 or over. however, we also sought to achieve a diverse sample in terms of age, gender, ethnicity, social connectedness and living arrangements. table 1 summarises participant characteristics. participants were aged between 60 and 84 and had been living in the area for between seven months and 84 years. one participant was asian and the remaining 21 participants were white. eight participants were living alone, and the others lived with at least one other person (a spouse/partner ± extended family). with the exception of one participant who was working part-time, all participants were retired. recruitment was via face-to-face conversations at community events and locations (such as a weekly café held in a local church) and contact details shared by community groups and organisations based in the area. we made substantial efforts to achieve a sample with greater ethnic diversity, including seeking assistance from individuals running local organisations and groups for people from non-white backgrounds, and posters in local culturally diverse food and clothing shops. we also made provisions for language translation in interviews. however, in the time available, we were unable to identify additional people from different ethnic groups who were willing to take part in an interview. longer-term development of relationships within the community would likely be needed to increase interest and trust, which was not possible in a study of this scale. all potential participants were given an information sheet about the study and a copy of the consent form to read. interviews were arranged at times to suit participants, and they were offered a choice of location. one participant chose to meet for their interview in a community building and all other interviews were conducted in people's own homes. after completing the consent form and giving an opportunity for the interviewee to ask any questions, we audio-recorded the interview with the participant's agreement. interviews were conducted by jl, hs or np. we initiated the interviews with a narrative approach, asking individuals to tell the story of their social lives since they had been living in the area. this facilitated the exploration of each individual's own concerns, meanings and priorities related to their social lives, rather than these being imposed by predetermined questions [36] . the same question was asked at the beginning of each interview: 'can you please tell me the story of your social life while you've been living in [this area]; your relationships with family, friends, neighbours and other people?'. participants were asked to talk about any events and experiences that were important for them, and invited to take as long as long as they needed to tell their story. this narrative section of the interview was followed by supplementary probing questions to explore areas of particular interest, including the role of technology in their social lives. these questions were not pre-defined in order that interviewers were free to explore anything that they felt was of interest and relevant to the overall aims of the study, maintaining a natural and spontaneous flow within the interview. brief reflective field notes were made by interviewers after each interview. electronic data files were stored in password-protected folders in the university filestore. interview recordings were transcribed and names were anonymised. we then completed initial inductive coding [37] of the data to explore (a) opportunities to improve connections at a local level, i.e., factors that had the potential to impact negatively on people's geographically proximate social relationships in terms of quality, quantity or satisfaction; and (b) participants' engagement with technology in relation to their social lives generally. codes were organised under themes, following the process outlined by braun and clarke [37] . for example, codes such as 'places people used to socialise no longer exist', 'many buildings are not accessible', and 'there are few facilities' were grouped together under the theme 'few local places to socialise'. coding and theme development were completed independently by two researchers (j.l., n.p.) and then discussed and refined with all members of the research team. while all names used in this paper are pseudonyms, participants in photographs gave consent for their images to be included in research outputs. the second phase of the study comprised an ideation workshop. we drew on the following conclusions from our interview analysis when designing the workshop: • there were concerns and perceptions about local community connections and characteristics that offered opportunities for design; • our participants predominantly used technology to connect with family, or friends at a distance; existing local technological connections in their social lives were less obvious; • many participants were actively using a variety of technologies, but their willingness to do so depended on perceptions of unmet needs and balancing the negative aspects (additional work, potential contribution to face-to-face disconnection) in their everyday lives. we designed the workshop to explore and generate ideas to improve and optimise social connections in the local area, focusing on four of the opportunities we identified in our interview analysis. based on the in-depth understanding about participants' use and perceptions of technology that we gained from the interviews, we designed 'playful' workshop activities that deliberately did not ask participants explicitly to consider how technology could address issues in local social connections. instead, we wanted to begin by eliciting participants' thoughts about the best ways to tackle these issues before considering any technological needs that arose from these suggestions. this approach avoids the tendency of previous research to foreground technology at the start of the design process. by deliberately not seeking to design a technology or technological interface in this study, we could instead reflect on the potential needs or roles for technology once we knew what type of interventions our participants had suggested. our approach also fitted well with our desire to draw on participants' knowledge, experience and capacity for creative thinking, and was in keeping with our aim of developing approaches to promote connection with, not for, older people, prioritising their participation in a bottom-up design process. all interview participants were sent a postal invitation to the workshop. eleven individuals initially confirmed their availability and nine attended on the day (6 women, 3 men). these individuals were aged between 68 and 84 and had been living in the area for between 30 and 69 years. the workshop was held in a church hall in the local area and refreshments were provided. participants were asked to read and complete the consent form on arrival. consent to being photographed was optional. the workshop was structured around four opportunities to improve local social connections that we identified as themes through our interview analysis. each theme represented shared concerns and negative perceptions about local relationships, connections and characteristics of the area that participants had talked about. the four themes were 'few local places to socialise', 'not knowing neighbours well', 'absence of a shared community feeling', and 'activities on offer not always conducive to socialising or making new friends'. these themes were chosen to take forward in the workshop based on their content being both appealing and generic enough for all participants to engage with, regardless of their individual circumstances and experiences. in line with age-friendly models, our aim was for a bottom-up approach in which workshop attendees' participation and contributions were fundamental to the resulting design ideas [38] . confronting ageist stereotypes, we also wanted to capitalise on participants' creative abilities and ingenuity along with their knowledge and experience as residents within the local area. in line with these priorities and our aim to explore participants' thoughts about how to improve connections at a local level without a specific focus on technology, we designed a range of playful ideation (idea-generating) activities to scaffold workshop discussions. choosing activities to maintain a 'playful mindset' was a central ambition in our design, as this has been identified as a key enabler when ideating [39] . participants worked in small groups, with each group asked to choose one theme to focus on throughout the activities. we gave groups the option of completing one, some, or all of the activities, depending on which appealed to them and how much time they spent on each activity. all groups tried at least two of the three activities: participants were asked to generate ideas about how to cause the issue/theme or how to make it worse. this generated a list of problems or criticisms that participants were then asked to reverse or convert into positive ideas or solutions ( figure 1 ). an example idea from participants was to remove the internet. they then converted this into an idea to provide free internet access alongside tv licences. mindset' was a central ambition in our design, as this has been identified as a key enabler when ideating [39] . participants worked in small groups, with each group asked to choose one theme to focus on throughout the activities. we gave groups the option of completing one, some, or all of the activities, depending on which appealed to them and how much time they spent on each activity. all groups tried at least two of the three activities: participants were asked to generate ideas about how to cause the issue/theme or how to make it worse. this generated a list of problems or criticisms that participants were then asked to reverse or convert into positive ideas or solutions ( figure 1 ). an example idea from participants was to remove the internet. they then converted this into an idea to provide free internet access alongside tv licences. this activity involved imagining how a famous person or character (fictional or real) with a wealth of skills, resources or power might respond to the issue. one group chose vladimir putin, president of russia, as their inspiration, with ideas that reflected their views on his leadership style, including mandatory socialising (e.g., meeting for a chat over a cup of tea or coffee) at particular times of day with street marshals to monitor and guarantee people's involvement. the third activity began with each group member writing an initial idea on a piece of paper which was then passed around the group for others to contribute to, comment on, or develop the initial idea ( figure 2 ). an example of this process was an initial idea to have more benches and ice cream vans driving round parks to encourage families with children to stay and chat. this resulted in the suggestion that the vans could double-up to provide other services like newspapers or bread, which might attract a wider range of people. this activity involved imagining how a famous person or character (fictional or real) with a wealth of skills, resources or power might respond to the issue. one group chose vladimir putin, president of russia, as their inspiration, with ideas that reflected their views on his leadership style, including mandatory socialising (e.g., meeting for a chat over a cup of tea or coffee) at particular times of day with street marshals to monitor and guarantee people's involvement. the third activity began with each group member writing an initial idea on a piece of paper which was then passed around the group for others to contribute to, comment on, or develop the initial idea ( figure 2 ). an example of this process was an initial idea to have more benches and ice cream vans driving round parks to encourage families with children to stay and chat. this resulted in the suggestion that the vans could double-up to provide other services like newspapers or bread, which might attract a wider range of people. data collection in the workshop comprised ideas written by participants on the templates provided (see figure 1 for example data). all data were stored in a locked filing cabinet within an access controlled workspace. the workshop activities generated an extensive list of ideas and suggestions for facilitating social interaction within the immediate local area. each group wrote down every idea that resulted from the activities they completed. after the workshop, we combined these ideas into one longer list and grouped and organised them under three overarching themes and 12 sub-themes that captured the overall range, content and types of ideas [37] . themes and sub-themes were developed by two researchers (jl, ts) and then discussed with all members of the research team. as described earlier, the interview data were coded to explore a) opportunities to improve connections at a local level, i.e., factors that had the potential to impact negatively on people's geographically proximate social relationships in terms of quality, quantity or satisfaction; and b) participants' engagement with technology in relation to their social lives generally. the following sections outline the main findings in relation to each of these topics. in our interviews with participants, we adopted a place-based approach to focus in on social lives at a geographically local level. it soon became apparent that there were many aspects of the locality that participants were content with, or did not wish to change. for example, some described strong friendships and connections with local friends and neighbours that had endured over time. others were actively involved in attending and/or organising local social events. however, there were shared concerns and negative perceptions around local relationships, connections and characteristics of the area that offered opportunities for further exploration as topics to design around. our analysis of the interview data specifically aimed to identify these opportunities to improve connections at a local level, by pinpointing factors that had the potential to impact negatively on people's geographically proximate social relationships in terms of quality, quantity or satisfaction. we report here on the four of these themes that were taken forward to the ideation workshop. these were chosen from a larger number identified, based on the criteria that they would be both appealing and generic enough for all participants to engage with, whatever their individual circumstances and experiences. table 2 outlines the four themes, along with linked examples from the interview data. data collection in the workshop comprised ideas written by participants on the templates provided (see figure 1 for example data). all data were stored in a locked filing cabinet within an access controlled workspace. the workshop activities generated an extensive list of ideas and suggestions for facilitating social interaction within the immediate local area. each group wrote down every idea that resulted from the activities they completed. after the workshop, we combined these ideas into one longer list and grouped and organised them under three overarching themes and 12 sub-themes that captured the overall range, content and types of ideas [37] . themes and sub-themes were developed by two researchers (jl, ts) and then discussed with all members of the research team. as described earlier, the interview data were coded to explore (a) opportunities to improve connections at a local level, i.e., factors that had the potential to impact negatively on people's geographically proximate social relationships in terms of quality, quantity or satisfaction; and (b) participants' engagement with technology in relation to their social lives generally. the following sections outline the main findings in relation to each of these topics. in our interviews with participants, we adopted a place-based approach to focus in on social lives at a geographically local level. it soon became apparent that there were many aspects of the locality that participants were content with, or did not wish to change. for example, some described strong friendships and connections with local friends and neighbours that had endured over time. others were actively involved in attending and/or organising local social events. however, there were shared concerns and negative perceptions around local relationships, connections and characteristics of the area that offered opportunities for further exploration as topics to design around. our analysis of the interview data specifically aimed to identify these opportunities to improve connections at a local level, by pinpointing factors that had the potential to impact negatively on people's geographically proximate social relationships in terms of quality, quantity or satisfaction. we report here on the four of these themes that were taken forward to the ideation workshop. these were chosen from a larger number identified, based on the criteria that they would be both appealing and generic enough for all participants to engage with, whatever their individual circumstances and experiences. table 2 outlines the four themes, along with linked examples from the interview data. beginning with the first of the four themes, most participants reported that there were few places in the immediate local area that they could use for socialising beyond their own homes. they described how there was no central community centre in the area, and no clearly distinguishable main high street. perceptions about the lack of local options contrasted with participants' opinions about the venues, centres and cafés available in other areas where they felt that community spaces and cafés were prominent and actively used and adopted by people living there. some participants were happy to socialise at home, but others saw this as too much of a burden or did not feel comfortable inviting people into their home. a noteworthy and unique characteristic of the local area highlighted by participants was the historic covenant on the land in the vicinity, preventing any licensed premises or pubs from operating. in the face of limited options in terms of usable spaces, local churches often hosted (or were booked to host) activities and events. however, this itself was a deterrent to some participants who felt uncomfortable attending events that had a religious connection-even if religion was not intended to be part of the event, such as a community café. overall, the perspective was that the community's physical features and built environment did not facilitate face-to-face social activities and interactions. the second theme (not knowing neighbours well) did not apply to all interview participants. in fact, some participants described their neighbours as good friends. these interviewees lived in quieter, more spacious streets, accommodating larger houses with gardens. other interview participants felt very disconnected from their neighbours. those living in particularly 'neighbourly' streets were aware that their situations were unusual in the wider local area where different road and housing types and tenures were more dominant, and fewer longstanding residents were living alongside the same neighbours for extended time periods. population churn, the movement of people in and out of streets, was perceived as a factor influencing the extent to which participants knew their neighbours. growing families and the number of properties available to rent in the area were cited as reasons behind this movement. streets were often busy with traffic-a factor that participants identified as not being conducive to unplanned meetings or chats with neighbours. while the physical proximity of neighbours potentially offered the most geographically close opportunities for social interaction, this had not translated into actual interactions for many participants. in particular, participants indicated that local issues of population mobility and transport routes contributed to the under-development of these relationships. the essence of the third theme (a lack of shared community feeling) was expressed by many participants. some attributed the absence of community to the area's geographical characteristics and location within the wider city, including the proximity of a motorway and the absence of a central focal point, or main high street, in the area. interview participants also commented on the lack of interaction between people of different ethnic and cultural backgrounds, despite the fact that the area was home to a diverse population. some talked about how this had been a longstanding issue, first noticed when their children were at school. together, both the physical environment and the population makeup of the area appeared to contribute to participants feeling that there were physical and cultural divisions within the geographical community. the fourth theme illustrates the complexity of developing new connections and relationships that extend beyond acquaintanceship: activities on offer are not always conducive to socialising or making new friends. even when participants were meeting people and seeking new friendships, these interactions did not often translate into deeper relationships. some participants described attending regular or one-off activities where they felt that the type and format of sessions were not helpful for getting to know people. for example, the focus was on a particular activity so chatting was only possible during brief time periods while setting up or packing away. another barrier was that some participants were more passive than others, and did not initiate conversations or connections themselves. in addition, participants mentioned that the same volunteers or people were often involved in several different groups and activities, resulting in a smaller pool of people to form friendships with. in other instances, it was simply that occasional casual conversations participants had with others did not result in deeper friendships or relationships that were sustained or developed beyond interactions at the events themselves, and individuals, therefore, remained acquaintances. taken together, these themes demonstrate clear barriers in, and characteristics of, local community connections. the themes capture issues that were impacting on the quality and quantity of participants' relationships in the local area, offering opportunities for participatory design processes to address these. alongside identifying opportunities to improve connections at a local level, the other focus of our analysis of the interview data was on understanding more about participants' existing engagements with technology in relation to their social lives. this engagement ranged from minimal (i.e., landline telephone only) to extensive (including social media, real-time audio/video interactions and applications). we use eight central themes to capture participants' accounts of the existing roles that technology played, or did not, play in their social lives. these themes, and examples of the data that support them, are outlined in table 3 . capturing and sharing images marie: "it's got an excellent camera. i use it as a camera because i'm useless at taking photographs otherwise." simon: "see, if marie uses a camera to take somebody's photograph, and eventually either cuts them in half or chops their head off, you know, which is-but, with this phone, it's absolutely brilliant." marie: "yes, yes." simon: "the pictures that she's taken when she's been on holiday and things, absolutely superb." "i get loads of photographs of the children when they're opening birthday presents. their mother takes a photograph and sends it with a comment on what they said when they were trying on things." (lynne) the first theme about the role of technology in interviewees' social lives focuses on its use to connect participants with people in geographically distant locations. in fact, many of the digitally mediated interactions described by participants bridged geographical distances. applications and platforms such as facetime, facebook and whatsapp (along with traditional landline phone calls) were commonly used to keep in touch with friends and family located in geographically separate locations. grandchildren were frequently mentioned as being a priority in seeking to connect face-to-face at a distance. while the financial savings of free long-distance technological connection were noted and appreciated by some, interviewees also reflected on the emotional value of being able to stay visually connected with loved ones. for claire, this connection even changed her perception of the duration of time passing between in-person interactions, making it feel like she had seen her son in person more recently than was the case in reality. in contrast to those using technology to bridge distances in order to maintain existing relationships, deborah was unusual among interviewees in that she had formed long-lasting friendships with people she met initially through the use of an online marketplace. as someone living alone in later life, she was using technology designed for one purpose (financial/accommodation transactions) to initiate and facilitate face-to-face interactions with strangers from geographically distant locations, offering the potential for developing new social relationships. our next theme encapsulates the role of technology in connecting family members and groups. family relationships were frequently discussed as examples of connections that were supported by technology, through informal chatting, sharing photographs or stories and news about day-to-day life events. family connections using technology ranged from group chats to individual messages, and instant short communications as well as ongoing asynchronous conversations. whatsapp was often highlighted in this context, particularly for its usefulness in communicating with a group, and across generations. examples included whatsapp groups with interviewees, their children and partners, and grandchildren. these were sometimes longstanding groups for general communication, but at other times were set-up for a specific purpose, such as organising a birthday party. cross-generational interactions were also perceived as improving the connectedness of family members who had previously felt 'left out' of family communications. john described the example of his sister, who was previously less connected with other members of the family but could now see photographs and hear about what other members of the family were doing, without them needing to make a special effort to include her. technology was seen, in cases like this, as a solution to the barriers to instantaneous communication with family members with diverse and busy lives and routines. however, telephone calls were also important to participants as a way of keeping in touch, particularly with others who were nearer in age such as siblings or friends. in addition, paul expressed his unease at the invasive nature of commonly used apps and platforms which, for example, access lists of contacts from the device they are using or collect data to support targeted advertising. his use of whatsapp was 'reluctant' on this basis, but he acknowledged its usefulness in keeping in touch when his son was abroad, highlighting the trade-off he had to negotiate between privacy and connection. we did not ask participants explicitly about the ways in which they chose to record social interactions or events, but the use of in-built cameras in mobile phones featured in participants' accounts of the role of technology in their social lives. we have described this theme as 'capturing and sharing images'. the ease of taking photographs with a smartphone in comparison to using a camera was noted by some participants, facilitating them in documenting social occasions. moreover, despite his privacy concerns about the invasiveness of technology more generally, paul valued the fact that he was able to recover digital images from an automatic cloud backup after he accidentally deleted photos (documenting an international trip) from his mobile phone. photographs as mementos of experiences in participants' social lives, like paul's trip, were treasured. additionally, the act of sharing and receiving images was a central feature of participants' digital interactions, connecting participants with events and experiences when they were not physically present. after initially dismissing much technology (apart from facetime) as insignificant in her social life, claire later reflected that it did play a large role in how she organised and arranged social events and interactions. the theme of 'sharing information and making arrangements' draws on these organisational uses of technology described by interviewees. information was generally not necessarily shared on social networking sites or more visible platforms, but interactions commonly took place through instant messaging and other technological channels rather than solely in person. in fact, for marie, there were additional benefits to using technology as a tool for organising or making arrangements with people. she preferred the control that it gave her in contrast with the unpredictability and social awkwardness she experienced when talking on the phone. technology was mainly described by interviewees in terms of its role as a tool for connecting, or supporting connections between, people. conversely, several participants noted the ways in which technology itself was a dimension of their social life, offering an alternative to interactions with people. perhaps because of its dominant focus on portraying human lives and activities, jane felt that television was a more 'personal' type of technology. patricia and brenda watched television at times when other company or interaction was inaccessible. for patricia, this was at 'silly hours' of the day or night, whereas brenda described how she might watch television, dvds or listen to cds when she found herself alone or 'down'. there were particular times when others living in her housing development were more likely to be spending time with family, such as weekends, where she used music or television as a strategy to deal with loneliness. at the other end of the spectrum, simon tended to avoid face-to-face social activities and events with other people, preferring to spend time playing games or reading on his computer. there were two main ways that participants described technology as contributing to disconnection in terms of social interactions and events: its prevalence as a platform for information about events; and its disruptive potential during face-to-face interactions. sally used the internet but chose not to engage with social media for privacy and security reasons, but felt that this was increasingly disadvantaging her when it came to finding out about local events. she reflected on her reliance on other people to keep her informed, and the difficulties of being separate from the dominant route of information sharing via social media. for sally, information sharing was happening in a way that excluded her, meaning that she missed out on attending social activities and events that she would have chosen to go to otherwise. in contrast, liz highlighted the capacity of technology to disrupt social interactions themselves. she described both a friend's extensive use of a smartphone, and purely the presence of a phone (in use or not), as disrupting face-to-face interactions and impacting on their quality. sally's and liz's accounts indicated a reluctance to allow technology to become pervasive in everyday life, balanced against a recognition that there were places and circumstances where it could be beneficial. along with concerns about the potential for technology to disrupt relationships, the positive impacts of technology in participants' social lives were also, in some cases, accompanied by additional unwanted work. our penultimate theme, therefore, centres around experiences of technological interaction as an additional 'chore'. sally described being 'bombarded' by messages, and she and others found their perceived continual need to respond and interact electronically to be a burden. the perpetual nature of communicating using interactive technologies such as email, texts and instant messages was also unpopular with some interviewees because of the amount of time it consumed. responding was not perceived as an optional activity. even if emails contained welcome content, the task of checking, opening and reading them was viewed as a compulsory individual task and responsibility. catherine likened this to the responsibility to open letters that came through the post, rather than a choice or pleasurable activity. our final theme sums up participants' thoughts about not needing digital technologies. more traditional technologies such as the telephone or television were commonly accepted as integral to daily life. in fact, their deep-seated role in participants' social lives meant that they were often no longer considered or mentioned (by participants) when talking about technology. instead, participants tended to focus on newer digital technologies such as social media, applications and email. regarding these more modern technologies, there was a sense for some participants that they were unnecessary. for example, when talking about social media, liz explained that she did not 'think there's a gap that i need them.' christopher used the internet and email but did not consider it necessary to go online to find out about local social events as he was exposed to paper-based publicity, such as posters and flyers, as well as information via word-of-mouth. for judith, the whole idea of using a computer or the internet was superfluous when she could instead rely on her family for support, asking them for anything she needed. overall, technological connections were predominantly bridging distances, with existing local technological connections less obvious. technology was mainly seen as a tool to be used to make connecting easier where there were needs, barriers or 'gaps' (geographical or generational distances, difficulties sharing information, capturing images, avoiding uncomfortable face-to-face interactions), but not at the expense of disrupting desired face-to-face interactions or in situations where technology was seen as unnecessary (other strategies would suffice). in addition, the additional work required to use technology as an aid to connection was an unwanted consequence. willingness to use technology depended on balancing the positive and negative aspects. as described earlier, the workshop was designed to build on the findings from our interviews. an extensive list of ideas was generated through our ideation activities, which we combined and organised under themes and sub-themes. table 4 summarises the themes and sub-themes identified in our analysis of the written workshop data. participants commented that the workshop had been enjoyable and thought-provoking-an outcome that supports us in challenging ageist stereotypes of older people as unable or unwilling to engage in creative, disruptive or wild thinking. the second theme brings together ideas that participants had for processes and actions that could play a part in promoting social interactions. these included: prioritising engagement within the wider community to develop ideas; connecting different groups with each other; improving provision of information about events and activities in the local area; connecting people with locations and activities in the city centre; and focusing particularly on making use of proximity as a tool in the process of connection. encouraging people to walk in the local area more often, and setting up hyper-local events such as street meetings, were examples of ideas to facilitate people in connecting with others living in close proximity. participants' ideas emphasise the importance and desire for strong relationships at a local level, particularly building on the existing work and connections of volunteers and groups that they were aware of. the third theme considers what types of mechanism could be used to drive change and engagement by local people, in order that involvement in supporting social connections is seen as an attractive opportunity. participants' ideas included the use of cooperative initiatives to develop or run transport services or community spaces, and incentives for small businesses to make the local area an attractive place to set up or move to. they also suggested that incentive schemes for local residents (such as loyalty cards or credits) to participate in local activities would encourage people to maintain involvement. participants proposed that making a public commitment to community work could not only increase the contributions made by individuals within the local area, but also contribute to an increased sense of community. taken together, these ideas portray a community with actively engaged members working to make positive changes, that directly and indirectly lead to individual connections being strengthened. we take forward one example sub-theme from each of these three main themes for further consideration in the second half of the discussion section of this paper, in order to begin thinking about how technology might contribute to supporting these types of initiative, as well as noting some of the challenges that would need to be addressed in designing such technologies. this paper makes a case for adjusting the design process to accommodate a bottom-up the three main themes we use to understand the workshop data are: social spaces and places; processes to promote social interactions; mechanisms to drive change. these themes capture different dimensions of participants' ideas for facilitating social interactions in the local area. ideas varied in both scale and scope (see table 4 for examples). the first theme describes ideas that related to the physical environment and developing spaces and places to promote interactions. the proposed changes were either to directly provide locations for organised or informal activities to take place, or to change environmental factors to increase the likelihood of people meeting and connecting in their everyday lives. ideas for developing locations for activities included making better use of existing spaces as well as creating new spaces or places. residents suggested taking advantage of the large areas of green space that were nearby and using them in new ways. they also thought that new community premises, such as a community centre, would be helpful. ideas to change other environmental factors included improving the environment for pedestrians and improving security of tenure to increase the length of time that people are resident in the same location before moving home. while some ideas residents suggested were more generic, others were particularly context-specific. participants drew on their local knowledge to consider what resources in the local area could be used, and identified other resources that were lacking. table 4 . themes from workshop data analysis. making better use of existing geographical features and spaces for social purposes, such as large areas of green space (e.g., figure 3 ) longer opening hours e.g., library marquees/undercover spaces in parks etc., for rainy days make better use of open/green spaces for community activities e.g., exercise equipment, open a beach, more benches, ice cream vans to encourage use of parks new transport options to support travel in the immediate local area and into the city centre frequent, small scale local transport e.g., minibus every 10 min extend the metro into the area to improve access to city focusing on proximate relationships i.e., at a street level or between those volunteering at the same events, as well as at the community level encourage greater walking in area e.g., parents taking children to school encourage volunteers to build friendships/relationships outside volunteering activities/context street level interventions e.g., street meetings/cups of tea, annual events community-driven/commissioned or cooperative initiatives around social spaces, information provision, transport and learning/training community/cooperative/volunteer-run hospitality venues buy a property on a co-operative basis and use as community resource/café/party venue community uber-style, tandems/sidecars or other forms of 'fun' transport, bike sharing, motorcycle lessons-teaching/learning/using transport cafes that also operate as training kitchen for cooking healthily, training in basic work skills by involvement in running community hub incentives to: sustain and attract small catering and hospitality businesses to the local area; encourage local people to participate in social activities increase incentives for small catering/hospitality businesses e.g., no rates/taxes for first years after opening happy hours in cafes etc., with free tea/coffee/cake, sponsored by local businesses credits for free attendance at social activities for residents e.g., swimming pool on particular days/times/a month, extra credits could be earned through volunteering dedicated time slots for social and/or physical activity/exercise time finding ways of improving the commitment and contributions of individuals to the local area to create and sustain a sense of community commitment of individuals to community e.g., minimum number of community work hours/community service and strategy to deal with those who do not contribute, volunteers to supervise weekend sporting activities for children, create sense of community between residents/students the second theme brings together ideas that participants had for processes and actions that could play a part in promoting social interactions. these included: prioritising engagement within the wider community to develop ideas; connecting different groups with each other; improving provision of information about events and activities in the local area; connecting people with locations and activities in the city centre; and focusing particularly on making use of proximity as a tool in the process of connection. encouraging people to walk in the local area more often, and setting up hyper-local events such as street meetings, were examples of ideas to facilitate people in connecting with others living in close proximity. participants' ideas emphasise the importance and desire for strong relationships at a local level, particularly building on the existing work and connections of volunteers and groups that they were aware of. the third theme considers what types of mechanism could be used to drive change and engagement by local people, in order that involvement in supporting social connections is seen as an attractive opportunity. participants' ideas included the use of cooperative initiatives to develop or run transport services or community spaces, and incentives for small businesses to make the local area an attractive place to set up or move to. they also suggested that incentive schemes for local residents (such as loyalty cards or credits) to participate in local activities would encourage people to maintain involvement. participants proposed that making a public commitment to community work could not only increase the contributions made by individuals within the local area, but also contribute to an increased sense of community. taken together, these ideas portray a community with actively engaged members working to make positive changes, that directly and indirectly lead to individual connections being strengthened. we take forward one example sub-theme from each of these three main themes for further consideration in the second half of the discussion section of this paper, in order to begin thinking about how technology might contribute to supporting these types of initiative, as well as noting some of the challenges that would need to be addressed in designing such technologies. this paper makes a case for adjusting the design process to accommodate a bottom-up component that precedes design of technological outputs. we begin our discussion of the findings from this study by considering the interview data, and their position in relation to wider debates and literature around technology and social interaction in later life. we then move on to discuss what the ideas generated by workshop participants offer in terms of implications, scope and challenges for future technology design around social connectedness, particularly when considered in the context of the interview findings. we use three sub-themes from the workshop (making better use of existing geographical places and spaces; focusing on proximate relationships; community driven/commissioned or cooperative initiatives) as examples to avoid our discussion of implications and challenges for future technology design being too generic, and to ensure that our focus remains on designing in the particular context of our research community and participants. within an age-friendly context, our analysis of interview data identifies a number of opportunities to design for increased social connectedness within local communities. participants felt that: there were few local places to socialise; they often did not know their neighbours well; there was an absence of shared community feeling; social activities on offer did not always lead to socialising or making new friends. in a policy and practice environment where technology-based initiatives are increasingly perceived as offering huge potential, our findings highlight the importance of age-friendly approaches that are grounded in the local context [1, 2] . this has become even more apparent during the covid-19 pandemic, which has exposed the need for digital connection as an alternative to face-to-face interactions. similarly, finding new ways to connect, including with people in proximate locations, has become even more important in ways we did not anticipate when conducting this study. every community is unique, so designing to optimise social connectedness at a local level requires understanding and recognition of context-specific characteristics. in addition, taking account of the social and structural particularities of places gives insight into meanings and functions that are the result of cumulative experiences over time [40] . in our study, the geographical layout of the community, restrictions on licensed premises and population churn were all factors that participants highlighted as playing a role in disconnection. however, these issues can also be seen as 'leverage points' where interventions could afford the greatest benefits within a specific local context [40] . our interview data also contribute to understanding more about how older people use and perceive technology in their social lives. unlike dickinson and hill's findings in 2009 that older people did not engage with instant messaging or other forms of computer technology aside from email [29] , participants connected using a range of methods and formations of communication. family connections using technology ranged from group chats to individual messages, and instant short communications as well as ongoing asynchronous conversations. participants were not necessarily using social networking sites to share information, as righi et al. [30] also found, but in our study these information-sharing interactions were commonly taking place through instant messaging and other technological channels rather than solely in person. these findings reflect changing levels of digital connection for older people in the uk [28] and emphasise the need for hci to reconsider longstanding stereotypes of older people as digitally inexperienced or uninterested [13] . the covid-19 pandemic has provided further evidence to counter these outdated stereotypes, with many older people embracing technology to facilitate connections with friends and family at a time when face-to-face meetings have been restricted. yet, while participants in our study made regular use of technology to support their connections with others, this use was carefully considered. technology was not, in itself, an attractive prospect unless it was perceived to fill a 'gap' and the 'chore' of using it did not overly impact on everyday life. similarly, lindley et al. reported that older people were cautious of the time commitments required to use technologies, although they also used technology as a way to manage levels of contact and control their own availability to other people [25] . in addition, participants in our study were aware of the potential for technology to contribute to disconnection. waycott et al. [41] reflect that the mismatching of values and assumptions guiding a technology-based social intervention with those of the older adults participating in the evaluation, noticeably contributed to individual decisions not to participate. in an increasingly digital society, our findings again indicate the importance of design processes that are in tune with the perceptions and values of older adults. marston and van hoof draw our attention to the fact that the world health organization's age-friendly cities model does not explicitly consider the role of technology [1, 42] . by adopting a lens of age-friendliness, studies like ours can ensure that methods and processes are rooted in opportunities, concerns and 'gaps' that are relevant and engaging to participants. consequently, we put forward an amended definition that highlights the need for explicit and thoughtful consideration of the role of technology in an age-friendly setting: underpinned by a commitment to respect and social inclusion, an age-friendly community is engaged in a strategic and ongoing process to facilitate active ageing by optimising the community's physical, social and digital environments and its supporting infrastructure. another contribution of our work comes from its findings about the potential for technology to contribute to building and strengthening connections in geographically-bounded communities. the combination of shared local concerns and opportunities for improving connections, combined with the knowledge that technology was infrequently used to sustain or support local connections, suggests this is a design space worth exploring. participants in this study were comfortable using digital technology to stay in touch with friends and family in geographically distant locations, particularly to maintain close family connections. kharicha et al. also found that engagement with the outside world by landline telephones and computers was an important strategy adopted by older people experiencing loneliness [43] . for this reason, it would seem plausible that technology to facilitate local, proximate, connections and social lives would also be acceptable, should it fill perceived gaps and not lead to unacceptable levels of additional effort. the methods we used in the workshop were intended to encourage 'playful' creativity, and they were successful in their purpose of generating a wide range of ideas as well as being acceptable and enjoyable for participants. in future, we would consider adapting these methods to reduce their paper-based nature, further enhancing their potential for prompting creative thinking by participants. exploring options beyond face-to-face participation may also be important in the context of covid-19 and its aftermath. drawing the interview findings together with one sub-theme from each of the themes we used to organise the ideas generated by workshop participants, we suggest a number of ways in which technology might support greater face-to-face connection in local community contexts and operationalise local people's ideas. by deliberately not placing technology in the foreground in the workshop, we contend that participants' ideas (technological or otherwise) about how to tackle local issues are more likely to align with their own values and perceptions, meaning that any technological needs that arise from these suggestions will be filling 'gaps' rather than technology being introduced as the automatic interface in connection. we maintain that design processes and spaces should be context-specific and bottom-up, but summarise general implications that offer scope for further exploration and consideration in community settings. workshop participants expressed interest in re-purposing spaces in the local area that they felt were underused, or offered potential as social spaces. this ranged from using existing green spaces or buildings on a permanent or temporary basis, to creating new spaces and places for social activities and events. a real-life example of creative use of space by older people that challenges expectations and norms was the transformation (for one night only) of a nightclub in manchester, uk, into a night-time venue reserved for older people [44] . in our study, there were suggestions that spaces could be acquired or managed by groups of local residents as cooperative initiatives. such work is ongoing in virtual spaces by older people in the uk creating a radio network [45] . other adaptations to the built environment were also suggested by participants to improve suitability for pedestrians. however, operationalising these ideas and coordinating the input of the local community presents challenges at many levels. while online platforms to facilitate community commissioning of digital services exist [46] , it is not immediately clear that these tools and processes would translate to local community commissioning of resources and events. moreover, it is unrealistic to expect the required intense interaction with such digital platforms, leading to the need for alternative situated means of participating and engaging in the processes. given the interest by study participants in leveraging local infrastructures and spaces, it is plausible to consider situated artefacts that would mediate between local, physical, and online engagements. for example, postervote is an innovative electronic polling system aiming to provide easy electronic voting for communities [47] . a traditional poster is augmented with buttons that can be pressed by community members to register digital responses to questions on the poster. providing infrastructure for residents to have greater input and control over the provision of their immediate local environments would facilitate their participation in the process of age-friendliness at a community level. while our workshop focussed on connections at a local i.e., electoral ward level, some discussions were about connecting with people who were located very close nearby or even physically 'connected' by living on the same street. in fact, two participants expressed surprise on discovering that they had both been living in the area for many years a few houses apart on adjacent streets, yet they had never interacted before. concerns about safety, privacy and possible lack of interest by others were mentioned as barriers to interventions at a street level. in recent years, we have witnessed a surge in location-based and serendipitous dating/meet-up services and networks (i.e., tinder [48] ). the core functionalities of these technologies are the abilities to discover similar individuals in your local area; privately extend an invitation to initiate a conversation; whilst maintaining a degree of privacy and safety through the network's services (not revealing personal details such as address or phone number). such solutions would have scope to support the hyper-local match-making of friendships within communities. however, our research showed that participants were not using existing online services designed to develop new relationships, indicating that these did not appeal. this is echoed by findings that older people who were lonely did not report using the internet to cultivate new friendships, despite using telephones and computers to engage with the outside world [43] . in fact, one participant, deborah, had instead capitalised on the ability of an accommodation matching platform to facilitate face-to-face interactions in her home with strangers, who then had the potential to become friends. the opportunity for such encounters (through mutually beneficial financial, or other resource, transactions) to result in long-lasting friendships is an area for further exploration. in particular, it would be interesting to consider how these types of interaction could be translated into a purely local context, given that deborah's formation of new friendships contrasts with experiences of those in our study who attended regular local activities but did not find them conducive to making friends. the findings from our study indicate an opportunity for design around community or cooperative ways of addressing local transport gaps. a number of ideas generated by workshop participants related to improving transport in the immediate local area in order to facilitate connection to physical spaces and locations to meet other people. community or cooperative initiatives were suggested as one option, or mechanism, for driving new models of transport in the area. volunteer-run minibus and car transport did exist in the local area, but these prioritised 'essential' travel such as hospital appointments and did not have the flexibility that participants thought important. while existing schemes (e.g., streetbank [49] -a website that facilitates possession sharing and borrowing between neighbours) have been successful in meeting other needs at a very local level, hyper-local journeys in suburban communities outside busy city centres are unlikely to offer sufficient cost/profit ratios to be attractive to existing sharing economy or peer-to-peer services such as uber. a small number of demand responsive transport (drt) schemes are running in the uk, and in theory sound promising. however, it is notable that a drt service actually operated in our study area in the past, but closed in 2011 [50, 51] . similarly, existing bicycle sharing schemes rely on scale of use within large communities or cities to remain profitable, but in contrast, restricted access to a smaller population might reduce the risk of damage and loss experienced by larger scale operations. consideration of what a hyper-local transport system might look like would include questions about who might provide and use the service, and what their incentives would be. participants in this study also suggested teaching, learning and training opportunities as potentially playing a role. this is another avenue for exploration in future technology design which could serve the dual purposes of creating new connections between those learning and teaching, as well as the transport itself facilitating connections between people living in the area. our study adopted an age-friendly, bottom-up approach to explore opportunities for facilitating social connectedness for older adults in a local community context. we focused on specific community issues that could be addressed and considered the physical, social and structural mechanisms (potentially mediated or supported by technology) that might offer routes to tackling these. by understanding more about our participants' current use and perspectives on the role of technology in their social lives, we highlight a need for design work to reduce emphasis on technology as the interface between people. in contrast to previous work, we focus on connection between people in geographically close locations. we also demonstrate the importance of understanding the specific local context within which any technological interventions will take place. our findings reflect changing patterns of technology use among older adults in the uk, suggesting that adoption of new technology is acceptable when it fills gaps and does not create intrusive levels of additional work or contribute to disconnection. our modified definition of age-friendliness highlights a need for the explicit and thoughtful consideration of the role of technology. we identify topics for consideration by those seeking to design with local communities, and make the case for an age-friendly approach to designing (digital) interventions to address social connectedness in later life. world health organization. global age-friendly cities: a guide; world health organization what makes a community age-friendly: a review of international literature exploring the age-friendliness of purpose-built retirement communities: evidence from england evolving images of place in aging and 'aging-in-place how should we tackle the loneliness epidemic is loneliness a health epidemic lonely older people as a problem in society-construction in finnish media prime minister's office; office for civil society; the rt hon theresa may mp. pm commits to government-wide drive to tackle loneliness the firekeepers: aging considered as a resource never too old older voices: supporting community radio production for civic participation in later life researching age-friendly communities: stories from older people as co-investigators an age-old problem: examining the discourses of ageing in hci and strategies for future research friends or frenemies? the role of social technology in the lives of older people an investigation into the patterns of loneliness and loss in the oldest old-newcastle 85+ study being alone in later life: loneliness, social isolation and living alone the high cost of isolation the social connectedness of older adults: a national profile the importance of social 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cities the who global network of age-friendly cities and communities: origins, developments and challenges. in age-friendly cities and communities in international comparison interviewing for social scientists office for national statistics research interviewing: context and narrative using thematic analysis in psychology les villes amies des aînés au québec: un mouvement de changement à large échelle en faveur des aînés experiences of place and neighbourhood in later life: developing age-friendly communities not for me: older adults choosing not to participate in a social isolation intervention who doesn't think about technology when designing urban environments for older people? managing loneliness: a qualitative study of older people's views an alternative age-friendly handbook later life audio and radio network proceedings of the 2016 chi conference on human factors in computing systems good practice guide: transport and social inclusion we thank all participants who took part in this research. our appreciation also goes to cathrine degnen for her involvement in the design, planning and acquisition of funding for the study, and to drake long, meena nanduri and marlo owczarzak for their support in facilitating the workshop. the authors declare no conflict of interest. key: cord-025856-gc7hdqis authors: chen, peter john; stilinovic, milica title: new media and youth political engagement date: 2020-06-02 journal: jays doi: 10.1007/s43151-020-00003-7 sha: doc_id: 25856 cord_uid: gc7hdqis this article critically examines the role new media can play in the political engagement of young people in australia. moving away from “deficit” descriptions, which assert low levels of political engagement among young people, it argues two major points. first, that there is a well-established model of contemporary political mobilisation that employs both new media and large data analysis that can and have been effectively applied to young people in electoral and non-electoral contexts. second, that new media, and particularly social media, are not democratic by nature. their general use and adoption by young and older people do not necessarily cultivate democratic values. this is primarily due to the type of participation afforded in the emerging “surveillance economy”. the article argues that a focus on scale as drivers of influence, the underlying foundation of their affordances based on algorithms, and the centralised editorial control of these platforms make them highly participative, but unequal sites for political socialisation and practice. thus, recent examples of youth mobilisation, such as seen in recent climate justice movements, should be seen through the lens of cycles of contestation, rather than as technologically determined. at the turn of the century, considerable interest was focused on new internet-based technologies and their potential to stimulate democratic improvements around the world. attention was particularly given to their role in revitalising the public due to its diverse meanings, and its applications subject to endless contestation (spicer 2019) , democracy is an essentially contested concept. active definitions for democracy lie across a spectrum of performances and values, from the "minimalist" versions that captures simple measures such as voter registration and turnout, to "maximalist" definitions that include activities like associational membership, active information seeking and civic dialogue (dahl 1971) . the discussion of democracy in this article focuses on a maximalist value of equality over other values, such as maximal individual liberty. given the recent prevenance of "collective crises" like the climate and pandemic, prioritising maximal individual liberty contrasts the necessary collective nature of contemporary, complex societies (wildavsky 2017). prioritising values like maximal individual liberty can be unsustainable and/or create inequalities that structurally undermine participation by others through self-interest (wildavsky 2017). in contrast, a maximalist view of democracy equally emphasises the production of democratic culture and institutions that promote just outcomes that sustain democratic practice. this sees generalised civic culture as important in developing practices by citizens that are realised through or by institutions that permit democratic modes of expression and collective action. this is important as recent challenges to individual well-being have collective origins (climate, pandemic, economic inequality). as such, it is complementary to a study of youth participation in the political processes of evolved democracies, such as australia, and the internet-based technologies that afford them access. in recent times, youth participation in democratic processes has been subject to controversy. krinsky (2008) notes that it is unremarkable that young people are often the focus of media and moral panics. therefore, it comes as no surprise that this particular demographic has been implicated as the focal point for three politically focused "crises" within the twenty-first century. the first panic is that young people are the source of "democratic decline". this reductionist view is commonly associated with lower formal participation rates, particularly voting, but also membership in key institutions like political parties (milner 2010) . in the compulsory voting context of australia, print highlights the focus on young people as a state educational project to become "active and informed citizens" (2015) . which, in the context of today's technologically driven political environment, would garner access to political discourse, engagement, and the use of advancing technologies to communicate, coordinate and mobilise. the second and third crises pertain to the increasing levels of structural inequality and the inability of the post-1970s neoliberal economic model-with a focus on egoistic individualism, and the resultant social and political acceptance of enduring and reproducing inequality (nozick 1975)-to ameliorate the causes of, resultant social conflict over, the environmental crisis. while these last two are empirical facts, the former is more contestable. to unpack this youth-focused concern, a good example is the often-cited lowy institute annual poll (kassam 2019) , which, at times, has shown a 28% gap between australians aged 18 to 29 years, and those over 30, in response to a question that asks if "democracy is preferable to any other kind of government". these types of findings are often reported in the media in rejectionist terms that overreads the data set and does not interrogate its context. for example, this type of finding has led to sensationalist claims in the media that "fewer than half of australian adults under the age of 45 actually believe in democratic government" (hildebrand 2018) . this type of coverage commonly is predicated on a discourse that young people are expected to perform a high degree of nativity about the political world, which, when displayed by older people, is attributed to pragmatism and experience. at the core of this is an implicit message that the status quo must be observed as a normative good. thus, young people are at the intersection of multiple fast and slow-moving crises, real or phantasmagorical. yet, with higher levels of concern for issues of social and climate justice (sealey and mckenzie 2016) , it becomes critical for them to have the capacity to engage in political practices and advance these concerns and question the foundations of political practice that have created or contributed to these social problems. therefore, contestable claims about current and potential democratic capacity have to be explored, particularly in the context of claims about technologies that afford or impede on youth participation. emerging information and communication technologies provide new (or remediate) "affordances", or possibilities for human action. affordances are important because of the way they encourage, allow, discourage and prevent particular behaviours. these can be deliberately or accidentally designed into a technology, be visible, or concealed (livingstone and das 2013) . when thinking about the application of this concept to politics, this is frequently captured in the "cost" hypothesis: the internet reduces the costs of political participation and allows some "natural" human desire to be afforded in greater abundance (negroponte 1995) . the positive aspects of the "cost" hypothesis become evident when considering the affordances made possible through advancing technologies. from the late 1990s onwards, the very nature of the internet-as a tool to communicate, aggregate and coordinate-has been associated with its democratising potential. therefore, at first instance, it appears logical to assume that contemporary youth, who have grown alongside these evolving technologies, would employ the internet as a communication tool to engage with political discourse, much in the same way that low-cost printing played an important role in youth politics of the 1960s and 1970s. more recently, with the advent of "platform" technologies (technologies that facilitate a range of applications, rather that provide a narrow set of specific functions) and social media channels, it is noted that young people increasingly use social media to engage in political discourse (yang and dehart 2016) . nonetheless, affordances not only have the ability to promote an engagement in political discourse, the design of certain technologies can also hinder participation. in retrospect, claims that assert the democratising potential of the internet have been predicated on loose understandings of the underlying character of the technology under discussion, that is, an exaggeration of its "true" network characteristics. the internet is not a "mesh" where each node has equal power relative to its peers, but a "powerscape" which virtually mirrors the hierarchical nature of power in the physical space where certain agendas, people and even locations are prioritised. equally, contestable are claims about the impacts of the technology such as deterritorialisation, or the notion that these technologies may separate the individual from the physical context as a primary definer of their social, economic and cultural needs (chen 2013). importantly, the cost claim, once so important to early arguments about the levelling effect of the internet (a view subject to very early empirical criticism; see small 2008) , can now be understood as generating compensatory costs: as data abundance increased, scarcity has shifted from the production of content to its consumption, and considerable time (cost) is now spent sorting, filtering and killfiling the vast amount of content generated and pushed at individuals, particularly through online automation (aka "bots"). additionally, free entry to the internet's public spheres is not cost-free for those marginalised subaltern populations-a term coined by postcolonial theorists to describe faction of society excluded from hierarchal structures of power-who also experience exclusion at a personal cost. virtual violence and harassment in online spaces have forcefully attempted to exclude these marginalised groups from the digital public sphere and are well-documented. in this context, youth within established democracies, despite having access to these virtual public spheres, form a part of not only the subaltern identity due to their cultural standing, but also the repression they experience from institutions such as the education system (spivak 1988) . as such, their participation, much like any other faction of subaltern society, is intensely contested (hartounian 2018; dhrodia 2017) . in thinking about social media from the perspective of democratic affordances, it is important to consider the political implications of its underlying technological and intuitional characteristics (howard and parks 2012) . that is, social media is largely only possible because of its reliance on large database systems that afford horizontal visibility within peer groups. thus, it is unsurprising that social media has been politically useful in the processes of political mobilisation. as evidenced in the work of groups like getup! (an australian-based independent movement for progressive participation in democratic processes), along with others, groups have successfully capitalised off of internet-based technologies to disseminate their message and motivate collective action (vromen 2017) . equally, xenos et al. (2014) have argued strongly for a positive relationship between young people's time spent on social media and political participation. based on a survey of young people (16-29) in the usa, uk and australia, and drawn from online panels, they argued that social media was positively related to increase political participation and produce a good regression analysis in support of this claim. the deterministic interpretation of this research can be contested, however. this analysis also strongly correlated reported levels of participation with respondents' sense of personal political efficacy. this leaves open the real possibility (as the authors identify) that their observations about technology use and political participation may be an expression of some other unmeasured causal agents, or that tool use is epiphenomenal to the connection between political interest and expression that would occur in any other socio-technical setting. significantly, reflecting our concern about the dominance of individualism, the same volume includes a longitudinal analysis of internet use that concludes that "…facilities on the internet often described as 'social' media offer environments which mainly draw young people's attention away from common concerns" (ekstrom et al. 2014 ). thus, the actual relationship remains open for investigation, and youth engagement in political participation on the internet is questionable, opening up the potential to explore how the use of social media and other internet-based technologies could mobilise youths into political engagement. recent attention has particularly been paid to youth mobilisations around climate issues, including the role of young people as leadership figures (i.e. greta thunberg) and peer mobilisation using new media (collin and mccormack 2019) . these observations are commonly placed into the now-familiar causal narrative of new media as inherently facilitative of collective action. however, until end-to-end case research is conducted, caution needs to be taken in ascribing causation. that is, participants may take a bus to participate in a demonstration. however, the bus itself has little to do with political action, much in the same way that social media might not necessarily be the driver for collective action. more specifically, to argue that social media was the driver behind climate youth protests remains a mostly correlative explanation when dealing with a population so ensconced in a mediated lifeworld, a reality in which all the immediate experiences of an individual are directly impacted and influenced by evolving media technologies. many of these mobilisation case examples are embedded in established social movement industries and, importantly, are not outside the scale of mobilisations seen in pre-internet youthled movements during the cold war. in similar "existential" issues of concern for young people (such as anti-conscription in the 1970s or anti-nuclear movements of the 1980s), mobilisation of youth movements was significant, preinternet. an alternative hypothesis is that we can see this as part of the routine, periodical "cycle of contention" of post-war youth mobilisations in which "good, decent, little people" with an apparent distrust towards establishment rally against the "corrupt and evil forces from above whose policies are responsible for their pain and suffering" (kazin 1998) . equally, we could argue that established collective action theory might be hierarchically higher than social media-specific theorising in explaining case examples, as it provides a better-substantiated explanation of a greater number of recurrent phenomena. further, the basic premises of the existence of a "deficit" have been challenged. collin (2015) , for example, argues that claims about youth disengagement are exaggerated. she points to volunteering and social movement participation rates as correctives to reliance on "formal" institutional measures of (dis)engagement. while longitudinal data on social media and volunteering in australia is scarce and unreliable (walsh and black 2015) , internationally, there is evidence that increased volunteering rates pre-date widespread internet adoption and may be associated with motivations like experience-gathering to enhance employability or college entry (jones 2000) . again, membership and volunteering may now be afforded via online channels, but this does not demonstrate a causal connection between the means and social practice. lastly, flexible definitions of participation serve as a correction of the institutionally oriented "democratic decline" literature by expanding what political participation looks like. they do so by recognising a shift towards informality in terms of participation in the public sphere ("everyday making"; bang and sørensen 1999) . this draws us to bennett's (2008) analysis of the implications of a social shift towards citizenship as "social movement citizenship" over dutiful/republican models that privilege participation within or through formal institutions. bennett's model emphasises a focus on concern for specific issues as a primary driver for the "hitand-run" participation of everyday making, combined with modes of participation that are more informal and expressive. this not only sits within a post-modern/post-war notion of justice as including recognition as well as other "rightscentric" motivators, but also recognises that the large participation rates in political organisations in the nineteenth and first part of the twentieth century might have less to do with their political functions, as much as their provision of social services, recreational opportunities and networking resources. these benefits are now seen outside of these explicitly political groups with postwar consumer culture, hyperpluralism and social diversification. while participation in the activities of formal political institutions is essential in liberal democracies, a decline in interest in more conventional models of government presents problems in realising political wins or accepting political compromises, the importance of linking these types of rights and recognition concerns with just structural outcomes (fraser 2001) . overall, social movement citizenship, or everyday making, presents challenges to an outcome-focused democratic analysis due to a tendency towards adhocracy, paradoxical disconnection and rapid demobilisation by political participants following their "hit-and-run" engagement. each is discussed in turn. movement politics tend towards fluid structures which more commonly produce flexible adhocracy. while these non-hierarchal power structures are an established advantage of movements, giving them the flexibility, dynamism and resistance to repression, reliance on adhocracy may not produce democratic socialisation. in the context of virtual collective spaces afforded by internet technologies, adhocracy, through decentralised electronic and online methods of collective action, tends to situate issues and problems in the context of "unique" or unusual issues that may require extra-normal methods to address. these types of organisational forms place politics into states of exception where the framing of the problem as exceptional encourages solutions based on the sovereign's ability to transcend the rule of law in the name of the "public good" (schmitt 1922) . therefore, they are less, not more, likely to consider democratic norms and suffer from low accountability and less-drawing potential. while these forms of governance can ameliorate the crises, the longer-term governance legitimated by invoking sovereign power is problematic under this model (see wallach's (2015) discussion of advocacy and the global financial crisis). while the lack of lesson-drawing limits the "developmental" value of participation in these forms of governance structure, this critique is emerging in response to state responses to the covid-19 crisis of 2020. second, while rejecting arguments about social media as fundamentally "siloing" its users (the so-called filter bubbles argument), issue-based politics can disconnect participants from other issue groups and meta-narratives seen either as generally necessary for social functioning or as important canvases against which popular debate is framed. bouvier (2017) equates this to reduced personal ownership of claims made online, due to anonymity, and the collapse of the existence of a shared symbolic order (the "big other"). new media, in undermining the cultural dominance of mass political media, has played an essential part in this process. as a type of networked politics, horizontal visibility can be low. one of the difficulties of the study of younger people's political engagement lies in its comparative "invisibility" within social media that is not readily observable to wider publics. as schuster (2013) observed, this invisibility can create a "generational divide" within movements, with older activists unaware of the depth of engagement of younger activists. this reinforces findings that social networks may not create social capital as anticipated (valenzuela et al. 2009 ). indeed, there are concerns that high levels of social media consumption may be alienating (hunt et al. 2018) . finally, and related the factors of velocity and transience associated with "internet time", rapid mobilisation and "flocking" (where attention shifts towards the next exceptional space or incident that garners high visibility, leaving the previous platform or issue empty) can be associated with rapid demobilisation (jackson and chen 2015) . as uldam and vestergaard (2015) argue, there is a need to refocus on civic participation beyond movement-based and protest-focused analysis. image is not action, and considerable over-attention to visible movement action raises questions about the extent to which the transition from expressive politics to agenda building to policy design, implementation and monitoring occurs. this saw considerable interest from post-war social movement "pracademics" (academics engaged in instrumental and action research), asking questions about "realising wins" and the problem of follow-through post demobilisation (see, for example, the practical work of moyer et al. 2001 , see in the map model for social movements). to understand the relationship between social media and democratic practice, we need to determine what type of practice space social media affords. "practice space" is used deliberately here over the more popular "public sphere" due to the authors' view of the tendency to misapply this concept to the new media environment. more specifically, the attraction of online media theorists to habermasian deliberation may not have been the right choice because this particular democratic model emphasises early parts of the policy process over later aspects of it highlighted above. thus, rather than see the commercial social media platforms as public spheres (true sandboxes), we can see them as sites with non-trivial visible and invisible geographies of power that not only provide political affordances, but also shape social expectation of social media citizenship. the monetisation of online spaces, combined with the collapse of the conventional advertising driven internet economy, has increasingly shifted social media into a primary role in what is called "surveillance capitalism". surveillance capitalism produces value through the observation, quantification and commodification of individuals' online behaviours. this data becomes the core product of these services, providing a new market with the potential to capitalise off knowledge about users' preferences (zuboff 2018) . this has implications for participation in and through these systems due to the role that surveillance plays in creating self-censorship, and the way preference engines generate sameness in the information consumed by individuals. these tendencies-in stark contrast to the view of information in markets as facilitating fair exchange, or the free-speech ethos maintained by the entrepreneurs who run social media enterprises-are problematic for democratic participation. this is due to the reduced capacity for preference formation (attacking performative aspects of speech practice) and preference realisation (via the selective satisfaction of wants at low cost). from the preference formation perspective, the impact of surveillance is demonstrated in stoycheff's (2016) study of the effect of social media users' awareness of surveillance. this experiment found that-even in "strong" free-speech jurisdictionspriming users' awareness of the possibility of surveillance produced more conservative online behaviour and speech. this impact should be concerning to developmental democrats. dahl (1971) , for example, emphasis on the processes of preference formation as a critical aspect of developmental citizenship, something that continues life long, but is vital in the transition into civic life in youth. preference formation is both an individualised practice, in that it is a developmentally acquired skill that individuals exhibit different levels of capacity in, and a collective capacity under conditions of equality. specifically, discourse within groups develops the capacity of the group to undertake political discourse through observation and the presence of relevant information. from a preference realisation perspective, the existence of these so-called preference-knowing machines has implications for human agency. this observation is made because surveillance capitalism, unlike traditional top-down political paternalism exhibited in democratic and authoritarian societies, is fully compatible with high levels of perceived individual efficacy. where "search" once drove the core economy of the internet and provided efficacy through agency, "sharing" and automagical result systems replace agency with expectation. "sharing" allows users to expect that aspects of their "wants" are provided automatically as these systems offer solutions to personal wants and adjust the platform in line with anticipated user desires. thus, efficacy is obtained in these surveillance regimes. significantly, this is achieved not through the type of agency commonly associated with democratic participation, rather a negative agency, surrendering to the panoptic view in recognition of its capacity to service the individual within very narrow and uncontested spheres. this exchange has a psychic cost. hoffmann et al. (2016) identified "privacy cynicism" as the tendency for users to engage in "a cognitive coping mechanism, allowing users to rationalise taking advantage of online services despite serious privacy concerns." this type of preference servicing/channelling is not something we see in corporate media spaces. through the continued valorisation of corporate modes of production in the political sphere, these types of negative agency, passive efficacy systems are proliferating within institutions (public, private and non-profit), and in the new interest in behavioural and persuasive "nudge" economics evidenced in the public sector. these projects-wrapped in the discourse of "big data" analytics-seek to understand their stakeholder groups, be they citizens, clients or employees, but only to the extent to which that knowledge fulfils institutional objectives. this is most obvious in the authoritarian internet of china, where the hard power has most recently been combined with "soft" incentivising through the "social credit system" (ramadan 2018 ) but can also be seen, to a seemingly less intrusive extent, in developed democracies through the aforementioned corporatised nature of e-governance and behavioural policy units. the naturalisation of the technologies underpinning these management systems, be they in liberal democracies or authoritarian regimes, further erodes the capacity of users to express consent (with legitimacy implications important in democratic regimes) and participate in process design, eroding the capacity for the transference of democratic capacity into other areas of life. socialisation within these systems of expectations thus displaces developmental citizenship as citizens are increasingly embedded in these systems of affordance. it is essential to learn from the failures of the "electronic democracy" (e-democracy) movement as a development which, at the turn of the century, aimed to streamline bureaucratic processes and motivate higher levels of participative engagement between power elites and their publics. attempts to create and propagate participative platforms advocated at this time significantly failed through a combination of low utilisation and limited state interest in cultivating and connecting with them. even where public management has embraced notions of popular legitimacy, such as the focus on connecting administration to public legitimacy through the reclassification of public sector management as the creation of "public value", this has not led to an embrace of participative media by public managers (bolívar 2016) . where participative design is undertaken, understanding the constitutive nature of affordances is essential. as mentioned, design choices activate and allow behaviours. thorson (2014) , for example, has argued that there are important differences in the value of new media associated with how the technologies are employed, with "active" use (i.e. search over sociability) correlated with more challenging modes of citizenship, or seeking divergent opinion exposure. matei and britt (2017) provide a useful analysis of wikipedia as an example of a platform that uses advocacy, creates a social hierarchy in production, but sustains openness to new entrants, accountability, and has sustained itself in the face of attacks on its primary function of knowledge production. as indicated, however, this cannot be seen as an engineering problem, and the cultivation of interest and practices to employ, discover and create new democratic affordances is necessary. the contemporary problem is that most civics education is undertaken in bad faith. as bennett (2008) observed, most academic and educational representation of democratic practice bears little resemblance to its actual practice, precisely because this practice in most established democracies falls far short of the underlying idealistic motivations embedded in civics instruction. as "telling people to participate in bad institutions is mere propaganda" (levine 2006), there has been a tendency to focus on political spaces that are presented as tabula rasa, be this technological spaces over the last two decades, or an emphasis on social movement participation because ever-renewing social movements maintain the appearance of both democratic because they are inherently participative, and new because they tend to be continuously renamed. coleman (2008) has highlighted the importance of skilling for "autonomous ecitizenship" that capacity building and skilling overcome the problem of bad faith by allowing young people to develop their own aspirational spaces. this has been demonstrated in applied research in schools (see black 2017) . this model presumes, however, that these skills are produced in a context where their democratic application is explicit, and that these self-actualising young e-citizens would employ these skills in a frictionless environment that provides them with an even playing field. if this illusion was able to be sustained by coleman in 2008, a decade later it cannot be. the corporate-dominated internet has proven libertarians wrong: atomised "heroic" individuals cannot find self-actualisation in the face of such overwhelming institutional power. individual liberalism is impossible in an age of such incredible institutional power. the "hidden affordances" of the sub-systems most internet users spend the majority of their time in online (as opposed to the delusion of the internet as a "sandbox") may be malleable to a literate few, but this presents the prospect of meritocracy heavily tilted by neoliberal access to education, not a sustainable democracy of equality. further, social media may provide greater affordances for reactionary and counter-democratic agents (the entrenched, corporations, the state) to limit movement and political agency (cammaerts 2015; uldam 2015) . this latter power is contestable. while online activists have attempted to moderate the policies of major internet platform operators, their capacity to act against organisations of this scale and transnational character has been most effective only where similar transnational capacity exists. thus, while there have been a range of statelevel investigations and proposed regulatory interventions in the way platforms operate (in australia primarily focused on ensuring representative democracy), the most significant developments have been seen at the level of the european union. this remains a moving target but provides an example of the need to revisit the politics of accessibility but focused on interventions within the walled gardens online. the internet is no longer a land without a history, and optimistic projections that new affordances have a deterministic correlation with democratisation need to be checked against the visible history of these claims, and the broader background context of societies that are more technologically saturated, and less democratic overall. while new media is undoubtedly at the heart of recent youth mobilisation politics, it is not clear if this is more than correlative or epiphenomenal. younger people are disproportionately institutionally situated in contexts obsessed by the "human capital" developmental school (becker 1993) in which citizenship rights are primarily held in abeyance, secondary to instrumental aims associated with participation in the private world's production and consumption. thus, recent youth mobilisations can be seen as remarkable contestations in the face of these systems, rather than a result of them to avoid falling into the twin traps of bad faith promotion of weak systems or magical thinking about new spaces and places for participation, systematic democratisation of spaces and places-both online and off-must be the focus of reform. participation without democratisation is the possible panacea that can consume the efforts of reformers. as the internet splits into three distinct jurisdictions-the surveillance capitalism space, authoritarian spaces and the regulated internet-new possibilities and natural experiments present themselves for investigation in the online space. to take advantage of these affordances civics education has demonstrated, it can produce positive improvements in rates of participation, but this will need to be met by increased opportunities for democratic agency in our classrooms, workplaces and the public sphere. the everyday maker: a new challenge to democratic governance human capital: a theoretical and empirical analysis, with special reference to education the wealth of networks: how social production transforms markets and freedom active citizenship and the 'making' of active citizens in australian schools policymakers' perceptions on the citizen participation and knowledge sharing in public sector delivery. in: sobaci mz (ed) social media and local governments what is a discourse approach to twitter, facebook, youtube and other social media: connecting with 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what young australians want from the 2016 election. youth action and australian research alliance for children and youth equal access, unequal success-major and minor canadian parties on the net what do we mean by democracy? reflections on an essentially contested concept and its relationship to politics and public administration can the subaltern speak? under surveillance: examining facebook's spiral of silence effects in the wake of nsa internet monitoring the networked young citizen: social media political participation and civic engagement civic engagement and social media: political participation beyond protest is there social capital in a social network site? facebook use and college students' life satisfaction, trust, and participation digital citizenship and political engagement: the challenge from online campaigning and advocacy organisations australian research alliance for children and youth wildavsky a (2017) culture and social theory the great equaliser? patterns of social media use and youth political engagement in three advanced democracies social media use and online political participation among college students during the us election 2012 the age of surveillance capitalism: the fight for a human future at the new frontier of power key: cord-020197-z4ianbw8 authors: celliers, marlie; hattingh, marie title: a systematic review on fake news themes reported in literature date: 2020-03-10 journal: responsible design, implementation and use of information and communication technology doi: 10.1007/978-3-030-45002-1_19 sha: doc_id: 20197 cord_uid: z4ianbw8 in this systematic literature review, a study of the factors involved in the spreading of fake news, have been provided. in this review, the root causes of the spreading of fake news are identified to reduce the encouraging of such false information. to combat the spreading of fake news on social media, the reasons behind the spreading of fake news must first be identified. therefore, this literature review takes an early initiative to identify the possible reasons behind the spreading of fake news. the purpose of this literature review is to identify why individuals tend to share false information and to possibly help in detecting fake news before it spreads. the increase in use of social media exposes users to misleading information, satire and fake advertisements [3] . fake news or misinformation is defined as fabricated information presented as the truth [6] . it is the publication of known false information and sharing it amongst individuals [7] . it is the intentional publishing of misleading information and can be verified as false through fact-checking [2] . social media platforms allow individuals to fast share information with only a click of a single share button [4] . in previous studies the effect of the spreading and exposure to misleading information have been investigated [6] . some studies determined that everyone has problems with identifying fake news, not just users of a certain age, gender or education [11] . the literacy and education of fake news is essential in the combating of the spreading of false information [8] . this review identify and discuss the factors involved in the sharing and spreading of fake news. the outcome of this review should be to equip users with the abilities to detect and recognise misinformation and also to cultivate a desire to stop the spreading of false information [5] . 2 literature background the internet is mainly driven by advertising [13] . websites with sensational headlines are very popular, which leads to advertising companies capitalising on the high traffic to the site [13] . it was subsequently discovered that the creators of fake news websites and information could make money through automated advertising that rewards high traffic to their websites [13] . the question remains how misinformation would then influence the public. the spreading of misinformation can cause confusion and unnecessary stress among the public [10] . fake news that is purposely created to mislead and to cause harm to the public is referred to as digital disinformation [17] . disinformation has the potential to cause issues, within minutes, for millions of people [10] . disinformation has been known to disrupt election processes, create unease, disputes and hostility among the public [17] . these days, the internet have become a vital part of our daily lives [2] . traditional methods of acquiring information have nearly vanished to pave the way for social media platforms [2] . it was reported in 2017 that facebook was the largest social media platform, hosting more 1.9 million users world-wide [18] . the role of facebook in the spreading of fake news possibly has the biggest impact from all the social media platforms [14] . it was reported that 44% of worldwide users get their news from facebook [14] . 23% of facebook users have indicated that they have shared false information, either knowingly or not [19] . the spreading of fake news is fuelled by social media platforms and it is happening at an alarming pace [14] . in this systematic literature review, a qualitative methodology was followed. a thematic approach was implemented to determine the factors and sub-factors that contribute to the sharing and spreading of fake news. the study employed the following search terms: ("fake news" (near/2) "social media") and (defin* or factors or tools) ("misinformation" (near/2) "social media") and (defin* or factors or tools). in this literature review, only published journal articles between 2016 and 2019 were considered. this review is not be specific to certain sectors i.e. the health sector or the tourism sector but rather consider on all elements that contribute to individuals sharing false information. studies that are not in english have been excluded in this review. only studies that are related to the research question have been taken into account. this article does not discuss the detection of fake news but rather the reasons behind the spreading of fake news. the analysis consisted of four phases: identification phase; screening phase; eligibility phase and inclusion phase. when conducting this literature review, the selection of articles were based on three main criteria: firstly, to search for and select articles containing the search terms identified above; secondly, selection based on the title and abstract of the article and finally selection based on the content of the article. in the identification phase of this literature review, science direct and emerald insight were selected to perform the literature review. science direct offered a total of 177 journal articles matching the search terms. emerald insight generated 121 journal articles that matched the search terms. continuing with the identification phase, the various articles were then combined and the duplicates were removed. in the screening phase of the source selection, all the article titles were carefully screened and a few articles were excluded as unconvincing. the eligibility of the abstract in the remaining articles were consulted and some articles were excluded based on the possible content of the article. the rest of the articles were further thoroughly examined to determine if they were valuable and valid to this research paper. upon further evaluation, these final remaining articles were further studied to make a final source selection. in this paper, possible reasons for and factors contributing to the sharing and spreading of false information are discussed. the reasons are categorized under various factors highlighted in the journal articles used to answer the research question. these factors include: social factors, cognitive factors, political factors, financial factors and malicious factors. while conducting the literature review, 22 articles highlighted the social factors; 13 articles discussed the role that cognitive factors have in contributing to the sharing and spreading of fake news; 13 articles highlighted the role of political factors; nine articles discussed how financial gain could convince a social media users to spread false information and 13 articles debated malicious factors and the effect that malicious factors have on the sharing and spreading of false information. figure 1 gives a breakdown of all 38 articles containing references to all the subcategories listed above. it was clearly evident that the two single sub-categories of social comparison and hate propaganda were the most debated. with the sub-factor, knowledge and education, closely behind. a high percentage of the articles, 34.2% (13 of 38), refer to the effects of social comparison on the spreading of false information; followed by 26.3% (10 of 38) of the articles referencing hate propaganda. knowledge and education was measured at 23.6% (9 of 38). furthermore, it was concluded that the majority of the 38 articles highlighted a combination of the social factors i.e. conformity and peer influence, social comparison and satire and humorous fakes, which measures at 60.5% (23 of 38). where the combination of the cognitive factors e.g. knowledge and education and ignorance measured at 39.4% (15 of 38) . political factors and sub-factors e.g. political clickbaits and political bots/cyborgs, were discussed in 34.2% (13 of 38) of the articles. in addition, financial factors e.g. advertising and financial clickbaits were referenced in 23.6% (9 of 38) of the journal articles. and lastly, malicious factors e.g. malicious bots and cyborgs, hate propaganda and malicious clickbaits measured at 34.2% (13 of 38). fake news stories are being promoted on social media platforms to deceive the public for ideological gain [20] . in various articles it was stated that social media users are more likely to seek information from people who are more like-minded or congruent with their own opinions and attitudes [21, 22] . conformity and peer influence. it is the need of an individual to match his or her behaviour to a specific social group [9] . the desire that social media users have to enhance themselves on social media platforms could blur the lines between real information and false information [12] . consequently, social media users will share information to gain social approval and to build their image [12] . recent studies have shown that certain false information can be strengthened if it belongs to the individuals in the same social environment [23] . the real power lies with those certain individuals who are more vocal or influential [24] . the need for social media users to endorse information or a message can be driven by the perception the social media user has about the messenger [25] . these messengers or "influencers" can be anyone ranging from celebrities to companies [24] . studies show that messages on social media platforms, like twitter, gain amplification because the message or information is associated with certain users or influencers [25] . information exchanging depends on the ratings or the influential users associated with the information [23] . social media users' influence among peers enhance the impact and spreading of all types of information [25] . these social media influencers have the ability to rapidly spread information to numerous social media users [26] . the level of influence these influencers have, can amplify the impact of the information [27] . the lack of related information in online communities could lead to individuals sharing the information based on the opinions and behaviours of others [23] . some studies show that social media users will seek out or share information that reaffirms their beliefs or attitudes [18] . social comparison. the whole driving force of the social media sphere is to post and share information [1] . social comparison can be defined as certain members within the same social environment who share the same beliefs and opinions [12] . when they are unable to evaluate certain information on their own, they adapt to compare themselves to other members, within the same environment, with the same beliefs and opinions [12] . the nature of social media allows social media users to spread information in realtime [28] . social media users generate interactions on social media platforms to gain "followers" and to get "likes" which lead to an increasing amount of fake news websites and accounts [10] . one of the biggest problems faced in the fake news dilemma, is that social media users' newsfeed on social media platforms, like facebook, will generally be populated with the user's likes and beliefs, providing a breeding ground for users with like-minded beliefs to spread false information among each other [16] . social media users like to pursue information from other members in their social media environment whose beliefs and opinions are most compatible with their own [21] . social media algorithms designed to make suggestions or filter information based on the social media users' preferences [29] . the "like" button on social media platforms, e.g. facebook, becomes a measuring tool for the quality of information, which could make social media users more willing to share the information if the information has received multiple likes [30] . social media users' belief in certain information depends on the number of postings or "re-tweets" by other social media users who are involved in their social media sphere [23] . one article mentioned that the false news spreading process can be related to the patterns of the distribution of news among social media users [31] . the more a certain piece of information is shared and passed along the more power it gains [6] . this "endorsing" behaviour results in the spreading of misleading information [25] . it is also known as the "herding" behaviour and is common among social media where individuals review and comment on certain items [23] . it is also referred to as the "bandwagon effect" where individuals blindly concentrate on certain information based on perceived trends [32] . the only thing that matters is that the information falls in line with what the social media user wants to hear and believe [16] . many studies also refer to it as the "filter bubble effect" where social media users use social media platforms to suggest or convince other social media users of their cause [33] . communities form as a result of these filter bubbles where social media users cut themselves off from any other individual that might not share the same beliefs or opinions [33] . it was found that social media users tend to read news or information that are ideologically similar to their own ideologies [29] . satire and humorous fakes. some of the content on social media are designed to amuse users and are made to deceive people into thinking that it is real news [2] . satire is referred to as criticising or mocking ideas or opinions of people in an entertaining or comical way [7, 29] . these satire articles consist of jokes or forms of sarcasm that can be written by everyday social media users [10] . most satire articles are designed to mislead and instruct certain individuals [13] . some social media users will be convinced that it is true information and will thus share the information [2] . the study of cognition is the ability of an individual to make sense of certain topics or information by executing a process of reasoning and understanding [34] . it is the ability of an individual to understand thought and execute valid reasoning and understanding of concept [34] . with an increasing amount of information being shared across social media platforms it can be challenging for social media users to determine which of the information is closest to the original source [22] . the issue of individuals not having the ability to distinguish between real and fake news have been raised in many articles [10] . users of social media tend to not investigate the information they are reading or sharing [2] . this can therefore lead to the rapid sharing and spreading of any unchecked information across social media platforms [2] . [10] . the trustworthiness of a certain article is based on how successful the exchange of the articles are [12] . the more successful the exchange, the more likely social media users will share the information [12] . social media users make supposedly reasonable justifications to determine the authenticity of the information provided [35] . people creating fake news websites and writing false information exploit the nonintellectual characteristics of some people [13] . for social media users to determine if the information they received is true or false, expert judgement of content is needed [1] . in a recent study, it was found that many social media users judge the credibility of certain information based on detail and presentation, rather than the source [11] . some individuals determine the trustworthiness of information provided to them through social media on how much detail and content it contains [11] . it is believed that people are unable to construe information when the information given to them, are conflicting with their existing knowledge base [34] . most social media users lack the related information to make a thorough evaluation of the particular news source [23] . for many years, companies and people have been creating fake news articles to capitalize on the non-intellectual characteristics of certain individuals [13] . a driving force of the spreading of false information is that social media users undiscerningly forward false information [5] a reason for the spreading of false information in many cases are inattentive individuals who do not realise that some websites mimic real websites [2] . these false websites are designed to look like the real website but in essence only contain false information. social media users tend to share information containing a provocative headline, without investigating the facts and sources [16] . the absence of fact-checking by social media users on social media platforms, increases the spreading of false information [2] . social media users tend to share information without verifying the source or the reliability of the content [2] . information found on social media platforms, like twitter, are sometimes not even read before they are being spread among users, without any investigation into the source of the information [16] . as mentioned earlier in sect. 5.1, the bandwagon effect causes individuals to share information without making valued judgement [32] . the spreading of false political information have increased due to the emergence of streamline media environments [22] . there has been a considerable amount of research done on the influence of fake news on the political environment [14, 18] . by creating false political statements, voters can be convinced or persuaded to change their opinions [3] . critics reported that in the national election in the uk (regarding the nation's withdrawal out of the eu) and the 2016 presidential election in the us, a number of false information was shared on social media platforms that have influenced the outcome of the results [8, 22] . social media platforms, like facebook, came under fire in the 2016 us presidential election, when fake news stories from unchecked sources were spread among many users [10] . the spreading of such fake news have the sole purpose of changing the public's opinion [8, 29] . various techniques can be used to change the public's opinion. these techniques include repeatedly retweeting or sharing messages often with the use of bots or cyborgs [15] . it also includes misleading hyperlinks that lures the social media user to more false information [15] . political clickbaits. clickbaits are defined as sources that provide information but use misleading and sensational headiness to attract individuals [16] . in the 2016 us presidential elections it was apparent that clickbaits were used to shape peoples' opinions [4] . in a recent study it was found that 43% (13 of 30) false news stories were shared on social media platforms, like twitter, with links to non-credible news websites [22] . webpages are purposely created to resemble real webpages for political gain [3] . news sources with urls similar to the real website url have been known to spread political fake news pieces, which could influence the opinion of the public [10] . political bots/cyborgs. a social media users' content online is managed by algorithms to reflect his or her prior choices [22] . algorithms designed to fabricate reports are one of the main causes of the spreading of false information [33] . in recent years, the rapid growth of fake news have led to the belief that cyborgs and bots are used to increase the spreading of misinformation on social media [22] . in the 2016 us election social bots were used to lead social media users to fake news websites to influence their opinions on the candidates [3] . hundreds of bots were created in the 2016 us presidential elections to lure people to websites with false information [3] these social bots can spread information through social media platforms and participate in online social communities [3] . one of the biggest problems with fake news is that it allows the writers to receive monetary incentives [13] . misleading information and stories are promoted on social media platforms to deceive social media users for financial gain [20, 29] . one of the main goals of fake news accounts are to generate traffic to their specific website [10] . articles with attractive headlines lure social media users to share false information thousands of times [2] . many companies use social media as a platform to advertise their products or to promote their products [26] . advertising. people earn money through clicks and views [36] . the more times the link is clicked the more advertising money is generated [16] . every click corresponds to advertising revenue for the content creator [16] . the more traffic companies or social media users get to their fake news page, the more profit through advertising can be earned [10] . the only way to prevent financial gain for the content creator is inaction [16] . most advertising companies are more interested in how many social media users will be exposed to their product rather than the possible false information displayed on the page where their advertisement is displayed [13] . websites today are not restricted on the content displayed to the public, as long as they attract users [13] . this explains how false information is monetized, providing monetary value for writers to display sensational false information [13] . financial clickbaits. clickbaits are used to lure individuals to other websites or articles for financial gain [2] . one of the main reasons for falsifying information is to earn money through clicks and views [36] . writers focus on sensational headlines rather than truthful information [13] . appeal rather than truthfulness drives information [5] . these attractive headlines deceive individuals into sharing certain false information [2] . clickbaits are purposely implemented to misguide or redirect social media users to increase the views and web traffic of certain websites for online advertising earnings [4] . social media users end up spending only a short time on these websites [4] . clickbaits have been indicated as one of the main reasons behind the spreading of false information [2] . studies debating the trustworthiness of information and veracity analytics of online content have increased recently due to the rise in fake news stories [37] . social media has become a useful way for individuals to share information and opinions about various topics [3] . unfortunately, many users share information with malicious intent [3] . malicious users, also referred to as "trolls", often engage in online communication to manipulate other social media users and to spread rumours [37] . malicious websites are specifically created for the spreading of fake news [2] . malicious entities use false information to disrupt daily activities like the health-sector environment, the stock markets or even the opinions people have on certain products [3] . some online fake news stories are purposely designed to target victims [3] . websites, like reddit, have been known as platforms where users can get exposed to bullying [38] . some individuals have been known to use the social media platform to cause confusion and fear among others [39] . malicious bots/cyborgs. malicious users, with the help of bots, target absent-minded individuals who do not check the article facts or source before sharing it on social media [2] . these ai powered bots are designed to mimic human behaviour and characteristics, and are used to corrupt online conversations with unwanted and misleading advertisements [38] . in recent studies it was found that social bots are being created to distribute malware and slander to damage an individual's beliefs and trust [3] . hate propaganda. many argue that the sharing of false information fuel vindictive behaviour among social media users [12] . some fake news websites or pages are specifically designed to harm a certain user's reputation [5, 10] . social media influencers influence users' emotional and health outcomes [12] . fake news creators specifically target users with false information [3] . this false information is specifically designed to deceive and manipulate social media users [21] . fake news stories like this, intend to mislead the public and generate false beliefs [21] . in some cases, hackers have been known to send out fake requests to social media users to gain access to their personal information [39] . the spreading of hoax has also become a problem on social media. the goal of hoaxes is to manipulate the opinion of the public and to maximize public attention [35] . social spammers have also become more popular over the last few years with the goal to launch different kinds of attacks on social media users, for example spreading viruses or phishing [2] . fake reviews have also been known to disrupt the online community through writing reviews that typically aim to direct people away from a certain product or person [2] . another method used by various malicious users, is to purchase fake followers to spread harmful malware more swiftly [26] . malicious clickbaits. it was reported on in a previous article that employees in a certain company clicked on a link, disguised as important information, where they provide sensitive and important information to perpetrators [4] . malicious users intending to spread malware and phishing hide behind a fake account to further increase their activities [26] . clickbaits in some cases are designed to disrupt interactions or to lure individuals into arguing in disturbed online interactions or communications [37] . these clickbaits have also been known to include malicious code as part of the webpage [4] . this will cause the social media users to download malware onto their device once they select the link [4] . various articles were used to identify and study the factors and reasons involved in the sharing and spreading of misinformation on social media. upon retrieving multiple reasons for the spreading of false information, they were categorized into main factors and sub-factors. these factors included social factors, cognitive factors, political factors, financial factors and malicious factors. considering the rapidly expanding social media environment, it was found that especially social factors have a very significant influence in the sharing of fake news on social media platforms. its sub-factors of conformity and peer-influence; social comparison and satire and humorous fakes have great influence when deciding to share false information. secondly, it was concluded that malicious factors like hate propaganda also fuel the sharing of false information with the possibility to financially gain or to do harm. in addition, it was concluded from this review that knowledge and education plays a very important role in the sharing of false information, where social media users sometimes lack the logic, reasoning and understanding of certain information. it was also evident that social media users may sometimes be ignorant and indifferent when sharing and spreading information. fact-checking resources are available but the existence thereof is fairly unknown and therefore often unused. hopefully better knowledge and education will encourage a desire among social media users to be more aware of possible unchecked information and the sources of information and to stop the forwarding of false information. a better understanding of the motives behind the sharing of false information can potentially prepare social media users to be more vigilant when sharing information on social media. the goal of this literature review was only to identify the factors that drive the spreading of fake news on social media platforms and did not fully address the dilemma of combatting the sharing and spreading of false information. while this literature review sheds light on the motivations behind the spreading of false information, it does not highlight the ways in which one can detect false information. this proposes further suggestions for follow-up research or literature studies using these factors in an attempt to detect and limit or possibly eradicate the spreading of false information across social media platforms. despite the limitations of this literature review, it helps to educate and provide insightful knowledge to social media users who share information across social media platforms. algorithmic detection of misinformation and disinformation: gricean perspectives a survey on fake news and rumour detection techniques an overview of online fake news: characterization, detection, and discussion detecting fake news in social media networks why students share misinformation on social media: motivation, gender, and study-level differences the diffusion of misinformation on social media: temporal pattern, message, and source behind the cues: a benchmarking study for fake news detection why do people believe in fake news over the internet? an understanding from the perspective of existence of the habit of eating and drinking this is fake news': investigating the role of conformity to other users' views when commenting on and spreading disinformation in social media the current state of fake news: challenges and opportunities identifying fake news and fake users on twitter why do people share fake news? associations between the dark side of social media use and fake news sharing behavior history of fake news getting acquainted with social networks and apps: combating fake news on social media what the fake? assessing the extent of networked political spamming and bots in the propagation of #fakenews on twitter fake news: belief in post-truth real411. keeping it real in digital media. disinformation destroys democracy democracy, information, and libraries in a time of post-truth discourse attention-based convolutional approach for misinformation identification from massive and noisy microblog posts third person effects of fake news: fake news regulation and media literacy interventions good news, bad news, and fake news: going beyond political literacy to democracy and libraries a computational approach for examining the roots and spreading patterns of fake news: evolution tree analysis effects of group arguments on rumor belief and transmission in online communities: an information cascade and group polarization perspective beyond misinformation: understanding and coping with the 'post-truth' era virtual zika transmission after the first u.s. case: who said what and how it spread on twitter distance-based customer detection in fake follower markets exploring users' motivations to participate in viral communication on social media detecting rumors in social media: a survey fake news judgement: the case of undergraduate students at notre dame university-louaize the emergence and effects of fake social information: evidence from crowdfunding fake news and its credibility evaluation by dynamic relational networks: a bottom up approach understanding the majority opinion formation process in online environments: an exploratory approach to facebook social media and the future of open debate: a user-oriented approach to facebook's filter bubble conundrum fake news': incorrect, but hard to correct. the role of cognitive ability on the impact of false information on social impressions social media hoaxes, political ideology, and the role of issue confidence fake news and the willingness to share: a schemer schema and confirmatory bias perspective the dark side of news community forums: opinion manipulation trolls social media? it's serious! understanding the dark side of social media social media security and trustworthiness: overview and new direction key: cord-103080-tzu61nbg authors: crowe, c. l.; domingue, b. w.; hu, g.; keyes, k. m.; kwon, d.; belsky, d. w. title: associations of loneliness and social isolation with healthspan and lifespan in the us health and retirement study date: 2020-07-11 journal: nan doi: 10.1101/2020.07.10.20147488 sha: doc_id: 103080 cord_uid: tzu61nbg background. loneliness and social isolation are emerging public health challenges for aging populations. methods. we followed n=11,305 us health and retirement study (hrs) participants aged 50-95 from 2006-2014 to measure persistence of exposure to loneliness and social isolation. we tested associations of longitudinal loneliness and social-isolation phenotypes with disability, morbidity, mortality, and biological aging through 2018. results. during follow-up, 18% of older adults met criteria for loneliness and, for 6%, symptoms persisted across two or more follow-up assessments. for social isolation, these fractions were 21% and 8%. hrs participants who experienced loneliness and social isolation were at increased risk for disease, disability, and mortality. older adults experiencing persistent loneliness were at a 59% increased hazard of mortality compared to those who were never lonely. for social isolation, the increase was 28%. effect-sizes were somewhat larger for counts of prevalent activity limitations and somewhat smaller for counts of prevalent chronic diseases. covariate adjustment for socioeconomic and psychological risks attenuated but did not fully explain associations. older adults who experienced loneliness and social isolation also exhibited physiological indications of advanced biological aging (cohen's-d for persistent loneliness and social isolation=0.26 and 0.21, respectively). for loneliness, but not social isolation, persistence of symptoms was associated with increased risk. conclusion. deficits in social connectedness prevalent in a national sample of older adults in the us were associated with morbidity, disability, and mortality and with more advanced biological aging. bolstering social connection to interrupt experiences of loneliness may promote healthy aging. loneliness and social isolation are prevalent experiences of older adults, with an estimated 20-30% reporting some feelings of loneliness or social isolation (1, 2) . they are also associated with increased morbidity and mortality (2) (3) (4) (5) . loneliness and social isolation therefore represent an emerging priority for public health intervention, the urgency of which is highlighted by the impact of shelter-in-place policies implemented to mitigate the covid-19 pandemic (6) (7) (8) (9) . loneliness and social isolation are distinct constructs representing features of social connectedness (10) . loneliness is the subjective feeling of being isolated. social isolation is the objective state of having limited social interactions. interventions are now being developed to reduce loneliness and social isolation with the aim of improving health and well-being among older adults (2, (11) (12) (13) . while there is some evidence that reducing loneliness may improve symptoms of depression in older adults (14), it is not known if intervention on loneliness and social isolation can impact physical health-related features of healthy aging. cross-sectional studies report associations of loneliness and social isolation with physical health deficits in older adults and also with mortality (2, 15 ). however, cross-sectional data cannot rule out confounding of associations by pre-existing economic and psychological risk factors that may cause deficits in social connectedness and also in healthy aging. they also cannot exclude the possibility of reverse causation, in which disease and disability lead to isolation and loneliness. moreover, cross-sectional data cannot identify variation in persistence of loneliness and social isolation, which are thought to be critical to adverse health impacts of these exposures. longitudinal data are therefore needed to address three questions about links from loneliness and social isolation to disease, disability, and mortality: first, are risks associated with loneliness and social isolation independent of economic and psychological vulnerabilities that may cause both social disconnection and deficits in healthy aging? household poverty and adverse neighborhood conditions can cause older people to become socially disconnected from their communities and are also associated with disease, disability, and mortality (16-18). in parallel, psychological vulnerabilities that put people at risk for loneliness and social isolation, including depressive symptoms and related personality features, are also linked with deficits in healthy aging (19) (20) (21) (22) . measurements of economic and psychological vulnerability are needed to disentangle the effects of loneliness and social isolation on deficits in healthy aging from the effects of correlated risk factors. second, do loneliness and social isolation precede the onset of deficits in healthy aging or, instead, could deficits in healthy aging cause individuals to become lonely or socially isolated? meta-analyses support deficits in social connectedness as predictors of future morbidity and mortality (23, 24). however, data are more limited on multimorbidity and disability (3, 25) . longitudinal data can help clarify the extent of prospective links between deficits in social connection and deficits in healthy aging (15). third, does the persistence of loneliness and social isolation worsen health impacts? interventions to address loneliness and social isolation aim to improve health by reducing the burden of loneliness and social isolation among individuals who are already lonely and isolated (11) . however, it is not known if reducing the persistence of loneliness and social isolation will offer protection against deficits in healthy aging. studies with measures of loneliness and social isolation at multiple time points can compare healthy aging outcomes among those whose symptoms persist as to those with intermittent exposure. beyond these questions, there is need to identify biological measurements that can indicate whether interventions for loneliness and social isolation are having a desired effect in preventing deficits in healthy aging. there is already evidence that loneliness may compromise to address these questions and build knowledge to inform design of future programs and policies, we analyzed data from the us health and retirement study (hrs), a large national sample of older adults followed longitudinally from 1992 and most recently surveyed in 2016-2018. we conducted analysis to evaluate the strength and validity of associations of loneliness and social isolation with mortality, disability, and morbidity, and explored a potential link between exposure to loneliness and social isolation and more advanced biological aging. the hrs is a longitudinal biennial cohort study of a nationally representative sample of noninstitutionalized adults over the age of 50 and their spouses. the hrs selected participants using multistage probability sampling designed to represent adults over the age of 50 in the united . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07. 10.20147488 doi: medrxiv preprint states. we analyzed hrs data from rand corporation (27) including 42,042 participants. we linked rand files with data from the hrs leave behind questionnaires (lbq) collected during 2006-2014 (28) and from the hrs venous blood study (vbs) collected in 2016 (29). loneliness & social isolation. we measured loneliness and social isolation from data collected loneliness. we measured loneliness using a 3-item version of the revised ucla (r-ucla) loneliness scale (30) . participants rated how frequently they felt they were 1) lacking companionship, 2) left out, and 3) isolated from others on a 3-point scale. previous analysis showed this version to have similar psychometric properties to the original 20-item version (30) . we coded item responses so that higher scores corresponded to more severe loneliness. to account for missing item-level data, we pro-rated scale scores for participants who responded to at least two of the three items. final scores ranged from 3-9. we followed the procedure of steptoe and colleagues (31) and classified participants in the top quintile of scale scores as lonely. this procedure classified participants scoring ≥7 as lonely. social isolation. there is not yet a gold standard measure of social isolation. consensus in the field is that scales should comprise multiple items and measure relationships with individuals, groups, and community organizations (32, 33) . we used a six-item scale meeting these criteria first validated in the english longitudinal study of aging (elsa) (5, 31) and . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07. 10.20147488 doi: medrxiv preprint adapted to the hrs (34) . we assigned a social isolation score to each participant based on whether they 1) were unmarried, 2) lived alone, 3) had less than monthly contact with children, 4) had less than monthly contact with other family members, 5) had less than monthly contact with friends, and 6) did not participate in any groups, clubs, or other social organizations, yielding scores 0-6. we pro-rated scale scores for participants providing data for at least three of the six items. we followed the procedure used for loneliness and classified participants in the top quintile of scale scores as socially isolated. this procedure classified participants scoring ≥3 as socially isolated. persistent exposure classification. for loneliness and social isolation, we classified participants with scores meeting or exceeding the threshold score at two or more assessment waves as having persistent exposure. we classified participants meeting or exceeding the threshold at only one assessment as having intermittent exposure. sensitivity analysis. we conducted sensitivity analysis to evaluate alternative measurements and thresholds to identify loneliness and social isolation (supplemental deficits in healthy aging. aging is the leading risk factor for many different chronic diseases and disabilities. however, not everyone experiences the onset of these conditions at the same rate. while some experience a healthy aging process that allows them to remain healthy throughout the later stages of life, others develop disabilities and morbidities much earlier in life. given the broad array of conditions that comprise healthy aging and the conceptualization of loneliness and social isolation as exposures that influence multiple organ systems and disease pathways, we tested associations with a range of indicators of healthy aging. we measured deficits in healthy aging from hrs mortality records collected through 2018, interview data on . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint chronic disease morbidity and disability collected through 2016, and a measurement of biological aging implemented in data from the 2016 venous blood study. hrs measured mortality from linkages with the national death index and from reports in exit interviews and in interviews with spouses. we measured activities of daily living (adl) disabilities as a count of the following activities with which the participant reported having at least some difficulty: bathing, dressing, eating, getting in/out of bed, and walking across a room. we measured instrumental activities of daily living (iadl) disabilities as a count of the following activities with which the participant reported having at least some difficulty: using the phone, managing money, taking medications, shopping for groceries, and preparing hot meals. we measured chronic diseases as a count of the following medical conditions with which the participant reported ever being diagnosed: high blood pressure, diabetes, cancer, chronic lung disease, heart disease, and stroke. we analyzed counts of adl disability, iadl disability, and chronic disease diagnoses as 0-3+. we measured biological aging from data collected in hrs's 2016 venous blood study (29) using the "phenotypic age" algorithm (35) (36) (37) . there are several methods to quantify biological aging from blood chemistry data. we focused on phenotypic age because comparative studies suggest this measure is more predictive of mortality, disability, and morbidity as compared to leading alternatives (36, 38, 39) . the phenotypic age algorithm was developed from a machine learning analysis of mortality in the national health and nutrition examination surveys (nhanes) iii dataset. the analysis screened 42 blood chemistry . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint biomarkers and chronological age to devise a prediction algorithm. the resulting algorithm included chronological age and 9 biomarkers: albumin, alkaline phosphatase, creatinine, creactive protein, glucose, mean cell volume, red cell distribution width, white blood cell count, and lymphocyte percent. the algorithm produced a value denominated in the metric of years. the years correspond to the age at which an individual's risk of death would be approximately normal in the nhanes iii sample. a phenotypic age older than a person's true chronological age indicates more advanced biological aging. social and economic circumstances. we measured participants' social and economic circumstances across three domains: neighborhood conditions, household wealth, and education. details are reported in the supplemental methods. psychological vulnerabilities. we measured participants' psychological vulnerabilities from assessments of the personality trait neuroticism and of symptoms of depression. details are reported in the supplemental methods. a timeline of exposure and outcome assessments is provided in figure 1 . our analysis sample included participants aged 50-95 at their baseline observation for loneliness and social isolation who provided at least two timepoints of data for these measures during table 1 . . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07. 10.20147488 doi: medrxiv preprint we tested associations of loneliness and social isolation with mortality, disability, chronic disease, and biological aging using regression methods. we analyzed time-to-event data on mortality using cox proportional hazards regression to estimate hazard ratios (hr). we analyzed count data on number of adl and iadl disabilities and chronic disease diagnoses using negative binomial regression models to estimate incidence rate ratios (irrs). we analyzed continuously distributed data on phenotypic age advancement using linear regression to estimate standardized effect-sizes (cohen's d). all models included covariate adjustment for age, age-squared, sex, age-sex interactions, race/ethnicity, and a dummy variable coding whether participants were assigned to the subsample of the hrs which first measured loneliness and social isolation in 2006 or 2008. analysis was performed using stata 15 (40) . analysis included 11,305 participants with at least two repeated measures of loneliness or social isolation who were aged 50-95 when they completed their first psychosocial questionnaire and were alive at the end of the exposure assessment period (2012 or 2014). sample characteristics are reported in supplemental table 2 . at the first waves of measurement (2006 and 2008) 10% of the sample met criteria for loneliness and 11% met criteria for social isolation. by the end of exposure assessment in 2014, the proportion that ever met criteria was 18% for loneliness and 21% for social isolation. of those who ever met criteria for loneliness or social isolation, 20% ever met criteria for both loneliness and social isolation (supplemental table 3 ). ever reporting loneliness and social isolation during follow-up was more common in women as compared to men (for loneliness, risk ratio (rr)=1. 34 is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july 11, 2020. table 4 . . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint disentangling effects of loneliness and social isolation on deficits in healthy aging from the effects of correlated risk factors loneliness and social isolation are not randomly distributed throughout the population. poorer social and economic circumstances and psychological vulnerabilities may put individuals at greater risk for loneliness and social isolation and increase risk for deficits in healthy aging. we therefore repeated our analysis adding covariate adjustment to account for these correlated risk factors. we measured participants' social and economic circumstances from their reports about neighborhood social cohesion and physical disorder, household wealth, and educational attainment. those from poorer social and economic circumstances more often reported loneliness and social isolation (supplemental table 5 ). social and economic circumstances accounted for some but not all of the associations of loneliness and social isolation with deficits in healthy aging. covariate adjustment for social and economic circumstances attenuated associations of loneliness and social isolation with all outcomes by 27-34% and 26-53%, respectively ( figure 3 , green bars). we measured psychological vulnerabilities from baseline reports of the personality trait neuroticism and depressive symptoms. participants with more psychological vulnerabilities at baseline more often reported loneliness and social isolation (supplemental table 5 ). psychological vulnerabilities accounted for some but not all of the associations of loneliness and social isolation with deficits in healthy aging. covariate adjustment for baseline levels of neuroticism attenuated associations of loneliness and social isolation with all outcomes by 16-28% and 2-15%, respectively. covariate adjustment for baseline depressive symptoms attenuated . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint associations of loneliness and social isolation with all outcomes by 54-66% and 28-60%, respectively ( figure 3 , blue and dark blue bars). we measured loneliness and social isolation prior to the assessment of deficits in healthy aging. however, this prospective design does not rule out the possibility that prior disability and disease might cause loneliness and social isolation. to refine our inference, we limited our measurement of loneliness and social isolation to the first two assessments and conducted analysis of incident disability and chronic disease during the interval between the second assessment of loneliness and social isolation and follow-up in 2016. we included all participants from the main analysis, regardless of whether they were free of any disability or disease at baseline. during follow-up of 2-6 years, 13% of participants (n=1,219) reported one or more incident adl disabilities, 13% (n=1,235) reported one or more incident iadl disabilities, and 24% (n=2,266) reported one or more incident chronic diseases (supplemental figure 1 ). comparing intermittent and persistent exposure phenotypes . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint of participants who ever met criteria for loneliness during follow-up between 2006-2014, 32% met criteria at multiple assessment waves. we classified these participants as persistently lonely (6% of the sample) and the remainder as intermittently lonely (12% of the sample). of participants who ever met criteria for social isolation during follow-up, we classified 37% as persistently socially isolated (8% of the sample) and the remainder as intermittently socially isolated (13% of the sample). figure 5 and reported in supplemental table 6 . in contrast to results for loneliness, we did not find evidence that participants who experienced persistent social isolation were at greater risk for any deficits in healthy aging as compared to participants who experienced intermittent social isolation (for mortality, persistentis the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint chronic disease, persistent-isolation irr=1.09, [1.04-1.14] as compared to intermittent-isolation irr=1.12, [1.08-1.16]). effect-sizes are graphed in figure 5 and reported in supplemental table 6 . evaluating biological aging as a potential mechanism linking loneliness and social isolation to deficits in healthy aging biological aging analysis included the subset of 5,874 participants who also participated in the 2016 hrs venous blood study. we measured participants' biological aging using the phenotypic age algorithm (35) (36) (37) . as reported previously (41) , participants' phenotypic ages were highly correlated with their chronological ages (r=0.76). in our analysis sample, participants' phenotypic ages were, on average, 0.50 years (sd=8.54) older than their chronological ages, indicating that participants' aging was similar to the expectation based on the nhanes reference sample in which the phenotypic age algorithm was developed. participants who reported more loneliness exhibited more advanced biological aging (persistent-loneliness d=0.26, 95% ci [0.14-0.39] as compared to intermittent-loneliness d=0.12, [0.04-0.20]). for social isolation, participants with any exposure tended to have more advanced biological aging as compared to those never exposed, but there was no evidence of increased risk due to persistent exposure (persistent-isolation d=0.21, [0.11-0.31] as compared to intermittent-isolation d=0.19, [0.10-0.27]). the relationships between chronological age and phenotypic age and plots of average phenotypic age advancement across strata of exposure persistence are shown in figure 5 . effect-sizes are reported in supplemental table 6 . . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint we conducted sensitivity analyses. first, to test if our findings depended on our measures of loneliness and social isolation, we repeated analysis using alternative codings of the 3-item r-ucla loneliness scale and the 6-item social isolation scale as well as alternative measures of social isolation. we also repeated analysis using a continuous loneliness and social isolation scores. the results from this sensitivity analysis were generally the same as the results from the main analysis. results are reported in supplemental table 4 and supplemental figure 2 . second, because our analysis sample included a large chronological age range, we compared findings in a younger subset of the sample (age 50-64) to the older subset of the sample (age 65-95). results were similar in both groups although effect-sizes tended to be somewhat larger for the younger subset. results are reported in supplemental table 7 . third, the group of participants identified as having intermittent loneliness and social isolation varied in the timing of their exposure relative to outcome assessment. among those who were intermittently lonely or socially isolated, we compared findings for those who were last lonely or socially isolated at their most recent assessment wave and those who were last lonely or socially isolated at earlier assessment waves. results are reported in supplemental table 8 . we tested how older adults' experiences of loneliness and social isolation were related to deficits in healthy aging using longitudinal, repeated measures data from the hrs. we . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint first, loneliness and social isolation are associated with deficits in healthy aging, and these associations are partly but not fully explained by correlated social and economic circumstances and psychological vulnerabilities that make loneliness and social isolation more likely. this result points to the centrality of social and economic circumstances to healthy aging. it also highlights the challenge of disentangling loneliness and social isolation from mental health symptoms that may be both causes and consequences of deficits in social connection. second, analysis of incident disability and chronic disease ruled out reverse causation as an explanation for the associations of loneliness and social isolation with disability but not in the case of chronic disease. third, older adults who experienced persistent symptoms of loneliness suffered more severe deficits in healthy aging as compared to those with intermittent experiences of loneliness. in contrast, we found no evidence for a similar increased risk due to persistence in the case of social isolation. fourth, associations of loneliness and social isolation with deficits in healthy aging were related to an overall process of biological aging. previous studies have linked loneliness and social isolation with dysregulation of the immune system (26), and our findings suggest that the biology of the relationships of loneliness and social isolation with deficits in healthy aging may encompass quantifiable declines across multiple physiological systems. these findings must be interpreted within the context of limitations. the measures of loneliness and social isolation used in our analysis are imprecise and are not parallel in what they capture. there are no current gold standard measures for the constructs we studied. misclassification is possible. we used measurements validated within the hrs and its sisterstudy elsa, the 3-item revised ucla loneliness scale (30) and the 6-item social isolation scale (5, 31, 34) . sensitivity analysis using alternative measures of loneliness and social isolation yielded results similar to those reported in the main analysis (see supplemental methods, . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. third, the observation that associations of loneliness and social isolation with mortality, disability, and morbidity were also reflected in an advanced state of biological aging suggests the possibility that methods to quantify biological aging, such as the phenotypic age algorithm used in this study, may provide sensitive endpoints for intervention trials. in our study, disease incidence over up to six years was unrelated to loneliness or social isolation. thus, timescales for most intervention follow-up may not be sufficient to detect impact on disease risk. because methods to quantify biological aging focus on changes that precede disease onset, they may be more sensitive to near-term biological changes resulting from enhanced social connection. for public health practice, our findings amplify prior work identifying feelings of loneliness as the proximate determinant of deficits in healthy aging. proposed interventions aim to improve health outcomes by reducing the length of exposure to loneliness and social isolation (11) . in our analysis, a less-persistent phenotype was associated with reduced risk only in the case of loneliness. deficits in healthy aging associated with social isolation were similar across levels of persistence, raising the possibility that interventions reducing length of exposure to social isolation without directly impacting loneliness may not improve health outcomes. our overall findings support a relationship of loneliness and social isolation with deficits in healthy aging and provide further motivation for intervention trials. they nevertheless highlight two enduring challenges facing research to understand the public health impacts of loneliness and social isolation and efforts to design effective interventions: first, deficits in . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint healthy aging are more concentrated in those individuals who experience persistent deficits in social connectedness. but these individuals represent a minority of the overall population exposed to loneliness or social isolation at any given point in time. longitudinal phenotyping will be important for advancing understanding of etiology and impact. second, liability to loneliness and social isolation is variable in the population and risk is greater in those with few socioeconomic resources and who struggle with mental health problems. tailoring interventions to meet the needs of these vulnerable populations will be critical. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint acknowledgement funding: this research was supported by the robert n butler columbia aging center, russel sage foundation (grant 1810-08987), and the jacobs foundation. clc is supported by a fellowship from the national institute of mental health (5t32mh013043). author contributions: the study was designed by dwb and clc. clc conducted all analyses with supervision from dwb and support from gh and dk. clc and dwb wrote the paper. all authors contributed critical feedback related to study design and execution and to manuscript preparation and revision. we are grateful to linda p. fried and to the psychiatric epidemiology training program at the columbia university mailman school of public health for feedback on earlier drafts of this manuscript. conflicts of interest: none. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint figure 1 . timeline of assessments of loneliness, social isolation, and deficits in healthy aging. hrs collected loneliness and social isolation data at every other assessment wave with half of the sample first surveyed in wave 8 (2006) and the other half first surveyed in wave 9 (2008). we included participants who completed at least two assessments of loneliness and social isolation. we classified participants who met criteria at one wave of measurement as "intermittent" cases and those who met criteria at two or more waves of measurement as "persistent" cases. the river plots show trajectories of loneliness and social isolation for participants who were measured at three timepoints and met criteria for loneliness or social isolation at least once during follow-up (n=737 for loneliness; n=961 for social isolation). the thickness of each path is indicative of the proportion of participants that followed each trajectory. for mortality, we analyzed data between the last assessment of loneliness and social isolation (wave 11 (2012) or wave 12 (2014)) and wave 13 (2016). hrs collected data on death such that data recorded in wave 13 included deaths through 2018. for analysis of disability and chronic disease, we considered prevalent and incident reports of activities of daily living (adl) or instrumental activities of daily living (iadl) limitations and chronic disease diagnoses. for analysis of prevalent disability and disease, we used the total number of adl or iadl limitations and chronic disease diagnoses in 2016. for analysis of incident disability and disease, we used the number of new cases of adl or iadl limitations and chronic disease diagnoses between participants' second assessment of loneliness and social isolation and 2016. in the incident analysis, exposure classification was based only on the first two assessments of loneliness and social isolation. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint figure 2 . associations of loneliness and social isolation with mortality, disability, and morbidity. panels a and b show results from analysis of loneliness and social isolation, respectively. cell i) plots survival curves for participants who ever reported loneliness or social isolation (red line) and participants who never reported loneliness or social isolation (blue line) estimated from a cox model including covariate adjustment for age, age-squared, sex, age-sex interactions, race/ethnicity, and a dummy variable coding whether participants were assigned to the subsample of the hrs which first measured loneliness and social isolation in 2006 or 2008. shaded areas show 95% confidence intervals. cell ii) plots the percent of participants reporting any activities of daily living (adl) limitations, any instrumental activities of daily living (iadl) limitations, and multimorbidity (i.e. two or more chronic disease diagnoses) among participants who ever reported loneliness or social isolation (red bars) and participants who never reported loneliness or social isolation (blue bars). . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint figure 3 . effect-sizes for associations of loneliness and social isolation with mortality, disability, and chronic disease, with adjustment for socioeconomic circumstances and psychological vulnerability. panels a and b show results from analysis of loneliness and social isolation, respectively, across different covariate adjusted models. the base model included covariate adjustment for age, age-squared, sex, age-sex interactions, race/ethnicity, and a dummy variable coding whether participants were assigned to the subsample of the hrs which first measured loneliness and social isolation in 2006 or 2008. the additional models included these covariates as well as a composite score for social and economic circumstances, a measure of the personality trait neuroticism, and a depressive symptom score. social and economic circumstances were measured from longitudinal data across all waves of loneliness/social isolation assessment. neuroticism was measured at the time of the first loneliness/social isolation assessment. depressive symptoms were measured from 1994-the time of the first loneliness/social isolation assessment. plots show effect-sizes for analysis of mortality (hazard ratios (hr)) and disability and chronic disease (incidence rate ratios (irr)), comparing those who ever reported loneliness or social isolation to those who never reported loneliness or social isolation. error bars represent 95% confidence intervals. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint figure 4 . associations of intermittent and persistent loneliness and social isolation with mortality, disability, and chronic disease. panels a and b show results from analysis of loneliness and social isolation, respectively. cell i) plots kaplan meier survival curves for participants who reported persistent loneliness or social isolation (red line), participants who reported intermittent loneliness or social isolation (orange line), and participants who never reported loneliness or social isolation (blue line). shaded areas show 95% confidence intervals. cell ii) plots effect-sizes for analysis of incident activities of daily living disability (adl), instrumental activities of daily living disability (iadl), and chronic disease (incidence rate ratios (irr)), comparing those who reported persistent loneliness or social isolation to those who never reported loneliness or social isolation (red bars) and those who reported intermittent loneliness or social isolation to those who never reported loneliness or social isolation (orange bars). error bars represent 95% confidence intervals. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint figure 5 . associations of loneliness and social isolation with biological aging, by levels of loneliness and social isolation persistence. panels a and b show results from analysis of loneliness and social isolation, respectively. cell i) shows a scatter plot of chronological age versus phenotypic age for participants who reported persistent loneliness or social isolation (red), participants who reported intermittent loneliness or social isolation (orange), and participants who never reported loneliness or social isolation (blue). cell ii) shows mean phenotypic age advancement (phenotypic age -chronological age) for participants exposed to loneliness and social isolation across the strata of never, intermittent, and persistent loneliness and isolation. phenotypic age advancement values are plotted as z-scores (m=0, sd=1). error bars show 95% confidence intervals. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint we used data from rand corporation and the leave behind questionnaire (lbq) to gather information on other variables of interest. we extracted data on gender, race/ethnicity, household wealth, educational attainment, and depression from the rand hrs longitudinal file includes. we extracted data on neighborhood social cohesion, neighborhood physical disorder, and neuroticism from the lbq. demographic covariates. rand considered gender a binary variable, either male or female. we derived race/ethnicity from one question regarding race and another question regarding hispanic/latino heritage. social and economic circumstances. we measured participants' social and economic circumstances across three domains: neighborhood conditions, household wealth, and education. we measured neighborhood conditions from reports about neighborhood social cohesion and physical disorder (scored using two 4-item scales (1)(44)). the neighborhood social cohesion index is based on the extent to which participants felt people in their neighborhood: 1) make them feel like they do not belong, 2) cannot be trusted, 3) are not friendly, and 4) are not helpful in times of need. the physical disorder index is based on the extent to which participants felt their neighborhood: 1) has a problem with vandalism, 2) is an unsafe place to walk alone after dark, 3) is dirty, and 4) has many vacant buildings. participants responded to each of these eight items using a seven-point scale. we reverse coded responses so that higher scores indicate more social cohesion and less physical disorder. for both measures, we calculated a score for each wave by averaging the responses for those who responded to at least two of the four items. finally, we calculated a z-score based on the average scores for participants from 2006 to 2014. we measured household wealth from dollar values computed by rand corporation based on structured interviews with participants about their assets. following the method we used previously (2) , values were inflated to constant dollars, inverse-hyperbolic-sign transformed to reduce skew, standardized by age and sex, and averaged across measurement waves, resulting in a single wealth value for each participant. we measured education as the highest level of educational attainment (coded 1-3 for less than high school, completed high school, and completed college or more). we calculated a composite score for socioeconomic circumstances as the sum of z-scores across neighborhood, wealth, and education domains. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint psychological vulnerabilities. we measured participants' psychological vulnerabilities in two ways. first, we measured the personality trait neuroticism. neuroticism was assessed with a 4item scale (3) at the time of the participant's first assessment of loneliness and social isolation. participants reported the extent to which they would use the following words to describe themselves: 1) moody, 2) worrying, 3) nervous, and 4) calm. we reverse coded all items except "calm" so higher scores indicate higher levels of neuroticism. second, we measured depressive symptoms. the hrs measured participants' depressive symptoms using the 8-item center for epidemiologic studies depression scale (ces-d, (4, 5) ) at all waves from 1994 on. however, given that one of the independent variables in this study is loneliness, we removed one item on loneliness and the depression score was based on how frequently in the past week the respondent felt: 1) depressed, 2) everything was an effort, 3) sleep was restless, 4) happy, 5) life was enjoyable, 6) sad, 7) unable to get going. we coded responses so higher scores indicate more severe depressive symptoms. others have followed this method to avoid item overlap and have found minimal decreases in internal consistency of the scale (6) (7) (8) . to measure long-term risk for depression, we averaged scores from all waves until the participant's first assessment of loneliness and social isolation. in our main analysis, we classified participants as lonely if their scale scores exceeded the 80 th percentile of the cohort distribution (scores ≥7 and ≥3 for loneliness and social isolation, respectively), following the procedure of steptoe et al. (9) . we conducted sensitivity analysis to test if our findings depended on our measures of loneliness and social isolation. loneliness. for loneliness, we repeated our analysis with two less restrictive classifications of the 3-item revised ucla (r-ucla) loneliness scale. first, we used a cut-point published for the english longitudinal study of aging (elsa), classifying participants as lonely if they had scores ≥6 (9) . second, we used a cut-point published for the hrs, classifying participants as lonely if they responded "some of the time" to any of three items asking about how frequently participants felt they were lacking companionship, left out, and isolated from others (10) . in addition to these alternative classifications, we also analyzed the 3-item ucla loneliness scale scores as a continuous measure. we calculated averages for each participant's loneliness score from 2006-2014 and then computed z-scores based on these averages. social isolation. for social isolation, we repeated our analysis with a less restrictive classification of the 6-item social isolation scale and two alternative measures. first, we used the 6-item social isolation scale with a cut-point published for the elsa (scores ≥2) (9) . second, we used a 10-item social isolation scale originally developed for the national social life, health, and aging project (nshap) (11) . after being adapted to the hrs, it included 10 items: items 1-3 counted the number of children (coded 0-5+), other family members (coded 0-10+), and friends (coded 0-10+). items 4-6 counted the frequency of contact with each of these relationships (coded 1-6 for the responses: 1) never/<1 time per year, 2) 1/2 times per year, 3) every few months, 4) 1/2 times per month, 5) 1/2 times per week, and 6) 3+ times per week). . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint item 7 counted church attendance (coded 1-5 for the responses: 1) never, 2) 1+ times per year, 3) 2/3 times per month, 4) 1 time per week, and 5) 1+ times per week). item 8 counted other organization/group attendance (coded 1-6 for the responses: 1) never, 2) <1 time per month, 3) about 1 time per month, 4) several times per month, 5) 1 time per week, and 6) 1+ times per week). item 9 indicated whether or not a participant volunteered in the past year (coded 0 or 1). item 10 counted the number of people living with the participant (coded 0-5+) (8) . for each item, we computed z-scores based on the distribution of values in the baseline interview (2006 or 2008 depending on which wave participants were administered their first psychosocial questionnaire). we then averaged z-scores across items to compute the 10-item social isolation scale for those who responded to at least 5 of the 10 items. participants who scored 1 sd above the mean or higher were classified as socially isolated. third, we used a 4-item scale developed for the national health and aging trends study (nhats) (12) , which we adapted to the hrs. after being adapted to the hrs, participants received one point for each of the following: 1) not living alone; 2) being able to open up "a lot" to their spouse, children, other family members, or friends; 3) attending religious services 2 or 3 times a month; and 4) participating in community organizations at least once a month. we created a sum score for those who responded to at least 2 of the items. following the methods used by cudjoe et al. (12) , we classified participants as socially isolated if their scale scores were ≤1. in addition to these alternative classifications, we also analyzed the 6-item social isolation scale scores as a continuous measure. we calculated averages for each participant's social isolation score from 2006-2014 and then computed zscores based on these averages. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint supplemental tables supplemental table 1 . sample characteristics. the table shows summary statistics for age at baseline, sex, and ethnicity for participants who were included in the analysis sample versus all participants who were potentially eligible for inclusion in the analysis sample. participants were potentially eligible for inclusion in the analysis sample if they ever received a leave behind questionnaire. the analysis sample was restricted to those who had repeated-measures data (i.e. two or more measures) on loneliness or social isolation and were aged 50-95 when they completed their first psychosocial questionnaire. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint supplemental table 3 . co-occurrence of loneliness and social isolation. the table shows a cross-tabulation of ever vs. never meeting criteria for loneliness and ever vs. never meeting criteria for social isolation. ever lonely never socially isolated 7,061 1,182 ever socially isolated 1,434 674 . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint supplemental figure 1 . analysis of incident disability and morbidity. panel a shows the percent of the analysis sample that reported at least one new adl limitation, iadl limitation, and chronic disease diagnosis between the second assessment wave and 2016. panel b shows effect-sizes for analysis of disability and chronic disease (incidence rate ratios (irr)) from negative binomial regression models including covariate adjustment for age, age-squared, sex, age-sex interactions, race/ethnicity, and a dummy variable coding whether participants were assigned to the subsample of the hrs which first measured loneliness and social isolation in 2006 or 2008. effect-sizes compare those who ever reported loneliness or social isolation to those who never reported loneliness or social isolation. red bars represent effect-sizes for loneliness, and brown bars represent effect-sizes for social isolation. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint supplemental table 4 . effect-sizes for associations of loneliness and social isolation with mortality, disability, and chronic disease morbidity. panels a and b report analysis of loneliness and social isolation, respectively. the panels report effect-sizes for the measures of loneliness and social isolation reported in the main text (far left column) along with two alternative codings of loneliness, one alternative coding of social isolation, and two alternative measures of social isolation proposed in previous studies. we classified participants as lonely if they (1) scored ≥7 on the 3-item r-ucla (31), (2) scored ≥6 on the r-ucla (31), and (3) responded "some of the time" to any of the 3-item r-ucla (2) . we classified participants as socially isolated if they (1) scored ≥3 on the 6-item scale (31), (2) scored ≥2 on the 6-item scale (31), (3) scored 1 standard deviation above the mean on the 10-item scale (45), and (4) scored ≤1 on the 4-item scale (1). effect-sizes and 95% confidence intervals are reported across measures. for mortality, effect-sizes are reported as hazard ratios (hr). for prevalent and incident activities of daily living (adl) disability, instrumental activities of daily living (iadl) disability, and chronic disease, effect-sizes are reported as incidence rate ratios (irr). analysis of incident disability and disease included 1,219 participants with at least one new case of adl disability, 1,235 participants with at least one new case of iadl disability, and 2,266 participants with at least one new chronic disease diagnosis. all models included covariate adjustment for age, age-squared, sex, age-sex interactions, race/ethnicity, and a dummy variable coding whether participants were assigned to the subsample of the hrs which first measured loneliness and social isolation in 2006 or 2008. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint supplemental figure 2 . association of continuous loneliness and social isolation scores with deficits in healthy aging. panels a and b show the relationship between z-scores (m=0, sd=1) of loneliness and social isolation, respectively, with prevalent disability and disease in 2016. we calculated z-scores based on the average of participants' loneliness and social isolation scores from 2006-2014. in each plot, z-scores are plotted against the number of predicted activities of daily living limitations (adls), instrumental activities of daily living limitations (iadls), and chronic disease diagnoses from negative binomial regression models. the base model included covariate adjustment for age, age-squared, sex, age-sex interactions, race/ethnicity, and a dummy variable coding whether participants were assigned to the subsample of the hrs which first measured loneliness and social isolation in 2006 or 2008 (red line). additional models added covariates for socioeconomic circumstances (green line), neuroticism (blue line), and depressive symptoms (dark blue line). shaded areas represent 95% confidence intervals. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint supplemental table 5 . effect-sizes for associations of social and circumstances and psychological vulnerabilities with the number of waves at which participants were classified as lonely or socially isolated. the table reports effect-sizes as incidence rate ratios estimated from negative binomial regressions for associations with the number of waves at which participants were classified as lonely or socially isolated. all models included covariate adjustment for age, age-squared, sex, age-sex interactions, race/ethnicity, and a dummy variable coding whether participants were assigned to the subsample of the hrs which first measured loneliness and social isolation in 2006 or 2008. for neighborhood social cohesion, neighborhood physical disorder, and household wealth, higher scores indicate better social and economic circumstances. for neuroticism and depressive symptoms, higher scores indicate more psychological vulnerabilities. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint supplemental table 6 . effect-sizes for associations of loneliness and social isolation (persistent vs. intermittent vs. never) with deficits in healthy aging. the table reports effectsizes for associations of intermittent or persistent loneliness or social isolation compared to never loneliness or social isolation with deficits in healthy aging. for associations with mortality, effectsizes are reported as hazard ratios (hr) estimated from cox proportional hazards models. for prevalent activities of daily living (adl) disability, instrumental activities of daily living (iadl) disability, and chronic disease, effect-sizes are reported as incidence rate ratios (irr) estimated from negative binomial regression models. for phenotypic age advancement, effectsizes are reported as standardized regression coefficients estimated from linear regression models, interpretable as cohen's d (d). all models included covariate adjustment for age, age-squared, sex, age-sex interactions, race/ethnicity, and a dummy variable coding whether participants were assigned to the subsample of the hrs which first measured loneliness and social isolation in 2006 or 2008. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint supplemental table 7 . association of loneliness and social isolation (ever vs. never) with deficits in healthy aging, stratified by age (50-64 years vs. 65-95 years). panels a and b reports effect-sizes for associations of ever being lonely or socially isolated, respectively, compared to never being lonely or socially isolated with deficits in healthy aging. results are stratified by age to compare effect-sizes for those who are 50-64 years old and those who are 65-95 years old. for associations with mortality, effect-sizes are reported as hazard ratios (hr) estimated from cox proportional hazards models. for prevalent activities of daily living (adl) disability, instrumental activities of daily living (iadl) disability, and chronic disease, effect-sizes are reported as incidence rate ratios (irr) estimated from negative binomial regression models. all models included covariate adjustment for age, age-squared, sex, age-sex interactions, race/ethnicity, and a dummy variable coding whether participants were assigned to the subsample of the hrs which first measured loneliness and social isolation in 2006 or 2008. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint supplemental table 8 . association of loneliness and social isolation (intermittent vs. never) with deficits in healthy aging, comparing those who were last lonely or socially isolated at their most recent assessment wave and those who were last lonely or socially isolated at previous assessment waves. the table reports effect-sizes for associations of being intermittently lonely or socially isolated compared to never being lonely or socially isolated with deficits in healthy aging. for associations with mortality, effect-sizes are reported as hazard ratios (hr) estimated from cox proportional hazards models. for prevalent activities of daily living (adl) disability, instrumental activities of daily living (iadl) disability, and chronic disease, effect-sizes are reported as incidence rate ratios (irr) estimated from negative binomial regression models. for all outcomes, effect-sizes are reported separately for those who were last lonely or socially isolated at their most recent assessment wave and those who were last lonely or socially isolated at previous assessment waves. for mortality and prevalent disability and disease, this comparison was between those last lonely or socially isolated in 2012-2014 vs. 2006-2010. for incident disability and disease, this comparison was between those last lonely at their second exposure assessment vs. first exposure assessment. all models included covariate adjustment for age, age-squared, sex, age-sex interactions, race/ethnicity, and a dummy variable coding whether participants were assigned to the subsample of the hrs which first measured loneliness and social isolation in 2006 or 2008. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july 11, 2020. . https://doi.org/10.1101/2020.07.10.20147488 doi: medrxiv preprint the epidemiology of social isolation: national health and aging trends study loneliness and health in older adults: a mini-review and synthesis loneliness, health, and mortality in old age: a national longitudinal study a systematic review of loneliness and common chronic physical conditions in adults loneliness, social isolation, and behavioral and biological health indicators in older adults social isolation and loneliness in older adults-a mental health/public health challenge a unified approach to loneliness. the lancet psychological distress and loneliness reported by us adults together: the healing power of human connection in a sometimes lonely world. harpercollins social isolation and loneliness in older adults: opportunities for the health care system interventions to reduce social isolation and 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the national health and nutrition examination study association of blood chemistry quantifications of biological aging with disability and mortality in older adults statacorp. stata statistical software: release 15. statacorp llc associations of genetics, behaviors, and life course circumstances with a novel aging and healthspan measure: evidence from the health and retirement study supplemental references neighborhoodlevel cohesion and disorder: measurement and validation in two older adult urban populations genetic analysis of social-class mobility in five longitudinal studies the midlife development inventory (midi) personality scales: scale construction and scoring validation of the eight-item center for epidemiologic studies depression scale (ces-d) among older adults a revised ces-d measure of depressive symptoms and a dsmbased measure of major depressive episodes in the elderly loneliness, social isolation, and behavioral and biological health indicators in older adults loneliness as a specific risk factor for depressive symptoms: cross-sectional and longitudinal analyses social isolation, loneliness and health among older adults social isolation, loneliness, and all-cause mortality in older men and women loneliness and health in older adults: a mini-review and synthesis measuring social isolation among older adults using multiple indicators from the nshap study the epidemiology of social isolation: national health and aging trends study key: cord-025278-6ttdtjvn authors: rao, pritika title: behavioral economics in the time of coronavirus: rebellion or “willful ignorance” in the face of “grand challenges” date: 2020-05-27 journal: rev evol polit econ doi: 10.1007/s43253-020-00015-2 sha: doc_id: 25278 cord_uid: 6ttdtjvn this article considers the curious case of human behavior in the context of the coronavirus pandemic. we have observed that individuals, societies, and nations are exhibiting various irrationalities that are worth studying more closely. applying the insights and research of reputed behavioral economists to these unprecedented circumstances, we explore possible explanations for individual and collective actions that appear, in many cases, to be highly counterintuitive. in the face of large-scale global issues, that lazaric (2020) refers to as “grand challenges,” fraught with uncertainties and informational asymmetries, we delve deeper into the complexities of the factors that influence decision-making at various levels as we try to make sense of behavior. we wonder if reasons include the outright rejection of facts or perhaps the unwillingness to even receive information that has the potential adversely affect one’s welfare or self-interests—a tendency that grossman and van der weele (2017) term “willful ignorance.” we conclude with a few lessons and recommendations that can help understand and motivate behavior. why is it that the very same people who longed for days when they could be paid to do nothing but netflix the day away do not seem to want to do so? why is it that it is so much harder to convince individuals to comply with rules that are intended to protect them? why are we determined to see things the way we want to, despite very grim facts and statistics staring us in the face? in light of the coronavirus, we consider the behavior of individuals and arrive at some interesting conclusions. there is the obvious discounting, a term economists and psychologists are very familiar with-the tendency to trade off present benefits for future ones. it seems that for some, the present value of exercising the freedom to walk free in the streets, visit a local supermarket or attend a party is much higher than the future benefit of protection from a contagious disease. some persons discount future payoffs because the uncertainty of a future is much higher, particularly those who are naïve, or those who are much older and have lived through other epidemics such as the swine flu, ebola, hiv, and sars, and therefore see no reason for this virus to disrupt their lives. others may even believe that contracting the disease is inevitable and in fact better for herd immunity (a stance initially adopted by the uk government), creating little incentive for them to stay indoors and isolate. there are also those who believe very strongly in conspiracy theories. there are numerous articles, messages, and videos that have been circulating that endorse these diverse opinions, generating informational inconsistencies. but behavioral economics suggests that access to the right information may not be the only factor that influences socially responsible behavior. grossman and van der weele (2017) cite an important behavioral trait that they term "willful ignorance," or the act of "avoiding information about adverse welfare consequences of self-interested decisions"(p.1). their study focuses on self-image and indulgent behavior even at the cost of social harm. most often cited in research pertaining to climate change; this attribute also explains why many believe that environmental harm is not man-made, and in fact barely even real. what's more, people are reluctant to receive information on the topic (stoll-kleemann et al. 2001; norgaard 2006) , even if it is free to do so. numerous researchers, economists, and psychologists have found that this ignorance acts as a safeguard against the person's reputation, protecting their self-image (e.g., dana et al. 2007; benabou and tirole 2006; bem 1972; baumeister 1998; fiske 2013) . norgaard (2006) has stated in her research that this "fear of being a bad person" is a motivation for individuals to avoid learning and engaging with the facts on climate change. this may explain the behavior of persons who are wandering outdoors despite recommendations, guidelines, and laws that prohibit this type of activity in such dangerous times. this is not a criticism of those workers who are risking their lives to perform essential services or blue-collar workers who have no choice but to report to work during this time. this piece concerns those who (counter-intuitively) gather in groups in the midst of a nationwide lockdown (to clap loudly and clang pans to thank health workers), or those who confidently venture out of their homes, citing cynicism, misplaced optimism, and displaying outright rebellion. those who are bombarded with information at workspaces, on social media and in peer groups, cannot claim "ignorance," and are therefore more likely to practice social distancing and self-isolation since they do not want the negative perception it may attract. social proof theory also suggests that individuals are hugely influenced by their perception of what others around them are doing. those who are retired or those who work in more laissez-faire settings have limited access to this level and volume of information (usually traditional media such as the television or newspapers) that they can comfortably claim to have never seen. this may also explain why in the past few months with the furor surrounding the passing of the contentious https://en.wikipedia.org/wiki/citizenship_(amendment)_act,_2019 that sought to amend the definition of an illegal immigrant, and grant fast-track citizenship to minority groups who have fled from persecution in muslim-majority nations. coupled with the implementation of the https://en.wikipedia.org/wiki/national_register_of_citizens, young members of intergenerational families found it extremely hard to debate with older generations and express their views on their perceived discrimination and the resultant communal violence and angst that this sparked across the nation. of course, there is also a whole lot of confirmation bias in there but there is also what dan galai and orly sade call the ostrich effect (2006), which they define as the tendency to "avoid apparently risky financial situations by pretending they do not exist" (pp. 2743, 2744) . in situations like the present, when the risk of community transmission is high, seeing people congregate in groups right in the middle of a government imposed janata curfew (enforced across india in an effort to encourage social distancing and prevent exactly this type of behavior) is absolutely illogical. while this seems a lot like a blatant rejection of facts and an act of rebellion, it might actually point to something much deeper. individuals do not act in isolation-they consider the context of their larger environment and assess their response in light of external circumstances. lazaric (2020), in a chapter titled "cognition and routines dynamics in times of grand challenges," argues that agency is the real game-changer in the face of global problems such as climate change or widespread technological or societal transformation that she refers to "grand challenges." agency is key to the tackling of big problems and driving new patterns or courses of action that influence routines. she references the work of margaret archer who highlights the notion of "self-talk" or internal dialogue that individuals engage in while designing actions, thereby suggesting differences in mental operation across individual personality types (2003). archer defines these groups of agents-"communicative reflexive" or those who are distrustful of their internal dialogue and are mostly socially immobile, "autonomous reflexives" who rely on judgment and past contextual experience: "meta reflexive" similar to the previous group but with strong ideals that govern their thinking, making them critical of structures, constraints, and situations that are inconsistent with these lofty visions. a consideration of individual thought processes certainly influence behavior in the event of "grand challenges." these "ill-structured problems" are difficult to reconcile since there are numerous unknowns with undefined goals, multiple solutions, and paths or none at all without consensual agreement on the appropriate solution (jonassen 1997) . in the absence of well-defined general rules, heuristics and the uncertainty, learners devise solutions based on personal opinions or beliefs by evaluating, dismantling, and rebuilding existing practices. these existing patterns in an organization and by extension, society is sometimes so widespread that creating new routines and patterns become much harder. amid these constraints, the interactions between different learners help frame new solutions and practices for the collective. as lazaric (2020) states, "archer's work on diverse types of self-talk at the individual level may help to rethink the ostensive and performative co-constitution of routines." the anchoring principle also seems to explain why the current pandemic is not being taken as seriously as it should. the first piece of information that emerged was a rather optimistic half-truth "coronavirus is nothing more than a really bad flu" or some version of this statement. as a result, most reject anything that suggests that it is more severe than that-dismissing it as panic, paranoia, or speculation. deliberate action during the early onset of the spread of the virus in the form of stern factual statements by experts and governments would have been extremely beneficial. although it is much easier to sit at home and avoid a painful commute, research shows that people rarely like to disturb the status quo. banks and other marketing agencies have cleverly factored this into their communication in the form of default options, knowing that our innate humanness will cause us to fall back into familiar patterns, no matter how detrimental they may be to us and those around us (think, addictive behaviors). "fast thinking" as opposed to kahneman's slow thinking, relies on automatic processing and mental shortcuts while in this situation, a more deliberate, analytical thinking is required. what can actually get people to stay at home and practice self-isolation and/or social distancing? in retrospect, what would have helped immensely was rapid response. if officials were quick to recognize the scale of disruption this could cause (learning from china's attempt to tackle the matter privately internally leading to an unchecked proliferation of cases), and communicated the severity top-level down, the anchoring principle would have kicked into effect, and a cascading of errors could have been prevented at the group/society level. challenging currently held beliefs within intergenerational families by presenting facts through videos for instance may work, albeit only to a limited degree. disseminating responsibilities at a local level, on the other hand, tends to work very well. giving residential layouts, apartments, office complexes, districts, etc., the ability to enforce stringent measures has worked because it places individual behavior under the lens of someone in authority, where an individual's need to protect self-image will come into play. simple, direct communication such as the rate of transmission (1 person can infect 2-3 persons who in turn can go on to infect 2-3 persons each) is highly effective since it puts the focus on individual action and counters misplaced overconfidence. achieving a fine balance between providing just enough information and enforcing the law to prevent social interaction, while simultaneously exercising precaution and care not to induce panic is a delicate, yet important consideration in the present time. grossman and van der weele (2017) make an important distinction in terms of a signaling model where preferences are studied against material payoffs with either an intrinsic concern for social welfare or a preference for a self-image as pro-social actor. these preference-signaling models suggest two interpretations: 1. a social-signaling interpretation with an external observer. 2. a self-signaling interpretation with an internal observer (this is a dual self-signaling model introduced by prelec and bodner (2003) , and widely adopted thereafter, wherein the decision-maker and observer are two aspects of a divided self, where for instance, the decision-maker is an informed actor who is aware of preferences and the observer may be a future self who lacks introspective knowledge or awareness of past motivations (grossman and van der weele 2017). as explained above, groups of persons with access to information tend to largely fall in either one of the categories above-where they are subject to either an external observer's judgment (through the wider network of social media or highly engaged peer groups) or at the very least have a highly elevated social self that values collective welfare. in the absence of an external observer and with the observer in the self-signaling interpretation, we find ourselves in the baffling social situation that we are in now, with willfully ignorant persons "looking the other way" and creating an environment for collective social catastrophe. policy that focuses only on disseminating information may not be optimal. instead, enforcing accountability with an added emphasis on self-image can be used to benefit the common good. diminishing the possibility of ignorance (willful or otherwise) will require targeted measures in the form of outright questioning or challenging of beliefs or establishing an external agent that uses the self-image aspect of behavior to their advantage. as stated previously, decisions are not made in isolation. this is the subject of research of many behavioral economists who have stated that in every type of organization, there are relationships or behavior that lie between custom and tradition (formal or informal rules). routines are defined as patterns of behavior that are motivated by a set of rules that comprise of past capabilities, memories, information, knowledge, and habits (becker et al. 2005) . routines involve both cognitive and political dynamics that inform collective learning, just as habits also take knowledge, social, and institutional structure considerations into account (lazaric 2000) . routines are adopted by individuals, but in the context of larger society. lazaric and denis (2001) have found that changing existing practices may lead individuals to adopt a defensive posture that extends beyond their cognitive level. a political level of motivation arises that may lead to conflict, despite an obvious opportunity for better learning and elevated social status. people flocked to beaches around the world in recent weeks from the usa to australia, declaring rather proudly that corona wasn't going to stop them from going about their lives. it seems that years of societal conditioning whether in the form of mantras such as "this too shall pass," "business as usual," or "not giving in to fear" have created large institutional biases. a review in the lancet 1 reported numerous negative effects of the quarantine ranging from confusion and anger to post-traumatic stress. it appears that democracies such as america, italy, and india are struggling in particular (compared to say, china) because they are accustomed to a certain level of freedom and agency that is suddenly revoked in a crisis of this kind. situations of uncertainty and unpredictability, no doubt, affect organizations and their ability to learn. furthermore, groups, teams, or "communities of practice" play a vital role in the creation of knowledge (cohendet and llerena 2003; lazaric and raybaut 2004) . within these communities, the presence of heterogeneity in the form of multiple aims and goals among members can hinder the ability to quickly resolve issues (march and simon 1958) . contradictory messaging from world leaders have left people confused, causing them to revert to long-held beliefs. in the case of the virus, the uk adopted a relatively more ad hoc approach and severely delayed testing and provision of care, as boris johnson with his classic british "carry on" rhetoric, was reluctant to enforce stringent containment measures. simon (1991) believes that the existence of some members who possess loyalty or an open mind give rise to a selection mechanism that may help convergence towards the larger organization's goal. in the healthcare industry, the innovation for cancer care in africa 2 project has noted that a unified goal on healthcare is critical to ensuring better outcomes. policy recommendations that read like a wish list are rarely implemented effectively because they are too vague. within markets too, great variety and heterogeneity is not necessarily a success. despite an increased amount of products, diagnostic firms, information, and healthcare providers, numerous cases of cancer are still reported in countries such as india and africa, because there exist issues some of which are societal stigma, habits, and beliefs that hinder a patients' ability to access quality, timely care. it is evident from the literature that merely an overload of information does not motivate individual behavior, routine, or collective change in the event of a "grand challenge." there are important considerations to be made regarding individual decision-making, routines, and signaling issues that are largely ignored when countries and organizations attempt to motivate behavior. conflicts of interest the author declares that there is no conflict of interest. the impact of virtual simulation tools on problem-solving and new product development organization self-perception theory incentives and prosocial behavior routines and incentives: the role of communities in the firm exploiting moral wiggle room: experiments demonstrating an illusory preference for fairness the 'ostrich effect' and the relationship between the liquidity and the yields of financial assets self-image and willful ignorance in social decisions instructional design models for well-structured and iii-structured problem-solving learning outcomes the role of routines, rules and habits in collective learning: some epistemological and ontological considerations forthcoming) cognition and routines dynamics in times of grand challenges how and why routines change: some lessons from the articulation of knowledge with iso 9002 implementation in the food industry knowledge creation facing hierarchy: the dynamics of groups inside the firm people to protect themselves a little bit: emotions, denial, and social movement nonparticipation time and decision: economic and psychological perspectives on intertemporal choice theories of bounded rationality the psychology of denial concerning climate mitigation measures: evidence from swiss focus groups key: cord-254779-cad6pb3n authors: asakura, kenta; gheorghe, ruxandra m.; borgen, stephanie; sewell, karen; macdonald, heather title: using simulation as an investigative methodology in researching competencies of clinical social work practice: a scoping review date: 2020-09-24 journal: clin soc work j doi: 10.1007/s10615-020-00772-x sha: doc_id: 254779 cord_uid: cad6pb3n this article reports a scoping review designed to synthesize current literature that used simulation as an investigative methodology (simulation-based research; sbr) in researching practice competencies in clinical social work. following arksey and o’malley’s scoping review framework, 24 articles were included in this scoping review. the majority of articles reported sbr studies conducted in canada and the u.s. and were published in the last 10 years, signifying that this is a burgeoning area of research in clinical social work. areas of clinical competencies included professional decision-making (33%), the role of cognition and emotion (21%), attending to culture and diversity (21%), and others, such as supervision skills (8%). using qualitative (46%), quantitative (42%), and mixed methods (13%) in research design, more than half of the sbr studies reported in the selected articles used live actors (54%) to simulate a realistic practice situation for research. selected articles also offered both benefits and limitations of sbr in social work. we offer suggestions for when to use sbr for research on clinical social work practice and strengthening a collaboration between clinicians and researchers in advancing practice-informed research. while the use of simulation was originally introduced in medical education (cleland et al. 2009 ), it is gaining much attention in clinical social work education rawlings 2012) , with the potential to enhance the knowledge, skill, judgement, and self-awareness of practicing clinical social workers. simulation in social work generally refers to a situation where a student or a practitioner engages with a trained actor (i.e., often known as "standardized patient," sp) or a virtual reality program that portrays a well-designed character and/or practice scenario. a growing body of research evidence suggests that simulation offers concrete experiential learning opportunties well-suited to assist students in applying knowledge, values and skills into practice kourgiantakis et al. 2019) , making simulation a widely recognized key word in clinical social work education. while simulation has been used in the training and assessment of clinical practitioners, it is also emerging as a novel methodology for research on practice competencies. understanding how simulation is used in this capacity can support practicing social workers in evaluating simulation-based research contributions and translating generated knowledge to their practice. there is a burgeoning body of literature suggesting that simulation can be used as a promising research methodology for the studies about practice competencies in medicine and other healthcare fields (e.g., cheng et al. 2014; halamek 2013) . while these reports and guidelines on simulation-asmethodology from medicine and other fields offer important research innovations, they might not be directly applicable when studying social work. to date, there is no report that discusses how simulation can be used as a research methodology in social work. the purpose of this scoping review was to systematically search and summarize the current state of social work literature, in which simulation (e.g., trained actors as standardized clients, virtual reality, staged environments) was used as an investigative methodology in researching practice competencies. as articulated by the council on social work education (2015), competencies of social work practice require one's ability to integrate "knowledge, values, skills, and cognitive and affective processes that include … critical thinking, affective reactions, and exercise of judgment" (p. 6) in attending to each unique client and practice situation. in this review, we will focus on competencies related to clinical practice, which "address(es) the needs of individuals, families, couples and groups affected by life changes and challenges" (national association of social workers 2005, p. 8). given that supervision is included in the nasw's standards of clinical social work practice, we also consider supervision skills as a part of clinical social work competencies. cheng et al. (2014) defined and categorized simulationbased research (sbr), a program of research that involves the use of live sps or any other kinds of simulated practice situations (e.g., computerized mannequin, virtual reality), into two types: (1) research that evaluates simulation-based teaching and learning, and (2) research that uses simulation as a methodological tool. much is already well known about the use of simulation in the teaching and learning of social work (e.g., bogo et al. 2014; kourgiantakis et al. 2019) . in this article, we focused on the latter type of sbr: the use of simulation as a novel research methodology. there is a growing body of research in medicine and other related fields, in which simulation is used as an investigative methodology in studying practice competencies. for instance, geurtzen et al. (2014) examined the cultural differences in prenatal counseling by examining how american and dutch neonatologists worked with a simulated patient. zhou et al. (2013) used data from the objective structured clinical examinations (osce), a type of experiential exam commonly used in professional schools where students' competency is assessed based on their engagement with sps. others hired and trained sps to portray a covert or mystery patient to examine the delivery of tb screening in clinics (christian et al. 2018) , service access and wait time in the public youth mental health system (olin et al. 2016) , and the quality of pharmacist practice (ibrahim et al. 2018) . a few clinical researchers have published review papers or guidelines on the use of simulation as a research methodology, including family medicine (beullens et al. 1997) , pediatrics (cheng et al. 2014) , neonatal medicine (halamek 2013) , pharmacy (watson et al. 2006 ) and public health (chandra-mouli et al. 2018) . these methodological reports on the use of simulation are written for specific research foci, such as patient safety (guise et al. 2017) , quality of healthcare (fitzpatrick and tumlinson 2017) and provider behaviors and communications (madden et al. 1997; siminoff et al. 2011) . in general, these methodological reports suggest simulation as a promising methodology for studying practice competencies. because much of what happens in medical care between physicians and real patients is highly unpredictable, standardization of patient presentations and highly controlled clinical environments allows the researchers to assess healthcare delivery and practitioners' skills objectively especially when the authenticity of the simulation is ensured (e.g., cheng et al. 2014; halamek 2013) . the use of simulated patients also makes research recruitment easier than when recruiting real patients (e.g., cheng et al. 2014) . it is also suggested that sbr is resource intensive (e.g., researchers' time, money, availabilities of technology) and can limit the number of research participants (guise et al. 2017) . others also emphasize the time, labor, and cost intensive nature of sbr (e.g., beullens et al. 1997; guise et al. 2017) . when relying on a simulated situation, research is often limited to one meeting between the physician and the patient, making it difficult for researchers to make longitudinal observation or keep track of changes over time (beullens et al. 1997) . finally, these reviews warn that the novelty of this research methodology means that much remains unknown about the best practices in the areas of data collection (e.g., video capture, technological requirements and limitations), the use of appropriate outcome measures, and data analysis (e.g., how to analyze the video) (e.g., cheng et al. 2014; guise et al. 2017; siminoff et al. 2011 ). there is surprisingly little sbr in psychology (e.g., clinical, counseling psychology) and psychiatry. this is likely because psychologists and psychiatrists often engage in clinical research, in which researchers examine actual therapy sessions, either through direct observation of audio-or video-recorded sessions or self-reports from therapists or clients (orlinsky et al. 2015) . psychotherapy process research (ppr) is a highly developed paradigm of clinical research, in which researchers examine what happens and how change happens in psychotherapy between the client and the therapist, with a focus on client outcomes (hardy and llewelyn 2015; knobloch-fedders et al. 2015) . although it is beyond the scope of this paper to discuss the large body of ppr, its primary focus is on what happens between the therapist and the client (hardy and llewelyn 2015) . studying actual therapy sessions, those engaged in ppr explicate the mechanisms of treatment and client change processes, understand key elements of effective treatment, develop theories and models of psychotherapy practice, and use research results to develop effective psychotherapy training (hardy and llewelyn 2015) . although a number of ppr studies might include social workers in their study samples along with other professionals, ppr appears to be a research paradigm primarily employed by psychologists and psychiatrists. with a few exceptions, such as studies on cross-cultural engagement (tsang et al. 2011; horvath 2013, 2014) , racial microaggression (lee et al. 2018 ) and whiteness (lee and bhuyan 2013) , social work researchers seem to rarely engage in ppr. this is likely due to reasons such as broad scopes of social work practice (i.e., services beyond outpatient therapy), and ethical concerns around the vulnerabilities of social work clients. simulation is well-suited to addresses these realities, and as such is beginning to emerge in social work as a research methodology for the direct observation and analysis of clinical practice. while research on clinical social work practice has historically relied on retrospective data from clinicians and clients (wilkins and jones 2018*) through surveys, interviews, and focus groups, sbr might provide a promising research methodology for advancing knowledge and research on social work practice. the purpose of this scoping review was to map out the current state of literature in which simulation was used as an investigative methodology in studying practice competencies of clinical social work. while methodological reports have been published in other healthcare fields (e.g., beullens et al. 1997; cheng et al. 2014) , there is no similar methodological report focused on social work. knowledge synthesis of existing relevant literature can lead to the advancement of this burgeoning area of research and assist clinical social workers in understanding how sbr aligns with practice and can contribute to their work. scoping review is a methodology particularly suitable for the current study as we seek to explicate the key concepts of sbr as a new area of research and documenting its emerging evidence (munn et al. 2018) . research questions guiding this scoping review were: (1) what are the characteristics of studies of clinical social work competencies that used simulation as a research methodology?; (2) how is simulation-based data used in the studies of practice competencies?; and (3) what benefits and limitations are there in the use of simulation as a research methodology in studying clinical social work practice competencies? scoping review is a knowledge synthesis methodology through which researchers "comprehensively summarize and synthesize evidence with the aim of informing practice, programs and policy and providing direction to future research priorities" (colquhoun et al. 2014 (colquhoun et al. , p. 1291 . we conducted this scoping review to synthesize the existing knowledge on the use of simulation-based data for research on practice competencies in order to guide future sbr and guide practice. we closely followed arksey and o'malley's framework (2005) , which consists of the following five stages enhanced by levac et al. (2010) : (1) identifying research questions, (2) identifying relevant studies, (3) selecting studies based on inclusion and exclusion criteria, (4) charting data, and (5) collating, summarizing and reporting the results. in enhancing the study rigor, we also followed the prisma extension for scoping reviews (prisma-scr) guidelines (tricco et al. 2018 ). and journal of teaching in social work. this 10-year timeframe was set for the hand search because simulation is a relatively new method and was not common in social work prior to 2010. finally, we also checked the reference lists of the relevant articles and consulted with a group of experts to ensure that we did not miss any other studies. using our content expertise, the lead author (ka) and a second team member (ks) worked together to develop the following inclusion criteria to identify empirical studies written in english and published in peer-review journals: (1) used simulation-based data (e.g., live sps, video-recordings of sps, virtual reality, data available from osce), (2) examined practice competencies (i.e., knowledge, values, and skills) related to clinical social work, and (3) included study samples comprised of social workers, social work students, or social work supervisors. we included any type of study design, and there were no geographical or time restrictions in our study selection. we excluded studies that used real clients or peer-based role plays, as simulation is designed to provide a realistic practice environment without engaging real clients or those with pre-existing relationships. we also excluded studies that used any static format of case studies, such as written-, audio-or image-based vignette as simulation is designed to create a dynamic, immersive practice situation for study participants. additionally, we excluded studies with the following characteristics: (1) study participation of social workers, social work students or social work supervisors was unclear, (2) the primary study purpose was on the evaluation of simulation-based education or training, including those studies in which competencies were measured (e.g., skills improvement among students as a result of simulation-based learning), and (3) the focus was on macro social work practice competencies (e.g., community organizing, policy-making). these inclusion and exclusion criteria were iteratively developed as the team became familiar with existing literature. we also contacted authors when information provided was unclear and excluded the studies when we did not receive clear answers from the authors. all titles and abstracts from the initial database search (n = 4224) were reviewed independently by two members (rg, sb) for eligibility. inter-rater agreement was 75% for this screening step based on a calibration exercise. any conflicting decisions were resolved by the lead author (ka) in consultation with another member (ks). then three members (ka, rg, sb) screened full articles (n = 275) for eligibility. inter-rater agreement was 93% for this screening step based on a calibration exercise. we used covidence, a web-based platform for scoping and systematic reviews, for the screening process. finally, we conducted a hand-search of reference lists of the included articles. in consultation between two authors (ka, ks), we developed a data extraction form which was piloted and used to chart following categories of data: the year of publication, study location, target competencies, study sample, scope of clinical practice, type of simulation-based data used (e.g., live sp, virtual reality), study design, rationale for using simulation-based data, simulation case development, data analysis, methodological strengths and limitations. three team members (ka, rg, sb) independently reviewed each of the identified articles (n = 24) and charted the data. finally, we conducted qualitative content analysis (sandelowski 2000) (msw)) or (ab(bsw) or ti(bsw)) or (ab(social near/3 (work* or casework* or case-work*)) or ti(social near/3 (work* or casework* or case-work*))) or (ab(case near/3 work*) or ti(case near/3 work*)) or (ab(socialwork*) or ti(socialwork*)) or (ab(social-work*) or ti(social-work*)) or (ab(casework*) or ti(casework*)) or (ab(case-work*) or ti(case-work*)) or ((ab(clinician* or supervis*) or ti(clinician* or supervis*)) and noft(social-work or socialwork)) or (ab(child near/1 (welfare or protection)) or ti(child near/1 (welfare or protection)))) or mainsubject.exact("social workers") or mainsubject.exact("psychiatric social workers") or mainsubject.exact("social casework") or mainsubject.exact("social group work") or mainsubject.exact("social work education")) simulation (((ab((simulat* or sample or standard* or virtual* or computer*) near/3 (patient* or client* or practice)) or ti((simulat* or sample or standard* or virtual* or computer*) near/3 (patient* or client* or practice))) or (ab(objective near/3 structur*) or ti(objective near/3 structur*)) or (ab(("role play" or "role played" or "role player" or "role players" or "role playing" or "role plays")) or ti(("role play" or "role played" or "role player" or "role players" or "role playing" or "role plays"))) or (ab(roleplay*) or ti(roleplay*)) or (ab(vignette*) or ti(vignette*)) or (ab(patient near/3 instructor*) or ti(patient near/3 instructor*)) or (ab(spi) or ti(spi)) or ((ab(sp) or ti(sp)) and noft(patient*)) or (ab(hps) or ti(hps)) or (ab(osce) or ti(osce)) or (ab(sbl) or ti(sbl))) or mainsubject.exact("simulation") or mainsubject.exact("role playing") or mainsubject.exact("vignette measure") or mainsubject.exact("computer simulation") or mainsubject.exact("virtual reality")) of the extracted data. any discrepancies or disagreements were discussed and resolved in the weekly team meetings. the lead author (ka) made the final decisions in consultation with another member of the team (ks), using our content expertise. the initial database search resulted in 4224 articles, and after removing 128 duplicates, we had 4,096 articles remaining. a total of 275 full text articles remained after the title and abstract exclusions. after the team members (ka, rg, sb) independently screened 275 full text articles, we excluded 251 as they did not meet the inclusion criteria (e.g., methods used were not considered simulation; study purpose were not on clinical practice competencies) and had 18 articles included for the study. we also identified an additional 6 articles through the hand-search of relevant journals and reference lists. taken together, a total sample of 24 articles met the criteria for this scoping review (see fig. 1 : prisma flowchart). in addressing the first research question, we examined the study characteristics of social work studies, in which simulation was used to study clinical practice competencies (e.g., knowledge, values, skills). table 2 summarizes the characteristics of the selected articles. most of the articles (n = 17, 71%) were published after 2010. the majority of the articles reported studies conducted in north america, with 12 articles from canada (50%) and six from the u.s. (25%). the remaining articles were from the united kingdom (n = 5, 21%) and denmark (n = 1, 4%). the study designs were almost evenly divided between qualitative and quantitative, with 11 qualitative (46%) and 10 quantitative (42%) articles, while mixed-methods studies were reported in three articles (13%). most articles involved social work students and/or social work practitioners: social work students (n = 7, 29%), social workers (n = 7, 29%), or both students and social workers (n = 5, 21%). a small number of articles involved study samples of interprofessional groups (n = 3, 13%) and social work supervisors (n = 2, 8%). sample size of those who participated in simulation varied, ranging from 12 *) to 151 (macdonell et al. 2019 . approximately half of the articles (n = 13, 54%) reported a sample size of 50 or less, while a sample size larger than 100 was reported in three articles (13%). in terms of the target competencies studied within the articles, the most common area was clinicians' professional decision-making (n = 8, 33%), for instance, in reporting of child abuse (e.g., leblanc et al. 2012*; tufford et al. 2015*) and assessing suicide risk (e.g., regehr et al. 2015 regehr et al. *, 2016 . five articles (21%) examined the role of the clinicians' cognitive skills and/or emotional reactions and states (bogo et al. 2013*; reeves et al. 2015*; sewell et al. 2020*; tufford et al. 2017 ). an additional five articles (21%) examined culture and diversity related to clinical practice, such as cultural empathy (garcia et al. 2012*) , stereotypes (kurtz et al. 1989*) , ethnicity (maki 1999*) table 3 shows a synthesis of the selected articles. to address the second research question of how simulationbased data are used in the studies of clinical competencies, we examined whether researchers provided a rationale for using simulation as a research methodology. we also looked into what types of simulation researchers used and whether and how researchers described the case development. finally, we identified how simulation-based data were used and analyzed in studying practice competencies. approximately half of the articles (n = 14, 58%) reported a rationale for using simulation as a research methodology, while the other half (42%) did not describe relevant information on why simulation-based data was used to answer their research questions. specific rationale located in the selected articles is discussed as methodological strengths in the subsequent section. about half of the articles (n = 13, 54%) reported using live sps (i.e., trained actors) to simulate a social work practice scenario. in six articles (25%), researchers used data collected during the osces for secondary data analysis. all of these studies (e.g., bogo et al. 2013*; logie et al. 2015*) used participants' qualitative reflection on their engagement with sps as a data source. in four studies (17%), researchers developed and used video-based case vignettes as a source of data. researchers reported filming simulated interactions between sps and practitioners in three of those articles (eskelinen and caswell 2006*; kurtz et al. 1989 *; stone 2019*), while an sp monologue was filmed and used as a data source in one article (maki 1999*) . virtual reality was used in one article (reeves et al. 2015*) to develop a virtual patient and an immersive practice environment in studying participants' emotional response to child protection. most of the articles (n = 18, 75%) described the process of developing simulated case scenarios, while no relevant information was located in seven articles (29%). of the 18 articles, researchers described specific processes of how the case vignettes were developed, with two common practices identified: (1) consultation with practitioners or experts during the case development phase (e.g., bogo reported an sp training. the degree of descriptions of sp training, however, varied. some provided no information other than sps being trained, while others described assisting sps in consistently enacting the case scenarios on both verbal (i.e., key phrases to use) and non-verbal elements (e.g., emotional intensity) of communication. in the articles that reported using qualitative research (n = 11), most researchers examined participants' written or verbal reflections on their simulated practice (e.g., osces, with live sps) in studying practice competencies. for the most part, qualitative methodologies were employed for studies that aimed to conceptualize practice competencies that are not yet well studied, such as cognitive and affective skills (e.g., sewell et al. 2020*; tufford et al. 2017 ) and engaging culture and diversity in practice (e.g., garcia to address the third research question, we reviewed the selected articles to examine benefits and limitations associated with using simulation as a research methodology. despite the fact that the use of simulation is a novel and innovative methodology in social work research, there was surprisingly little relevant discussion found. in terms of strengths of using simulation as a research methodology, three themes emerged: simulation offers (1) in reviewing the selected articles, several limitations were noted in relation to using simulation as a research methodology. first, a few researchers (e.g., forrester et al. (2008*) and maki (1999*) cautioned that, not using real clients with real presenting problems, the use of simulation is not suitable for researchers if their research questions involve client outcomes (e.g., impacts of therapeutic alliance on clients; improvement in client presenting concerns). finally, two articles (regehr et al. 2015*; stone 2019*) suggested issues related to socio-cultural diversity in simulated case scenarios (e.g., only white simulated clients). especially for a study of social work practice, the use of simulation might limit its applicability and relevance to real life clinical practice if the simulated cases do not reflect the sociocultural diversities present in contemporary social work practice. we identified 24 articles in this scoping review focused on the use of simulation as an investigative methodology (i.e., sbr) for researching clinical social work competencies. we synthesized the characteristics of relevant studies, the ways in which simulation-based data are used in research on clinical competencies, and relevant methodological benefits and limitations of sbr. results on the characteristics of the selected articles suggest that the use of simulation is a relatively new methodology in clinical social work, with a majority of articles published in the last ten years. given the small number of articles published prior to 2010 and the large number of articles using data available from osce-based student assessment, the emergence of simulation-based teaching in social work for the last ten years (kourgiantakis et al. 2019 ) has likely played an important role in vitalizing sbr. while social work competence consists of a number of elements-the worker's knowledge, values, skills, and cognitive and affective processes (cswe 2015) , only a few areas of competence were studied in the selected articles. previously, a written case vignette method was often used in the studies of various social work competencies, most notably professional decision-making (e.g., ashton 1999; stokes and schmidt 2012) , social work values (e.g., walden et al. 1990; wilks 2004 ) and attitudes about marginalized populations (e.g., camilleri and ryan 2006; schoenberg and ravdal 2000) . in comparison to the onedimensional and static nature of written vignettes, simulation stimulates dynamic and immersive practice situations for researchers. as sbr becomes commonplace in social work, researchers might consider expanding target competencies to study in the future, such as assessment, diagnosis and treatment planning. another important point to note is the use of sbr for conceptualizing the role of cognition and emotion in social work practice (e.g., bogo et al. 2013*; sewell et al. 2020*) . the notion of competency was re-conceptualized a few years ago (cswe 2015) to recognize the important role of clinicians' cognitive and affective processes in social work practice. direct observation of and reflection on practice allowed researchers to explicate and translate these rather abstract concepts into concrete competency-based skillsets. as sbr has played an essential role in advancing the conceptualization of cognitive and affective processes, perhaps a similar research process can be used to identify and explicate other important competencies relevant to clinical practice, such as navigating countertransference, working with a therapeutic impasse, and engaging in an anti-oppressive clinical practice. strengthening partnerships between researchers and practicing clinicians can ensure complex practice realities frame future research efforts, resulting in generating relevant knowledge for enhancing practice. in terms of the current use of simulation as a research methodology, most sbr in social work have hired and trained live sps in creating an immersive, dynamic and realistic practice environment for research. one scarcity observed here was the use of virtual simulation as a platform for research. given recent technological advancement and a great need for remote, often online-based, practice especially felt during the covid-19 pandemic, however, it seems that virtual simulation poses much promise in enhancing the use of simulation in social work research. much has been written about the utility of virtual simulation in the teaching and learning of social work practice (e.g., asakura et al. 2018; asakura et al. in press; washburn et al. 2016) . given that the data collected during the osces have been used and analyzed for the studies of practice competencies, researchers might consider collecting data through these pedagogical innovations and research clinical competencies in a virtual environment. case development was another important area which emerged in our review study. there seems to be three components that can guide case development in future sbr. first, development of a realistic and trustworthy client case, an unarguably essential element of case development, can be further facilitated when the case is closely grounded in people's real experiences. here we can draw from a robust body of literature on simulation-based social work education. scenarios should contain detailed information about the client's history, current cognitive and emotional patterns, and key verbatim responses to use kourgiantakis et al. 2019; sewell et al. 2020*) . furthermore, scenarios can be developed in consultation with social work practitioners or experts in the area (e.g., bogo et al. 2013*; logie et al. 2015*; regehr et al. 2010a*) . consultation with service users might also help the researchers in strengthening the trustworthiness of the scenarios when relevant and feasible. the second key component is sp training for live sp or video-recorded simulation. this training might involve rehearsing the scenario with the sp and assisting the sp in demonstrating verbal content and non-verbal communications (e.g., facial expression, tone of voice) relevant to the vignette (e.g., leblanc et al. 2012*; sewell et al. 2020*) . finally, pilot-testing of the case vignette with social workers and experts of a particular scope of practice might further strengthen the face validity and authenticity of the simulation used in the study. results of our review study offer two key points for when to use this methodology and why. first, sbr offers an ethical fit for research on social work practice. studying actual clinical sessions, ppr is a strong methodology for observing real-time data on clinical practice (knobloch-fedders et al. 2015) . ppr, however, typically involves the observation of therapeutic relationships over time (i.e., longitudinal research) and requires longer-term, intensive involvement from clients (tsang et al. 2003) . social workers also often work in ethically sensitive, mandated social and health service contexts (bogo 2018) , such as child protection, residential treatment, prisons, and inpatient hospitals. in these non-voluntary settings, social workers often work with vulnerable populations without alternative access to treatment. our scoping review suggests that accessing actual client sessions might not be the most ethically appropriate research methodology for social work. by simulating a realistic and trustworthy practice situation, sbr offers a methodological solution to researching social work practice that otherwise could not be observed due to legal and ethical reasons without involving or putting actual clients at risk for potential harm. the second key point derived from this review study is a methodological fit between simulation and research on practice competencies. simulation allows for the alignment and standardization of the practice environment, client characters, and scenarios for a specific research purpose. this finding corroborates the arguments made by sbr in medicine and other healthcare disciplines (e.g., cheng et al. 2014; halamek 2013) . actual client-worker interactions as seen in ppr are uniquely different and often unpredictable depending on the client's presenting concerns and the client-worker relational dynamics. while actual clinician-client therapeutic processes need to be observed (i.e., ppr) when the study involves client outcomes, sbr might be better suited when researchers' primary goal is to theorize or examine practice competencies. designing and standardizing a specific case scenario allows researchers to control these variables, at least to some extent, and more easily identify similarities and differences in how research participants demonstrate various elements of practice competencies. the current review study found that there is a rather inconsistent inclusion of a methodological rationale for using simulation as an investigative tool in the current social work sbr articles. although half of the articles included a brief mention of a rationale, overall, a robust argument was missing as to why simulation was the most suitable methodology for their respective study purpose and inquiry. we suggest that researchers make concerted efforts to make explicit a rationale for using simulation-based data in answering their respective research questions. additionally, there was no clear consensus about how social work researchers might approach study design and data analysis of simulation-based data. there was insufficient information in the current study to suggest when and how to use quantitative or mixed methods in social work sbr. we found that qualitative approaches might be suitable for a collection and analysis of post-simulated practice reflection, especially for the purpose of identifying or assessing under-studied clinical competencies (e.g., attending to culture and diversity in logie et al. 2015*; cognitive and affective processes in sewell et al. 2020*) . nonetheless, no qualitative study was identified in which simulation-based data were analyzed inductively from the participants' practice. this points to the importance of articulating promising data collection methods for directly observing clinical practice (e.g., using video equipment) and data analytic methods for qualitative coding as a priority for further advancement of sbr. as those involved in medical or other healthcare sbr pointed out an absence of methodological best practices for this novel research methodology (e.g., cheng et al. 2014; guise et al. 2017; siminoff et al. 2011) , this is an area that merits continuing attention also from social work sbr researchers. a disconnect between researchers and clinicians and between research and practice has been long noted in social work (gehlert et al. 2017) . consultation with practicing clinicians in developing and pilot-testing vignettes as noted in many of the papers in this review (e.g., leblanc et al. 2012*) can enhance the accurate representation of client situations without reliance on stereotypes. this can also enhance the validity for simulations and the overall value of research findings. given that the very purpose of simulation is to create a practice situation closely grounded in everyday clinical practice, active involvement from clinical social workers can only strengthen the quality of sbr and knowledge development in clinical social work. sbr provides a uniquely important opportunity for practiceinformed research (cswe 2015) , in which researchers and clinicians can collaboratively work together in designing and conducting meaningful studies serving the needs of practitioners and grounded in the perspectives of clinicians and their clients. one limitation of any literature review, including this scoping review, is potential omission of some relevant studies (peters et al. 2020) . due to the time and resource constraints (e.g., access to databases), we focused our review on relevant articles published in peer-review journals through the databases available in our university library system. our review also excluded dissertations, books, book chapters, grey literature, and those published in non-english languages. as another limitation of this scoping review, we did not assess the quality of each empirical study included in this review. given the novelty of sbr in social work, however, this scoping review aimed to provide a snapshot of current relevant literature, not to critically appraise research quality. in order to maintain study rigor, we used multiple independent reviewers for each and every phase of the review (i.e., screening, study selection, and charting) and followed the prisma-scr checklist for reporting (tricco et al. 2018 ). these methods were designed to increase overall consistency, transparency and safeguards against biases throughout the study. in this scoping review, we synthesized the current social work literature (n = 24) in which simulation was used as an investigative methodology in studying clinical social work competencies. sbr offers a promising methodological solution to building knowledge about what clinical competencies might look like and how clinicians can engage various knowledge, values, and skills into a unique practice situation. the proximation to practice means the findings from studies using this methodology can provide relevant insight and serve to support clinical social workers. recognizing both strengths and limitations of this novel research methodology, continued engagement with and investment in sbr can only advance the literature on clinical social work practice. scoping studies: towards a methodological framework teaching note-social work serial: using simulated client sessions to teach social work practice a call to action on artificial intelligence and social work education: lessons learned from a simulation project using natural language processing worker judgements of seriousness about and reporting of suspected child maltreatment the use of standardized patients in research in general practice social work practice: integrating concepts, processs & skills adapting objective 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covid-19: active measures to support community-dwelling older adults date: 2020-03-20 journal: travel med infect dis doi: 10.1016/j.tmaid.2020.101638 sha: doc_id: 264655 cord_uid: v0v7zsaw nan the coronavirus disease 2019 (covid-19) has rapidly spread around the world [1] , posing enormous health, economic, and social challenges to societies. as there are no proven drug and vaccine treatments [2] , non-pharmaceutical measures are essential to slow the spread of the epidemic [3] . social distancing (e.g., cancellation of large gathering, school closures) is an essential part of public health measure for infection control [3] . in line with this, many social events and activities have been cancelled or scaled-down in many countries including japan, wherein there is already a high number of reported covid-19 cases [1] . however, concerns have been raised from the community frontlines in japan following the covid-19 outbreak. first, communities may not have enough knowledge on whether maintaining, scaling-down, or cancelling social gatherings during the outbreak while minimising health risk. in addition, older adults may have higher fatality rates from covid-19. to avoid this, social gatherings can be cancelled considering the elderly, just to hedge risk. given that the impact of social distancing may depend on the transmission situation and severity of the disease [4] , social distancing should be implemented carefully. practical information should be provided to community-dwelling adults to help maintain appropriate community activity levels. in fact, some voluntary community activities were maintained owing to personal advice from health professionals. another issue is social isolation. in many countries, including japan, living alone and social isolation have been growing concerns. cancelling social gatherings and scaling down elderly care services can put community-dwelling adults, especially older adults, at an increased risk and severity of social isolation. in march 2020, an older woman in the local tokyo community said, 'lunch is not tasty; i feel a loss of appetite from eating alone owing to the loss of a gathering place during the lunch break'. thus, the isolating effects of social distancing should not be ignored, and efforts are needed to mitigate the negative psychological impact. 3 although recent technological advances may help detect and provide care for groups at high risk of social isolation, community-dwelling older adults may not have access to smartphones or internet services [5] . therefore, multiple plans and measures to maintain social ties should be prepared at the individual level (family, friends, neighbourhood, etc.), organizational or community levels, and societal levels to prevent or mitigate the negative impact of social isolation and its related problems (from the preparedness phase) on the already vulnerable among the population during an epidemic such as covid-19. no funding received. the authors declare no conflict of interest. world health organization. coronavirus disease 2019 (covid-19) situation report -50 therapeutic options for the 2019 novel coronavirus priorities for the us health community responding to covid-19 closure of schools during an influenza pandemic mental health services for older adults in china during the covid-19 outbreak we thank the community residents for sharing information about their current situations. key: cord-281836-j1r771nq authors: hernando-amado, sara; coque, teresa m.; baquero, fernando; martínez, josé l. title: antibiotic resistance: moving from individual health norms to social norms in one health and global health date: 2020-08-28 journal: front microbiol doi: 10.3389/fmicb.2020.01914 sha: doc_id: 281836 cord_uid: j1r771nq antibiotic resistance is a problem for human health, and consequently, its study had been traditionally focused toward its impact for the success of treating human infections in individual patients (individual health). nevertheless, antibiotic-resistant bacteria and antibiotic resistance genes are not confined only to the infected patients. it is now generally accepted that the problem goes beyond humans, hospitals, or long-term facility settings and that it should be considered simultaneously in human-connected animals, farms, food, water, and natural ecosystems. in this regard, the health of humans, animals, and local antibiotic-resistance–polluted environments should influence the health of the whole interconnected local ecosystem (one health). in addition, antibiotic resistance is also a global problem; any resistant microorganism (and its antibiotic resistance genes) could be distributed worldwide. consequently, antibiotic resistance is a pandemic that requires global health solutions. social norms, imposing individual and group behavior that favor global human health and in accordance with the increasingly collective awareness of the lack of human alienation from nature, will positively influence these solutions. in this regard, the problem of antibiotic resistance should be understood within the framework of socioeconomic and ecological efforts to ensure the sustainability of human development and the associated human–natural ecosystem interactions. the problem of antibiotic resistance (ar) has been traditionally addressed by focusing on humanlinked environments, typically health care facilities. nevertheless, it is now generally accepted that most ecosystems may contribute to the selection and spread of ar (aminov, 2009; martinez et al., 2009; davies and davies, 2010; martinez, 2014; berendonk et al., 2015; larsson et al., 2018) . a key conceptual point is that, based on cultural, humanitarian, and economic reasons, we have historically preserved the health of individual humans and farming animals. to that purpose, the same families of antimicrobial agents have been used. as a consequence, their positive (healing) and negative (selection of ar, therapeutic failure) effects have influenced the common health of humans and animals in particular locations (one health). the concept one health, first used in early twentieth century, expands the integrative thinking about human and animal medicine, including for the first time ecology, public health, and societal aspects (zinsstag et al., 2011) . in the case of ar, the one health perspective focuses on the risk assessment of emergence, transmission, and maintenance of ar at the interface between humans, animals, and any other linked (local) environment (robinson et al., 2016; jean, 2017) . consequently, the application of one health approaches demands integrative surveillance tools and interventions based on multidisciplinary approaches that include ecological and sociodemographic factors, besides more classic epidemiological models. global health is based on a broad collaborative and transnational approach to establish "health for all humans." in this case, it focuses ar at a general (global) scale, considering that the selection and global spread of antibiotic-resistant bacteria (arbs) and antibiotic resistance genes (args) are a problem that influences the health of human societies with disparate social and economic structures and is linked to many societal and ecological factors (chokshi et al., 2019) . interventions to reduce ar burden in a global world certainly require common and integrated policy responses of countries, international organizations, and other actors (stakeholders included). its goal is the equitable access to health and minimizing health risks all over the globe. besides its objective aspects (i.e., how travelers, migrating birds, or international commerce may contribute to ar spread), it has important international political aspects. it focuses in how countries and international organizations address the elements connecting and potentially spreading ar among humans, animals, and natural ecosystems at the earth scale (wernli et al., 2017) . in summary, the problems and the potential solutions concerning ar are not confined to particular regions, but have a global dimension: a problem for all humans, animals, and natural ecosystems, which should be solved with interventions aiming to improve health for all of them koplan et al., 2009; laxminarayan et al., 2013) . in the context of ar, a healthy environment would be an environment where ar is low or can be controlled by human interventions (hernando-amado et al., 2019; andersson et al., 2020) . of course, the global health concept of "health of an environment" (iavarone and pasetto, 2018; pérez and pierce wise, 2018; bind, 2019; van bruggen et al., 2019) or, in general, planetary health (lerner and berg, 2017) , has an unavoidable anthropogenic flavor. in practice, we consider "healthy environments" or "healthy ecosystems" those that minimize their current or their potential harm for the human individual or the society, in our case for ar. in other words, we adopt a selfish strategy, which should be necessarily implemented by the international (global) institutions. selfishness (kangas, 1997 ) applies mainly to individuals, but also to societal groups. however, these groups have not enough possibilities to act alone in the case of infectious diseases in general and ar in particular, which may expand worldwide. therefore, individual selfishness for health should be integrated in local one health and also in global health actions. the goal of controlling ar is a highly complex one, and its dimension has been compared to climate change or biodiversity loss, problems where individual actions are not enough for providing a solution, and consequently, individual freedom is confronted with collective responsibility (looker and hallett, 2006) . the construction of human societies reflects the tension between individual freedom and social rules/laws. the implementation of different social rules/laws for regulating human activities within a society is mainly based on moral (as kant's categorical imperative (kant, 1785) or religious-based brotherhood (matthew 22:35-40) statements), social stability (as anticrime laws; schiavone, 2012) , organizative (type of government and how it is formed, group identity), and efficacy (as antitrust laws; ricardo, 1821) arguments. however, these arguments mainly apply for establishing the socioeconomic organization as well as the individual welfare within a society. the situation concerning human health is somehow different. there are individual diseases, such as cancer or stroke, and social diseases, such as transmissible infections. for the firsts, social norms (as consciousness of the importance of the control of cholesterol, excess sugar uptake, or hypertension levels) are well established, and even laws (non-smoking regulations) had been implemented in occasions. however, the main impact of these regulations is at the individual health level (wikler, 2002) , because the associated diseases are not physically transmissible. a different situation happens in the case of infectious diseases in general and of ar in particular. for these diseases, everything that happens in a single person affects any one around. further, the fact that an arg emerging in a given geographic area can spread worldwide implies that neither individual norms nor country-based norms have been sufficient until now to counteract the worldwide spread of ar. one important aspect of laws in democratic societies is that they must be well accepted by the community, so that the acceptation of social norms usually comes first than their implementations as rules/laws. actually, the efficiency of democracy for responding to social crisis (as current ar or covid-19 crises), in opposition to other more autocratic regimens where decisions are implemented top-down, had been the subject of debate from the early beginning of democratic revolutions (tocqueville, 1838; hobbes, 1968; rousseau, 1974; spinoza, 2007) . in this regard, it is important to remark that one health aspects of ar can be tackled in the basis of countrylevel regulations that are linked to the socioeconomic and cultural aspects of each country (chandler, 2019; chokshi et al., 2019) . however, because global earth governance does not exist, global health control of ar is based on recommendations, rather than in rules/laws. consequently, the acceptance of social norms, starting within individuals or small organizations and expanding throughout the whole society (figure 1) , is fundamental to provide global solutions to the ar problem (nyborg et al., 2016; chandler, 2019) . the acceptance by the community of these social norms, considering that the way of promoting these norms might differ in different parts of the world (cislaghi and heise, 2018; cislaghi and heise, 2019) , largely depends on the transfer to the society of the knowledge required to understand the mechanisms and the impact for human health of the emergence and transmission of ar, an information that is discussed below. figure 1 | how the interactions among individual health, one health, global health, and social norms influences antibiotic resistance. the right panel shows the different levels of dissemination of antibiotic resistance. in the left panel, the different types of norms (from individual to global norms) that can impact antibiotic resistance at each level are shown. these norms influence all levels of transmission: the individual promotes (red arrows) his own individual health, but doing it also promotes the health of the group, and the health of the group promotes global health of the human society at large. at each level, there is a positive action (red broken lines) on antibiotic resistance. such dynamics largely depends on social norms (blue arrows) rewarding the individual or the groups whose behavior promotes health. below the left panel, the basic social norm, progress and development, has consequences on the whole ecobiology of the planet (lower panel with bullet points), influencing the undesirable open circulation of antimicrobial resistant bacteria (with their mobile genetic elements) and antibiotic resistance genes. the classic definition of ar is based only on the clinical outcome of the infected patient. an organism is considered resistant when the chances for the successful treatment of the infection it produces are low . this definition, which is the most relevant in clinical settings, presents some limitations for studies based on one health approaches that include the analysis of non-infective organisms, which lack a clinical definition of resistance, as well as analysis of the distribution of args, in several occasions, using non-culture-based methods . even in the case of animal medicine, antibiotic concentration breakpoints defining resistance are still absent for some veterinary-specific antimicrobials and poorly defined for different types of animals with disparate weights, which would influence the availability of the drug inside animal body (toutain et al., 2017; sweeney et al., 2018) . to analyze ar beyond clinical settings, the term resistome, understood as the set of genetic elements that can confer ar, irrespectively of the level of resistance achieved, in a given organism/microbiome was coined (d'costa et al., 2006; wright, 2007; perry et al., 2014) . ar acquisition is the consequence of either mutation (or recombination) or recruitment of args through horizontal gene transfer (hgt), transformation included. ar mutations are generally confined to their original genomes, propagating vertically and not spreading among bacterial populations, although some few exceptions of horizontal transfer of chromosomal regions containing ar mutations have been described (coffey et al., 1991; ferrandiz et al., 2000; novais et al., 2016; nichol et al., 2019) . the set of mutations that confer ar can be dubbed as the mutational resistome. current wholegenome-sequencing methods of analysis can allow defining the mutational resistome in an isolated microorganism (cabot et al., 2016; lopez-causape et al., 2017) . however, they are not robust enough yet for determining the mutational resistome in metagenomes. consequently, the impact of these analyses in one health studies is still limited and will not be further discussed in the present review. concerning their relevance for acquiring ar, args can be divided in two categories. the first one comprises the genes forming the intrinsic resistome (fajardo et al., 2008) , which includes those that are naturally present in the chromosomes of all (or most) members of a given bacterial species and have not been acquired recently as the consequence of antibiotic selective pressure. despite that these genes contribute to ar of bacterial pathogens, they are responsible just for the basal level of ar, which is taken into consideration when antibiotics are developed. in this regard, unless these genes, or the elements regulating their expression mutate, they are not a risk for acquiring resistance and have been considered as phylogenetic markers . further, it has been discussed that these genes may contribute to the resilience of microbiomes to antibiotic injury (ruppe et al., 2017b) , hence constituting stabilizing element of microbial populations when confronted with antibiotics more than a risk for ar acquisition by pathogens. the second category, dubbed as the mobilome, is formed by args located in mobile genetic elements (mges) that can be transferred both vertically and horizontally, hence allowing ar dissemination among different bacteria (frost et al., 2005; siefert, 2009; jorgensen et al., 2014; lange et al., 2016; martinez et al., 2017) . while the analysis of the resistome of microbiota from different ecosystems has shown that args are ubiquitously present in any studied habitat (d'costa et al., 2006; walsh, 2013; jana et al., 2017; lanza et al., 2018; chen et al., 2019b) , the impact of each one of these args for human health is different. indeed, it has been stated that the general resistome of a microbiome is linked to phylogeny and to biogeography, indicating that most args are intrinsic and do not move among bacteria (pehrsson et al., 2016) . however, some args escape to this rule and are shared by different ecosystems and organisms (forsberg et al., 2012; fondi et al., 2016) . these mobile args, frequently present in plasmids (tamminen et al., 2012; pehrsson et al., 2016) , are the ones that are of special concern for human health. although not belonging to the antibiotic resistome, genes frequently associated with resistance to other antimicrobials, such as heavy metals or biocides, as well as the genes of the mges backbones, eventually involved in the transmission and selection of args among microbial populations, the mobilome at large, are also relevant to track the emergence and dissemination of ar among different habitats martinez et al., 2017; baquero et al., 2019) . hgt processes are recognized as the main mechanisms for transmission of genetic information (baquero, 2017) . from the ecological point of view, hgt should be understood as a cooperative mechanism that allows the exploitation of common goods as args by different members within bacterial communities. in fact, some studies suggest that the ecological consequences of hgt events in ar evolution are contingent on the cooperation of complex bacterial communities, besides the acquisition of individual adaptive traits (smillie et al., 2011) . however, the understanding of the ecological causes and consequences of args transmission among organisms and microbiomes is still limited from the one health and global health perspectives. hgt-mediated ar is a hierarchical process (figure 2 ) in which args are recruited by gene-capture systems as integrons and afterward integrated in mges as plasmids, insertion conjugative elements, or bacteriophages (frost et al., 2005; garcia-aljaro et al., 2017; gillings et al., 2017; botelho and schulenburg, 2020) , which afterward are acquired by specific bacterial clones. selection at each of these levels will also select for all the elements involved in ar spread. for instance, the acquisition of an arg by a clone may promote the expansion of the latter (and of all the genetic elements it contains, other args included) in antibiotic-rich environments, such as hospitals or farms schaufler et al., 2016) , and vice versa, the introduction of an arg in an already successful clone may increase the chances of this resistance gene for its dissemination even in environments without antibiotics, unless the associated fitness costs are high. in this sense, if arg acquisition reduces the fitness, and this implies a decreased capability for infecting humans (see below), the burden for human health might eventually be lower. nevertheless, it is relevant to highlight that ar transmission cannot be understood just by analyzing the genetic mechanisms involved and the consequences of such acquisition for the bacterial physiology. indeed, as discussed below, there are ecological and socioeconomic elements that strongly influence ar dissemination. the evolution of ar comprises the emergence, the transmission, and the persistence of arbs (martinez et al., 2007; baquero et al., 2011) . concerning human health, selection of arbs/args is particularly relevant at the individual health level, whereas transmission is a main element to be taken into consideration at the one health and global health levels (figure 2) . indeed, unless ar is transmitted, it will be just an individual problem that would not affect the community at large. it is generally accepted that non-clinical ecosystems are often primary sources of args (davies, 1994) . as above stated, after their capture and integration in mges (figure 2 ), args and their bacterial hosts can contaminate different ecosystems, which might then be involved in their global spread (martinez, 2012; fondi et al., 2016; gillings, 2017; gillings et al., 2017) . this means that nearly any ecosystem on earth, along with the humandriven changes produced in it, may modulate evolution of ar. importantly, the huge escalation and worldwide expansion of a limited set of animals, plants, and their derived products, including foods, due to the anthropogenic selection of a few breeds and cultivars for mass production in livestock and agricultural industries (okeke and edelman, 2001; zhu et al., 2017) of economic interest have collapsed the variability and biodiversity of animals and plants (seddon et al., 2016) . because these organisms harbor particular host-adapted bacteria, which are frequently under antibiotic challenge, this situation, together with the ecological similarities of human habitats, might favor ar spread (martiny et al., 2006; manyi-loh et al., 2018) . indeed, while in underdeveloped areas of the world food animals are very diverse, intensive farming, common in developed countries, ensures a "shared-stable" environment where only the most productive types prevail (kim et al., 2017) . the common genetic origin of these types and the process of microbiota acquisition from nearby animals in intensive farming should homogenize also their microbiomes with consequences for ar dissemination. actually, it has been shown that the loss of microbial diversity figure 2 | genetic, ecological, and socioeconomic elements mediating the transmission of antibiotic resistance. args are ubiquitously present in any studied microbiome (a). however, only a few of them are transferred to human/animal pathogens, hence constituting a health problem. the genetics events implied include the acquisition of args by gene-recruiting genetic elements such as integrons (b); the integration of these elements in mges as plasmids, bacteriophages, or frontiers in microbiology | www.frontiersin.org figure 2 | continued insertion conjugative elements (c); and the acquisition of these elements by specific bacterial clones (d). these arbs can share these elements among the members of gene-sharing communities (e) and also move among different ecosystems, including humans, animals (particularly relevant farm animals), and natural ecosystems (with a particular relevance for water bodies). the connection of these ecosystems, as well as the reduced diversity of animals, plants, and in general habitats as the consequence of human activities, allows the different microbiomes to be in contact, favoring args transmission among the microorganism they encompass (f). this transmission is facilitated at the global scale by travel, animal migration, trade of goods, and eventually by meteorological phenomena, climate change included (g), hence producing a global health problem (h). while most studies on the dissemination of args focus on mges (davies, 1997; muniesa et al., 2013; lanza et al., 2015; garcia-aljaro et al., 2017) , recent works suggest that the contribution of natural transformation (orange arrow), allowing the direct uptake of args by natural competent microorganisms, may have been underestimated (domingues et al., 2012; blokesch, 2017) . further, competence can occur due to interbacterial predation (veening and blokesch, 2017) , a biological interaction that may facilitate the acquisition of beneficial adaptive traits by predator bacterial species (cooper et al., 2017; veening and blokesch, 2017) . other hgt mechanisms, such as dna packing in extracellular vesicles (ecv) or transference of dna through intercellular nanotubes, also seem to be relevant in nature (dubey and ben-yehuda, 2011; fulsundar et al., 2014) . while the biotic conditions that may enhance hgt have been studied in detail, less is known concerning abiotic modulation of args transfer. under contemporary conditions, at least 10 24 microorganisms are affected by a freeze-and-thaw cycle, at least 10 19 are agitated by sand, and at least 10 17 are subjected to conditions suitable for electrotransformation every year (kotnik and weaver, 2016) . may favor ar spread (chen et al., 2019a) . note that, beyond the transmission of particular ar spreading clones, ar is expected to spread in farms by the modification (eventually homogenization) of animals' microbiota. notwithstanding, even farm workers are subject to microbiome acquisition from animals, leading to microbiome coalescence sun et al., 2020) . it is to be noticed, and the recent covid-19 crisis exemplifies it, that besides economic development, cultural habits are relevant in the use of animals for food, a feature that has not been analyzed in detail, particularly with respect to their role as vectors potentially involved in ar dissemination. despite that the homogenization of hosts may help in ar transmission, the spread of arbs has some constraints, because the differential capability of each bacterial clone for colonizing different hosts may modulate their dissemination. indeed, while some species and clones are able to colonize/infect different animal species, humankind included, several others present some degree of host specificity (price et al., 2017; sheppard et al., 2018) . further, it has been shown that the capacity to colonize a new host is frequently associated with a reduction in the capacity for colonizing the former one. the same happens for mobile args; they are encoded in mges that present different degrees of host specificity, which defines the formation of gene-exchange communities, where the interchange of genetic material among members is facilitated (skippington and ragan, 2011) . conversely, the incorporation of different replicons and modules within plasmid backbones, a feature increasingly reported (douarre et al., 2020) , would enable arg replication in different clonal/species background and thus modify the community network of args. actually, the risk for humans of animal-based ar seems to be linked in most cases to shuttle, generalist clones able to colonize humans and particular animals (price et al., 2017; sheppard et al., 2018) . the understanding of the elements driving the transfer of ar among animals, humans included (figure 3) , requires the comprehensive survey of the clones and args that are moving among them (european food safety authority et al., 2020). tools to track the global epidemiology of antimicrobial-resistant microorganisms such as bigsdb (jolley et al., 2018) or comprehensive databases of args, ideally providing information of their mobility (zankari et al., 2012; alcock et al., 2020) , are fundamental for studying ar transmission at a global level. it is worth mentioning that, because humans constitute a single biological species, the human-associated organisms spread easily among all individuals. in fact, more prominent differences in humans' microbiome composition can be observed between individuals than among ethnic groups, even though, as expected, the resemblance in microbiotas is higher among those groups that are geographically clustered (deschasaux et al., 2018; gaulke and sharpton, 2018) . some groups of human population are, however, more prone to acquire arbs, due either to socioeconomic or to cultural factors. in lmics (low-to medium-income countries) and brics (brazil, russia, india, china, and south africa) countries, the combination of wide access to antibiotics, weak health care structures, and poor sanitation defines certainly a dangerous landscape. moreover, the progressive aging of the western population might favor the establishment and further expansion of an elderly reservoir of arbs and args, an issue that deserves further studies. the hypothesis that the microbiome of elder people might be a reservoir of ar is based not only on their cumulative history of antibiotic exposure and contacts with health care centers, but also on the rampant use of antibiotics of this population more prone to suffer from acute, chronic, or recurrent infections. significant worldwide advances in the organization of medical care of the elderly people lead to frequent hospitalizations, but health care centers may also facilitate the selection and further amplification of ar in the community. in addition, this may subsequently favor the entry of high-risk clones and of args in the hospital setting (hujer et al., 2004) . as stated above, there is a global increasing permeability of the natural biological barriers that have historically prevented bacterial dissemination through different ecosystems. besides local spread of ar in environments shared by animals and humans, which has to be addressed under a one health approach, ar can disseminate worldwide (figure 2 ) by economic corridors that promote the global interchange of goods and trade or human travelers or by natural bridges, such as animal migration paths or natural phenomena such as air and water movements (okeke and edelman, 2001; baquero et al., 2008; allen et al., 2010; overdevest et al., 2011; kluytmans et al., 2013; fondi et al., 2016) . the result is the appearance of similar arbs and args in different geographic areas. as the consequence, ar is a global health problem in the sense that an arb that emerges in a given place can rapidly spread worldwide. indeed, multidrugresistant bacteria, similar to those encountered in clinical settings, have been detected in human isolated populations that were not previously in contact with antibiotic, as well as in wildlife (clemente et al., 2015) . this indicates that pollution with args is present even in places where antibiotic concentrations are low (kümmerer, 2004) and might involve mechanisms of transmission that do not require selection. for instance, migrating birds can carry enteropathogenic bacteria resistant to different antibiotics (middleton and ambrose, 2005; poeta et al., 2008) , and international travelers, even those not receiving antibiotic treatments, also contribute to ar transfer among different geographic regions (murray et al., 1990; reuland et al., 2016) . in the group of long travelers are refugee people, in which dissemination of multidrug-resistant strains is favored by the poor sanitary conditions and overcrowding camps that refugees confront (maltezou, 2016) . a final issue concerning ar is its stability in the absence of selection. it has been proposed that the acquisition of ar reduces bacterial competitiveness in the absence of antibiotics (fitness costs) (andersson and hughes, 2010; martinez et al., 2011) ; certainly, a wishful proposition such as, if true, the reduction in the use of drugs or eventually antibiotic-cycling strategies should decrease ar (beardmore et al., 2017) . nevertheless, eliminating the use of an antibiotic does not produce a full decline of ar (sundqvist et al., 2010) . in fact, different studies have shown that ar not always reduces fitness but also can even increase bacterial competitiveness (andersson and hughes, 2010; schaufler et al., 2016) . in addition, compensatory mutations or physiological changes that restore fitness can be selected in resistant bacteria (andersson, 2006; schulz zur wiesch et al., 2010; olivares et al., 2014) . it is a fact, however, that although arbs are found nearly everywhere, including wild animals, natural ecosystems, or people from isolated populations without contact with antibiotics, among others (durso et al., 2012; clemente et al., 2015; alonso et al., 2016; fitzpatrick and walsh, 2016; power et al., 2016) , ar prevalence is consistently lower when antibiotics are absent, which suggests that pollution may impact ar, a feature that is discussed below. pollution of natural ecosystems is associated with activities that have driven relevant economic transition, in principle favoring human welfare, such as mining, industry, intensive land use, or intensive farming, among others. notwithstanding, globalization of health services, as well as the shift toward intensive farming, besides their positive contribution to human wellbeing, has rendered an increasing pollution by compounds with pharmacological properties of natural ecosystems, particularly water bodies, which may disrupt the stability of these ecosystems (oldenkamp et al., 2019) . among them, antibiotics are considered the most relevant cause of ar selection. despite regulations for reducing their use (van boeckel et al., 2017) , a substantial increase in global antibiotic consumption has occurred in the last years, and an even greater increase is forecasted in the next years (klein et al., 2018) . however, antibiotics are not the unique pollutants that can prime the selection and spread of ar. in this regard, it is important to highlight that heavy metals are one of the most abundant pollutants worldwide (panagos et al., 2013) . their abundance results from anthropogenic-related activities, such as mining, industry, agriculture, farming, or aquaculture and even for therapeutic use in ancient times. importantly, they may persist in nature for long periods of time. further, likely because metal pollution occurred before the use of antibiotics, heavy metal resistance genes were incorporated to mge backbones before args (mindlin et al., 2005; staehlin et al., 2016) . this means that heavy metals may coselect for mges and the args they harbor (partridge and hall, 2004; staehlin et al., 2016; zhao et al., 2019a) . even more, the presence of heavy metals, as well as of biocides or sublethal antibiotic concentrations (jutkina et al., 2018; zhang et al., 2018) , may stimulate hgt, as well as modify the dynamics of antibiotics, such as tetracyclines, in natural ecosystems (hsu et al., 2018) . coselection may also occur when a single resistance mechanism, such as an efflux pump, confers resistance to both heavy metals and antibiotics (cross-resistance) (pal et al., 2017) . although most published works analyze the effect of different pollutants on their capacity to select arbs or args, it is important to highlight that args should also be considered pollutants themselves. actually, a recent work indicates a close relationship between the abundance of args and fecal pollution (karkman et al., 2019) . in this respect, it is worth mentioning that, differing to classic pollutants, args/arbs are not expected to disappear along time and space, but rather, their abundance may even increase as the consequence of selection and transmission (martinez, 2012) . while the direct selection of ar by antibiotics or the coselection mediated by other pollutants, as the aforementioned heavy metals, has been discussed (wales and davies, 2015) , the effect of other types of human interventions on the dissemination of args and arbs through natural ecosystems has been analyzed in less detail. as an example, it has been proposed that wastewater treatment plants, where commensals, arbs, args, and antibiotics coexist, could act as bioreactors favoring the selection and transmission of args between different organisms (rizzo et al., 2013; su et al., 2017; manaia et al., 2018) , although evidences supporting this statement are scarce (munck et al., 2015; azuma et al., 2019) . in addition to the aforementioned pollutants with a direct effect in ar selection, it is worth noting that there are other abundant contaminants, such as sepiolite (present in cat litters or used as a dietary coadjuvant in animal feed) or microplastics, present in almost all aquatic ecosystems, which can favor the transmission of args or mges between bacterial species (rodriguez-beltran et al., 2013; kotnik and weaver, 2016; arias-andres et al., 2018) , hence amplifying the ar problem at a global scale. finally, the possible effect of climate change on the spread of ar is worth mentioning. indeed, it modifies the biogeography of vectors (such as flies, fleas or birds) involved in the spread of infectious diseases (fuller et al., 2012; beugnet and chalvet-monfray, 2013) . in addition, the increase of local temperatures seems to correlate with an increased ar abundance in common pathogens (macfadden et al., 2018) . besides, climate change is affecting ocean currents (martinez-urtaza et al., 2016) , which may allow the intercontinental distribution of arbs and args (martinez, 2009a,b) . although this phenomenon might contribute to the globalization of ar, further research is needed to clearly demonstrate a cause-effect relationship. it is relevant to mention that increased pollution and climate change are the unwanted consequences of human development. it would then be worth discussing how human development in general may impact (positively and negatively) ar, a feature that is analyzed below. human development is a necessity of our human behavior, although different models of development have been and are proposed, each one producing different impacts in the structure of human societies and on the preservation and stability of natural ecosystems (fenech et al., 2003; farley and voinov, 2016; seddon et al., 2016) . nevertheless, even for different socioeconomic models, there are some social norms that tend to be widely accepted, in particular those aiming to improve individual well-being. this implies the establishment of a society of welfare, understood as a right of any human on earth, a feature that depends on the economic development, and can be particularly relevant in the case of transmissible infectious diseases in general and of ar in particular. a continuously repeated mantra in worldwide ar policies is that the abusive consumption of antibiotics for the treatment or prevention of infections in humans and animals constitutes the major driver of ar. however, we should keep in mind that antibiotics constitute an important example of human progress supporting individual and global human health. in fact, the origin of the massive production of antimicrobials was a consequence of the needs resulting from world war ii in the 1940s. this was followed by many decades of human progress, most importantly by the common understanding of equal human rights, which was followed by the economic and social development (including medicine and food industry) of densely populated regions in the planet, including india and china. these countries are currently among the leaders in the production and consumption of antimicrobial agents. notwithstanding, as in any area of economy, progress bears a cost that, in this case, is antibiotic pollution of the environment, globally accelerating the process of the emergence, the transmission, and the persistence of arbs (martinez et al., 2007; baquero et al., 2011) . the non-controlled use of antibiotics is facilitated in lmics with disparate economic growth by different factors. heterogeneous regulation of antibiotic sales and prescriptions (often weak or missing) and the increase of online on-bulk sales in recent years contribute to their overuse (mainous et al., 2009 ). most of live-saving medicines represent out-of-pocket costs in most lmics, which led to an exacerbated use of cheap (usually old and less effective) antibiotics, phasing out their efficacy and increasing the demands and prices for the most expensive ones, eventually resulting in treatment unavailability (newton et al., 2011) . further, the cost of treating ar infections is much higher than that of treating susceptible ones, which is increasing the cost of health services (wozniak et al., 2019) . conversely, the growing economic capability of lmics in the brics category triggers the access of the population to health services and last-resort antibiotics. these countries also face a sudden high demand for meat and thus a prompt industrialization of animal production that has favored the misuse of antibiotics for growth promotion facilitated by their online availability (mainous et al., 2009 ). in addition, counterfeit or substandard antibiotics recently become a serious global problem (gostin et al., 2013) , which is exacerbated in lmics, where they represent up to a third of the available drugs. noteworthy, 42% of all reports received by the who global surveillance and monitoring system on substandard and falsified medicines worldwide come from africa, and most of them correspond to antimalarials and antibiotics (newton et al., 2011; gostin et al., 2013; hamilton et al., 2016; petersen et al., 2017) . despite this situation, it is important to highlight that human consumption of antibiotics is an unavoidable need to preserve human health. in fact, most health problems dealing with infections in lmics are still caused by a poor access to antibiotics, not by an excessive use of them. proof of this is the fact that the distribution of antibiotics has reduced endemic illnesses and children mortality in sub-saharan africa (keenan et al., 2018) . this means that, while a global decline in the use of antibiotics would be desirable to diminish the problem of ar, there are still several parts in the globe where antibiotic use should still increase to correctly fight infections. in fact, our primary goal should not be to reduce the use of antibiotics, but to ensure the effective therapy of infectious diseases for the long term. this does not mean that ar is not a relevant problem in lmics; it means that reducing antibiotic use is not enough to solve the problem. indeed, the current high morbidity and mortality due to infectious diseases (malaria, tuberculosis, low respiratory infections, sepsis, and diarrhea) in lmics will be worsened in the absence or low efficiency of therapeutic treatments. further, ar has economic consequences. according to world bank, 24.1 million people could fall into extreme poverty by 2050 because of ar, most of them from lmics (jonas and world bank group team, 2017) . consequently, besides a global health problem, ar has an important economic impact (rudholm, 2002) , hence constituting a global development problem, endangering not only the achievements toward the millennium development goals but also the sustainable development goals (van der heijden et al., 2019). world bank estimates that ar could impact the gross domestic product from 1 to 3.8%, which is even higher than what is estimated for the climate change (jonas and world bank group team, 2017) . these economic foresights are linked to the threads of increased poverty, food sustainability, global health deterioration (associated with both food safety and affordability to health care), and environment protection. all these issues are also impacted by the overuse and misuse of antibiotics, its lack of effectiveness, and the affordability to medicines and health care (van der heijden et al., 2019) . when talking about reducing antibiotic consumption, it is important to remind that up to two-thirds of overall antibiotic usage is for animal husbandry (done et al., 2015) . further, recent work states that the use of antibiotics in crops, particularly in lmics, might have been largely underestimated (taylor and reeder, 2020) . despite that evidences on the presence of common args distributed among animals and humans were published decades ago wegener et al., 1997; aarestrup, 1998; aarestrup et al., 1998) , and although the use of antibiotics as growth promoters has been banned in different countries (cox and ricci, 2008) , they are still allowed in many others (mathew et al., 2007) . of relevance is the fast increase of antibiotic consumption for animal food production in china (23% in 2010) and other brics countries . as stated previously, in these countries, increased income has produced a fast increase in meat products demand, due to changes in diet of their population. in addition, the increasing international competitiveness in meat production of these countries has fostered the rampant development of their industrial farming. together with the fact that legislation on antibiotics use remains weak, this situation increases the risk of emergence of ar linked to animal production. nevertheless, the problem is not restricted only to lmics, because antibiotics consumption rose as well in the highincome countries as the united states (13%) , where approximately 80% of the antimicrobials purchased in 2011 were applied in livestock production as non-therapeutic administration (done et al., 2015) . the development of intensive methods of fish production has also contributed to the rise in the use of antimicrobials and the selection of resistance determinants that can be shared among fish and human bacterial pathogens (cabello et al., 2013) . economic development has facilitated as well more global transport, waste disposal, and tourism, favoring ar spread within and between different geographical areas (ruppe et al., 2017a; ruppe and chappuis, 2017) . however, economic growth can also reduce the ar burden, especially when it enables the development of regulations and infrastructures that might reduce the risks of infection and ar spread. this is particularly relevant in the case of public health interventions on food, water, and sewage. because ar pathogens are mainly introduced in natural ecosystems through the release of human/animal stools (karkman et al., 2019) , the best way of reducing this impact is through the use of wastewater treatment plants, which are still absent in several places worldwide. indeed, it has been described that drinking water is a relevant vehicle for the spread of arbs in different countries (walsh et al., 2011; fernando et al., 2016) and that raw wastewater irrigation used for urban agriculture may increase the abundance of mobile args in the irrigated soil (bougnom et al., 2020) . notably, the analysis of args in wastewaters has shown that the prevalence of args in the environment in each country might be linked to socioeconomic aspects mainly related to economic development, as general sanitation, particularly the availability of drinking and wastewater treatments, malnutrition, number of physicians and health workers, human overcrowding, or external debt grace period (hendriksen et al., 2019) . the field of ar has mainly focused in the mechanisms of selection; the main driver for the increased burden of ar would be then the use of antibiotics itself. however, these results indicate that transmission, even in the absence of direct human-to-human contact, might be, at least, equally relevant. in this situation, an important element to reduce the ar burden will be to break the transmission bridges among different ecosystems that could be reservoirs of args. even when wastewater-treatment plants are available, the presence of arbs in drinking, fresh, and coastal waters, as well as in sediments nearby industrial and urban discharges, has been described in several countries (ma et al., 2017; leonard et al., 2018) . as in the case of fecal contamination markers, a reduction in the amount of args to non-detectable levels would be extremely difficult even when advanced water treatment procedures are applied. a standard definition of polluting arb/arg markers, as well as their acceptable levels, is then needed. this would be required not only for potable water, but also for water reutilization, as well as for land application and release of sewage effluents, because in all cases the reused water/sewage may carry arbs and args, together with pollutants, such as antibiotics, metals, biocides, or microplastics, which, as above stated, may select for ar (baquero et al., 2008; moura et al., 2010; yang et al., 2017; zhu et al., 2017; larsson et al., 2018; imran et al., 2019; wang et al., 2020) and may even induce hgt. the examples discussed above justify that human health in general and ar in particular are closely interlinked with economic development (sharma, 2018) . economic differences are also found at individual level, because there is a positive relationship between economic status and health (tipper, 2010) . in addition, social behavior might also impact ar, a feature discussed in the following section. different socioeconomic factors can modulate the spread of infective bacteria in general and of ar in particular. among them, the increasing crowding of humans and foodborne animal populations favors transmission at the local level (one health), whereas trade of goods and human travel (figure 2 ) favor worldwide transmission (global health) (laxminarayan et al., 2013; hernando-amado et al., 2019) . besides these global changes in social behavior, linked to economic development, more specific socioeconomic factors (income, education, life expectancy at birth, health care structure, governance quality), sociocultural aspects (inequalities, uncertainty avoidance, integration of individuals into primary groups, gender biases, cultural long-term orientation), and personality dimension highly influence antibiotic use and ar transmission (gaygısız et al., 2017) . for instance, although the governance quality seems to be the most important factor associated with a proper antibiotic use, western countries with distinct national culture patterns show different levels of antibiotics consumption (kenyon and manoharan-basil, 2020) . a better understanding of human social responses facing ailments, especially epidemics and antibiotic use, requires then a more detailed analysis of the differences between collectivistic (individuals living integrated into primary groups) and individually long-term oriented societies (oriented to future individual rewards) (hofstede, 2001; gaygısız et al., 2017; kenyon and manoharan-basil, 2020) . consistent with the sociological elements of ar, many of the aspects influencing ar reviewed above depend on social norms (figure 1) . in the classic view of the psychoanalyst erich fromm presented in his book "escape from freedom" (fromm, 1941) , human individual behavior is oriented to avoid being excluded from a higher social group. indeed, not following social common rules can be eventually considered as a mental disorder; a sociopathology. a social norm is defined as a predominant behavioral pattern within a group, supported by a shared understanding of acceptable actions and sustained through social interactions within that group (nyborg et al., 2016) . in democratic societies, laws usually derive from already accepted social norms; otherwise, they would be changed, and in that sense, the establishment of accepted social norms for fighting ar is a prerequisite to implement the global approaches, based on worldwide rules, which are required for tackling this relevant problem. interestingly, the ar problem is a bottom-up process, where small emergent changes (in some type of individual patients, in some groups, in some locations) cumulatively escalate to gain a global dimension. frequently, that occurs by crossing tipping points, that is, points where the local ar incidence becomes significant enough to cause a larger, eventually global, health problem. because of that, the implementation of solutions should be adapted to the control of critical tipping points in the small groups of individuals to disrupt the bottom-up processes. however, as ar spread can occur everywhere and at any time, global surveillance and mechanisms of control should be implemented to prevent a top-down process of global ar expansion. individual selfishness for ar is the cornerstone of social norms. this concept was coined and developed by one of us over a decade ago (baquero, 2007) . let us imagine that each individual is aware that each consumption of an antibiotic increases the personal risk of himself/herself or for his/her closer relatives (frequently exchanging microorganisms) of dying because of an antibiotic-resistant infection. the situation is analogous to the consumption of cholesterol-rich or highly salted food, or drinks with excess of sugar, concerning individual health. however, in the case of ar, it requires the understanding of the impact of individual actions at the global level. in this respect, anti-ar social actions should resemble more antitobacco and even general pollution/ecological campaigns. at the individual level, there is inertia that precludes changing habits, until a tipping point is crossed and health is compromised. the conclusions of studies mainly based on long-term cohort analysis, such as the framingham program for the influence of diet or smoking on personal cardiovascular disease (mahmood et al., 2014) , have become social norms that are naturally imposed by the ensemble of individuals. this creates a kind of societal culture, leading to appropriate individual behaviors, in occasions without the need of specific laws (diet), in occasion favoring the implementation of such laws (antismoking). however, we lack similar studies on issues such as these dealing with personalfamiliar risks that have successfully shifted social norms, driven by groups of individuals and based on the promotion of individual behaviors in the case of ar. despite that quantitative models on how individual antibiotic use may impact ar at the population level are still absent, it is worth mentioning that a reduced antibiotic consumption has also begun to occur in a number of countries just as a result of a change in individual behavior (edgar et al., 2009) , and some tools and indicators to address these changes have been suggested (ploy et al., 2020) . the "tragedy of the commons" metaphor, first proposed in the xix century (lloyd, 1833) and later on discussed in 1968 (hardin, 1968) , has been used for addressing the sociology of ar, by showing how individual selfishness promotes antibiotic use, increases resistance, and influences the health of the community by impairing antibiotic efficacy (baquero and campos, 2003; foster and grundmann, 2006) . ensuring the prestige of individuals that follow the social rules is needed to counteract the tragedy of the commons. nevertheless, it is important noticing that the tension between individual freedom and social rules that is inherent to the construction of democratic societies (tocqueville, 1838; hobbes, 1968; rousseau, 1974; spinoza, 2007) also applies here. one example of this situation is vaccination, considered in the last century as one of the most important advances to fight infectious diseases and now being the focus of antivaccination campaigns (megget, 2020) , a movement that has been considered by the who as one of the top 10 global health threats of 2019 1 . it is commonly accepted that social norms are mainly created by learning and education, a rational path that promotes health (chen and fu, 2018) . also, the increasing activities of "personalized medicine, " including antibiotic stewardship, follow the same trend (gould and lawes, 2016) . however, the antivaccination movement is an example of how the narrative, as well as the use of decentralized, social information channels such as the internet search, blogs, and applications to facilitate communication such as twitter, facebook or whatsapp, is of particular relevance in the construction of social norms, not necessarily based on scientific and rational grounds (jacobson et al., 2020; scott and mars, 2020) . the impact of social norms goes beyond human societies as human activities alter natural ecosystems; consequently, humans cannot be aliens of nature. we should then shape a socioecological system, linking the individuals, the groups, and the entire society, as well as natural ecosystems, also potentially damaged by ar, in a common multilevel adaptive system based on social norms and policies at the individual, local (one health), and global (global health) scale (levin et al., 2013) . the recent crisis of covid-19 illustrates the influence of social norms in the individual behavior. each one of the individuals, protecting himself/herself, also protects the others. a person not wearing on face mask is frowned upon, and on the contrary, somebody attaching to the rules increases reputation. the individual adopts the right behavior being influenced by the judgment. of others. in addition, different political regimes (democracy or autocracy), as well as their organization (centralized, federal), together with the capacity of the health services to support the norms and their efficacy to communicate the chosen policy to the citizenry, may shape the individual responses to social norms (greer et al., 2020; häyry, 2020; kavanagh and singh, 2020) . notwithstanding, two reasons that have been proposed to explain the low prevalence of covid-19 in japan were related with social norms more than with biological issues. these reasons, which are not common to other countries, were the socially accepted use of face masks and the mandatory vaccination of all the population against tuberculosis, which might protect from sars-cov-2 infection (iwasaki and grubaugh, 2020) , a feature that is still to be confirmed. the loss of social prestige of individuals taking antibiotics without prescription, as well as the pharmacies delivering these drugs or do not respect environmental protection, or the overconsumption of antibiotics in hospitals or in farms, or even in certain countries, is progressively constituting a "social norm, " converted in rules able to reduce ar emergence and spread. of course, family and school education, as well as governmental campaigns, including the use of social media (grajales et al., 2014) reinforces such social norms, which could allow the support of the society for the implementation of different interventions, some of them described below. controlling resistance not only requires establishing local interventions, which could be relatively easily implemented, but would also require global interventions that every country should follow, despite their disparate regulatory systems. local and global interventions are necessarily intertwined; for example, the use of a new drug to treat a single individual depends on regulations at the county level (one health approach), but the worldwide prevalence and transmission of resistance to this drug, as well as the regulations of its use, should be established internationally (global health approach). three main interventions to tackle ar have been historically considered: first, reduction of the antibiotic selective pressure by decreasing antimicrobials use; second, reduction of transmission of arbs using improved hygienic procedures that prevent spread; third, development of novel antimicrobials with limited capacity to select arbs or the design of new treatment strategies based on use of non-antibiotic-based approaches or, more recently, on the exploitation of trade-offs associated with ar evolution (imamovic and sommer, 2013; gonzales et al., 2015; barbosa et al., 2018; imamovic et al., 2018) . these interventions have been basically limited to local initiatives, applied mainly to hospitals and, more recently, to farms. however, ar has emerged and spread globally, in bacteria from different environments, so the health and dynamics of the global microbiosphere could be affected by antibiotics. in a sense, ar is affecting the planetary health (lerner and berg, 2017) , and the needed interventions for tackling this problem cannot be restricted to hospital settings (figure 3) . the proposed reduction in the use of antibiotics (blaskovich, 2018 ) must be compensated with alternative approaches for fighting infectious diseases. in this regard, strategies based on improving the capability of the immune system for counteracting infections (levin et al., 2017; traven and naderer, 2019) or the use of non-antibiotic approaches to prevent them, such as vaccines (jansen and anderson, 2018) , may help to reduce the burden of ar infections. indeed, vaccination against haemophilus influenzae and streptococcus pneumoniae has been demonstrated to be an effective intervention for reducing ar (jansen and anderson, 2018) . however, while vaccination has been extremely useful to prevent viral infections, it has been less promising in the case of bacterial ones. recent approaches, including reverse vaccinology, may help in filling this gap (delany et al., 2013; ni et al., 2017) . moreover, vaccination should not be restricted to humans, because veterinary vaccination can also contribute to animal wealth and farm productivity (francis, 2018) . besides, the use of vaccines in animal production reduces the use of antibiotics at farms/fisheries, hence reducing the selection pressure toward ar. other strategies to reduce antibiotic selective pressure include the use of bacteriophages (a revitalized strategy in recent years) (viertel et al., 2014; forti et al., 2018) , not only in clinical settings, but also in natural ecosystems (zhao et al., 2019b) , as well as the use of biodegradable antibiotics (chin et al., 2018) or adsorbents, able to reduce selective pressure on commensal microbiome (de gunzburg et al., 2015 . besides reducing the chances of selecting arbs, the use of antibiotics adsorbents may preserve the microbiomes, reducing the risks of infections (chapman et al., 2016) . importantly, the procedures for removing antibiotics should not be limited to clinical settings, but their implementation in wastewater treatment plants would reduce selection of ar in non-clinical ecosystems (tian et al., 2020) . concerning the development of new antimicrobials (hunter, 2020) , while there is a basic economic issue related to the incentives to pharmaceutical companies (sciarretta et al., 2016; theuretzbacher et al., 2017) , the focus is on the possibility of developing novel compounds with low capacity for selecting ar (ling et al., 2015; chin et al., 2018) . for this purpose, multitarget (li et al., 2014) or antiresistance drugs, such as membrane microdomain disassemblers (garcia-fernandez et al., 2017) , are also promising. furthermore, antimicrobial peptides, with a dual role as immunomodulators and antimicrobials, may also help fight infections (hancock et al., 2016) . in fact, some works figure 3 | local and global intervention strategies to tackle ar and knowledge gaps that could help improve existing ones. most interventions for reducing antibiotic resistance are based on impairing the selection of arbs/args, which is just the first event in ar spread. our main goal, as for any other infectious disease, figure 3 | continued would be reducing transmission. this does not mean that selective pressure is not relevant for transmission. indeed, without positive selection, hgt events are not fixed, allowing the enrichment of some args that are consequently more prone to diversification, both because they are more abundant and more frequently subjected to selection (davies, 1997; martinez, 2009a,b; salverda et al., 2010 ) and because they can explore different landscapes when present as merodiploids in multicopy plasmids (rodriguez-beltran et al., 2018) . therefore, reducing the selective pressure, either due to antibiotics or by other coselecting agents as heavy metals, still stands as a major intervention against ar emergence and transmission. to address this issue, we need to know more on the amount of pollutants, their selective concentrations, and their mechanisms of coselection and cross-selection in different ecosystems. this is a general example illustrating the gaps in knowledge in the ar field that need to be filled as well as strategies that may help in tackling this problem. the figure includes several other examples of the gaps of knowledge (red) that require further studies and the interventions (blue) that may help to tackle ar. have shown that arb frequently present collateral sensitivity to antimicrobial peptides (lázár et al., 2018) and that, importantly, some antimicrobial peptides present limited resistance or crossresistance (kintses et al., 2019; spohn et al., 2019) . from a conservative point of view, based on the use of the drugs we already have, it would be desirable to fight ar using evolution-based strategies for developing new drugs or treatment strategies. regarding this, the exploitation of the evolutionary trade-offs associated with the acquisition of ar, as collateral sensitivity, could allow the rational design of treatments based on the alternation or the combination of pairs of drugs (imamovic and sommer, 2013; gonzales et al., 2015; barbosa et al., 2018; imamovic et al., 2018) . in addition to interventions that reduce the selective pressure of antibiotics or that implement new therapeutic approaches, reducing transmission is also relevant to fight infections. the development of drugs or conditions (as certain wastewater treatments) able to reduce mutagenesis or to inhibit plasmid conjugation may also help in reducing the spread of resistance (thi et al., 2011; alam et al., 2016; lin et al., 2016; lopatkin et al., 2017; valencia et al., 2017; kudo et al., 2019) . besides specific drugs to reduce the dissemination of the genetic elements involved in ar, socioeconomic interventions to break the bridges that allow transmission between individuals and, most importantly (and less addressed), between resistance entities (hernando-amado et al., 2019) are needed (figure 3) . more efficient animal management, not only allowing less antibiotics use but also reducing animal crowding (and hence ar transmission), as well as improved sanitation procedures, including the universalization of water treatment, will certainly help in this task (berendonk et al., 2015; manaia, 2017; hernando-amado et al., 2019) . notably, wastewater treatment plants are usually communal facilities where the residues of the total population of a city are treated. hospitals are the hotspots of ar in a city; hence, on-site hospital (and eventually onfarm) wastewater treatment may help to reduce the pollution of communal wastewater by antibiotics and arbs (cahill et al., 2019; paulus et al., 2019) , hence reducing ar transmission. concerning trade of goods, it is relevant to remark that, although there are strict regulations to control the entrance of animals or plants from sites with zoonotic of plant epidemic diseases (brown and bevins, 2018) , there are no regulations on the exchange of goods from geographic regions with a high ar prevalence, a feature that might be taken into consideration for reducing the worldwide spread of ar. once arbs are selected and disseminated, interventions based on the ecological and evolutionary (eco-evo) aspects of ar lehtinen et al., 2019) should be applied to restore (and select for) susceptibility of bacterial populations, as well as to preserve drug-susceptible microbiomes in humans and in animals . eco-evo strategies include the development of drugs specifically targeting arbs. for that, drugs activated by mechanisms of resistance, vaccines targeting high-risk disseminating resistance clones or the resistance mechanisms themselves (kim et al., 2016; ni et al., 2017) , or drugs targeting metabolic paths that can be specifically modified in arbs ) might be useful. the use of bacteriovores such as bdellovibrio to eliminate pathogens without the need for antibiotics has been proposed; although its utility for treating infections is debatable, it might be useful in natural ecosystems (shatzkes et al., 2016) . more recent work suggests that some earthworms may favor the degradation of antibiotics and the elimination of arbs (wikler, 2002) , a feature that might be in agreement with the finding that arbs are less virulent (and hence might be specifically eliminated when the worm is present) in a caenorhabditis elegans virulence model ruiz-diez et al., 2003; paulander et al., 2007; olivares et al., 2012) . however, the information on the potential use of worms for reducing ar in the field is still preliminary and requires further confirmation. noteworthy, ar is less prone to be acquired by complex microbiomes (mahnert et al., 2019; wood, 2019) , a feature that supports the possibility of interventions on the microbiota to reduce ar. among them, fecal transplantation (chapman et al., 2016; pamer, 2016) or the use of probiotics able to outcompete arbs (keith and pamer, 2019) has been proposed as strategies for recovering susceptible microbiomes. the recent crisis of covid-19 (garrett, 2020) resembles the pandemic expansion of args and clearly shows that pandemic outbreaks cannot be solved by just applying local solutions. further, unless all population is controlled, and comprehensive public-health protocols are applied to the bulk of the population, such global pandemics will be hardly controlled. the case of covid-19 is rather peculiar, because we are dealing with a novel virus. very strict interventions have been applied, mainly trying to control something that is a novel, unknown, disease; we have been learning along the pandemic and still ignore what will come further. ar is already a very well-known pandemic affecting humans, animals, and natural ecosystems (anderson, 1999; verhoef, 2003) . in this case, we have tools that might predict the outcome, and likely because the degree of uncertainty is lower than in the case of covid-19, we have not applied clear, common, and comprehensive procedures to reduce the spread of ar. it is true that we know the evolution of antibiotics consumption and ar prevalence in several countries, and also interventions, mostly based on social norms, have been applied. social norms have reduced the unnecessary prescription of antibiotics, or pharmacy sales without prescription, and the use of antibiotics for fattening animals has been banned in several countries, being still allowed in several others. nevertheless, these actions are not general, and more aggressive, global actions are still needed. coming back to the covid-19 example, while the aim of health services worldwide is to detect any possible source of sars-cov-2, surveillance of infections (eventually by arbs) is not universal. in other words, it does not apply to all citizens in all countries. the reasons can be just political such as the inclusion of immigrants in public health services (scotto et al., 2017) or the consequence of limited financial resources and technical capacity that countries such as those belonging to the lmic category can face (gandra et al., 2020) . the problem is not only on citizens, because different non-human reservoirs, such as wastewater, drinking water, or freshwater, may jointly contribute to ar dissemination (hendriksen et al., 2019) . in this regard, it is important to highlight that low quality of water is regularly associated to poverty. universalization of health services, sanitization, access to clean water, and in general reduction of poverty are relevant step-forward elements for reduction of the burden of infectious diseases in general and of ar in particular. the time has come to tackle ar, and this cannot be done just by taking actions at the individual or even country level, but by taking convergent actions across the globe. as stated by john donne (1923) in his poem, "no man is an island, " written after his recovery from an infectious disease (likely typhus): "no man is an iland, intire of itselfe; every man is a peece of the continent, a part of the maine; if a clod bee washed away by the sea, europe is the lesse, as well as if a promontorie were, as well as if a manor of thy friends or of thine owne were; any mans death diminishes me, because i am involved in mankinde; and therefore never send to know for whom the bell tolls; it tolls for thee." this reflection on how infectious diseases in general should be faced by the society was published at 1624, but the idea behind still applies nowadays, especially for ar. all authors have contributed to the concept of the review and in its writing. jm was supported by grants from the instituto de salud carlos iii [spanish network for research on infectious diseases (rd16/0016/0011)], from the spanish ministry of economy and competitivity (bio2017-83128-r) and from the autonomous community of madrid (b2017/bmd-3691). work in tc and fb laboratory was supported by grants funded by the joint programming initiative in antimicrobial resistance (jpiamr third call, starcs, jpiamr2016-ac16/00039), the instituto de salud carlos iii of spain/ministry of economy and competitiveness and the european development regional fund "a way to achieve europe" (erdf) for co-founding the spanish r&d national plan estatal de i + d + i 2013-2016 (pi18/1942), ciberesp (ciber in epidemiology and public health; cb06/02/0053), the regional government of madrid (ingemics-b2017/bmd-3691) and the fundación ramón areces. the funders did not have any role neither in the design, nor in the writing of the current review. association between decreased susceptibility to a new antibiotic for treatment of human diseases, everninomicin (sch 27899), and resistance to an antibiotic used for growth promotion in animals surveillance of antimicrobial 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surface water of eutrophic urban lakes are related to heavy metals, antibiotics, lake morphology and anthropic impact identification of acquired antimicrobial resistance genes sub-inhibitory concentrations of heavy metals facilitate the horizontal transfer of plasmidmediated antibiotic resistance genes in water environment evidence for co-selection of antibiotic resistance genes and mobile genetic elements in metal polluted urban soils comparing polyvalent bacteriophage and bacteriophage cocktails for controlling antibioticresistant bacteria in soil-plant system microbial mass movements from "one medicine" to "one health" and systemic approaches to health and well-being key: cord-263255-zdufwtn4 authors: cato, susumu; iida, takashi; ishida, kenji; ito, asei; mcelwain, kenneth mori; shoji, masahiro title: social distancing as a public good under the covid-19 pandemic date: 2020-08-13 journal: public health doi: 10.1016/j.puhe.2020.08.005 sha: doc_id: 263255 cord_uid: zdufwtn4 abstract objectives the purpose of this study is to show that social distancing is a public good under the covid-19 pandemic. study design we apply economic theory to analyze a cross-sectional survey. methods economic theory is complemented with empirical evidence. an online survey of those aged 30-49 in japan (n=2,177) was conducted between april 28 may 7. respondents were selected by quota sampling with regard to age group, gender and prefecture of residence. our main figure shows the proportion of people who increased/did not change/decreased social distancing, relative to the level of altruism and sensitivity to public shaming. the results of ols and logit models are shown in supplementary materials. results social distancing is a public good under the covid-19 pandemic, for which the free-rider problem is particularly severe. altruism and social norms are crucial factors in overcoming this problem. using an original survey, we show that people with higher altruistic concerns and sensitivity to shaming are more likely to follow social-distancing measures. conclusions altruism and social norms are important for reducing the economic cost of the pandemic. the concept of public goods has been explored in various fields of the social sciences. by definition, public goods are non-rivalrous (their usage by one individual does not reduce their availability to others) and non-excludable (individuals cannot be excluded from using them). as a result, people have an incentive to freeride: receiving the benefits without paying for the costs. i social distancing during the covid-19 pandemic is one such public good. consider a selfish individual who maximizes his/her own utility, which consists solely of personal benefits and costs. the personal benefit of social distancing is the reduction of one's probability of infection, while the personal cost (assuming employment opportunities are unchanged) comes from foregoing enjoyable activities, such as dining out. he/she chooses the degree of social distancing by balancing these benefits and costs. however, selfish individuals do not take the social benefit of social distancing into account. because social distancing by one individual decreases not only the probability of his/her own infection but also that of others, the social benefit of social distancing is greater than its personal benefit. this gap results in the insufficient provision of social distancing. the management of covid-19 thus requires the resolution of a collective action problem, where the lack of alignment between individual incentives and common objectives produces socially suboptimal outcomes. crucially, inefficiency due to this collective action problem can be particularly severe in the case of covid-19. for one, social distancing is beneficial to society as a whole, but public goods are more difficult to provide in larger groups, where freeriding incentives are stronger. ii for another, because the health effects of covid-19 are heterogeneous, those who expect minimal symptoms, such as younger age cohorts, have weaker incentives to maintain social distance. even if the share of such people is small, the collective consequences can be dire. in sum, even if some people follow social distancing measures for self-preservation reasons alone, the social average is likely to be substantially lower than the level required to eradicate the pandemic. however, social and psychological mechanisms can mitigate the collective action problem. the first is altruism. although the argument thus far has relied on the assumption of selfishness, numerous studies in ethics, psychology, and economics have demonstrated that people care about others. iii in particular, the empathy-altruism hypothesis suggests that people have intrinsic motivations to help others because of empathy, or the incorporation of the utility of others into one's own utility function. this claim is consistent with the traditions of moral philosophy since adam smith and david hume. figure 1 shows the results from an original social survey in japan, where we measured respondents' psychological traits and inquired about various social distancing actions. those who agreed that "it is important to help people around you and make them happy" (top row) were more likely to have reduced how often they dined out. thus, we find a positive effect of altruism on social distancing behaviours. this pattern is robust in ols and logit models that control for respondents' demographic characteristics (supplementary material (1)). this evidence is theoretically explained as follows. an altruistic individual takes the probability of being a silent spreader into account when they choose his/her level of social distancing. thus, his/her willingness to dine out or engage in other public activities is lower than that of selfish individuals. as a consequence, altruistic individuals are expected to maintain social distance more than selfish individuals. this mechanism might not always work. in figure 1 , we examine one specific type of behaviour: dining out. other types of social distancing may be reduced by altruism. for example, somebody with strong empathy for those facing physical or emotional hardships, especially family and friends, may feel compelled to engage them in face-to-face interactions for altruistic reasons. in such a case, altruistic concerns may have a negative influence on social distancing, as well as a positive one. a second mechanism that can mitigate the collective action problem is shaming, an extrinsic motivation driven by social norms and obligations. iv v people who violated social distancing j o u r n a l p r e -p r o o f guidelines have been publicly criticized in many countries, including japan, the uk, and the u.s. (2)). fear of these implicit or explicit sanctions-such as peer pressure, public shame, exclusion, and criticism from neighbours and colleagues-can generate incentives to abide by social norms. the third and fourth rows in figure 1 provide evidence of this. survey respondents who agreed that "it is important to always avoid doing anything people would say is wrong" were more likely to have reduced the frequency of dining out. this observation suggests that public shame can encourage social distancing (supplementary material (1) ). however, if shaming results in the stigmatization of infected persons as norm-breakers, not to say as public health risks, then that can generate the worse outcome of people hiding their illness. it is incumbent upon policymakers to provide accurate local information about infections and promote altruism without stigmatization, for example, by avoiding naming individuals or businesses with confirmed infections. [ figure 1 around here] the above-mentioned two mechanisms rely on voluntary actions, but not all individuals are sufficiently altruistic or norm-abiding. as such, legal enforcement, including extensive monitoring and penalties for violations, may be necessary for infection control. however, the cost of enforcement is tremendously high: the epicentres of infection are mainly metropolitan areas, whose lockdown-even if temporary-can result in severe economic damages. vi since voluntary or nudgebased approaches are not accompanied with high economic cost, these can help to reduce collective costs; moreover, these might successfully preserve civil liberties. at the same time, in the presence of altruistic, other-regarding concerns, small legal sanctions may be enough. designing these sanctions can be tricky: seemingly simple penalties, such as imposing a fee, can reduce altruistic behaviour, if j o u r n a l p r e -p r o o f individuals come to believe that they are absolved morally for violating social norms as long as they pay the fee. vii viii we should note here that the results of our survey on japan should be generalized only with caution. altruistic concerns or social norms change over time,and their effectiveness also varies across cultural backgrounds. further studies from different countries are essential before we can reliably conclude how policymakers can overcome collective action problems during this pandemic. that said, the economic argument and social-psychological evidence discussed above point to the following policy implication. each of the three mechanisms for mitigating collection action problems-altruism, shaming, and legal sanctions-have inherent advantages and disadvantages, and none may be strong enough individually to produce socially optimal outcomes. however, combining these mechanisms may yield sufficient social distancing with low economic costs, because there are possible complementary effects between them. thus, an important task for policymakers is to integrate psychological, social, and legal measures to ensure that these public goods are provided adequately. figure 1 : social distancing by altruism and sensitivity to shame note: each row shows the distribution of responses to the following question: has your frequency of going out for dinners increased or decreased since last march? the first two rows divide the sample according to the respondent's altruism, elicited by the following question: do you think it is important to help people around you and make them happy? the first row presents those who answered affirmatively, whereas the second row corresponds to those with neutral or negative responses. likewise, the third and fourth rows divide the sample by the respondents' sensitivity to shame, elicited by the following question: do you think it is important to avoid doing anything people would say is wrong? these questions on altruism and sensitivity to shame are modified from the world values survey. our survey (n=2,177) was conducted between april 28 and may 7, using an access panel provided by rakuten insight. j o u r n a l p r e -p r o o f the pure theory of public expenditure the logic of collective action: public goods and the theory of group incentives and prosocial behavior collective action and the evolution of social norms health vs. wealth? public health policies and the economy during covid-19 (no. w27099) economic incentives and social preferences: substitutes or complements? we thank an anonymous referee for helpful comments. this paper was supported by kakenhi (jp17h02478, jp18k01501, jp20k01689), and the group-joint-research project grant ("social sciences of digitalization") of the institute of social science, the university of tokyo. there is no conflict.authors contributions: cato (survey design, writing, data analysis); iida (survey design, data collection); ishida (survey design, data analysis); ito (survey design, data interpretation); mcelwain (survey design, writing, data interpretation); shoji (survey design, writing, data analysis) key: cord-285522-3gv6469y authors: bello-orgaz, gema; jung, jason j.; camacho, david title: social big data: recent achievements and new challenges date: 2015-08-28 journal: inf fusion doi: 10.1016/j.inffus.2015.08.005 sha: doc_id: 285522 cord_uid: 3gv6469y big data has become an important issue for a large number of research areas such as data mining, machine learning, computational intelligence, information fusion, the semantic web, and social networks. the rise of different big data frameworks such as apache hadoop and, more recently, spark, for massive data processing based on the mapreduce paradigm has allowed for the efficient utilisation of data mining methods and machine learning algorithms in different domains. a number of libraries such as mahout and sparkmlib have been designed to develop new efficient applications based on machine learning algorithms. the combination of big data technologies and traditional machine learning algorithms has generated new and interesting challenges in other areas as social media and social networks. these new challenges are focused mainly on problems such as data processing, data storage, data representation, and how data can be used for pattern mining, analysing user behaviours, and visualizing and tracking data, among others. in this paper, we present a revision of the new methodologies that is designed to allow for efficient data mining and information fusion from social media and of the new applications and frameworks that are currently appearing under the “umbrella” of the social networks, social media and big data paradigms. data volume and the multitude of sources have experienced exponential growth, creating new technical and application challenges; data generation has been estimated at 2.5 exabytes (1 exabyte = 1.000.000 terabytes) of data per day [1] . these data come from everywhere: sensors used to gather climate, traffic and flight information, posts to social media sites (twitter and facebook are popular examples), digital pictures and videos (youtube users upload 72 hours of new video content per minute [2] ), transaction records, and cell phone gps signals, to name a few. the classic methods, algorithms, frameworks, and tools for data management have become both inadequate for processing this amount of data and unable to offer effective solutions for managing the data growth. the problem of managing and extracting useful knowledge from these data sources is currently one of the most popular topics in computing research [3, 4] . in this context, big data is a popular phenomenon that aims to provide an alternative to traditional solutions based on databases and data analysis. big data is not just about storage or access to data; its solutions aim to analyse data in order to make sense of them and exploit their value. big data refers to datasets that are terabytes to of challenges in obtaining valuable knowledge for people and companies (see value feature). • velocity: refers to the speed of data transfers. the data's contents are constantly changing through the absorption of complementary data collections, the introduction of previous data or legacy collections, and the different forms of streamed data from multiple sources. from this point of view, new algorithms and methods are needed to adequately process and analyse the online and streaming data. • variety: refers to different types of data collected via sensors, smartphones or social networks, such as videos, images, text, audio, data logs, and so on. moreover, these data can be structured (such as data from relational databases) or unstructured in format. • value: refers to the process of extracting valuable information from large sets of social data, and it is usually referred to as big data analytics. value is the most important characteristic of any big-data-based application, because it allows to generate useful business information. • veracity: refers to the correctness and accuracy of information. behind any information management practice lie the core doctrines of data quality, data governance, and metadata management, along with considerations of privacy and legal concerns. some examples of potential big data sources are the open science data cloud [8] , the european union open data portal, open data from the u.s. government, healthcare data, public datasets on amazon web services, etc. social media [9] has become one of the most representative and relevant data sources for big data. social media data are generated from a wide number of internet applications and web sites, with some of the most popular being facebook, twitter, linkedin, youtube, instagram, google, tumblr, flickr, and wordpress. the fast growth of these web sites allow users to be connected and has created a new generation of people (maybe a new kind of society [10] ) who are enthusiastic about interacting, sharing, and collaborating using these sites [11] . this information has spread to many different areas such as everyday life [12] (e-commerce, e-business, e-tourism, hobbies, friendship, ...), education [13] , health [14] , and daily work. in this paper, we assume that social big data comes from joining the efforts of the two previous domains: social media and big data. therefore, social big data will be based on the analysis of vast amounts of data that could come from multiple distributed sources but with a strong focus on social media. hence, social big data analysis [15, 16] is inherently interdisciplinary and spans areas such as data mining, machine learning, statistics, graph mining, information retrieval, linguistics, natural language processing, the semantic web, ontologies, and big data computing, among others. their applications can be extended to a wide number of domains such as health and political trending and forecasting, hobbies, e-business, cybercrime, counterterrorism, time-evolving opinion mining, social network analysis, and humanmachine interactions. the concept of social big data can be defined as follows: "those processes and methods that are designed to provide sensitive and relevant knowledge to any user or company from social media data sources when data sources can be characterised by their different formats and contents, their very large size, and the online or streamed generation of information." the gathering, fusion, processing and analysing of the big social media data from unstructured (or semi-structured) sources to extract value knowledge is an extremely difficult task which has not been completely solved. the classic methods, algorithms, frameworks and tools for data management have became inadequate for processing the vast amount of data. this issue has generated a large number of open problems and challenges on social big data domain related to different aspects as knowledge representation, data management, data processing, data analysis, and data visualisation [17] . some of these challenges include accessing to very large quantities of unstructured data (management issues), determination of how much data is enough for having a large quantity of high quality data (quality versus quantity), processing of data stream dynamically changing, or ensuring the enough privacy (ownership and security), among others. however, given the very large heterogeneous dataset from social media, one of the major challenges is to identify the valuable data and how analyse them to discover useful knowledge improving decision making of individual users and companies [18] . in order to analyse the social media data properly, the traditional analytic techniques and methods (data analysis) require adapting and integrating them to the new big data paradigms emerged for massive data processing. different big data frameworks such as apache hadoop [19] and spark [20] have been arising to allow the efficient application of data mining methods and machine learning algorithms in different domains. based on these big data frameworks, several libraries such as mahout [21] and sparkmlib [22] have been designed to develop new efficient versions of classical algorithms. this paper is focused on review those new methodologies, frameworks, and algorithms that are currently appearing under the big data paradigm, and their applications to a wide number of domains such as e-commerce, marketing, security, and healthcare. finally, summarising the concepts mentioned previously, fig. 1 shows the conceptual representation of the three basic social big data areas: social media as a natural source for data analysis; big data as a parallel and massive processing paradigm; and data analysis as a set of algorithms and methods used to extract and analyse knowledge. the intersections between these clusters reflect the concept of mixing those areas. for example, the intersection between big data and data analysis shows some machine learning frameworks that have been designed on top of big data technologies (mahoot [21] , mlbase [23, 24] , or sparkmlib [22] ). the intersection between data analysis and social media represents the concept of current web-based applications that intensively use social media information, such as applications related to marketing and e-health that are described in section 4. the intersection between big data and social media is reflected in some social media applications such as linkedin, facebook, and youtube that are currently using big data technologies (mon-godb, cassandra, hadoop, and so on) to develop their web systems. finally, the centre of this figure only represents the main goal of any social big data application: knowledge extraction and exploitation. the rest of the paper is structured as follows; section 2 provides an introduction to the basics on the methodologies, frameworks, and software used to work with big data. section 3 provides a description of the current state of the art in the data mining and data analytic techniques that are used in social big data. section 4 describes a number of applications related to marketing, crime analysis, epidemic intelligence, and user experiences. finally, section 5 describes some of the current problems and challenges in social big data; this section also provides some conclusions about the recent achievements and future trends in this interesting research area. currently, the exponential growth of social media has created serious problems for traditional data analysis algorithms and techniques (such as data mining, statistics, machine learning, and so on) due to their high computational complexity for large datasets. this type of methods does not properly scale as the data size increases. for this reason, the methodologies and frameworks behind the big data concept are becoming very popular in a wide number of research and industrial areas. this section provides a short introduction to the methodology based on the mapreduce paradigm and a description of the most popular framework that implements this methodology, apache hadoop. afterwards apache spark is described as emerging big data framework that improves the current performance of the hadoop framework. finally, some implementations and tools for big data domain related to distributed data file systems, data analytics, and machine learning techniques are presented. mapreduce [25, 26] is presented as one of the most efficient big data solutions. this programming paradigm and its related algorithms [27] , were developed to provide significant improvements in large-scale data-intensive applications in clusters [28] . the programming model implemented by mapreduce is based on the definition of two basic elements: mappers and reducers. the idea behind this programming model is to design map functions (or mappers) that are used to generate a set of intermediate key/value pairs, after which the reduce functions will merge (reduce can be used as a shuffling or combining function) all of the intermediate values that are associated with the same intermediate key. the key aspect of the mapreduce algorithm is that if every map and reduce is independent of all other ongoing maps and reduces, then the operations can be run in parallel on different keys and lists of data. although three functions, map(), combining()/shuffling(), and reduce(), are the basic processes in any mapreduce approach, usually they are decomposed as follows: 1. prepare the input: the mapreduce system designates map processors (or worker nodes), assigns the input key value k1 that each processor would work on, and provides each processor with all of the input data associated with that key value. 2. the map() step: each worker node applies the map() function to the local data and writes the output to a temporary storage space. the map() code is run exactly once for each k1 key value, generating output that is organised by key values k2. a master node arranges it so that for redundant copies of input data only one is processed. 3. the shuffle() step: the map output is sent to the reduce processors, which assign the k2 key value that each processor should work on, and provide that processor with all of the map-generated data associated with that key value, such that all data belonging to one key are located on the same worker node. 4. the reduce() step: worker nodes process each group of output data (per key) in parallel, executing the user-provided reduce() code; each function is run exactly once for each k2 key value produced by the map step. 5. produce the final output: the mapreduce system collects all of the reduce outputs and sorts them by k2 to produce the final outcome. fig. 2 shows the classical "word count problem" using the mapreduce paradigm. as fig. 2 shown, initially a process will split the data into a subset of chunks that will later be processed by the mappers. once the key/values are generated by mappers, a shuffling process is used to mix (combine) these key values (combining the same keys in the same worker node). finally, the reduce functions are used to count the words that generate a common output as a result of the algorithm. as a result of the execution or wrappers/reducers, the output will generate a sorted list of word counts from the original text input. (01, "i thought i") (02, "thought of thinking") (03, "of thanking you") finally, and before the application of this paradigm, it is essential to understand if the algorithms can be translated to mappers and reducers or if the problem can be analysed using traditional strategies. mapreduce provides an excellent technique to work with large sets of data when the algorithm can work on small pieces of that dataset in parallel, but if the algorithm cannot be mapped into this methodology, it may be "trying to use a sledgehammer to crack a nut". any mapreduce system (or framework) is based on a mapreduce engine that allows for implementing the algorithms and distributing the parallel processes. apache hadoop [19] is an open-source software framework written in java for the distributed storage and distributed processing of very large datasets using the mapreduce paradigm. all of the modules in hadoop have been designed taking into account the assumption that hardware failures (of individual machines or of racks of machines) are commonplace and thus should be automatically managed in the software by the framework. the core of apache hadoop comprises a storage area, the hadoop distributed file system (hdfs), and a processing area (mapreduce). the hdfs (see section 2.4.1) spreads multiple copies of the data across different machines. this not only offers reliability without the need for raid-controlled disks but also allows for multiple locations to run the mapping. if a machine with one copy of the data is busy or offline, another machine can be used. a job scheduler (in hadoop, the jobtracker) keeps track of which mapreduce jobs are executing; schedules individual maps; reduces intermediate merging operations to specific machines; monitors the successes and failures of these individual tasks; and works to complete the entire batch job. the hdfs and the job scheduler can be accessed by the processes and programs that need to read and write data and to submit and monitor the mapreduce jobs. however, hadoop presents a number of limitations: 1. for maximum parallelism, you need the maps and reduces to be stateless, to not depend on any data generated in the same mapreduce job. you cannot control the order in which the maps run or the reductions. 2. hadoop is very inefficient (in both cpu time and power consumed) if you are repeating similar searches repeatedly. a database with an index will always be faster than running a mapreduce job over un-indexed data. however, if that index needs to be regenerated whenever data are added, and data are being added continually, mapreduce jobs may have an edge. 3. in the hadoop implementation, reduce operations do not take place until all of the maps have been completed (or have failed and been skipped). as a result, you do not receive any data back until the entire mapping has finished. 4. there is a general assumption that the output of the reduce is smaller than the input to the map. that is, you are taking a large data source and generating smaller final values. apache spark [20] is an open-source cluster computing framework that was originally developed in the amplab at university of california, berkeley. spark had over 570 contributors in june 2015, making it a very high-activity project in the apache software foundation and one of the most active big data open source projects. it provides high-level apis in java, scala, python, and r and an optimised engine that supports general execution graphs. it also supports a rich set of high-level tools including spark sql for sql and structured data processing, spark mllib for machine learning, graphx for graph processing, and spark streaming. the spark framework allows for reusing a working set of data across multiple parallel operations. this includes many iterative machine learning algorithms as well as interactive data analysis tools. therefore, this framework supports these applications while retaining the scalability and fault tolerance of mapreduce. to achieve these goals, spark introduces an abstraction called resilient distributed datasets (rdds). an rdd is a read-only collection of objects partitioned across a set of machines that can be rebuilt if a partition is lost. in contrast to hadoops two-stage disk-based mapreduce paradigm (mappers/reducers), sparks in-memory primitives provide performance up to 100 times faster for certain applications by allowing user programs to load data into a clusters memory and to query it repeatedly. one of the multiple interesting features of spark is that this framework is particularly well suited to machine learning algorithms [ [29] ]. from a distributed computing perspective, spark requires a cluster manager and a distributed storage system. for cluster management, spark supports stand-alone (native spark cluster), hadoop yarn, and apache mesos. for distributed storage, spark can interface with a wide variety, including the hadoop distributed file system, apache cassandra, openstack swift, and amazon s3. spark also supports a pseudo-distributed local mode that is usually used only for development or testing purposes, when distributed storage is not required and the local file system can be used instead; in this scenario, spark is running on a single machine with one executor per cpu core. a list related to big data implementations and mapreduce-based applications was generated by mostosi [30] . although the author finds that "it is [the list] still incomplete and always will be", his "big-data ecosystem table" [31] contains more than 600 references related to different big data technologies, frameworks, and applications and, to the best of this authors knowledge, is one of the best (and more exhaustive) lists related to available big data technologies. this list comprises 33 different topics related to big data, and a selection of those technologies and applications were chosen. those topics are related to: distributed programming, distributed files systems, a document data model, a key-value data model, a graph data model, machine learning, applications, business intelligence, and data analysis. this selection attempts to reflect some of the recent popular frameworks and software implementations that are commonly used to develop efficient mapreduce-based systems and applications. • apache pig. pig provides an engine for executing data flows in parallel on hadoop. it includes a language, pig latin, for expressing these data flows. pig latin includes operators for many of the traditional data operations (join, sort, filter, etc.), as well as the ability for users to develop their own functions for reading, processing, and writing data. • apache storm. storm is a complex event processor and distributed computation framework written basically in the clojure programming language [32] . it is a distributed real-time computation system for rapidly processing large streams of data. storm is an architecture based on a master-workers paradigm, so that a storm cluster mainly consists of master and worker nodes, with coordination done by zookeeper [33] . • stratosphere [34] . stratosphere is a general-purpose cluster computing framework. it is compatible with the hadoop ecosystem:, accessing data stored in the hdfs and running with hadoops new cluster manager yarn. the common input formats of hadoop are supported as well. stratosphere does not use hadoops mapreduce implementation; it is a completely new system that brings its own runtime. the new runtime allows for defining more advanced operations that include more transformations than only map and reduce. additionally, stratosphere allows for expressing analysis jobs using advanced data flow graphs, which are able to resemble common data analysis task more naturally. • apache hdfs. the most extended and popular distributed file system for mapreduce frameworks and applications is the hadoop distributed file system. the hdfs offers a way to store large files across multiple machines. hadoop and hdfs were derived from the google file system (gfs) [35] . cassandra is a recent open source fork of a stand-alone distributed non-sql dbms system that was initially coded by facebook, derived from what was known of the original google bigtable [36] and google file system designs [35] . cassandra uses a system inspired by amazons dynamo for storing data, and mapreduce can retrieve data from cassandra. cassandra can run without the hdfs or on top of it (the datastax fork of cassandra). • apache giraph. giraph is an iterative graph processing system built for high scalability. it is currently used at facebook to analyse the social graph formed by users and their connections. giraph was originated as the open-source counterpart to pregel [37] , the graph processing framework developed at google (see section 3.1 for a further description). • mongodb. mongodb is an open-source document-oriented database system and is part of the nosql family of database systems [38] . it provides high performance, high availability, and automatic scaling. instead of storing data in tables as is done in a classical relational database, mongodb stores structured data as json-like documents, which are data structures composed of fields and value pairs. its index system supports faster queries and can include keys from embedded documents and arrays. moreover, this database allows users to distribute data across a cluster of machines. • apache mahout [21] . the mahout(tm) machine learning (ml) library is an apache(tm) project whose main goal is to build scalable libraries that contain the implementation of a number of the conventional ml algorithms (dimensionality reduction, classification, clustering, and topic models, among others). in addition, this library includes implementations for a set of recommender systems (user-based and item-based strategies). the first versions of mahout implemented the algorithms built on the hadoop framework, but recent versions include many new implementations built on the mahout-samsara environment, which runs on spark and h2o. the new spark-item similarity implementations enable the next generation of co-occurrence recommenders that can use entire user click streams and contexts in making recommendations. • spark mllib [22] . mllib is sparks scalable machine learning library, which consists of common learning algorithms and utilities, including classification, regression, clustering, collaborative filtering, and dimensionality reduction, as well as underlying optimization primitives. it supports writing applications in java, scala, or python and can run on any hadoop2/yarn cluster with no preinstallation. the first version of mllib was developed at uc berkeley by 11 contributors, and it provided a limited set of standard machine learning methods. however, mllib is currently experiencing dramatic growth, and it has over 140 contributors from over 50 organisations. • mlbase [23] . the mlbase platform consists of three layers: ml optimizer, mllib, and mli. ml optimizer (currently under development) aims to automate the task of ml pipeline construction. the optimizer solves a search problem over the feature extractors and ml algorithms included in mli and mllib. mli [24] is an experimental api for feature extraction and algorithm development that introduces high-level ml programming abstractions. a prototype of mli has been implemented against spark and serves as a test bed for mllib. finally, mllib is apache sparks distributed ml library. mllib was initially developed as part of the mlbase project, and the library is currently supported by the spark community. pentaho is an open source data integration (kettle) tool that delivers powerful extraction, transformation, and loading capabilities using a groundbreaking, metadata-driven approach. it also provides analytics, reporting, visualisation, and a predictive analytics framework that is directly designed to work with hadoop nodes. it provides data integration and analytic platforms based on hadoop in which datasets can be streamed, blended, and then automatically published into one of the popular analytic databases. • sparkr. there is an important number of r-based applications for mapreduce and other big data applications. r [39] is a popular and extremely powerful programming language for statistics and data analysis. sparkr provides an r frontend for spark. it allows users to interactively run jobs from the r shell on a cluster, automatically serializes the necessary variables to execute a function on the cluster, and also allows for easy use of existing r packages. social big data analytic can be seen as the set of algorithms and methods used to extract relevant knowledge from social media data sources that could provide heterogeneous contents, with very large size, and constantly changing (stream or online data). this is inherently interdisciplinary and spans areas such as data mining, machine learning, statistics, graph mining, information retrieval, and natural language among others. this section provides a description of the basic methods and algorithms related to network analytics, community detection, text analysis, information diffusion, and information fusion, which are the areas currently used to analyse and process information from social-based sources. today, society lives in a connected world in which communication networks are intertwined with daily life. for example, social networks are one of the most important sources of social big data; specifically, twitter generates over 400 million tweets every day [40] . in social networks, individuals interact with one another and provide information on their preferences and relationships, and these networks have become important tools for collective intelligence extraction. these connected networks can be represented using graphs, and network analytic methods [41] can be applied to them for extracting useful knowledge. graphs are structures formed by a set of vertices (also called nodes) and a set of edges, which are connections between pairs of vertices. the information extracted from a social network can be easily represented as a graph in which the vertices or nodes represent the users and the edges represent the relationships among them (e.g., a re-tweet of a message or a favourite mark in twitter). a number of network metrics can be used to perform social analysis of these networks. usually, the importance, or influence, in a social network is analysed through centrality measures. these measures have high computational complexity in large-scale networks. to solve this problem, focusing on a large-scale graph analysis, a second generation of frameworks based on the mapreduce paradigm has appeared, including hama, giraph (based on pregel), and graphlab among others [42] . pregel [37] is a graph-parallel system based on the bulk synchronous parallel model (bsp) [43] . a bsp abstract computer can be interpreted as a set of processors that can follow different threads of computation in which each processor is equipped with fast local memory and interconnected by a communication network. according to this, the platform based on this model comprises three major components: • components capable of processing and/or local memory transactions (i.e., processors). • a network that routes messages between pairs of these components. • a hardware facility that allows for the synchronisation of all or a subset of components. taking into account this model, a bsp algorithm is a sequence of global supersteps that consists of three components: 1. concurrent computation: every participating processor may perform local asynchronous computations. 2. communication: the processes exchange data from one processor to another, facilitating remote data storage capabilities. 3. barrier synchronisation: when a process reaches this point (the barrier), it waits until all other processes have reached the same barrier. hama [44] and giraph are two distributed graph processing frameworks on hadoop that implement pregel. the main difference between the two frameworks is the matrix computation using the mapreduce paradigm. apache giraph is an iterative graph processing system in which the input is a graph composed of vertices and directed edges. computation proceeds as a sequence of iterations (supersteps). initially, every vertex is active, and for each superstep, every active vertex invokes the "compute method" that will implement the graph algorithm that will be executed. this means that the algorithms implemented using giraph are vertex oriented. apache hama does not only allow users to work with pregel-like graph applications. this computing engine can also be used to perform computeintensive general scientific applications and machine learning algorithms. moreover, it currently supports yarn, which is the resource management technology that lets multiple computing frameworks run on the same hadoop cluster using the same underlying storage. therefore, the same data could be analysed using mapreduce or spark. in contrast, graphlab is based on a different concept. whereas pregel is a one-vertex-centric model, this framework uses vertexto-node mapping in which each vertex can access the state of adjacent vertices. in pregel, the interval between two supersteps is defined by the run time of the vertex with the largest neighbourhood. the graphlab approach improves this splitting of vertices with large neighbourhoods across different machines and synchronises them. finally, elser and montresor [42] present a study of these data frameworks and their application to graph algorithms. the k-core decomposition algorithm is adapted to each framework. the goal of this algorithm is to compute the centrality of each node in a given graph. the results obtained confirm the improvement achieved in terms of execution time for these frameworks based on hadoop. however, from a programming paradigm point of view, the authors recommend pregel-inspired frameworks (a vertex-centric framework), which is the better fit for graph-related problems. the community detection problem in complex networks has been the subject of many studies in the field of data mining and social network analysis. the goal of the community detection problem is similar to the idea of graph partitioning in graph theory [45, 46] . a cluster in a graph can be easily mapped into a community. despite the ambiguity of the community definition, numerous techniques have been used for detecting communities. random walks, spectral clustering, modularity maximization, and statistical mechanics have all been applied to detecting communities [46] . these algorithms are typically based on the topology information from the graph or network. related to graph connectivity, each cluster should be connected; that is, there should be multiple paths that connect each pair of vertices within the cluster. it is generally accepted that a subset of vertices forms a good cluster if the induced sub-graph is dense and there are few connections from the included vertices to the rest of the graph [47] . considering both connectivity and density, a possible definition of a graph cluster could be a connected component or a maximal clique [48] . this is a sub-graph into which no vertex can be added without losing the clique property. one of the most well-known algorithms for community detection was proposed by girvan and newman [49] . this method uses a new similarity measure called "edge betweenness" based on the number of the shortest paths between all vertex pairs. the proposed algorithm is based on identifying the edges that lie between communities and their successive removal, achieving the isolation of the communities. the main disadvantage of this algorithm is its high computational complexity with very large networks. modularity is the most used and best known quality measure for graph clustering techniques, but its computation is an np-complete problem. however, there are currently a number of algorithms based on good approximations of modularity that are able to detect communities in a reasonable time. the first greedy technique to maximize modularity was a method proposed by newman [50] . this was an agglomerative hierarchical clustering algorithm in which groups of vertices were successively joined to form larger communities such that modularity increased after the merging. the update of the matrix in the newman algorithm involved a large number of useless operations owing to the sparseness of the adjacency matrix. however, the algorithm was improved by clauset et al. [51] , who used the matrix of modularity variations to arrange for the algorithm to perform more efficiently. despite the improvements to and modifications of the accuracy of these greedy algorithms, they have poor performance when they are compared against other techniques. for this reason, newman reformulated the modularity measure in terms of eigenvectors by replacing the laplacian matrix with the modularity matrix [52] , called the spectral optimization of modularity. this improvement must also be applied in order to improve the results of other optimization techniques [53, 54] . random walks can also be useful for finding communities. if a graph has a strong community structure, a random walker spends a long time inside a community because of the high density of internal edges and the consequent number of paths that could be followed. zhou and lipowsky [55] , based on the fact that walkers move preferentially towards vertices that share a large number of neighbours, defined a proximity index that indicates how close a pair of vertices is to all other vertices. communities are detected with a procedure called netwalk, which is an agglomerative hierarchical clustering method by which the similarity between vertices is expressed by their proximity. a number of these techniques are focused on finding disjointed communities. the network is partitioned into dense regions in which nodes have more connections to each other than to the rest of the network, but it is interesting that in some domains, a vertex could belong to several clusters. for instance, it is well-known that people in a social network for natural memberships in multiple communities. therefore, the overlap is a significant feature of many realworld networks. to solve this problem, fuzzy clustering algorithms applied to graphs [56] and overlapping approaches [57] have been proposed. xie et al. [58] reviewed the state of the art in overlapping community detection algorithms. this work noticed that for low overlapping density networks, slpa, oslom, game, and copra offer better performance. for networks with high overlapping density and high overlapping diversity, both slpa and game provide relatively stable performance. however, test results also suggested that the detection in such networks is still not yet fully resolved . a common feature that is observed by various algorithms in real-world networks is the relatively small fraction of overlapping nodes (typically less than 30%), each of which belongs to only 2 or 3 communities. a significant portion of the unstructured content collected from social media is text. text mining techniques can be applied for automatic organization, navigation, retrieval, and summary of huge volumes of text documents [59] [60] [61] . this concept covers a number of topics and algorithms for text analysis including natural language processing (nlp), information retrieval, data mining, and machine learning [62] . information extraction techniques attempt to extract entities and their relationships from texts, allowing for the inference of new meaningful knowledge. these kinds of techniques are the starting point for a number of text mining algorithms. a usual model for representing the content of documents or text is the vector space model. in this model, each document is represented by a vector of frequencies of remaining terms within the document [60] . the term frequency (tf) is a function that relates the number of occurrences of the particular word in the document divided by the number of words in the entire document. another function that is currently used is the inverse document frequency (idf); typically, documents are represented as tf-idf feature vectors. using this data representation, a document represents a data point in n-dimensional space where n is the size of the corpus vocabulary. text data tend to be sparse and high dimensional. a text document corpus can be represented as a large sparse tf-idf matrix, and applying dimensionality reduction methods to represent the data in compressed format [63] can be very useful. latent semantic indexing [64] is an automatic indexing method that projects both documents and terms into a low-dimensional space that attempts to represent the semantic concepts in the document. this method is based on the singular value decomposition of the term-document matrix, which constructs a low-ranking approximation of the original matrix while preserving the similarity between the documents. another family of dimension reduction techniques is based on probabilistic topic mod-els such as latent dirichlet allocation (lda) [65] . this technique provides the mechanism for identifying patterns of term co-occurrence and using those patterns to identify coherent topics. standard lda implementations of the algorithm read the documents of the training corpus numerous times and in a serial way. however, new, efficient, parallel implementations of this algorithm have appeared [66] in attempts to improve its efficiency. unsupervised machine learning methods can be applied to any text data without the need for a previous manual process. specifically, clustering techniques are widely studied in this domain to find hidden information or patterns in text datasets. these techniques can automatically organise a document corpus into clusters or similar groups based on a blind search in an unlabelled data collection, grouping the data with similar properties into clusters without human supervision. generally, document clustering methods can be mainly categorized into two types [67] : partitioning algorithms that divide a document corpus into a given number of disjoint clusters that are optimal in terms of some predefined criteria functions [68] and hierarchical algorithms that group the data points into a hierarchical tree structure or a dendrogram [69] . both types of clustering algorithms have strengths and weaknesses depending on the structure and characteristics of the dataset used. in zhao and karypis [70] , a comparative assessment of different clustering algorithms (partitioning and hierarchical) was performed using different similarity measures on high-dimensional text data. the study showed that partitioning algorithms perform better and can also be used to produce hierarchies of higher quality than those returned by the hierarchical ones. in contrast, the classification problem is one of the main topics in the supervised machine learning literature. nearly all of the wellknown techniques for classification, such as decision trees, association rules, bayes methods, nearest neighbour classifiers, svm classifiers, and neural networks, have been extended for automated text categorisation [71] . sentiment classification has been studied extensively in the area of opinion mining research, and this problem can be formulated as a classification problem with three classes, positive, negative and neutral. therefore, most of the existing techniques designed for this purpose are based on classifiers [72] . however, the emergence of social networks has created massive and continuous streams of text data. therefore, new challenges have been arising in adapting the classic machine learning methods, because of the need to process these data in the context of a one-pass constraint [73] . this means that it is necessary to perform data mining tasks online and only one time as the data come in. for example, the online spherical k-means algorithm [74] is a segment-wise approach that was proposed for streaming text clustering. this technique splits the incoming text stream into small segments that can be processed effectively in memory. then, a set of k-means iterations is applied to each segment in order to cluster them. moreover, in order to consider less important old documents during the clustering process, a decay factor is included. one of the most important roles of social media is to spread information to social links. with the large amount of data and the complex structures of social networks, it has been even more difficult to understand how (and why) information is spread by social reactions (e.g., retweeting in twitter and like in facebook). it can be applied to various applications, e.g., viral marketing, popular topic detection, and virus prevention [75] . as a result, many studies have been proposed for modelling the information diffusion patterns on social networks. the characteristics of the diffusion models are (i) the topological structure of the network (a sub-graph composed of a set of users to whom the information has been spread) and (ii) temporal dynamics (the evolution of the number of users whom the information has reached over time) [76] . according to the analytics, these diffusion models can be categorized into explanatory and predictive approaches [77] . • explanatory models: the aim of these models is to discover the hidden spreading cascades once the activation sequences are collected. these models can build a path that can help users to easily understand how the information has been diffused. the netint method [78] has applied sub-modular, function-based iterative optimisation to discover the spreading cascade (path) that maximises the likelihood of the collected dataset. in particular, for working with missing data, a k-tree model [79] has been proposed to estimate the complete activation sequences. • predictive models: these are based on learning processes with the observed diffusion patterns. depending on the previous diffusion patterns, there are two main categories of predictive models: (i) structure-based models (graph-based approaches) and (ii) content-analysis-based models (non-graph-based approaches). moreover, there are more existing approaches to understanding information diffusion patterns. the projected greedy approach for non-sub-modular problems [80] was recently proposed to populate the useful seeds in social networks. this approach can identify the partial optimisation for understanding the information diffusion. additionally, an evolutionary dynamics model was presented in [ [81] , [82] ] that attempted to understand the temporal dynamics of information diffusion over time. one of the relevant topics for analysing information diffusion patterns and models is the concept of time and how it can be represented and managed. one of the popular approaches is based on time series. any time series can be defined as a chronological collection of observations or events. the main characteristics of this type of data are large size, high dimensionality, and continuous change. in the context of data mining, the main problem is how to represent the data. an effective mechanism for compressing the vast amount of time series data is needed in the context of information diffusion. based on this representation, different data mining techniques can be applied such as pattern discovery, classification, rule discovery, and summarisation [83] . in lin et al. [84] , a new symbolic representation of time series is proposed that allows for a dimensionality/numerosity reduction. this representation is tested using different classic data mining tasks such as clustering, classification, query by content, and anomaly detection. based on the mathematical models mentioned above, we need to compare a number of various applications that can support users in many different domains. one of the most promising applications is detecting meaningful social events and popular topics in society. such meaningful events and topics can be discovered by well-known text processing schemes (e.g., tf-idf) and simple statistical approaches (e.g., lda, gibbs sampling, and the tste method [85] ). in particular, not only the time domain but also the frequency domain have been exploited to identify the most frequent events [86] . the social big data from various sources needs to be fused for providing users with better services. these fusion can be done in different ways and affect to different technologies, methods and even research areas. two of these possible areas are ontologies and social networks, next how previous areas could benefit from information fusion in social big data are briefly described: • ontology-based fusion. semantic heterogeneity is an important issue on information fusion. social networks have inherently different semantics from other types of network. such semantic heterogeneity includes not only linguistic differences (e.g., between 'reference' and 'bibliography') but also mismatching between conceptual structures. to deal with these problems, in [87] ontologies are exploited from multiple social networks, and more importantly, semantic correspondences obtained by ontology matching methods. more practically, semantic meshup applications have been illustrated. to remedy the data integration issues of the traditional web mashups, the semantic technologies uses the linked open data (lod) based on rdf data model, as the unified data model for combining, aggregating, and transforming data from heterogeneous data resources to build linked data mashups [88] . • social network integration. next issue is how to integrate the distributed social networks. as many kinds of social networking services have been developed, users are joining multiple services for social interactions with other users and collecting a large amount of information (e.g., statuses on facebook and tweets on twitter). an interesting framework has been proposed for a social identity matching (sim) method across these multiple sns [89] . it means that the proposed approach can protect user privacy, because only the public information (e.g., username and the social relationships of the users) is employed to find the best matches between social identities. particularly, cloud-based platform has been applied to build software infrastructure where the social network information can be shared and exchanged [90] . the social big data analysis can be applied to social media data sources for discovering relevant knowledge that can be used to improve the decision making of individual users and companies [18] . in this context, business intelligence can be defined as those techniques, systems, methodologies, and applications that analyse critical business data to help an enterprise better understand its business and market and to support business decisions [91] . this field includes methodologies that can be applied to different areas such as e-commerce, marketing, security, and healthcare [18] ; more recent methodologies have been applied to treat social big data. this section provides short descriptions of some applications of these methodologies in domains that intensively use social big data sources for business intelligence. marketing researchers believe that big social media analytics and cloud computing offer a unique opportunity for businesses to obtain opinions from a vast number of customers, improving traditional strategies. a significant market transformation has been accomplished by leading e-commerce enterprises such amazon and ebay through their innovative and highly scalable e-commerce platforms and recommender systems. social network analysis extracts user intelligence and can provide firms with the opportunity for generating more targeted advertising and marketing campaigns. maurer and wiegmann [92] show an analysis of advertising effectiveness on social networks. in particular, they carried out a case study using facebook to determine users perceptions regarding facebook ads. the authors found that most of the participants perceived the ads on facebook as annoying or not helpful for their purchase decisions. however, trattner and kappe [93] show how ads placed on users social streams that have been generated by the facebook tools and applications can increase the number of visitors and the profit and roi of a web-based platform. in addition, the authors present an analysis of real-time measures to detect the most valuable users on facebook. a study of microblogging (twitter) utilization as an ewom (electronic word-of-mouth) advertising mechanism is carried out in jansen et al. [94] . this work analyses the range, frequency, timing, and table 1 basic features related to social big data applications in marketing area. trattner and kappe [93] targeted advertising on facebook real-time measures to detect the most valuable users jansen et al. [94] twitter as ewom advertising mechanism sentiment analysis asur et al. [95] using twitter to forecast box-office revenues for movies topics detection, sentiment analysis ma et al. [96] viral marketing in social networks social network analysis, information diffusion models content of tweets in various corporate accounts. the results obtained show that 19% of microblogs mention a brand. of the branding microblogs, nearly 20% contained some expression of brand sentiments. therefore, the authors conclude that microblogging reports what customers really feel about the brand and its competitors in real time, and it is a potential advantage to explore it as part of companies overall marketing strategies. customers brand perceptions and purchasing decisions are increasingly influenced by social media services, and these offer new opportunities to build brand relationships with potential customers. another approach that uses twitter data is presented in asur et al. [95] to forecast box-office revenues for movies. the authors show how a simple model built from the rate at which tweets are created about particular topics can outperform marketbased predictors. moreover, the sentiment extraction from twitter is used to improve the forecasting power of social media. because of the exponential growth use of social networks, researchers are actively attempting to model the dynamics of viral marketing based on the information diffusion process. ma et al. [96] proposed modelling social network marketing using heat diffusion processes. heat diffusion is a physical phenomenon related to heat, which always flows from a position with higher temperature to a position with lower temperature. the authors present three diffusion models along with three algorithms for selecting the best individuals to receive marketing samples. these models can diffuse both positive and negative comments on products or brands in order to simulate the real opinions within social networks. moreover, the authors complexity analysis shows that the model is also scalable to large social networks. table 1 shows a brief summary of the previously described applications, including the basic functionalities for each and their basic methods. criminals tend to have repetitive pattern behaviours, and these behaviours are dependent upon situational factors. that is, crime will be concentrated in environments with features that facilitate criminal activities [97] . the purpose of crime data analysis is to identify these crime patterns, allowing for detecting and discovering crimes and their relationships with criminals. the knowledge extracted from applying data mining techniques can be very useful in supporting law enforcement agencies. communication between citizens and government agencies is mostly through telephones, face-to-face meetings, email, and other digital forms. most of these communications are saved or transformed into written text and then archived in a digital format, which has led to opportunities for automatic text analysis using nlp techniques to improve the effectiveness of law enforcement [98] . a decision support system that combines the use of nlp techniques, similarity measures, and classification approaches is proposed by ku and leroy [99] to automate and facilitate crime analysis. filtering reports and identifying those that are related to the same or similar crimes can provide useful information to analyse crime trends, which allows for apprehending suspects and improving crime prevention. traditional crime data analysis techniques are typically designed to handle one particular type of dataset and often overlook geospatial distribution. geographic knowledge discovery can be used to discover patterns of criminal behaviour that may help in detecting where, when, and why particular crimes are likely to occur. based on this concept, phillips and lee [100] present a crime data analysis technique that allows for discovering co-distribution patterns between large, aggregated and heterogeneous datasets. in this approach, aggregated datasets are modelled as graphs that store the geospatial distribution of crime within given regions, and then these graphs are used to discover datasets that show similar geospatial distribution characteristics. the experimental results obtained in this work show that it is possible to discover geospatial co-distribution relationships among crime incidents and socio-economic, socio-demographic and spatial features. another analytical technique that is now in high use by law enforcement agencies to visually identify where crime tends to be highest is the hotspot mapping. this technique is used to predict where crime may happen, using data from the past to inform future actions. each crime event is represented as a point, allowing for the geographic distribution analysis of these points. a number of mapping techniques can be used to identify crime hotspots, such as: point mapping, thematic mapping of geographic areas, spatial ellipses, grid thematic mapping, and kernel density estimation (kde), among others. chainey et al. [101] conducted a comparative assessment of these techniques, and the results obtained showed that kde was the technique that consistently outperformed the others. moreover, the authors offered a benchmark to compare with the results of other techniques and other crime types, including comparisons between advanced spatial analysis techniques and prediction mapping methods. another novel approach using spatio-temporally tagged tweets for crime prediction is presented by gerber [102] . this work shows the use of twitter, applying a linguistic analysis and statistical topic modelling to automatically identify discussion topics across a city in the united states. the experimental results showed that adding twitter data improved crime prediction performance versus a standard approach based on kde. finally, the use of data mining in fraud detection is very popular, and there are numerous studies on this area. atm phone scams are one well-known type of fraud. kirkos et al. [103] analysed the effectiveness of data mining classification techniques (decision trees, neural networks and bayesian belief networks) for identifying fraudulent financial statements, and the experimental results concluded that bayesian belief networks provided higher accuracy for fraud classification. another approach to detecting fraud in real-time credit card transactions was presented by quah and sriganesh [104] . the system these authors proposed uses a self-organization map to filter and analyse customer behaviour to detect fraud. the main idea is to detect the patterns of the legal cardholder and of the fraudulent transactions through neural network learning and then to develop rules for these two different behaviours. one typical fraud in this area is the atm phone scams that attempts to transfer a victims money into fraudulent accounts. in order to identify the signs of fraudulent accounts and the patterns of fraudulent transactions, li et al. [105] applied bayesian classification and association rules. detection rules are developed based on the identified signs and applied to the design of a fraudulent account detection system. table 2 shows a brief summary of all of the applications that were previously mentioned, providing a description of the basic functionalities of each and their main methods. [99] technique to discover geospatial co-distribution relations among crime incidents network analysis chainey et al. [101] comparative assessment of mapping techniques to predict where crimes may happen spatial analysis, mapping methods gerber [102] identify discussion topics across a city in the united states to predict crimes linguistic analysis, statistical topic modelling kirkos et al. [103] identification of fraudulent financial statements classification (decision trees, neural networks and bayesian belief networks) quah and sriganesh [104] detect fraud detection in real-time credit card transactions neural network learning, association rules li et al. [105] identify the signs of fraudulent accounts and the patterns of fraudulent transactions bayesian classification, association rules epidemic intelligence can be defined as the early identification, assessment, and verification of potential public health risks [106] and the timely dissemination of the appropriate alerts. this discipline includes surveillance techniques for the automated and continuous analysis of unstructured free text or media information available on the web from social networks, blogs, digital news media, and official sources. text mining techniques have been applied to biomedical text corpora for named entity recognition, text classification, terminology extraction, and relationship extraction [107] . these methods are human language processing algorithms that aim to convert unstructured textual data from large-scale collections to a specific format, filtering them according to need. they can be used to detect words related to diseases or their symptoms in published texts [108] . however, this can be difficult because the same word can refer to different things depending upon context. furthermore, a specific disease can have multiple associated names and symptoms, which increases the complexity of the problem. ontologies can help to automate human understanding of key concepts and the relationships between them, and they allow for achieving a certain level of filtering accuracy. in the health domain, it is necessary to identify and link term classes such as diseases, symptoms, and species in order to detect the potential focus of disease outbreaks. currently, there are a number of available biomedical ontologies that contain all of the necessary terms. for example, the biocaster ontology [109] is based on the owl semantic web language, and it was designed to support automated reasoning across terms in 12 languages. the increasing popularity and use of microblogging services such as twitter are recently a new valuable data source for web-based surveillance because of their message volume and frequency. twitter users may post about an illness, and their relationships in the network can give us information about whom they could be in contact with. furthermore, user posts retrieved from the public twitter api can come with gps-based location tags, which can be used to locate the potential centre of disease outbreaks. a number of works have already appeared that show the potential of twitter messages to track and predict outbreaks. a document classifier to identify relevant messages was presented in culotta [110] . in this work, twitter messages related to the flu were gathered, and then a number of classification systems based on different regression models to correlate these messages with cdc statistics were compared; the study found that the best model had a correlation of 0.78 (simple model regression). aramaki [111] presented a comparative study of various machinelearning methods to classify tweets related to influenza into two categories: positive and negative. their experimental results showed that the svm model that used polynomial kernels achieved the highest accuracy (fmeasure of 0.756) and the lowest training time. well-known regression models were evaluated on their ability to assess disease outbreaks from tweets in bodnar and salathé [112] . regression methods such as linear, multivariable, and svm were applied to the raw count of tweets that contained at least one of the keywords related to a specific disease, in this case "flu". the models also validated that even using irrelevant tweets and randomly generated datasets, regression methods were able to assess disease levels comparatively well. a new unsupervised machine learning approach to detect public health events was proposed in fisichella et al. [113] that can complement existing systems because it allows for identifying public health events even if no matching keywords or linguistic patterns can be found. this new approach defined a generative model for predictive event detection from documents by modelling the features based on trajectory distributions. however, in recent years, a number of surveillance systems have appeared that apply these social mining techniques and that have been widely used by public health organizations such as the world health organization (who) and the european centre for disease prevention and control [114] . tracking and monitoring mechanisms for early detection are critical in reducing the impact of epidemics through rapid responses. one of the earliest surveillance systems is the global public health intelligence network (gphin) [115] developed by the public health agency of canada in collaboration with the who. it is a secure, web-based, multilingual warning tool that continuously monitors and analyses global media data sources to identify information about disease outbreaks and other events related to public healthcare. the information is filtered for relevance by an automated process and is then analysed by public health agency of canada gphin officials. from 2002 to 2003, this surveillance system was able to detect the outbreak of sars (severe acute respiratory syndrome). from the biocaster ontology in 2006 arose the biocaster system [116] for monitoring online media data. the system continuously analyses documents reported from over 1700 rss feeds, google news, who, promed-mail, and the european media monitor, among other data sources. the extracted text is classified based on its topical relevance and plotted onto a google map using geo-information. the system has four main stages: topic classification, named entity recognition, disease/location detection, and event recognition. in the first stage, the texts are classified as relevant or non-relevant using a naive bayes classifier. then, for the relevant document corpora, entities of interest from 18 concept types based on the ontology related to diseases, viruses, bacteria, locations, and symptoms are searched. healthmap project [117] is a global disease alert map that uses data from different sources such as google news, expert-curated discussions such as promed-mail, and official organization reports such as those from the who or euro surveillance, an automated real-time system that monitors, organises, integrates, filters, visualises, and disseminates online information about emerging diseases. another system that collects news from the web related to human and animal health and that plots the data on google maps is epispider [118] . this tool automatically extracts information on infectious disease outbreaks from multiple sources including promedmail and medical web sites, and it is used as a surveillance system by table 3 basic features related to social big data applications in health care area. ref. num. summary methods culotta [110] track and predict outbreak detection using twitter classification (regression models) aramaki et al. [111] classify tweets related to influenza classification bodnar and salathé [112] assess disease outbreaks from tweets regression methods fisichella et al. [113] detect public health events modelling trajectory distributions gphin [115] identify information about disease outbreaks and other events related to public healthcare classification documents for relevance biocaster [116] monitoring online media data related to diseases, viruses, bacteria, locations and symptoms topic classification, named entity recognition, event recognition healthmap [117] global disease alert map mapping techniques epispider [118] human and animal disease alert map topic and location detection [126] collecting user experiences into a continually growing and adapting multimedia diary. classification of patterns in sensor readings from a camera, microphone, and accelerometers many eyes [127] creating visualisations in collaborative environment from upload data sets visualisation layout algorithms tweetpulse [128] building social pulse by aggregating identical user experiences visualising temporal dynamics of the thematic events public healthcare organizations, a number of universities, and health research organizations. additionally, this system automatically converts the topic and location information from the reports into rss feeds. finally, lyon et al. [119] conducted a comparative assessment of these three systems (biocaster, epispider, and healthmap) related to their ability to gather and analyse information that is relevant to public health. epispider obtained more relevant documents in this study. however, depending on the language of each system, the ability to acquire relevant information from different countries differed significantly. for instance, biocaster gives special priority to languages from the asia-pacific region, and epispider only considers documents written in english. table 3 shows a summary of the previous applications and their related functionalities and methods. big data from social media needs to be visualised for better user experiences and services. for example, the large volume of numerical data (usually in tabular form) can be transformed into different formats. consequently, user understandability can be increased. the capability of supporting timely decisions based on visualising such big data is essential to various domains, e.g., business success, clinical treatments, cyber and national security, and disaster management [120] . thus, user-experience-based visualisation has been regarded as important for supporting decision makers in making better decisions. more particularly, visualisation is also regarded as a crucial data analytic tool for social media [121] . it is important for understanding users needs in social networking services. there have been many visualisation approaches to collecting (and improving) user experiences. one of the most well-known is interactive data analytics. based on a set of features of the given big data, users can interact with the visualisation-based analytics system. such systems are r-based software packages [122] and ggobi [123] . moreover, some systems have been developed using statistical inferences. a bayesian inference scheme-based multi-input/multi-output (mimo) system [124] has been developed for better visualisation. we can also consider life-logging services that record all user experiences [125] , which is also known as quantify-self. various sensors can capture continuous physiological data (e.g., mood, arousal, and blood oxygen levels) together with user activities. in this context, life caching has been presented as a collaborative social action of storing and sharing users life events in an open environment. more practically, this collaborative user experience has been applied to gaming to encourage users. systems such as insense [126] are based on wearable devices and can collect users experiences into a continually growing and adapting multimedia diary. the insense system uses the patterns in sensor readings from a camera, a microphone, and accelerometers to classify the users activities and automatically collect multimedia clips when the user is in an interesting situation. moreover, visualisation systems such as many eyes [127] have been designed to upload datasets and create visualisations in collaborative environments, allowing users to upload data, create visualisation of that data, and leave comments on both the visualisation and the data, providing a medium to foment discussion among users. many eyes is designed for ordinary people and does not require any extensive training or prior knowledge to take full advantage of its functionalities. other visual analytics tools have shown some graphical visualisations for supporting efficient analytics of the given big data. particularly, tweetpulse [128] has built social pulses by aggregating identical user experiences in social networks (e.g., twitter), and visualised temporal dynamics of the thematic events. finally, table 4 provides a summary of those applications related to the methods used for visualisation based on user experiences. with the large number and rapid growth of social media systems and applications, social big data has become an important topic in a broad array of research areas. the aim of this study has been to provide a holistic view and insights for potentially helping to find the most relevant solutions that are currently available for managing knowledge in social media. as such, we have investigated the state-of-the-art technologies and applications for processing the big data from social media. these technologies and applications were discussed in the following aspects: (i) what are the main methodologies and technologies that are available for gathering, storing, processing, and analysing big data from social media? (ii) how does one analyse social big data to discover meaningful patterns? and (iii) how can these patterns be exploited as smart, useful user services through the currently deployed examples in social-based applications? more practically, this survey paper shows and describes a number of existing systems (e.g., frameworks, libraries, software applications) that have been developed and that are currently being used in various domains and applications based on social media. the paper has avoided describing or analysing those straightforward applications such as facebook and twitter that currently intensively use big data technologies, instead focusing on other applications (such as those related to marketing, crime analysis, or epidemic intelligence) that could be of interest to potential readers. although it is extremely difficult to predict which of the different issues studied in this work will be the next "trending topic" in social big data research, from among all of the problems and topics that are currently under study in different areas, we selected some "open topics" related to privacy issues, streaming and online algorithms, and data fusion visualisation, providing some insights and possible future trends. in the era of online big data and social media, protecting the privacy of the users on social media has been regarded as an important issue. ironically, as the analytics introduced in this paper become more advanced, the risk of privacy leakage is growing. as such, many privacy-preserving studies have been proposed to address privacy-related issues. we can note that there are two main well-known approaches. the first one is to exploit "k-anonymity", which is a property possessed by certain anonymised data [129] . given the private data and a set of specific fields, the system (or service) has to make the data practically useful without identifying the individuals who are the subjects of the data. the second approach is "differential privacy", which can provide an efficient way to maximise the accuracy of queries from statistical databases while minimising the chances of identifying its records [130] . however, there are still open issues related to privacy. social identification is the important issue when social data are merged from available sources, and secure data communication and graph matching are potential research areas [89] . the second issue is evaluation. it is not easy to evaluate and test privacy-preserving services with real data. therefore, it would be particularly interesting in the future to consider how to build useful benchmark datasets for evaluation. moreover, we have to consider this data privacy issues in many other research areas. in the context of law (also, international law) enforcement, data privacy must be prevented from any illegal usages, whereas governments tend to trump the user privacy for the purpose of national securities. also, developing educational program for technicians (also, students) is important [131] . it is still open issue on how (and what) to design the curriculum for the data privacy. one of the current main challenges in data mining related to big data problems is to find adequate approaches to analysing massive amounts of online data (or data streams). because classification methods require previous labelling, these methods also require great effort for real-time analysis. however, because unsupervised techniques do not need this previous process, clustering has become a promising field for real-time analysis, especially when these data come from social media sources. when data streams are analysed, it is important to consider the analysis goal in order to determine the best type of algorithm to be used. we were able to divide data stream analysis into two main categories: • offline analysis: we consider a portion of data (usually large data) and apply an offline clustering algorithm to analyse the data. • online analysis: the data are analysed in real time. these kinds of algorithms are constantly receiving new data and are not usually able to keep past information. a new generation of online [132, 133] and streaming [134, 135] algorithms is currently being developed in order to manage social big data challenges, and these algorithms require high scalability in both memory consumption [136] and time computation. some new developments related to traditional clustering algorithms, such as the k-mean [137] , em [138] , which has been modified to work with the mapreduce paradigm, and more sophisticated approaches based on graph computing (such as spectral clustering), are currently being developed [139] [140] [141] into more efficient versions from the state-of-theart algorithms [142, 143] . finally, data fusion and data visualisation are two clear challenges in social big data. although both areas have been intensively studied with regard to large, distributed, heterogeneous, and streaming data fusion [144] and data visualisation and analysis [145] , the current, rapid evolution of social media sources jointly with big data technologies creates some particularly interesting challenges related to: • obtaining more reliable methods for fusing the multiple features of multimedia objects for social media applications [146] . • studying the dynamics of individual and group behaviour, characterising patterns of information diffusion, and identifying influential individuals in social networks and other social media-based applications [147] . • identifying events [148] in social media documents via clustering and using similarity metric learning approaches to produce highquality clustering results [149] . • the open problems and challenges related to visual analytics [145] , especially related to the capacity to collect and store new data, are rapidly increasing in number, including the ability to analyse these data volumes [150] , to record data about the movement of people and objects at a large scale [151] , and to 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identification in social media learning similarity metrics for event identification in social media visual analytics visual analytics tools for analysis of movement data space, time and visual analytics this work has been supported by several research grants: co key: cord-015255-1qhgeirb authors: busby, j s; onggo, s title: managing the social amplification of risk: a simulation of interacting actors date: 2012-07-11 journal: j oper res soc doi: 10.1057/jors.2012.80 sha: doc_id: 15255 cord_uid: 1qhgeirb a central problem in managing risk is dealing with social processes that either exaggerate or understate it. a longstanding approach to understanding such processes has been the social amplification of risk framework. but this implies that some true level of risk becomes distorted in social actors’ perceptions. many risk events are characterised by such uncertainties, disagreements and changes in scientific knowledge that it becomes unreasonable to speak of a true level of risk. the most we can often say in such cases is that different groups believe each other to be either amplifying or attenuating a risk. this inherent subjectivity raises the question as to whether risk managers can expect any particular kinds of outcome to emerge. this question is the basis for a case study of zoonotic disease outbreaks using systems dynamics as a modelling medium. the model shows that processes suggested in the social amplification of risk framework produce polarised risk responses among different actors, but that the subjectivity magnifies this polarisation considerably. as this subjectivity takes more complex forms it leaves problematic residues at the end of a disease outbreak, such as an indefinite drop in economic activity and an indefinite increase in anxiety. recent events such as the outbreaks in the uk of highly pathogenic avian influenza illustrate the increasing importance of managing not just the physical development of a hazard but also the social response. the management of hazard becomes the management of 'issues', where public anxiety is regarded less as a peripheral nuisance and more as a legitimate and consequential element of the problem (leiss, 2001) . it therefore becomes as important to model the public perception of risk as it does to model the physical hazard-to understand the spread of concern as much as the spread of a disease, for example. in many cases the perception of risk becomes intimately combined with the physical development of a risk, as beliefs about what is risky behaviour come to influence levels of that behaviour and thereby levels of exposure. one of the main theoretical tools we have had to explain and predict public risk perception is the social amplification of risk framework due to kasperson et al (1988) . as we explain below, this framework claims that social processes often combine to either exaggerate or underplay the risk events experienced by a society. this results in unreasonable and disproportionate reactions to risks, not only among the lay public but also among legislators and others responsible for managing risk. but since its inception the idea of a 'real', objective process of social risk amplification has been questioned (rayner, 1988; rip, 1988 ) and, although work in risk studies and risk management continues to use the concept, it has remained problematic. the question is whether, if we lose the notion of some true risk being distorted by a social process, we lose all ability to anticipate and explain perplexing social responses to a risk event in a way that is informative to policymakers. we explore this question in the context of risks surrounding the outbreaks of zoonotic diseases-that is, diseases that cross the species barrier to humans from other animals. recent cases of zoonotic disease, such as bse, sars, west nile virus and highly pathogenic avian influenza (hpai), have been some of the most highly publicised and controversial risk issues encountered in recent times. many human diseases are zoonotic in origin but in cases such as bse and hpai the disease reservoirs remain in the animal population. this means that a public health risk is bound up with risk to animal welfare, and often risk to the agricultural economy, to food supply chains and to wildlife. this in turn produces difficult problems for risk managers and policymakers, who typically want to avoid a general public amplifying the risk and boycotting an industry and its products, but also want to avoid an industry underestimating a risk and failing to practice adequate biosecurity. the bse case in particular has been associated with ideas about risk amplification (eg, eldridge and reilly, 2003) and continues to appear in the literature (lewis and tyshenko, 2009) . other zoonoses, such as chronic wasting disease in deer herds, have also been seen as recent objects of risk amplification (heberlein and stedman, 2009) . in terms of the social reaction, not all zoonoses are alike. endemic zoonoses like e. coli 157 do periodically receive public attention-for example following outbreaks at open farms and in food supply chains. but it is the more exotic zoonoses like bse and hpai that are more clearly associated with undue anxiety and ideas about social risk amplification. yet these cases also showed how uncertain the best, expertly assessed, supposedly objective risk level can be, and this makes it very problematic to retain the idea of an objective process of social risk amplification. such cases are therefore an important and promising setting for exploring the idea that amplification is only in the heads of social actors, and for exploring the notion that this might nonetheless produce observable, and potentially highly consequential, outcomes in a way that risk managers need to understand. our study involved two main elements, the second of which is the main subject of this article: 1. exploratory fieldwork to examine how various groups perceived risks and risk amplification in connection with zoonoses like the avian influenza outbreaks in 2007; 2. a systems dynamics simulation to work out what outcomes would emerge in a system of social actors who attributed amplification to other actors. in the remainder of the paper we first outline the fieldwork and its outcomes, and then describe the model and simulation. although the article concentrates on the latter, the two parts provide complementary elements of a process of theorising (kopainsky and luna-reyes, 2008) : the fieldwork, subjected to grounded analysis, produces a small number of propositions that are built into the systems dynamics model, and the model both operationalises these propositions and explores their consequences when operationalised in this way. the modelling is a basis for developing theory that is relevant to policy and decision making, rather than supporting a specific decision directly. a discussion and conclusion follow. traditionally, the most problematic aspect of public risk perception has been seen as its sometimes dramatic divergence from expert assessments-and the way in which this divergence has been seen as an obstacle both to managing risks specifically and to introducing new technology more generally. this has produced a longstanding interest in the individual perception of risk (eg, slovic, 1987) and in the way that culture selects particular risks for our attention (eg, douglas and wildavsky, 1982) . it has led to a strong interest in risk communication (eg, otway and wynne, 1989) . and it has been a central theme in the social amplification of risk framework (or sarf) that emerged in the late 1980s (kasperson et al, 1988) . the notion behind social risk amplification, developed in a series of articles (kasperson et al, 1988; renn, 1991; burns et al, 1993; kasperson and kasperson, 1996) , is that a risk event produces signals that are processed and sometimes amplified by a succession of social actors behaving as communication 'stations'. they interact and observe each other's responses, sometimes producing considerable amplification of the original signal. a consequence is that there are often several secondary effects, such as product boycotts or losses of institutional trust, that compound the effect of the original risk event. a substantial amount of empirical work has been conducted on or around the idea of social amplification, for example showing that the largest influence on amplification is typically organisational misconduct (freudenberg, 2003) . it continues to be an important topic in the risk literature, not least in connection with zoonosis risks (eg, heberlein and stedman, 2009; lewis and tyshenko, 2009 ). there has always been a substantial critique of the basic idea of social risk amplification. its implication that there is some true or accurate level that becomes amplified is hard to accept in many controversial and contested cases where expertise is lacking or where there is no expert consensus (rayner, 1988) . the phenomenon of 'dueling experts' is common in conflicts over environmental health, for instance (nelkin, 1995) . more generally, the concept of risk amplification seems to suggest that there is a risk 'signal' that is outside the social system and is somehow amplified by it (rayner, 1988) . this seems misconceived when we take the view that ultimately risk itself is a social construction (hilgartner, 1992) or overlay on the world (jasanoff, 1993) . and it naturally leads to the view that contributors to the amplification, such as the media (bakir, 2005) , need to be managed more effectively, and that risk managers should concentrate on fixing the mistake in the public mind (rip, 1988) , when often it may be the expert assessment that is mistaken. it thus becomes hard to sustain the idea that there is a social process by which true levels of risk get distorted. and this appears to undermine the possibility that risk managers can have a way of anticipating very high or very low levels of social anxiety in any particular case. once risk amplification becomes no more than a subjective judgment by one group on another social group's risk responses, it is hard to see how risk issues can be dealt with on an analytical basis. however, subjective beliefs about risk can produce objective behaviours, and behaviours can interact to produce particular outcomes. and large discrepancies in risk beliefs between different groups are still of considerable interest, whether or not we can know which beliefs are going to turn out to be more correct. in the remainder of this article we therefore explore the consequences of the idea that social risk amplification is nothing more than an attribution, or judgment that one social actor makes of another, and try to see what implications this might have for risk managers based on a systems dynamics model. before this, however, we describe the fieldwork whose principal findings were meant to provide the main structural properties of the model. the aim of the fieldwork was to explore how social actors reason about the risks of recent zoonotic disease outbreaks, and in particular how they make judgments of other actors systematically amplifying or attenuating such risks. this involved a grounded, qualitative study of what a number of groups said in the course of a number of unstructured interviews and focus groups. it follows the general principle of using qualitative empirical work as a basis for systems dynamics modelling (luna-reyes and andersen, 2003) . focus groups were used where possible, for both lay and professional or expert actors; individual interviews were used where access could only be gained to relevant groups (such as journalists) as individuals. the participants were selected from a range of groups having a stake in zoonotic outbreaks such as avian influenza incidents and are listed in table 1 . the focus groups followed a topic guide that was initially used in a pilot focus group and continually refined throughout the programme. they started with a short briefing on the specific topic of zoonotic diseases, with recent, well-publicised examples. the professional and expert groups were also asked to explain their roles in relation to the management of zoonotic diseases. participants were then invited to consider recent cases and other examples they knew of, discuss their reactions to the risks they presented, and discuss the way the risks had been, or were being, managed. their discussions were recorded and the recordings transcribed except in two cases where it was only feasible to record researcher notes. the individual interviews followed the same format. analysis of the transcripts followed a typical process of grounded theorising (glaser and strauss, 1967) , in which the aim was to find a way of categorising participants' responses that gave some theoretical insight into the principle of risk amplification as a subjective attribution. the categories were arrived at in a process of 'constant comparison' of the data and emerging, tentative categories until all responses have been satisfactorily categorised in relation to each other (glaser, 2002) . in glaser's words, 'validity is achieved, after much fitting of words, when the chosen one best represents the pattern. it is as valid as it is grounded'. our approach also drew on template analysis (king, 1998) in that we started with the basic categories of attributing risk amplification and risk attenuation, not a blank sheet. a fuller account of the analysis process and findings is given in a parallel publication (busby and duckett, 2012) . the first main theme to emerge from the data was the way in which actors privilege their own views, and construct reasons to hold on to them by finding explanations for other views as being systematically exaggerated or underplayed. it is surprising in a sense that this was relatively symmetrical. we expected expert groups to characterise lay groups as exaggerating or underplaying risk, but we also expected lay groups to use authoritative risk statements from expert groups and organisations of various kinds as ways of correcting their own initial and tentative beliefs. but there was no evidence for this kind of corrective process. the reasons that informants gave for why other actors systematically amplify or attenuate risk were categorised under five main headings: cognition, or the way they formed their beliefs; disposition, or their inherent natures; situation, or the particular circumstances; strategy, or deliberate, instrumental action; and structure, or basic patterns in the social or physical world. for example, one group saw the highly pathogenic avian influenza (hpai) outbreak at holton in the uk in 2007 as presenting a serious risk and explained the official advice that it presented only a very small risk as arising from a conspiracy between industry and government that the dispositions of the two naturally created. this second main theme was that some groups of informants often lacked specific and direct knowledge about relevant risks, and resorted to reasoning about other actors' responses to those risks. this reasoning involved moderating those observations with beliefs about whether other actors are inclined to amplify or attenuate risk. lay groups received information through the media but they had definite, and somewhat cliche´d, beliefs about the accuracy of risk portrayals in the media, for example. thus some informants saw the media treatment of hpai outbreaks as risk amplifying and portrayed the media as having an incentive to sensationalise coverage, but others (particularly virologists) saw media coverage as risk attenuating out of scientific ignorance. a third theme was that risk perceptions often came from the specific associations that arose in particular cases. for example, the holton hpai outbreak involved a large food processing firm that had earlier been involved in dietary and nutritional controversies. the firm employed intensive poultry rearing practices and was also importing partial products from a processor abroad. this particular case therefore bound together issues of intensive rearing, global sourcing, zoonotic outbreaks and lifestyle risks-incidental associations that enabled some informants to perceive high levels of risk and indignation, and portray others as attenuating this risk. the fourth theme was that some actors have specific reasons to overcome what they see as other actors' amplifications or attenuations. they do not just discount another actor's distortions but seek to change them. for example, staff in one government agency believed they had to correct farmers who were underplaying risk and not practicing sufficient bio-security, and also correct consumers who were exaggerating risk and boycotting important agricultural products. such actors do not simply observe other actors' expressed risk levels but try to communicate in such a way as to influence these expressed levels-for example through awareness-raising campaigns. the fieldwork therefore pointed to a model in which actors like members of the public based their risk evaluations on what they were told by others, corrected in some way for what they expected to be others' amplifications or attenuations; discrepancies between their current evaluations and those of others would be regarded as evidence of such amplifications, rather than being used to correct their own evaluations. the findings also indicated a model in which risk managers would communicate risk levels in a way that was intended to overcome the misconceptions of actors like the public. these are the underpinning elements of the models we describe below. systems dynamics was a natural choice for this modelling on several grounds. first, there is an inherent stress on endogeneity in the basic idea of social risk amplification, and in particular in the notion that it is an attribution. risk responses first and foremost reflect the way people think about risks and think about the responses of other people to those risks. second, the explicit and intuitive representation of feedback loops was important to show the reflective nature of social behaviour: how actors see the impact of their risk responses on other actors and modify their responses accordingly. third, memory plays an important part in this, since the idea that some actor is a risk amplifier will be based on remembering their past responses, and the accumulative capacity of stocks in systems dynamics provides an obvious way of representing social memory. developing a systems dynamics model on the grounded theory therefore followed naturally, and helped to add a deductive capability to the essentially inductive process of grounded theory (kopainsky and luna-reyes, 2008) . kopainsky and luna-reyes (2008) also point out that grounded theory can produce large and rich sets of evidence and overly complex theory, making it important to have a rigorous approach to concentrating on small numbers of variables and relationships. thus, in the modelling we describe in the next section, the aim was to try to represent risk amplification with as little elaboration as possible, so that it would be clear what the consequences of the basic structural commitments might be. this meant reduction to the simplest possible system of two actors, interacting repeatedly over time during the period of an otherwise static risk event (such as a zoonosis outbreak). applications of systems dynamics have been wide-ranging, addressing issues in domains ranging from business (morecroft and van der heijden, 1992) to military (minami and madnick, 2009) , from epidemiology (dangerfield et al, 2001) to diffusion models in marketing (morecroft, 1984) , from modelling physical state such as demography (meadows et al, 2004) to mental state such as trust martinez-moyano and samsa, 2008) . applications to issues of risk, particularly risk perception, are much more limited. there has been some application of system dynamics to the diffusion of fear and sarf, specifically (burns and slovic, 2007; sundrani, 2007) , but not to the idea of social amplification as an attribution. probably the closest examples to our work in the system dynamics literature deal with trust. luna-reyes et al (2008), for example, applied system dynamics to investigate the role of knowledge sharing in building trust in complex projects. to make modelling tractable, the authors make several simplifying assumptions including the aggregation of various government agencies as a single actor and various service providers as another actor. each actor accumulates the knowledge of the other actor's work, and the authors explore the dynamics that emerge from their interaction. greer et al (2006) modelled similar interactions-this time between client and contractor-each having its own, accumulated understandings of a common or global quantity (in this case the 'baseline' of work a project). martinez-moyano and samsa (2008) developed a system dynamics model to support a feedback theory of trust and confidence. this represented the mutual interaction between two actors (government and public) in a social system where each actor assesses the trustworthiness of the other actor over time, with both actors maintaining memories of the actions and outcomes of the other actor. our approach draws from all these studies, modelling a system in which actors interact on the basis of remembered, past interactions as they make assessments of some common object. the actors are in fact groups of individuals who are presumed to be acting in some concerted way. although this may seem questionable there are several justifications for doing so: (1) the aim is not to represent the diversity of the social world but to explore the consequences of specific ideas about phenomena like social risk amplification; (2) in some circumstances a 'risk manager' such as a private corporation or a government agency may act very much like a unit actor, especially when it is trying to coordinate its communications in the course of risk events; (3) equally in some circumstances it may be quite realistic to see a 'public' as acting in a relatively consensual way whose net, aggregate or average response is of more interest than the variance of response. in the following sections we develop a model in three stages. in the first, we represent the conventional view of social risk amplification; in the second, we add our subjective, attributional approach in a basic form; and in the third we make the attributional elements more realistically complex. the aim is to explore the implications of the principal findings of the fieldwork, and our basic theoretical commitments to social risk amplification as an attribution, with as little further adornment as possible, while also incorporating elements shown in the literature to be important aspects of risk amplification. in the first model, shown in figure 1 , we represent in a simple way the basic notion of social risk amplification. the fundamental idea is that risk responses are socially developed, not simply the sum of the isolated reactions of unconnected individuals. the model represents a population as being in one of two states of worry. this is simpler than the three-state model of burns and slovic (2007) particularly adds to the model. there is also no need for a recovering or removal state, as in sir (susceptible infectious recovered) models (sterman, 2004, p 303) , since there is no concept of immunity and it seems certain that people can be worried by the same thing all over again. the flow from an unworried state to a worried state is a function of how far the proportion in the worried state exceeds that normally expected in regard to a risk event such as a zoonotic disease outbreak. members of the public expect some of their number to become anxious in connection with any risk issue: when, through communication or observation, they realise this number exceeds expectation, this in itself becomes a reason for others to become anxious. this observation of fellow citizens is not medium-specific, so it is a combination of observation by word-of-mouth, social networks and broadcast media. in terms of how this influences perception, various processes are suggested in the literature. for example, there is a variety of 'social contagion' effects (levy and nail, 1993; scherer and cho, 2003) relevant to such situations. social learning (bandura, 1977) or 'learning by proxy' (gardner et al, 2000) may also well be important. we do not model specific mechanisms but only an aggregate process by which the observation of worry influences the flow into a state of being worried. the flow out of the worried state is a natural relaxation process. it is hard to stay worried about a specific issue for any length of time, and the atrophy of vigilance is reported in the literature (freudenberg, 2003) . there is also a base flow between the states, reflecting the way in which-in the context of any public risk event-there will be some small proportion of the population that becomes worried, irrespective of peers and public information. this base flow also has the function of dealing with the 'startup problem' in which zero flow is a potential equilibrium for the model (sterman, 2004, p 322) . the public risk perception in this model stands in relation to an expert, supposedly authoritative assessment of the risk. people worry when seeing others worry, but moderate this response when exposed to exogenous information-the expert or managerial risk assessment. what ultimately regulates worry is some combination of these two elements and it is this regulatory variable that we call a resultant 'risk perception'. unlike burns and slovic (2007) we do not represent this as a stock because it is not anyone's belief, and so need not have inertia. the fact that various members of the public are in different states of worry means that there is no belief that all share, as such. instead, risk perception is an emergent construct on which flows between unworried and worried states depend (and which also determines how demand for risky goods changes, as we explain below). in the simplest model we simply take this resultant risk perception as a weighted geometric mean of the risk implied by the proportion of the population worried and the publically known expert risk assessment. the expert assessment grows from zero toward a finite level, for a certain period, before decaying again to zero. this reflects a time profile for typical risk events-for example zoonotic outbreaks such as sars-where numbers of reported cases climb progressively and rapidly to a peak before declining (eg, leung et al, 2004) . the units for risk perception and the expert assessment are arbitrary, but for exposition are taken as probabilities of individual fatality during a specific risk event. numerical values of the exogenous risk-related variables are based on an outbreak in which the highest fatality probability is 10 à3 . but risks in a modern society tend to vary over several orders of magnitude. typically, individual fatality probabilities of 10 à6 are regarded as 'a very low level of risk', whereas risks of 10 à3 are seen as very high and at the limit of tolerability for risks at work (hse, 2001) . because both assessed and perceived risks are likely to vary widely, discrepancies between risk levels are represented as ratios. the way in which the expert assessment is communicated to the public is via some homogenous channel we have simply referred to as the 'media'. in our basic model we represent in very crude terms the way in which this media might exaggerate the difference between expert assessment and public perception. but the sarf literature suggests there is no consistent relationship between media coverage and either levels of public concern or frequencies of fatalities (breakwell and barnett, 2003; finkel, 2008) , so the extent of this exaggeration is likely to be highly case specific. it is also possible that the media have an effect on responses by exaggerating to a given actor its own responses. the public, for example, could have an inflated idea of how worried they are because newspapers or blogs portray it to be so. but we do not represent this because it is so speculative and may be indeterminable empirically. finally, the base model also represents the way in which risk perception influences behaviour, in particular the consumption of the goods or services that expose people to the risk in question. the 2005 holton uk outbreak of hpai, for example, occurred at a turkey meat processing plant and affected demand for its products; the sars outbreak affected demand for travel, particularly aviation services. brahmbhatt and dutta (2008) even refer to the economic disruption caused by 'panicky' public responses as 'sars type' effects. there are many complications here, not least that reducing consumption of one amenity as a result of heightened risk perception may increase consumption of a riskier amenity. air travel in the us fell after 9/11 but travel by car increased and aggregate risk levels were said to have risen in consequence (gigerenzer, 2006) . a further complication is that in certain situations, such as bank runs (diamond and dybvig, 1983 ), risk perceptions are directly self-fulfilling rather than self-correcting. the most common effect is probably that heightened risk perceptions will lead to reduced demand for the amenity that causes exposure, leading to reductions in exposure and reductions in the expert risk assessment, but it is worth noting that the effect is case-specific. the expert risk assessment is therefore not exogenous, and there is a negative feedback loop that operates to counteract rising risk perceptions. as we show later from the simulation outcomes, the base model shows a public risk perception that can be considerably larger than the expert risk assessment. it therefore seems to show 'risk amplification'. but there is no variable that stands for risk in the model: there are only beliefs about risk (called either assessments or perceptions). the idea that social risk amplification is a subjective attribution, not an objective phenomenon, means that this divergence of risk perception and expert assessment does not amount to risk amplification. and it says that actors see others as being risk amplifiers, or attenuators, and develop their responses accordingly. this means that we need to add to sarf, and the basic model of the previous section, the processes by which actors observe, diagnose and deal with other actors' risk assessments or perceptions. what our fieldwork revealed was that the social system did not correct 'mistaken' risk perceptions in some simpleminded fashion. in other words, it was not the case that people formed risk perceptions, received information about expert assessment, and then corrected their perceptions in the correct direction. instead, as we explained earlier, they found reasons why expert assessments, and in fact the risk views of any other group, might be subject to systematic amplification or attenuation. they then corrected for that amplification. risk managers, on the other hand, had the task of overcoming what they saw as mistaken risk responses in other groups, not simply correcting for them. therefore in the second model, shown in figure 2 , we now have a subsystem in which a risk manager (a government agency or an industrial undertaking in the case of zoonotic disease outbreaks) observes the public risk perception in relation to the expert risk assessment, and communicates a risk level that is designed to compensate for any discrepancy between the two. commercial risk managers will naturally want to counteract risk amplification that leads to revenue losses from product and service boycotts, and governmental risk managers will want to counteract the risk amplification that produces panic and disorder. as beck et al (2005) report, the uk bse inquiry found that risk managers' approach to communicating risk 'was shaped by a consuming fear of provoking an irrational public scare'. the effect is symmetrical to the extent that the public in turn observes discrepancies between managerial communications and its own risk perceptions, and attributes amplification or attenuation accordingly. attributions are based on simple memory of past observations. this historical memory of another actor's apparent distortions is sometimes mentioned in the sarf literature (kasperson et al, 1988; poumadere and mays, 2003) . this memory is represented as stocks of observed discrepancies, reaching a level m i (t)for actor i at time t. the managerial memory, for example, is r public ðtþ r expert ðtþ dt m i (t)40 implies that actor i sees the other actor as exaggerating risk, while m i (t)o0 implies perceived attenuation. the specific deposits in an actor's memory are not retrievable, and equal weight is given to every observation that contributes to it. the perceived scale of amplification is the time average of memory content, and the confidence the actor has in this perceived amplification is 1àe à|m(t)| where confidence grows logarithmically towards unity as the magnitude of the memory increases. the managerial actor modifies the risk level it communicates by the perceived scale of public amplification raised to the power of its confidence, while the public adjusts the communicated risk level it takes account of by the perceived scale of managerial attenuation raised to the power of its confidence in this. in the third model, in figure 3 , we add three elements found in the risk amplification literature that become especially relevant to the idea of risk amplification as a subjective attribution: confusion, distrust and differing perceptions about the significance of behavioural change. the confusion issue reflects the way an otherwise authoritative actor's view tends to be discounted if it shows evidence of confusion, uncertainty or inexplicable change. two articles in the recent literature on zoonosis risk (bergeron and sanchez, 2005; heberlein and stedman, 2009 ) specifically describe the risk amplifying effect of the authorities seeming confused or uncertain. the distrust issue reflects the observation that 'distrust acts to heighten risk perception . . . ' (kasperson et al, 2003) , and that it is 'associated with perceptions of deliberate distortion of information, being biased, and having been proven wrong in the past' (frewer, 2003, p 126) . a distinguishing aspect of trust and distrust is the basic asymmetry such that trust is quick to be lost and slow to be gained (slovic, 1993) . in figure 3 , the confusion function is based on the rate of change of attributed amplification, not rate of change communication itself, since some change in communication might appear justified if correlated with a change in public perception: g ¼ 1 à e àg c g ðtþ j j ; where c g (t) is the change in managerial amplification in unit time. the distrust function is based on the extent of remembered attributed amplification: f ¼ 1 à e àf m g ðtþ j j ; where m g (t) is the memory of managerial risk amplification at time t and f is the distrust parameter. there is no obvious finding in the literature that would help us set the value of such a parameter. the combination of the confusion and distrust factors is a combination of an integrator and a differentiator. it is used to determine how much weight is given to managerial risk communications in the formation of the resultant risk perception. it is defined such that as distrust and confusion both approach unity, this weight w tends to zero: w ¼ w max (1àg)(1àf). this weight was exogenous in the previous model, so the effect of introducing confusion and distrust is also to endogenise the way observation of worry is combined with authoritative risk communication. the third addition in this model is an important disproportionality effect. the previous models assume that risk managers base their view of the public risk perception on some kind of direct observation-for example, through clamour, media activity, surveys and so on. in practice, the managerial view is at least partly based on the public's consumption of the amenity that is risk, for example the consumption of beef during the bse crisis, or flight bookings and hotel reservations during the sars outbreak. the problem is that when a foodstuff like beef becomes a risk object it may be easy for many people to stop consuming it, and such a response from the consumer's perspective can be proportionate to even a mild risk assessment. reducing beef consumption is an easy precaution for most of the population to take (frewer, 2003) , so rational even when there is little empirical evidence that there is a risk at all (rip, 2006) . yet this easy response of boycotting beef may be disastrous for the beef industry, and therefore seem highly disproportionate to the industry, to related industries and to government agencies supporting the industry. unfortunately there is considerable difficulty in quantifying this effect in general terms. recent work (mehers, 2011) looking at the effect of heightened risk perceptions around the avian influenza outbreak at a meat processing plant suggests that the influence on the demand for the associated meat products was very mixed. different regions and different demographic groups showed quite different reactions, for example, and the effect was confounded by actions (particularly price changes) taken by manufacturer and retailers. our approach is to represent the disproportionality effect with a single exogenous factorthe relative substitutability of the amenity for similar amenities on the supply and demand side. the risk manager interprets any change in public demand for the amenity multiplied by this factor as being the change in public risk perception. if the change in this inferred public risk perception exceeds that observed directly (for example by opinion survey), then it becomes the determinant of how risk managers think the public are viewing the risk in question. this relative substitutability is entirely a function of the specific industry (and so risk manager) in question: there is no 'societal' value for such a parameter, and the effects of a given risk perception on amenity demand will always be case specific. for example, brahmbhatt and dutta (2008) reported that the sars outbreak led to revenue losses in beijing of 80% in tourist attractions, exhibitions and hotels, but of 10-50% in travel agencies, airlines, railways and so on. the effects are substantial but a long way from being constant. in this section we briefly present the outcomes of simulation with two aims: first to show how the successive models produce differences in behaviour, if at all, and thereby to assess how much value there is in the models for policymakers; second to assess how much uncertainty in figure 3 model of a more complex attributional view of risk amplification. outcomes such as public risk perception is produced by uncertainty in the exogenous parameters. figure 4 shows the behaviour of the three successive models in terms of public risk perception and expert risk assessment. for the three models, the exogenous variables are set at their modal values and when variables are shared between models they have the same values. the expert risk assessment is thus very similar for each model, as shown in the figure, rising towards its target level, falling as public risk perception reduces exposure, and then ceasing as the crisis ends around day 40. in the base model, the public risk perception is eight times higher than the expert assessment at its peak, which occurs some 20 days after that in the expert assessment. but once the attributional view of risk amplification is modelled, this disparity becomes much greater, and it occurs earlier. in the simple attributional system the peak discrepancy is over 40 times, and in the complex attributional system nearly 400 times, both occurring within 8 days of the expert assessment peak. thus the effect of seeing risk amplification as the subjective judgment of one actor about another is, given the assumptions in our models, to polarise risk beliefs much more strongly and somewhat more rapidly. we can no longer call the outcome a 'risk amplification' since, by assumption, there is no longer an objective risk level exogenous to the social system. but there is evidently strong polarisation. there is some qualitative difference in the time profile of risk perception between the three models, as shown in the previous figure where the peak risk perception occurs earlier in the later models. there are also important qualitative differences in the time profiles of stock variables amenity demand and worried population, as shown in figure 5 . when the attributional view is taken, both demand and worry take longer to recover to initial levels, and when the more complex attributional elements are modelled (the effects of mistrust, confusion and different perceptions of the meaning of changes in demand), the model indicates that little recovery takes place at all. the scale of the recovery depends on the value of the exogenous parameters, and some of these (as we discuss below) are case specific. but of primary importance is the way the weighting given to managerial communications or expert assessment is dragged down by public attributions. this result indicates the importance of a complex, attributional view of risk amplification. unlike the base model, in the attributional model it is much more likely there will be an indefinite residue from a crisis-even when the expert assessment of risk falls to near zero. figures 6 and 7 show the time development of risk perception in the third model in terms of the mean outcome with (a) 95% confidence intervals on the mean and (b) tolerance intervals for 95% confidence in 90% coverage over 1000 runs, with triangular distributions assigned to the exogenous parameters and plausible ranges based solely on the author's subjective estimates. the exogenous parameters fall into two main groups. the first group is of case-specific factors and would be expected to vary between risk events. this includes, for example, the relative substitutability of the amenity that is the carrier of the risk, and the latency before changes in demand for this amenity change the level of risk exposure. the remaining parameters are better seen as social constants, since there is no theoretical reason to think that they will vary from one risk event to another. these include factors like the natural vigilance period among the population, the normal flow of people into a state of worry, the latency before people become aware of a discrepancy between emergent risk perception and the proportion of the population that is in a state of worry. figure 6 shows the confidence and tolerance intervals with the social constants varying within their plausible ranges and the case-specific factors fixed at their modal values, and figure 7 vice versa. thus figure 6 shows the effect of our uncertainty about the character of society, figure 4 outcomes of the three models. whereas figure 7 shows the effect of the variability we would expect among risk events. the substantial difference between the means in risk perception between the two figures reflects large differences between means and modes in the distributions attributed to the parameters, which arises because plausible ranges sometimes cover multiple orders of magnitude (eg, the confusion and distrust constants both range from 1 to 100 with modes of 10, and the memory constant from 10 to 1000 with a mode of 100). these figures do not give a complete understanding, not least because interactions between the two sets of parameters are possible, but they show a reasonably robust qualitative profile. figure 8 shows the 'simple' correlation coefficients between resultant risk perception and the policy-relevant exogenous parameters over time, as recommended by ford and flynn (2005) as an indication of the relative importance of model inputs. at each day of the simulation, the sample correlation coefficient is calculated for each parameter over the 1000 runs. no attempt has been made to inspect whether the most important inputs are correlated, and to refine the model in the light of this. nonetheless the figure gives some indication of how influential are the most prominent parameters: the expert initial assessment level (ie, the original scale of the risk according to expert assessment), the expert assessment adjustment time (ie, the delay in the official estimate reflecting the latest information), the base flow (the flow of people between states of non-worry and worry in relation to a risk irrespective of the specific social influences being modelled) and the normal risk perception (the baseline against which the resultant risk perception is gauged, reflecting a level of risk that would be unsurprising and lead to no increase in the numbers of the worried). the first of these is case-specific, but the other three would evidently be worth empirical investigation given their influence in the model. it is extremely difficult to test such outcomes against empirical data because cases differ so widely and it is unusual to find data on simultaneous expert assessments and public perceptions over short-run risk events like disease outbreaks, particularly outbreaks of zoonotic disease. but a world bank paper of 2008, on the economic effects of infectious disease outbreaks (primarily sars, a zoonotic disease), collected together data gathered on the 2003 sars outbreak, and some-primarily that of lau et al (2003) -showed the day-by-day development of risk perception alongside reported cases. figure 9 is based on lau et al's data (2003) , and shows the number of reported cases of sars as a proportion of the hong kong population at the time, together with the percentage of people in a survey expressing a perception that they had a large or very large chance of infection from sars. the two lines can be regarded as reasonably good proxies for the risk perception and expert assessment outcomes in figure 4 and they show a rough correspondence: a growth in both perception and expertly assessed or measured 'reality', followed by a decay, in which the perception appears strongly exaggerated from the standpoint of the expert assessment. the perceptual gap is about four orders of magnitude-greater than even the more complex attributional system in our modelling. moreover, the risk perception peak occurs early, and in fact leads the reported cases peak. it is our models 2 and especially 3 in which the perception peak occurs early (although it never leads the expert assessment peak). the implications of the work the social amplification of risk framework has always been presented as an 'integrative framework' (kasperson et al, 1988) , rather than a specific theory, so there has always been a need for more specific modelling to make its basic concepts precise enough to be properly explored. at the same time, as suggested earlier, its implication that there is some true level of risk that becomes distorted in social responses has been criticised for a long time. we therefore set out to explore whether it is possible to retain some concept of social risk amplification in cases where even expert opinion tends to be divided, the science is often very incomplete, and past expert assessment has been discredited. zoonotic disease outbreaks provide a context in which such conditions appear to hold. our fieldwork broadly pointed to a social system in which social actors of all kinds privilege their own risk views, in which they nonetheless have to rely on other actor's responses in the absence of direct knowledge or experience of the risks in question, in which they attribute risk amplification or attenuation to other actors, and in which they have reasons to correct for or overcome this amplification. to explore how we can model such processes has been the main purpose of the work we have described. and the resulting model provides specific indications of what policymakers need to deal with-a much greater polarisation of risk beliefs, and potentially a residue of worry and loss of demand after the end of a risk crisis. it also has the important implication that risk managers' perspectives should shift, from correcting a public's mistakes about risk to thinking about how their own responses and communications contribute to the public's views about a risk. our approach helps to endogenise the risk perception problem, recognising that it is not simply a flaw in the world 'out there'. it is thus an important step in becoming a more sophisticated risk manager or manager of risk issues (leiss, 2001) . it is instructive to compare this model with models like that of luna-reyes et al (2008) which essentially involve a convergent process arise from knowledge sharing, and the subsequent development of trust. we demonstrate a process in which there is knowledge sharing, but a sharing that is undermined by expectations of social risk amplification. observing discrepancies in risk beliefs leads not to correction and consensus but to self-confirmation and polarisation. our findings in some respects are similar to greer et al (2006) , who were concerned with discrepancies in the perceptions of workload in the eyes of two actors involved in a common project. such discrepancies arose not from exogenous causes but from unclear communication and delay inherent in the social system. all this reinforces the long-held view in the risk community, and of risk communication researchers in particular, that authentic risk communication should involve sustained relationships, and the open recognition of uncertainties and difficulties that would normally be regarded as threats to credibility (otway and wynne, 1989) . the reason is not just the moral requirement to avoid the perpetuation of powerful actors' views, and not just the efficiency requirement to maximise the knowledge base that contributes to managing a risk issue. the reason is also that the structure of interactions can be unstable, producing a polarisation of view that none of the actors intended. actors engaged with each other can realise this and overcome it. a basic limitation to the use of the models to support specific risk management decisions, rather than give more general insight into social phenomena, is that there are very few sources of plausible data for some important variables in the model, such as the relaxation delay defining how long people tend to stay worried about a specific risk event before fatigue, boredom or replacement by worry about a new crisis leads them to stop worrying. it is particularly difficult to see where values of the case-specific parameters are going to come from. other sd work on risk amplification at least partly avoids the calibration problem by using unit-less normalised scales and subjective judgments (burns and slovic, 2007) . and one of the benefits of this exploratory modelling is to suggest that such variables are worthwhile subjects for empirical research. but at present the modelling does not support prediction and does not help determine best courses of action at particular points in particular crises. in terms of its more structural limitations, the model is a small one that concentrates specifically on the risk amplification phenomenon to the exclusion of the many other processes that, in any real situation, risk amplification is connected with. as such, it barely forms a 'microworld' (morecroft, 1988) . it contrasts with related work such as that of martinez-moyano and samsa's (2008) modelling of trust in government, which similarly analyses a continuing interaction between two aggregate actors but draws extensively on cognitive science. however, incorporating a lot more empirical science does not avoid having to make many assumptions and selections that potentially stand in the way of seeing through to how a system produces its outcomes. the more elaborate the model the more there is to dispute and undermine the starkness of an interesting phenomenon. we have had to make few assumptions about the world, about psychology and about sociology before concluding that social risk amplification as little more than a subjective attribution has a strongly destabilising potential. this parsimony reflects towill's (1993) notion that we start the modelling process by looking for the boundary that 'encompasses the smallest number of components within which the dynamic behaviour under study is generated'. the model attempts to introduce nothing that is unnecessary to working out the consequences of risk amplification as an attribution. as ghaffarzadegan et al (2011) point out in their paper on small models applied to problems of public policy, and echoing forrester's (2007) argument for 'powerful small models', the point is to gain accessibility and insight. having only 'a few significant stocks and at most seven or eight major feedback loops', small models can convey the counterintuitive endogenous complexity of situations in a way that policymakers can still follow. they are small enough to show systems in aggregate, to stress the endogeneity of influences on the system's behaviour, and to clearly illustrate how policy resistance comes about (ghaffarzadegan et al, 2011) . as a result they are more promising as tools for developing correct intuitions, and for helping actors who may be trapped in a systemic interaction to overcome this and reach a certain degree of self-awareness (lane, 1999) . the intended contribution of this study has been to show how to model a long-established, qualitative framework for reasoning about risk perception and risk communication, and in the process deal with one of the main criticisms of this framework. the idea that in a society the perception of a risk becomes exaggerated to the point where it bears no relation to our best expert assessments of the risk is an attractive one for policymakers having to deal with what seem to be grossly inflated or grossly under-played public reactions to major events. but this idea has always been vulnerable to the criticism that we cannot know objectively if a risk is being exaggerated, and that expert assessments are as much a product of social processes as lay opinion. the question we posed at the start of the paper was whether, in dropping a commitment to the idea of an objective risk amplification, there is anything left to model and anything left to say to policymakers. our work suggests that there is, and that modelling risk amplification as something that one social actor thinks another is doing is a useful thing to do. there were some simple policy implications emerging from this modelling. for example, once you accept that there is no objective standard to indicate when risk amplification is occurring, actors are likely to correct for other actors' apparent risk amplifications and attenuation, instead of simple-mindedly correcting their own risk beliefs. this can have a strongly polarising effect on risk beliefs, and can produce residual worry and loss of demand for associated products and services after a crisis has passed. the limitations of the work point to further developments in several directions. first, there is a need to explore various aspects of how risk managers experience risk amplification. for example, the modelling, as it stands, concentrates on the interactions of actors in the context of a single event or issue-such as a specific zoonotic outbreak. in reality, actors generally have a long history of interaction around earlier events. we take account of history within an event, but not between events. a future step should therefore be to expand the timescale, moving from intra-event interaction to inter-event interaction. the superposition of a longer term process is likely to produce a model in which processes acting over different timescales interact and cannot simply be treated additively (forrester, 1987) . it also introduces the strong possibility of discontinuities, particularly when modelling organisational or institutional actors like governments whose doctrines can change radically following elections-rather like the discontinuities that have to be modelled to represent personnel changes and consequences like scapegoating (howick and eden, 2004) . another important direction of work would be a modelling of politics and power. it is a common observation in risk controversies that risk is a highly political construction-being used by different groups to gain resources and influence. as powell and coyle (2005) point out, the systems dynamics literature makes little reference to power, raising questions about the appropriateness of our modelling approach to a risk amplification subject-both in its lack of power as an object for modelling, and its inattention to issues of power surrounding the use of the model and its apparent implications. powell and coyle's (2005) politicised influence diagrams might provide a useful medium for representing issues 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'the social amplification of risk' risk communication and the social amplification of risk should social amplification of risk be counteracted folk theories of nanotechnologists a social network contagion theory of risk perception perception of risk perceived risk, trust and democracy business dynamics: systems thinking and modelling for a complex world understanding social amplification of risk: possible impact of an avian flu pandemic. masters dissertation, sloan school of management and engineering systems division acknowledgements-many thanks are due to the participants in the fieldwork that underpinned the modelling, and to dominic duckett who carried out the fieldwork. we would also like to thank the anonymous reviewers of an earlier draft of this article for insights and suggestions that have considerably strengthened it. the work was partly funded by a grant from the uk epsrc. key: cord-025192-ujvnio3f authors: gatens, moira; steinberg, justin; armstrong, aurelia; james, susan; saar, martin title: spinoza: thoughts on hope in our political present date: 2020-05-25 journal: contemp polit theory doi: 10.1057/s41296-020-00406-4 sha: doc_id: 25192 cord_uid: ujvnio3f nan theology, and philosophy. often seen by greek philosophers as a passivity of weak and ignorant souls, then as a virtue (along with faith and charity) by some christian thinkers, hope is configured as an ambivalent passion in early modern philosophy. for spinoza, hope and confidence are linked but are also essentially connected to their opposites, namely, fear and despair. as spinoza states in the ethics, 'there is neither hope without fear, nor fear without hope' (e3defaff xiii). 1 the future is uncertain and when we hope for the best outcome such hopeful feelings imply our confidence in gaining a good outcome. but doubt may give rise to anxiety when it appears likely that what it is that we fear will come to pass and so we fall into despair. what is clear is that the hope-fear dyad arises through our ignorance of the forces that determine our lives, and the more ignorant we are of these forces, the more we are at the mercy of hope and fear. our power to imagine gives rise to both hoped for and feared perceptions: i imagine conversing with colleagues at an international spinoza conference in madrid; i imagine dying in a plane crash on my way to a conference in madrid. the human capacity to imagine the future extends to political imaginings, too. i imagine my prime minister making sweeping changes to the management of climate change, and especially to those things that would decrease the risk of repeating the tragic loss of precious human and non-human life and property in the 2019-2020 australian bushfires; i imagine my prime minister granting lucrative leases on coal mines and continuing to support reckless, short-term profit business practices. exercises of the imagination are dependent on images, impressions, and memories that over time become increasingly complex and linked with each other in ways that make them significant. for example, we develop personal narratives of our life experiences as well as participate in forming and maintaining national and global narratives. according to spinoza, all our knowledge begins in and builds upon the imagination. these imaginative stories that we construct are untrustworthy accounts of the nature of the things that we have come into contact with, and of the world in general. our impressions and narratives involve systemic distortions and tell us more about the experiencing bodies -their specific compositions, dispositions, and desires -than about the nature of the causes of those experiences. in the ethics, and elsewhere, spinoza explains that we have a natural disposition to invert causes and effects, that is, our usual attitude is to experience an effect as if it were a cause. he refers to this as turning nature 'upside down' (e1appen). this attitude lies at the centre of spinoza's critique of free will. our consciousness of the ways in which external things determine us to act is, on his view, misrecognised as expressions of our own volition. the illusion of free will can be traced to our ignorance of causes. we imagine that we are independent and self-contained wholes, encountering other discrete bodies in nature. our egocentric perspective encourages this mistake of considering ourselves as centres of action, as free and self-determined. spinoza observes: people 'are conscious of their actions and ignorant of the causes by which they are determined. this, then, is their idea of freedom -that they do not know the cause of their actions' (e2p35s). so long as we imagine ourselves as separate from nature, as privileged loci of freedom and selfdetermination, we lack the knowledge of our true nature and context (see gatens, forthcoming) . these natural dispositions to experience hope and fear, and engage in imaginary thinking, leave us vulnerable to superstition, to manipulation, and to the actions of dishonourable and dishonest people and corrupt institutions. the exigencies of our social and political contexts often render us gullible -we believe the fake news, we trust the wrong people, or, to paraphrase spinoza, we allow ourselves to be tricked into fighting for our own subjection as if it were for our salvation (ttp, preface, p. 68). what we need are realistic political hopes that would justify a grounded confidence and cautious optimism in achieving them through our reflectively endorsed actions. what would count as realistic hope and justify confident action in our present? this is not a question to which any single person can adequately respond. what is required is collective deliberation and concerted political action. this, in turn, requires courage, honesty, vision, and trust -all of which are in short supply today in political leadership in the contemporary west. spinoza notes that vacillation of mind (the primary source of doubt and fear) is a common experience but he notes further that to remain captive to this state of inaction can be a sign of cowardice and reveal a lack of strength of character (fortitudo). his analysis holds for political as well as for personal behaviour. spinoza recognised the need for courage and honesty in government if it is to achieve its main aim: security (securitas). when caught between hope and fear, decisive action based in reasonable hope is far preferable to action based on fear or, worse still, an idiotic dithering when trapped between hope and fear. powerful leaders must learn how to engage and galvanise the constructive collective affects and hopes of the people they aim to govern. the social imagination is a powerful force that may be recruited to encourage certain actions and discourage others. in the theologico-political treatise, spinoza offers an incisive account of how moses used narrative, song, prayer, and law to bind the hebrews, recently freed from slavery, into a unified affective community, now motivated by shared loves, fears, and hopes materialised through sanctioned images, enforced rituals, and socially authorised attachments. but it is not only theological polities that rely on the collective imagination. all complex bodies engage in collective imaginings -democratic bodies no less than theocracies (see gatens and lloyd, 1999, chapters 4-6) . to imagine otherwise, to think that democratic politics could be made reasonable, and based purely in rational deliberation, is to be held 'captive to a myth' (tp, chapter 1, p. 506). affects are a permanent and necessary part of the human condition and because we are imitative creatures, they are also highly contagious (e3p27). politics must acknowledge, and work with, this powerful collective political force. the contributions comprising this critical exchange consider spinoza's theory of hope in a political context. what he has to say about hope as an affect experienced by individuals does not automatically or neatly map onto his analysis of collective hope in politics (see steinberg, 2018) . the political is not merely the personal, writ large. from the point of view of the free man sketched in the ethics, part 4, every passion involves passivity and so detracts from freedom and reason. but there is no such thing as a perfectly rational human being -we are all, by nature, subject to (individual and collective) passions. but collective human endeavour gives rise to new powers of action and intensely political affects. as a recent anthology argues, spinoza was a prescient theorist of the social and political implications of relational ontology (armstrong et al., 2019) . insofar as, for him, everything that exists is connected to everything else, and the power of any given body is constitutively determined by the good and bad compositions it is able to form with other bodies, being itself is always political. although other human beings are among the most dangerous things we can encounter -because they are more cunning than the other animals -spinoza also judged that when human beings combine their powers harmoniously then homo homini deus est (man is god to man, e4p35s). each contribution here attempts to bring spinoza's account of hope to bear critically on our political present in a way that endeavours to enhance our collective powers of action and our shared capacities for joyful fellowship. the contributors hail from the united states of america, australia, the united kingdom, and germany, and each brings something of their own political context to bear on the question of hope and the political. justin steinberg analyses the fear-fuelled hope that has marked president trump's conservative politics, and contrasts this with a potentially empowering spinozist hope that is tied to one's confidence in the state and its institutions. aurelia armstrong draws on spinoza's insights to analyse the specious 'privatisation' of hope recently mobilised by right-wing media and conservative climate change denialists, and the harnessing of a shared, social, and ultimately more constructive form of hope by climate change activists. for susan james, the disempowering affects and lack of stable consensus, recently witnessed in political debates over brexit, can be usefully addressed through a spinozist framework that casts hope and fear in a mutually corrective and jointly empowering role. this framework encourages a community to reflect on its shared hopes along with the potential risks that accompany them. finally, martin saar reflects on the value of a (neo)spinozist perspective that treats hope as an indicator of the transindividual social conditions that help shape political agency. saar's analysis helps us appreciate that the cultivation of constructive forms of hope will need to critically attend to considerations of context, which can foreclose, as well as open, particular paths of intervention. the 'affective turn' in political theory has many faces. although spinoza is often appropriated as a warrant for quite diverse forms of theorising affective politics, such warrants are not always sound. the contributions to this critical exchange follow respect the distinction between spinoza's philosophy and contemporary attempts to re-vision his thought for the present (saar, for example, refers to (neo)spinozism). it is surely the case that contemporary democratic societies have little in common with the mid-seventeenth-century dutch republic in which spinoza lived, and which helped to form his views about politics. however, certain of his insights into human ways of being and ways of knowing remain key to figuring out what beings like us might do in order to better understand our present, and through such understanding act to enhance our collective power to enjoy free and reasonable lives. steinberg remarks, below, upon the volatility of the dutch republic of spinoza's time, torn as it was by wars and civil unrest. we should recall too that it was one of the sites of the bubonic plague pandemic of 1665-1666 that reportedly killed up to 100,000 people in london. hope and fear -about plagues, wars, and natural disasters -are not new, and remain the two most powerful drivers of our political behaviour, and the constructive institutional management of these passions is essential if governments are to provide safety and security. also essential to the effectivity of our political institutions is some understanding of the collective imagination and our enthralment to images. the power of the social imaginary to play on our vulnerabilities, to manipulate as well as to enhance our political strengths, should not be underestimated (saar, 2015) . despite spinoza's commitment to the view that the true purpose of the state is to ensure our freedom and safety (securitas), and his assertion that democracy is the most natural state form, he nevertheless notes that 'the mob is terrifying if unafraid' (e4p54s) and asserts that no state -no matter how virtuous its rulers, or how well formed its institutions -can dispense with fear or punishment. for him, it is always a question of finding a judicious balance between these passional states but, as some contributors note, spinoza recommends the inducements of hope, reward, and love over the threats of fear and punishment. rulers who can inspire trust and love in the polis will be stronger than those who rule by deception and fear. this is because love is a joyful passion and as such involves an increase in our power, unlike hatred (and fear) which are always sad and debilitating. governments that encourage well-grounded hope for the future will be more loved than feared by those whom they govern, and so will constitute more joyful and more powerful political bodies. spinoza's robust opposition to human exceptionalism is apposite for our times. his critique of theology (james, 2012) , of human narcissism in relation to our imagined privileged status in nature (lloyd, 1994) , and of our epistemic hubris, all repay study today. as part of nature, (and a very tiny part at that), our hopes and interests are easily crushed by the many non-human forces of nature (fire, pandemics, famine, tsunami, earthquake). but the power that we do possess is to endeavour to understand ourselves, our context, and the ways in which our future possibilities are determined by past and present causes. perhaps then we may begin to intelligently address spinoza's lament that most people 'do not know themselves' (ttp, preface, p. 66) and nor do most governments know themselves or what their best form is. on spinoza's account the best kind of state is one where men pass their lives harmoniously, i mean that they pass a human life, one defined not merely by the circulation of the blood … but mostly by reason, the true virtue and life of the mind. (tp, chapter 5, p. 530, emphasis original) to form reasonable, peaceful, and secure democratic political societies, based in a harmony of powers (e4appen xv-xvi), is the excellence to which he bids us to aspire. spinoza's philosophy offers a novel vantage point from which to approach politics today. his cautious philosophy of hope can inspire a range of strategies and resources for imagining our future otherwise. to do so, we need first to understand that we are a part of nature -a status we share with all other beings -and that our well-being depends on respecting and sustaining the complex interdependencies of all human and non-human life. this spinozistic realisation of what our genuine powers and vulnerabilities are, would compel us, through an inborn impulse to preserve ourselves (conatus), to select, to build, and to maintain joyful networks of active affects and to form connections between affirmative and non-reactive powers, all supported and enhanced, ideally, by reasonable collective bodies. this would amount to embodying, expressing, and nurturing that type of power that understands itself as enabled by connection and interdependence -rather than opting for a reactive and instrumentalist power that reckons its worth by what it can use, abuse, or dominate. for spinoza, the attainment of our political aspirations does not depend on reason alone, nor on desire alone, but also on a capacity to mobilise a collectively imagined hoped-for future. moira gatens. america may be the land of optimism, but it peddles a rather tainted brand of hope. the 'american dream' sags heavily atop the buckling myth of meritocracy. and if the land of the ever-expanding frontier promised an escape from suffering for some, it came only at the expense of the suffering of others, building hope on a foundation of expropriation, exploitation, and slavery. it is perhaps for this reason that barack obama's version of hope, converted in veritable brand thanks in part to a winsome shepard fairey image, seemed novel, promising a kind of national convalescence. but while his election was historic, it soon became apparent that obama himself was an inveterate incrementalist, not a transformative politician. while this dashed the hopes of some, the vision of obama as an iconoclast persisted in right-wing media and cyberspace, giving rise to anxiety and vitriol that generated first the tea party movement and then the populist wave that propelled donald trump into power. trump's version of hope is a form of reactionary nostalgia ('make america great again') buoyed by fear of immigrants, muslims, criminality, the 'deep state', the waning global significance of the u.s., and the erosion of 'american' norms and ways of life. trumpian hope is born of, and sustained through, a thousand gnawing fears. the psycho-social dynamics behind trump's rise were shrewdly diagnosed 350 years ago in spinoza's tractatus theologico-politicus (ttp). while spinoza was writing in post-westphalian europe, in what would come to be regarded as the dutch golden age, the political situation in the young dutch republic was still rather volatile, as theological disputes, civil factions, controversies about confessional liberties, and ongoing wars left the country frayed. with free thought perpetually under threat, spinoza published the ttp in 1670 in order to defend the freedom of philosophising from those who would 'suppress it as much as they can with their excessive authority and aggressiveness' (ep 30, vol 2). the work opens with a description of how most people 'vacillate wretchedly between hope and fear' (ttp, preface, p. 65), proceeding to sketch how this gives rise to superstition and subservience. the account runs something like this: when people are anxious they are eager to find sources of hope or signs of something better to come, irrespective of the epistemic merits of these sources (ttp, preface, p. 66). consequently, fear breeds a desperate form of hope, resulting in a misplaced trust (see gatens' introductory remark about fake news). credulity then gives rise to stable superstition when the governors mobilise the affective power of religion for political ends (ttp, preface, p. 68). hope and fear function together here for, by keeping people anxious and miserable -bereft of other sources of hope -shrewd, deceptive political leaders can position themselves as saviours, beacons of hope in a bleak world. in addition to hope and fear, spinoza points to hate and anger as affects that feed politicised superstition (ttp, preface, p. 68), the suggestion being that the politically powerful are only able to evade blame for mass suffering by diverting frustration onto some perceived common enemy. in spinoza's time, religious liberals and heretics were scapegoats; in trump's america, the great bogeyman is the big government left, who would destroy the foundation on which american greatness precariously rests. in both cases, a politically manipulated anxiety begets credulity, antagonism, and ultimately commitment to a specious form of hope. as the other contributors to this critical exchange duly observe, fear and hope bear a unique connection, for 'there is neither hope without fear, nor fear without hope' (e3defaff xiii exp). beyond this point about the entanglement of these two affects, spinoza seems to treat hope and fear alike as obstacles to freedom, claiming that 'affects of hope and fear cannot be good of themselves', and that 'the more we strive to live according to the guidance of reason, the more we strive to depend less on hope, to free ourselves from fear' (e4p47s). from all of this, we might expect that spinoza would be critical of the role of hope in politics. in fact, though, as i have argued at length in my recent book, spinoza's political psychology: the taming of fortune and fear (esp. chapter 4), in his political treatises spinoza sharply distinguishes those who are motivated by hope from those who are motivated by fear, treating the former as vastly superior to the latter. not only does spinoza think that hopeful citizens will preserve the institutions and laws of the state more steadfastly than fearful citizens, he also thinks that hopeful citizens are freer, less constrained, and more willing than their fearful counterparts. unlike the desperate, fear-fuelled, trumpian form of hope described in the preface of the ttp, the form of hope that he recommends arises from living in a wellfunctioning state. the latin term that he uses to capture this notion is securitas, which he defines in the ethics as hope 'concerning which the cause of doubting has been removed' (e3defaff xiv; e3p18s2). in his political treatises, spinoza cites security (securitas) as one of the chief aims of the state (tp, chapter 1, p. 506; chapter 5, p. 529; ttp, chapter 20, p. 346, chapter 11, . the psychological or affective import of these claims has often been overlooked, as security is often read as something more like physical safety, despite the fact that spinoza explicitly connects security with freedom from fear (ttp, chapter 20, p. 346, chapter 11, . by understanding security as confidence in the state and its institutions -a kind of civic trust -we can better appreciate his endorsement of hopeful governance. in what remains, i want to examine in more detail why this form of hope is good, situating spinoza's account in relation to some recent philosophical work. the question of why hope, as a mental state or attitude, is good must be distinguished from the question of why it is good to be hopeful. one reason why it is good to be hopeful is just that hope is an indicator of expected utility. provided that one is generally capable of tracking expected utility, being generally hopeful implies being more likely to obtain the objects of one's desires than if one is generally fearful. but this still leaves us to answer why hope as an attitude is itself good. much of the current philosophical literature focuses on the empowering function of hope. victoria mcgeer, for instance, has argued that hope enables one to acknowledge and respond to limitations on agency, fostering resilient and imaginative responses: hoping can empower us to acknowledge, explore, and sometimes patiently bide our limitations as agents -riding out feelings of anxiety, fear, or anticipated disappointment that might otherwise cause us to give up on our projects … in hoping, we create a kind of affectively charged 'scaffolding' for ourselves, providing the motivational energy to explore how we might exercise our capacities in new and creative ways. (2008, 246; cf. 2004) philip pettit makes a similar point, treating hope as a form of protection against 'loss of self-efficacy' and the 'panics and depressions' that we may experience in the face of setbacks (2004, pp. 157 and 160) . and in a similar vein, luc bovens adds that 'a hopeful rather than a defeatist attitude may at least be partly responsible for bringing some task to a successful end ' (1999, p. 671) . on this view, hope is valuable in part because it gives one motivational fortitude to pursue one's aims and projects in times of adversity (in this critical exchange, see james' remarks that deliberators and negotiators who lack hope are prone to 'settle for uninspiring resolutions'). mcgeer also claims that hope can empower us to trust others and that by displaying trust in others we can empower them to exercise their own agential capacities (mcgeer, 2008, p. 242) . hope thus enables one to develop and exercise one's own powers, while also empowering others. building on this general line of argument, katie stockdale has recently examined the ways in which oppression and systemic injustice diminish one's capacity to hope, restricting one's sense of what is possible and thwarting self-realisation (2019, p. 34). stockdale draws on cheshire calhoun's idea of 'frames of agency'that is, the background beliefs and attitudes that are preconditions of engaging in normative reflection and practical reasoning, which include 'confidence in one's relative security from disastrous misfortune and indecent harm ' (2008, p. 198 ) -to show that being a member of an oppressed group can lead one to feel so powerless as to lack the requisite conditions for agency (one may think here of fromm's conception of ohnmacht discussed in saar's contribution to this critical exchange). to support this, she considers the way in which depression and despair -and the correspondingly high rates of alcoholism and suicide -have ravaged indigenous communities in america (2019, pp. 34-36). stockdale's point here is that if we accept that a certain amount of hope enables humans to cultivate and exercise their capacities as practical agents, we ought to regard it as a political imperative to establish conditions that foster this hope. to what extent do spinoza's views align with those sketched above? with respect to the claim that hope enables one to exercise one's agential capacities, while spinoza does not directly articulate such a position, scattered remarks suggest that he was committed to some version of it. consider the reasoning behind his claim in the ethics that one cannot think less of oneself than is just: for whatever man imagines he cannot do, he necessarily imagines; and he is so disposed by this imagination that he really cannot do what he imagines he cannot. for so long as he imagines that he cannot do this or that, he is not determined to do it, and consequently it is impossible for him to do it. (e3defaff xxviii exp) spinoza is implying here that in order to be capable of doing something, one must first imagine that one can do it, which is not possible without hope. to lack hope, then, is to render oneself incapable. one might see in this account grounds for what might be called (in a nod to bernard williams' notion of proleptic mechanisms) 'proleptic hope': hoping even when it is not especially warranted, so as not to preclude altogether the possibility of realising these hopes. further evidence that he thought that hope is required for the exercise of agency may be found in the ttp: 'we are completely ignorant of the order and connection of things itself, i.e. of how things are really ordered and connected. so for practical purposes it is better, indeed necessary, to consider things as possible' (ttp, chapter 4, p. 126). while, regrettably, spinoza does not elaborate on this point, one natural way of reading the claim that it is better and necessary 'for conduct of life [usum vitae]' to regard things as possible is that, from a deliberative perspective, the idea of an open future is an indispensable fiction. after all, to act as though the future is not open -as, for instance, by embracing a version of the 'lazy argument' of fatalists -would be, once again, to foreclose one's agency or power. to hope is to imagine future states as possible (e4p12), which enables one to reason about how best to realise one's desires. furthermore, spinoza clearly embraces something like stockdale's view that oppression damages one's capacity for hope, leaving one enervated and dispirited. we see this in his analysis of oppressive states, which are marked by pervasive fear bordering on despair: a commonwealth whose subjects, terrified by fear, don't take up arms should be said to be without war, but not at peace … when the peace of a commonwealth depends on its subjects' lack of spirit -so that they're led like sheep, and know only how to be slaves -it would be more properly called a wasteland than a commonwealth. (tp, chapter 5, p. 530) he advances an account of one such 'wasteland' in his discussion of the ottoman empire in the subsequent chapter, which, on spinoza's unflattering portrayal, was able to endure only by reducing the subjects into slavish, languid subservience: no state has stood so long without notable change as that of the turks … still, if slavery, barbarism, and being without protection are to be called peace, nothing is more wretched for men than peace … peace does not consist in the privation of war, but in a union or harmony of minds. (tp, chapter 6, p. 533) the fact that subjects of the ottoman empire did not rebel despite their wretched conditions can be explained by their despondency, or lack of spirit (see armstrong's remarks in this critical exchange on how this might function as a critique of hobbes). in sum, then, spinoza recognised that a lack of hope is incapacitating, and that it is a fundamental political concern to ensure that people feel hopeful. spinoza's views on the value of hope also push beyond the prevailing contemporary discussions in an interesting way. in addition to thinking that security is good because of what it facilitates, spinoza also thinks that to live and act from security rather than fear is itself to live more willingly and, in a sense, more authentically. we find the links between hope and willingness as well as fear and compulsion throughout spinoza's political writings. in the ttp, he writes that one who acts from fear is 'compelled [coactus] by evil' and 'acts like a slave' (ttp, chapter 4, p.135) . he proceeds to contrast compelled, fearful action with willing, hopeful action: in each state the laws must be so instituted that men are checked not so much by fear as by the hope of some good they desire very much. for in this way everyone will do his duty eagerly. (ttp, chapter 5, p. 144) he then proceeds to praise moses for taking 'the greatest care that the people should do their duty, not so much from fear, as voluntarily', binding the people 'with benefits', or perceived rewards -that is, by hope (ttp, chapter 5, pp. 145-46; cf. ttp, chapter 14, p. 164). spinoza relies on the same conceptual pairs of hope-willingness and fearconstraint in the political treatise: a free multitude is guided by hope more than by fear, whereas a multitude which has been subjugated is guided more by fear than by hope. the first want to cultivate life; the second care only to avoid death. the first are eager to live for themselves; the second are forced to belong to the victor. so we say that the second are slaves, and the first free. (tp, chapter 5, p. 530) and when discussing a model aristocracy, he writes that legislators should 'take special care that the subjects do their duty voluntarily rather than because the law compels them to' (tp, chapter 10, p. 599), treating 'hope' as a species of willing motives (tp, chapter 10, pp. 599-600; cf. tp, chapter 9, p. 594). to engage the world securely and willingly, as opposed to fearfully and grudgingly, is to affirm one's actions more directly, which is to express one's striving more fully. this is best seen through spinoza's analysis of action from timidity [timor] , which is defined as that affect. by which a man is so disposed that he does not will what he wills, and wills what he does not will … [it] is therefore nothing but fear insofar as a man is disposed by it to avoid an evil he judges to be future by encountering a lesser evil (see p28). (e3p39s) to act from timidity is to seek to evade some evil rather than to affirm the good in the action. we see this later in his example of a sick man who, from timidity, 'eats what he is repelled by, whereas the healthy man enjoys his food, and in this way enjoys life better than if he feared death, and directly desired to avoid it' (e4p63s2). people whose actions are motivated largely by fear are conquered by external causes. by contrast the secure person is able to affirm directly the good in their action. the difference between regarding a course of action as directly good and regarding it as a lesser evil may be merely notional, but learning to direct one's attention to the good in one's actions is important for spinoza's cognitive therapy: [i]n ordering our thoughts and images, we must always (by ivp63c and iiip59) attend to those things which are good in each thing so that in this way we are always determined to acting from an affect of joy. for example, if someone sees that he pursues esteem too much, he should think of its correct use, the end for which it ought to be pursued, and the means by which it can be acquired, not of its misuse and emptiness, which only someone sick of the mind thinks of. (e5p10s, emphasis added) being able to affirm one's actions is a sign of strength, whereas acting aversively is a sign that one's striving has been overwhelmed or redirected by external causes. of course, spinoza is not recommending altering people's sense of security by hook or by crook (e.g. by mass indoctrination). rather, the aim is to promote security through good governance. ultimately, he wishes to promote hope as an indicator of expected utility, an instrumentally empowering attitude, and as a direct expression of power. this leaves us to ask how exactly the state can foster security. while spinoza's own account is far too detailed to treat adequately here, i will simply note that it involves dismantling institutions that promote anxiety and prejudice, tamping down factional or tribal strife, promoting widespread participation, ensuring conditions of relative equality, and governing transparently (for my account, see spinoza's political psychology, chapters 6-8). what are the prospects of bringing about the conditions of security in trump's america, where inequality continues to grow, rule of law and democratic institutions are steadily eroded, and partisanship and distrust reign supreme? admittedly, they are quite dim. but they are even dimmer if we lack hope. for that reason, perhaps we must now summon resources for proleptic hope, for only by acting hopefully in these bleak circumstances can we create conditions that might one day justify this hope. on new year's eve 2019 i stood on a beach on the south coast of australia surrounded by fires with a thousand other evacuees. i would later discover that the fires that had engulfed australia's south coast that day had destroyed the home that my partner's grandparents had built there thirty years ago, and from which my family had just escaped. despite the horrors of that day and of the days to come, i felt a sense of hope. here was the kind of proof of australia's extreme vulnerability to climate change that would surely persuade the australian government to abandon its denialist stance and embrace stronger climate policy settings. in the weeks that followed, that hope gave way to fear and despair as the australian government instead did everything in its power to avoid admitting to the link between climate change and the severity of the 2019-2020 bushfire season. the fires were blamed on arsonists or on the failures of hazard reduction burning, but behind these scapegoating tactics the implicit message was clear: to take action on climate change would be to risk the loss of a way of life built on a fossil fuel economy. when faced with an event with the potential to build broader social support for meaningful action on climate change, the australian government responded with a strategy of fear and misinformation: australians were encouraged to fear the costs of action on the economy and their standard of living over the costs of inaction. with the enthusiastic assistance of the murdoch press, fears about climate change were displaced and projected onto 'greenies' and 'progressive elites' who were accused by some on the far right of being part of a 'global socialist plot' to rob ordinary australians of their rights and livelihoods, and the australian nation of its sovereignty. citizens concerned about climate change were thus positioned as economy-wrecking enemies of the australian way of life. instead of serving to unite australians in common cause around a common hope for a liveable future, the bushfire crisis in australia was cunningly exploited to entrench social divisions and foster mutual fear. in foreclosing the possibility of reasoned public debate, this strategy of fear also ensured that the power interests vested in maintaining the political and economic status quo would continue to be shielded from scrutiny. spinoza could not have foreseen the ecological crisis that we face today, but he would certainly have recognised the hopes and fears constitutive of the various personal and political responses to this crisis. of all the passions, spinoza regarded hope and fear as some of the most important in creating and sustaining communal identities and in shaping the character of social and political life. in sharing hopes and fears with others, we express a common outlook on the world, and because our hopes and fears motivate us to pursue the things we hope for and to evade or overcome the things we fear, shared hopes and fears also constitute collective patterns of action and response. in the ethics, spinoza presents hope and fear as two expressions of a single affective complex. our hopes and fears track the ways in which our bodies and minds are empowered and disempowered in relation to uncertain outcomes. spinoza defines hope (spes) as 'an inconstant joy which has arisen from the image of a future or past thing whose outcome we doubt', and fear (metus) as 'an inconstant sadness, which has also arisen from the image of a doubtful thing' (e3p18s). the inconstancy of the affects of hope and fear is a function of the fact that their objects -the idea of the outcome we hope for, or fear will come to passare uncertain. this element of uncertainty explains why, on spinoza's account, 'there is neither hope without fear, nor fear without hope' (e3defaff xiii), for to be in a state of hopeful suspense and doubt about an outcome one desires is at the same time to be fearful of not attaining it. conversely, when one fears an outcome, one at the same time hopes that it will not come to pass. gripped by hope that the bushfire crisis may prompt the australian government to rethink its climate policies, i am also fearful that it may not. by the same token, what i know of the australian government's track record on climate change may lead me to fear that the bushfire crisis will not result in the policy changes that i nevertheless can't help but hope for. the passions of hope and fear thus appear bound together in a 'wretched' vacillation. it is because our hopes and fears enmesh us in uncertainty, doubt, and anxiety about the future that they are particularly important political tools. the desire to resolve a state of anxious uncertainty by securing the ends we hope for renders us easier to control with promises of security. the same desire for certainty makes us vulnerable to the influence of the ambitious who seek to exploit our hopes and fears by offering superstitious interpretations that serve to consolidate their influence and power over us. managing the relationship between hope and fear is thus central to politics, and the role these affects play in any particular political community will determine its character in fundamental ways. in reflecting on the political deployment of the affects in his political writings, spinoza suggests that it is the ratio of hope to fear that is most important in determining the character of states. this observation entails both a descriptive and an evaluative element, as the following passage from the political treatise indicates: a free multitude is guided by hope more than by fear, whereas a multitude which has been subjugated is guided more by fear than by hope. the first want to cultivate life; the second care only to avoid death. the first are eager to live for themselves; the second are forced to belong to the victor. so we say that the second are slaves, and the first free. (tp, chapter 5, p. 530) in this passage, spinoza suggests that in political communities in which hope prevails over fear, people are more empowered, joyful, and freer, than in communities in which fear dominates (steinberg, 2018, chapters 4-8) . these comments occur in the context of spinoza's reflections on the arts of governance. he is recommending, contra hobbes, that the wise state adopt an affective strategy of motivating obedience to its laws and institutions by fostering hope of benefits rather than fear of punishment. this strategy, he suggests, is the best way to engender loyalty to the state and thus a better means of securing political stability than a hobbesian strategy of fear (steinberg, 2018; field, 2020) . when the state seeks to secure participation and loyalty by appealing to our aspirations for freedom and empowerment, it binds us to itself predominantly by the joyful bond of hope for empowerment. and when, through the lens of hope, we see political society as an enabling condition of life, and an arena for the pursuit of the good, we are motivated to participate in it more actively. because, for spinoza, freedom and empowerment can only be realised in community as an ongoing collective project, a hopeful orientation towards community plays a vital, contributory role in the project of freedom. in the ttp, spinoza himself engages in a careful exercise of what we might, following moira gatens, describe as 'reasonable hope' for a 'free republic' when he imagines the construction of a society in which everyone would enjoy a right to participate in governance and to express their opinions without fear of intimidation. can we develop spinoza's insights about hope and fear in order to think through the politics of climate change in australia? can these insights help us to understand and evaluate the different affective patterns of hope and fear operative in the political project of the environmental movement on the one hand, and in the australian government's conservative political response to this movement on the other? consider, first, how we might envisage the affective economy of hope and fear operating in the politics of the environmental movement. it might seem natural to think that the environmental movement, because it tends to appeal to dreadful images of an unliveable future to motivate commitment to its cause, is itself primarily motivated by fear to avoid the evil that an unliveable future represents. however, this characterisation seems to me to be fundamentally misleading, since it suggests that this movement lacks any positive commitments. when one considers what the environmental movement is committed to, the answer must surely be that it is committed to pursuing the kind of socio-political transformation required if we are to construct more sustainable ways of life. in that sense, and using the terms that spinoza provides, its primary orientation is towards hope for the good that a transformed society represents -a more sustainable and liveable future -and it only secondarily fears not being able to achieve this outcome. as long as those involved in this movement are able to remain hopeful of making progress in bringing about this desired future, fears about what it would mean to fail will not devolve into the despair that certainty of failure produces (e3defaff xv), but may instead function to further energise their resolve by reminding them of the stakes of failure. in this case, we see how fear might be harnessed to support hope's aspirations. thus, as susan james argues so richly below, although fears of failure always shadow hopes of success, the ratio of hope to fear, and the relationship established between them, makes all the difference to whether the affective dynamic thus established contributes generally to empowerment, or on the contrary, to disempowerment. this affective economy, in which hope for the good is made to prevail over fear of an evil, can thus be understood, not just as a description of how the environmental movement contingently happens to be constituted, but instead as an affective relationship that can and must be cultivated. as such, it corresponds, in the socio-political sphere, to the practice of cognitive therapy that spinoza recommends to individuals in the ethics when he advises that, in order to reduce the influence of painful, disempowering affects, 'we must always attend to those things which are good in each thing so that in this way we are always determined to acting from an affect of joy' (e5p10s). one of the key advantages of the privileging hope over fear is the fact that hope is a species of joy, which corresponds to an increase in power, while fear is a species of sadness that signals its diminution. thus, any social organisation or political order in which hope mostly prevails over fear will be experienced as generally more empowering than one in which the intrinsically disempowering passion of fear predominates. however, although hope is more empowering than fear, it suffers, as all passive affects do, from an instability that derives from the fact that it signals our dependence on undependable external things. it is the unstable and fluctuating nature of passive affects that explains why spinoza attends so closely to the issue of how to design social and political institutions capable of channelling and stabilising their expression. in addition to these institutional checks, spinoza also considers the non-institutional ways in which our affects come to acquire a relatively stable and settled cast. the key mechanism he identifies in this regard is the imitation of the affects, whereby perceived resemblances between individuals form the basis of imaginary identifications, which provide the basis for common collective affects. in other words, according to spinoza, we come to imitate the affects of others we perceive to be like us (e3p27d). in this process of imaginative identification, each individual's affects are strengthened and reinforced through being shared with other individuals. in light of the imitation of the affects, we can see how the hope that motivates individuals as part of the environmental movement might be reinforced through being shared, and also stabilised through its directedness towards an idea of a common goal, so as to create a fairly stable affective basis for a strong form of civic engagement and activism. this relatively stable, shared, social form of hope, which expresses the desire, or striving, for a common good, serves as an example of an affective regime that agrees with 'the rules of human reason' insofar as it provides affective scaffolding for the rational endeavour privileged by spinoza, namely, 'that all should strive together, as far as they can, to preserve their being; and that all, together, should seek the common advantage of all' (e4p18s). for spinoza the realist, affects are the true basis for civil unity, which is why he regards politics as an art of cultivating the affective life of the body politic in ways that support the rational desire for empowerment (steinberg, 2018, chapter 8) . turning now to the conservative political reaction to the environmental movement, what can we say about the affective economy of hope and fear that sustains it? does its tendency to downplay worries about the seriousness of climate change mean that it is motivated by a hopeful, if misguided and vague, optimism about the future? what, in spinoza's terms, is the uncertain outcome that is the object of conservative politics, and about which it entertains hopes and fears? i think it is uncontentious to describe this object, or uncertain outcome, as the possibility of changes to the present. what motivates conservative politics is the desire to secure the present against change, to preserve the status quo, so that business as usual -fossil fuelled consumer capitalism -can continue unabated. because the possibility of preserving the present only becomes uncertain, and thus an object of fear, when it is threatened by something external, we can understand the conservative political response to the environmental movement to be driven by fear of the threat that this movement poses to its continued enjoyment of present goods. however, once fear ceases to be about an uncertain outcome, and is instead directed at what is imagined to be a threatening and hostile external force, it gives rise to hatred. the sad expressions of this hatred, and the conflict and division to which it gives rise, are very much in evidence in the politics of scapegoating and the 'culture wars' engaged in by australia's conservative government and its mouthpiece, the right-wing australian media. i don't want to linger over these issues here. of more interest to the present topic of hope is the question of what happens to hope, and how hope is managed, within a conservative political landscape dominated by fear of change. what are the hopes that shadow fear of changes to the present, and that serve to attach us to the socio-political present more strongly? the answer to this question depends entirely on how one is situated in relation to the political present. here i will focus only on the kind of hope that binds beneficiaries of the existing political and economic order to this order, thus serving to ensure its preservation. another, equally important account of the affective dynamics of hope and fear could, however, be developed for those who are directly disadvantaged by this order, but who cling to it desperately nonetheless (for an example of just such a dynamic, see justin steinberg's description above of the trumpian version of hope, in which reactionary nostalgia is sustained by multiple fears). for those who directly benefit from the existing political and economic order, investment in that order typically takes the form of privatised hopes. the privatisation of hope is the individualisation of hope and its expression in a variety of personal aspirations and expectations tied to a narrow understanding of one's immediate utility. these are the hopes and dreams one entertains for one's own and one's family's advancement and personal fulfilment, for example. by attaching us to the existing political and economic order via hope for the private advantage that it promises to secure for us, privatised hopes also serve to invest us in the preservation of that order. moreover, because the privatisation of hope detaches personal expectations from the wider world, it serves to weaken the sense of our belonging to a collective, and thereby also weakens collective capacities to solve collective problems like climate change. understood as an affective strategy, the privatisation of hope constitutes an effective means of undermining social solidarity and obscuring the social and political sources of problems. it thus serves as the vehicle of our attachment to conditions that we might otherwise perceive as antithetical to our more broadly conceived interests, if our capacities for understanding and acting on these interests had not been systematically undermined (for an alternative account of this affective dynamic, see martin saar's analysis of 'hope as ideology' below). it is via the mechanism of hope's privatisation that the conservative political agenda is advanced, and the structures of the existing political and economic order of consumer capitalism are preserved. in this disempowering relation between structure and affect, we see an example of how a particular distribution of the affects of hope and fear can lead us to support our own servitude, making us fight for slavery as if for our survival (ttp, preface, p. 68). to think with spinoza about the place of hope and fear in politics is to become attentive to the determining role played by these affects in our social and political lives. spinoza invites us to be alert to the ways in which hope and fear may be fostered and deployed, and to consider how the different relationships established between them may serve either to empower or to disempower individuals and societies. spinoza's political recommendations regarding how best to manage hope, in its necessary relation to fear, might be fruitfully understood as developing the elements of a political therapy of the affects. adapting these therapeutic insights to our own context can serve, at the very least, to make us aware of the political significance of our supposedly private hopes and fears. in his most philosophically ambitious mood spinoza is not an advocate of hope. as we develop our rational understanding, he argues, the transient satisfaction we derive from hoping gives way to the steady joy of concentrating on what we understand. 'the more we strive to live according to the guidance of reason', the ethics explains, 'the more we strive to depend less on hope, to free ourselves from fear, to conquer fortune as much as we can, and to direct our actions by the certain counsels of reason' (e4p47s). a community of perfect philosophers would therefore have no use for hope. but as moira gatens reminds us in her introduction to this critical exchange, spinoza is well aware that we are not perfect philosophers. since losing hope is one of the most painful things that can happen to us (crichton, 2020, p. 160) , we need to ask how we ordinary human beings can live hopefully without succumbing to disappointment or despair. for spinoza, this is both a philosophical and, as martin saar points out, a political problem. as well as pointing to the remote possibility of transcending hope, philosophy indicates in both theoretical and practical terms how we can use hope to cultivate joyful and empowering ways of life. however, the difficulty of doing so is made especially complicated by the fact that hope is always accompanied by fear, and the satisfaction of hoping is always to some degree offset by anxiety. hope, in spinoza's view, is tainted by sadness. if we are to live joyfully, it seems, we must therefore disjoin it from fear. in his recent book, justin steinberg calls this the inseparable counterparts challenge, and my discussion of the problem implicitly draws on his account (steinberg, 2018, pp. 83-94) . a number of commentators have taken up this interpretation of spinoza's argument, and it is clear from aurelia armstrong's contribution that it illuminates many aspects of his thought. nevertheless, i shall argue that the interdependence of hope and fear cannot be overcome and must instead be accommodated. by following the implications of spinoza's claim that there is no hope without fear, and focusing on the range of ways in which these affects can interact, we can distinguish the dysfunctional relationships between them that have attracted most attention in the literature from the jointly empowering role they are also able to play. that hope and fear are interdependent, i shall suggest, is one of spinoza's deepest and most hopeful insights, and has an immediate bearing on our own political situations. spinoza's discussion of this theme is rooted in his exceptionally rich analysis of the diversity of our affects. in the first place, affects vary with their objects. hoping to have a nice dinner, for example, has a different quality from hoping one's child is still alive, or in spinoza's more precise formulation, since the hope arising from a involves the nature of object a, while the hope arising from b involves the nature of the object b, these two affects are by nature different because they arise from different causes (e3p56 adapted). at the same time, our affects reflect our individual, embodied histories. the same piece of music may make one person joyful and another melancholy, while a thunderstorm may terrify one community and inspire hope in another. although we classify affects into types, they are in truth unique (lebuffe, 2009, pp. 189-190; saar 2015, p. 120 ). more than this, however, many of the situations we encounter arouse contrasting affects in us, as when admiration is tinged with envy, or love vies with resentment (e3p7s). we are torn between different feelings and desires, and experience what spinoza calls fluctuatio animi. in her 1856 translation of the ethics, george eliot renders this phrase as fluctuation of mind (eliot, 2020), where the latin fluctuatio carries connotations of being swept by one affect after another as a wave (fluctus) is driven by the wind (e3p59s). we fluctuate, for example, when a single situation simultaneously arouses contrasting affects and moves us to opposing courses of action. we also fluctuate when one affect is partially overlaid by another, as when a generally contemptible politician does something worthy of respect, and our approval alternates with disdain. fluctuations such as these are a manifestation of our power to be affected in many ways at once (e3p17s). an object arouses more than one affect, and neither gives way to the other. but fluctuations can also constitute new affects. jealousy (zelotypia), spinoza claims, 'is nothing but a fluctuation of mind born of love and hatred together, accompanied by the idea of one who is envied' (e3p35s). to borrow his example, a man who discovers that the woman he loves is also seeing someone else may start to hate her without ceasing to love her (e3p35). out of his emotional conflict jealousy is born. spinoza's most telling analysis of fluctuatio focuses, however, on the relationship between hope and fear. while these passions always occur together, they do not constitute a new affect. nevertheless, each is implicated in the other, so that there is 'neither hope without fear nor fear without hope' (e3defaff xiii). what ties the two together is the fact that each is a response to doubt or uncertainty. according to spinoza's symmetrical definitions, 'hope is an inconstant joy born of the idea of a future or past thing whose outcome we to some extent doubt', while 'fear is an inconstant sadness born of the idea of a future or past thing whose outcome we to some extent doubt' (e3defaff xii, xiii). when we confront uncertainty, fear of a disempowering state of affairs is always offset by at least a corner of hope, and hope of empowerment is always intertwined with anxiety. to put it another way, whenever we are in doubt about a potentially joyful or saddening outcome, we fluctuate between hope and fear. indeed, as spinoza explains, doubt and this species of fluctuation are really the same thing (e3p17s). because so much of our affective life revolves around our desires for uncertain ends, fluctuating hopes and fears are bound to be integral to our existence and will remain so as long as we fall short of perfect understanding. learning to live as well as we can is therefore a matter of learning to manage the relationship between hope and fear so that it contributes as far as possible to a satisfying way of life. at this point, spinoza suggests, everything depends on how our hopes and fears fluctuate, i.e. on the balance between the two affects, and on the pattern of their alternation. in general terms, we are most disempowered when the balance tips towards fear. as spinoza remarks more than once, when governments attempt to rule by fear rather than hope, their efforts to exert control over their subjects tend to generate anxiety and resentment, and threaten the peacefulness of the state (ttp, chapter 5, p. 139 and p. 145) . but this already dangerous condition can be rendered even more disempowering by the pattern of fluctuation between people's hopes and fears. at the extreme, people dominated by fear may suffer from the abrupt and irresolvable alternation of affects that spinoza calls consternation (consternatio) -'a fear which keeps a man so senseless or vacillating' that he is reduced, as moira gatens puts it, to feeble dithering and is unable to act (e3defaff xlii). (here curley's translation of fluctuatio as vacillation seems wholly appropriate). however, spinoza's most detailed examination of the disempowering effects of longer patterns of fluctuation focuses on superstition, a fragile and ultimately unsuccessful strategy for diminishing fear by tipping the balance of affect towards hope. superstition, as spinoza conceives of it, is the attempt to suppress anxiety by fantasising the existence of powers capable of protecting one against the dangers one is afraid of, and ritually placating them. when supplicants try to win the favour of the gods by offering sacrifices, for instance, or when witches take themselves to be doing the devil's work in order to turn away evil, they resort to superstition to quieten their apprehensiveness and bolster their confidence. commenting on this strategy, spinoza remarks that the people most thoroughly enslaved to superstition are those who invest great hope in uncertain goals and suffer a correspondingly intense fear of not attaining them. as their anxiety gains hold, they turn to superstitious practices to tip the balance of their affects towards hope, and 'appeal to divine aid with prayers and unmanly tears' (ttp, preface, p. 66). by reassuring themselves that god will protect them, they suppress their doubts and restore a more positive outlook. to the extent that superstition diminishes fear, it can be empowering, but spinoza is adamant that the hopefulness it yields is vitiated by a longer, destructive pattern of fluctuating affect. because the powers to which superstition appeals are the fruit of fantasy, the hope that people invest in them is likely to be disappointed, and the fear that superstition was meant to allay is liable to return (ttp, preface, p. 68). usually, then, superstition can only provide short-lived periods of hopefulness in an outlook inherently susceptible to anxiety and cannot definitively suppress a painful pattern of fluctuating affect (gatens and lloyd, 1999, pp. 30-33) . this pattern also has further damaging consequences. dispirited by relentless alternations of hope and fear, some people move in the direction of despair, tipping the balance of their affects even more sharply towards disempowerment. others relieve the discomfort of doubt by fixing on some source of hope and rigidly suppressing the anxieties associated with it. although both strategies block the fluctuation of hope and fear and to this extent relieve sadness, they do so at a cost. people who take these ways out disempower themselves, in one case by stifling their desire for a more joyful way of life and in the other by blunting their sensitivity to risk and doubt. although spinoza's exploration of superstition focuses on the religious culture of his time, the patterns of affect he traces have a political dimension. martin saar's reminder that affects are always political is illustrated, for example, by the claim that, because superstitious people 'are easily led, under the pretext of religion, now to worship their kings as gods, now to curse and loathe them as the common plague of humankind', superstition 'has been the cause of many uprisings and bloody wars' (ttp, preface, p. 68). here spinoza attributes political conflict to 'the pretext of religion', but he also suggests that political institutions themselves may generate superstitious fluctuations of hope and fear by advocating fantastical antidotes to political uncertainty (james, 2006) . contemporary states, for example, promise complete security whilst warning of insidious terrorist movements. governments reassure us we can continue as we are, while our own experience tells of environmental armageddon. increasingly, we find ourselves vulnerable to the anxiety that arises when the balance of our fluctuating affects tips and fear dominates hope. increasingly, we try to relieve the discomfort of fluctuating affects, whether by giving up hope or refusing to acknowledge any grounds for fear. it is easy enough to find examples of these disempowering strategies within our own political communities, and a single parochial case will be enough to illustrate the point. during the recent british struggle over whether or not to leave the european union, opposing sides defended their positions by offering wildly divergent interpretations of the political future britain might hope for and the risks attendant on failing to secure it. in parts of the brexit-friendly press, an image of an independent, homogeneous, internationally respected nation with firm control of its borders was contrasted with a dependent, even enslaved state, in which a flood of needy immigrants threatened to destroy long-established ways of life. by contrast, the anti-brexit media dwelt on an image of an advanced, prosperous, culturally rich and politically stabilising europe. to abandon it, they claimed, would be economically disastrous, culturally retrograde, and would put peace at risk. bounced between these contradictory and to some extent imaginary ideals and dystopias, superstitiously fluctuating hopes and fears became the order of the day. lack of a stable consensus stretched constitutional processes to breaking point, and both individual and collective agents suffered increasingly from consternatio. as the anxiety provoked by the prolonged fluctuation of hope and fear took hold, the two disempowering responses associated with spinoza's analysis of superstition became increasingly common. some voices invested ever more rigidly in whatever it was they hoped for and denied associated risks. (confronted by unfavourable predictions about the economic effects of brexit, for example, it became enough to dismiss them as scaremongering.) meanwhile other agents, individual and collective, descended into the spectrum of affects closest to despair. debilitated by the disquieting sense that there was nothing worth hoping for, fear came to dominate their lives. to protect ourselves against these disempowering responses, spinoza urges us to make hope the dominant partner in the balance of our affects and ensure that the pattern of fluctuation between hope and fear is not itself a source of overwhelming anxiety. at one level, following this path comes naturally. as justin steinberg points out above, the striving that constitutes our essence is a striving for empowerment, and we are consequently more strongly inclined to empower ourselves by hoping than to disempower ourselves by dwelling on our fears. although apprehension can get the upper hand, we are nevertheless oriented towards hopefulness and strive to live as hopefully as we can (martin, 2014) . how, though, do we maintain a hopeful balance of affects? how do we keep the anxieties that are the unavoidable counterpart of hope within bounds, and avoid the destabilising patterns of fluctuation manifested in consternation and superstition? spinoza's most direct response is a straightforward political recommendation: it is more empowering, he says, to rule by hope rather than fear. this formulaic piece of advice may seem insufficient, but underlying it we can discern a way for hope and fear to play a jointly empowering role. the interconnectedness of hope and fear draws attention to the complexity of our affective interpretations of the world. through the fluctuating relationship between these affects we track both opportunity and risk, as hope delineates what we take ourselves to be able to achieve, whilst anxiety makes the limits of our power present to us. each affect offsets the other, keeping our vulnerability as well as our possibilities in play. without the counterweight of fear, our disposition to construe the world hopefully -to imagine things that increase our power of acting and deny the existence of things that diminish it (e3p12) -would make us more likely to overreach ourselves and ignite the saddening forms of fluctuation we have examined. as it is, our aspiration to empower ourselves comes with a potentially fruitful check; the fluctuation of hope with fear serves as a reminder of our frailty and moves us to exercise caution (spinoza's personal motto) as we pursue our desires. learning to attend to the fluctuations of our hopes and fears, and cultivating the ability to use them as a means to our individual and collective empowerment, is a vital though extremely demanding process (armstrong, 2018, pp. 42-44) . in all aspects of our lives, the task of empowering ourselves partly depends on our ability to help one another keep our fears in check, and we can do this in many ways, whether by talking through the particular anxieties that individually threaten to depress us, or by devising measures to prevent panicking governments from irrevocably damaging the social fabric. at the same time, our empowerment depends on learning how to prevent our hopes from distorting our sense of what we can achieve by taking off into a realm of ungrounded optimism. a community can take steps in this direction by articulating its shared hopes along with the risks that accompany them, and expressing them in specific and realisable policies. in doing so, it constitutes the hopes and counterbalancing fears that dominate public life and shapes the fluctuations of mind that its members habitually undergo (tp, chapter 5, p. 138). by creating a compelling and hopeful political culture, it ensures that fear is guided by hope, rather than the other way around. a sensitivity to the interdependence of hope and fear is also a condition of successful deliberation. unless negotiators are moved by the hope of reaching a satisfying resolution, are anxious to avoid the risks at stake, and remain sensitive to both affects by feeling and responding now to one, now to the other, the lives they are discussing will be in danger of becoming mere numbers on a spreadsheet, and any solution they arrive at is likely to be a disappointment. again, however, great skills are called for. when negotiators are too hopeful they may underestimate risk; when they are not hopeful enough they may settle for uninspiring resolutions; and when they are side-tracked by superstition or consternation they will be unable to reach stable decisions. in its most productive form, the unavoidable fluctuation of our hopes and fears expresses itself in a nimble yet cautious openness to possibility, and in social practices that allow us to develop more empowering ways of life. as i have tried to show, one of spinoza's many achievements is to have drawn attention to the interdependence of hope and fear and made their relationship a topic of sustained philosophical and political reflection. standing on his shoulders and adapting his insights to our circumstances, we too may be able to align our hopes and fears so that our sensitivity to risk supports the pursuit of our shared aspirations, and reduces our vulnerability to disempowerment or sadness. susan james power, powerlessness, and the politics of hope hopeless times usher in the need for hope. among philosophers, the urge to make room for hope amidst hopelessness is increasingly felt. for quite some time, the topics of hope, progress, and utopia were not at the centre of academic debates, but recently this has fundamentally changed. the current health crisis, the ongoing 'turn to affect', and the re-evaluation of emotions in politics have contributed to this widespread tendency. to expect from spinoza scholarship, and (neo)spinozist authors, some elucidation of these topics is appropriate, given that many of us have promoted the relevance and timeliness of seventeenth-century philosophy for current theorising and, more broadly, for reflecting about politics, power, institutions, and social action (cf., among many, balibar, 1998; gatens and lloyd, 1999; negri, 2013) . my systematic interest in the connection between affects and politics, or, differently put, between the individual and the non-individual, predates my efforts as a spinoza interpreter. to theoretically and diagnostically account for the interrelations of individual experience and non-individual factors, be they social, interpersonal, institutional, or material, to me seems to be the core interest of political and social theorising. to understand the emotions or affective dispositions of persons, of which hope is a prominent case, in such a way means to understand them in relation to the social world persons inhabit; a world that shapes, frames, or conditions thinking, feeling, and acting. this general interest implies that i am less concerned with the straightforwardly ethical and epistemological questions of how hope, as a hopeful affective attitude or virtue, can be retrieved or cultivated (if it is lost) or whether hope can be justified (and is not just wishful thinking). rather, hope (or the lack thereof), in my perspective, amounts to an important indicator of social conditions and social tensions. before i turn to spinoza and hope, let me illustrate this general perspective from a different angle. in the mid-1930s, erich fromm, then a prominent contributor to the frankfurt school of critical theory (from which he was later expelled as a 'revisionist'), articulated the theoretical desideratum for the convergence of individual-psychic and social-material factors. in a series of important articles, fromm argued for a methodological marriage between psychoanalysis and a marxism of sorts (cf. fromm, 1932) . in a fascinating article, fromm focuses on the feeling of powerlessness or 'ohnmacht' (fromm, 1937) . this slightly oldfashioned word literally means 'without power'. at the same time, it refers to a mental state and a real-world state of affairs: having no power and being aware of not having it. (interestingly, and posing some problems for translation, ohnmacht can also refer to being unconscious, i.e. possessing no conscious cognitive powers.) the experience of powerlessness or ohnmacht, fromm claims, is a valuable entry point into the analysis of the social and political origins of fascism, specifically in its entanglement with the problem of illusionary hope: a feeling of powerlessness with regard to real changes … a 'belief in better times to come ' [and] this hope for change, however it might look, was the fertile soil [nährboden] for the growth of exactly those ideologies that led to the victory of the authoritarian state (fromm, 1937, pp. 115-116, my translation) . this slight detour has led me to a point where i can explain what i would expect from a (neo)spinozist treatment of the problem of hope that is neither purely ethical nor purely epistemological but social-theoretical or critical. trusting that my four co-contributors will present and interpret spinoza's 'official' and explicit treatment of hope as an affect more expertly than i ever could (as they have impressively demonstrated), i will restrict myself to some methodological remarks. the spinozian framework, i would like to claim, is particularly well suited to capture the correlation between individual or psychic-affective experience (like the feeling of powerlessness or hope) and non-individual social factors (like social tensions and conflicts). this framework thinks through these phenomena together, as two sides of the same coin. it treats the affective, subjective realm of reactions and experiences as an indicator of a mechanism that deeply relates the self to the outside world and its objectively determining, conditioning forces. the spinozist perspective on affect always relates affective experiences to transitions or changes in the real capacity to act or potentia agendi of an agent (cf. e3d3). this power-toact is less an individual feature or possession of that agent than it is an effect within a whole transindividual network of factors -most of which are not under her control. this interesting and non-accidental connection between a specific affect and power is illustrated in fromm's treatment of ohnmacht. this powerlessness is rather close to, but of course not identical with, hopelessness. fromm places them alongside one another, but in a negative way, suggesting that a feeling of powerlessness or objective hopelessness may give rise to subjective (but illusory) hope. power and (the feeling of) powerlessness therefore acquire, methodologically speaking, the character of basic, explanatory notions for other affective states (like hope). and this, i contend, is also what spinoza is trying to achieve. spinoza does not aim, at least not in the first instance, at a general ethical discourse about the value or utility of this or that affect, as such. rather, he defines affects as the affections of the body as well as the ideas of these affections augmenting or diminishing the power-to-act (cf. e3d3, e3p11s). the spinozian framework thinks the affects of individuals and groups through the capacity or power-to-act that can or cannot be realised, that is, through socially conditioned possibilities and impossibilities to act (cf. lordon, 2013; andermann, forthcoming) . fromm and spinoza both make this methodological shift: having or not having a specific affect, being hopeful or not, is discussed in terms of the social world in which this affect is produced or in which it can emerge. this perspective is fruitful for turning (personal or subjective) affective events into objects of inquiry indicating and referencing (transindividual or social) power relations and represents an important resource for contemporary political and social theorising. before i explicitly return to hope, let me briefly recall three well-known instances from spinoza's works where he displays the very theoretical gesture i am trying to pin down. in these passages, specific emotional patterns or affective dispositions -fear, greed, and love -are placed firmly in a social or institutional context so that they appear as products or effects of a specific social and political arrangement. the specific affects under scrutiny then lose their brute or natural character as individual psychological features and acquire the status of explananda in a social-theoretical narrative: they appear as something that it makes sense to have or to express in a given society under certain institutional circumstances (cf. saar, 2013, and forthcoming) . first, in the tractatus theologico-politicus, spinoza famously treats fear as one of the most overtly political emotions there are, and for several reasons. it tends to be an affect that can be politically manipulated and exploited, with religion being the name for the most effective symbolic machine that feeds on human beings' existential need to make sense of the unknown and of the threats a contingent life can entail (ttp, preface; james, 2006) . fear also tends to be the outcome of an active production of religious and moral teachings that create new objects for fearful projection. in addition, fear is a highly contagious, highly social force, and is, as spinoza in his most hobbesian mood seems to imply, a highly important driving factor in binding people together under state authority. this authority -the 'highest power', summa potestas -seductively promises to protect but more effectively threatens to strike down and sanction any trespasser of the civil order (ttp, chapter 16). there is a whole politics of fear surrounding, shaping, and inciting this seemingly all-too-human, all-too-natural emotion; there are whole institutions that build upon it and reproduce it in a vicious circle of sorts. second, ambition, greed, and a certain craving for recognition permeate social life to such a degree that it is hard to call them individual emotional dispositions at all. in his official theory of the affects in part 3 of the ethics, spinoza discusses these affects in isolation. however, in the more institutionally oriented sections of the tractatus politicus, they are shown to be elements of a social dynamic that structurally conditions individual behaviour and produces certain effects that can either harm or stabilise the social order. following machiavelli, spinoza recommends the construction of the political system in such a way that the individual ambition of political agents can be channelled towards the good of the whole civitas (cf. tp, chapter 7, p. 548; chapter 10, p. 599; walther, 2018 ). an urge to excel and even dominate can find a place and serve a function within a welldesigned society: the motivational energies that are created in comparing oneself to others and desiring to outdo them should be harnessed, not denied. at the heart of political processes, there is a whole economy or art of balancing the diverging and even competing ambitions of political subjects (cf. del lucchese, 2009, chapter 2). third, for spinoza, love and affective identification or investment are major elements of community-building and community-maintaining. his (one might say) 'passionate' version of republicanism depicts citizens not only as rational choosers of a certain order and authority. rather, in this picture, citizens also attach their hearts to common symbols, meanings, rituals, and narratives, which are expressive of a shared identity. both political treatises (the ttp and the tp), the first in a more historical register, the second in a more prudential register, place an enormous weight on the power of these practices to bind individuals together and forge a collective political body. political authorities are best advised to actively shape or even bring about these positive affects, which are the products of politics as much as they are, to a certain degree, its precondition, or, to put it more cautiously, the condition of a stable and lasting political community. there is a whole politics of love and identification needed and presupposed as the affective underside of the state, law, and institutions (cf. gatens and lloyd, 1999, chapter 5) . all three examples just recalled share the methodological feature i aim to highlight: spinoza de-naturalises and de-individualises the affects in question and places them firmly in a social, even institutional context. how one feels also reflects sets of practices in place, specific institutions of power, and certain discourses in force. concerning the examples just mentioned, it becomes clear that, for spinoza, fear, ambition, and love are also always socially and politically produced, cultivated, modified, and harvested. it does not take much to generalise this point to other affects: in the current moment, panic, despair, and feelings of insecurity come to mind. instead of seemingly isolated, seemingly spontaneous, seemingly individual reactions and dispositions, the spinozist will see here an entire politics: that is, she will see strategies and utilities attached to and inherent in these affects. a spinozist analysis of affective dispositions cannot avoid addressing the society that makes them possible or impossible, that uses, shapes, and redirects affective energies in highly specific and functional ways. but this also means that the very potentia agendi of the individual undergoing or experiencing an affective state is a matter of interference with, and intervention in, the powers of other entities, be they persons, groups, or institutions. this methodological shift from a treatment of affect as individual or purely psychological to its treatment as social and political is, by my lights, one of spinoza's major contributions to social and political theorising (cf. lordon, 2013, chapter 3; saar, forthcoming) . but what does it mean for the case of hope? to reiterate, i am less concerned with analysing spinoza's own explicit arguments about hope. rather, my aim is to methodologically delineate what a (neo)spinozist perspective on this phenomenon amounts to. such a framework could, i suggest, take on the really hard political cases and make sense of situations where the value of hope is far from clear. treating hope as a factor of power, as its tool and product, ultimately reveals it as a political entity and problem, with different valences in particular contexts, serving different purposes, strategies, and circumstances. (a) radical hopelessness there are social or political situations where hope is not present at all, where objective hopelessness mirrors objective powerlessness (cf. flam, 1998) . spinozists could consistently maintain that a body without much power to act or govern itself cannot accordingly form any coherent idea of a good it could reach by itself. the absence of such a positive affect or horizon is possible and should not be taken lightly. having hope or not (for spinoza at least) is not a matter of will, but a matter of objective conditions. this perspective might help to disarm more voluntaristic conceptions that rely on the mere will to believe 'yes, we can', which is sometimes nothing more than a version of the 'just do it' mentality of today's consumer culture, devoid of political analysis, or even plausibility. we should, however, treat the objective absence of hope as an extreme (yet not impossible) case of an almost complete totalitarian shut-down of the circuit of action and freedom. (b) ambivalent hope in most other social conjunctions, some hope(s) will be produced, differing in degree for different social and political groups. some of these groups will need such hope(s) more badly than others to keep up and to keep on struggling or resisting. it would be cynical to deny hope as a motivational factor, and no (neo)spinozist will argue for this. but she will keep reminding herself that needing and having hope and needing and having (some) power (to do some things) will need to correlate, that hope can be a surrogate or ersatz-affect where rage or indignation, or where a sober strategic analysis of what is possible and impossible, would be more apt. i take spinoza's explicit scepticism towards hope qua individual affect to express this ambivalence (cf. e3p18s2 and e3p50s), and i happily subscribe to susan james's brilliant characterisation of this topos in her contribution to this critical exchange. whether hope in a context of political struggle or conflict is a strengthening of, or a deflection from, political action is a strategicopolitical question. it will depend on the cartography or topology of powers and capacities, of alliances and hegemonies. (c) hope as ideology there is yet another problematic case, where hope is present, almost too present, and established as a cultural norm that conceals the many forms of powerlessness that objectively exist. just recall fromm's harsh (and not too subtle) judgment of a vague hope for the better as an ideological fog preventing the masses from seeing their objective misery. nobody will deny that late-capitalist society remains highly invested in existential hopes and dreams, of a better life for one's children, of romantic fulfilment, of careers and consumerist practices. any sober social analysis, however, will show how unrealistic many of these hopes and dreams are, given the myriad of structural and systemic exclusions and disadvantages some groups face. but these hopes and dreams still fuel whole lives and help accommodate objective social realities that would not be maintained without these phantasmatic investments. lauren berlant has coined the phrase 'cruel optimism' for this kind of psychological entrapment, which describes 'a relation of attachment to compromised conditions of possibility'. berlant argues (through more or less psychoanalytic means) for the pervasive character of cruel optimism in contemporary culture (berlant, 2010, p. 94; cf. similarly ahmed, 2010) . in his opening reference to the 'american dream' in this critical exchange, justin steinberg strikes the same note, and it deserves underlining: hope for the better can be a major impediment to a realistic and non-illusionary assessment of social realities, and can be nothing more than an ideological imperative serving the interests of those whose lives and social status do not have to change to be acceptable. in my view, a (neo)spinozist perspective on hope today should be prepared to argue along lines that are adequate and responsive to these three cases. this stance would, for sure, be all for hope as a resource for social change, political motivation, and civic engagement, and would never deny that in order to counter and endure a grave social crisis (like a pandemic or a financial crash) hope is much in need. but it could also critically expose the many promises, functions, and seductions of hope. it could describe hope as a mind-set of political subjects, reflecting the political context in which these subjects act and understand themselves. in the ultra-realist (neo)spinozist picture, affects as ontological features of the human should always be part of real politics. raising, mobilising, and channelling hope will be one strategy of political projects aiming at affecting the minds and souls of citizens. which politics? which affects? which hopes? these are questions that philosophy, or theoretical reflection alone, will not be able to settle. for spinoza, a philosopher who knew the limits of philosophy, these are questions of real and imagined power, of real and imagined agency, and of who can do what, how and when -and who cannot. note 1 all references to spinoza's works are to curley's two volume translation collected works of spinoza and use the following abbreviations: e for the ethics, arabic numerals for its five parts, p for proposition, s for scholium, d for definition, c for corollary, appen for appendix, and defaff for the definition of the affects that appear at the end of e3. so, e2p18s refers to ethics, part 2, proposition 18, scholium. the ethics appears in volume 1 (spinoza 1985) and both the theologico-political treatise and the political treatise appear in volume 2 (spinoza 2016) . abbreviations for these texts will be ttp and tp, respectively, followed by the chapter number and page number. spinoza's letters appear in both volumes and are abbreviated by ep followed by the letter number and volume number. the promise of happiness forthcoming) die macht der affekte: spinozas theorie immanenterindividuation affective therapy: spinoza's approach to self-cultivation ethics and self-cultivation: historical and contemporary perspectives spinoza and relational autonomy: being with others cruel optimism the value of hope losing one's self dreams and delusions: psychiatric explorations conflict, power and multitude in machiavelli and spinoza: tumult and indignation potentia: hobbes and spinoza on power and popular politics mosaic of fear: poland and east germany before 1989 ü ber methode und aufgabe einer analytischen sozialpsychologie zum gefühl der ohnmacht forthcoming) spinoza's notion of freedom collective imaginings: spinoza, past and present spinoza on superstition: coming to terms with fear spinoza on philosophy, religion, and politics: the theologico-political treatise the cambridge companion to spinoza's ethics part of nature: self-knowledge in spinoza's ethics la société des affects: pour un structuralisme des passions how we hope: a moral psychology the art of good hope trust, hope and empowerment spinoza for our time: politics and postmodernity human all too human: a book for free spirits hope and its place in mind die immanenz der macht: politische theorie nach spinoza spinoza and the political imaginary. qui parle: critical humanities and social sciences forthcoming) power, affect, society: critical theory and the challenges of (neo-) spinozism the collected works of spinoza the collected works of spinoza spinoza's political psychology: the taming of fortune and fear social and political dimensions of hope spinoza's constitutional economics. natur the contributors to this critical exchange are grateful to millicent churcher for her excellent assistance in preparing this critical exchange for submission to contemporary political theory. moira gatens is challis professor of philosophy at the university of sydney. she teaches and researches in the areas of political philosophy, early modern philosophy, feminist philosophy, and philosophy and literature. her most recent publications include 'frankenstein, spinoza and exemplarity' (2019) in textual practice and (with millicent churcher) 'reframing honour in heterosexual imaginaries' (2019) in angelaki. she is currently completing a book on spinoza and art with anthony uhlmann. key: cord-140624-lphr5prl authors: grundel, sara; heyder, stefan; hotz, thomas; ritschel, tobias k. s.; sauerteig, philipp; worthmann, karl title: how much testing and social distancing is required to control covid-19? some insight based on an age-differentiated compartmental model date: 2020-11-02 journal: nan doi: nan sha: doc_id: 140624 cord_uid: lphr5prl in this paper, we provide insights on how much testing and social distancing is required to control covid-19. to this end, we develop a compartmental model that accounts for key aspects of the disease: 1) incubation time, 2) age-dependent symptom severity, and 3) testing and hospitalization delays; the model's parameters are chosen based on medical evidence, and, for concreteness, adapted to the german situation. then, optimal mass-testing and age-dependent social-distancing policies are determined by solving optimal control problems both in open loop and within a model predictive control framework. we aim to minimize testing and/or social distancing until herd immunity sets in under a constraint on the number of available intensive care units. we find that an early and short lockdown is inevitable but can be slowly relaxed over the following months. the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is a strain of coronavirus which causes the respiratory illness coronavirus disease 2019 . in 2020, on march 11 th , the world health organization (who) declared the outbreak of sars-cov-2 a pandemic [41] . due to the novelty of the virus, there was (and, at the time of submitting this manuscript, still is) significant uncertainty concerning the severity and mortality of covid-19. furthermore, as of october 2020, no vaccine has completed the trials necessary for approving widespread use [24] . therefore, many countries are enforcing nonpharmaceutical countermeasures [19, 20] , e.g. 1) social distancing, 2) increased public hygiene, 3) travel restrictions, 4) self-isolation (quarantine), and 5) population-wide mass testing for sars-cov-2 infection. however, enforcing these countermeasures for long periods of time can have severe economic and social consequences, both at the national and the global scale [28] . therefore, there is a need for identifying economic strategies for simultaneously relaxing the countermeasures and containing the pandemic. model-based decision support systems can be used for exactly this purpose. they use predictive models to assist decision makers in identifying and evaluating candidate strategies (e.g. [1] ). in particular, given a dynamical model of the spread of sars-cov-2, economically optimal (open-loop) mitigation strategies can be identified by solving optimal control problems (ocps) over several months or even years. a key advantage of this approach is that it can directly account for constraints, e.g. related to the capacity of public healthcare systems. however, given the uncertainty surrounding sars-cov-2 and covid-19, it is advisable to implement the optimal mitigation strategies in closed-loop, i.e. to repeatedly update the strategies when new data becomes available. this is referred to as model predictive control (mpc) [32] and is an established method for advanced process control [31] . the predictive capabilities of the underlying model are crucial for the efficacy of the resulting mitigation strategy, and a common challenge is to identify suitable model parameters. epidemics are often modelled using deterministic compartmental models [18] , e.g. the classical sir model, where individuals are either susceptible, infectious, or removed, or the seir model which, additionally, takes the incubation time into account. optimal control of compartmental models was already an active research topic before the sars-cov-2 pandemic (see [35] for a review). in particular, optimal control of sir models has been considered, e.g. for arbitrary social interaction models [2] and to identify time-optimal mitigation strategies [3, 16] . optimal control of more complex models has also been considered. for instance, fischer et al. [12] consider optimal control of a model with two species, bussell et al. [6] demonstrate the importance of closed-loop mitigation strategies (i.e. of incorporating feedback), and watkins et al. [39] consider mpc of stochastic compartmental models. in [11] the authors determine control strategies to maintain hard infection caps in a disease-vector model based on the theory of barriers. this approach, however, exploits the low dimensionality of the model. application of these techniques to complex compartmental models, therefore, requires model order reduction. in response to the sars-cov-2 pandemic, many researchers have presented optimal control strategies, for instance based on pontryagin's maximum principle (e.g. [21, 30, 42] ). these strategies typically involve 1) extended sir or seir models, 2) nonpharmaceutical countermeasures (often social distancing), and 3) minimization of the number of infected as well as the economic cost of the countermeasures (and often other quantities as well, e.g. the number of deaths). furthermore, they rarely satisfy hard constraints, for instance related to health care or testing capacities. in the following, we highlight some of the key developments in decision support for sars-cov-2 mitigation based on optimal control. gondim and machado [14] use a model with three age groups to compute optimal quarantine strategies (for susceptible individuals) which minimize the number of infected and the cost of quarantining. bonnans and gianatti [4] compute social distancing strategies based on a model with a continuous age structure. here, the strategies minimize a combination of 1) the number of deaths, 2) the peak number of hospitalized, and 3) the cost of social distancing. similarly, richard et al. [33] present optimal social distancing strategies based on a model with a continuous age and infection duration structure, which minimize the number of deaths and the cost of social distancing. morato et al. [25] compute on-off (also called bang-bang) social distancing strategies which minimize 1) the number of symptomatic infectious people and 2) the duration of the social distancing policies, subject to constraints on intensive care unit (icu) occupancy. they use extended sir models. carli et al. [7] use mpc to compute social distancing and travel restriction strategies for an extended multi-region sir model, minimizing the cost of the countermeasures and preventing an overload on the hospitals. köhler et al. [22] use mpc to minimize the number of fatalities caused by covid-19, subject to constraints on the economic cost of social distancing. they take a modified sidarthe model [13] as basis and use interval arithmetic in the mpc to propagate model uncertainties. finally, tsay et al. [37] use mpc to minimize the cost of social distancing and testing, subject to an upper bound on the peak number of infectious people who have been tested positive. they use the unscented kalman filter to estimate the noisy state variables of an extended seir model. in this work, we address some of the key questions that decision makers involved in the mitigation of the sars-cov-2 pandemic are facing: 1) is mass testing alone sufficient to avoid overloading of icus? 2) if not, how much social distancing is then required? 3) how much can social distancing measures be reduced by targeting specific age groups? 4) how do strategies obtained by short and long-term planning differ? 5) what are the benefits of increasing the daily testing capacity or the icu capacity? here, the limited icu capacity is considered as an example for constraints imposed by the health care system or political considerations. of course, different constraints such as limited personnel for contact tracing could be incorporated as well. we address the above questions by proposing a novel compartmental model and using optimal control as well as mpc to compute open and closed-loop social distancing and testing strategies. the model contains three age groups, and it accounts for several of the key challenging characteristics of covid-19, i.e. 1) the incubation time, 2) different levels of symptom severity depending on age, 3) delay of testing results (and the following self-isolation), and 4) delay of hospitalization. furthermore, we choose values of the epidemiological model parameters based on the current state of knowledge in order to ensure that our numerical results match reality. for concreteness, we use the covid-19 outbreak in germany to determine parameters depending on demographics and the health care system. however, we expect our conclusions to carry over to outbreaks in other developed countries as well. the remainder of this paper is structured as follows. in section 2, we describe the novel compartmental model of the sars-cov-2 outbreak in germany, and in section 3, we motivate our choice of model parameters. in section 4, we demonstrate that optimal control can be used as a decision support tool based on the proposed model, and we conclude the paper in section 5. in this section, we propose a dynamical model tailored to covid-19. the aim is to be able to evaluate the effect of population-wide mass testing (in combination with quarantine) and social distancing measures on the development of the pandemic. to this end, we extend the well-known sir model. we start with an illustration of the connection between 1) infectious disease models based on randomly acting individual agents and 2) their approximation by ordinary differential equation compartmental models. this exposition will highlight the interpretation and conversion of parameters when moving from a random to a deterministic model. for simplicity, we consider the classical sir model in this subsection. however, the connection, especially the interpretation of parameters, is similar for more complex models such as the one described in section 2.2. consider a population of n pop individuals or agents each being either susceptible, infectious or removed. at time t ∈ [0, ∞) denote the (random) set of susceptibles by s t , the set of infectious by i t and the set of removed by r t . time is modeled continuously and measured in days. we assume a homogeneous population with contacts between agents a and b following a poisson process with intensity λ which does not depend on the agents considered. infections occur randomly upon contact with a fixed probability α if one of the agents is susceptible and the other infectious. thus, potentially infectious contacts also follow a poisson process with respective intensity αλ. similarly, we model other events, in this simple model only recoveries, to occur according to a poisson process. this implies that the time an agent spends in the infectious compartment is exponentially distributed with rate η, say, which we also assume to be the same for each agent (see [27] for models where these quantities follow other distributions). we denote by s(t) = e |st| npop , i(t) = e |it| npop and r(t) = e |rt| npop the expected share of the population which are susceptible, infectious and removed, respectively. since for large n pop the change of |st| npop over a short time interval can, due to the law of large numbers, be well approximated by its expectation, s(t) will provide a sufficient approximation of |st| npop over the finite time horizon considered for a country the size of germany. by the same argument, i(t) and r(t) approximate |it| npop and |rt| npop , respectively, sufficiently well. if a is susceptible he will transition to the infectious compartment upon having an infectious contact. at a fixed time t with a ∈ s t , there are two possible sources of infection for a: either some b ∈ i t which is already infectious or some c ∈ s t which will become infectious himself at some later time. to determine the probability that b infects a in the time frame (t, t + ∆t], we analyze two competing events: the first is an infectious contact between a and b, and the second is b's recovery from the infectious state. both events happen independently of one another with exponentially distributed time of occurrence, the first with rate αλ and the second with rate η. thus the first time of occurrence of one of these is again exponentially distributed with rate αλ+η and the probability that the first occurrence is an infectious contact is αλ αλ+η . in total for c ∈ s t to infect a in (t, t + ∆t], c has to become infectious himself before he in turn can infect a. this happens only with probability o((∆t) 2 ) and can, thus, be neglected in the following calculations. in total a is moved out of the susceptible compartment with probability approximating |st| npop and |it| npop by s(t) and i(t) using the law of total expectation yields as we assume the time from infection to removal to be exponentially distributed with rate η, a similar but more straight-forward calculation reveals where η −1 is the mean stay of a single agent in the infectious compartment. we now set β = n pop αλ, which can be interpreted in this model as the daily amount of (potentially) infectious contacts a single agent has. since s(t) + i(t) + r(t) = 1 for all t, we obtain the following system of odes: to determine suitable parameter values for β and η in this simplistic model, we reiterate that these are best thought of in the probabilistic setting. for the coefficients of the linear terms on the right-hand side, the interpretation is straight-forward: it is the rate of the exponential distribution underlying the time until an agent leaves the compartment. its inverse is the mean stay in this compartment. for coefficients of interaction (product) terms, here β, the interpretation is the rate at which an agent in the first compartment causes other agents to leave the second compartment. in our setting, this is the daily amount of infections one infectious agent causes which can readily be seen from the definition of β. see section 3 for a more detailed discussion of the parameter values we use in our model. as above mentioned, these interpretations for the parameters carry over in a straight-forward manner to more sophisticated models such as the one considered in the following. the sir model provides a good starting point to study the dynamics of pandemics. however, due to its simple structure it is not suited to model the covid-19 pandemic adequately. in particular it does not include hospitalization, age-specific disease progressions and interventions. therefore, we extend the sir model in three ways. 1. we introduce eight additional compartments. in detail, we take into account that people can be infected, but not yet infectious. we call them exposed (or latent) and denote the compartment by e, see also [18] . moreover, we split the infectious compartment into three depending on how the course of the infection will be. we distinguish between severe cases i s that are going to need intensive care, i.e. they will move to h icu at some point in time; mild cases i m that are going to visit a physician and hence be quarantined, i.e. removed; and asymptomatic cases i a that might recover without being detected. furthermore, we incorporate the possibility of being tested but not yet detected by introducing the compartments t s (severe) and t o (other). we assume that the patients with severe cases will visit a physician at some point before being sent to an icu. to this end, we introduce p as a pre-icu compartment which comprises isolated patients at home or on a regular hospital ward. moreover, we split the compartment of removed people into known and unknown cases r = r u + r k . 2. each compartment is further divided into n g groups, n g ∈ n, depending on the age of a subject in order to study how these groups affect each other. 3. social distancing and hygiene measures affect the contact rate as well as the transmission probability. therefore, β can be used as a time-dependent control input β(t). the resulting seitphr model reads aṡ where the subscript i ∈ {1, 2, . . . , n g } denotes the age group in ascending order. we enforce ng i=1 n i = 1, where n i denotes the relative size of age group i. we assume a mean incubation time γ −1 independent of both the course of infection and the age of the patient. however, depending on the age, there are different probabilities π s i , π m i , and π a i for the three courses of infection, where π s i + π m i + π a i = 1 for all i. similar to the sir model (1), the parameters denoted by η correspond to people being removed from the system, i.e. η s and η m denote those who visit a physician and, therefore, are put into quarantine immediately, while η a represents unreported recovery. we denote the total number of susceptibles and unreported cases by describes the rate of those being tested per day, where tests are distributed uniformly at random among all individuals in u i . in addition, symptomatic cases who visit physicians are assumed to be tested as well. therefore, the total number of tests at time t ≥ 0 is given by note that testing does not affect the state of non-infectious subjects. parameters τ s and τ o denote the rate from being tested positive to being detected, and hence being put into quarantine. furthermore, ρ is the rate from pre-hospital quarantine to hospitalization and σ from hospitalization to being reportedly removed, i.e. σ incorporates both mortality and recovery rate of hospitalized patients. the basic structure of the seitphr model (2) is depicted in figure 1 . figure 1 : flow of the seitphr model for one age group. the controls are indicated with dashed red edges. unreported compartments are highlighted by the left red triangle, while tested and detected compartments are highlighted by the right blue trapezium. for a concise notation we stack the state vectors into x = (x 1 , . . . x ng ) and the controls into u = (β, θ), where and β = (β ij ) ng i,j=1 with β ij : r ≥0 → r ≥0 and θ = (θ 1 , . . . , θ ng ). similarly, we denote π ∈ r 3ng , τ ∈ r 2 , and η ∈ r 3 . thus, we write system (2) aṡ where p = (π, η, τ, ρ, σ, γ) ∈ r 3ng+8 collects all parameters. furthermore, we introduce the initial condition before we present our choices for the parameters of model (2), let us reiterate that some of the parameters of our model depend on age. we indicate this dependence by an appropriate index which we drop if the parameter is constant across agegroups. for example, π s i is the age-dependent probability of having a severe course of disease while we assume η a , the rate with which asymptomatic cases recover, to be age-independent. n i we use data on the population size of germany at the end of 2019 from the genesis-online database of the destatis [36] . the first age group consists of individuals aged younger than 15 years, the second of those older than 15 but younger than 60 years, and the last comprises all individuals older than 60 years. these groupings result in proportions n 1 = 0.14, n 2 = 0.58 and n 3 = 0.28. the rate at which an infected agent in compartment i j infects susceptibles in compartment s i depends on the contact structure of a population as well as the probability that a contact between a susceptible and infectious agent leads to a transmission of the disease. we base our contact process on data from the polymod study on daily contacts in several european countries [26] . from this data we calculate a contact matrix c = (c ij ) whose (i, j)-th entry is the mean amount of contacts an individual in age group i has with age group j; here we only consider those contacts labeled as physical, since those are more likely to lead to viral transmission. let us denote by β 0 ij the rate at which a single infectious agent from age group j infects susceptible agents from age group i if no countermeasures, such as social distancing, are in place. we model β 0 ij to be proportional to c ij and let α be the corresponding proportionality constant. if a single infectious agent is introduced without interventions such as test, quarantine and social distancing measures in place into the otherwise completely susceptible, i.e. virgin, population, the mean amount of secondary cases he causes is the basic reproduction number there is a wide variety of estimates for r 0 in the literature [29] , with most estimates in the interval [2, 3.5] . we choose a value of r 0 = 2.5 as early, higher estimates might be biased upwards due to imported and undetected cases. fixing η −1 = 6 (see the discussion on η a below) we calculate α = 5.79% and in turn β 0 ij from (4): γ the rate at which latent cases become infectious is the inverse of the mean incubation time. this parameter is modeled age-independent and chosen to be 0.19, which corresponds to a mean incubation time of 5.2 days [23] . these parameters denote the proportion of individuals in age group i that have severe, mild or asymptomatic course of disease. for germany, the robert koch institut (rki) has published data on severity of disease progression for 12, 178 cases by age-groups [34] . for our purposes we define a severe case to be a case that will eventually be admitted to intensive care, a mild case being one developing influenza-like symptoms, pneumonia or being admitted to hospital for other reasons. all other cases we classified as asymptomatic. thus we obtain π i = (π s i , π m i , π a i ), the proportion of severe, mild and asymptomatic cases in age group i, respectively, as (π 1 , π 2 , π 3 ) = 1 100 observe that the oldest age group is at highest risk with 3.02% of infected individuals admitted to icu. also the proportion of severe cases in the youngest age group is higher than in the middle age group. this might be explained by the fact that cases in the youngest age group are detected less frequently due to them being tested less, leading to overreporting of severe cases. η s , η m , η a these are the rates at which infectious individuals are removed from the infection process, if no mass-testing is implemented, i.e. if θ i = 0. for individuals with severe or mild course of disease when they develop symptoms leading to self-isolation, quarantine prescribed by a physician, or to direct hospitalization. one characteristic of covid-19 is that even presymptomatic cases transmit sars-cov2 [17] . we assume the time from being infectious to symptom onset to be 2 days after which we add 2 more days which it takes before the infectee visits a physician. thus we choose η s = 0.25. for mild progressions we assume the same mean duration from being infectious to symptomatic, though in this case individuals self-isolate, visit a physician or receive a positive test result after a mean waiting time of again 2 more days; consequently, we also set η m = 0.25. for asymptomatic cases in i a i the only way to be removed from the infection process is by recovery from the infection. in [40] positive virus samples were found in patient's throats for up to 8 days after symptom onset. assuming a lower viral load for asymptomatic cases with only 4 days of potential infectiousness and adding the 2 days of presymptomatic transmission we chose η a = 0.17, corresponding to a mean time of 6 days to recovery for asymptomatic cases. τ o , τ s as we assume the testing related to the controls θ i to be of a random nature, tested individuals are not yet removed from the infection process. instead we assume positive test results to become available after a mean delay of 2 days. however, severe cases may visit a physician and thus go into immediate quarantine before receiving their test result. the latter transition occurs with rate η s , and hence the faster transition occurs with rate τ s = 1 2 + η s = 0.75. non-severe cases that are tested, t o i , are removed if they recover naturally (with rate η a ), or receive a positive test result, or visit a physician. that leads to τ o = η m + η a + 1 2 = 0.92 for each age group. ρ this parameter is the rate at which severe cases move from being in the pre-icu state to the intensive care unit. this includes time spent in quarantine at home as well as time spent in the hospital in normal care while being isolated. in [10] the median time from symptom onset to being in intensive care for 50 patients was 9 days. as the median of an exponential distribution exp(ζ) is log 2 ζ we choose a mean stay of 9 log 2 − 2 ≈ 10.98 = ρ −1 days, accounting for the mean two days from symptom onset to the transition into the pre-icu compartment. σ this is the mean time spent on intensive care until discharge or death. according to [10] patients with acute respiratory distress symptoms (ards) spent a median amount of 13 days in intensive care and patients without ards spent a median amount of 2 days in intensive care. of the 50 patients considered in this study, 24 were afflicted with ards. converting again between median and mean for the assumed exponential distribution yields a mean time of σ −1 = the divi-intensivregister offers daily information on the amount of free intensive care hospital beds in germany. on 20 october 2020 they reported a capacity of 8, 872 free beds with 879 actively treated covid-19 patients [9] . we therefore round the maximal icu-beds available for covid-19 patients to 10, 000. t max in late august until the beginning of october the rki conducted between 1 and 1.2 million weekly sars-cov-2 tests in germany. this motivates our upper bound t max = 1,200,000 7 of daily tests. x 0 we initialize our model at time t = 0 with entries of x 0 set to 0 except for those related to the susceptible, latent and infectious compartments. our choice of initial values is informed by the number of active cases reported by the rki in late march assuming the proportion of underreporting to be 50%. we hence set the total number of infectious agents at t = 0 to 524 and the number of latent agents to 1672 distributed among the age-groups according to n i . as we explain in remark 1 our model is robust against misspecification of the initial values. figure 2 demonstrates the simulation capabilities of our model. here, the course of the pandemic is visualized if no countermeasures are implemented, i.e. no social distancing (β(t) = β 0 ) and no mass-testing (θ(t) = 0). as expected, the pandemic evolves too fast to satisfy any reasonable cap on the number of required icus. in particular, the number h icu of required icus exceeds 100,000 whereas we noted above that in germany only about 10,000 icus are available to treat covid-19 patients. therefore, countermeasures are indispensable to avoid an overload on the hospitals. note that if we distinguish different age groups the pandemic evolves faster, but less icus are required, as the pandemic spreads mostly in the less vulnerable, younger age groups. similar observations, viz. herd immunity being achieved faster in heterogeneous populations in comparison to homogeneous ones, have already been made by [5] . in this section, we provide information on how to keep the epidemic manageable. to this end, we formulate suitable optimal control problems (ocps) and solve them numerically. since we neither take vaccines nor re-infections into account, we consider the epidemic to be over once herd immunity is achieved, i.e. a state where the introduction of new infectious agents does not lead to an outbreak. therefore, our main goal is to reach herd immunity with as few social distancing as possible while maintaining strict limits on the icu occupancy to avoid a breakdown of the health care system. we call a control u = (β, θ) of the system (3) , . . . , n g }, and is satisfied for all t. a natural stopping point for simulations is when the share of susceptibles has decreased enough to ensure herd immunity even when all countermeasures are lifted completely. the time-dependent effective reproduction number r(t), that is the mean number of secondary cases a primary cases will cause at time t, can be used to determine whether herd-immunity has been reached: this will be the case if r(t) is less than 1. if there is only one infected compartment, as in a simple sir model, the latter condition is equivalent toi̇(t) < 0. if there is more than one infected compartment, as in model (2), [8, 38] have suggested to compute r ngm (t), based on the so-called next-generation matrix, as a proxy for the effective reproduction number. then, r ngm (t) exhibits the same threshold property as r(t), that is r ngm (t) < 1 implies herd immunity. thus we use r ngm (t) to check whether our simulations have reached herd immunity. a time horizon of two years (104 weeks) sufficed for all our simulations. this section is structured as follows. first, we verify the existence of a feasible testing strategy, i.e. without enforcing social distancing. note that due to delays in testing, the existence of a solution is not trivial and depends on the initial value. next, we establish an upper bound on the maximal number of tests per day and investigate to what extent social distancing is required in order to ensure feasibility. throughout our simulations, we assume the length of one control interval to be one week. this reflects the practical constraint that the government cannot change policies arbitrarily often but more realistically on a weekly basis. throughout our simulations we use the matlab-inherent sequential quadratic programming (sqp) tool to solve the ocps. here, our goal is to maintain a hard cap on the number of required icus with as few tests as possible without enforcing social distancing, i.e. β ≡ β 0 . to this end, we solve the ocp the objective function penalizes the total number of tests over the entire time horizon [t 0 , t f ] with t f > t 0 ≥ 0. the equality constraint (6c) captures the system dynamics while the one-sided box constraints (6e) ensure that the testing rates cannot be negative. figure 3 depicts the optimal controls as well as the total number of tests and the number of detected cases per day while figure 4 shows the impact on the evolution of the epidemic. here, we computed the effective reproduction number r ngm (t) at each time step, demonstrating that we reached herd immunity. we observe that there exists a testing strategy that ensures feasibility, which was not obvious from the outset because of the assumed delays. in particular, the bound (6b) is active once it's reached, i.e. h icu ≡ h icu max , and becomes inactive when the number of susceptible people falls below a certain threshold and r ngm (t) < 1 indicating the onset of herd immunity. (6) satisfies the socalled turnpike property [15] . typically, turnpikes indicate the optimal operating state of a system. these are steady states at which the running costs are minimized. in our example, since we do not penalize the number of required icus, the best strategy is to stay at the upper bound while saving tests. once the objective function value is zero the system leaves the state eventually. in particular, regardless of the initial value, the system is steered towards this optimal operating point. as a consequence, a rough estimation suffices as initial guess for our simulations. a rigorous analysis of these turnpikes, however, is left for future research. however, these results are only of theoretical interest, since this optimal testing strategy would be prohibitively expensive and might not even be implementable at all. for instance, regarding figure 3 , one observes that the mean testing rate reaches about 0.5, which corresponds to being tested every two days on average. moreover, the total number of tests per day required for this approach is more than 12,000,000 on average (over 65 weeks), compared to t max ≈ 170, 000 daily tests which are currently conducted in germany. note that, even with this enormous testing effort, the number of detected cases, t s + t o , is rather small since the number of infectious individuals is small compared to the total population. in conclusion, mass-testing alone currently does not suffice to maintain hospitalization caps in reality. these arguments support the government's decision to introduce additional measures like social distancing and hygiene concepts. however, cheap rapid test kits might change the situation favorably as they could be made widely available, self-administered while giving immediate test results. in the following subsections, we enforce t max as an upper bound on the amount of daily tests. under this additional constraint we then determine the minimal amount of social distancing required to reach herd immunity. the success of such measures depends on the acceptance and thus compliance by the general population. in a first step, we determine an optimal social distancing strategy by penalizing the deviation of β from β 0 equally over all age groups. this might increase acceptance in the general population due to the (perceived) fairness of such measures: everyone is treated equally and contacts are reduced by the same proportion for everyone. in reality such strategies may be hard to conceive as different measures affect the age groups differently, i.e. closing schools and nurserys affects those in the lowest age group the most while leaving the oldest age group unaffected. nevertheless a mixture of many different non-pharmaceutical measures may be able to achieve such a reduction in contacts. we introduce a time-varying factor δ = δ(t) describing the amount of social distancing that is implemented. moreover, we choose to penalize the 2 deviation of this control input from δ = 1 in the objective function in order to smooth the optimal control. for instance, penalizing the 1 deviation yields bang-bang controls, i.e. the optimal solution jumps back and forth between the two extremal options: no contact restrictions and lock down (simulations not shown). therefore, we determine an optimal homogeneous social-distancing policy by solving min θ,δ note that we allow to distribute the tests among the age groups by not fixing θ i , but enforcing (7e) and (7g). furthermore, we introduce a regularization term with weight κ = 10 −5 . the choice of κ is based on simulations. in contrast to (6), we always find a feasible solution of (7) if the epidemic has not yet evolved too far. more precisely, by choosing δ = 0, which corresponds to a complete lockdown, we are (theoretically) able to stop the spread. therefore, if the initial number of people with a severe course of infection is sufficiently low, the upper bound on the number of icus will not be violated. a highly fluctuating social distancing strategy may lead to low acceptance in the general population, because people have to adapt to new rules every few weeks. thus before we solve (7) let us have a look at what happens if we consider a constant value for δ over time, i.e. a social distancing strategy without fluctuations. figure 5 (left) shows that fewer contacts result in a longer time for the epidemic to abate on the one hand, but a lower number of total infections within the considered time horizon on the other hand. moreover, figure 5 (middle) visualizes that quite strict social distancing is needed in order to meet the icu capacities. the maximal value of δ to stay feasible is 0.487, i.e. contacts needed to be more than halved over three years. furthermore, once we lift the restrictions, see figure 6 , there might be another outbreak. in particular, the stronger the restrictions were in the beginning, the stronger the second outbreak will be. therefore, it is essential to establish herd immunity before lifting all restrictions, and to adapt the policy over time. a visualization of the optimal solution of (7) can be found in figures 7 and 8 . as mentioned above, the bound on h icu is not violated. since the weight κ is chosen sufficiently small, the upper bound on the total number of tests per day is active as long as the upper bound on δ is not. however, note that not all age groups are tested equally. more precisely, only the middle-aged group is tested at all. the reason is that this group is the largest (n 2 > n 1 + n 3 ) and has the highest contact rates (c.f. (5) ) and therefore, contributes more to the spread of the epidemic than the other groups. furthermore, we observe that the social distancing policy has to be quite strict in the beginning. in particular, min t δ(t) ≈ 0.3 which corresponds to a reduction of average contacts per person by 70%. however, this can be qualitatively compared to the measures taken in germany starting in mid march 2020 when contacts were reduced by school and restaurant closures as well as other contact restrictions. in conclusion, social distancing is an effective tool to keep the epidemic manageable. comparing the results of (7) to the simulations with constant δ we see that a (partial) lockdown appears inevitable. however, our simulations suggest to let the epidemic evolve for a few weeks, then enforce a contact reduction down to approximately 30% for 2-4 weeks before slowly lifting the restrictions over the next 12 months until herd immunity is achieved. the constraint that contacts are reduced by the same proportion for each age group is restrictive and it is plausible that more efficient solutions exist when contact reductions are distributed differently across age groups. one reason to consider such a strategy is that it may be more efficient at stopping the spread of the epidemic; as mentioned above the middle-age group is the driver of the epidemic while the oldest age group consists of the most vulnerable individuals. in any case, such an age-differentiated social distancing strategy needs to be accepted by the whole population to be successful. hence, we improve the social distancing policy computed above by allowing it to depend on age. given the solution (θ , δ ) of (7), we solve the ocp min θ,β here, we use δ to define β min ij = min t δ (t)β nom ij , i.e. the lower bound on β in (8) is the worst case of (7). therefore, no one is treated worse than when applying homogeneous social distancing. note that (θ , β) with β = δ β 0 is feasible for problem (8) . as in (7) we penalize testing as soon as β(t) = β 0 holds. results for (8) can be found in figures 9 and 10 , wherē describes the average number of contacts per person and day in a heterogeneous population. here, we used κ = 10 −5 . the corresponding value for β 0 isβ 0 = figure 9 : optimal age-dependent social-distancing strategy for three age groups over two years. figure 10 : evolution of the compartments associated with controls depicted in figure 9 . 0.4167. this allows to compare the solution β ij (t) withβ 0 δ (t) obtained from (7) . similar to the solution of (7), the upper bound on testing is active most of the time, while essentially only the middle-aged group is tested. the social distancing measures are less restrictive than for (7) which makes compliance with the measures more likely. however, the measures could be perceived as unfair, since the contacts of the oldest age group are restricted most. moreover, the contacts of the middle-age group are least restricted. therefore, the working class would be allowed to go to work which benefits the economy. in conclusion, social distancing is crucial to avoid an overload on the hospitals. in addition, testing middle-aged people helps to reduce the required amount of social distancing. furthermore, all presented strategies support a lock down a few weeks into the epidemic, which is followed by lifting the restrictions step by step until herd immunity sets in. age-differentiated social distancing might be hard to argue for, but it helps to end the epidemic several months earlier and, therefore, support the economy. the control strategies derived in the previous subsections provide rough guidelines for how the epidemic can be controlled. however, from a decision maker's perspective, it will be hard to argue for policies taking effect in the far future. in particular, there are many uncertainties that might affect the performance of the control strategy over the time span of two years, and hence the control strategy needs to be adjusted over time. therefore decision need to be revised constantly adapting to the changing conditions during the epidemic's progress. model predictive control (mpc) provides a state of the art methodology to tackle such figure 11 : optimal control for solving (8) in closed loop for varying prediction horizon length. for the sake of readability, we depicted average values of θ and sums of t tot over the age groups. figure 12 : evolution of the epidemic based on the controls depicted in figure 11 . for the sake of readability, only the sum over the age groups is visualized. problems. the basic idea of mpc is to consecutively solve a series of ocps over a smaller horizon of k control intervals rather than solving a single ocp over the whole horizon. more precisely, only the first part of the optimal control derived by solving such an auxiliary ocp is implemented. then, the time window is shifted, and the procedure is repeated based on updated measurements. for a detailed introduction to mpc we refer to [32] . here, we tackle (8) via mpc; the earlier problems can be treated analogously. the mpc scheme for (8) is summarized in algorithm 1. input: prediction horizon length k, length of control interval ∆t. set time t = t 0 . repeat: 1. obtain current statesx = x(t). results based on varying prediction horizon lengths can be found in figures 11 and 12 . the basic structure of both the optimal control and the associated states is comparable to the open-loop solution presented in the previous subsection. therefore, we stopped the simulations after one and a half years. the length of the prediction horizon affects mainly the optimal social distancing policy. in particular, the larger the prediction horizon, the less social distancing is needed in total. more precisely, for bigger k, we implement a slightly stricter lockdown but can start it later and relax it earlier. furthermore, the larger k gets the closer the optimal solution is to the open-loop solution. in particular, the mpc solutions qualitatively resemble the open-loop solution: after an early lockdown, social distancing is slowly lifted. for k = 3, the icu capacity reaches its upper limit earlier due to the laissezfaire policy in the beginning. however, this constraint also becomes inactive earlier. for even shorter prediction horizons recursive feasibility cannot be guaranteed, i.e. the icu cap might be violated (simulations not shown). so far, we assumed both the upper bounds on the number of tests per day, and on the number of icus to be fixed at our chosen values. in practice, these conditions may change: free icu capacity might exhibit seasonal patterns and the number of possible tests per day depends on infrastructure and available personnel. in addition, varying the upper bounds is useful to illustrate the benefits of increased testing and higher icu capacities. in this subsection, we investigate the impact of these parameters on the optimal social distancing policy numerically. first, we study the effect t max has on the social distancing by solving (7) via mpc, see figure 13 (left). as pointed out in the previous subsection, the prediction horizon length affects the start and end time of measures as well as its peak (simulations not shown). in addition, increasing t max by some factor t max fac ≥ 1 shifts the whole δ curve upwards, i.e., as expected, the more tests are available, the less social distancing is required. furthermore, figure 13 (left) visualizes the impact of t max on the objective function value of (7). figure 13 : impact of t max on social-distancing costs (left) and of h max on both social-distancing costs (middle) and testing (right). in the last two subfigures the currently available number of icus in germany is highlighted by a vertical dashed line. the dashed horizontal lines in the right-most figure indicate the total testing capacities over the entire simulation horizon. factor of modification of t max denoted by t max fac . second, we investigate the impact of the number of icus on the optimal solution of (8) . results can be found in figures 13 and 14 . for the simulations in figure 13 (middle and right) we used mpc with prediction horizon k = 12 weeks. figure 13 (middle) clearly shows that the number of available icus directly affects the cost function value. while for a small value of h icu max , every additional icu contributes, for large values, a saturation seems to take place. in particular, doubling the current number of available icus does help, but the benefit becomes negligible when increasing it further. these phenomena are almost unaffected by doubling or halving t max . however, when there are not enough icus, then the upper bound on t tot is always active, see figure 13 (right), where t tot is at its maximum value all the time. moreover, an increase in the number of icus clearly figure 14 : impact of the available number h icu max of icus and the prediction horizon k on the average social distancing. the dotted cyan line refers to the number of currently available icus in germany. the vertical dotted black line marks the end of social distancing measures for that setting. leads to a reduction in the social distancing measures, as can be seen in figure 14 . in summary, increasing test capacities and/or icu capacities helps to reduce measures like social distancing. however, the impact of the number of available icus appears to be much stronger. nonetheless the qualitative shape of the solutions over time is not affected by varying these constraints. in this paper, we demonstrated how mitigation of the covid-19 epidemic can be achieved by a combination of age-stratified testing and social distancing measures while avoiding a breakdown of the health care system. we showed that in our compartmental model mass testing alone is insufficient to achieve this goal, as it would require unrealistic testing capacities. as a remedy, we designed optimal social distancing strategies with a focus on applicability and acceptance in the general population, i.e. strategies with slowly changing contact reductions. the resulting social distancing measures imitate the measures actually taken in germany, but are lifted at a much slower pace. agedifferentiated contact reductions may improve upon these results as they yield qualitatively similar social distancing strategies and prioritize relaxing restrictions for the work-force and children. to model the process of policy making more realistically, we used mpc which allows to adapt to deviations from the envisioned course of the epidemic by solving the optimal control problem repeatedly. our analysis reveals that longer prediction horizons allow for faster lifting of restrictions although long-term predictions may be infeasible in practice. additionally we showed that the amount of available intensive care units is a key factor influencing the required amount of social distancing. we believe that our model with the chosen parameters reflects reality sufficiently well to provide qualitatively valid insight on how testing and social distancing can control the spread of sars-cov-2. we learned that mass testing alone is, assuming realistic testing capacities, not sufficient to avoid a breakdown of the health care system in germany. to prevent this, one has to implement strict contact reductions early on, which, ideally, should then be eased slowly. if one allows these reductions to vary by age, one is able to relax restrictions for the (working) middle age group, at the cost of reducing contacts of the more vulnerable older population. while short-term planning of measures is unable to control the exponential growth of cases, medium-term planning produces strategies that, qualitatively, do not differ from optimal ones while being flexible enough to adapt to new circumstances. finally, as expected, the number of available intensive care units dictates how fast herd-immunity can be reached and how much total social distancing is necessary. however, we caution the reader against interpreting these results in a quantitative way, as our model has not been devised to produce precise predictions. similarly, we want to stress that we do not provide concrete policies to implement, as the impact of particular countermeasures on β is not easily quantified. concerning other influences on the epidemic's evolution, note that we have not yet considered vaccinations nor re-infections, both of which could be included in our model without difficulties, if parameters are available to model them. as our model is based on odes, interaction effects such as contact tracing cannot be included. agent-based (stochastic) models are able to handle these critical effects and could be seen as a natural extension of our (deterministic) compartmental model. to solve the resulting stochastic optimal control problems would then require more sophisticated techniques, however. a model for covid-19 with isolation optimal 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interventions for optimal control of covid-19 we thank kurt chudej (university of bayreuth) for insights on modelling pandemics and manuel schaller (tu ilmenau) for fruitful discussions on optimal control and the turnpike property. key: cord-011824-4ge9i90s authors: andrews, jack l.; foulkes, lucy e.; bone, jessica k.; blakemore, sarah-jayne title: amplified concern for social risk in adolescence: development and validation of a new measure date: 2020-06-23 journal: brain sci doi: 10.3390/brainsci10060397 sha: doc_id: 11824 cord_uid: 4ge9i90s in adolescence, there is a heightened propensity to take health risks such as smoking, drinking or driving too fast. another facet of risk taking, social risk, has largely been neglected. a social risk can be defined as any decision or action that could lead to an individual being excluded by their peers, such as appearing different to one’s friends. in the current study, we developed and validated a measure of concern for health and social risk for use in individuals of 11 years and over (n = 1399). concerns for both health and social risk declined with age, challenging the commonly held stereotype that adolescents are less worried about engaging in risk behaviours, compared with adults. the rate of decline was steeper for social versus health risk behaviours, suggesting that adolescence is a period of heightened concern for social risk. we validated our measure against measures of rejection sensitivity, depression and risk-taking behaviour. greater concern for social risk was associated with increased sensitivity to rejection and greater depressed mood, and this association was stronger for adolescents compared with adults. we conclude that social risks should be incorporated into future models of risk-taking behaviour, especially when they are pitted against health risks. adolescence is a sensitive period of development, characterised by significant changes in both the biological and social environment. in particular, adolescence is a time of social reorientation, greater susceptibility to peer influence and heightened sensitivity to social rejection [1] . adolescents are also stereotyped as risk takers, which is likely due to evidence that risk behaviours, such as binge drinking, risky driving and smoking, are heightened during this period of life [2, 3] . this commonly held perspective, that adolescence is a period of heightened risk taking, conceals a more nuanced reality. social context significantly affects adolescents' engagement in health risk behaviours. for example, evidence from car accidents shows that, for young drivers, the risk of engaging in a fatal car accident increases with the number of passengers in the car [4] . this is reflected in the experimental literature, with one study finding that, when playing alone, adolescents and adults take a similar number of risks on an incentivised computerised driving task (the stop light task). however, when adolescents played the same driving game in the presence of friends, they took significantly more risks, which was not the case for adults [5] . adolescents are also more likely to smoke, binge drink and take illicit substances with their peers, compared to when alone [6] . however, not all adolescents take risks, and recent work has led to the suggestion that adolescence is in fact a time of increased sensitivity to risk, characterised by wide variation in risk seeking and risk averse sit at the extreme end of concern for social risk, when the environmental cues potentially signal that one's social burden is significantly greater than one's social value. however, few studies have directly investigated whether adolescence is a period of heightened concern for social risk, and the extent to which concern for social risk predicts depressive symptomatology. current questionnaire measures of risk-taking behaviour do not uniformly include social risks as a risk-taking domain, and instead focus on the domains of health (e.g., taking illicit substances), financial (e.g., gambling) or legal (e.g., stealing) risk. one adult risk-taking questionnaire, the domain-specific risk-taking questionnaire (dospert) includes a social risk subscale, but this includes items that are not applicable to adolescent populations. for example, the social-risk items in this measure include 'approaching your boss to ask for a raise' and 'taking a job that you enjoy over one that is prestigious but less enjoyable' [22] . another issue with current questionnaire measures of risk taking is the conflation between health and social risk. many health risks carry with them some degree of social risk, e.g., smoking may carry with it both health and social risk considerations. further, it is unclear whether concerns about social risk are independent of concerns for other risk domains, such as health risk behaviours, so whether or not an individual's propensity to take risks is uniform across risk domains. given these issues, we developed and validated a measure of concern for health and social risk, which is suitable for both adolescents and adults. in this measure, we conceptualised a social risk as any behaviour that marks individuals as being different from their peers-for example, openly endorsing music that friends do not like, or befriending an unpopular peer. we attempted to isolate the social-risk items by including social risks that involve little or no obvious health risk. we conceptualised a health risk as risks to one's physical wellbeing, such as crossing a street on a red light. we included health risk behaviours that have as little conflation with social risk as possible. we had four primary hypotheses. we first hypothesised that concern for social risk would be distinct from health risk concerns. in order to establish this, we developed a measure using exploratory and confirmatory factor analysis (efa; cfa) to assess whether health and social risk domains are distinct constructs. second, and in order to validate our measure, we hypothesised that higher concern for social risk would be associated with greater sensitivity to rejection and lower mood. we hypothesised that this relationship would be stronger for adolescents compared with adults. third, we hypothesised that greater concern for each risk domain would be positively related to risk perception and negatively related to engagement in that risk domain. finally, we hypothesised that concern for social risk would decrease with age from early adolescence to late adulthood, relative to concern for health risk. sample 1 (exploratory factor analysis: efa; adults). participants (n = 500) were recruited from two sources: the university participant pool (n = 177) and prolific, an online participant recruitment and data collection platform (n = 323). participants (295 females, 204 males, one did not disclose gender) were aged 18-60 years (mean = 32.2, sd = 10.72). sample 2 (confirmatory factor analysis: cfa; adults). participants (n = 415) were recruited via prolific. participants (284 females, 129 males, two did not disclose gender) were aged 18-77 years (mean = 36.53, sd = 13.10). sample 3 (confirmatory factor analysis: cfa; adolescents). participants (n = 484) were recruited from schools in the greater london area, as part of ongoing research projects in our lab. participants (333 females, 107 males, four did not disclose gender) were aged 11-17 years (mean = 13.54, sd = 1.91). all participants were from the united kingdom and all completed the questionnaires online. ethical approval was obtained from the university ethics board (7199/001; 3453/001). participants were paid at a rate of approximately £10 per hour for their time. we developed a questionnaire measure in order to assess the degree to which adolescents and adults are concerned about engaging in health and social risk behaviours. given that many social risks also incur health risks, we developed items with as little conflation between the two as possible. we developed a list of social-risk items, e.g., "spend time with someone your friends don't like", and health risk items, e.g., "cross a main road when the crossing light is red". a panel of five researchers with expertise in adolescent social development reviewed an initial list of items and provided feedback on the content and suitability for individuals aged 11 and above, with the aim of making sure each item was distinct from the opposing type of risk. following this, a total list of 16 items was included in the scale validation: eight health and eight social (see table 1 ). in the version of the questionnaire given to participants, individuals were asked: "for each statement please rate how worried you would feel doing this behaviour. (if you have never done it, imagine how you would feel)." answers were given on a sliding scale from, "not worried at all (0)" to "very worried (100)". the questionnaire was administered online and the numbers (0-100) were visible along a slider (see supplementary materials for final questionnaire). all participants completed a number of additional measures in order to assess the construct validity of the hsrq. all participants included in the adult cfa completed each additional measure (n = 415). however, due to time constraints imposed by testing sessions, a subset of the participants in the adolescent cfa completed the rejection sensitivity (c-rsq; n = 207) and depressed mood (mfq; n = 281) measures only. questionnaire is a validated measure of sensitivity to actual or perceived rejection [23] . individuals were presented with nine scenarios such as "you approach a close friend to talk after doing or saying something that seriously upset him/her" and are asked to rate their rejection concern and level of acceptance expectancy. scores are computed by reversing the level of acceptance expectancy and multiplying this by the level of rejection concern. scores across the nine items are then averaged to create a total rejection sensitivity score; higher scores indicate higher rejection sensitivity. we hypothesised that higher scores on the social subscale of the hsrq would be positively associated with higher scores on the a-rsq. adolescents: children's rejection sensitivity questionnaire (c-rsq). participants completed the anxious expectations subscale of the children's rejection sensitivity questionnaire, which is a valid measure of rejection sensitivity in children [24] . participants were presented with six scenarios and were asked to report on a scale of 0-6 their expected likelihood of the outcome of the scenario and how nervous they would be given the content of the scenario. their expected likelihood was multiplied by their nervous expectation for each scenario and then a mean score was derived across all items. higher scores relate to greater rejection sensitivity. we hypothesised that higher scores on the social subscale of the hsrq would be positively associated with higher scores on the c-rsq. adults: personal health questionnaire depression scale (phq-8). the phq-8 is a validated eight item measure of depression [25] . participants were asked how often over the past two weeks they have experienced eight different symptoms, such as "how often were you bothered by feeling down, depressed, or hopeless?" participants were asked to report on a 4-point scale (0 = "not at all" [ . . . ] 3 = "nearly every day"). we hypothesised that higher scores on the social subscale of the hsrq would be positively associated with higher scores on the phq-8. the mfq [26] is a depression screening tool for individuals aged 6 to 17 years old. it is a validated measure of depression in children and young people [27] . individuals were presented with 13 questions, such as "i felt miserable or unhappy" in the past two weeks. responses were scored on a 3-point scale (0 = "not true", 1 = "somewhat true", 2 = "true"). we hypothesised that higher scores on the social subscale of the hsrq would be positively associated with higher scores on the mfq. adults: domain-specific risk-taking (dospert) scale. participants completed the health and social risk subscales of the 30 item dospert scale, a validated risk-taking measure for adults [22] . individuals were asked to report on a 5-point scale their likelihood of engaging in each activity or behaviour such as "speaking your mind about an unpopular issue in a meeting at work" ("1= "very unlikely" to 5= "very likely") and their assessment of how risky each situation or behaviour was ("1= "not at all risky" to 5= "extremely risky"). we hypothesised that higher scores on the social subscale of the hsrq would be negatively associated with the social risk engagement subscale of the dopsert and positively associated with the social risk perception subscale of the dospert, with the same being true for the health risk subscales. adolescents. note that adolescents did not complete a social risk-taking measure because the items from the dospert are not appropriate for this age group (e.g., "approaching your boss to ask for a raise") and there is no existing social risk-taking measure for adolescents. all data was analysed primarily using the laavan (version 0.6-5), psych (version 1.9.12.3) and semtools (version 0.5-2) packages in r (version 3.62; r core team, 2013). we first conducted an exploratory factor analysis (efa) using oblique (oblimin) rotation on the initial 16 items relating to health and social risks (eight health, eight social) on a sample of 500 adults. we determined the suitability of our sample size and data for efa based on the kaiser-meyer-olkin (kmo) index (>0.70) and bartlett's test (<0.05) [28] . we determined the number of factors to retain based on examination of the scree plot, retention of factors with eigenvalues of 1 or greater and factors with at least three items. items with factor loadings of <0.4 were removed. following factor and item reduction based on the above criteria, we subjected the same data to a confirmatory factor analysis (cfa) to assess the strength of the proposed factor structure. we then used cfa to assess the strength of this factor structure in two new samples: one adult group (aged 18-77; n = 415) and one adolescent group (aged 11-17, n = 485). in line with the recommendations outlined by [29] , our primary measure of model fit was root mean squared error of approximation (rmsea). an rmsea of around <0.08 indicates reasonable fit [29] . we also assessed the model fit with the standardised root mean square residual (srmr; <0.08 reasonable fit), comparative fit index (cfi; >0.9 reasonable fit), and the tucker-lewis index (tli; >0.9 reasonable fit). we computed measures of internal consistency using cronbach's alpha and mcdonalds omega. we further tested the fit of each two-factor cfa using aic, by comparing a one-factor solution (where all items are loaded onto one higher order risk factor) with the two-factor solution (health and social risk). a lower aic represents a better fit to the data. to assess convergent and divergent validity, we assessed the relationship between the new hsrq, rejection sensitivity [23, 24] and depressed mood [25, 27] across both cfa samples using pearson r correlations. we then compared the strength of the relationship between the adolescent and adult sample with a z statistic. one additional risk-taking questionnaire, the dospert [22] , was used to brain sci. 2020, 10, 397 6 of 14 relate the hsrq to risk perception and engagement health and social risks, in the adult sample only. in order to establish the test-retest reliability of the hsrq, we invited 100 participants from the adult cfa sample to complete the questionnaire a second time 11-12 days after the first completion. we used pearson r correlations to establish the relationship between these individuals' scores at time point 1 and 2. using all the data collected (n = 1399), we computed a mean score of the validated health and social subscale. we determined the relationship between age and the two subscales of the hsrq using multiple linear regression. we included age, gender and risk domain (health, social) in the model, as well as an age*risk domain interaction, to predict risk concern. we used aic to compare between linear, quadratic and cubic models, with a lower aic representing a better fit. analyses showed that the sample size (n = 500) was suitable for conducting factor analysis (kmo = 0.88, bartlett's test <0.001). factor loadings of each item are presented in table 1 . three factors showed eigenvalues above our threshold of 1: 5.92, 2.53, 1.14, respectively. a fourth factor with an eigenvalue of 0.88 was removed. the third factor (eigenvalue 1.14) only consisted of two items and so was removed. this resulted in a two-factor, 11-item solution. the two factors contained items pertaining to health risks (5 items) and social risks (6 items). we tested the strength of this two-factor solution on the same sample with cfa. the two-factor solution fit the data well (rmsea = 0.07 (0.06-0.08), srmr = 0.05, cfi = 0.95, and tli = 0.93). we conducted a cfa on a new sample of 415 adults. the sample size was deemed appropriate for testing a model comprising of 24 parameters (11 factor loadings, 11 error variances and 2 factor correlations). the model approximates to a 17:1 subject to parameter ratio, above the recommended 10:1 [30] . the two-factor structure adequately fit the data according to our primary fit index; rmsea = 0.08 (0.07-0.09). other model fit indices were good (srmr = 0.06) or fell just below the suggested cut off (cfi = 0.87 and tli = 0.83). factor loadings of each item (see table 2 ) were medium to high (0.42-0.76) except for one item (loading of 0.28). although this item loading was low, we decided to retain it in order to maintain consistency with the factor structure in the adolescent sample and given its good loading in the adult efa and the adolescent cfa sample. there was a positive correlation between the health and social subscale of the hsrq (r(482) = 0.21, p < 0.001). measures of internal consistency were good (see table 3 ). an additional cfa to assess a one-factor structure did not achieve good model fit (rmsea = 0.12 (0.11-0.13), srmr = 0.10, cfi = 0.72, and tli = 0.70), indicating that concern about risk taking is not a unitary construct and is instead domain specific (health, social). the aic of the two-factor model (42983.13) was lower than the aic of the one-factor model (43126.50), suggesting that the two-factor model provided a better fit. to measure the test-retest reliability of the hsrq, 100 adult participants were invited to complete the questionnaire a second time, 11-12 days later; 68 participants responded. pearson r correlation between the two time points indicated good test-retest reliability (social risk subscale: r(66) = 0.62, p < 0.001; health subscale: r(66) = 0.74, p < 0.001). to assess convergent and divergent validity, participants also completed measures of rejection sensitivity (a-rsq), depressed mood (phq-8) and risk taking (dospert). association with rejection sensitivity. the social risk subscale positively correlated with rejection sensitivity (r(413) = 0.22, p < 0.001) such that individuals who scored high on concern for social risk also scored high in rejection sensitivity (see figure 1, panel b) . the health risk subscale did not significantly correlate with rejection sensitivity (r(413) = −0.00, p = 0.99). association with depressed mood. the social risk subscale positively correlated with depressed mood (r (413) = 0.13, p = 0.009) such that individuals who scored high on concern for social risk also scored high in depressed mood (see figure 1 , panel d). the health risk subscale did not significantly correlate with depressed mood (r(413) = −0.05, p = 0.27). association with risk taking. the social risk subscale of the hsrq negatively correlated with the likelihood of engaging in social risks subscale of the dospert (r(413) = −0.32, p < 0.001) and was positively correlated with the perception of social risks subscale of the dospert (r(413) = 0.29, p < 0.001). in other words, individuals who scored high on concern for social risk on the hsrq were less likely to engage in social risk behaviours and more likely to rate social risk behaviours as risky. the health risk subscale of the hsrq was negatively correlated with the likelihood of engaging in health risks subscale of the dospert (r(413) = −0.18, p < 0.001) and was positively correlated with the perception of health risks subscale of the dospert (r(413) = −0.29, p < 0.001). thus, individuals who scored high on concern for health risks were less likely to engage in health risk behaviours and more likely to rate health risk behaviours as risky. we conducted a cfa on a new sample of 484 adolescents. the sample size was deemed appropriate for testing a model comprising of 24 parameters (11 factor loadings, 11 error variances and 2 factor correlations). the model approximates to a 20:1 subject to parameter ratio, above the recommended 10:1 [30] . the two-factor structure fit the data well (rmsea = 0.07 (0.06-0.08), srmr = 0.05, cfi = 0.95, and tli = 0.93). factor loadings of each item were medium to high (0.54-0.79) (see table 2 ). there was a positive correlation between the health and social subscale of the hsrq (r(482) = 0.21, p < 0.001). measures of internal consistency were good (see table 3 ). an additional cfa to assess a one-factor structure did not achieve good model fit (rmsea = 0.18 (0.17-0.19), srmr = 0.16, cfi = 0.60, and tli = 0.50), indicating that concern about risk taking is not a unitary construct across domains, and is instead domain specific (health, social), as in the adult sample. the aic of the two-factor model (49696.51) was lower than the aic of the one-factor model (50280.89), suggesting that the two-factor model provides a better fit. validation to assess convergent and divergent validity, a subset of the adolescent participants completed measures of rejection sensitivity (c-rsq; n = 207) and depressed mood (mfq; n = 281). association with rejection sensitivity. the social risk subscale positively correlated with rejection sensitivity (r(205) = 0.52, p< 0.001) such that individuals who scored high on concern for social risk also scored high in rejection sensitivity (see figure 1 , panel a). the health risk subscale did not significantly correlate with rejection sensitivity (r(205) = −0.01, p = 0.83). association with depressed mood. the social risk subscale positively correlated with depressed mood (r(279) = 0.31, p < 0.001) such that individuals who scored high on concern for social risk also scored high in depressed mood (see figure 1 , panel c). the health risk subscale did not significantly correlate with depressed mood (r(279) = −0.11, p = 0.06). we compared the strength of the correlations between concern for social risk, rejection sensitivity and depression between the adolescent cfa and adult cfa sample. the strength of the correlations between concern for social risk and rejection sensitivity and depression was stronger for adolescents than for adults (rejection sensitivity: z = 4.12, p < 0.001; depression: z = 2.45, p = 0.007). we conducted a multiple regression to assess the relationship between the hsrq and age, using data collected across all participants (n = 1399; aged 11-77). the outcome was risk concern (i.e., the mean score of the health and social subscales) and the predictor variables were age, gender, risk domain (health, social), and an age by risk domain interaction. the overall regression model was significant (r 2 = 0.14, f(3,2793) = 113.2, p < 0.001; see table 4 for estimates). there was a significant main effect of age (β = −0.15; 95% ci: −0.23-0.07; p < 0.001) and risk domain (β = −11.69; 95% ci: −15. 18-8.19 ; p < 0.001) and a significant interaction between age and risk domain (β = −0.16; 95% ci: −0.27-0.04; p < 0.001). there was no main effect of gender (β = 1.07 95% ci: −0.54-2.69; p < 0.19). . the strength of the correlations between concern for social risk and rejection sensitivity and depression was stronger for adolescents than for adults (rejection sensitivity: z = 4.12, p < 0.001; depression: z = 2.45, p = 0.007). we conducted a multiple regression to assess the relationship between the hsrq and age, using data collected across all participants (n = 1399; aged 11-77). the outcome was risk concern (i.e., the mean score of the health and social subscales) and the predictor variables were age, gender, risk domain (health, social), and an age by risk domain interaction. the overall regression model was significant (r 2 = 0.14, f(3,2793) = 113.2, p < 0.001; see table 4 for estimates). there was a significant main effect of age (β = −0.15; 95% ci: −0.23-0.07; p < 0.001) and risk domain (β = −11.69; 95% ci: −15. 18-8.19 ; p < 0.001) and a significant interaction between age and risk domain (β = −0.16; 95% ci: −0.27-0.04; p < 0.001). there was no main effect of gender (β = 1.07 95% ci: −0.54-2.69; p < 0.19). to explore the interaction between age and risk domain, we plotted the relationship ( figure 2 ) and used simple slope analyses. the slope for both risks was significant (social: β = −0.31, p < 0.001); health: β = −0.15, p < 0.001). there was a significant difference between the gradient of these slopes (t(2794) = 2.7, p = 0.008), driven by a steeper decline across age in concern for social risk compared to concern for health risk. this linear model (aic: 25125.34) outperformed a quadratic model (aic: 25142.67) and cubic model (aic: 25156.83). relationship between concern for social risk and rejection sensitivity for adolescents (r(205) = 0.52, p < 0.001; panel (a) and adults (r(413) = 0.22, p < 0.001; panel (b). relationship between risk concern and depression for adolescents (r(279) = 0.31, p < 0.001; panel (c) and adults (r(413) = 0.13, p = 0.009; panel (d). the strength of the correlations between concern for social risk and rejection sensitivity and depression was stronger for adolescents than for adults (rejection sensitivity: z = 4.12, p < 0.001; depression: z = 2.45, p = 0.007). to explore the interaction between age and risk domain, we plotted the relationship ( figure 2 ) and used simple slope analyses. the slope for both risks was significant (social: β = −0.31, p < 0.001); health: β = −0.15, p < 0.001). there was a significant difference between the gradient of these slopes (t(2794) = 2.7, p = 0.008), driven by a steeper decline across age in concern for social risk compared to concern for health risk. this linear model (aic: 25125.34) outperformed a quadratic model (aic: 25142.67) and cubic model (aic: 25156.83). −0.016 0.06 −2.7 0.008 note: *= an interaction term; β= beta coefficient; se= standard error; t = t statistic (the β divided by the se); p = significance. relationship between age and concern for health risk (slope: β = −0.15, p < 0.001) and social risk (slope: β = −0.31, p < 0.001). there was a significant difference between the gradient of these slopes (t(2794) = 2.7, p = 0.008), driven by a steeper decline across age in concern for social risk than for concern for health risk. in this study, we developed a questionnaire measure of concern for health and social risk behaviours for use in adolescents and adults. our results showed that concerns related to engaging in social risks are distinct from concerns related to engaging in health risks. overall, we found that people reported greater concern for health risk compared with social risk. we investigated age differences in concern for health and social risk, and found that concern for both health and social risk decreased with age, from adolescence through adulthood. however, concern for social risk decreased to a greater extent than concern for health risk. this suggests that, relative to adults, adolescents are more concerned about social risks than health risks. this heightened concern for social risk in adolescence has implications for understanding why adolescents engage in health and legal risks. one hypothesis is that adolescents are motivated to avoid what they consider to be a greater immediate risk, the social risk of being rejected or excluded by their peers [13] . avoiding social risks can be considered an important goal during adolescence, a period when social status and friendships provide psychological and physical health benefits [14, 15] . the association between our new measure, the health and social risk questionnaire (hsrq), rejection sensitivity and depression indicate the potential relevance of social risk for understanding adolescent behaviour and mental health. individuals who report greater concern for social risk were relationship between age and concern for health risk (slope: β = −0.15, p < 0.001) and social risk (slope: β = −0.31, p < 0.001). there was a significant difference between the gradient of these slopes (t(2794) = 2.7, p = 0.008), driven by a steeper decline across age in concern for social risk than for concern for health risk. in this study, we developed a questionnaire measure of concern for health and social risk behaviours for use in adolescents and adults. our results showed that concerns related to engaging in social risks are distinct from concerns related to engaging in health risks. overall, we found that people reported greater concern for health risk compared with social risk. we investigated age differences in concern for health and social risk, and found that concern for both health and social risk decreased with age, from adolescence through adulthood. however, concern for social risk decreased to a greater extent than concern for health risk. this suggests that, relative to adults, adolescents are more concerned about social risks than health risks. this heightened concern for social risk in adolescence has implications for understanding why adolescents engage in health and legal risks. one hypothesis is that adolescents are motivated to avoid what they consider to be a greater immediate risk, the social risk of being rejected or excluded by their peers [13] . avoiding social risks can be considered an important goal during adolescence, a period when social status and friendships provide psychological and physical health benefits [14, 15] . the association between our new measure, the health and social risk questionnaire (hsrq), rejection sensitivity and depression indicate the potential relevance of social risk for understanding adolescent behaviour and mental health. individuals who report greater concern for social risk were more likely to report greater sensitivity to rejection (adolescents: c-rsq; adults: a-rsq). social rejection is an unpleasant feeling and therefore it makes sense that individuals with a heightened degree of sensitivity to the negative effects of social rejection would be more concerned with engaging in situations that could lead to, or indicate a possibility of, social rejection. within the adult sample, individuals who scored high on concern for social risk were less likely to engage in socially risky behaviours and were more likely to rate social risk behaviours as risky. this finding indicates that higher concern for social risk is related to an increase in rejection sensitivity and an increase in socially risk-averse behaviour. concern for social risk was also related to depressive symptomatology (adolescents: mfq; adults: phq-8), such that individuals with greater concern for social risk were more likely to report higher levels of depressive symptoms. this finding supports the predictions made by the social risk hypothesis of depression [20] . this hypothesis proposes that, when cues in the environment signal that one's social burden is significantly greater than their social value, depression manifests as an adaptive mechanism to remove the individual from social situations which might confer further risk of social rejection. we showed that concern for social risk was more strongly associated with rejection sensitivity in adolescents (11-17 years) , than in adults (18+ years). during adolescence, individuals are particularly sensitive to social evaluative concerns [11] , and peer perceptions influence adolescents' social and personal worth [31] . adolescents are also hypersensitivity to social rejection relative to adults [10] . this fits with our finding that concerns for social risk are more tightly linked to rejection sensitivity among adolescents, relative to adults. in addition, and as previously discussed, adolescents with good quality friendships and higher social status have more favourable psychological and physical outcomes later in life. thus, it is potentially beneficial and adaptive for adolescents to try to avoid the risk of social rejection [14, 15] . additionally, the association between concern for social risk and depressive symptoms was stronger in adolescents than adults. this suggests that the social environment may be particularly salient for mental health during this developmental period [18, 32] . this is important because the incidence of many mental health problems, including depression, increases significantly during adolescence [33] . our findings have a number of implications. at the theoretical level, the way in which risk behaviours have been traditionally conceptualised has focused heavily on the health, financial, legal and recreational domains. our results suggest that social risk should be incorporated into our understanding of risk-taking behaviour. for some individuals, taking a social risk, and placing themselves at risk of social rejection, is a real and 'risky' decision. at the practical level, interventions aimed at reducing health and legal risk behaviours should recognise the importance of concerns surrounding social risks. one promising approach is to focus on peer-led interventions, which work to influence social norms surrounding unhealthy or illegal behaviours [34] . this approach encourages healthy behaviours by reducing the social risk of being ostracised by peers. interventions using a peer-led approach have shown positive results for unhealthy behaviours such as bullying [35] and smoking [36] . the hsrq is a valid measure for individuals aged 11+. however, this measure has not been validated for children below 11 and very little is known about social risk in this younger age group. future work should explore the extent to which the current items and factor structure are valid for use in children below this age. additionally, we did not test the relationship between our measure of concern for social risk and engagement in real-life social risks in the adolescent sample (11-17 years) because of a lack of appropriately validated scales for this age group. this is a limitation when making comparisons with the adult sample (18+) and future work should explore the relationship between our concern for social risk measure and engagement in real-life social risks among adolescents. further, our sample was collected from the united kingdom and therefore this measure should be cross-culturally validated for use in other socio-cultural environments. in addition, the hsrq is based on self-report, and an important line of subsequent work is to relate responses on this questionnaire measure to a task-based assessment of social risk. finally, the present study was not designed to investigate the degree to which individuals weigh up the health vs. social consequences of a given 'risky' decision. therefore, an important outstanding question is the degree to which individual variation in concern for health and social risk impacts involvement in 'risky' behaviours, especially when individuals are presented with risks that often carry both social and health consequences, such as smoking or dangerous driving. in the current study, we developed a self-report measure of concern for health and social risk for use with adolescents and adults. we found that heightened concern for social risk was related to increased sensitivity to rejection and depression, with this relationship being stronger for adolescents compared to adults. this supports the body of evidence that adolescence is a period of heightened sensitivity to the social environment. in addition, both concern for health and social risk decreased with age, but the rate of decrease was steeper for social versus health risk, suggesting that adolescence is a period of amplified concern for social risk. practically, these findings have potential implications for policy. within an educational context, an understanding of social risk may offer insight into why adolescents are more or less motivated to engage with school work. for example, if individuals who try hard at school are perceived as unpopular or uncool, then being openly motivated in the classroom could be a social risk [37] . within a legal context, concerns surrounding social risk may be a factor in adolescents' decisions to engage in criminal behaviour, particularly in peer contexts when opting out of a group behaviour could risk being excluded from the group. together, these findings highlight the importance of social risk in adolescent behaviour and suggest that interventions to reduce risk-taking behaviours in this age group should consider the role of social risk. the following are available online at http://www.mdpi.com/2076-3425/10/6/397/s1, table s1 : health and social risk questionnaire (hsrq). is adolescence a sensitive period for sociocultural processing? the relationship between early age of onset of initial substance use and engaging in 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health this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflicts of interest. key: cord-016889-7ih6jdpe authors: shibuya, kazuhiko title: identity health date: 2019-12-03 journal: digital transformation of identity in the age of artificial intelligence doi: 10.1007/978-981-15-2248-2_11 sha: doc_id: 16889 cord_uid: 7ih6jdpe identity health has especially specific meanings for social relationships in contemporary digital age. first, computerized digital communication makes many citizens in severe maladaptation. the who often warns mental addictions of internet usages and online gaming among the youth. the advent of social media and online networking has endangered them in ambiguous situations which are not stabilizing in those basic grounds for human relationships. further, because social networking sites and social gaming frequently enforce each member to interconnect with the others, many of participating members often hold harder mental debts to respond and maintain their interconnections. in this situation, in other words, it can say that all of users simultaneously might share common conditions under mental illness. who (the world health organization) has already published their warning reports on gaming disorder and its mental addiction (who 2015) . and their site also says: "gaming disorder is defined in the 11th revision of the international classification of diseases (icd-11) as a pattern of gaming behavior ("digital-gaming" or "videogaming") characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences". those who can be identified as icd-11 case are not globally well known, but suspicious cases are roughly estimated as adults (approximately 4.2 million) and youths (approximately a million) in japan (data at 2017). since the beginning of the internet revolution, internet communication and online activities among the youth had been frequently accused by serious concerns in mental health. the first is violent behavior induced by playing violence game. until recently, video game has been argued by media psychologists (xu 2018) . they often verified violent behavior of adolescents related to experiences and the extent of game playing. the causal relationships across those patterns have not been clarified enough yet. some reasons endorsed by experimental designs are still difficult to interpret clearly (bruner and bruner 2006) . secondly, there are still controversial issues on online addiction cases (griffiths 2013) . colleagues (2012, 2016) have been publishing serial reports on online addictions. the number of people diagnosed with the condition of addiction for internet usage has been increasing in the era of social media. especially, adolescents and young adults are eager to immerse in online cyber-world activities. they consume their time through browsing web, watching online video, participating in online games, and internet communication. in japan, mic 2 (ministry of internal affairs and communications) at 2018, reported the latest statistics that the total average of internet usage time of young citizens (ages vary from 10 to 17) was 2 h and 49 min every day. their motivations for internet usages diversified categories such as watching online movie (79%), playing games (76%), and communicating by sns and emails (66%) (multiple answers). the most important is how we think about such online additions and youth's sound development. these are a kind of mental illnesses and conditions as a maladaptation of gaming and social withdrawals from actual society, or they are overadaptation in somewhat online communities rather than physical environment. the former is to step further grounding in social living, and the latter may suggest that they extraordinarily prefer to online human relationships. it should be clinically observed in each case. thus, online gaming and social networking sites are indeed based on somewhat human relations and such online communities organized by providers often offer to share some comforts, cooperative achievements, and entertainments among active participants. and simultaneously those services require much engagement among participants, and then such mental obligations enforce each participant to keep playing online game and committing with the other online partners during longer times (oberst et al. 2017) . here, it experientially indicates that group commitments reduce anxiety of members and enhance comfort and mental bonding among members (leary and baumeister 2000; baumeister et al. 2005) . their group life intends to maintain such conditions in in-group memberships, and commitment belonged in group whether offline or not has crucially important meaning for them. to date, advanced data analysis on our phr (personal health record) and personality dispositions has been conducting in medics (pol and thomas 2013) . further, the advancement of big data and the ai driven medical services is to rush into the daily life contexts (marin et al. 2016; king et al. 2017) . namely these services can offer to assess and promote both mental and physical health of each individual. first, as mentioned valuation by the ai at chap. 4, those services already contain some questionnaires on psychological assessments related to personality characteristics, health attitudes, and social adaptation in daily life. those assessed data might intend to statistically reveal our strength of mental health and degree of adaptation in social relations, and then automatic prediction for those who answered personality tests enables to trustfully measure financial limitations for loans and transactions in actual contexts. therefore, our mental conditions and its social adaptations, to date, have been unveiled by such ways, and those applied services could be built for somewhat vigilance system on mutual trust among citizens. mental disorder and maladaptation of each individual have possibilities to further pervade unsound influences among the others, and vice versa. financial bad-debt by personality dysfunctions of individual will also engender chain bankruptcy among stakeholders, but those services would intend to predict such consequences in advance through checking personality maladaptation in daily life. hence, our digital life has been already founded in those mechanisms, and the ai and big-data operations indeed interlude into our mentality. secondly, wearable devices and sensing tools for human behavior can help monitoring and analyzing latent patterns of physical and mental conditions in daily life (morahan-martin and schumacher 2003; clifton 2016; zhu et al. 2019) . and telephone communication patterns using smart phone can be interacted by identifiable chronotype of each user in daily activities (aledavood et al. 2018) . medical cares in each country has the demands to organize national health information systems, and it includes big data in the relations to national assurances for health cares, medical quality, demographic statistics, financial investment, quality of life (qol), quantifications for modeling (shibuya 2006) , and other social welfares (brady et al. 2012) . those information systems may be governing own centered database, but it will be replaced by distributed blockchain database in the future. during the previous era, there were some troubles yet to bridge between clinical psychology and sociological studies as well as computational models and experimental cases. sympathy interpretations for client's latent mental process and their needs should be taken carefully. but case studies often mean that there are no effective ways to explore future patterns and expectations based on past clinical cases in the daily interactions (leary 1983; kircher and leube 2003) . traditionally, the clinical psychological way is usually beneficial to manage mental dynamics that are impossible to be generalized and formalized. clinical psychology and its fundamental assumptions usually hesitate to do generalizations from clinical case studies. that is because each personal condition and mental distress may be too individualized, and rather researchers in this field recommend qualitative and intensive caring ways for understanding each personal experiences embedded in actual conditions. historically, emerging diseases have been suffering us ever since our civilization (roeser et al. 2012) . human history could be said as somehow survival process from lethal diseases. for example, there were smallpox, pest, dysentery, tuberculosis, and other diseases. otherwise recent outbreaks of emerging diseases such as hiv, ebola, sars (severe acute respiratory syndrome : shibuya 2006) , zika, and others are still ongoing matters, and those medical ways such as drugs and examination tools have not completed enough yet. in contrary, smallpox can be exemplified as a success case. the humankind had finally achieved the extinction of this disease threat in natural conditions using vaccine as a land-breaking medical way. parts of above diseases could be cured by specific medicines, but known well, there is another problem on resistant bacteria against those medicines. to date, in those fields, immunological and medical investigations have been accelerated by biotechnological and gene-technological advancements. those who obtained the nobel prize in physiology or medicine, and nobel prize in chemistry contributed toward enhancing medical progress for wellbeing of the humankind. in fact, there were contributions by japanese scientists in the medical field (e.g., tonegawa, s, yamanaka, s, ohmura, s, ohsumi, y, etc.). but, the humankind cannot completely repel both disease and death. according to the who report "top 10 causes of death globally 2016 3 ," infectious diseases such as lower respiratory infections (over 2 million deaths), diarrheal diseases (nearly 2 million deaths), and tuberculosis (nearly 2 million deaths) still remain within list of top 10. otherwise, the worst three cases were ischemic heart disease (nearly 10 million deaths), stroke (nearly 6 million deaths), and chronic obstructive pulmonary disease (approximately 3 million deaths). additionally, total deaths caused by alzheimer disease and other dementias can be estimated to approximately 2 million per year globally. in those areas, as mentioned before, computational searches by the ai driven system and big-data analysis will boost enhancing diagnosis of subtle symptoms, image processing on medical data, pharmacologic utility discovery, and statistical precisions for future risks of each patient. precision of diagnosis by the ai's pattern recognition systems on medical images has outperformed more accurately than human doctors (zhang et al. 2019) . as larger growing size of knowledgebase on medical science increasingly requires much experience for them, and it will be impossible to operate any clinical cases unless the ai's supports can be provided. and other computational contributions to epidemics can enumerate such as computer simulations of mathematical models on spreading infectious diseases (e.g., sir (susceptible-infected-recovered), small-world networking model (moore and newman 2000; newman 2002) ), gene analysis of virus in bioinformatics (ksiazek et al. 2003) , and risk management on health data of patients and medical policies for future controls of emerging diseases (shibuya 2006) . in terms of medical cares, epidemiological actions should lay weights on governmental policy, because there are great needs to control against secondary contagions and predict precisely dynamic trends on diseases. traditionally, those fields must be accumulated from onsite clinical data on diagnosis of patients and analyze statistical trends which localized in each region. regarding these concerns, to date, online query results mostly reflect citizens' intentions and latent needs for specific actual events in society. recently, ginsberg and his colleagues (2009) had unveiled such facts by their big data, and their findings by statistical analyzations on logistic positive correlations between actual trends of data from cdc 4 (centers for disease control and prevention, usa) and web-query data among citizens had become a pioneer for big-data age. namely this study clearly suggested that citizens were usually apt to seek more accurate and necessary information in uncertainty conditions such as disaster (see chap. 10), unwelcome infectious disease, terrorism, and other fascinated events. their study seemed to be a first breakthrough for researches using web data analysis. as an implication of this finding, many researchers realized significant meanings on synchronizing and corresponding evidence between web trends and offline events. namely "big data" can be analyzed by computational engineering methodologies such as artificial intelligence, statistical machine learning techniques, and natural languages processing, and it can open the gate to investigate novel findings automatically. let me exemplify an actual case. according to data from the who, 5,6 from the spring of 2009 to 2010, global pandemic caused by new type of influenza (h1n1) had suffered global citizens. the total amount of the death was estimated as 14,286 in globally (the present data at 2010). at the peak of this pandemic, the author investigated those trends using google insights for search services. japanese patients were roughly estimated as totally 15.6 million (it finally includes at least 203 death cases), nevertheless many citizens have traditional customs encouraged to treat and keep their hygiene in daily living. below fig. 11 .1 indicates a trend of google query result inputted into keyword "influenza" in japanese. at 2009, it was certainly that there were mostly three peaks during this year. and fig. 11 .2, in contrary, shows only seasonal trends of ordinary influenza (except for data of pandemic patients), and both peaks (earlier weeks of this year and the late of year) can be identified during 2009 year. seasonal trends on influenza can be also recognized in each year, and only bizarre peak around the middle of this year can be specified. namely, because the pandemic caused by new type of influenza virus occurred around the beginning of may 2009, it can understand that the middle peak in fig. 11 .1 was underlying in above pandemic influences. and then, in this japan case, google trends could entirely indicate correlational patterns between information needs among citizens and actual influenza trends, and each peak corresponded with seasonal or pandemic ones. as an alternative of google query, using twitter as one of microblogging tools, signorini et al. (2011) revealed synchronizing phenomena on online tweets about influenza corresponded with actual trends of influenza given from cdc data, and 5 https://www.who.int/csr/disease/swineflu/en/ https://www.who.int/wer/2009/wer8421.pdf?ua=1 6 implementation of the international health regulations (2005) http://apps.who.int/gb/ebwha/ pdf_files/wha64/a64_10-en.pdf?ua=1 fig. 11 .1 trends of google query result which inputted into a keyword "influenza" in japanese. y axis means frequencies of a query on a specific keyword and x axis shows each year in this case they could find efficient results. those metrics have stronger merits being qualified for online and real-time analyzation than trend data obtained from google query. similarity, broniatowski et al. (2013) reported significant correlation between normalized prevalence data on influenza filtered from twitter's real-time tweets data and cdc actual trends of influenza. they further attempted to forecast influenza trends using data from twitter (paul et al. 2014) , and then social media consequently enables to do real-time sensing among citizens. as succeeding previous chap. 10, in the digitized society, disaster, environment, and climate data have also become a target for big-data analyzation. larger natural disasters and human-made hazards have globally potentials to corner to the crisis of humanity. because our global society has been endlessly threatened by various disasters (unisdr 2018), more than 160 million citizens have been globally harming by natural disasters every year. and this data contains more than 100,000 deaths per year. natural disasters are almost interrelated to numerous factors such as climate, demography, environment, and anthropogenic events. further, it seemed obvious that complicated factors related to climate changes in global level have . y axis denotes reported new patients, and x axis periodically shows serial weeks. each line (from 01 to 11) means each site given data from medical hospital. this figure was cited from idsc (infectious disease surveillance center, japan) (http://idsc.nih.go.jp/idwr/kanja/weeklygraph/01flu.html) been influencing those meteorological disasters (e.g., hurricanes, drought, flood, etc.). of course, the anthropogenic factors (e.g., industrial damages to the environment, carbon gas emissions) should be occupied in system models in order to examine detail mechanisms (meadows et al. 2004) . especially, at 2015, after serial tragedies of the tohoku quakes and fukushima nuclear disasters, the unisdr as a part of the united nations (at 2019, unisdr was renamed to undrr 7 : the un office for disaster risk reduction) held the global conference on disaster management at both tokyo and sendai city of japan. as consequences of much discussion, the committee finally proposed following the four priorities for global actions which entitled "sendai framework for disaster reduction 8 ." 1. priority 1: understanding disaster risk 2. priority 2: strengthening disaster risk governance to manage disaster risk 3. priority 3: investing in disaster risk reduction for resilience 4. priority 4: enhancing disaster preparedness for effective response and to "build back better" in recovery, rehabilitation, and reconstruction disaster management means just our preparedness against disasters. certainly, the digitized global world can offer artificial space satellites, wireless internet, mobile computing, social networking services, and other mechanical relief robots. and the ai driven systems and big-data analyzations on the disaster can be useful for us. recently, noaa (the national oceanic and atmospheric administration, usa) has released their online services, which is named as the coastal inundation dashboard. 9 it visually enables people to know and prepare for floods. in this way, nevertheless digitized systems for global monitoring the earth, collaboration with each nation and analyzation of vast necessary data had been pervasively equipped, but our acquired technologies for forecasting and preventing disasters have not been achieved enough yet. as above four priorities said, the undrr as a part of the united nations lays heavier weights on rather mitigations and resilience from disasters. because of such inevitable reasons why our survival efforts from the tremendous disasters are never diminishing, there are still greater needs to consider the human existential issues in disaster management. here, as introduced a bit at chap. 10, the author had a chance to conduct own researches on the tohoku quake and nuclear disasters in fukushima. and this time, a part of findings and evidences can be exhibited in health topic (shibuya 2012 (shibuya , 2015 (shibuya , 2017 (shibuya , 2018 (shibuya , 2021 ). after 2011, the fukushima case 10 of nuclear power plant accident had incubated another problem (oecd/nea ines (international nuclear event scale) ranked level 7 (the worst)). this fukushima case can be called as a nuclear power plants' crisis (nrc 2011; roeser et al. 2012; oecd/nea 2016; shibuya 2017) . at the time, many of fukushima citizens lost not only hometown, but background of their identities. in this point, they forced to be laid in identity crisis. according to theoretical sociologists berger et al. (1973) and giddens (1991) , they commonly argued that western post-modernizations could reconstruct mindsets on reality and social identification ways among citizens during achieving industrial progresses, if above severe incidents of nuclear power plants and those systems failures could be regarded as malfunctions as a symbol of modernity, above consequences of nuclear crisis on the fukushima case (and other human-made disasters) might be contextualized to reexamine social adaptation and consciousness among fukushima citizens by sociological verifications. how did daily belief systems among fukushima naã¯ve citizens against the safety surrounding in nuclear power plants deal with? their attitudes had been rather steadily stabilizing among many of them before the crisis. however, risk cognition, social constructive senses of reality, and meaningful understanding against nuclear disasters among citizens would be collapsed in those conditions. they were betrayed by advanced technologies, government, and optimistic beliefs shared among them. it is probably that their theoretical discussions have few suggestions for any policies on fukushima case more than awkward theoretical bases, and rather there are quite needs to tackle grounding in actuality, resilience of identification, purifying environment, and rebuilding community for the fukushima citizens (science council of japan (scj) 2011; shibuya 2021 (in press)). actually, this fukushima case was a reluctantly controversial issue on an accident of nuclear power plant by academic researchers in japan. since the tohoku quake, many natural scientists in japan were very criticized by ordinary citizens. especially these were academic scholars such as nuclear physicists, governmentside natural science researchers and engineers at nuclear power plant, and of course politicians must be also confronted with such serious criticisms (funabashi and kitazawa 2012) . with deep reflections, the science council of japan (scj) (2011) published globally their investigated documents by belonging scientists and researchers in various academic fields. this report laid stress on the fact description of the fukushima nuclear power plant accidents and the statement of actual conditions for researchers in foreign countries. here, the author conducted to investigate this scj's statement (2011) in depth using text mining. table 11 .1 shows a result by text mining analyzation on the whole contents of scj's statement, and it depicted a part of frequent and important words (it extracted around top 10 words among the most frequent words) and its total counts within above scj's statement text. at a glance, it appeared that their motivations were implicated by some words such as nuclear, radioactive, cooling, accident, safety, emergency, evacuation, and so on. tepco means an abbreviated name of administrative company for electric power plants in fukushima. figure 11 .3 shows an example of network structure of words' co-occurrence. in this case, it configured mathematically to color each separated subgraph structure that limited to important co-occurrence words. the author found some clusters of words on radioactive materials, fukushima nuclear plant, accident inside-out and others. these patterns were weighted and frequently articulated by document writers. otherwise, fig. 11 .4 depicts a result of three-dimensional visualization which analyzed by mds (multi-dimensional scaling: this time was configured by kruskal and jaccard models). this method located statistically each word in cubic dimensions, and it appeared some clusters such as power plants (e.g., power, plant, nuclear, and fukushima), quake (e.g., tsunami, earthquake, situation, and operation) and others. as result of these malfunctions, confidence for ruling party critically had been fallen down. what text mining analysis made clear was that this report concluded the negative consensus against the nuclear hazard among scientific community in japan, and their statements explicitly described that mythical beliefs among stakeholders were no avail in the case of fukushima nuclear power plant accident. obviously, they intended to publish the truths for globally foreign academicians and citizens in terms of mainly nuclear physics and energy engineering after the fukushima crisis. as mentioned at chap. 10, without doubts, many of global citizens were eager to know more accurate and immediate information in detail at that time of moment. those results by text mining could exhibit japanese governance of risk management against nuclear power plants and energy policies before the fukushima case. there were no rational reasons for excuses that risk communication and consensual discussion had not been openly organized among stakeholders in fukushima, as it was differently the canada's case (johnson 2008) . rather, tepco and governmental ministry had oppressed to scientifically contemplate and examine nuclear risks and their published data by ordinary citizens and external professionals. with these backgrounds, the focal point of disputes on the compensations has been accused by plaintiff (i.e., citizens, evacuees, and victims) under trials in courts (oecd/ nea 2016). for the digitized society, this fukushima case indicated further unneglectable facts. iot and xaas will be deployed anywhere (geng 2017) . many of those systems such as computational controls and sensing networking related to power plants and sensitive artifacts will be impossible to keep under controls unless electric fig. 11 .3 it depicts a part of network structure of co-occurrence words by text mining. this configuration was to separately color each subgraph structure which limited to important co-occurrence words power can be continually provided. nuclear power plants and its control systems per se always also require independent electric power for controlling those mechanisms. serial incidents of the fukushima nuclear power plants can be determined by the serious factors on both the loss of external electric power supply and vent malfunctions for refrigerating systems caused by tremendous tsunami attacks. besides, until now, the ai-driven robots sensing inner-damaged power plants cannot be activated over the physical limitations because inner-damaged power plants still remain with higher radiation dose (i.e., the human dies immediately and computational mechanisms will be disabled by radiations sooner). then, the lessons for the digitized future must be intensively deduced and learned by convincible investigations. in the usa, after this disaster, a taskforce team was immediately assembled for investigations to report the cause of the nuclear power plants, reconstruction of the nuclear power plants for safety, and future policy on energy management in the after that, it should turn eyes to persevering purification from the radiation damage caused by the nuclear accidents, its environmental restoration, health monitoring, and socioeconomic reconstruction in community (nrc 2011; iaea 2011) . consequently, the fukushima case definitely needs to solve nuclear accidents and future design for long-term reconstruction on their devastated communities and hometown. at least, the following points should be tackled. 1. decommissioning work for the wrecked nuclear power plants in fukushima 2. removal of nuclear fuel and substances 3. chemical management on nuclear substances 4. purifications in polluted places 5. temporary storage and final disposal of contaminated soil, water, and garbage 6. medical health survey and care for victims 7. risk assessment against environment and people exposed by nuclear substances 8. city and socioeconomic reconstructions as consequences of serial incidents of the nuclear power plants in fukushima, nuclear pollution provoked the severe disputes on human rights, health, radiation contaminations to foods and environmental restorations. both environments (soil, waters and air) as well as ordinary peoples who lived in fukushima were polluted and exposed by both nuclear substance and radiation (gibney 2015; merz et al. 2015; oecd/nea 2016) . sampling data accumulated by agricultural scientists endorsed that many of crops absorbed radioactive substances such as 90 sr, 134 cs, 137 cs, and others (takahashi 2016) . and excessive intake and exposure of radioactive pollutants will endanger citizens' and workers' health (hiraoka et al. 2015) . consequentially, enacted provisions often reflect social actualities. for conquests against those hardships of citizens and evacuees, the "basic act on reconstruction in response to the great east japan earthquake (24th, june 2011)" enacted the basic policies for reconstructions. for example, a part of provisions clearly stipulated as follows. â�¢ article 2. the reconstruction in response to great east japan earthquake will be implemented based on the following -the unprecedented disaster resulted in enormous damage, where countless lives were lost, numerous people were deprived of their basic living infrastructures and have been forced to evacuate in and out of the disaster-affected regions. also, the disaster's influence extends over the entire nation; the economic stagnation in the disaster-afflicted areas is affecting business activities and peoples' lives nationwideâ�¦(hereafter omitted) at the 2014fy, the total budget of fukushima prefecture for reconstruction after the disaster was approximately 1714.5 billion yen (including both quakes and nuclear disaster countermeasure portion of 870.5 billion yen). and it includes population declining and aging countermeasures as well as restoration of birth number (142.3 billion yen). in addition, other items were 245.5 billion yen for environmental restorations, 144.3 billion yen for living reconstruction assistance, 36 billion yen for expenses to protect medical health of the citizens, 31.6 billion yen for expenses for children and youths who will be responsible for the future, and other expenses. further, in addition to above costs, the fukushima case requires unprovoked compensations and its litigation disputes are ongoing matters in courts (shibuya 2017) . namely, there are still requirements to solve future designing for reconstruction from devastation in their hometown. next, the total amount of casualties in japan was more than 20,000 at the time of 2012. moreover, as aftermath of the fukushima disaster, one of the hardest matters was collective immigration of evacuees from their hometowns to other places in japan (akabayashi and hayashi 2012; library of congress 2013) . at the peak (may 2012), gross migrants from fukushima (e.g., total population of evacuees) were estimated over 160,000. and including this, gross migrants (e.g., total evacuees in japan) were estimated over 340,000 at the time of 2012. this estimation was not too low. please recall similar past cases, for example, the case of chernobyl in 1986 reported that total population of evacuees was approximately 116,000 around 30 km (ines level 7). and, in 1979, the case of the three mile island accident was estimated over 240,000 around 24 km (ines level 5). table 11 .2 shows a part of outflow data on migrants across major cities (it includes mobility data within same city). it queried into big data of mic (e.g., demographic data of migration and population) and the geospatial information authority of japan (e.g., geospatial data and distance information). the numbers of citizens lived in fukushima prefecture has been notably decreasing from 2.1 million (2011) to 1.9 million (2015) . and this area is statistically 13,780 km 2 (the third widest area in japan). and it compares fukushima with people lived in major metropolis such as tokyo area (total population is approximately 13 million people and within 9 million people in 23 special districts), nagoya area (approximately 2.2 million people within central city), and osaka area (approximately 2.6 million people within central city) in japan. it namely denotes moving flows within fukushima cities, moving toward one of metropolises from fukushima and moving patterns between metropolises. actually, there is still another problem in residential data. in year 2015, a national census every 5 years was carried out in japan, and it has achieved to unveil many data discrepancies and inconsistencies of population in each local area of fukushima. comparing with statistics on resident data holding municipal government office and actual population from census, the latter cases were almost too lower than estimated populations in many cases of fukushima. to date, these missing populations have not been traced properly and many evacuees did not intentionally apply immigration cards to municipal government office. it means that many of them still have strong intentions to go back to fukushima in the near future. however, the stumbling blocks still remain against their returns, even though the government purifies radioactive substances and pollutions around their towns. according to the general surveys by tokyo capital government for evacuees and interviews for evacuees by the author (shibuya 2017), they found that evacuees' motivations which choose the destination and refuge were relying on following critical factors: (1) to tie with any kindred relationships (a factor of human relationship), (2) rich opportunities for jobs in the new address (a factor of new job opportunity), (3) conveniences to manage their own real estates, farms, livestock, and factories in their hometown (a factor of holding estates). first factor implies mutual cooperation and helping among local acquaintances, and second answer clearly reflects their needs for jobs in new dwelling. and third factor relates to geospatial location, and parts of them have been living in two places of both fukushima and refuges. namely, their conditions were back and forth between hometown and refuge. thus they could not leave to far refuges, and geographical area around 300 km within fukushima and refuges satisfied their above motivations using transportations such as the bullet train, highways, and other land transportations (it drives toward the destination within 2 h). for those who required living needs, tokyo and nearby area of tokyo could properly offer new job opportunities and dwelling availabilities for them. our identifications are often determined by not only own cognitive factors but human relational and spatiotemporal factors, and their daily conditions of mental health would be interlinked with those internal and external surroundings. the fukushima case similarly indicated those mental malfunctions of evacuees caused by the human-made disaster. when such individuals lose all (or a part) of the linkages with both human relationships and living place, their mental foundation for identification will be seriously damaged in severe situations. such accidents and events caused by both natural and human-made disasters will be easy to engender secondary damages against social adaptation and subjective well-being of each individual. it is too important to care for each, but there are resilient needs to wholly repair and revive the community among them and their human relationships such as social capital (putnum 2000; kawachi and berkman 2003; kawachi et al. 2008; oecd/nea 2016) and family bondages. even though digitized communication styles renewed our daily commitment for online community, physical-contact based commitments in onsite community have still special meanings for their well-being. frey and osborne (2013) reported how will contemporary industries and jobs be changed and replaced by computerization and the ai-driven robotics, and they simulated socioeconomic trend patterns of jobs fitted by gaussian stochastic model. their estimations have indeed shown that the ai society will engender emerging job market and require other skills for citizens. but it will be clearly understood whether correct or not in the future. but, will a meaning on working life be steeply altered by such innovation? some theorists said that both living and working are indispensable relations each other. as one of the renown episodes, psychoanalyst freud answered that it requires "lieben und arbeiten" for becoming sound and independent adult. the former "lieben" means the accepting and loving for the others as a partner. and the latter "arbeiten" devotes to achieving the goals for maintaining daily living by own works and pursuing enhancement of own intellectual abilities and skills. both are still certainly the fundamental necessary factors for people. and a life-course approach in developmental psychology has much suggestion to wholly understand our mental development and health promotion during the life process (erikson 1950 (erikson , 1959 (erikson , 1982 . in each development stage of identity, each individual closely faces the problems and what should be conquered by each of them. such tasks can be furnished for own rich experiences of each, and each can be reorganized to adapt in own life process (e.g., self-actualization). working, learning, and other daily activities will be achieved by undertaking self-development and adaptation in social surroundings. it motivates to enhance each quality of life (qol) through own working experiment. it is certainly that the ai and big-data-based society enables to change our qol and working life. such innovation progress in our working styles has already become the cascading to collapse larger barriers by the big wave of digital transformation. working environment has been crucially invested in the contexts of either employees or employer. but quality in working environment cannot be determined by factors of material and physical surroundings, and it should be cared about human factors such as enhancement of human relationships and well-being (oecd 1976; strack et al. 1991; buunk and gibbons 1997) . for example, oecd 11 proposed total framework ("measuring well-being and progress: well-being research") , and they enumerated necessary factors related to measuring both economic and well-being value in working and daily life. the digital transforming society will enlarge our working from actual physical space to virtual online space through tele-existence and online collaboration tools. and our working skills and abilities will be required conquering the harder roads of uphill progress of the ai and data sciences (boyd and holton 2018) . further, traditional stressful working environments can be attempted to quantify and coordinate with each parameter of employees such as personality characteristics, demanded skill levels, abilities, chemistry among members, and other necessary factors. now, such hr (human resource) technology (i.e., a case using business microscope 12 ) enhances our working styles and improves productivities in various situations (khartri and samuel 2019) . analytics teams have vividly rushed to dive into the ocean of big data, but matching between the needs and their analyzed solutions can be improved by further efforts. active workers are usually facing issues at the marriage and family in their life courses. in some developed countries, the reasons, due to which unmarried rate during the lifespan of the youth generation has been increasing, may be understandable in work-life balance context. in japan, statistical data of ipss (national institute of population and social security research, japan) 13 show such facts: men's case of unmarried rate excessed 20%, and women's case was 10.6% at 2010. many adolescents frequently hesitate to lose their free time and conformity, and it simultaneously means that they hate any interruptions by others and physical contacts. as necessary, they can choose tentative friends online (su and hu 2019) . using smartphone, many matching service applications for marriage among future partners have been launched in japan. and then, the matching needs can be bridged with the youths for their marriages. those matching services might be applied by stable matching problem in economics of mechanism design (roth 1982) . such algorithm can be formalized for matching pairs of stable marriage. otherwise, daily living enriches its big data (ganchev et al. 2019) . especially, there are strong requirements for children and elder people in their local community and living environment. first, smart sensing and ubiquitous technologies aim to enhancing our daily life (shibuya 2004) , and smart cities and smart house have cutting-edges for improving health services for us (lee 2012) . for example, the digital human research center in japan proposed an autonomous caring system and simulators 14 for toddlers and little infants. due to their sudden and unpredictable manner of behaviors, serious accidents such as injuries and death at home often happen. this system intends to monitor and analyze daily patterns for improving their safety. of course, those systems which are equipped in smart houses are also applicable for elder people to watch their daily cares and health monitoring. on the other hands, secondly, airbnb and similar sharing house services have been launched in many nations, and big data on those paring patterns between house-owners and visitors will be arranged to analyze such trip purposes, sharing durations, other preferences by the ai-driven services (koh et al. 2019) . in these regards, digitization has already reshaped our quality of living in those contexts. using smartphone, mental health monitoring can be possible recently (ben-zeev et al. 2015; bakker et al. 2016) . especially, using social media data, there were innumerable examinations to analyze the relations with mental health and diagnosis of discourses on twitter and sns services. for example, there were enumerable cases on depression trends in community corresponding with data of geospatial location (yang and mu 2015) , depression detection on twitter (guntuku et al. 2017) , adhd (attention deficit hyperactivity disorder) diagnosis using discourses on twitter (coppersmith et al. 2015) , and other borderline cases in clinical psychology (e.g., hopeless, loneliness, social withdrawal). as social networking services clearly indicate a part of human relationships online (lazakidou 2012) , it can consider that their relations itself still have sharing illness personalities and depressed mental health. namely, there is a possibility that latent patients were apt to be participating in such social media, and some of them flocked online each other. inclusive cares within communal and relationship level can be also very effective for each person. traditionally, in the studies of communication and communal health, the concept on illness identity in interactive communication has potentials to recognize identification process for caring illness and health (hecht et al. 2004) . illness identity could be regarded as interactive processes from personal to communal layers in terms of the communication theory of identity. these mechanisms should be inclusively cared by various viewpoints from personal to social communal level. that is because, for example, social anxiety, depression, and other mental (and physical) illness could not be easily emancipated from not only individuals but also more diverse interactions and social groups. according to wegner et al., they discussed mental control and relationships with the others. and their findings can be understood only by including perspectives of social contexts. that is, it should pay attention to not only individual experiences of depression and mental distress but social relationship and interaction process with standpoints from the others (aneshensel et al. 2012 ). as implied earlier, rapport interaction between clinical psychologists and clients has been better focused in empathy oriented understanding as client-centered therapy (rogers 1995) . clinical psychological cases such as autism, psychopathy and other diagnoses usually display specific patterns of behaviors and assertions. especially, those who have specific disabilities against soundly interactions with the others are managed by tom (theory of mind), and this study intends to reveal our mental manners to recognize and coordinate with the others in dyad models (semeijn 2019; freitas et al. 2019) . such client cannot understand any intentions asserted by the others, and they often confuse meanings pretending and deceptions by the others. namely, understanding for the others flexibly requires more imaginable coordination in social context. and the loss of such basic intellectual skills becomes difficult for them to behave appropriately against troublesomeness with the others. in other words, some evolutionary psychologists and neuroscientists told that the humankind could be evolved both to lie against the others and detect 11.4 therapy for human by ai deceptive intentions. they further said that acquisitions for those neural mechanisms of social intelligence took advantages of beating against other wild animals during surviving history of ancient peoples. according to attachment theory by developmental psychologist bowlby, it authorized that physical attachment between mother and children offers strong and comfort foundation during child development (bretherton 1992) . suggestively, serial experiments also shown that an alternative of "mother" could be sufficiently replaced for children. for example, a fluffy doll as alternative of mothership could fulfill having comfort emotions for child (in their experiments, they tried to use a child of monkey). in this concern, personal intelligent robots have potentials to assist our daily life (coeckelbergh 2010) . as an example case, paro already achieved improving many patients of mental illness and alzheimer diseases. it calls robot therapy assisted by ai and adorable doll-like robots. 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equipment health monitoring in complex systems self-consciousness, self-agency, and schizophrenia offline biases in online platforms: a study of diversity and homophily in airbnb a novel coronavirus associated with severe acute respiratory syndrome virtual communities, social networks and collaboration understanding social anxiety the nature and function of self-esteem: sociometer theory advances in computational environment science: selected papers from 2012 international conference on environment how information technology can change our lives in a globalized world the limits to growth analysis of japanese radionuclide monitoring data of food before and after the fukushima nuclear accident epidemics and percolation in small loneliness and social uses of the internet the near-term task force review of insights from the fukushima dai-ichi accident negative consequences from heavy social networking in adolescents: the mediating role of fear of missing out measuring social well-being: a progress report on the development of social indicators five years after the fukushima daiichi accident: nuclear safety improvements and lessons learnt twitter improves influenza forecasting the demography of health and healthcare bowling alone: the collapse and revival of american community handbook of risk theory: epistemology, decision theory, ethics, and social implications of risk client-centered therapy: its current practice, implications and theory the economics of matching: stability and incentives report to the foreign academies from science council of japan on the fukushima daiichi nuclear power plant accident interacting with fictions: the role of pretend play in theory of mind acquisition a framework of multi-agent based modeling, simulation and computational assistance in an ubiquitous environment actualities of social representation: simulation on diffusion processes of sars representation a study on participatory support networking by voluntary citizens -the lessons from the tohoku earthquake disaster a simulation on networked market disruptions and resilience from an exploring study on networked market disruption and resilience the society for risk analysis: asia conference a risk management on demographic mobility of evacuees in disaster the use of twitter to track levels of disease activity and public concern in the u.s. during the influenza a h1n1 pandemic subjective well-being: an interdisciplinary perspective gender-specific preference in online dating radiological issues for fukushima's revitalized future problematic use of social networking sites: antecedents and consequence from a dual system theory perspective the benefits and dangers of enjoyment with social networking websites disaster displacement: how to reduce risk, address impacts and strengthen resilience robot therapy for prevention of dementia at home-results of preliminary experiment public health implications of excessive use of the internet, computers, smartphones and similar electronic devices exploiting psychology and social behavior for game stickiness gis analysis of depression among twitter users use of a therapeutic, socially assistive pet robot (paro) in improving mood and stimulating social interaction and communication for people with dementia: study protocol for a randomized controlled trial pathologist-level interpretable whole-slide cancer diagnosis with deep learning unsupervised bayesian inference to fuse biosignal sensory estimates for personalizing care key: cord-031068-0k5lw6i1 authors: golightley, malcolm; holloway, margaret title: editorial: unprecedented times? social work and society post-covid-19 date: 2020-08-05 journal: br j soc work doi: 10.1093/bjsw/bcaa110 sha: doc_id: 31068 cord_uid: 0k5lw6i1 nan new respect for frontline social care workers who are caring for the most vulnerable often at great risk to themselves. one thing that is clear, is that social work, along with allied professions, must adapt and change but do so without losing sight of its core ethos and skills. in so doing, as classical crisis theory taught us (caplan, 1964) , we must draw on previous experiences of loss and challenge as we seek the way out of this current crisis. here is where theory and research must play its part and the british journal of social work will, we are confident, prove up to the task of dissemination of emerging responses and critical debate-as it has in the past. 1 in considering the content of this our valedictory editorial, we returned to the plans for the journal which we had outlined at the outset. our aims were 3-fold: we wanted to facilitate front line debate between research and practice, embracing ethics, policy and education alongside; we wanted to support the visibility and development of the social work research community and specifically highlighted social work ph.d.s; we wanted to strengthen and widen the international appeal of the bjsw. all three of these objectives are critical for social work to go forward after what has been termed the greatest threat to human society of modern times. arguably, however, this is a very first-world perspective. globally, the poorest and most socially disadvantaged people are also the worst affected by climate change and the developing field of green social work needs to be high on our agenda. the threat of pandemic and climate change are interconnected and economists, for example, are beginning to see green solutions as also the way forward in economic recovery. recovery of a sense of well-being after the stress, loneliness, isolation and anxiety or fear experienced by many of the most disadvantaged and vulnerable in our communities, must cause us to consider what resources those of us more fortunate have been able to draw upon-and how to support service users in finding and connecting with these, whether it be accessing a green space, engaging in a therapeutic activity or reconnecting with buried spiritual resources. the literature on spirituality (religious and secular) and especially eco-spirituality may assist here: there will be moments when the deeply negative aspects of our work, indeed of human existence, threaten to overturn and crack open our carefully constructed world-views as we try to make new sense of it all . . .. this journey into the relatively unknown territory of social work and spirituality is, we suggest, a new way of 'knowing', fit for purpose when facing the challenges of contemporary social work. (holloway and moss, 2010, p. 182) the articles which we publish in this issue each address one or more of our three initial aims. they also show social work striving for new knowledge, or 'ways of knowing' as it grapples with both new challenges and those well-rehearsed 'wicked problems'. although all articles published in the bjsw are, of course, evidence of social work research, the five grouped together at the start of this issue show some of the new directions being taken as well as providing evidence of the growing strength of the social work research community at all levels. first, an australian team (waling, lyons, alba, minichiello, barrett, hughes, fredriksen-goldsen and edmonds) presents their qualitative study of older trans women's perceptions of residential care. their findings show how past experiences of discrimination and abuse had fuelled fears about institutional care in the future, including that they might not have appropriate health care and treatment options available, to the extent that many were actively putting in place alternative care plans. this study was funded by the australian research council and has the potential to influence health and social care services for the trans community not only in australia but also wider. next, a uk team (wilberforce, abendstern, batool, boland, challis, christian, hughes, kinder, lake-jones, mistry, pitts and roberts) looks at what service users want from mental health social work. pointing out that most studies of mental health social work present the views of social workers, this research was co-produced with services users. funded by the national institute for health research (nihr) school for social care research, this research also makes an important contribution to the interprofessional literature by distinguishing the hallmarks (as rated by service users) of good social work practise in mental health. a single-authored ethnographic study follows, from mira sö rmark. located in sweden, this study nevertheless looks at an issue of growing international concern, intimate partner violence perpetrated by men towards female partners. interestingly, sö rmark also suggests that the only way to understand these men's accounts (and hence to develop effective social work interventions) is through a rich appreciation of their lived experience, which incorporates both internal individual worlds and external structural explanations. this research is representative of the social work tradition of small, theorydriven qualitative studies conducted by a single researcher. the next article comes from ireland and is an example of a growing trend in social work research-the longitudinal qualitative study. burns, christie and o'sullivan looked at the problem of retention amongst child protection and child welfare social workers, identified as an issue in a number of european countries. however, whilst much attention has been given to turnover, particularly in the early years post-qualification, this study found that those social workers who stayed the course beyond five years became progressively more embedded and committed to this specialism. this has important implications for the duty and motivation of employers to offer a supportive environment in which social workers may develop confidence and expertise. the critical effect of the work environment is emphasised by astvik, welander and larsson, who also looked at worker retention in another longitudinal study, this time of swedish social services. their focus was on the impact of the new public management style on social workers' levels of stress and burnout, rather than the content of the work per se, but the overriding conclusions mirror that of the irish study. in this section, we have selected articles which illustrate the range of issues and location of authors across the globe which find their way into the pages of the bjsw. first, hassan, siddiqu and friedman analyse through a quantitative study the impact of infertility on women in pakistan. the authors show how an issue which in the west might seem to belong primarily to health care not social work, becomes very much social work's concern in a context in which infertility is critically bound up with stigma, marginalisation, oppression, intimate partner violence and consequent negative effects on women's health and well-being. next, a chinese-american team (wang, victor, hong, wu, huang, luan and perron) applied a systematic review of empirical intervention studies to explore the care of children left behind in mainland china whilst their parents seek employment abroad. funded by the national social science fund of china, the authors suggest that the sheer scale of the problem of children made vulnerable and at-risk by this practice, demands priority attention from the still new profession of social work in china. again, although not unknown in countries with welldeveloped child welfare systems, this research shines a light on a practice little studied to date. moving to australasia, petersen and parsel examine a problem common in developed countries-homelessness-looking specifically at the plight of homeless older people. although their conclusion that housing, older people's care and health services must intersect to tackle this problem is not new, their placing this into the context of troubled family relationships as a cause of older people's homelessness highlights an angle, central to social work, which is not usually the first consideration. from new zealand, raewyn tudor looks at an increasingly important field for social work in the twenty-first century in an article looking at how social workers responded to natural disaster in the aftermath of the 2011 earthquake in christchurch. tudor used a positive critique to examine the practice accounts of school social workers, putting them alongside the main features of recovery policies which provide for individual assistance for vulnerable groups who are unlikely to access community self-help initiatives. the social workers used therapeutically inclined relational work with their clients to encourage their well-being. the increasing involvement of social workers in post-disaster work will be returned to in a forthcoming special issue of this journal. to round up this focus on international social work, the next two articles (from norway and belgium, respectively) examine how social workers respond to the intractable social problem of poverty and suggest that poverty-aware social work requires a critical and sustained commitment to move beyond individual self-reflection towards critical analysis of the political, economic and social policy contexts in which we work. throughout europe, there has been a trend towards increased levels of child poverty; although this is greater in southern and eastern countries, no country has challenged this trend. malmberg-heimoneen and t/ge used a clusterrandomised design to examine government and family interventions in norway and their impact upon child poverty. roets, van bevern, saar-heiman, degerickx and vandekinderen focus on students' understandings of poverty in a study conducted in flanders, belgium. building on the central notion that social workers need to be able to understand poverty in a conceptual framework embracing individual, cultural and structural explanations of poverty in order that they can adopt a way of working that is both critical and reflexive, their article offers a qualitative analysis of the reflections that students made about the learning process in a post-academic course and suggest ways in which teaching can help social workers better understand social issues. both these studies emphasise the need for structural explanations and a social work practice that is rooted in the community. this final group of articles all provide examples of research directly informing social work practise in different ways. the first article (mendes and rogers) examines young people who are moving from out-of-home care and looks at what lessons australian social work practice can learn from the extended care programmes in the usa and england. they examine public evaluations of extended care programmes and make recommendations for future australian programmes for care leavers. the next article (talbot, fuggle, foyston and lawson) has an interconnected theme of care services and provides an evaluation over ten years of the adolescent multi-agency specialist service, an edge of care service provided in islington, england. it also represents effective co-working between academics and practitioners. it is generally agreed that late entry to the care system often has poorer outcomes for the individual and if care can be prevented for adolescents then this would be beneficial. the complex needs of the adolescent and family provide significant challenges for social work services and other agencies. continuing the theme of children in care, shaw and greenhow report on recent research that examined the perceptions of professionals about the sexual and criminal exploitation of children in care. based in the north-west of england and using focus groups and semi-structured interviews they provide further evidence of the vulnerability of children who are 'looked after' and how this can be exploited. significantly they raise the issue of an approach that is all too often prosecution-led rather than seeing children as a vulnerable group open to exploitation. few could doubt that at the present time many countries have to work out how to respond to the arrival at their borders of large numbers of asylum seekers. so, the article by larkin and lefevre is timely in that they examine the complex inter-subjective encounters of unaccompanied minors (under age eighteen years) who usually have little understanding of the role of social workers. these are a diverse group of young people who are generally underrepresented in the literature and this article helps to shed light on the many challenges they face. niamh flanagan, in a single-authored article, takes a step back from the notion of research informing practise to consider the wide range of sources which practitioners use to inform their practice. she suggests that social workers adopt a pragmatic approach to the gathering of information that includes, but by no means is limited to, research. one such example is provided in the next article in which an academic researcher and a researcherpractitioner based in seville, spain, evaluate a project utilising the role of theatre in social work. the article by muñoz-bellerín and cordero-ramos covers a decade of working alongside homeless individuals in which theatre is used as a tool to promote capacity within the group with consequent empowerment. with echoes of community social work in the uk and the powerful writing of boal (1979) , the article makes for informative reading demonstrating how it might be possible to create informal spaces where marginalised people can interact meaningfully with mainstream society. this seems an appropriate note on which to conclude our final editorial. we wish the new editors and future writers in the bjsw good courage and good fortune as they take up the reins and look forward to seeing the journal go from strength to strength. theatre of the oppressed principles of preventive psychiatry university of hull key: cord-252344-5a0sriq9 authors: saleh, sameh n.; lehmann, christoph u.; mcdonald, samuel a.; basit, mujeeb a.; medford, richard j. title: understanding public perception of coronavirus disease 2019 (covid-19) social distancing on twitter date: 2020-08-06 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.406 sha: doc_id: 252344 cord_uid: 5a0sriq9 objective: social distancing policies are key in curtailing severe acute respiratory coronavirus virus 2 (sars-cov-2) spread, but their effectiveness is heavily contingent on public understanding and collective adherence. we studied public perception of social distancing through organic, large-scale discussion on twitter. design: retrospective cross-sectional study. methods: between march 27 and april 10, 2020, we retrieved english-only tweets matching two trending social distancing hashtags, #socialdistancing and #stayathome. we analyzed the tweets using natural language processing and machine-learning models, and we conducted a sentiment analysis to identify emotions and polarity. we evaluated the subjectivity of tweets and estimated the frequency of discussion of social distancing rules. we then identified clusters of discussion using topic modeling and associated sentiments. results: we studied a sample of 574,903 tweets. for both hashtags, polarity was positive (mean, 0.148; sd, 0.290); only 15% of tweets had negative polarity. tweets were more likely to be objective (median, 0.40; iqr, 0–0.6) with ~30% of tweets labeled as completely objective (labeled as 0 in range from 0 to 1). approximately half of tweets (50.4%) primarily expressed joy and one-fifth expressed fear and surprise. each correlated well with topic clusters identified by frequency including leisure and community support (ie, joy), concerns about food insecurity and quarantine effects (ie, fear), and unpredictability of coronavirus disease 2019 (covid-19) and its implications (ie, surprise). conclusions: considering the positive sentiment, preponderance of objective tweets, and topics supporting coping mechanisms, we concluded that twitter users generally supported social distancing in the early stages of their implementation. on march 11, 2020, the world health organization (who) declared the novel coronavirus (covid-19) outbreak a pandemic and emphasized the need for global governmental commitment to control the threat, citing then 118,319 confirmed cases and 4,292 deaths worldwide. 1 to contain severe acute respiratory coronavirus virus 2 (sars-cov-2), countries closed their international borders. 2 despite travel restrictions, global cases continued to increase 3 requiring enactment of key community mitigation, which garnered significant public attention. 4, 5 these mitigation strategies, named nonpharmaceutical interventions (npis), are approaches outside medications, therapies, and vaccines to prevent further spread of sars-cov-2 and to reduce the strain on the healthcare system. npis fall under 3 main categories: personal, environmental, and community. personal npis refer to behaviors like staying home when sick, coughing or sneezing in a tissue or elbow, wearing a mask, and washing hands with soap and water or using hand sanitizer. environmental npis refer to appropriate surface cleaning of high-throughput areas and commonly used objects. community npis refer to social distancing and closure of areas where large gatherings may occur, such as schools, businesses, parks, and sporting events. used previously for other viral outbreaks such as influenza, 6 social distancing or physical distancing refers to increasing the space between individuals and avoidance of larger gatherings in an attempt to reduce viral transmission. 7 this community npi has been a main components of effectively fighting the covid-19 pandemic. [8] [9] [10] managing and changing public opinion and behavior are vital for social distancing to successfully slow transmission of covid-19, preserve hospital resources, and prevent exceeding the healthcare system's capacity. 11 to affect public opinion, one must first examine and understand it. social media, specifically its microblogging platform twitter, serves as an ideal medium to provide this understanding. twitter has >145 million daily active users 12 and allows individuals to post, repost, like, and comment on 'tweets' of up to 280 characters. analysis of twitter has been used previously within the healthcare realm to understand public sentiment and opinion on topics ranging from diabetes, 13 cancer therapy, 14 and novel healthcare policies such as the affordable care act. 15 within the field of emerging infectious diseases, twitter analysis has been used to study public opinion and sentiment on measles, 16 influenza, 17 and zika virus outbreaks. 18 we hypothesized that performing sentiment, emotion, and content analysis of tweets related to social distancing on twitter during the covid-19 pandemic could provide valuable insight into the public's beliefs and opinions on this policy. we further hypothesized that the knowledge gained could prove valuable for public health communication as well as dissemination and refinement of information strategies. from march 27 to april 10, 2020, we extracted daily relevant samples 19 of english-only tweets related to social distancing and created a 2-week cross-sectional data set of social media activity. we used the rtweet package 20 to access twitter's application programming interface (api) via rstudio version 1.2.1335 (r foundation for statistical computing, vienna, austria). the hashtags #socialdistancing and #stayathome, which were the top trending social distancing hashtags at the time of data extraction, were used to identify tweets related to social distancing. we used 15 of the 89 collected tweet metadata variables in our analysis (table s1 online). we cleaned the tweets by removing characters and words of no or little analytical value and transforming text to its root form. we used python version 3.6.1 software (python software foundation, wilmington, de) for all data processing and analyses. further details are discussed in appendix a (online). institutional review board approval was not required because this study used only publicly available data. we used python's textblob library 21 to perform sentiment analysis for all tweets through natural language processing and text analysis to identify and classify emotions (positive, negative, or neutral) and content topics. textblob applies the afinn sentiment lexicon 22 from a polarity scale of −1 (most negative) to 1 (most positive). we visualized the polarity distribution using bins for strongly negative (−1 to −0.51), negative (−0.5 to −0.01), neutral (0), positive (0.01 to 0.5), and strongly positive (0.51 to 1). we used a recurrent neural network model developed by colneric and demsar to label the primary emotion for each tweet based on ekman's emotional classification (anger, disgust, fear, joy, sadness, or surprise). 23 using χ 2 testing and bonferroni correction to adjust for multiple comparisons, we compared the proportion of each sentiment polarity and emotion for each hashtag. we evaluated changes in effect size between hashtags using the absolute difference in percentage points. we used python's textblob library to perform subjectivity analysis and labeled each tweet from a range of 0 (objective) to 1 (subjective). objective tweets relay factual information, whereas subjective tweets typically communicate an opinion or belief. for the 2 hashtags #stayathome and #socialdistancing, we visualized sentiment using a histogram of values and compared the median sentiment between hashtags using the mann-whitney u test. through terminology matching, we used key words present in social distancing rules (eg, "stay at least 6 feet [2 meters] from other people" or "avoid large gatherings") to identify tweets with potentially objective information about these rules (table s2 online). 7 we manually reviewed 5% of the resulting tweet subset to verify what percentage of these tweets truly included information about social distancing rules and extrapolated prevalence for the full subset of tweets. to understand the major topics being discussed in our tweet sample, we applied an unsupervised machine-learning algorithm called latent dirichlet allocation (lda) 24 using the gensim python library. 25 lda is a commonly used topic-modeling approach to identify clusters of documents (in our case, tweets) by a representative set of words. the most highly weighted words in each cluster provide insight into the content of each topic. lda requires users to input the number of expected topics. to determine the optimal number of topics, we trained multiple lda models using different numbers of topics ranging from 4 to 50 and computed a topic coherence score (produced by comparing semantic similarity of a topic's most highly weighted words) for each lda model. selecting the lda model with the highest score, we ultimately chose 10 topics for the final model. an author without access or insight into the topic model initially labeled the topics using the 20 most frequently used terms ordered by weight. all authors then reached consensus on the topic labels. we identified the prevalence of topics by labeling tweets according to their most dominant topic. we identified example tweets whose content pertained >99% to 1 specific topic ( table 2 , last column). we extracted 1,352,082 tweets during the 2-week period. after removal of repeat and non-english tweets, 574,903 tweets across 347,142 users (range, 1-836 tweets per user; mean, 1.6 tweets per user) were included in the analysis (table 1) . of those tweets, 98.3% were unique. the hashtag #socialdistancing was included in 264,254 tweets and #stayathome was included in 332,075 tweets; 21,453 tweets contained both hashtags. twitter for iphone was the most commonly used platform (31%), followed by twitter for android (27.5%). moreover, <50% of tweets had media (image or video) and more than one-third had a hyperlink. the median user had >3,000 posts and >400 followers at the time of tweeting. also, 5% of accounts were verified, signified by a blue badge next to a user's profile name indicating that an account of public interest is authentic. our tweet data set contained 13,962,279 words and 93,337,108 characters. the 200 most frequently used words associated with each hashtag before processing are illustrated in fig. 1 . after processing, for both #socialdistancing and #stayathome, the most common word was 'day' (20,637 and 28,798 times, respectively). the next 19 most frequent words for #socialdistancing were 'practice' (13, 988 there was net positive sentiment polarity toward both #socialdistancing and #stayathome, with mean polarity scores of 0.150 (standard deviation [sd], 0.292) and 0.144 (sd, 0.287) respectively. positive and neutral tweets accounting for 52.2% and 33.1% of tweets, respectively (fig. 2) . moreover, <15% of tweets were negative and <2% were strongly negative. although statistical differences between polarity categories were detected due to the large sample sizes, the differences in effect sizes were minimal (fig. 2) . neutral and positive tweets had the largest absolute differences. compared to #stayathome, #socialdistancing had 3.6% fewer neutral tweets and 3.2% more positive tweets. tweets tended to be more objective in nature and~30% demonstrated near or complete objectivity (fig. 3) . the median subjectivity scores were similar for #socialdistancing (0.4; interquartile range [iqr], 0-0.59) and #stayathome (0.4; iqr, 0-0.6; p = .13). we matched 6,417 tweets that included key words related to social distancing rules and manually reviewed 320 of them. of the 320 tweets, 249 were confirmed to be related to social distancing rules, yielding a rate of 77.6%. extrapolating this to all social distancing tweets, we estimate that 4,980 (1.1% of all) tweets referenced social distancing rules. joy was the predominant emotion expressed in >50% of tweets with topics ranging from enjoying recreational activities, connecting with family members, and working from home. examples: if you are lucky enough to have even a small garden, now is the time to spend sprucing it up. our spring gardening feature has helpful advice and new ideas to try, to help you make the most of it and #stayathome and surprise was the next most prevalent emotion, and tweets included themes of prolonged policy interventions and discovery of novel talents. examples: to save lives, #socialdistancing must continue longer than we expect. and i played golf with my wife today. odd, i didn't even know she could play. #socialdistancing, #familytime" the least common emotions found in tweets were sadness, disgust, and anger (fig. 4) . we detected statistical differences in all emotions between #stayathome and #socialdistancing tweets. the largest differences in effect size were joy (#stayathome with 6.6% more) and fear (#socialdistancing with 11.9% more). we identified and subjectively labeled the 10 main tweet topics. table 2 displays the mean topic sentiment polarity and subjectivity score, key words, and example tweets. "public opinion and values", "media and entertainment", and "quarantine measures and effects" emerged as the three most prevalent topics in 88,993, 71,589, and 65,229 tweets, respectively. discussion of "spring and good sentiments" had the highest mean polarity of 0.26. "public opinion and values" and "quarantine measures and effects" had the lowest mean polarity of 0.07. mean subjectivity scores for all topics ranged from 0.33 to 0.43, with "public opinion and values" having the highest subjectivity score. understanding the beliefs, attitudes, and thoughts of individuals and populations can aid public health organizations (eg, the who) and government institutions to identify public perception and gaps in communication and knowledge. we analyzed twitter activity around the 2 most common social distancing trending hashtags at the study time to understand emotions, sentiment polarity, subjectivity, and topics discussed related to this npi. tweets predominantly showed positive sentiment polarity. tweets were primarily linked to emotions of joy (~50%), fear, and surprise. anger and disgust were the 2 least common emotions expressed. analyzing key words, we demonstrated that tweets were primarily objective in nature and were used to disseminate public health information. we identified and labeled 10 main topics demonstrating insight into the thoughts and perceptions of the public. social media data and channels provide a rich platform to perform public sentiment analysis and have already been used to examine covid-19 perceptions. one study leveraged social media to distribute a survey to nearly 9,000 individuals in the united states. 26 another large study surveyed 6,000 participants in the 4 . emotion analysis for all tweets and stratified by tweets with the hashtag #socialdistancing and #stayathome. comparison between the two hashtags is done using χ 2 testing. bonferroni correction was used to define statistical significance at a threshold of p = .008 (0.05/n, where n = 6 since 6 comparisons were completed). united kingdom and the united states. 27 despite the robust combined sample size of 15,000 participants, there were inherent limitations to the design. these studies utilize nonprobability sampling like convenience and snowball sampling that are plagued by significant selection bias as well as potential reporting bias, making them prone to sampling error. through probability sampling from the twitter api, we analyzed nearly 575,000 english tweets across 350,000 users, providing a broader understanding of public perception that is likely more representational of the population. using a machine-learning approach, we also explored topics and perceptions without introducing predefined researcher notions, thus limiting the risk of biases inherent to the question design. recent public opinion polls from a similar time period have shown that the overwhelming majority of us citizens favored the continuation of social distancing measures. 28, 29 the positive attitude is clearly reflected in the sentiments found in the analyzed tweet sample. most tweets were either positive or neutral in nature. as public sentiment shifts, we would expect this to be reflected in tweet sentiment as well. for government and public health officials, tweet sentiments may be an important measure to determine the public willingness to continue distancing, which in turn could inform future infection prediction models and social distancing policies. many tweets tend to express an opinion; however, tweets associated with #socialdistancing and #stayathome were predominately objective suggesting that these hashtags were used to transmit objective information potentially serving an important public health function. combined with the large volume of tweets and the finding that 1.1% described social distancing rules, twitter has the potential to fulfill an important educational function for public health messages. joy, fear, and surprise were the dominant emotions for the early phase of social distancing. this correlated well with the topics we discovered, which included leisure activities, community support, and messages of hope (ie, joy), concerns about food insecurity, spreading of the infection, effects of the quarantine (ie, fear), unpredictability of covid and its unforeseen implications (ie, surprise). as time progresses and the effects of social distancing become more prominent, we would anticipate that other themes such as loss of income, unemployment, inflation, and financial burden would increase in frequency. the topics we discovered can be aggregated into 4 larger domains. activities that can be performed during social distancing included 3 topics: media and entertainment, activities, and music and media sharing. tweets concerning the actual rationale and effect of the social distancing included 3 topics: public opinions and values, quarantine measures and effects, and quarantine and isolation. two of these were the most prevalent topics. one domain covered the logistics of staying at home falling under a single topic: supplies, food, and orders. the last domain pertained to messages of support and cheering up others: thank healthcare and reduce spread, community support and businesses, spring and good sentiments. our study has several limitations. first, we used social media data and specifically twitter for our analysis. although there are >300 million monthly active twitter users, our methodology likely introduced some sampling bias to those with internet and technology access. second, we used 2 noncomprehensive trending hashtags to identify the most relevant social distancing tweets. we may have missed alternative terminology or key words such as "self isolation" and "corona lockdown," which appeared as weighted terms in our topic modeling. however, given that these 2 hashtags were the top-trending social distancing hashtags, we expect that these were representative of social distancing during the study period. we recognize that the study period serves as an initial snapshot, rather than a complete evolution, of public perception towards social distancing and that sentiment and topics likely have changed over time. a longitudinal analysis will be a part of future directions. third, despite analyzing a large number of tweets, we used only a subset of tweets during this time frame, which may have resulted in selection bias. having analyzed only english tweets, our conclusions may not be generalizable to non-english speaking populations. since most tweets do not have geolocation, we are also limited in making conclusions based on geographic areas or countries. fourth, a 2017 study 30 found that between 9% and 15% of all twitter accounts are bots, which may have affected our analysis. we used the twitter bot analyzer botometer 31 to analyze a random sample of 3,900 users in our dataset. we found that 90% of users have a <20% chance of being a bot. figure s1 shows the complete probability distribution. excluding the remaining 10% of users did not change sentiment, emotion, or subjectivity analysis. finally, we recognize the risk of labeling bias through assignment of topic themes to weighted terms. we attempted to prevent this by having 2 authors perform the topic modeling and 1 author independently perform the labeling task. in the early phases of social distancing, we were able to successfully obtain and analyze a representative subset of tweets related to this topic. performing sentiment, emotion, and content analysis of tweets provided valuable insight into the public's beliefs and opinions on social distancing. tweets were predominately objective with joy, fear, and surprise as leading emotions. tweets contained social distancing instructions in >1% of tweets. in the early phases of social distancing, tweets were skewed toward leisure activities and discussion of rationale and effect of social distancing. as social distancing progresses and then is lifted, we anticipate sentiment and topics to change. although "attitude is only one antecedent of behavior," the positive emotions, the preponderance of objective tweets, and the topics supporting coping mechanisms led us to conclude that twitter users generally supported the social distancing measure. analyzing tweets about nonpharmaceutical interventions such as social distancing based on content, sentiment, and emotion may prove valuable for public health communication, knowledge dissemination, as well as adjustment of mitigation policies in the future. future research to implement this analysis in real-time using the twitter streaming api 32 could augment directed messaging based on user interest and emotion. covid-19) situation report -52. world health organization website coronavirus: travellers race home amid worldwide border closures and flight warnings. the guardian website where america didn't stay home even as the virus spread. the new york times website the social-distancing culture war has begun. the atlantic website effectiveness of workplace social distancing measures in reducing influenza transmission: a systematic review coronavirus disease 2019 (covid-19) social distancing. centers for disease control and prevention website mathematical assessment of the impact of non-pharmaceutical interventions on curtailing the 2019 novel coronavirus impact assessment of nonpharmaceutical interventions against coronavirus disease 2019 and influenza in hong kong: an observational study covid-19: a look into the modern age pandemic covid-19 strategy update. world health organization website q1 2019 earnings report. twitter website diabetes on twitter: a sentiment analysis utilizing twitter data for analysis of chemotherapy public response to obamacare on twitter disease detection or public opinion reflection? content analysis of tweets, other social media, and online newspapers during the measles outbreak in the netherlands in 2013 pandemics in the age of twitter: content analysis of tweets during the 2009 h1n1 outbreak identifying key topics bearing negative sentiment on twitter: insights concerning the 2015-2016 zika epidemic search tweets-standard search api. twitter website cran r project website textblob: simplified text processing a new anew: evaluation of a word list for sentiment analysis in microblogs emotion recognition on twitter: comparative study and training a unison model latent dirichlet allocation parallelized latent dirichlet allocation. gensim website us public concerns about the covid-19 pandemic from results of a survey given via social media knowledge and perceptions of covid-19 among the general public in the united states and the united kingdom: a cross-sectional online survey just 14% of americans support ending social distancing in order to reopen the economy, according to a new poll kff health tracking pollearly april 2020: the impact of coronavirus on life in america. kaiser family foundation website online human-bot interactions: detection, estimation, and characterization botornot: a system to evaluate social bots filter real-time tweets. twitter website acknowledgments.financial support. no financial support was provided relevant to this article. supplementary material. to view supplementary material for this article, please visit https://doi.org/10.1017/ice.2020.406 key: cord-259394-mno88lzj authors: zhu, wei; wei, yi; meng, xiandong; li, jiping title: the mediation effects of coping style on the relationship between social support and anxiety in chinese medical staff during covid-19 date: 2020-11-04 journal: bmc health serv res doi: 10.1186/s12913-020-05871-6 sha: doc_id: 259394 cord_uid: mno88lzj background: the covid-19 has been a pandemic around the world, which affirmatively brought mental health problems to medical staff. we aimed to investigate the prevalence of anxiety in chinese medical staff and examine the mediation effects of coping styles on the relationship between social support and anxiety. methods: a cross-sectional study via internet survey was conducted from 15 march to 30 march, 2020. the social demographic data, self-rated anxiety scale, social support rate scale and trait coping style scale were collected. pearson correlation and a structural equation model were performed to examine the relationships of these variables. the bootstrap analysis was conducted to evaluate the mediation effects. results: a total of 453 medical staff participated in this study. the mean score of sas was 46.1 (sd = 10.4). up to 40.8% of the participants had anxiety symptoms. the participants lived with family members had lower sas score (45.1 ± 9.8 vs 49.6 ± 11.8). social support was negatively associated with anxiety, mediated by positive coping and negative coping partially significantly with an effect size of − 0.183. conclusions: chinese medical staff had a high level of anxiety during the covid-19 pandemic. coping styles had effects on the association between social support and anxiety. sufficient social support and training on positive coping skills may reduce anxiety in medical staff. supplementary information: the online version contains supplementary material available at 10.1186/s12913-020-05871-6. likely to have decreased energy and experience social isolation [9, 10] , which may aggravate anxiety inversely. additionally, a study on 180 medical staff treating covid-19 by xiao [11] revealed that anxiety had a negative association with sleep quality. therefore, it is important to emphasize mental health, especially anxiety, in medical staff during the covid-19 pandemic [7, 12, 13] . social support is a critical approach to reduce anxiety. social support generally refers to a belief that individuals are cared for, loved, esteemed and sharing the mutual obligation of a social network [14] . the friends, family members, colleagues, and even communities of individuals can provide social support from emotional, material and spiritual aspects [15, 16] . the positive effects of sufficient social support on anxiety has been proven in previous studies [17, 18] . support from a social network provides a way for individuals to share negative or traumatic life events [19] . this interaction between individuals and their social supporters may bring empathy and emotional well-being, thus achieving a better mood [20, 21] . additionally, glozah [22] believed that adequate social support can lead to increased courage, a better interpersonal understanding and a sense of professional achievement by increasing self-efficacy. these positive emotional experiences provided by social support can effectively decrease anxiety. coping styles are also correlated with anxiety. when facing difficult or stressful life events, individuals will take different cognitive, emotional or behavioural response strategies, which are defined as coping styles [23] . these styles were divided into positive coping and negative coping by jiang [24] , of which positive coping meant a problem-solving strategy and negative coping meant an emotion-focused coping mechanism, even not coping [25] . previous studies found that coping style was correlated with anxiety [26] [27] [28] : positive coping was associated with anxiety negatively; negative coping was associated with anxiety positively. there are some assumptions about the mechanism of coping style influencing anxiety. classen [29] reported that individuals with a positive coping strategy usually had a fighting spirit and a better emotional expression performance, which was considered to indicate good psychological adjustment ability, leading to lower anxiety. coping styles may also influence anxiety through individuals' normal or pathological changes of biological levels [23] . based on the associations between social support, coping styles and anxiety, the potential inter-relationship between social support and coping styles was also reported in some studies. ren [30] conducted a survey in pregnant women after an earthquake, in which they found that negative coping style was significantly associated with a lower level of subjective social support, objective social support and support use. furthermore, social support and coping styles were both associated with mental health disorders in pregnant women. geng [31] found that coping styles counterbalanced the effect of social support on selfmanagement behaviours, which can influence the mental health status [32] . thus, it is reasonable to hypothesize that coping styles may counterbalance the relationship between social support and anxiety. previous studies confirmed that social support, coping styles and anxiety were inter-related. however, research focused on mechanism was more important than on the associations between different variables. therefore, we aimed to evaluate the anxiety level of medical staff during the covid-19 pandemic and examine whether coping styles mediate the association between social support and anxiety. this cross-sectional study was performed in chinese medical staff who worked during the outbreak of covid-19 in sichuan province via an internet survey from march 15 to march 30, 2020. the questionnaire (additional file 1) was built on a network platform (www.wjx.cn) and then was shared on social media including wechat and tencent qq. a convenience sampling method was used to recruit participants in this study. the inclusion criteria were as follows: 18 years old or above; regular employees; worked at their posts rather than engaged in advanced studies or went on a business trip during the survey. after a brief written informed consent at the beginning of the survey, three questionnaires about social support, anxiety symptoms and coping styles were required. sociodemographic data including age, gender, marital status, living with family members or not, employee type and seniority, were also required. while constructing the online questionnaire, the integrity check function of the platform was used, meaning the questionnaire could not be submitted unless all questions were answered. after extracting the data from the platform, two researchers re-checked the quality of the questionnaires to eliminate those with missing data independently until a 100% consensus was reached. coping styles: the trait coping style questionnaire (tcsq) developed by jiang [33] was used to evaluate the coping styles of chinese medical staff. this questionnaire consists of two dimensions (positive coping and negative coping) with 20 items and uses a five-point likert-scale, where 1 means "absolutely not" and 5 means "absolutely yes". the total score of each dimension ranges from 10 to 50, with higher scores indicating that someone may be more likely to utilize a positive or negative coping style. the cronbach's alpha value of positive and negative coping dimensions was 0.70 and 0.69, respectively [33] . in this study, the cronbach alpha coefficient was 0.84. social support: the chinese social support rate scale developed by xiao [34] was used to assess social support. this questionnaire contains 10 items, which are divided into three dimensions, including subjective support (items 1, 3, 4, 5), objective support (items 2, 6, 7) and availability (items 8, 9, 10) . the score of items 1, 2, 3, 4, 8, 9 and 10 ranges from 1 to 4. item 5 consists of 4 choices, where the total score is the sum of each choice ranges from 1 (never) to 4 (always). the score of items 6 and 7 is the count of the choice. a higher total score indicates better social support. the cronbach's alpha of this scale value was 0.76 [35] . in this study, the cronbach alpha coefficient was 0.66. anxiety symptoms: the self-rated anxiety scale developed by zung [36] was used to evaluate anxiety symptoms. it is a four-point likert-scale with 20 items. the standard total score ranges from 25 to 100, which is converted from the original score by multiplying by 1.25. a higher score indicates a higher level of anxiety. a score of 50-59 is classified as mild anxiety; a score of 60-69 is classified as moderate anxiety; and a score over 69 is classified as severe anxiety. this scale was proved good reliability and validity. the cronbach alpha value in chinese population was 0.76 [37] . in this study, the cronbach alpha coefficient was 0.80. socio-demographic variables were described using appropriate methods. pearson correlation and multiple liner regression were performed to examine the relationships between social support, anxiety, and coping styles. these analyses were conducted in spss 23.0 (spss inc., chicago, usa, il), with a significant p value of 0.05. then, a structural equational model was conducted to assess the hypothesized mediation model using amos 24.0 (spss inc., chicago, usa, il). the root-mean-square-error of approximation (rmsea), goodness-of-fit index (gfi), adjusted goodness-of-fit index (agfi) and akaike information criterion (aic) were used to evaluate the optimum model. the process macro provided by hayes [38] was used to perform the bootstrap analysis to examine the mediation effects with 1000 bootstrap samples. the mediation effects were considered significant if the confidence intervals did not include the value of zero [39] . this study was approved by the ethics committee of west china hospital, sichuan university (id: 2020-254). we provided an online written informed consent at the beginning of the online questionnaire. the survey started after the participants agreed to participate in this study and filled out the informed consents. all participants were informed that they had the right to withdraw from this study at any time. socio-demographic characteristics and anxiety level of the participants a total of 453 chinese medical staff participated in this study with 94.9% female and 5.1% male participants (table 1) . of the participants, nurses were the largest proportion (87.4%). the participants in this study were mainly individuals under 45 years old (85.4%), and 77.7% of participants lived with their family members during the covid-19 outbreak. the mean score of sas was 46.1 (sd = 10.4). a total of 185 (40.8%) participants showed anxiety symptoms. of the participants with anxiety, 28.6% had moderate and severe anxiety. the sas scores showed no significant differences regarding age, gender, marital status, employee type or seniority. the participants living with family members had lower sas scores (45.1 ± 9.8 vs 49.6 ± 11.8, p < 0.001). correlation analysis between social support, coping styles and anxiety table 2 shows the mean, sd and correlations of the social support rate scale, self-rated anxiety scale, positive coping and negative coping. the social support rate scale was negatively correlated with negative coping (r = − 0.283, p < 0.01) and self-rated anxiety scale (r = − 0.294, p < 0.01); social support rate scale was positively correlated with positive coping (r = 0.146, p < 0.01). negative coping was positively correlated with self-rated anxiety scale (r = 0.448, p < 0.01); positive coping was negatively correlated with self-rated anxiety scale (r = − 0.237, p < 0.01). the multiple regression analysis indicated that social support and coping style were significantly related to anxiety symptoms, explaining 28.3% of all variance (table 3) . the structural equation model (sem) was conducted to measure the associations and importance of social support on anxiety in medical staff (fig. 1) . the fitness of the model was acceptable: χ 2 /df = 3.59, p < 0.01, gfi = 0.983, agfi = 0.948, cfi = 0.958, rmsea = 0.076, aic = 53.159. the social support rate scale scores positively affected positive coping (β = 0.15, p = 0.007) and negatively affected negative coping (β = − 0.33, p < 0.001) and selfrated anxiety scale scores (β = − 0.18, p < 0.001). positive coping negatively affected self-rated anxiety scale scores (β = − 0.23, p < 0.001). negative coping positively affected self-rated anxiety scale scores (β = 0.40, p < 0.001). the social support rate scale had a direct effect on the self-rated anxiety scale. additionally, the social support had indirect effects on the self-rated anxiety scale through positive coping and negative coping paths, indicating the partial mediation effects of coping style. the results of bootstrap analysis are showed in table 4 . the 95% confidence intervals of the indirect effects of two different coping styles did not include the value of zero neither, showing significant differences. this study found that chinese medical staff experienced a high level of anxiety. sufficient social support can reduce anxiety directly. meanwhile, social support affected anxiety through positive coping and negative coping paths indirectly. this study found that chinese medical staff working during the outbreak of covid-19 had a higher level of anxiety compared to the chinese medical staff norms (40.8% vs 31.0%) [8] . during the internet survey, the confirmed covid-19 cases in china almost reached their highest level. the medical staff were required to finish routine treatment and prevent the infection of covid-19 simultaneously, which may led to a higher workload and stress. additionally, wearing protective equipment may lead to medical staff communicating with colleagues less frequently. these facts may contribute to a higher level of anxiety during the covid-19 pandemic. the infection of medical staff also led to more anxiety [11] . therefore, mental health care programmes for the medical staff are urgently needed. chen [40] took a series of actions to maintain the mental health of their medical staff during the outbreak of covid-19, which included setting up a rest area, providing food and information on the care of covid-19 patients, etc. liu [12] developed an online mental health service programme for medical staff during the covid-19 pandemic, providing online counselling 24 h a day and all days of the week. however, the efficacy of the two programmes remains unknown. it was not surprising to find that social support had a positive effect on anxiety directly. for medical staff, the story sharing and emotional expression to their friends and family members may lead to positive emotional experiences [41] , resulting in decreased anxiety. communication with colleagues is another form of receiving social support, giving medical staff the feeling of professional achievement and confidence in their work [42] , reducing anxiety. this finding was consistent with previous results [18, 20] . therefore, some measures can be adopted, such as setting up rest and communication aera, encouraging emotional expression and story sharing and providing mental health counselling services, to give sufficient social support for medical staff. moreover, hospital managers can educate the family members on listening and this study also found that the relationship between social support and anxiety was partially mediated by coping styles. we demonstrated that positive coping strengthened the positive effect of social support on anxiety; negative coping negatively influenced the effect of social support on anxiety. in other words, when individuals received sufficient social support, they were more likely to use positive coping strategies to achieve a lower level of anxiety. if there was not enough social support, individuals tended to take negative actions facing problematic life events, resulting in higher anxiety. additionally, if the level of social support remained stable or there was no way to provide more social support in short time, such as, the front-line medical staff living in a single room after work, providing positive coping skills may be helpful to reduce anxiety. particularly, the total mediation effects of coping styles were 52.3%, suggesting an important role of coping style in the relationship between social support and anxiety. in conclusion, healthcare workers are on the front line of the battle against covid-19 and are paying the highest price for this global health emergency [43] . protecting healthcare workers by providing psychological support and emotional skills to deal with anxiety is a priority [12, 44] . sufficient social support affirmatively reduced the anxiety of healthcare workers. thus, providing coping skills to healthcare workers may also contribute to decreasing anxiety when a coping style mediates the relationship between social support and anxiety. there were some limitations in this study. first, this study was conducted through an internet survey, which may reduce the comprehensive understanding of the items of the scales. second, the small samples were selected based on a convenience sampling method, thus the representativeness may be reduced. third, the crosssectional study cannot provide the causal relationships between these variables. a large sample-size and clinical review-based cohort study is needed in future. chinese medical staff had a high level of anxiety during the covid-19 pandemic. the mediation analysis found that coping styles affected on the association between social support and anxiety. sufficient social support and training on positive coping skills may reduce anxiety in medical staff. the online version contains supplementary material available at https://doi. org/10.1186/s12913-020-05871-6. additional file 1. authors' contributions wz contributed to the conceptualization, methodology, data analysis and interpretation and original manuscript preparation. yw contributed to the investigation and data curation. xdm contributed to the conceptualization, methodology, data analysis of this study and revised the manuscript for important intellectual content. jpl contributed to the conceptualization, methodology of this study and revised the manuscript for important intellectual content. all authors read, commented upon, and approved the final manuscript. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. this study was approved by the ethics committee of west china hospital, sichuan university (id: 2020-254). we provided an online written informed consent at the beginning of the online questionnaire. the survey started after the participants agreed to participate in this study and filled out the informed consents. all participants were informed that they had the right to withdraw from this study at any time. not applicable. early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia covid-19: too little, too late? who. coronavirus disease 2019 (covid-19) situation report evaluating life events and chronic stressors in relation to health: stressors and health in clinical work mental health and psychosocial problems of medical health workers during the covid-19 epidemic in china the mental health of medical workers in wuhan, china dealing with the 2019 novel coronavirus 2019-ncov epidemic: address mental health care to empower society relationship between anxiety and burnout among chinese physicians: a moderated mediation 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during the covid-19 outbreak perceived social support and mental health among single vs. partnered polish young adults functions of loneliness, social support, health behaviors, and stress in association with poor health tribute to healthcare operators threatened by the covid-19 pandemic protecting the mental health of healthcare workers during the covid-19 emergency publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors declared no conflicts of interests.received: 12 july 2020 accepted: 28 october 2020 key: cord-033287-24zkbi3z authors: ali, sana title: combatting against covid-19 & misinformation: a systematic review date: 2020-10-07 journal: hu arenas doi: 10.1007/s42087-020-00139-1 sha: doc_id: 33287 cord_uid: 24zkbi3z accompanied by false information, mass media content is hindering efforts to cope with the current outbreak. although the world health organization and other concerned bodies are notified regarding misinformation, myths and rumors are highly prevalent. this paper aims to highlight the misinformation and its potential impacts during the covid-19 by using the systematic review approach. the researcher randomly selected n = 35 research articles published from 2015 to 2020, witnessing the misinformation as a major concern during previous endemics and the current covid-19 pandemic. myths and rumors through traditional and new media platforms cause xenophobia, lgbt rights violations, and psychological disorders among the masses. despite the efforts made by the world health organization, much more is required to nullify the impacts of misinformation and covid-19. therefore, the researcher recommended improved global healthcare policies and strategies to counteract against misinformation to mitigate the impacts of covid-19. corona virus is a threatening respiratory disease that has been described more than fifty years ago, causing various diseases in animals, including gastroenteritis, damaging the central nervous system, and respiratory system (weiss and navas-martin 2005) . however, it is only linked with damaging the respiratory system leading to death (van der hoek 2007) . one of the most prominent outbreaks of severe acute respiratory syndrome (sars) can be traced back in 2003 with an ecological origin in bats and affirmed that the virus does not have any laboratory origins (who 2020), while middle east respiratory syndrome (mers-cov), also raised as one of the most acute respiratory diseases (world health organization 2014) . many studies also found that these viruses affect the animals and transmit to humans, for instance, sars-cov-1 first infected the cats and then transmitted to humans. likewise, middle east respiratory syndrome (mers-cov) was found in camels and transmitted to humans (who 2020) . the available genetic sequence data showed a close between viruses found in camels also found in humans (world health organization 2014) . therefore, on december 31st, 2019, the world health organization was formally notified regarding a cluster of pneumonia cases in wuhan, china. ten days later, the world health organization again informed about 282 confirmed cases in the neighboring countries, including japan, thailand, and korea. twelve people were in critical condition, 51 were hospitalized due to severe illness, and six were died (chaplin 2020) . during january 2020, a total of 2,798 cases of corona virus had been reported worldwide. besides, several travel-related and isolation cases were reported from the united states, vietnam, austria, and korea. as of january 28th, more than 80 deaths were also confirmed in china (cortellis 2020). as a result, the world health organization declared it a global health emergency and introduced several healthcare protocols to mitigate its potential impacts (baumeister 2019) . similarly, the covid-19 outbreak also raised many social and economic challenges worldwide (j. wang and wang 2020) . also, the vaccine is yet not developed, which further worsens the situation (cortellis 2020) whereas, unicef (2020) considers taking all the preventive measures as an only immunization to mitigate the virus transmission. for this purpose, media platforms realized the need to educate the people to bring the positive attitudinal changes as mass media are the essential resources to supply credible information (zhong et al. 2020 ) however, combating rumors and myths regarding corona virus is a major challenge for media today. for instance, fox news faced criticism for spreading particular misinformation and false beliefs regarding the pandemic as hannity and tucker carlson tonight were the two most-watched shows framing the pandemic as a part of president trump's political agenda (bursztyn et al. 2020) . in this context, there are four main areas where people seek information but are highly accompanied by rumors and false information (geerdink 2020) (i) transmission and the symptoms of the disease, (ii) cure and prophylactics, (iii) origins and causes (iv) impacts and effectiveness of policies designed by healthcare organizations (culp 2020) . figure 1 below illustrates the primary sources of infodemic that can make pandemic worse and even more challenging. in february 2020, the world health organization affirmed the covid-19 pandemic accompanied by misinformation (who 2020). according to colomina (2020) , one of the significant differences between covid-19 and previous outbreaks is that now fears are immediately viralized to provoke confusion and uncertainty. in this regard, social media platforms are mainly disseminating false information along-with traditional media resources. although increased access to digital media platforms facilitated exponential access to information during the current pandemic, several fabricated stories are shared without quality checking and background (pan american healthcare organization, 2020). the rapid spread of the corona virus during the past couple of months led to several conspiracy theories prevailing through online resources with a common theme that virus is artificially created according to a particular agenda. this information was disseminated initially from unknown social media accounts and engaged more than 20 million people worldwide (mian and khan, 2020) . as the world health organization warned about misinformation due to an independent media usage, today, people are finding it hard to search for a reliable source of information, hindering the response efforts causing severe damage to the struggle for mitigating the outbreak (article 19 2020). as noted by bontcheva (2020) , both misinformation creates confusion regarding scientific contributions to counteract against covid-19. direct transmission adversely affects every individual and society on this planet, causing more harm and destruction during the current outbreak. thus, this study supports the existing literature concerning misinformation and its potential impacts, especially during the current covid-19 pandemic. review studies are unique as they authenticate the previous studies and provide more ideas for future research on the same topic (young 2017) . therefore, in the third section, the researcher discussed relevant studies witnessing information and their potential impacts. in the fourth section, the researcher discussed the steps are taken up by the world health organization, united nations, and other concerned bodies to mitigate the misinformation and further made the conclusions. finally, in the last section, study, contributions and limitations are mentioned along-with the relevant recommendations. recent trends in mass media ecosystems raise critical concerns regarding misinformation and audience susceptibility to contain it. as compared to past, misinformation is more capable of rapid dissemination due to audience-centered social media platforms. along with traditional media channels, online platforms are a subtle source of misinformation that further worsen the situation (lazer et al. 2017) . however, misinformation is not the result of sub-standard media practices, instead, it results from poor media practices. nevertheless, poor practices misinformation leak into real news media practices, and for this reason, today, media resources are confronting the risk of "being drowned by cacophony" (ireton and posetti 2018) . in this regard, wojczewski et al. (2015) examined the portrayals of local healthcare crises and healthcare services in ugandan newspapers. the researchers utilized the qualitative approach and selected two popular newspapers in uganda. results revealed that although newspapers published several news reports during the designated period, they attributed the healthcare issues to weak government, corruption, and lack of attention towards the healthcare management system. therefore, the researchers concluded that the reports were narrowly targeting political entities and less concerned about the health wellbeing. gollust et al. (2019) further addressed misinformation in televisions as a result of agenda-setting and causing severe threats to local healthcare systems and undermining ongoing health-wellbeing efforts. the researchers cited the example of cancer-based news reports on the us news media channels and highlighted how most of the news and programs were based on cancer, neglecting other diseases, including hiv. this excessive exposure to the single health issue also contained rumors, myths, and false information about cancer, diagnosis, and treatment in the past. also affirmed by ophir (2019) , as he investigated the american newspapers' coverage of three famous endemics in the past, including zika, h1n1, and ebola. the researchers used content analysis and interview techniques and selected a sample of n = 5,006 articles from the local newspapers. findings showed that the relevant news articles mainly contained framed information, capable of spreading misinformation. after exposure to selected news articles, respondents also revealed an increased uncertainty towards the crisis and emergency risk communication (cerc) and the centers for disease control and prevention (cdc). however, critics especially describe the current period as an "era of false information" spread through digital media resources. all the media types facilitate this dissemination but new media platforms are comparatively more productive resources (y. wang et al. 2019) . the researchers also analyzed the relevant literature witnessing false information on digital media platforms. the researchers selected a sample of n = 57 research articles and found that misinformation could be easily found during the healthcare crisis, especially ebola and zika viruses. similarly, misinformation was also reported concerning cancer, hiv, and others. similarly, swire-thompson and lazer (2020) scrutinized the correlation between misinformation and online available healthcare mobile applications and social media posts. according to the researchers, during past online health misinformation, for instance, measles, mumps, and rubella vaccination cause autism among children. the systematic review of the literature also validated that digital platforms are the richest sources of misinformation. likewise, misinformation is only characterized as an organized effort to avail power, personal interest, and control over the belief system. another study to examine the misinformation through social media was conducted by ghenai and mejova (2018) . the researchers selected a sample of n = 4,212 to obtain discussions about cancer, its diagnosis, and treatment. results indicated that the rumors about cancer treatment were the main topic of discussion, containing many retweets. bold claims about different drinks and foods i.e., ginger, banana, honey, and others, were the most circulated myths about the treatment. therefore, with the value of 0.000*** (p ≤ 0.005), the researchers found a strong significant correlation between digital media and misinformation. the right to freedom of information and expression is absolute; sometimes, it is accompanied by propaganda and misinformation. an explicit example can be seen during the covid-19 pandemic, where different media platforms are found disseminating the myths and false information (article 19 2020). for this purpose, hall jamieson and albarracín (2020) examined the united states electronic news media coverage regarding misinformation. probability-based surveys during the beginning of covid-19 revealed that news reports on nbc news broadcasted accurate information and reinforced awareness behavior; however, fox news was mainly found disseminating conspiracy regarding covid-19. the misinformation mainly involved rumors i.e., cdc is exaggerating the pandemic to harm donald trump's reputation. however, according to r, d, waran (2020), besides the disease outbreak, misinformation through different media resources is also a major challenge. for many, social media platforms are comparatively more powerful to spread information. to further validate this, the researchers also investigated the extent to which social networking sites are spreading misinformation using a qualitative study approach. the researchers selected purposive sampling techniques, open-ended interviews, and systematic study methods for data gathering purposes. results revealed that respondents expressed social networking sites as containing both information and misinformation; however, due to lack of knowledge containing reliable resources, people mostly expose to unauthentic information. misinformation not only leads them to gather misinformation but also share with others through online platforms. similarly, brennen et al. (2020) examined the sources of misinformation regarding covid-19 in great britain. the researchers randomly selected social media platforms and traditional media resources. findings revealed that out of three prominent (youtube, facebook, twitter) social media platforms, twitter contains comparatively highest (59%) number of misinformation. likewise, television, compared to print media, spread more misinformation, reinforcing public engagement to disseminate false information through interpersonal communication. another study to authenticate this phenomenon was conducted by (kouzy et al. 2020) . the researches randomly selected n = 14 most trending hashtags on twitter and analyzed n = 673 tweets from individual users. results showed that total n = 153 tweets contained myths and 31% of information was also from unverified accounts, out of which 12% of accounts misinformation and decontextualized details. also investigated the role of online platforms, particularly twitter, to spread misinformation during the covid-19. the researchers used the content analysis approach and selected a random sample of n = 1000 tweets. findings showed that a majority of tweets contained false information (92.0%), but only 63.3% misinformation was retweeted. according to the researchers, these 63.3% tweets can still be very detrimental for the efforts concerning mitigation of covid-19. during the current pandemic, online platforms are easily accessible, easy to use, and are preferred mainly due to substantial public involvement. accompanied by a lack of objective information, these platforms are a significant source of misinformation and unauthentic news (accessnow.org 2020). in this regard, li et al. (2020) scrutinize the role of youtube videos for disseminating the misinformation during covid-19. the researchers randomly selected a sample of n = 145 online videos and used the content analysis technique. results revealed that the majority (64%) of online videos mostly contained misinformation i.e., myths, vaccination discovery, and decontextualization. therefore, more than one-quarter of the most-viewed youtube videos contained misinformation, and the sources were popular news platforms. aspi (2020) also investigated the chinese state media and diplomatic twitter accounts and types of information spread through them. the researchers selected a random sample of tweets during march 2020 and found that much of the misinformation was firmly related to conspiracy theories concerning disease origins and the vaccination. moreover, n = 65 of the twitter accounts were also from unauthentic resources containing retweets of trolls and myths. therefore, the number of misinformation and retweets were comparatively higher than accurate information and their spread by ordinary users. likewise, sharma et al. (2020) designed a track board to identify misinformation through different twitter accounts. the researchers gathered streaming data from march 1st, 2020 to may, 12th 2020, and found a massive number of tweets containing discussions on covid-19. results gathered from 30.80 million tweens revealed that the majority of tweets were themed on four primary topics: political bias, reliability, conspiracy, and clickbait. although the number of misinformation varied from country to country, the retweeting behavior was a primary mechanism of spreading misinformation. furthermore, laato et al. (2020) examined the extent to which online platforms are spreading misinformation during the covid-19 pandemic, and what are the potential reasons behind it? the researcher used a structured survey questionnaire and gathered responses from n = 294 respondents in bangladesh. respondents revealed that they receive and share the information without any authentication and filtration. although they know that information comes from unknown resources, they still share it as online information sharing is a typical behavior today. the researchers concluded that this information sharing behavior is the leading cause of misinformation that may bring adverse outcomes. pennycook et al. (2020) also analyzed the online information-sharing behavior during covid-19 among americans. the researchers selected a sample of n = 1600 participants and gathered data by using close-ended survey questionnaires. the results indicated that the majority of the respondents prefer to share information without validation. for them, information sharing is essential to aware the masses. however, affirmation is not considerable. on the other hand, a few respondents with critical thinking revealed that they are considerate about information sharing and do not pass on any posts without authentication. xenophobia mass media provide individual narratives to a different phenomenon, including biomedical research. narrative communication deeply affects public perception, especially during the healthcare crises (caulfield et al. 2019) . riddled with decontextualization, pseudoscience, fake news and rumors, many consider covid-19 as a result of intentionality and the personal interests as the falsity is not an only problem, but also rumors are spread by highly influential individuals even accompanied by hate speech and racism as well (geerdink 2020; colomina 2020) . these rumors are strongly associated with the stigmatization of immigrants and discrimination against them. the covid-19 pandemic's politicization is adopted by several anti-immigrant and hate groups spreading various conspiracy theories claiming the spread of corona virus as a result of migration (iiom 2020). with thousands of new cases every day, corona virus causes unprecedented disruption in human societies. due to the broader spread of misinformation, our understanding of covid-19 is still evolving. undermining all the efforts made by health experts worldwide, this misinformation is characterized by adverse outcomes, including intolerance, racism, inequality, and unhealthy behaviors (limaye et al. 2020) . in this regard, rzymski and nowicki (2020) examined whether and to what extent asian medical students face discrimination in poland. the researcher conducted a cross-sectional study and randomly selected a sample of n = 85 students from poland having asian origin. participants revealed that they are facing discrimination and isolation due to their origin. they also have to spend their time in isolation, which is adversely affecting their career development. similarly, jeung et al. (2020) analyzed the frequency of xenophobic news reports in american news media and their impacts on real-life situations from february 2020 to march 2020. the researchers conducted both content analysis and review of relevant literature (n = 216 articles) witnessing xenophobia. results indicated that the number of discriminatory news reports increased from n = 93 per day to n = 140 during march. an average of n = 16 cases is reported regarding xenophobia, which means that news reports are highly influential on real-life behavior, increasing the xenophobia among the public. according to article 19 (2020), misinformation causes anti-foreigner and anti-chinese sentiments in several parts of the globe. this misinformation can be primarily seen on the social media platform. however, traditional media also push highly discriminatory content and business communities posting online platforms signed petitions to ban the chinese customers. many conspiracy theories also attributed corona virus to jews, muslims, bahai's, and other communities, resulting in discrimination and hate crimes (united nations 2020). also, the xenophobia against chinese is prevalent among european nations. during the current health crisis, the situation hinders the dialogue between beijing and europe, amplifying significant disagreements between these two (aies 2020). also affirmed by reny and barreto (2020) , as they investigated the americans' perceptions towards asians, mainly chinese during covid-19. the researcher selected a sample of n = 4,311 american respondents and used close-ended structured questionnaires. results showed that xenophobia and anti-asian attitudes were strongly associated with the covid-19 misinformation. initially, the anti-asian attitude was low but highly increased due to a variety of myths, rumors, and decontextualization of news reports. similarly, the world health organization also declared lesbian, gay, bisexual, trans, and intersex (lgbti) communities more vulnerable during the current pandemic. due to the stigmatization and discrimination against lgbti, several individuals face difficulty accessing healthcare services. they face online hate speech and bullying at home due to the lockdown situation, hindering their fundamental human rights (unhr 2020). according to gmhc (2020), even old age lgbt individuals living in congregate facilities may also face deprivation of medical; services. healthcare professionals can refuse their treatment and consider them as potential careers covid-19 (unconscious bias). also, among many public healthcare systems, the lgbt community lacks sex and marital status, making them ineligible for the provision of healthcare services (lokot and avakyan 2020). jayaseelan et al. (2020) investigated the impacts of social media based misinformation on audience behavior during covid19. the researcher used a qualitative approach and selected a sample of n = 13 undergraduate university-level students. findings showed that students consider social media as a source of information, and most of them like to share the information with others without authentication. however, misinformation covers a significant part of these posts affecting their healthcare behavior and raises uncertainty regarding the local healthcare system. furthermore, false information about covid-19 is not a new phenomenon as many academics, researchers, journalists, and policymakers approached world health organization and emphasized that this would cause serious risk to public mental and physical health (brennen et al. 2020) . people living in isolation, risk of infectious disease, and quarantine rely mainly on media for information that is more vulnerable to psychological disorders. curiosity and fear lead them to seek information through different media platforms. in this regard, misinformation plays a vital role in undermining one's mental health by inducing fear, anxiety, and stress. misinformation also caused food insecurities among the masses with low socio-economic status, intensively exacerbated demand-supply gaps, and largely disrupted supply chain worldwide (tasnim et al. 2020) . in this regard, ravi philip rajkumar (2020) investigated the impacts of covid-19 and myths on individuals' mental health. the researcher conducted a thematic review study and found that anxiety, stress, and depression are the most prominent psychological problems during covid-19. also, these disorders were strongly associated with disturbed sleep among the public. therefore, the researcher suggested avoiding syndromal mental health concerns raised by covid-19 should be eliminated by counteracting against the misinformation and its potential resources. also affirmed by tasnim et al. (2020) as they highlighted the misinformation as an increased challenge during global healthcare emergency. misinformation mainly contains hoaxes, decontextualization, and myths about the origin and etiology of the disease-causing mental disorders among the public. the spread of misinformation is also undermining healthy behaviors and efforts to spread healthcare awareness among the masses. figure2 below provides a graphical representation of misinformation sources, types, and potential impacts. literature review studies tend to highlight existing concerns with valid argumentation. it is more like finding pieces of a puzzle which further highlights the importance of the relevant phenomenon (library 2017). in this regard, the current study also utilized a systematic review approach to retrieve suitable research investigations (habes et al. 2020 ). the researchers systematically gathered peer-reviewed published research articles from 2015 to june 2020. these articles contained diverse study methods (survey, content analysis, interview, literature review & others) and paradigm models (quantitative, qualitative) to identify the widespread misinformation and its impacts. moreover, the researcher mainly gathered articles from the top 17 journals of media, social sciences, psychology, medicine, health, humanities, and human rights from the 2018 isi web of knowledge journal citation reports according to the value of their impact factor, scopus and web of science indexation. the selected journals involved: international journal of biological science, educational research and reviews, social science and medicine, health communication, annual review of public health, and others. however, many of the citations also belong to situation reports, perspectives, policy briefs public by the world health organisation, international labour organization (ilo), and others. therefore, a total of n = 35 of the published research content was reported according to the designated criteria. the data of each criterion is given below with the relevant tables and graph: figure 3 above shows the percentage of relevant articles by year. however, it is observable that out of n = 35 research articles, the majority of misinformation related papers published in 2020 during the peak of the covid-19 pandemic. besides the healthcare challenges, misinformation also created chaos creating even more severe challenges (nguyen and nguyen 2020 ). table 1 above shows the study design of the cited articles. the studies involve experimental design, case study, review approach, and others. however, n = 8 or 23% cited articles involve policy briefs and situational reports issued by the world health organization, unesco, pan american health organization (paho), unicef, and international labour organization (ilo). similarly, according to the paradigm models, it is observable that a majority n = 13 or 37% of studies were quantitative, n = 6 or 17% were qualitative, and 46% of articles were research essays, commentaries, perspectives, policy briefs and, situational reports. table 2 above shows the different types of data collection methods in the selected literature. the majority of studies (n = 9 or 26%) utilized the media content analysis technique to investigate the potential types and sources of information. however, 31% of the articles contained policy briefs, situational reports, research perspectives, and others. likewise, the selected literature also contained an analysis of diverse types of media types. in this regard, a majority (n = 12, 35%) of studies focused on print media and social media to investigate the widespread misinformation. according to orso et al. (2020) , due to an increased number of information sources, people widely depend on mass media. during the pandemic, this dependence is creating several problems due to the rampant misinformation. mainstream media platforms mostly contain fake news and rumors. the long-standing issue of misinformation regarding different sociopolitical issues is under constant discussion. however, misinformation during the current pandemic raised many concerns regarding public health and communication (ognyanova et al. 2020) . n = 35 studies and reports explicitly witnessed rampant misinformation and its impacts on minorities worldwide (posetti and bontcheva 2020) . these results are compatible with the world health organization (who 2020), declaring misinformation as an equally challenging phenomenon (vicol 2020) . similarly, most cited studies witnessed social media as a primary source of misinformation due to increased online media dependence (ali 2019) . these results are consistent with the study conducted by brennen et al. (2020) , as they found a strong significant correlation between social media platforms (facebook, youtube & twitter) and fake news. also validated by pulido, ruiz-eugenio, et al. (2020) , as they stated that although globalization plays a vital role in spreading healthcare information, social networking platforms also contain misinformation. covid-19 is a dominant part of online discourse, and harmful, personal, and opinionated content adversely affects the current situation. misinformation is a critical risk for global health and well-being, and during the covid-19 outbreak, people are unable to find any unreliable source of information (tedros adhanom ghebreyesus 2020). likewise, much of the information we receive from social media resources are unreliable (orso et al. 2020) . the situation gets worst when users re-share the news without further confirmation (mian and khan 2020) . as noted by islam et al. (2020) , social media platforms facilitate users to share information of their choice, enjoying the freedom, and represent their opinion. this lack of control over thoughts further amplified radical thinking and claimed to be significant misinformation (tucker et al. 2018) . conspiracy beliefs raised by misinformation adversely affected the efforts to mitigate the impacts of covid-19 and minorities worldwide (barua et al. 2020) . the cited literature also witnessed these impacts, mainly resulting in xenophobia, lgbt rights violation and, several psychological disorders (ravi philip rajkumar 2020; rzymski and nowicki 2020; lokot and avakyan 2020). according to international laws, the extraordinary situation requires extraordinary measures that means many fundamental rights, including access to information, freedom to opinion, and freedom to impart the information, restrict the media resources to spread correct information regarding covid-19 (accessnow.org 2020). for this purpose, healthcare organizations and individuals are equally obligated to spread correct information and government resources (toppenberg-pejcic et al. 2019) . to counteract against the impacts of misinformation, it is essential to: however, as both traditional and digital media platforms are accessible today, it is difficult to curb the misinformation. especially interconnected-ness through new media and mobile technology is identifying the resources, and mitigating the impacts of misinformation are the significant challenges (sharma et al. 2020) . particularly, misinformation during the current pandemic amplified more significant concerns hindering the global efforts to overcome the outbreak (pennycook et al. 2020) . this multitude of "falsehoods" has even become a matter of life and death. for this purpose, stakeholders and media organizations have the responsibility to spread accurate, objective, and appropriate news as the misinformation hinders global healthcare efforts (usaid 2020). struggle to overcome the pandemic crucially depends on the public holding appropriate beliefs and attitudes. however, the novel corona virus outbreak is mostly accompanied by false information for the strategic gain on different media platforms, posing a threat to all the ongoing contributions (bursztyn et al., 2020; aspi, 2020) . for this purpose, besides counteracting against the covid-19 pandemic, social media pandemic also needs attention as both viruses and misinformation spread at the same pace, having the same impacts and challenging the global healthcare scenario today (depoux et al. 2020) . therefore, misinformation largely plagued the scientific efforts and communities during the current pandemic. a topic like safety measures, vaccination, disease origins, and others primarily contain myths. for instance, home remedies can cure the coronavirus. according to most of them, vitamin-c and garlic intakes are the miracle remedies to treat the disease (mian and khan 2020) . similarly, corona virus can spread through eyes, coronavirus is a humanmade virus for personal interests and terrorism, receiving packages and letters from china is not safe, and others (carpha 2020). this study also highlighted the widespread misinformation on different media platforms and their impacts. the world is mostly facing misinformation as covid-19 significantly amplified the growth and spread of misinformation through different media platforms. although the role of social media is prominent, traditional media platforms are also a source of spreading rumors and false beliefs. accompanied by hate speech, online bullying, and discrimination, misinformation is a significant challenge during the current pandemic. counteracting against the misinformation can help to mitigate the impacts of corvid-19 in the short-term. it will also help us "build back better" by addressing the primary cause of the outbreak by promoting common humanity, solidarity, unity, and inclusion (united nations 2020). in this regard, accuracy nudges should be the top priority for the media platforms to counter the tide of misinformation during the current pandemic positively. depending on the existing literature, this study is capable of increasing our knowledge regarding misinformation during the current pandemic. an extensive number of cited studies are significantly witnessing the rampant misinformation as a significant social challenge. furthermore, the researcher also proposed a graphical abstract that will support future researchers to examine misinformation and its impacts, especially during the significant healthcare crisis. this study does not contain any methodology or primary data, which limits its scope. similarly, a majority of citations from american investigation is another major limitation. however, the researcher carefully analyzed the gathered data and made the relevant conclusions. therefore, to further validate this phenomenon, the researcher recommends more 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literature review on the spread of health-related misinformation on social media coronavirus pathogenesis and the emerging pathogen severe acute respiratory syndrome coronavirus coronavirus disease 2019. a & a practice portrayal of the human resource crisis and accountability in healthcare: a qualitative analysis of ugandan newspapers who -middle east respiratory syndrome coronavirus (mers-cov) summary and literature update-as of quality of literature review and discussion of findings in selected papers on integration of ict in teaching knowledge, attitudes, and practices towards covid-19 among chinese residents during the rapid rise period of the covid-19 outbreak: a quick online cross-sectional survey key: cord-029728-fwzm6c61 authors: omorogiuwa, tracy be title: covid-19 and older adults in africa: social workers’ utilization of mass media in enforcing policy change date: 2020-07-23 journal: int soc work doi: 10.1177/0020872820941748 sha: doc_id: 29728 cord_uid: fwzm6c61 dominating headlines in the last few months, global attention has been fixed on the coronavirus pandemic given its rampaging impact on social events and human affairs. more than any other groups, older adults have been disproportionately affected by the deadly contagion. this situation poses legitimate concerns to the social work profession, whose mandate is to liberate vulnerable people and promote social development. although the covid-19 pandemic has continued to take a devastating toll on older adults in the short-term, its long-term consequences may be far more profound unless urgent attention is directed to mitigate this situation. given the promulgation of social distancing and shutdowns among a number of african countries, many social workers have found it increasingly difficult to address the difficulties faced by older adults. this article canvasses for the utilization of the mass media in initiating policy response to the challenges of older adults throughout the continent. commanding features over the most recent couple of months, worldwide consideration has been fastened on the coronavirus pandemic, given its rampaging sway on social events or get-togethers and human issues. more than some other gatherings, more seasoned grown-ups/elderly persons have been excessively influenced by the destructive infection. this circumstance presents authentic worries to the social work calling, whose order is to free powerless individuals and advance social turn of events. in spite of the fact that the covid-19 pandemic has kept on negatively affecting older adults, its long term impacts might be far significant except if critical consideration is taken. although studies abound as to the importance of the mass media in initiating policy change (de vreese, 2005; eveland, 2002; iyengar, 1991; jerit et al., 2006; lawrence, 2000; lee et al., 2008; schudson, 2003; walgrave and van aelst, 2006) , there is slim evidence in africa pointing towards social workers' usage of the media in policy advocacy for vulnerable groups (amadasun, 2020a; international federation of social workers [ifsw] , 2020). before considering how social workers can 'activate' this powerful but often overlooked tool, we examine the grievous effects of the pandemic on older adults in africa. studies have shown that many older adults throughout the continent are dependent on their children and relatives, as well as reliant on the informal economy (such as the agriculture and fishing industries, including engaging in petty trade and menial jobs) for survival (omorogiuwa, 2017) . customarily, families are the bedrock of caregiving to older adults, but recent development, wrought by the forces of globalization, has collapsed africa's age-long kinship system, thereby elevating the vulnerability of this at-risk group all the more (omorogiuwa, 2020) . promulgations of social distancing and mandatory self-isolation (in a bid to curtail the spread of the contagion) have resulted in a negative trade-off, affecting the livelihood of older adults. this has been exacerbated in light of emerging reports attesting to inadequacy in palliative measures (human rights watch, 2020; okojie, 2020) , including the diversion of these limited resources by affluent officials (daily trust, 2020; hassan, 2020) . suffice to assert that this situation is trenchant owing to the non-inclusion of social workers in the administration of welfare packages. furthermore, as the global economy plummets, exceeding the great recession of 2007 -2009 (gopinath, 2020 international monetary fund, 2020) , mass layoffs, including cuts in paychecks and unemployment, have ensued. implicit in the foregoing repertoire is that many families that hitherto had maintained the traditional values of kinship care may be forced to sever ties with their aged relatives and parents. equally, on perceiving the dire situation and the challenges their caregivers face, older adults may feel compelled to 'relieve' their relatives of caregiving duties. again, the largely dilapidated state of the public healthcare infrastructure suggests that many senior citizens will be unable to secure healthcare in emergency situations. this is aggravated by reports of grossly inadequate test kits, ventilators, personal protective equipment, and isolation centres -all essentials for treatment and recovery (finnan, 2020; médecins sans frontières, 2020) . disturbingly, the resultant effect of this situation is that many older adults may have contracted the virus but are unaware of such reality. this, on the whole, may spell doom for the general population. this means that, as core stakeholders, social workers have got more reasons to be worried (rightly so, since we are most affected by the pandemic) (amadasun, 2020b) as we cannot afford to lose more of our highly resourced but undervalued citizens than we already have done. on a positive note, the covid-19 pandemic has brought to the fore, more vociferously than ever, the imperative of urgent policy response to the challenges of senior citizens in africa. pointedly, these challenges, as hinted earlier, range from lack of (in some cases) and inadequate (in many cases) social protection for older adults, to insufficient geriatric healthcare institutions and community-based care. these facilities are needed in abundance throughout the continent, and they require the services of multi-professionals, including social workers. in fact, given the biopsychosocial focus of the social work profession, many practitioners would be instrumental in this regard (amadasun and omorogiuwa, 2020) . it is against this background that social workers must be at the vanguard of promoting policy change in the context of the challenges faced by older adults in africa, through the instrumentality of the mass media. given the restrictions on social gathering, social workers can drive their actions through the tripartite (figure 1 ) layer of the mass media. the overall aim of our actions should be premised on education, counselling and advocacy. via education, we can inform the public and policymakers about the plight of older adults, which is aggravated by the indiscriminate allocation of palliative measures, as well as their deprivation of access to medical care. through this role, social workers can restate their expertise in social welfare administration and reclaim their position in this regard. through the counselling role (abiodun et al., 2011; omorogiuwa, 2016) , we can consolidate the resilience displayed so far by older adults by emphasizing their strengths, while urging policymakers to step up action for service delivery. in the context of advocacy, social workers have an integral role to play and immense responsibility to assume. researchers have identified three policy fronts necessary for making an impact: ad hoc, intermediate and long-term (amadasun, 2020b; amadasun and omorogiuwa, 2020; finnan, 2020; ifsw, 2020; omorogiuwa, 2016) . in specific terms, amadasun (2020b) defined ad hoc policy action as designed to address the immediate needs of older adults, facilitated through cash transfers or in-kind services (e.g. food deliveries). intermediate policy response is aimed at evaluative action and corrective purpose (amadasun and omorogiuwa, 2020) . according to these researchers, social workers can set out to evaluate the effectiveness of ad hoc policy intervention with a view to consolidating achieved gains and/ or to making corrections in the event of shortfall in policy objectives. long-term policy response is construed as actions aimed at eliminating structural impediments (amadasun, 2020b) . in this sense, social workers should advocate for alternative means of care (e.g. community-based approach to care, not as a replacement but as a complement to existing institutional care) in order to decongest the limited and overstretched public healthcare facilities, while canvassing for investments in socioeconomic and public health infrastructures. the coronavirus pandemic has restated the necessity of urgent policy response to older adults in africa. although the impact of the mass media in initiating policy change at both micro and macro levels is well noted, social workers, as agents of social change, have scantly deployed this channel to working with older adults in africa. this article has underscored the imperative of employing the mass media in (1) supporting older adults, (2) raising awareness about their challenges and (3) engaging in policy change through investments in social protection programmes and alternative means of care to older adults. taken together, it is believed that social workers can play a pivotal role in improving the social conditions of older adults in africa, not only during the pandemic but also in its aftermath. print: writing opinion pieces in major national and local tabloids electronic: engagement in talk shows and utilizing jingles in national and local tv and radio stations social: employing internet channels (e.g. youtube, skype, zoom, hashtags, etc.) furthermore, this study has significant implications for social workers in the international arena and in healthcare settings. using the mass media, social workers can help empower the older adults not only in africa but also in other parts of the world, by striving to understand cultural diversity, appreciate cross-cultural knowledge and be open to indigenous ways to problem-solving. healthcare social workers should be sensitive to alternative models whose focal point is built around restoration through strengths and relationship promotion instead of depending solely on the overly formalized clinical outlook and its concomitant pathological and disempowering language. drawing on service-users' strengths by promoting collaborations, story-telling and knowledge sharing, especially in a group context, is one way practitioners worldwide can empower and help older adults recover from and/or cope with difficult times as typified by the current pandemic. the author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article. the author(s) received no financial support for the research, authorship and/or publication of this article. tracy be omorogiuwa https://orcid.org/0000-0002-8675-7180 counselling services for remediating the biopsychosocial challenges of the aged in nigeria social work for social development in africa social work and covid-19 pandemic: an action call coronavirus and social work: blueprint to holistic intervention nigeria: adamawa government, apc trade words over diversion of palliative news framing: theory and typology news information processing as mediator of the relationship between motivations and political knowledge lack of covid-19 treatment and critical care could be catastrophic for africa the great lockdown: worst economic downturn since the great depression federal government wants citizens to report diversion of palliative resources nigeria: protect most vulnerable in covid-19 response: extended lockdown threatens livelihoods of millions international federation of social workers (ifsw) (2020) statement on ifsw and covid-19. available online at virus outbreak will slow global economic growth this year is anyone responsible? how television frames political issues citizens, knowledge and the information environment game-framing the issues: tracking the strategy frame in public policy news framing policy debates: issue dualism, journalistic frames, and opinions on controversial policy issues covid-19 will worsen access to healthcare in burkina faso 56% of nigerians say palliatives not sufficient for individuals, businesses amid lockdown the psychosocial problems of the elderly: implications for social work practice childhood experiences: an afro-centric perspectives on child labour international social work in perspective the contingency of the mass media's political agenda setting power: toward a preliminary theory tracy be omorogiuwa is a senior lecturer in the department of social work, university of benin, with research productivity in elite journals and three flagship texts which have continued to serve students and practitioners in nigeria. key: cord-271432-pn02p843 authors: banerjee, tannista; nayak, arnab title: u.s. county level analysis to determine if social distancing slowed the spread of covid-19 date: 2020-07-06 journal: rev panam salud publica doi: 10.26633/rpsp.2020.90 sha: doc_id: 271432 cord_uid: pn02p843 objective. to analyze the effectiveness of social distancing in the united states (u.s.). methods. a novel cell-phone ping data was used to quantify the measures of social distancing by all u.s. counties. results. using a difference-in-difference approach results show that social distancing has been effective in slowing the spread of covid-19. conclusions. as policymakers face the very difficult question of the necessity and effectiveness of social distancing across the u.s., counties where the policies have been imposed have effectively increased social distancing and have seen slowing the spread of covid-19. these results might help policymakers to make the public understand the risks and benefits of the lockdown. in march 2020, the world health organization (who) named a new category of coronavirus (sars-cov-2) that has started a global pandemic, causing the disease later named covid-19. this virus is said to have existed in bats for a long time, before it transferred from bats to humans and then from humanto-human sometime by the end of 2019 in wuhan, china. the disease spreads very rapidly from human-to-human as infected people transmit the virus when contaminating surfaces by touch or via droplets from coughing and sneezing [1] [2] [3] . according to the us center for disease control and prevention (cdc), the virus often spreads unbeknownst of a host with mild or no symptoms and yet kills many in its wake. after covid-19's emergence and spread in china, it started spreading globally via international air-travel and then through community spread within its new host countries. the who declared covid-19 a global pandemic in early march 2020, and many countries' health organizations began warning about the extreme contagiousness of the disease. given that there is no effective pharmaceutical intervention against the virus and as socialization in common spaces, including the workplace, is the main source of infection, medical researchers worldwide advised early intervention in the form of strict social distancing as the most definitive tool to slow the virus' rapid spread and save thousands of lives [4] . compelled by such warnings and some early validation of the effectiveness of the lockdown in china and a few other countries, governments across the globe have been forced to resort to extreme economy-wide lockdowns of all but the most essential services. economists and data scientists around the world have already started thinking about the economic and social effects of the covid-19. in the online book economics in the time of covid-19 edited by baldwin and mauro [5] many different economic questions have been discussed by some leading economists. the book analyzes possible economic effects of covid-19, including macroeconomic effects, financial effects and travel and trade sectors effects. however, the important question that we concentrated on in this paper is: how the us consumers' decisions to adhere to the social distancing regulations are affecting the spread of the virus? for example, it has been shown that non-pharmaceutical interventions like school closures could lower the peak mortality of influenza pandemics [6] . the objective was to analyze different measures of social distancing using consumer movements from their home census blocks and to their work census blocks. this generated a good measure of social distancing for populations in the united states by each county for the last two months and allowed us to analyze the effects of the covid-19 lockdown measures across and within these counties. we connected several databases to create a complete database for our model design. social distancing measures were created from safegraph [7] "social distancing" database. safegraph's unique database provides daily mobile devices data for the u.s. and canada. this database is collected by census block group level (12 digit fips codes). the period analyzed was from february 1, 2020 to march 31, 2020. the mobile device data tracks each consumer's mobile device and provides raw device counts. the population covered in the database, and in this study, includes thousands of anonymous mobile devices' customers from all across the u.s. states and territories. the number of total devices residing in homes in the census block by 12-digit fips code defines the total number of devices. home is defined where the device spent last 6 weeks between 6 p.m. and 7 a.m. the total number of devices that did not leave their home location (geohash-7 measure) during the day defines the number of completely stay-at-home devices. full-time work location is specified if a device spent at least 6 hours a day between 8 a.m.-6 p.m., at a location other than their home location for at least 6 weeks. total number of devices at full-time work per day is provided by safegraph. next, we obtained information on distance and time spent outside the home during the time. median distance traveled from home is provided as the median distances travelled in meters by the devices from the home locations within a day (distances > 0). the database calculates the median across all of the devices (detailed description is available in [8] ). median_ home_time it is presented in minutes for all devices included in the total number of devices during the time period. safegraph calculates this variable per devices by summing the observed minutes at home across the day. then the database calculates the median of all these devices. we obtained county level non-pharmaceutical intervention (npis) data from new york times "see which states and cities have told residents to stay at home" and keystone "county level covid-19 non-pharmaceutical database" [9] . the npis include local government imposed social distancing regulations, including social distancing regulations for vulnerable persons, social distancing of the general population, gathering size limitations, closure of public venues, closure of schools and universities, non-essential services closure and lock down between january 21, 2020 and march 31, 2020. the npis data is also defined by county. county level covid-19 infections data was obtained from the centers for disease control and prevention coronavirus updates [10, 11] . the rural-urban characteristics of the county was obtained from the united states department of agriculture economic research service, rural-urban continuum codes [12] . we dropped duplicate observations from counties in wyoming and some counties from alaska for which county information was not available for any other data sources. we also dropped one single fips code for which there was some problem with data collection reported by safegraph. median distance traveled from home is measured in meter and excluded zero values. we used the daily census block-level database to create daily county level data. for the completely_home_devices it and full_ time_work it variables for the county i on day t, we took total sum of the variables by the county level. for both median_home_time it and median_distance_traveled it variables we calculated the median weighted total number of devices in the census block f for county i in t. we used stata function [aweight] in stata16. small geographical bias is possible as acknowledged by the data collectors. they tested the reporting bias and calculated it to be less than one percent and, therefore, the data is very accurate for this study. the weighted measures control for the effect of more populous counties. completely_home_devices it , full_time_work it , median_home_ time it and median_distance_traveled it variables were our social distancing measures. that is, social distancing in this study was measured by what proportion of a county's population is staying home completely; how much time they were spending indoors, versus outdoors, in public spaces like working full-time, which is critical for this analysis. further, we concentrated on social distancing measures at individual county level because we matched the above social distancing measures with county level covid-19 infections data and npis data. the complete data is detailed enough to help us to measure each consumer's physical movement between counties and to different places of work. this allowed us to create a panel measure of social distancing by each county and enabled to design a difference-in-difference analysis of the impact of the lockdowns on the rate of spread of covid-19 after controlling for all county, time and county-time fixed effects. difference-in-difference analysis estimates the effect of npis through social distancing for the counties where npis were enacted compared to non-npis enacted counties. thus we were able to filter out many unknown factors present, such as the numbers of tests done, availability of local test centers, general difference in demographic, and political and public health infrastructures across these counties, among others. all the counties with npis enacted between february 1 and march 31, 2020 served as our treatment counties. if a county did not have any npi then we considered that as a sample in the control group. we created a dummy variable, npis, which equals one if county i ordered npis on, or after day t (where day 1 starts february 1, 2020), and zero otherwise. our treatment counties were in states including new york and california, which have been extremely affected by covid-19. to analyze the effect of these social distancing measures on covid-19 cases and how this effect is working on the treatment counties comparing to the control counties, we estimated the following difference-in-difference (did) model: where t represents the day starting from february 1, 2020 and i represents the county. the ln(cases) presents the natural logarithm of the number of confirmed covid-19 cases. we added one to the raw cases, before taking the logs, to control for zeros. npi it is our treatment variable. npi it is a dummy variable, which equals one if the county imposed npis on or before date t, and zero otherwise. the parameter a 1 measures the average effect of npis for county i after it was imposed on date t. x it is a vector of interactions of the social distancing variables with the npis. the parameter l measures the mean effect of npis as a result of the social distancing in county i comparing to control counties. we also included separate county, county-time and state fixed effects in c t , time fixed effect (t) and a binary factor variable u it as the urban-rural dummy variable that is equal to one if the county is an urban county. e it is the county and time specific error term. time invariant factors of a county or state, including geographical variables, political outlook, local public health and demographic differences, state infrastructure differences, etc., were controlled in our modelling design for by the county and state fixed effects. the time fixed effects captured the time varying pan-usa variables. more importantly, the county-time fixed effects were included to take account for any local county level time varying factors, such as local temperature variances as well as the number of test centers set up and the number of tests that were being administered, etc. as a further robustness measure, we clustered the standard errors at the county level. we re-estimated equation 1 with various lags. we present the daily change in the natural logarithm of the confirmed number of cases [ln(cases)], daily number of completely stay at home devices and daily median time spent at home (minutes) for each day during the duration of our study, in figure 1 (a, b and c) . figure 1a shows the highest affected states from the database, and it represents a sharp increase in the number of cases after march 4, 2020 with california and new york seeing the highest number of cases. figure 1b depicts that, in these highly affected states, there was a sharp increase in percentage of devices stationed completely at home after march 15, 2020 and people started spending more time indoors after march 17, 2020. together, figures 1b and 1c show that an increasing number of people started spending extended times at home after march 11. california observed the highest number of people staying at home till the 3 rd week of march, but after that new jersey was the state leading this measure. table 1 presents the summary statistics of all the variables for all counties and also by treated and control groups. as noted above, we estimated equation (1) with the right hand side treatment and interaction variables included at t, with a five days' and a fifteen days' lag. column 1 of table 2 shows that after controlling for county, state, time and county-time fixed effects, counties where npis were enacted, full time work and distance-travelled-from-home increased the covid-19 cases by 54% (p-value 0.001) and 13% (p-value 0.001), respectively. this might be because the first counties to have enacted an npi are also those which were fast becoming the infection hot spots, combining with an artefact of the nature of the contagion that it can start an infection as early as within hours of contact. column 2 of table 2 shows that at the five-day lag of the interaction variables, distance-travelled-from-home increased the covid-19 cases by 16% (p-value 0.001). full-time-work variables after npis were imposed, were no longer significant. this is an interesting finding, as it might indicate exposure to the risks from full-time work not being significant anymore, as awareness of the virus increases, and most people who are sick are staying at home or quarantining. on the other hand, distance travelled from home now might indicate visits to the stores and other points of interest where likely the virus was spreading through droplets found in the air, or the other forms of spread discussed in the introduction. after running the regressions with more days of lags for the interaction variables, we found significant negative effects of time-spent-at-home at the fifteen-day lag for the counties with npis, as well as significant positive effects of npi*full-time-work and npi*distance-travelled-from-home in the treatment counties compared to control counties. time spent at home decreased covid-19 cases by 49%, 15 days after npis were enacted compared to control counties (column 3). after 15 days of enactment of the npis, the effects of full time work and distance travelled from home on covid-19 infection increased to 84% and 25% (compared to 54% and 13% immediate effects). we have repeated the estimation with further days of lags, and found similar results till the 17 th day lag. but given that much of the npis were enacted towards the end of our sample period, means we lose samples very quickly and the significance of the estimates disappears after the 17 th day. figure 2 presents the effect on npis on the covid-19 cases across two counties. the red line presents the change in cases for the county (e.g., la county, ca) where npi was enacted earlier and the blue line represents the change in covid-19 cases for the county (e.g., jefferson county, al) where npi was enacted later in the march. covid-19 has quickly made us realize that each of us, as socially responsible agents, have a major role to play in this difficult time. yet, we also realize that we know very little about the nature of the control of the covid-19 so far within the u.s. and globally. active research is going on around the world to find a cure and vaccination for this deadly virus. however, it will probably be months before we could see any viable and effective vaccine for the covid-19. therefore, understanding the control measures of the viral disease is the most important question for the world at this current time. non-pharmaceutical control measures against infectious diseases have been used throughout mankind's documented history. these measures have included school closure, as discussed and implemented for seasonal influenza pandemics [6] . the earliest literature studying the combined effect of quarantine, school closure, and workplace distancing on covid-19 infections include the rev panam salud publica 44, 2020 | www.paho.org/journal | https://doi.org/10.26633/rpsp.2020.90 note: table 2 presents the effect of social distancing on log(covid cases) by county. explanatory variables are the interaction variables. robust standard errors are shown in the parenthesis. ***, **, and * denote 99%, 95%, and 90% levels of confidence. npi, non-pharmacological interventions cross-country study [13] and a study based specifically on singapore [14] . both these studies found a negative effect of npis on covid-19 infections. china also proved that aggressive quarantine measures can reduce the spread of the virus, but literature [15] suggests that the same mechanism might not work for other countries. therefore, the estimation of the effect of npis through social distancing for the u.s. offers crucial insights. the u.s. is currently facing an increasing threat of infection, combined with the dilemma of the process of reopening the economy and risking thousands of lives to covid-19 infections. this paper contributes to this pandemic literature by analyzing the exact lagged effect of the social distancing on the covid-19 spread in the u.s. population. the novelty of the study is that it analyzed the u.s. populations' social distancing decision at the individual consumer level and estimated the impact of social distancing on the covid-19 spread for the county. this analysis is disaggregated and an advancement over the literature which shows that social distancing, has a negative effect on the covid-19 spread for the us population at the aggregate level [16] . this study had some limitations. not all population use cell phones, and the social distancing data is collected from the cell phone data by safegraph. a new survey conducted by the pew research center shows that 95% the u.s. population own some kind of a cell phone and 81% own a smartphone [17] . however, the sample do not represent 100% of the population and if the cell phone is switched off when the person is at home or goes out of the house for a short duration and the cell phone does not ping, then the observation will be missing from the database. given the vast coverage of the data, we are not concerned that the results will be influenced with this small bias. in future studies, it will be interesting to include additional measures of social distancing by the points of interest visits and the durations of these visits by consumers. for example, the visit to the grocery store, shopping malls, commercial establishments, airports or other locations affects the covid-19 infections differently. this is outside the scope of this paper but, if undertaken, this analysis will provide a complete picture of how social distancing in different segments of the economy is affecting the public health. this paper analyzes the u.s. consumers' decisions to adhere to the social distancing regulations and the effectiveness of social distancing on covid-19. as people stay at home it can reduce the spread of the virus by 49% after two weeks of the social distancing decision, and as people start working fulltime it increases the spread of the virus by 84% within two weeks. this result is close but more accurate to the prediction in the literature [18] that school closure and other npis reduce the covid-19 cases by 60%. we conclude that as people spent more time at home; did not work full-time; and, traveled less distance from home it reduced covid-19 infections for the county with about a two weeks lagged effect. social distancing is important in controlling the infections and it is important to encourage these non-pharmaceutical intervention within each county. author contributions. tb received the original data. tb and an planned the analysis, analyzed the data and interpreted the results. tb and an wrote the paper. all authors critically revised the paper, reviewed and approved the final version. the rev panam salud publica 44, 2020 | www.paho.org/journal | https://doi.org/10.26633/rpsp.2020.90 datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. centers for disease control and prevention. how covid-19 spreads the sars-cov-2 outbreak: what we know prevalence of comorbidities in the novel wuhan coronavirus (covid-19) infection: a systematic review and meta-analysis global infectious disease surveillance and health intelligence economics in the time of covid-19 closing the schools: lessons from the 1918-19 u.s. influenza pandemic safegraph detailed data manual the new york times coronavirus stay at home order centers for disease control and prevention. coronavirus updates usa facts, coronavirus location maps rural-urban continuum codes no place like home: a cross-national assessment of the efficacy of social distancing during the covid-19 jmir public health surveill interventions to mitigate early spread of covid-19 in singapore: a modelling study china's aggressive measures have slowed the coronavirus. they may not work in other countries strong social distancing measures in the united states reduced the covid-19 mobile fact sheet how will country-based mitigation measures influence the course of the covid-19 epidemic? lancet acknowledgments. we thank safegraph for generously providing the social distancing metrics database for this analysis, and dr. aditi sengupta and dr. ayanangshu nayak for their helpful comment on an earlier version of the manuscript. disclaimer. authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the rpsp/pajph and/or the pan american health organization (paho). anã¡lisis a nivel de condado para determinar si el distanciamiento social ralentizã³ la propagaciã³n de la covid-19 en los estados unidos resumen objetivo. analizar la efectividad del distanciamiento social en los estados unidos. mã©todos. se empleã³ un mã©todo novedoso de contacto con telã©fonos celulares (ping) para cuantificar las medidas de distanciamiento social de todos los condados de ee.uu. resultados. usando un enfoque de diferencia en diferencias los resultados indicaron que el distanciamiento social ha sido efectivo para reducir la propagaciã³n de la covid-19. a medida que los responsables de la formulaciã³n de polã­ticas se enfrentan a la muy difã­cil cuestiã³n de la necesidad y la eficacia del distanciamiento social en estados unidos, los condados en los que se han impuesto las polã­ticas han aumentado efectivamente el distanciamiento social y en ellos se ha enlentecido la propagaciã³n de la covid-19. estos resultados pueden ayudar a los responsables de las polã­ticas a hacer comprender a la poblaciã³n los riesgos y beneficios de las restricciones. coronavirus; pandemias; conducta social; cuarentena; estados unidos key: cord-005159-6agnsbyd authors: turner, bryan stanley; dumas, alex title: vulnerability, diversity and scarcity: on universal rights date: 2013-07-12 journal: med health care philos doi: 10.1007/s11019-013-9500-6 sha: doc_id: 5159 cord_uid: 6agnsbyd this article makes a contribution to the on-going debates about universalism and cultural relativism from the perspective of sociology. we argue that bioethics has a universal range because it relates to three shared human characteristics,—human vulnerability, institutional precariousness and scarcity of resources. these three components of our argument provide support for a related notion of ‘weak foundationalism’ that emphasizes the universality and interrelatedness of human experience, rather than their cultural differences. after presenting a theoretical position on vulnerability and human rights, we draw on recent criticism of this approach in order to paint a more nuanced picture. we conclude that the dichotomy between universalism and cultural relativism has some conceptual merit, but it also has obvious limitations when we consider the political economy of health and its impact on social inequality. the generic concepts of 'ethics of rights' and 'ethics of duties' (patrão neves 2009)-found implicitly in most official bioethics documents-can be viewed as two relevant ideas for a sociological study of human rights and global health policy. they identify basic human needs and socio-cultural conditions that should be safeguarded by political institutions. the fact that health is now considered a basic good within international conventions is an important point of departure for universal rights to health (unesco 2011) . the duties that are associated with these rights are also expressed by the moral obligation to develop a social contract that would achieve a modicum of social justice by for example reducing social inequalities. both dimensions of the ethics debate (rights and duties) converge on the notion of 'institution'. in sociology, the problems of developing universal institutions to achieve a civilized level of social protection, while respecting personal autonomy, lie at its core. in an effort to promote 'multidisciplinary and pluralistic dialogue' (unesco 2005) in bioethics, this article makes a contribution to ongoing debates about universalism and cultural relativism from the perspective of sociology. we argue that bioethics has a universal range because it relates to three shared human characteristics,-human vulnerability, institutional precariousness and scarcity of resources. these three components of our argument provide support for a related notion of 'weak foundationalism' that emphasizes the universality and interrelatedness of human experience, rather than their cultural differences. after presenting a theoretical position on vulnerability and human rights, we draw on recent criticism of this approach in order to paint a more nuanced picture. we conclude that the dichotomy between universalism and cultural relativism has some conceptual merit, but it also has obvious limitations when we consider the political economy of health and its impact on social inequality. the idea that different cultures produce not only different ethics and values but also vastly different ways of experiencing the world has become the dominant assumption of both anthropology and sociology. in terms of philosophical anthropology, our social being-in-the-world is deeply rooted in distinctive and separate sets of cultural practices, often referred to simply as 'habitus' (bourdieu 2000) . the implication is that we cannot assume that the experiences of sickness and disease, and experiences of the body are universal and it follows that some assumptions of western bioethics cannot be generalized. in sociology the problem of relativism occurs under the general discussion of 'social constructionism', namely that the phenomena of the social world have no consistent or permanent essence; they are always and already produced by social conditions. perhaps the classic illustration of the argument was the work of margaret lock (1993) on the cross-cultural experience of menopause in american and japanese women. she found that, while the discomforts of menopause in the united states were widely prevalent, japanese women did not experience negative symptoms to the same extent. medical sociologists therefore concluded that the social construction of menopause was at the source of its medicalization in some areas of the word. while social constructionism is a basic premise of modern anthropology and sociology, it has certain limitations in the context of rights. we defend the idea some conditions such as human vulnerability, precariousness institutions and scarcity of resources, are common to human societies and can serve as a grounding for future research in bioethics. in short we defend a position that we call 'weak foundationalism'. without rejecting cultural relativism, we argue that humans share a physical embodiment, which has significant consequences regardless of cultural variations. for example, the prospect of post-humanism is threatening to alter what it is to be human and is generating many ethical questions that appear to go beyond cultures or religious denomination; it is in this perspective that the study of embodiment in social sciences is central to ethical life (frank 2012: 395) . we also elaborate the notion of institutional precariousness that occurs in context of scarcity. the result is that over many issues we have to co-operate through mutual recognition just in order to survive. we start with the observation that cultural relativism runs up against at least two obvious counter arguments. the first is that the notion of cultural specificity is contradicted by the widespread assumption in the social sciences that globalization is the dominant form of social change in the modern world. globalism is especially evident in the fact that the world is shaped by a common technology and production system. for example, access to medical technology, international vaccination co-ordination efforts, and sharing of information through the world health organisation can be viewed as proof that most countries are to some degree part of globalized networks. while the interaction between global and local cultures often results in hybrid cultures that sociologists describe as a process of 'glocalization', there are important common processes that result in shared problems and experiences. medical anthropologists, by grasping the relativist implications of her work, can too easily ignore one of the conclusions of margaret lock's research, which was that japanese women would come to acquire menopausal difficulties as a result of globalization. this first point is supported primarily by the nature of human ageing, demographic data and considerations on the specificity of the social classification of disease. let us take two examples of the emergence of a common 'health world' with respect to globalization and health. perhaps the most important demographic revolution of the late twentieth century was the decline in female total fertility rates and the greying of human populations. this demographic change is more or less uniform regardless of cultural differences and especially religious differences. by the beginning of this century, only four countries in the world have a fertility rate above five, and half the world's population now live in societies that have fertility rates that are near or below the replacement level (macinnes and pérez diaz 2009: 150) . obviously there are important differences. china's one-child policy is very different from the demographic situation of the united states, but there are common global processes: the improvement in female education, the availability of contraceptives, rising prosperity of the middle classes and changing attitudes towards children. in association with changing fertility, there is the longer life expectancy and lower death rates that translate into a strong trend of ageing of the world's population. for most societies demography is central to various health, labour and economic policies. it would also be possible to construct a list of such shared health circumstances related to ageing-cancer, alzheimer's disease, strokes, and so forth. with globalization, there is the rapid transmission of conditions such as hiv/aids, sars, and the annual influenza outbreak. there are also more 'exotic' problems such as the arrival and spread of west nile virus to texas where 118 people died and 3,000 were infected in the summer of 2012. we can therefore legitimately argue that in the past humans lived in communities that were more or less isolated and hence diseases with geographically and culturally specific. this communal autonomy and isolation was relative. in the medieval world, the bubonic plague devastated human communities across much of europe. the modern world is very different. an outbreak of sars in east asia can reach ottawa in a matter of days if not hours. another example would be diabetes. there is a worldwide epidemic of diabetes. it is clearly widespread among urban, sedentarized and developed societies from australia to the united states, where lack of exercise, fast food and urbanization contribute to its rising incidence among young people. obviously more efficient detection and monitoring contribute to the growth of the disease, but it is also widespread among indigenous peoples from australian aboriginals to native americans. the second counter argument is the widespread, if not universal, acceptance of human rights. sociologists have suggested that the cultural contexts of moral debate are not as radically incommensurable as many philosophers suggest, and thus the process of globalization has provided a counter-balance to national and cultural diversity (mouzelis 2011). the contemporary almost universal acceptance of human rights suggests that the globalization of the principles of the declaration of 1948 can mitigate if not overcome the fragmentation and diversity of human cultures. there are of course many well-known problems with human rights, such as the difference between the acceptance and enforcement of rights (woodiwiss 2009 ). human rights began to emerge on the global political agenda in the 1970 s when growing dissatisfaction with the historic the role of states in the international order and widespread recognition of the failures of communism opened up opportunities for rethinking the role of rights in international affairs. human rights emerged as a serviceable ideology for a variety of social movements such as women's internationalism, political dissidents in poland and hungary, and as the basis of global ngo activity. the presidency of jimmy carter, who in his inauguration in 1977 declared an absolute commitment to human rights as the basis of american foreign policy, was also an important development. however, the critical turning-point occurred when academic lawyers came to embrace human rights as the normative framework of international law. these lawyers, who began to question the prevailing realist doctrines of international relations theory, embraced human rights as part of their core business (moyn 2010) . one standard argument against human rights has been that they are western and individualistic. but even this argument has lost a lot of traction. the so-called 'asian values debate' has more or less disappeared. at one stage both mahatir in malaysia and lee kwan yew in singapore sought to ground a view of human rights in confucianism with its emphasis on the family, order and respect, but for critics of these societies such values were thought to be a screen to hide the authoritarianism of their respective regimes (kamaludeen and turner 2012) . although the spread of human rights is far from complete, there is a growing network of international law that is binding on nations. the united nations convention on the law of the sea (1982) is a significant illustration of this development (charney and smith 2002) . the growth of legally binding relations within the european community has also been seen by legal scholars as an important example of legal internationalism. for example in 1951 the treaty establishing the european coal and steel community made provision for an independent court, the court of justice, to interpret and enforce of the treaty's provisions. another example is the creation of the european court of human rights in 1959. these international legal relations have multiplied with juridical globalization in clear recognition of the need to develop a set of universal norms to address global concerns relating to major issues, especially the environment (charney 1993) . in addition, important normative instruments developed in bioethics and human rights over the last decades (e.g., declaration of helsinki, belmont report, european convention on bioethics, universal declaration of bioethics and human rights) have identified a number of shared human conditions that should be preserved through political means. the notion of shared vulnerability-that is commonly used in bioethics as an answer to relativistic claims in health policy-is a good example in this regard. generally speaking, the notion of vulnerability holds two meanings. first, the word refers to a universal and persistent character of human beings (e.g., kottow 2004; luna 2009; patrão neves 2009; ruof 2004) . in some respect, it holds an ontological priority over other bioethical principles (solbakk 2011) . second, it holds a more variable status, which is dependent on a sociocultural context. socioeconomic inequalities increase vulnerability, and humans thus become vulnerated and, as a consequence, more susceptible to disease and shorter lives (kottow 2004) . essentially, global rights institutions and conventions protect humans because they are vulnerable. the arguments invoking a 'bioethics of protection' or a 'duty to aid' often put forward the significance of international solidarity as an answer to health inequalities (e.g., schramm and braz 2008; london 2005) . as stated in a recent report of the international bioethics committee: ''vulnerability might provide a bridge between the moral 'strangers' of a pluralistic society, thereby enhancing the value of solidarity rather than mere individual interest'' (unesco 2013: 2). economic development does not automatically reduce the vulnerability of every sector of society, and hence there is a continuing need for basic forms of protection. vulnerability, diversity and scarcity 665 with respect to recent biotechnological developments, various treaties and conventions on the integrity of the human species testify to the existence of a global risk society. in 'protecting the endangered human ' annas, andrews and isasi (2002) suggest an international treaty prohibiting cloning and inheritable alterations in response to species altering technology: 'prevention … must be based on the recognition that all human are the same, rather than on an emphasis on our difference ' (2002: 136) . we believe that sociological arguments about globalization and human rights can contribute to philosophical debates in bioethics since the empirical findings of sociological research have an obvious bearing on bioethics and health policy. however we do not want to present a counter argument in terms of various empirical examples. we need to develop our position at a much more fundamental and conceptual level. these examples from our discussion so far indicate that what human beings share in common, even when they are profoundly divided by culture and religion, is their ontological vulnerability. this point has been emphasized in vulnerability and human rights, in which turner (2006) argued from a sociological perspective that the concept of vulnerability, which is derived from the latin vulnus or 'wound', recognises the corporeal dimension of human existence, namely our embodiment; it describes the condition of sentient, embodied creatures, who are exposed to the dangers of their natural environment, and who are conscious of their precarious circumstances. our vulnerability signifies our capacity to be open to wounding, and therefore to be open to the world. this theme of human vulnerability clearly has strong religious connotations. it can be easily related to the christian tradition the symbol of which is the cross of jesus. but it can also be recognized in the teachings of the buddha. in a discussion of the buddhist idea of dukkha or suffering, robert bellah (2011:532) notes that it can also be translated as meaning that life is 'unsatisfactory'. one reason life is less than satisfactory is because we experience it as transient and tragic. he concludes that 'fundamentally it is the recognition of the vulnerability and fragility of life' (bellah 2011: 532) . one might also relate this concept of human vulnerability to the shi'ite tradition of islam with its profound sense of martyrdom and suffering. these comparisons suggest that vulnerability is not cultural specific but speaks to the human condition as a shared ontology. human beings are ontologically vulnerable and insecure, and their natural environment, uncertain. in order to protect themselves from the uncertainties and challenges of the everyday world, they must build social institutions (especially political, familial and cultural institutions) that come to constitute 'society'. we need a certain level of trust in order to build companionship and friendship to provide us with mutual support in times of uncertainty. we need the creative force of ritual and the emotional ties of common festivals to renew social life and to build effective institutions, and we need the comforts of social institutions as means of fortifying our individual precarious existence. because we are vulnerable, it is necessary to build political institutions to provide for our collective security. these institutions are, however, themselves precarious and they cannot begin to function without effective leadership, political wisdom and good fortune to provide an enduring and reliable social environment. however rituals typically go wrong; social norms offer no firm or enduring blue-print for action in the face of rapid social change; and the guardians of social values-priests, academics, lawyers and politicians-turn out to be all too easily open to corruption, mendacity and self interest. nevertheless the uncertainties and contingencies of everyday life also generate inter-societal patterns of dependency and connectedness, and in psychological terms this shared world of risk and uncertainty results in sympathy, empathy and trust without which society would not be possible. all social life is characterised by this contradictory, unstable and delicate balance between scarcity, solidarity and security. in its report on the principle of respect for human vulnerability and personal integrity, the international bioethics committee notably indicates that the 'most significant worldwide barrier to improving the levels of attainment of health through health care interventions is the scarcity of resources' (unesco 2011: 29) . drawing on sociology, in recent publications we have placed greater emphasis on this problem of scarcity (especially on the political economy of scarcity), because we believe that debates about human rights have often neglected some of the basic economic problems associated with rights claims. the idea of scarcity has been a basic assumption of economics in which, considering its most generic meaning, it signifies a shortage of means to achieve desirable ends of action. a shortage of income means that i cannot purchase basic commodities to satisfy needs such as food and shelter. adam smith in the wealth of nations recognized the often negative consequences of swings between years of plenty and years of scarcity, and in the latter case for example in 1,740 workers could often be hired for less than subsistence. our arguments relating to vulnerability and precariousness also have an economic dimension by grasping the relationship between vulnerability and economic analysis of environment. in the entropy law and the economic process, nicholas georgescu-roegen (1971) argued that waste is an unavoidable aspect of the development process of modernization, and that human beings inevitably deplete natural resources and create environmental pollution. economic progress merely speeds up the inevitable exhaustion of the earth's natural resources. georgescu-roegen's theory showed that classical economics had neglected the problem of natural scarcity, thinking that technology and entrepreneurship could eventually solve the problem described by thomas malthus of population growth in relation to fixed resources. his economic theory of waste applied the ideas of alfred lotka (1925) on biology to the accumulation of capital. human beings have to rely on what lotka called 'exosomatic instruments' to develop the environment, unlike animals which depend on 'endosomatic instruments'. in some respects this distinction is an old anthropological argument. reptiles evolve wings to fly; human beings create aeroplanes. however, wings involve low entropy solutions and do not deplete natural resources; technological solutions, such as jet-propelled aeroplanes, are high entropic solutions that use up finite energy. because humans are ontologically vulnerable, they develop high entropy strategies that have the unfortunate consequence of creating a precarious environment. more importantly, the entropy law implies a pessimistic conclusion that social conflict is inevitable. because resources are scarce, humans degrade their environment, and they must consequently compete within limited space. these malthusian conditions of social conflict in modern times have been further exacerbated by the mechanization of violence and by the de-stabilising impact of new wars. we can as a result interpret social citizenship as an institutional attempt to reduce conflict through, typically modest, income redistribution in the framework of the nation state, and human rights as conflict-reducing instruments between and within states. as argued by etzioni (1993) , increased social divisions and power of lobby groups can be linked to moral relativism. although this assertion has been criticized, it shows that systems that privileges the virtues of the market and individual freedom, fail to nurture the roots of the community (turner and rojek 2001) . while recognizing the common vulnerability of human beings, as sociologists we cannot ignore the precariousness of human institutions and the basic condition of scarcity. in order to engage with other human beings as moral agents worthy of our respect, there has to be mutual recognition. this basic starting point of ethics is referred to as 'recognition ethics' (williams 1997) . in a human community, this basic act of recognition requires some degree of equality. for example, hegel's master-slave analysis takes account of the fact that neither slave nor master can arrive at mutual recognition, because the master perceives the slave as his property, while the slave is too lowly to recognise the master. hence, without some degree of social equality, there can be no ethical community, and hence a system of rights and obligations cannot function. material scarcity undercuts the roots of social community without which conscious, rational agency is always compromised. taking their cue from the critique of liberal theories of rights by karl marx (1818-1883) , sociologists have remained sceptical about human rights traditions that have no corresponding social policies to secure some minimum level of equality through strategies of redistribution such as progressive taxation (waldron 1987) . rights to individual freedoms without democratic egalitarianism are thought to be merely symbolic not real claims for recognition. without some degree of equality, however basic, bioethics can have no real purchase on the social world. recognition requires some basic redistribution. the vulnerability thesis has received some criticism because it is very relevant to some human rights but not to others. it is limited by its inability to explain the individual rights of liberalism. in fact, it is often is used to prevent excess freedom that may increase inequalities. it can also be criticised on the grounds that we do not automatically feel responsible for the suffering of others. relativism 'opens the door' to moral queuing principles in function of interest groups and political agendas. in luc boltanski's distant suffering (1999) , there has been some discussion about whether we can sympathize with those with whom we are not connected. our argument that embodiment is a valid basis for the defence the universalism of human rights is partly grounded in the notion of the ubiquity of human misery and suffering. in 1850 arthur schopenhauer opened his essay 'on the suffering of the world' (2004) with the observation that every 'individual misfortune, to be sure, seems an exceptional occurrence; but misfortune in general is the rule'. while the study of misery and misfortune has been the stuff of philosophy and theology, there is little systematic study of these phenomena by sociologists. one exception is barrington moore (1970:11) who argues in reflections on the causes of human misery that 'suffering is not a value in its own right. in this sense any form of suffering becomes a cost, and unnecessary suffering an odious cost'. in general political opposition to human misery becomes a stand-point that can transcend and unite different cultures and values. a critic might object that suffering is too variable in its cultural manifestations and too indefinite in its meanings and local significance to provide such a common, indeed universal, standpoint. what actually constitutes human vulnerability, diversity and scarcity 667 suffering might well turn out to be culturally and historically specific. those who take note of the cultural variability of suffering have made similar arguments against a common standard of disability. although one could well accept this anthropological argument on the grounds that suffering involves essentially the devaluation of a person as a consequence of accident, affliction or torture, pain is less variable. whereas bankruptcy for example could involve some degree of variable psychological suffering through a loss of face, a toothache is a toothache. if we claim that disability is a social condition (basically the loss of social rights) and thus relative, we might argue that impairment is the underlying condition about which there is less political dispute or philosophical uncertainty. in short, some conditions or states of affairs are less socially constructed than others. suffering is often, perhaps always, a threat to our dignity, which is obviously culturally variable. pain by signalling a deeper somatic malfunction is a threat to our existence. yet another criticism is the medical technology paradox. the more medical science improves our global health condition, the less vulnerable we are. therefore technological progress could make this vulnerability thesis historically specific. in principle if we live longer, because we have become less vulnerable with advances in medical technology, then the relevance of human rights might well diminish. this paradox however helps us to sharpen our argument, which is that we are human, because we are vulnerable. the irony of medical advances is that we could only finally escape our vulnerability by ultimately escaping from our own humanity. technological change threatens to create a post-human world in which, with medical progress, we could in principle live forever. this criticism presents an interesting argument, but there are two potentially important counter-arguments. the first is that, if we could significantly increase our life expectancy, then we would live longer but in all probability with higher rates of discomfort and disability. the quantity of life might increase in terms of years, but there would be a corresponding decline in its quality. a post-human world is a medical utopia that has all the negative features of a brave new world. secondly, medical improvements in the advanced societies are likely to increase the inequality between societies, creating a more unequal and insecure international order. in such a risk society, where human precariousness increases and human vulnerability decreases, the need for human rights protection would continue to be important. the prospect of living forever might require us to inhabit, in max weber's pessimistic metaphor, an 'iron cage' in which our existence is by courtesy of lifesupport machines. a post-human world would in principle require a different ethical system namely a post-human ethics (fukuyama 2004) . scarcity is nonetheless at the centre of bioethics. for many scholars, scarcity is regarded as socially constructed in the sense that it is produced by a consumer culture in which expectations are elastic and diverse. the theory of positional goods suggests that demand for status goods can be controlled only with great difficulty (hirsch 1977) . our notion of inescapable vulnerability may be questioned by the optimism often generated by medical technologies that promise to provide replacement organs, brain implants, and a wealth of interventions aims to extend life 'indefinitely'. the task of bioethics is to address the problems of scarcity in societies of abundance and to consider the consequences of medical technology that will increase social inequality. with the scarcity of resources, there is always social competition and conflict-even in the richest societies of the developed world (turner and rojek 2001) . the occupy wall street slogan-we are the 99%-may become a relatively permanent feature of social movements in this century. there are few discussions on the nature of scarcity in terms of bioethics. if scarcity itself is not a product of modernity, globalization, or ageing populations, new technologies are important factors involved in the politics of life. bioethics will need to consider its relations to humans suffering and protective institutions. geriatric technologies are bringing new standards of longevity and quality of life, and are generating new social and ethical questions. characteristics of patients such as age, capacity to pay, degree of success of medical intervention, and social value of the individual, are all deciding factors that are used to different degrees that determine access to health care in the face of scarcity (moody 2002) . the opportunity costs of massive investments of health care for older populations are also being evaluated in terms medical ethics and social justice. ageing societies are faced with the difficult questions of 'choosing who's to live', and under what conditions, by limiting resources for the very old (walters 1996) . researchers in biogerontology have revived the medical utopia of wanting to significantly extending life well beyond the current human life span, situated approximately at 125 years. whether this life extension is achievable or not is somewhat irrelevant for our discussion. however, the justifications for funding such a project have been interpreted as 'cutting through ethics' turner 2007, 2013) . our criticism of cultural relativism does not endorse a pure foundationalist approach; we recognize that societies are different and have different value systems. however, we cannot minimise the import of universalist claims because there are shared similarities between humans and potent social forces such as globalization that shape and reshape human experiences. perhaps bioethics is deemed to follow a version of the 'glocalization' model, where, on the one hand, it would acknowledge and act upon the fact that globalized forces are being opposed to the legitimate resistance of local cultures, and on the other hand, it would strongly promote universal thresholds when in comes to health and human rights. our contribution to the understanding of conventional bioethics is also based in the strong assumption that there is always a struggle over scarce resources and that scarcity will continue to dominate the lives of large sections of the population, even within the wealthiest countries (bury 2000) . bioethics needs political economy. if we do not hold any firm foundationalist arguments in contexts of scarcity, we must recognize the inflation of demand for health technologies, increased competition for scarce resources and increased health inequalities. we note that our argument is somewhat similar to the position taken by hervé juvin (2010) in the coming of the body. for juvin, globalized societies are market-driven and characterized by individualism, indeterminacy, increased concerns over health and body appearance. without a strong and forceful legal framework that overrides individual investments in biomedicine, social inequalities will increase further eroding social and intergenerational relations. opposition to austerity measures in many european societies in 2012 may become a regular feature of street politics with growing unemployment and increasing inequality. indignation against visible inequality may evolve into political rage (reich 2012). furthermore, a strict opposition between universalism and cultural relativism is problematic because related forms of ethics are characterized by mutual recognition and empathy between people of different cultures. these forms of ethics also recognize cultural identity as a key component of agency, and without sufficient agency it is difficult to mobilize individuals to preserve their institutions. political anthropology has been dealing with these tensions for some time; however they are mainly framed in efforts to safeguard cultural diversity, which is quite different from the problem of sustaining human rights and bioethics. sociology has brought more attention towards increasing social inequalities. amongst other things, income inequality underlines new power struggles over life and health between the rich and the poor areas of the world. assuming there is a connection between health and wealth, relativism can nourish liberalism in biomedicine to the expense of vulnerable groups. post-humanists, for example, are transforming the discursive space in which bioethical debates are taking pace, and are proposing a detraditionalization of biomedical practices,-a process described as a moving away from nature and tradition that is essentially market-driven (giddens 1995) . this opposition to 'tradition' is radically changing the foundations of a politics of life. contemporary health care systems and research policies are faced with ethical questions that are derived from the relationship between the 'infinite demand' for health care services and the 'finite systems' of institutions (foucault 1988) . scarcity is thus creating an 'ethic of limits' in which universal claims for global health are being challenged by various forms of relativism. in this regard, a sharper focus on social inequalities in bioethics within the on-going discussion on cultural diversity will certainly clarify universal thresholds regarding health status and reinforce key objectives of social justice that are central to all major conventions in human right and bioethics. protecting the endangered human: toward an international treaty prohibiting cloning and inheritable alterations religion in human evolution distant suffering: morality, media and politics pascalian meditations. cambridge: polity press. bury, m. 2000. health, ageing and the lifecourse universal international law international maritime boundaries the life extension project: a sociological critique statecraft and soulcraft: foucault on prolonging life the spirit of community social security the varieties of my body: pain, ethics and illusion the entropy law and the economic process affluence, poverty, and the idea of a post-scarcity society. geneva: united nations research institute for social development the social limits to growth the coming of the body governing as gardening: reflections on soft authoritarianism in singapore. citizenship studies vulnerability: what kind of principle is it? medicine encounters with aging. mythologies of menopause in japan and north america justice and the human development approach to international element of physical biology elucidating the concept of vulnerability. layers not labels transformations of the world's population: the demographic revolution aging and controversies reflections on the causes of human misery and upon certain proposals to eliminate them encyclopedia, genealogy and tradition: a sociocultural critique of macintyre's three moral discourses the last utopia. human rights in history beyond outrage. what has gone wrong with our economy and our democracy, and to fix it vulnerability, vulnerable populations, and policy on the suffering of the world bioethics of protection: a proposal for the moral problems of developing countries the principle of respect for human vulnerability and global bioethics vulnerability and human rights universal declaration of bioethics and human rights report of the international bioethics committee of unesco on social responsibility and health report of the international bioethics committee of unesco on the principle of respect for human vulnerability and personal integrity nonsense on stilts. bentham, burke and marx on the rights of man introduction. in choosing who's to live: ethics and aging hegel's ethics of recognition taking the sociology of rights seriously key: cord-018024-fzjbdsg0 authors: pellegrino, edmund d.; thomasma, david c. title: the good of patients and the good of society: striking a moral balance date: 2004 journal: public health policy and ethics doi: 10.1007/1-4020-2207-7_2 sha: doc_id: 18024 cord_uid: fzjbdsg0 the relationship between the good of individual patients and the special good is examined when they are in conflict. the proposition is advanced that the ethical resolution of such conflicts requires an ethic of social medicine comparable to the existing ethic of clinical medicine. comparing and contrasting the obligations clinicians incur under both aspects of the ethics of medicine is propadeutic to any ordering of priorities between them. the suggested partition of obligations between patient good and the common good is applicable beyond medicine to the other health professions. in previous works we have held that an authentic ethic of clinical medicine must have its roots in a philosophy of medicine in which the good of the patient determines the obligations and virtues of the health professional. 2 3 4 in this essay we extend the same line of reasoning to the medicine of society. we contend that an authentic ethic of social medicine must have its roots in a philosophy of society in which the common good determines the obligations and virtues of the health professional. we deem a parallel development of the ethics of individual and social medical ethics to be a requisite for any ordering of priorities between, and among, them when they come into conflict in decision making. though the ethics of medicine has traditionally centered on the obligations of physicians to individual patients, there has always been a need to recognize the ethical issues arising from the fact that medicine is always practiced within a social context. the factual basis for the recognition of this fact was late in coming in the history of medicine. 5 it is, however, especially pressing today for several reasons. physicians and nurses today practice within organizations, institutions, and systems; they are members of interprofessional health care teams and professional associations; access, availability, and distribution of health care has become a question of justice, and fairness; the economic, societal, and political impact of medical decisions have ethical significance, as does the conduct of health care organizations; potential be included under the same rubric. the ethics of the medicine of society, to be properly delineated, should be located within a broader context of a philosophy of society. we prefer this term to a social philosophy, which is currently used too diffusely for our purposes. 7 by a philosophy of society we mean a study of the nature, being, and existence of humans living and working together. it is studies of the organisms humans generate to fulfill their essential nature as social and political beings, beings who need society and social instruments to attain their good as humans. the locus of study of a philosophy of society may be the family, community, state, nation, profession, or even the global community. a philosophy of society begins with the question-"what is society, what is its nature, to what does it tend, and what is its telos or end?" the telos of society is ultimately the good of the persons who constitute that society, the good essential to their fulfillment of their potential as humans. this is a good that cannot be fully achieved by humans living isolated from each other. within such a philosophy of medicine the medicine of society has a specific function. that function is the use of medical knowledge to cultivate the health of the social organism by treating illness and preventing disease in its members since a healthy society cannot thrive without healthy citizens. an ethic of the medicine of society is directed to the good of the social organism, to the common good, the good shared by all and owed to all. to be sure, the ethic of the medicine of society will be shaped by the philosophy of society within which it exists. in a libertarian society conceived as a voluntary association of free individuals (gesellschaft), the ethics of social medicine will be constructed in terms of free markets, individual choice, and little or no government involvement. in a communitarian society (gemeinschaft) in which the individual is defined by the group, the ethic would emphasize just distribution of goods, controlled markets, limitations on individual freedoms, and government involvement. in each case, the well functioning of society and its members is sought. the philosophy of society that provides the framework for the ethic of the medicine of society that we espouse lies between these extremes. it is rooted in the social philosophies of aristotle and thomas aquinas. this social philosophy holds to a reciprocal view of the relations of the good society and the good person. neither has sovereignty over the other. it avoids totalitarianism, which exalts the common good above the individual as it avoids anarchism of exalting the good of the individual over the good of the whole. a truly dynamic philosophy of society recognizes the necessity of a continuously negotiated struggle to balance individual and common good. within this dynamic relationship of individual and common good, health and health care can be seen as societal goods because health is a good of human life, an essential component of human flourishing. in his politics aristotle speaks of the special care that should be taken of the inhabitants of a society. 8 in establishing a city he lists health as a first necessity. 9 his reference here is not just to providing individual care but to the public health as a common good. aquinas, likewise, takes the function of the state to be the promotion of the common good which he specifies in terms of preservation of peace, promotion of moral well being, and ensuring a sufficient supply of the material necessities of life. 10 according to aquinas the state, like society, is necessary for the development of human potentialities and its function is to provide the conditions for the good life. clearly, the conception of society set out by aristotle and aquinas is incompatible with the extremes of a libertarian, laissez faire conception of society or, on the other hand, with a marxist, all-consuming state-controlled economy. for both aquinas and aristotle the good for humans and the good for society are not determined by social preference. rather, the good is defined by natural law that sees societies and life in communities as essential for humans if humans are to develop their full potentialities as human beings. 11 neither aristotle nor aquinas could imagine the enormous capabilities of today's medicine, which when properly used, can enhance social and individual flourishing. but it is not unreasonable to assume that they would regard health and medical care as among the responsibilities of a good society toward its citizens, but not their highest good. health would be at the least a material and instrumental good for both the individual and the society. at best it would be a material necessity that the state should assure for all. health care could not be a privilege to be enjoyed only by those fortunate enough to afford it. it could not be left to the fortuitous interplay of commerce, the competitive marketplace, and the medical entrepreneur. in a good society health care is a common good as well as an individual good. herein lies the tension that is of such growing concern today when health care resources are generally regarded as limited relative to the potential benefit they offer if used optimally. that tension brings commutative and distributive justice into conflict. 12 traditionally the physician has felt ethically bound to commutative justice, i.e. the obligation to be faithful to a promise of trust that he or she will act primarily in his or her patients' best interests. but, in recent years, increasing pressure from governments, health plan administrators, ethicists, and the public have tended to add distributive justice, i.e. the preservation and conservation of social resources to the physician's ethical obligation. some ethicists and policy makers suggest that a "new" medical ethic is neces-sary, one in which the physician's ethical concern should be transferred from the primacy of the patient to the primacy of the society. 13 a further extension of this trend is to move the patient's trust relationship away from doctor to the institution. the health "system," not the physician, in effect becomes the patient's healer, advocate, and guarantor of safety. 14 our line of argument rejects these calls for a "new" ethic of medicine. it also resists trends to establish societal duties as primary for clinicians. we acknowledge that medicine as a practice, and physicians and health professionals within that practice, do have social obligations. nonetheless, these obligations can, and must, be served without sacrifice of the trust relationship inherent in the clinical encounter. we therefore distinguish the obligations of the clinician that are dictated by the ends of clinical medicine and those of the public health physician or nurse dictated by the end of the common good. the clinical relationship centers on a vulnerable, anxious, dependent, often suffering individual person. by offering to help, the clinician "professes" to possess medical knowledge that she will use for the patient's good. the clinician serves the common good by her dedication to the good of individual patients. clinicians, physicians, and nurses are de facto advocates for the good of their patients. for public health physicians and nurses the relationship is with the whole society. the end or purpose of the relationship is the good of humans as a collectivity, the common good. public health physicians act for the good of all to the extent that medical knowledge can serve that good. they are the de facto advocates for the common good. their "patient" is society and its ills. they serve the good of society's individual members secondarily by assuring a healthy community in which the individual can flourish. clinical medicine and public health medicine having different immediate ends cannot be conflated. they remain in a dynamic relationship with each other since the end of each is essential for human well-being. this is consistent with the social philosophy we have espoused above. clinical medicine and the medicine of society, however, can in exercising their obligations, each within its own domain, conflict with each other. that conflict may be generated on either side of the relationship. in the one case the undeviating commitment of the clinician on the good of his patient can conflict with societal attempts to conserve resources, impose standards of clinical care, or provide tort relief for medical error. by the same token, the efforts of those who practice the medicine of society may conflict with the pursuit of patient good by over-regulation of bedside decisions, limiting hospital access, or providing inadequate mental health care for the poor, or overburdening clinicians with paperwork that takes time from care of patients. on the social philosophy we have espoused practitioners of clinical medicine and of the medicine of society both serve a human good, each from its own perspective. when they do conflict in fact, there is need for some ethical priority setting. such a setting of priorities requires a framework in which the ethical foundation for both clinical and social medicine can be interrelated. much of the history and literature of ethics and bioethics consists of elaborations of the ethics of clinical medicine and individual patient care. similar frameworks for the ethics of the medicine of society are still in a state of development. in the next section of this essay we offer a philosophy and ethic of the medicine of society based in a definition of the ends of social medicine. first, a word about ends is necessary because we ground individual and social ethics of medicine in the ends that distinguish them. today's confusion about the ends of medicine and the need for their redefinition lies in the erosion of the classical-medieval notion of ends, their relation to the good, and the relation between the idea of the good and ethics. 15 the good is the end or telos of human activity, and the end is that for which a thing exists, that which an act is designed to bring about. ends are rooted in the nature of things themselves. they answer the question "what for?" 16 we do not impute ends to things; things are not good because we desire them. we desire them because they are good. we may put things, like medicine, to certain goals and purposes, but whether these are good or bad uses depends upon whether they fulfill the ends for which medicine exists and that define it qua medicine. aristotle and aquinas, whose line of reasoning we follow here, were concerned chiefly with the larger conception of the good for humans as the end of human activity. both structured their moral philosophies on the good as the end of human life. that end in its ultimate sense was, for aristotle, a life consistent with the natural virtues, which led to happiness. for aquinas, it was a life lived in accord with the natural and spiritual virtues that led to the beatific vision and fulfilment of the spiritual nature of humans. both aristotle and aquinas used medicine as an example of a human activity with a definable end and good, a lesser good, of course, than the ultimate good of human beings as such. they defined the final end of medicine as health, toward which the activity of medicine tended, that which made it what it was, and distinguished it from other human activities. yet health was for them a subsidiary end, oriented toward the life of an individual in society an enhancing as many of that individual's powers of fulfillment as possible. thus, in determining the ends and good of human life, and in the realm of lesser good in everyday life, ends and the good are intimately related. today, discussion of ends has been replaced by discussion of values and choices. the rights to choose and to value have become the warp and woof of bioethics, rather than a search for the good of individuals and society. iris murdoch put it this way: "the philosopher is no longer to speak of something real and transcendent but to analyze the familiar activity of endowing things with value." 17 the shift from consideration of ends to consideration of "value" choices lies at the root of confusion about social medicine and its philosophy as well. on the modernist view, social medicine should be aimed at whatever people value or choose among the sentiments of liberal society. the continuing debate about prescribing growth hormones for healthy, but smaller than average children, is an example of how social mores about size and its importance directly influence clinical medicine and public policy. the debate about the proper use of this and other capabilities of modern medicine, like so many others, will be interminable if it is not anchored somehow in a notion of the good for humans as it relates to the powers of modern biotechnology. the ongoing debates about "enhancement" versus "treatment" are an example of our society's confusion about the proper ends and uses of medical knowledge. in one of our books we defined four levels in the complex notion of the good of the patient in the clinical encounter. 18 in an analagous way we can develop a quadripartite notion of the ends and good of social medicine: 1) the first and lowest level is the medical good of society, that can result from the application of medical knowledge to cultivate the health of society as an organism; 2) the second level is the good of society as society perceives it; 3) the third level is the ontological good of society qua society; and 4) the last level is the spiritual and non-historical good, that which fosters the flourishing of the human spirit. taken together, these four levels of social good anchor the ends of medical knowledge when it is applied in a social context. the medical good of society relates most closely to the techné of medicine, nursing, dentistry, etc. it is the good determined as indicated by the current state of medical knowledge, by what is subsumed under the rubric of the standard of care. the good of social medicine is aimed at the medical good of the social organism as a whole: prevention of disease and disability, assuring a healthy environment, containing and ending epidemics, public education in matters of health, advising appropriate agencies on such matters as occupation health, safety of food and water supplies, occupational health and safety, responding to natural or man-made catastrophe, etc. in short, all those domains subsumed under the title of public health and social medicine are dedicated to the medical good of the social organism. on this view, then, the medical goods of society differ from the medical goods of clinical medicine only in scope, not in kind. the training of the health professionals at this level focuses especially upon dealing with the larger forces operating in groups and communities. the associated moral problems of medicine at this level center on the difficulties involved in adjudicating the proper balance between providing these goods for the sake of the entire community, based upon its needs, and the other levels of social goods and services beyond health, such as education, housing, etc. even in nations that provide access to health care for all, elements of distributive justice must be considered so that the health budget does not compromise the resources available for other social goods not related to medicine. in clinical medicine the medical good can actually become harmful. if it is provided solely on the grounds of clinical or physiological effectiveness, it may result in harm, overtreatment, etc. so too, the medical good or society cannot be allowed to overmaster other social goods that may matter more to communities. a good example was provided in the public discussions leading to the oregon "experiment," when senior citizens covered by medicaid chose to put resources into home visits by health professionals to check medications rather than into access to emergency room care. this was their perception of their good (our second level). yet, were they to experience a medical emergency, like a stroke, heart attack, hemorrhage, etc., emergency care might well be their first choice. in this case, the good defined by purely medical criteria conflicted with society's perception of its medical good. it is arguable whether or not this was socially the best choice. yet in the allocation of resources, the final decision rests with society and not the physician. we would argue that in this case the medical good of society was compromised. robert veatch, however, might argue that whatever society decides is a good, should be provided by health professionals. social consensus, he contends, determines the good, not the physician. 19 we think this is an error of delegation. health professionals are trained to determine the medical good of individuals and society. society may reject their choice but this it does at its own peril, just as the patient does who rejects effective antibiotic treatment from an infection. the task of the health professional is to provide information necessary for a rational policy choice. society's perception of its own good may differ for many reasons, especially in the allocation of its resources. while the final decision is a social one, the health professional must retain a personal and professional integrity as a critic of the scientific and technical content of that decision. society is, thus, not the final arbiter of the medical (scientifically indicated) good of society, just as a jehovah's witness patient does not determine the clinical medical good of receiving a blood transfusion. she deems the medical good to be a spiritual harm. however, the religious patient accepts or rejects the scientifically-based medical good for the sake of her perception of the good at a higher level. similarly, society may balance provisions of social medical good based upon higher values. 20 for example, in the current world epidemic of corona virus infection (sars), rights of privacy are seen by some as endangered by certain quarantine regulations. thus, like individual patients, society may not perceive the medical good, as defined by health professionals, as "good." "society" may prefer other good things it perceives as preferable to the health care -economic growth, the ability to compete economically with other nations, military service, public safety, liberty in personal choice and risk taking, education, housing, recreation, etc. seat belts, car seats for infants, safe driving, restrictions on hand guns, abstinence from tobacco and addictive substances, etc., have been widely promoted by the medical profession as good for the social organism as a whole. they have often been neglected in favor of freedom of choice, economics, or lifestyle preferences. we have just mentioned and given examples of how patients and societies may perceive other goods to be more important than the medical good being suggested or recommended to them, and how this dynamic is also part of the social dynamic in health care. the social medical good serves the many complex facets of what individual societies may perceive as their own good. at this level a social philosophy of medicine would be concerned with political choices, preferences, and concerns that may distinguish one society from another. here society determines the balances it wishes to provide its citizens, and its political processes should facilitate to public dialogue and decisions about that balance. although medicine is a universal discipline and is practiced world-wide, it is not the duty of the physician to make these social choices except as he or she functions as a citizen, an invited consultant, or as an agent of the government in carrying out its social policies about health care. since each country and society is unique in its demographics and customs, they will balance the social medical good in different ways. these choices are determined by interactions between and among citizens, their specific economic and natural environments, and their cultural and religious histories. just as individual patients might decide how a specific treatment fits into her life-plans, so too, society decides what elements of health care fit into its own plans for human development. all social good must ultimately be related to the general good for human societies. humans are social animals and need a healthy society to sustain their flourishing; similarly, a healthy society is not possible without healthy citizens. clinical medicine and social medicine intersect in preserving the dignity of the human person. to do so, each must respect human rationality and freedom in decision-making. to serve the good for society as society, health professionals must foster the inherent value of the person independent of wealth, prestige, education, and social position. in clinical medicine the patient is a fellow human being alongside the health professional. they are joined together at this level by bonds of solidarity, trust, and mutual respect. at the societal level, doctor and patient are united by the same bonds with the whole of society and ultimately with all humanity. it is at this third level that many of the familiar principles and concerns of biomedical ethics are philosophically rooted, such as respect for autonomy, beneficence, non-maleficence, and justice. these are principles which a society, concerned with preservation of the dignity of its citizens as humans, must assure. at this level, the qualities of justice are to be observed with respect to health care. justice here is understood as the equality of treatment of all human beings who are equally vulnerable with respect to illness and death. one of the axioms of moral medicine is that each individual person must be treated as a class instance of the human race. this axiom is applicable to both clinical and social medicine. denial of care to the poor or disvaluing the lives of handicapped persons, for example, violates their inherent dignity as human persons, not just their "share" of the health care marketplace. intentionally putting some members of society at risk presumably to help others, without their consent, as was done in radiation experiments in our country, is a violation of fundamental human rights. 21 the newly-developing efforts in bioethics to reintroduce global, environmental, and international human rights concerns would also be placed at this level. 22 thus, the first and second level, i.e. social medical good and perceived goods, must be related to the third, the good for human beings as human beings. at this level, both clinical medicine and social medicine intersect in the good end of preserving the dignity of the human person, by respecting his and her rationality and decision-making. they recognize, especially, the inherent value of the person as independent of wealth, prestige, education, social position, and other characteristics that so often serve to separate rather than unite human beings. as in clinical medicine, the patient is a fellow human being with the health professional. they are bound together at this third level of good by bonds of solidarity and mutual respect. in a more classical sense, the prima facie principles of contemporary bioethics and the universal rights of humans, as enunciated by the united nations, come together in the natural law. the good of society and the good of each person in that society are mutually re-enforcing. they link the good of man (and woman) with the good of society in a dynamic tension. they underlie the characters of the good society and the good person. at this level, justice requires that health care be treated as an obligation of a good society -as a moral obligation of a good society to its citizens. this is because health care is a universal human need -a need all humans experience if they are to lead fulfilling lives and be cared for when they are ill. each citizen, thus, has a claim on his fellows -not to health, but to care when he or she is ill. health care is in essence an obligation a good society owes its citizens in justice. the fourth and highest level of good for clinical encounters, between patient and health professional, is the spiritual good of the patient, as we have noted. 23 this is the good of the patient as a spiritual being who transcends ordinary material concerns. analogously, there is a spiritual dimension in the community itself, though it is more difficult to define. this dimension is always present, but it becomes more visible in times of crisis, for example, after a terrorist attack like that of september 11, 2001. for some thinkers, the social ethic of medicine stands or falls on the adequacy of its articulation with deeply embedded spiritual values inherent in the very notion of the community. 24 25 for loewy, the spiritual dimension is compassion that must emerge from the fact of suffering of all creatures; 26 for welie, it is the intersubjectivity of suffering and shared values that grounds the clinical encounter; 27 for jensen, it is the brotherhood of a common culture and concern; 28 and for still others, it is the solidarity with the sick and the potential for human development. for christians, generally it is the solidarity of all humans as children of the same creator. the spiritual good of a society encompasses the transcendent principles of the culture. it gives ultimate meaning to human lives. it is that for which humans will make the greatest sacrifices of other good things to preserve. from the perspective of the structures of human existence, the spiritual destiny of the human being is the highest and ultimate good. for many cultures this will mean the religious beliefs of their citizens. for example, despite the physical need to examine a pregnant woman in clinical medicine, a different method of examination might be required in some islamic societies where privacy is a religious value. or, even though a respirator may be appropriate for a patient suffering from severe trauma, for the navajo american indian, this may violate a profound religious belief about god and nature and be proscribed. 29 this is not to assert that all cultural practices should be tolerated simply because there exists a religious tradition to support them. 30 at the very least, however, efforts must be made to understand and if possible accommodate the lower order of medical good to the higher order of the spiritual good of individuals and societies. thus far we have argued that the public aspects of medicine, and the social ethics of medicine that results, may be interpreted within the same framework as that of the clinical encounter. by keeping the anchor in the clinical encounter as we have in this chapter, we tried to avoid the contemporary tendency to over-medicalize all of society's problems. physicians need not be, indeed, should not be social engineers, as the nazi experience so clearly taught us. 31 for example, domestic violence contributes enormously to emergency room admissions. clinicians have a duty to address this violence within the realm of their expertise and the clinical case. nonetheless, not all physicians need take on the public health features of this violence. otherwise their time would be consumed and their other responsibilities to those in immediate need, would be neglected. therefore, there is need for clinicians to observe a certain economy of pretension with respect to the frequent and obvious social dimension of their practice. for us this "clinical parsimony," means that a social ethic of medicine might address itself to the social issues encountered clinically. but the "patient" is now society, and the good is the public's health. the duties and obligations, the characteristics and virtues, of public health physicians are, if not the same as those that engage individual patients are at least analogous. this is not to deny that many illnesses experienced by individuals are caused by social problems, such as poverty, ignorance, poor hygiene, lack of access to safe water, and the like. 32 indeed, these broader causes of illness and disease quite rightly are the subject matter of public health and social medicine, and reflect the adequacy of the provision of health care in any society. thus, in the model of a social ethic of health care we are using the causes and effects of health and disease include social and even cultural conditions. other methodologies are clearly possible in deriving a philosophy of social medicine. some are based upon the idea of limiting clinical pretensions that has guided our thinking. but there are other methodologies that tilt the balance between individual and social concerns in favor of the latter. for many european thinkers, the focus of a philosophy of social medicine is less on its analogies with clinical medicine, and more on the power it engenders in its public relationship to both society and individual patients. 33 the starting point of these models of a philosophy of social medicine is social power, its dominance and frequent arrogance, and the need to reign it in. 34 foucault's empirical philosophy of the clinic fits this model. it is a heuristic theory that not only describes current practices, but also relates these in theory to one's own experiences of illness and repair. 35 feminist bioethics might also be seen as another form of this view, insofar as it focuses upon the power relation of gender within medicine and the vulnerabilities that arise from differences in the social status of genders. similarly, philosophies of medicine that concern the rise and power of technology would be examples of this kind of philosophy of social medicine. 36 in commenting on aristotle's on sense and the sensed object, 37 aquinas grapples with the distinction between the particular and individual in medicine and the more universal causes and effects of medicine. he notes: ...it is for the physician to consider their [universal principles of health and disease] particular principles; he is the artisan who causes health and like any art his must concern itself with the singulars that come under this project, since operations bear on singulars. 38 clinically-oriented physicians are primarily oriented to particularities. nonetheless, the "universal principles of health and disease" are discoverable, analyzable, and manipulatable by persons other than those professing to heal individuals. basic scientists, for example, are charged with, or have taken on, the laudable goals of improving the health of all human beings. furthermore, examining the structures of illness and healing are at least in part the goals of a philosophy of medicine. the individualities pursued by physicians arise from more general causes and return back, mutatis mutandis, to existential structures of human existence through the individual. a good philosophy of social medicine, then, will not neglect the centrality of the clinical encounter as the origin of questions about general causes of illness and disease, as well as the social effects of their neglect or their alteration. in this regard, aquinas notes further: health can only be found in living things, from which it is clear that the living body is the proper subject of health and disease...since it pertains to natural philosophy to consider the living body and its principles, it must also consider the principles of health and disease. ...the study of health and disease is common to philosopher and physician. but since art is not the chief cause of health, but aids nature and assists it, it is necessary that the physician take from natural philosophy the more important principles of his science, as the navigator borrows from the astronomer. this is why physicians practicing medicine well begin from natural science. 39 since the time of aquinas, of course, "natural philosophy" has developed into the whole panoply of physical and social sciences, as well as philosophies of nature and science. yet the insight about general principles arising from the living body and returning through it to common features of human existence is important if we are to avoid the trap of making medicine responsible for all social causes of health and disease. an interdisciplinary and international effort can effect eradication of certain diseases. but medicine alone cannot assure human rights in health care. it must work with other disciplines, playing its restricted role in the clinical arena while articulating it efforts with politics, law, sociology, etc., to guarantee international human rights in health care. 40 by clinical medicine, then, we mean the use of medical knowledge and skill for the healing of sick persons, here and now, in the individual physician-patient encounter. clinical medicine so defined is the activity that defines clinicians qua clinicians and sets them apart from other persons who may have medical knowledge but do not use it specifically in clinical encounters, like the basic scientist or public health physician. clinical medicine is the clinician's locus ethicus, whose end is a right and good healing action and decision for individual patients. similarly, nursing at the bedside, dentistry, clinical psychiatry, social work, etc, each has its own locus ethicus. 41 moreover, clinical medicine is the instrument through which many public poli-cies come to affect the lives of sick persons. no matter how broadly or socially-oriented we take medicine to be, illness will remain a universal human experience. its impact upon individual human persons is the reason why medicine and physicians exist in the first place. 42 using clinical medicine as the paradigm for a philosophy of social medicine does not neglect the other branches of medicine, each of which has its own distinctive end. thus, for basic scientists the end is the acquisition of fundamental biological knowledge of health and illness. this knowledge becomes a part of clinical medicine specifically when it is applied to the needs of a particular human being here and now. similarly, preventive medicine has as its defining end, i.e., the cultivation of health and avoidance of illness. hence, social medicine has its end in the health of the community or the whole body politic. when the knowledge and skills of any of the other branches of medicine are used in the healing of a particular person, then the ends of that branch fuse with the ends of clinical medicine. in clinical medicine, clinical nursing, etc., the good of the patient is the end, primus inter pares. 43 in social medicine, it is the good of society. throughout we have emphasized the primacy of the clinician's ethical responsibilities to be located in the good of his or her patient. under what conditions may this responsibility be balanced by ethical obligations to the good of society? first of all, in situations of natural disaster, just war, epidemics, and overwhelming emergency the clinician's knowledge and skill must be directed to the common good, the larger issue of social and community survival. similarly, when a patient is a threat to the community, e.g. when the patient has a contagious disease and continues to place others at risk, the autonomy of the patient is no longer inviolable. autonomy is limited when it results in the identifiable, probably, grave harm to others. the same is true of patients with hiv infection who refuse to tell their sexual partners, or an airline pilot, locomotive engineer, or crane operator whose condition poses a threat to the safety of others. in short, whenever the good of the patient, as perceived by the patient, poses a definable, grave, or probable risk to identifiable third persons, the physicians covenant with her patient is superceded by her duty to avoid a greater threat to third parties or to society at large. in ordinary circumstances the physician's implicit promise to serve his own patient is a primary obligation. but within that obligation the physician is bound to consider societal good when both good ends can be sensed simultaneously. thus, physicians are obliged to use the less expensive treatment if it is equally effective to the more expensive, even if there is some slight marginal benefit to the latter. even more crucial is the obligation to avoid misuses, abuse, or overuse of treatments or diagnostic procedures. this is a violation of the obligation of competence, which requires the use of modalities of medicine that are effective, beneficial, and not disproportionally burdensome. in the long run, the best contribution the physician can make to conserve societal resources is to practice rational, effective, scientifically evaluated medicine. this happens also to be in the interests of the individual patient as well. this does not mean that the physician should accept or assume the role of rationer or self appointed guardian of society's resources. to do so is to be in a morally unacceptable role of divided loyalty. rationing should be explicit, not implicit. it should be determined by societal and institutional authority. the physician must still inform his patient about what is appropriate treatment. she must try by all legitimate means to obtain what is needed. but the final allocation of resources at both the micro and macro levels is a social not a professional decision. when not joined in a covenant of trust with a particular patient, the physician has several obligations related to the common good. for example, physicians, nurses, and other health professionals are obliged to provide accurate, up to date unbiased technical information to policy makers, institutions, and administrators. they are required to avoid the kind of conflict of interest inherent in misleading exaggerations of benefit to advance one's favorite treatment procedure. conversely, policymakers must be wary of one expert's depreciation of a competitors claims. the expertise of health professionals must be available as a sound factual basis for the decisions of policy and law makers. without it political and economic considerations may distort good standards of care. the requisite objectivity is difficult to achieve in our health care system that is, today, commercialized and market oriented to an alarming degree. academic scientists and physicians are no less susceptible to self interest than their commercial counterparts. it is a rare research scientist who is totally free of conflict between his duties as physician and scientist, and his personal pursuit of self-interest, prestige, and power. yet, without reliable, verifiable, and accurate technical information, health care policy in the interest of the common good is impossible to design. recovery of moral, as well as scientific, credibility has become a major task for today's health professionals. the moral high road is, of course, extremely difficult to follow. without it, however the profession of medicine and the other health professions will lose what-ever moral credibility they still retain. society, in the end, will be the loser. first, because it will be denied reliable technical information upon which to base public policy. second, it will lose the example of one of the few remaining groups among which there is a substantial number who are dedicated to something other than their own self-interest. a society without an island, or two, of morally motivated professionals is a morally deprived society. this takes us to the third level at which the professional may fulfill his or her societal duties and that is a member of a professional association or society. a medical or nursing association is defacto a moral community. its members are united by a common public oath or commitment to act primarily for the benefit of those they purport to serve. they share in addition some set of moral precepts expressed in a moral code. unless these moral dimensions are explicitly rejected, society assumes that they are the ethical signatures of the professions. that professional societies today do not behave as moral communities does not erase the fact that their major ethical justification for existence is to advance the ends and purposes of the professions. if those ends and purposes are no longer moral in nature, professional associations become unions, guilds, or even the conspiracies against the public that george bernard shaw took them to be. 44 while not conspiracies, professional organizations today have become corporations, public relations agencies, and profit making organizations. their size, capital holdings, and budgets are sometimes far in excess of what is required to function as moral communities, that is, as associations of professionals acting collectively to advance the purposes of medicine or the other health professions. those purposes are focused upon the needs of sick persons or societies and not the propagation of self-interest. 45 when they behave as moral communities, professional associations provide effective means whereby health professionals could fulfill their societal responsibilities. these associations should above all be advocates for the sick. they should act collectively via public education and political action to promote a just health care system, one in which the obligation of a good society toward its members to assure access, availability, and just distribution of health care could be realized. associations of health professionals have enormous latent moral power if only they choose to use it. they can influence public opinion, and raise public moral sensitivity to injustices, but only if they are genuinely acting for the good of society and not their own profit. we appreciate how far this notion of professional associations as moral communities is at present from the realities. however, as with all things in the moral realm, we can hope that what ought to be, may in fact, come to be. finally, health professionals can fulfill their social obligations as citizens. here they can be advocates for what they believe to the elements of a just society or health care system. here they can and, of course, will differ. it is here that they can express their own preferences apart from those of their fellow professionals. but here too, their votes and political participation should be guided by a sense of social good that transcends their own selfish self interest. medicine has always existed within a social context in which the uses of medical knowledge and clinical decisions have impacted the good of society as well as the individual patient. in recent centuries the factual foundations for these interrelationships have been demonstrated. as a result, it has become clear that the social repercussions of medicine have serious ethical implications for both physicians and society. we have, therefore, examined the relationship between the good of the individual patients and the common good in an effort to define a morally sound relationship between them, especially when they come into conflict. the proposition has been advanced that a philosophy and ethic of social medicine (or the medicine of society) is required that is comparable to the existing philosophy and ethic of clinical medicine. by comparing and contrasting the ethics and functions of clinical and social medicine some order of priority can be established when they come into conflict. the implications for clinicians in the partition of their ethical obligations to both patients and society are spelled out in terms of both an ethic of clinical and social medicine. while the physician is used as the example, the implications for all other clinicians are essentially the same, within the specific ethical framework of each profession. note: this paper was being written when dr. thomasma died unexpectedly. i have retained him as coauthor although i have revised the text substantially. nonetheless, i believe he would have no objection to the changes a philosophical basis of medical practice, toward a philosophy and ethic of the healing professions for the patient's good: the restoration of beneficence in health care the internal morality of clinical medicine: a paradigm for the ethics of the helping and healing professions diseases of workers (1713), rev., trans. wilmer cave wright medical ethics: a code of institutes and precepts adapted to the professional conduct of physicians and surgeons (1803) complete system of medical polity (system einer vollstandigen medicinishcen polizey) (manheim, schwann, 1777-8) referenced in fielding h. garrison, history of medicine diseases of civilization rationing health care: conflicts within the concept of justice managed care: rationing without justice, but not unjustly 15 (ne1094a1 and book i) the imperative of responsibility: in search of an ethics for technological age metaphysics as a guide to morals for the patient's good: the restoration of beneficence in health care another example at this point would be the effort by chinese society to limit the number of children its citizens could have for the sake of reducing its ever-burgeoning population versus the desire of individual citizens to bear children consent, coercion, and conflicts of rights the lingua franca of human rights and the rise of a global bioethic for the patient's good: the restoration of beneficence in health care naming the silences: god, medicine, and the problem of suffering the human person as the image of god human dignity, vulnerability and personhood freedom and community: the ethics of interdependence the face of suffering: the philosophical-anthropological foundations of clinical ethics changing values in medical and health care decision making joseph j. jacobs on alternative medicine and the national institutes of health an example might be the practice of female castration in some african cultures. this practice has been widely criticized by bioethicists and physicians treading carefully on the moral high ground: response to 'dubious premises -evil conclusions: moral reasoning at the nuremberg trials unhealthy societies: the affliction of inequality challenges for a philosophy of medicine of the future: a response to fellow philosophers in the netherlands in the influence of edmund d. pellegrino's philosophy of the birth of the clinic; an archeology of medical perception medicine and the reign of technology technology in medicine: ontology, epistemology, ethics and social philosophy at the crossroads the basic works of aristotle preface to the commentary on sense and the sensed object autonomy and international human rights the internal morality of clinical medicine: a paradigm for the ethics of the helping and healing professions the group tended to expand the definition of medicine so broadly as to absorb or "medicalize" almost all aspects of life. such an expansion defeats any attempt to define ends. it places ends in conflict with each other and weakens any attempt to establish a hierarchy of goods among the many ends "medicine" may serve. see: i. nordin the doctor's dilemma professional medical associations: ethical and practical guidelines key: cord-255360-yjn24sja authors: o'connor, daryl b.; aggleton, john p.; chakrabarti, bhismadev; cooper, cary l.; creswell, cathy; dunsmuir, sandra; fiske, susan t.; gathercole, susan; gough, brendan; ireland, jane l.; jones, marc v.; jowett, adam; kagan, carolyn; karanika‐murray, maria; kaye, linda k.; kumari, veena; lewandowsky, stephan; lightman, stafford; malpass, debra; meins, elizabeth; morgan, b. paul; morrison coulthard, lisa j.; reicher, stephen d.; schacter, daniel l.; sherman, susan m.; simms, victoria; williams, antony; wykes, til; armitage, christopher j. title: research priorities for the covid‐19 pandemic and beyond: a call to action for psychological science date: 2020-07-19 journal: br j psychol doi: 10.1111/bjop.12468 sha: doc_id: 255360 cord_uid: yjn24sja the severe acute respiratory syndrome coronavirus‐2 (sars‐cov‐2) that has caused the coronavirus disease 2019 (covid‐19) pandemic represents the greatest international biopsychosocial emergency the world has faced for a century, and psychological science has an integral role to offer in helping societies recover. the aim of this paper is to set out the shorter‐ and longer‐term priorities for research in psychological science that will (a) frame the breadth and scope of potential contributions from across the discipline; (b) enable researchers to focus their resources on gaps in knowledge; and (c) help funders and policymakers make informed decisions about future research priorities in order to best meet the needs of societies as they emerge from the acute phase of the pandemic. the research priorities were informed by an expert panel convened by the british psychological society that reflects the breadth of the discipline; a wider advisory panel with international input; and a survey of 539 psychological scientists conducted early in may 2020. the most pressing need is to research the negative biopsychosocial impacts of the covid‐19 pandemic to facilitate immediate and longer‐term recovery, not only in relation to mental health, but also in relation to behaviour change and adherence, work, education, children and families, physical health and the brain, and social cohesion and connectedness. we call on psychological scientists to work collaboratively with other scientists and stakeholders, establish consortia, and develop innovative research methods while maintaining high‐quality, open, and rigorous research standards. the global impact of the coronavirus disease 2019 (covid-19) is unprecedented. by the 20 june 2020, in excess of 8 million cases of covid-19 worldwide had been confirmed and covid-19-related deaths were close to half a million. however, its impact should not only be measured in terms of biological outcomes, but also in terms of its economic, health, psychological, and social consequences. the covid-19 pandemic is unique with respect to the ongoing risks associated with the large numbers of infected people who remain asymptomatic, the impacts of the countermeasures on societies, the likelihood of second or third waves, and the attention it has received due to its global reach (particularly in high-income countries). the effects of the covid-19 pandemic will likely shape human behaviour in perpetuity. psychological science is uniquely placed to help mitigate the many shorter-and longer-term consequences of the pandemic and to help with recovery and adjustment to daily life. the immediate research response to covid-19 was rightly to focus resources on the transmission of covid-19, identify biologics with which to treat those infected with the virus, and develop vaccines to protect populations. however, biomedical science can only go so far in mitigating the severe negative health, economic, psychological, and social impacts of covid-19. the future availability of a vaccine currently remains uncertain; therefore, the primary weapons to mitigate the pandemic are behavioural, such as encouraging people to observe government instructions, self-isolation, quarantining, and physical distancing. even if a vaccine becomes available, we will still require changes in behaviour to ensure its effective delivery and universal uptake, so we need to prioritize research that will make the greatest contributions to our understanding of the effects of, and recovery from, the pandemic. the important contributions made by psychological scientists to understanding the impact of previous pandemics, including the ebola disease outbreak, severe acute respiratory syndrome (sars), and the middle east respiratory syndrome (mers), are welldocumented and mean we knew already a lot about public messaging and stress among frontline workers when the covid-19 outbreak began (e.g., brooks et al., 2020 , holmes et al., 2020 rubin, potts, & michie, 2010; tam, pang, lam, & chiu, 2004; thompson, garfin, holman, & silver, 2017; wu et al., 2009) . however, the unique features of covid-19, including its virulence, the large proportions of people who remain asymptomatic but may still spread the virus (centre for evidence-based medicine, 2020), the stringent lockdown procedures imposed at pace on whole societies, and its global reach mean there is an urgent and ongoing need for social science research (world health organisation, 2020) . the collective and individual responses to severe acute respiratory syndrome coronavirus-2 (sars-cov-2) and to the introduction of measures to counter it have fundamentally changed how societies function, affecting how we work, educate, parent, socialize, shop, communicate, and travel. it has led to bereavements at scale, as well as frontline workers being exposed to alarming levels of stress (e.g., british medical association, 2020; greenberg, docherty, gnanapragasam, & wessely, 2020) . there have additionally been nationwide 'lockdowns' comprising physical distancing, quarantines, and isolation with the associated effects on loneliness, forced remote working, and homeschooling (e.g., hoffart, johnson, & ebrahimi, 2020; holmes et al., 2020; lee, 2020) . however, as well as having adverse psychological effects, the measures introduced to fight the pandemic may have led to positive social and behavioural changes. most obvious are the remarkable levels of compassion and support that have developed among neighbours and within communities as well as positive changes in behaviours such as hand hygiene, homeschooling, and physical activity. therefore, in addition to mitigating the negative effects of the pandemic, it is important to understand how any positive effects can be maintained as restrictions ease. there are, and will undoubtedly continue to be, inequalities in the effects of the pandemic and its aftermath; recognizing these vulnerability and resilience factors will be key to understanding how the current situation can inform and prepare us for dealing with future crises. of course, while we, as psychological scientists, are interested in the general effects of the pandemic, we are acutely aware of the fact that these effects disproportionately impact on different groups (box 1). the issue of inequality is of central importance and runs through the research priorities that we describe below and it is a picture is emerging of covid-19 not as a single pandemic, but multiple parallel pandemics with some people facing numerous severe challenges and others experiencing few or none (williamson et al., 2020) . for those most vulnerable groups, the social, economic, and consequent psychological challenges of the pandemic are likely to be far-reaching and sustained. a clear priority for psychological scientists is to understand how best to help those in need and to consider the following factors in their research efforts. in western europe and the united states, the death rate among people with black, asian, and minority ethnic backgrounds is substantially higher than that of the general population. it is not known what is causing the disproportionate impact nor how it can be mitigated. psychological science is in a good position to explore the biopsychosocial antecedents and consequences of having a black, asian, or minority ethnic background in the context of covid-19. individuals living in poverty face disproportionate challenges in relation to education, work, income, housing, and physical and mental health. for these most vulnerable groups, the social, economic, and consequent psychological challenges of the pandemic are likely to be far-reaching and sustained. moreover, an impending financial crisis means that people who have never before experienced hardships may suddenly find themselves in precarious circumstances. a quarter of people in the uk experience mental health problems every year, with particularly high levels in young people (mental health foundation, 2020) . the changed social conditions of the pandemic may increase the severity of mental health challenges, particularly when standard (face-toface) treatment and support are difficult to access. at the same time, pregnant women and those with existing long-term conditions such as transplant patients, cancer patients, and chronic obstructive pulmonary disease patients have been designated 'extremely vulnerable' and asked to self-isolate for long periods of time with uncertainties over access to support. those individuals who have recovered from covid-19 might also have new biological vulnerabilities, uncertainty over immunity post-covid-19, and risk stigma arising from infection. individuals with disabilities, learning disabilities, special educational needs, and developmental disorders may also be more vulnerable due to the increased psychological challenges associated with shielding and self-isolation. the challenges generated by the pandemic vary markedly across the lifespan and will influence the nature of current and future psychological needs of different groups. many young people have struggled with reductions in direct social contact, decreased motivation, and uncertainty caused by disrupted training and education. adults have experienced multiple stresses as a consequence of intensified caring responsibilities, financial concerns, job uncertainty, and health conditions. for many older people, the greatest challenges have been social isolation, disruptions in access to health and social care, and coping with bereavement. in addition to the challenges surrounding age, there are emerging data to suggest that the effects of covid-19 may exacerbate existing inequalities for women. for example, women are more likely to be key workers and primary caregivers, thereby being exposed to higher levels of psychological and financial stress (fawcett society, 2020). the covid-19 pandemic is likely to have had a disproportionate impact on groups with low levels of social inclusion and/or those who traditionally have declined support services, such as people living in poverty, traveller communities, and people who are homeless. being separated from wider support networks may also be particularly difficult for those living in hostile households such as victims of domestic abuse and lgbt people living with family members who are unaccepting of their identity. many of those detained in secure settings have been exposed to marked changes in service delivery and reduced social contact, increasing their vulnerability to the psychological effects of the pandemic. surely not a coincidence that the murder of george floyd during a global pandemic prompted a global civil rights movement drawing attention to inequalities. in this position paper, informed by a group of experts and a survey (box 2), we highlight the many ways in which psychological science, its methods, approaches, and interventions can be harnessed to help governments, policymakers, national health services, education sectors, and economies recover from covid-19 (box 3) and other future pandemics (if they occur). specifically, we have identified the shorter-and longerterm priorities around mental health, behaviour change and adherence, work, education, children and families, physical health and the brain, and social cohesion and connectedness in order to (1) frame the breadth and scope of potential contributions from across the discipline, (2) assist psychological scientists in focusing their resources on gaps in the literature, and (3) help funders and policymakers make informed decisions about the shorter-and longer-term covid-19 research priorities to meet the needs of societies as they emerge from the acute phase of the crisis. the methodology we employed to develop the main research priority domains is described in box 2, and the seven priority domains are outlined below and summarized in table 2 . how does collective identification impact on social responsibility and adherence to anti-pandemic measures? one of the most striking aspects of the covid-19 pandemic has been the importance of social psychology to the outcomes. given the highly differentiated nature of susceptibility to the virus (box 1), one might have expected many (especially the young and fit) to conclude that they have more to lose than gain by observing the rigours of lockdown and other preventative measures. if they had acted on such an individualistic calculus, then far more people would get infected and far more (especially the old and infirm) would die. however, on the whole, people did not act on the basis of such narrow self-interest, and the vast majority supported the lockdown (e.g., duffy & allington, 2020) . what is more, conversely, well-functioning social support is likely to confer resilience against the negative psychological impacts of the pandemic. finally, it is important that psychological scientists consider the interconnectedness of the above factors. for example, individuals who are young and from a bame background who are also from a less affluent socio-economic background may be disproportionately impacted by the educational, economic, and other consequences of the measures taken to contain and recover from the pandemic. similarly, many of the solutions to the problems posed by the pandemic involve the use of new technologies that assume the requisite skills, access to devices, and internet connectivity meaning that the 'digital divide' will likely have been exacerbated by the pandemic (ons, 2019). this paper outlines research priorities for psychological science for the covid-19 pandemic. in april 2020, the british psychological society convened a core group of nine experts who met regularly for 4 weeks in order to develop the research priorities. the nine experts 1 represent broad areas of the discipline, namely biological, clinical, cognitive, developmental, educational, health, occupational, and social, and were assisted by a wider advisory group 2 of psychological scientists (n = 16) drawn from a range of uk higher education institutions and areas of research expertise. we also received input from two international experts. briefly, we used an iterative expert consensus procedure (e.g., merry, cooper, soyannwo, wilson, & eichhorn, 2010) to elicit and distil the judgments of experts on the research priorities for psychological science. unlike other consensus methods, which typically start with a list of priorities that are then ranked over the course of 2 or 3 meetings (e.g., fitch, bernstein, aguilar, burnand, & lacalle, 2001; mcmillan, king, & tully, 2016) , the present approach both generated and judged the priorities over 10 hour long face-to-face meetings of the core group. consensus was achieved through discussion, and the experts were encouraged to discuss with the wider advisory group and their professional networks in between meetings. given the need to establish the priorities rapidly, a lengthy consultation process or an extensive review of all relevant scientific literatures was not possible. however, a brief online survey of psychological scientists was launched early in may 2020 with the aim of ensuring that the core and advisory groups had not missed any key research priorities, and to identify the highest ranked priorities in each of the broad areas of psychology to help inform the final wider-ranging research priority domains. the online survey had two components: first, participants were asked the open-ended question, 'please can you tell us what are your priorities for psychological science research in response to the covid-19 pandemic?' second, participants were asked to rank order the top five research priorities identified by the core group in each of the eight broad areas of the discipline (i.e., biological, clinical, cognitive, developmental, educational, health, occupational, social). the survey was distributed to psychologists via heads of uk psychology department email lists, the social media outlets of professional psychology networks (including the british psychological society), and snowball email methods by the expert and advisory group members. we received replies from 539 psychological scientists representing all of the main areas of the discipline. respondents were 75.6% female, 73.8% were aged between 31 and 60 years, and 20.1% self-identified as being from a minority group. the highest ranked research priorities in each of the broad areas are presented in table 1 (see appendix for the full list of 40 priorities). as a result of the time constraints, a detailed qualitative analysis was not possible for inclusion in this paper; nevertheless, the core group gave consideration to all of the free responses provided. overall, there were differing degrees of specificity, and respondents provided numerous, additional, and wellspecified research questions. however, at the broadest level, respondents' priorities coalesced around the question of how do we address the negative biopsychosocial effects of the covid-19 pandemic? the degrees of specificity related to population (e.g., people with black, asian, and minority ethnic backgrounds, children, people with low socio-economic status, people living with long-term conditions), type of intervention (e.g., service provision, environmental/social planning), methodology (e.g., qualitative, online, survey, laboratory-based), and setting (e.g., workplace, school, prison), but there was broad agreement. perceived personal risk bears no relation to whether people adhere to government instructions: whether or not one identifies with the broader community and hence acts on the basis of the risks to the community as a whole is the key driver (jackson et al., 2020) . so, getting people to think in collective rather than personal terms is critical to controlling the pandemic (reicher & drury, 2020) . or, in the rather more forceful terms of new york governor andrew cuomo: 'yeah it's your life do whatever you want, but you are now responsible for my life. you have a responsibility to me. it's not just about you . . . we started saying, "it's not about me it's about we." get your head around the we concept. it's not all about you. it's about me too. it's about we'. how can we nurture the development and persistence of mutual aid and pro-social behaviour? the significance of such 'we-thinking' is not limited to issues of adherence and social responsibility. the literature on behaviour in disasters and emergencies (drury, 2018) suggests that the experience of common fate in such events leads to a sense of shared social identity that in turn underpins solidarity and cohesiveness between peopleeven strangers. we have seen numerous examples of 'we-thinking' in the time of pandemic, which have played a key role in sustaining people through difficult circumstances. these range from neighbours knocking on doors to see whether people need help to over three million people contributing to more than four thousand mutual aid groups across the uk (butler, 2020) . so, how can we nurture such we-thinking in order to build mutual aid in communities and ensure it endures even after the acute phase of the covid-19 pandemic is over? what is the relationship between group membership, connectedness, and well-being? there is growing evidence of the role of group membership in sustaining both physical and mental health (haslam, jetten, cruwys, dingle, & haslam, 2018) . in addition to asking in general terms about how group identities are created, sustained, or else undermined in times of crises, we also need to investigate further the interface between group processes and health during and after periods of crisis. in other words: how can we keep people psychologically together even when they are physically apart and what is the relationship between face-to-face and virtual groups in terms of their health effects? more generally, that is not to say that all research priorities were covered in the original survey. two issues in particular stood out from the comments we received. the first was the importance of dealing with inequalities and differences between groups in the experience of the pandemic. the second was the need to address the positive as well as the negative developments coming out of the response to covid-19. these were both incorporated into revisions of the paper and now occupy a much more central place than before. we are thankful to all those anonymous respondents whose comments helped improve our argument. a more rigorous, thematic analysis of these data is now available (see bps, 2020c). the picture was very similar when respondents were asked to place research priorities identified by the expert group into rank orders. that is, broadly speaking, the priorities that received the highest rankings, irrespective of area of subdiscipline, were related to the need to address the negative biopsychosocial effects of the covid-19 pandemic. box 3: psychological science: methods, approaches, and interventions to help meet the immediate and longer-term covid-19 research priorities the future research landscape will be challenging due to the ongoing physical distancing requirements; however, psychological scientists are equipped with a broad range of methods, approaches, and interventions that will allow these research priorities to be met. some examples are as follows: internet-mediated research will be an important approach utilized by psychological scientists to collect data in the immediate post-pandemic phase and at longer-term follow-ups. internet-mediated research can be reactive (e.g., online surveys, online interviews) and non-reactive (e.g., data mining, observations from screen-time apps) and can be integrated with objective assessments of behaviour as well as with biological and social markers of physical and mental health. internet-mediated research can also be used to run experiments with online software available such as gorilla, psychopy, and e-prime. recent work has summarized the range of software for building behavioural tasks, and their efficacy in being used online (sauter, draschkow, & mack, 2020) . changes in the use of research methodologies may provide a catalyst for the formation of new collaborations and training to develop research skills in the psychological science community. at the same time, trust around data security and confidentiality will need to be built between researchers and the general public from whom we sample. however, in 2018, more than an estimated 100 million people aged 16-74 years in the european union reported they had not used the internet in the preceding 3 months (eurostat, 2019) , and researchers will need to think creatively about conducting research projects remotely. for example, participants can have study materials delivered by post (e.g., salivettes for cortisol sampling or asking participants to self-sample), replacing face-to-face communication with telephone and/or video calls, and the use of personal protective equipment when collecting data. psychological therapies and behaviour change interventions can already be delivered remotely and evidence suggests that remote delivery does not necessarily mean inferior delivery (e.g., irvine et al., 2020) . urgent research is needed to translate interventions that are typically delivered in-person to telephone and online delivery modalities. psychologists are well-positioned to collect valuable qualitative data concerning people's relevant experiences, perspectives, and practices associated with covid-19, which could inform psychologybased interventions to improve well-being and social cohesion. multiple participant-centred qualitative research methods can be rapidly deployed to elicit first-hand accounts from members of different communities, including (online) interviews, focus groups, and qualitative questionnaires, focusing on the psychological and social impact (jowett, 2020) . beyond the immediate term, qualitative data can be gathered longitudinally so that insights can be generated into the experiences of diverse groups over time, identifying salient crisis points and effective resolutions. implementation science is a branch of psychological science that is dedicated to the uptake and use of research into clinical, educational, health care, organizational, and policy settings. principles of implementation science can be used to help stakeholders navigate the extensive and unwieldy psychological science research literature. to inform policymakers and support professional decisionmaking about implementation, psychological research needs to be disseminated in an accessible format. one example of a well-regarded translational system is the us institute of education sciences what works clearinghouse (https://ies.ed.gov/ncee/wwc/), which provides reviews and recommendations about evidence-based practices for professionals working in educational settings. can we learn from this in order to improve the plight of socially isolated people as we emerge from the acute phase of the pandemic? under what conditions does unity and social solidarity give way to intergroup division and social conflict? finally, in addressing the positive potential of social psychological processes, we must not forget their darker side. 'we' thinking can all too easily slip into 'we and they' thinking, where particular groups are excluded from the community and then blamedeven an important feature of the covid-19 pandemic has been requested by government to provide psychological science expertise at pace. the inclination of many psychological scientists is to begin designing a new study or conducting a systematic review following preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines, but this does not meet the needs of policymakers. it would be valuable for psychological scientists providing expert advice to acquaint themselves with the terminology and procedures that are familiar to civil servants who are more likely to have use for a quick scoping review or rapid evidence assessment (collins, coughlin, miller, & kirk, 2015) rather than embarking on a time-consuming systematic review of systematic reviews (keyworth, epton, goldthorpe, calam, & armitage, 2020) . there are many challenges involved with conducting covid-19-related research including dealing with vulnerable groups, giving due consideration to ethical concerns, as well as issues around running studies in the light of physical distancing requirements. therefore, having relevant patient and public involvement and including individuals with lived experience (as appropriate) in designing studies will be of paramount importance. psychological science has been leading the way in promoting and adopting open science principles and practices. nevertheless, psychological scientists need to ensure they balance the urgency of conducting covid-related research (during and in the recovery period) with ensuring research quality and open research practices. therefore, in order to help maintain quality, openness, and rigour, we urge researchers to endeavour to use registered reports, where possible (e.g., https://osf.io/rr/), or preregister their research hypotheses and analysis plans (e.g., https://aspredicted.org/) and make their data findable, accessible, interoperable, reusable (fair) recognizing the principle of 'as open as possible; as closed as necessary' (bps, 2020a (bps, , 2020b norris & o'connor, 2019) . moreover, we urge researchers to utilize pre-print servers, such as psyarxiv, in order to ensure their latest research findings are made publicly available rapidly and at no cost. we hope that openness will drive quality, but as yet there is no substitute for articles being peer-reviewed prior to wider acceptance by the scientific community. psychological science has responded swiftly to the covid-19 pandemic, but there is a danger of duplication of efforts and participant fatigue in the proliferation of online surveys, experiments, and focus groups that have arisen. we need to harness the ongoing efforts of psychological scientists worldwide in a coordinated effort on the scale of the large hadron collider (cern, 2009) to deliver truly evidence-based interventions to help societies emerge from the covid-19 pandemic. this will include cross-cultural research to understand why mortality rates, mitigation measures, and adherence to government instructions have differed so markedly between countries. finally, we urge researchers to register their research studies and findings on international repositories (https://osf. io/collections/coronavirus/discover). attackedfor the crisis. thus, un head antonio guterres has warned of a 'tsunami of hate' unleashed by the pandemic (davidson, 2020) . this hate and violence can take different forms: of anti-authority riots as in france (willsher & harrap, 2020) , or of racist violence against minorities as in india (mazumdaru, 2020) . in sum, insights from social psychology can be a valuable resource in a crisis; it can bring people together and generate constructive social power. but equally, it can set people apart and create problems that endure well beyond the crisis itself. it is evidently of the greatest importance to understand the processes that determine whether people unite or divide in hard timesand notably to understand the role of leadership, which has been so significant and so diverse in different countries during covid-19. work environment and working arrangements consistent with previous pandemics (e.g., rubin et al., 2010) , the work-related challenges of the pandemic have been particularly high and widely recognized for health and social what is the impact of remote and flexible working arrangements on employee health, mental wellbeing, teamwork, performance, organizational productivity, and colleague/client relationships? what is the impact of social distancing in the workplace on employee health, mental well-being, teamwork, performance, organizational productivity, and colleague/client relationships? how can organizational resilience be developed to deal with the impact of covid-19 whilst supporting employees and protecting jobs? how will the covid-19 pandemic affect children's development? how will the covid-19 pandemic affect family functioning? how do school closures influence children's educational progress and well-being? what kinds of support improve long-term outcomes for children and young people? how can support services be effectively delivered to vulnerable children and young people, families, and schools? what are the immediate and longer-term consequences of covid-19 for mental health outcomes? what changes in approaches resulting from the pandemic need to be harnessed for the future? 6. physical health and the brain does covid-19 have neurological effects on the brain with consequences for mental health? what are the psychobiological impacts of the covid-19 pandemic on physical and mental health? how do we best apply existing theories and tools to promote sustained behaviour change among policymakers, key workers, and the public/patients? how do we develop new theories and tools to promote sustained behaviour change? care workers in direct contact with patients suffering the effects of covid-19, leaving them vulnerable to trauma, fatigue, and other manifestations of chronic stress. what is unique about covid-19 is that changed working conditions and anxiety about infection have affected almost all employees, with particular challenges being faced by delivery workers, shop assistants, teachers, emergency services personnel, care home staff, transport staff, and social workers. the full economic severity of the covid-related restrictions is uncertain, although up to two million people could lose their employment in the uk alone (wilson, cockett, papoutsaki, & takala, 2020) . for those people still working, and those about to return to work, there are notable changes that will likely affect working practices in the foreseeable future. therefore, understanding the impact of the covid-19 pandemic on the work environment and new working arrangements is paramount to kick starting the economy and adjusting to daily life. what is the impact of remote and flexible working arrangements on employee health, mental wellbeing, teamwork, performance, organizational productivity, and colleague/client relationships? for many workers, particularly those in white-collar occupations, work took place entirely from home during the lockdown. it is possible that the lockdown will accelerate the general increase observed in home working practices (ons, 2019). a move to greater levels of remote working has clear economic benefits for employers (e.g., reduced estates costs). the flexibility to balance work and family life is also attractive to many employees (cf. strategic review of health inequalities in england, 2010 ). overall, the evidence points to positive benefits of remote working in terms of well-being (charalampous, grant, tramontano, & michailidis, 2019) , although these effects are not consistent. for example, it may lead to greater levels of professional isolation (golden, veiga, & dino, 2008 ). an increase in remote working will likely occur with a concomitant increase in the use of online technology to support communication and aspects of collaborative working. this has the potential to blur boundaries between work and home domains, resulting in negative impacts on well-being and productivity from work-home interference (van hoof, geurts, kompier, & taris, 2006) . greater use of technology may also be associated with different perceptual and cognitive demands that may affect productivity and wellbeing including social connections with work colleagues (e.g., mark et al., 2016) . what is the impact of physical distancing in the workplace on employee health, mental well-being, teamwork, performance, organizational productivity, and colleague/client relationships? until an effective vaccine is available, physical distancing rules will need to continue to be in place in work environments and we may experience multiple stay-at-home versus return-towork cycles. there is very little research exploring physical distancing and its effect on the general workplace, but returning to work will likely be both a welcome change and a potential stressor. while we have research from teams working in difficult and extreme environments (power, 2018; smith, kinnafick, & saunders, 2017) and research on professional isolation (golden et al., 2008) , this is an unprecedented opportunity to study adaptation across a breadth of individuals and organizational settings. how can organizational resilience be developed to deal with the impact of covid-19 whilst supporting employees and protecting jobs? the unprecedented demands that the pandemic has placed on organizations also offer a unique opportunity to understand how organizational resilience and preparedness for dealing with disruptions and emergencies can be developed. while a pandemic of this nature is rare, we can anticipate increasing periods of disruption due to covid-19 flareups and additionally, for example, in response to climate-induced events (e.g., recent australian fires, uk flooding), which are predicted to occur more frequently (banholzer, kossin, & donner, 2014) . although we know a lot about individual resilience, we know relatively little about organizational resilience, especially in the context of well-being and performance (taylor, dollard, clark, dormann, & bakker, 2019; fasey, sarkar, wagstaff & johnston, under review) and the ingredients such as the structures, processes, culture, and leadership that are essential for developing organizational resilience. parenting can be a challenging and anxiety-provoking experience at any time, but the covid-19 pandemic has brought these challenges and anxieties into sharp focus. for most families, the lockdown will represent the longest period of parenting they have experienced without (1) the support of extended family members, friends, and childcare professionals; (2) the routine of school and out-of-school activities; and (3) any face-to-face social life outside the home. these changes in the social environment may have both negative and positive impacts on children and their families. at the most extreme end of the spectrum, the restrictions in place to combat the spread of the virus have been associated with worrying increases in domestic violence and child abuse. however, all families are likely to have experienced greater levels of stress (social care institute for excellence, 2020). the majority of carers with school-age children are dealing with homeschooling for the first time, and many carers are having to adapt to working from home while also looking after their children and older relatives. these pressures will be particularly acute for single-carer families. of course, such multi-tasking concerns apply only to carers fortunate enough to have maintained employment. it is important to support families during the current crisis, but also to understand the implications of these unprecedented changes in family life for family functioning and children's development as we emerge from the pandemic. how will the covid-19 pandemic affect family functioning? many effects of the pandemic on children's development are likely to be indirect, functioning through its impact on caregiving and family functioning. it is crucial for this research to include family members such as grandparents and non-resident parents and siblings. children in families who are already vulnerable due to domestic violence or abuse, social or economic disadvantage, or physical or mental ill health are likely to be most adversely affected. there is an urgent need for research to examine how these vulnerabilities moderate changes in family functioning post-pandemic and their impacts on the child. the ability to regulate behaviour and emotional responses is a key aspect of successful social interaction in individuals of all ages (e.g., baumeister & heatherton, 1996; kochanska, murray, & harlan, 2000) . family members may develop new self-regulation strategies as a result of having extended contact with the same restricted group of people. while such strategies may be adaptive, individuals facing extreme social or financial challenges may cope by psychologically distancing themselves from family members, ruminating on negative events, or engaging in behaviours that are harmful. understanding how adaptive and maladaptive self-regulation strategies change post-pandemic may prove useful in identifying individuals who need additional psychological support. school closures and social restrictions may provide a unique opportunity for family members to gain insight into each other's lives, potentially reducing disagreements and improving family functioning. research should investigate whether reporting such improvement during the crisis is associated with lower caregiving stress and better mental health. it is also important to study how families can maintain any positive aspects of functioning that have resulted from the pandemic as restrictions are eased. how will the covid-19 pandemic affect children's development? the effects of the pandemic will undoubtedly vary as a function of the child's age. while carers with young infants may have concerns about the negative impact of the lockdown on their babies' development, the infants themselves will be unaware of the abnormal nature of their social environment. optimal later development is predicted by caregivers' ability in the first year of life to see the world from the infant's point of view and respond appropriately to their cues (e.g., fraley, roisman, & haltigan, 2013; zeegers, colonnesi, stams, & meins, 2017) . the social restrictions do not obviously impede this type of infantcaregiver engagement, and young infants may therefore be least affected by the pandemic. older children who recognize the drastic changes in social contact may find transitioning back to pre-pandemic social behaviour difficult. it is therefore important to study how children and young people manage this transition and investigate whether the lockdown has raised the incidence of emotional and behavioural difficulties. studying the effects of the pandemic and its aftermath on particular groups that are known to be vulnerable to educational and health disadvantage (e.g., looked after children or children with developmental disorders) should be prioritized. positive effects of the pandemic on children's behaviour and social interaction are also anticipated. many children and young people will have found new ways to communicate with friends, entertain themselves, and keep themselves physically active. time away from school may have been spent learning new skills, developing new hobbies, or helping or supporting others. investigating changes in children and young people's empathy, altruism, theory of mind, creativity, innovation, problem-solving, and cognitive flexibility post-pandemic will help shed light on potential positive outcomes of the social restrictions associated with the pandemic. the challenges posed by the covid-19 pandemic have never been more evident than for the education and well-being of children and young people. in april 2020, a third of the world's population were experiencing extended periods of lockdown with closure of schools and nurseries. parents, many of whom had work and other family responsibilities had to adopt the additional role of educator in home environments not set up for formalized learning. ad hoc arrangements were put in place at speed by schools with limited opportunities to develop clear definitions of learning activities, provide access to learning resources, and establish effective home-school communication. early surveys have shown wide variation in homeschooling arrangements, including stark differences between state and private schools in access to online learning and pupil-teacher communication (sutton trust, 2020) . there is a wealth of evidence about the factors that facilitate effective learning in schools, such as curricula and teaching strategies (hattie, 2009) . other studies have established that children's academic attainment and adjustment are predicted by higher caregiver education (erola, janolen, & lehti, 2016) and engagement in schooling (harris & goodall, 2008) . however, little is known on how to set up and deliver home education effectively under the unique conditions of the pandemic. while for some children the extended period at home is likely to have distinct positive benefits, research prior to covid-19 on substantial externally driven disruptions in schooling has shown adverse effects on child achievement and well-being (meyers & thomasson, 2017; sunderman & payne, 2009 ). the outcomes for the individual child are likely to depend on the capacity of families to step in and effectively support curriculum delivery at home. studies of other severe unplanned disruptions to schooling and family lives such as long-running strikes and natural disasters have shown greatest impacts on long-term educational and emotional outcomes for the most disadvantaged children (jaume & will en, 2019; masten & osofsky, 2010) . at particular risk of disproportionate adverse outcomes are children from families living in poverty, those receiving social care support, individuals with special educational needs and disabilities, and young people with mental health problems. there are high levels of concern that the recognized attainment gap for children from disadvantaged families (education in england: annual report 2019. education policy institute) could be magnified by the pandemic conditions. there is an urgent need to identify and understand both the positive and negative factors that influence children's educational outcomes during and after the pandemic, and to use this knowledge to target support to those who need it most. the unanticipated consequences of the pandemic pose challenges for conventional designs depending on pre-intervention assessments. understanding its impacts on children's lives will require a robust body of research that draws on the diverse research methods of psychological science. this will require large-scale multidisciplinary data collection in addition to smaller-scale quantitative and qualitative approaches that will be vital for understanding the experiences of children, families, and professionals. some key questions to be addressed by this research are outlined below. in addition to collecting data on home-based support for learning, detailed contextual data are needed about social and environmental factors that are likely to interact in determining positive educational outcomes at particular educational phases (e.g., reading, writing, and maths in primary schools), as well as a range of mental health outcomes (e.g., anxiety, depression, self-harm, resilience). this will include research into the effect of social distancing on a range of social outcomes in children and young people (e.g., inclusion/ exclusion, friendships). what kinds of support improve long-term outcomes for children and young people? knowledge about the impacts of school disruptions on all children and young people will allow evidence-based interventions and resources to be targeted at those with greatest need. robust evaluations are required to scrutinize how interventions are accessed, by whom and with what degree of success. how can support services be effectively delivered to vulnerable children and young people, families, and schools? with reduced resources and restricted movement, professionals (such as practitioner psychologists) have had to adapt and develop new ways of delivering services. researchers in psychological science have a key role to play in working with practitioners and service providers to evaluate systems put in place for monitoring and delivering professional support during and in the aftermath of the pandemic. what are the immediate and longer-term consequences of covid-19 for mental health outcomes? there is expected to be an increase in mental health problems as a result of the covid-19 pandemic and the measures used to counter it. we already have evidence for the long-term mental health effects of previous pandemics and disasters (e.g., tam et al., 2004; thompson et al., 2017; wu et al., 2009 ) and an emerging literature on the near-term effects of covid-19 (e.g., ahmad & rathore, 2020; williamson et al., 2020) . but previous pandemics have been more localized and circumscribed making covid-19 different. social distancing, school closures, self-isolation, and quarantine have lasted longer than anything previously experienced. we know that these factors, together with financial uncertainty and concerns about health, are predictive of mental health difficulties, particularly anxiety. the current pandemic amplifies these factors and not only exacerbates problems in those with pre-existing mental health difficulties, but also increases the chance of new onset in those with no previous contact with mental health services. concerns about mental health effects may be particularly heightened for children, who have experienced high levels of disruption to normative developmental opportunities (including opportunities for social and outdoor play) and education, and potentially high levels of family stress (https://emergingminds.org.uk/cospace-study-2ndupdate/). various poor mental health outcomes are also potentially associated with the disease itself. information about the long-term consequences comes from similar viruses such as sars and the mers. for example, many people who suffered from sars seemed to experience detrimental psychological effects even a year later (rogers et al., 2020; tam et al., 2004; thompson et al., 2017; wu et al., 2009) . therefore, we need to establish the immediate and long-term consequences of covid-19 on mental health outcomes in the population generally, but also in vulnerable, shielding, and self-isolating groups (box 1). we urgently need to understand how all these factors interact and whether these consequences will require psychological interventions and supports not currently available. what changes in approaches resulting from the pandemic need to be harnessed for the future? even if the mental health consequences of this pandemic are not as predicted, we still expect increases in mental health problems. we know that mental health accounts for an increasing proportion of sick leave and that one in eight children and young people experience a diagnosable mental health problem (nhs digital, 2018) . childhood mental health problems often recur in adulthood (kessler et al., 2007) and are associated with physical health difficulties, poor academic, and occupational functioning, and are the primary predictor of low adult life satisfaction (layard, clark, cornaglia, powdthavee, & vernoit, 2014) . the increased prevalence will place a further burden on a mental health system that was already stretched and will increase waiting times and accentuate gaps in care. during the pandemic, mental health services rapidly changed. inpatients were discharged, even if they were detained in hospital because they were a risk to themselves or others. some people benefited, but we do not know how this reduction in bed use was managed. was it because the right supports and accommodation were provided? the move to remote contact in mental health services had been slow and of varied quality prior to covid-19 with challenges for both staff and service users. but the shift during the pandemic was swift, and although undoubtedly nhs staff felt pressure during the changeover, there now seems to be a steadier state. again, some service users may have benefited from this change with reductions in travel and, for some, better access to care and treatment. however, although the digital divide is reducing (robotham, satkunanathan, doughty, & wykes, 2016) , it remains highest in those who already have high unmet needs, including people in rural areas, those on lower incomes, people with lower levels of formal education, and older people. if remote working is tobe abeneficial part of an evolved mental health service, then we need to understand how to provide that 'webside' manner that will increase adherence and promote a therapeutic alliance. we also urgently need to evaluate the effectiveness of remotely delivered, digital interventions in the immediate and longer term. future interventions will need to be deliverable remotely, depending on local resources. for example, from an international perspective, many low-to-middle-income countries do not have high broadband penetration; hence, optimizing digital delivery that depends strongly on good internet connections will further widen the welfare gap. physical health and the brain the effects of covid-19 on health outcomes will be far-reaching and complex. for those falling ill, there are the direct consequences of the disease symptoms, such as respiratory failure in severe cases, alongside potentially direct viral effects on the brain. there are also more indirect population-wide effects of covid-19 pandemic-related stress and anxiety on physical and mental health, not only from the disease itself but also from changes in lifestyle including delayed treatment and screening for other known or suspected conditions. moreover, it is also likely that from an international perspective, in many lowto-middle-income countries, the pandemic will result in greater hunger/starvation, which will have severe impacts upon health. does covid-19 have neurological effects on the brain with consequences for mental health? at one level, covid-19 might alter mental health by the direct actions of the specific virus (severe acute respiratory syndrome coronavirus-2; sars-cov-2) on the brain. while neurological dysfunction is often described in covid-19, including dizziness, and loss of taste and smell, these conditions are common to other respiratory tract infections and need not reflect a neurological disease per se (needham, chou, coles, & menon, 2020) . data from cerebrospinal fluid and post-mortem analyses will help resolve issues over the penetrance of sars-cov-2. it is, however, known that the target receptor for sars-cov-2 is the angiotensin-converting enzyme-2 receptor (ace 2). disruption of the blood-brain barrier during illness might enable entry of the virus, potentially aided by the presence of ace 2 receptors in glial cells and brain endothelium. other potential routes of entry include the cribriform plate and olfactory epithelium, as well as via peripheral nerve terminals, permitting entry to the cns through synapse connected routes (ahmad & rathore, 2020) . at the same time, there is an array of immunological responses, including the cytokine 'storm' in severe cases, alongside non-immunological insults to the central nervous system provoked by covid-19. the latter include hypoxia, hypotension, kidney failure, and thrombotic and homeostatic changes involving neuroendocrine function (needham et al., 2020) . together and separately, they may contribute to brain dysfunction in ways that vary with the severity of the infection, other underlying conditions (needham et al., 2020) , and the treatment for those other conditions (south, diz, & chappell, 2020) . largescale studies help confirm differential clinical risk factors for death following infection (williamson et al., 2020) , prompting genotype analyses, while noting that covid-19 might also induce epigenetic changes, including ace 2 demethylation (sawalha, zhao, coit, & lu, 2020) . additional health concerns include post-viral fatigue and whether it might provoke a long-lasting syndrome. research consortia are initiating comparisons between populations that have or have not contracted covid-19. challenges for psychological scientists include how to assess impacts on cognition and mental health, both in the short term and long term. a part of this challenge is how to deliver effective, online psychological testing (e.g., for 'shielded' populations), or to help follow-up large population cohorts, while not biasing the sample away from those least likely to use these platforms. an integral part of some investigations will be the inclusion of multiple neuroimaging methods, despite the era of distancing. just one of many questions would be the impact of covid-19 on mild cognitive impairment and its conversion to dementia. there is a premium on studying pre-existing cohorts (e.g., uk biobank, alspac), where retrospective, baseline data exist. such data are especially precious in the present landscape where everyone is, to some degree, affected by the pandemic. the power of these pre-existing cohorts will, however, be heavily influenced by the proportion of the population who contract covid-19. what are the psychobiological impacts of the covid-19 pandemic on physical and mental health? despite the umbrella term 'stress' covering many different things, there is agreement that in its different forms, stress can lead to physiological changes (e.g., neuroendocrine, cardiovascular), with negative consequences for health (o'connor, thayer & vedhara, in press). three principal research questions can be identified: (1) to what extent does pandemic-related stress, anxiety, and worry impact on biological mechanisms that influence health (i.e., hypothalamic-pituitary-adrenal axis regulation and cortisol dynamics, the autonomic nervous system, and gene expression) as well as on health behaviours (e.g., eating, sleep, alcohol consumption)? (2) how best to counter their adverse effects? and (3) how might such stress exacerbate existing medical and mental health conditions, and for how long? for all three questions, there will be considerable variations between groups and individuals (box 1). one challenge will be to collate and verify relevant information, including that from 'smart' devices that can provide daily physiological data, activity information, and other measures of diurnal patterns, including sleep. one of the groups most likely to be negatively affected by stress is health care professionals. the pandemic may exacerbate the already high prevalence of secondary traumatic stress, burnout, and physical exhaustion among health care professionals, as well as impact on patient safety and medical error (e.g., dar & iqbal, 2020; figley, 1995; hall, johnson, watt, tsipa, & o'connor, 2016) , due to excessive workload and workplace trauma (e.g., itzhaki et al., 2018) . while resources such as support from managers and colleagues can help protect health care professionals against traumatic stress, the longerterm impact is likely to be substantial on individuals, their families, on the national health services and the wider care industry. amongst other groups of concern (box 2) are those caring for a vulnerable relative or partner at home. one novel feature of daily life in the wake of the covid-19 pandemic in countries around the world are near-daily government briefings. one focus of these briefings is government instructions to the public as to how to behave. adherence to these and future instructions will be key to dealing with future crises. moreover, many sections above share in common the requirement that people adhere to instructions, whether it is practitioners delivering psychological therapies effectively over the telephone or employees continuing to maintain physical distancing at work. in the initial response to the pandemic, many governments instructed people to (1) stay inside as much as possible; (2) stay >1 m away from other people at all times; and (3) maintain hand hygiene, among other measures such as wearing face coverings. the evidence suggests that public adherence to government covid-19-related instructions worldwide has been high (ons, 2020), but it is not clear for how long people will continue to adhere to instructions that impinge on personal freedoms. what is clear is that there is a dearth of workers sufficiently trained to advise policymakers and to implement behaviour change interventions rapidly and at scale. the british psychological society's guidance on behaviour change is a good starting point for ensuring that instructions and messaging is clear (british psychological society, 2020a). appointing chief behavioural science advisers to governments would ensure that cuttingedge psychological science advice is placed at the heart of policymaking. as people begin to emerge from the acute phase of the pandemic and the changes that were made to tackle it, it is important that psychological science is at the heart of ensuring that health-enhancing behaviours are sustained and that health-damaging behaviours are changed or prevented. there are numerous approaches to developing such interventions, including the behaviour change wheel (michie, atkins, & west, 2014) and intervention mapping (bartholomew eldrigde et al., 2016) , but they require the expertise of psychological scientists to deliver and to evaluate them (west, michie, rubin, & amlôt, 2020) . one of the main challenges now, and in the future, will be to ensure there is a workforce equipped with the competencies to develop behaviour change theory and tools that will bring about sustained changes in behaviour. taught post-graduate courses exist that could be scaled up and/or adapted to continuing professional development qualifications to meet this demand and help ensure that the changes in behaviour that will be required for the foreseeable future are sustained. how do we best apply existing theories and tools to promote sustained behaviour change among policymakers, key workers, and the public/patients? we sometimes forget that we have the theories and evidence for solutions that can be applied at pace to address novel problems. although we have never seen a lockdown before and so cannot predict what the outcomes will be directly, we do know what processes underpin adherence to instructions, and so can advise on the levers that can sustain adherence. in unprecedented and uncertain times now and in whatever the future might bring, the nature of psychological science allows us to make unique and invaluable contributions. if the covid-19 pandemic teaches us one thing, it is on the need to accelerate the translation of evidence from psychological science into practice. how do we develop new theories and tools to promote sustained behaviour change? at the same time, we should not forget the 'slow' approach to research (armitage, 2015) that involves addressing key research questions with multiple perspectives and methodologies, and accumulating such knowledge in prisma-guided systematic reviews. it is vital that continued investment is made into behaviour change research. only with this can we refine and develop the theories that best explain human behaviour (e.g., michie et al., 2014) . key research priorities include identifying which behaviour change techniques work best, for whom, in which contexts, and delivered by what means (e.g., epton, currie, & armitage, 2017) as well as how to counter the conspiracy theories and misinformation that arise during crises that seem to be aimed at derailing the very behaviours required to keep us safe and to reduce risk. in this position paper, we have set out seven research priority domains in which psychological science, its methods, approaches, and interventions can be harnessed in order to help governments, policymakers, national health services, education sectors, economies, individuals, and families recover from covid-19. these are mental health, behaviour change and adherence, work, education, children and families, physical health and the brain, and social cohesion and connectedness. we have also highlighted that a clear overarching research priority relates to understanding the inequalities in the effects of the pandemic and recovery; recognizing the vulnerability and resilience factors that will be key to understanding how the current pandemic can inform and prepare us for dealing with future crises. we call on psychological scientists to work collaboratively with other scientists in order to address the research questions outlined, refine them and to adopt multidisciplinary working practices that combine different disciplinary approaches. an important next step will be to engage with wider stakeholders, potential users, individuals with lived experience, and beneficiaries of the research. addressing each of the research priority domains will benefit enormously from larger scale working and coordinated data collection techniques and the establishment of research consortia with their associated economies of scale. we also call on psychological scientists to further develop and adapt innovative research methodologies (e.g., remote testing and intervention delivery, online data collection techniques), while maintaining high-quality, open, and rigorous research and ethical standards in order to help with the recovery as we emerge from the acute phase of the crisis. how can we use biological markers to facilitate people's return to work? how do we link covid-19-related biomarkers to existing population cohort databases? how do we address the negative biological impacts of the covid-19 virus on mental health? what are the impacts of covid-19 infection, treatment, and recovery on the brain? how do school closures influence educational progress, and physical and mental health outcomes for all children and young people? what 'homeschooling' 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impacts of the covid-19 recession. institute for employment studies coronavirus disease (covid-19) the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perfection, and altruistic acceptance of risk mind matters: a three-level meta-analysis on parental mentalization and sensitivity as predictors of infant-parent attachment christopher armitage's contribution is supported by the nihr manchester biomedical research centre and the nihr greater manchester patient safety translational research centre. the views expressed in this publication are those of the authors and not necessarily those of nihr. armitage would like to thank professors madelynne arden and alison wearden for their support in writing. til wykes would like to acknowledge the support of her nihr senior investigator award. the set of priorities utilized for the survey of the psychological community.how do we increase adherence (and ability to adhere) to uk government covid-19related instructions? how do we promote maintenance of positive behaviour changes and reverse negative behaviour changes resulting from covid-19-related lockdown? how do we address the negative psychological impacts of the covid-19 pandemic? how do we maximize recovery from covid-19 for those infected with the virus? what is the impact of covid-19-related stress on biological processes and health outcomes? what makes people adhere to anti-covid measures? what are the bases of anti-social behaviours such as stockpiling? how do mutual aid groups form and what makes them endure? when does social cohesion give way to scapegoating, prejudice, and intergroup conflict? what creates (or prevents) the potential for protests and collective disorder in the crisis? what are the long-term mental health effects of covid-19? what coping mechanisms are useful in reducing mental health problems during a pandemic? how do we provide beneficial remote psychological therapy and maintain therapeutic alliance? has discussion of mental health during the pandemic reduced stigma and discrimination in the community? people detained in hospital under the mental health act were discharged to free up bedshow was this possible? what are the impacts of covid-19 infection, treatment, and recovery on cognition, behaviour, and the brain? what are the drivers of covid-19-related stress and its cognitive, neural, and physiological mechanisms and consequences? what are the perceptual and cognitive demands of digital and other alternative forms of communication and how do they impact on work and social connectivity? what factors influence the effectiveness of communication of scientific evidence and national guidance, and how do they influence behaviour? how do restrictions of movement, communication, and social support influence the cognitive, physical, and mental health of older individuals, and what factors lead to improved outcomes? how has the covid-19 pandemic affected parenting? how has the covid-19 pandemic affected children's development? how has the covid-19 pandemic affected family functioning? which factors moderate family members' response to the covid-19 pandemic? what support is most effective for families during the covid-19 pandemic? how do we assess biological markers of health and well-being remotely?continued key: cord-017351-73hlwwdh authors: quarantelli, e. l.; boin, arjen; lagadec, patrick title: studying future disasters and crises: a heuristic approach date: 2017-09-12 journal: handbook of disaster research doi: 10.1007/978-3-319-63254-4_4 sha: doc_id: 17351 cord_uid: 73hlwwdh over time, new types of crises and disasters have emerged. we argue that new types of adversity will continue to emerge. in this chapter, we offer a framework to study and interpret new forms of crises and disasters. this framework is informed by historical insights on societal interpretations of crises and disasters. we are particularly focused here on the rise of transboundary crises – those crises that traverse boundaries between countries and policy systems. we identify the characteristics of these transboundary disruptions, sketch a few scenarios and explore the societal vulnerabilities to this type of threat. we end by discussing some possible implications for planning and preparation practices. disasters and crises are as old as when human beings started to live in groups. through the centuries, new types have emerged. for instance, the development of synthetic chemicals in the 19th century and nuclear power in the 20th century created the possibility of toxic chemical disasters and crises from radioactive fallouts. older crisis types did not disappear: ancient types such as floods and earthquakes remain with us. the newer disasters and crises are additions to older forms; they recombine elements of old threats and new vulnerabilities. the literature on crisis and disaster research suggests that we are at another important historical juncture with the emergence of a new distinctive class of disasters and crises not often seen before (ansell, boin, & keller, 2010; helsloot, boin, jacobs, & comfort, 2012; tierney, 2014) . in this chapter, we discuss the rise of transboundary crises and disasters. we seek to offer a heuristic approach to studying these new crises and disasters. we offer a heuristic approach to understanding the disasters and crises of the future. it is presented primarily as an aid or guide to looking further into the matter, hopefully stimulating more investigation on conceptions of disasters and crises in the past, the present, and the future. unlike in some areas of scientific inquiry, where seemingly final conclusions can be reached (e.g., about the speed of light), the basic nature of the phenomenon we are discussing is of a dynamic nature and subject to change through time. the answer to the question of what is a disaster or crisis has evolved and will continue to do so (see perry' s chapter in this handbook). human societies have always been faced with risks and hazards. earthquakes, hostile inter-and intra-group relationships, massive floods, sudden epidemics, threats to take multiple hostages or massacre large number of persons, avalanches, fires and tsunamis have marked human history for centuries if not eons. disasters and crises requiring a group reaction are as old as when human beings started to live in stable communities. 1 the earliest happenings are attested to in legends and myths, oral traditions and folk songs, religious accounts and archeological evidence from many different cultures and subcultures around the world. for example, a "great flood" story has long existed in many places (lang, 1985) . as human societies evolved, new threats and hazards emerged. to the old there have been added new dangers and perils that increasingly have become potentially dangerous to human groups. risky technological agents have been added to natural hazards. these involve chemical, nuclear and biological threats that can accidentally materialize as disasters. intentional conflict situations have become more damaging at least in the sense of involving more and more victims. the last 90 years have seen two world wars, massive air and missile attacks by the military on civilians distant from battle areas, many terrorist attacks, and widespread ethnic strife. genocide killed one million persons in rwanda; millions have become refugees and tens of thousands have died in darfur in the sudan in africa. while terrorism is not a new phenomenon, its targets have considerably expanded. some scholars and academics have argued that the very attempt to cope with increasing risks, especially of a technological nature, is indirectly generating new hazards. as the human race has increasingly been able to cope with such basic needs as food and shelter, some of the very coping mechanisms involved (such as the double edged consequences of agricultural pesticides), have generated new risks for human societies (beck, 1999; perrow, 1999) . for example, in 2004, toxic chemicals were successfully used to eradicate massive locust infestations affecting ten western and northern african countries. those very chemicals had other widespread negative effects on humans, animals and crops (irin, 2004) . implicit in this line of thinking is the argument that double-edged consequences from new innovations (such as the use of chemicals, nuclear power and genetic engineering) will continue to appear (tenner, 1996) . we cannot say that the future will bring more disasters, as we have no reliable statistics on prior happenings as a base line to use in counting (quarantelli, 2001) . at present, it would seem safer to argue that some future events are qualitatively different, and not necessarily that there will be more of them in total (although we would argue the last is a viable hypothesis that requires a good statistical analysis). societies for the most part have not been passive in the face of these dangers to human life and well-being. this is somewhat contrary to what is implicit in much of the social science literature especially about disasters. in fact, some of these writings directly or indirectly state that a fatalistic attitude prevailed in the early stages of societal development (e.g., quarantelli, 2000) . this was thought because religious beliefs attributed negative societal happenings to punishments or tests 1 this seems to have occurred about five to six thousand years ago (see lenski, lenski, & nolan, 1991) . however, recent archeological studies suggest that humans started to abandon nomadic wanderings and settled into permanent sites around 9,500 years ago (balter, 2005) so community recognized disasters and crises might have an even longer history. by supernatural entities (the "acts of god" notion, although this particular phrase became a common usage mostly because it served the interests of insurance companies). but prayers, offerings and rituals are widely seen as means to influence the supernatural. so passivity is not an automatic response to disasters and crises even by religious believers, an observation sometimes unnoticed by secular researchers. in fact, historical studies strongly indicate that societal interpretations have been more differentiated than once believed and have shifted through the centuries, at least in the western world. in ancient greece, aristotle categorized disasters as the result of natural phenomena and not manifestations of supernatural interventions (aristotle, 1952) . the spread of christianity about 2,000 years ago helped foster the belief that disasters were "special providences sent directly" from "god to punish sinners" (mulcahy, 2002, p. 110) . in the middle ages, even scholars and educated elites "no longer questioned the holy origins of natural disasters" (massard-guilbaud, platt, & schott, 2002, p. 19) . starting in the 17th century, however, explanations started to be replaced by "ones that viewed disasters as accidental or natural events" (mulcahy, 2002, p. 110) . this, of course, also reflected a strong secularization trend in western societies. perhaps this reached a climax with the 1755 lisbon earthquake which dynes notes can be seen as the "first modern disaster" (2000, p. 10). so far our discussion has been mostly from the perspective of the educated elites in western societies. little scholarly attention seems to have been given to what developed in non-western social systems. one passing observation about the ottoman empire and fire disasters suggests that the pattern just discussed might not be universal. thus, while fire prevention measures were encouraged in cities, they were not mandated "since calamities were considered" as expressions of the will of god (yerolympos, 2002, p. 224) . even as late as 1826 an ottoman urban building code stated that according to religious writing "the will of the almighty will be done" and nothing can and should be done about that. at the same time, this code advances the idea that nevertheless there were protective measures that could be taken against fires that are "the will of allah" (quoted in yerolympos, 2002, p. 226) . of course, incompatibility between natural and supernatural views about the world are not unique to disaster and crisis phenomena, but that still leaves the distinction important. 2 even recently, an australian disaster researcher asserted that in the 2004 southwestern asian tsunami most of the population seemed to believe that the disaster was "sent either as a test of faith or punishment" (mcaneney, 2005, p. 3). or as another writer noted, following the tsunami, religiously oriented views surfaced. some were by: "fundamentalist christians" who tend to view all disasters "as a harbinger of the apocalypse". others were by "radical islamists" who are inclined to see any disaster that "washes the beaches clear of half-nude tourists to be divine" (neiman, 2005, p. 16) . after hurricane katrina, some leaders of evangelical groups spoke of the disaster as punishment imposed by god for "national sins" (cooperman, 2005) . in the absence of systematic studies, probably the best hypothesis that should be researched is that at present religious interpretations about disasters and crisis still appear to be widely held, but relative to the past probably have eroded among people in general. the orientation is almost certainly affected by sharp cross-societal difference in the importance attributed to religion as can be noted in the religious belief systems and practices as currently exist in the united states and many islamic countries, compared to japan or a highly secular western europe. apart from the varying interpretations of the phenomena, how have societies behaviorally reacted to existing and ever-changing threats and risks? as a whole, human groups have evolved a 2 for an interesting attempt to deal with these two perspectives see the paper entitled disaster: a reality or a construct? perspective from the east, written by jigyasu (2005) an indian scholar. variety of formal and informal mechanisms to prevent and to deal with crises and disasters. but societies have followed different directions depending on the perceived sources of disasters and crises. responses tend to differ with the perception of the primary origin (the supernatural, the natural or the human sphere). for example, floods were seen long ago as a continuing problem that required a collective response involving engineering measures. stories that a chinese emperor, 23 centuries before christ, deepened the ever-flooding yellow river by massive dredging and the building of diversion canals may be more legend than fact (waterbury, 1979, p. 35) . however, there is clear evidence that in egypt in the 20th century bc, the 12th dynasty pharaoh, amenemher ii completed southwest of cairo what was probably history's first substantial river control project (an irrigation canal and dam with sluice gates). other documentary evidence indicates that dams for flood control purposes were built as far back as 1260 b c in greece (schnitter, 1994, p. 1, 8-9) . such mitigatory efforts indicate both the belief that there was a long-term natural risk as well as one that could be coped with by physically altering structural dimensions. later, particular in europe, there were many recurrent efforts to institute mitigation measures. for example, earthquake resistant building techniques were developed in ancient rome, although "they had been forgotten by the middle ages" (massard-guilbaud et al., 2002, p. 31) . the threats from floods and fires spurred mitigation efforts in greece. starting in the 15th century, developing urban areas devised many safeguards against fires, varying from regulations regarding inflammable items to storage of water for firefighting purposes. in many towns in medieval poland, dams, dikes and piles along riverbanks were built (sowina, 2002) . of course, actions taken were not always successful. but, if nothing else, these examples show that organized mitigation efforts have been undertaken for a long time in human history. there have been two other major behavioral trends of long duration that are really preventive in intent if not always in reality. one has been the routinization of responses by emergency oriented groups so as to prevent emergencies from escalating into disasters or crises. for example, in ancient rome, the first groups informally set up to fight fires were composed of untrained slaves. but when a fire in 6 a.d. burned almost a quarter of rome, a corps of vigiles was created that had full-time personnel and specialized equipment. in more recent times, there are good examples of this routinization in the planning of public utilities that have standardized operating procedures to deal with everyday emergencies so as to prevent them from materializing into disasters. in the conflict area, there are various un and other international organizations, such as the international atomic energy agency and the european union (eu), that also try to head off the development of crises. in short, societies have continually evolved groups and procedures to try to prevent old and new risks and threats from escalating into disasters and crises. a second more recent major trend has been the development of specific organizations to deal first with wartime crises and then with peacetime disasters. societies for about a century have been creating specific organizations to deal first with new risks for civilians created by changes in warfare, and then improving on these new groups as they have been extended to peacetime situations. rooted in civil defense groups created for air raid situations, there has since been the evolvement of civilian emergency management agencies (blanchard, 2004) . accompanying this has been the start of the professionalization of disaster planners and crisis managers. there has been a notable shift from the involvement of amateurs to educated professionals. human societies adjusted not only to the early risks and hazards, but also to the newer ones that appeared up to the last century. the very existence of the human race is testimony to the social coping mechanisms of humans as they face such threats. here and there a few communities and groups have not been able to cope with the manifestations of contemporary risks and hazards (diamond, 2005) . but these have been very rare cases. neither disasters nor crises involving conflict have had that much effect on the continuing existence of cities anywhere in the world. throughout history, many cities have been destroyed. they have been: "sacked, shaken, burned, bombed, flooded, starved, irradiated and poisoned", but in almost every case they have phoenix-like been reestablished (vale & campanella, 2004, p. 1) . around the world, from the 12th to the 19th century, only 42 cities were "permanently abandoned following destruction" (vale & campanella, 2004, p. 1) . the same analysis notes that large cities such as baghdad, moscow, aleppo, mexico city, budapest, dresden, tokyo, hiroshima and nagasaki all suffered massive physical destruction and lost huge numbers of their populations due to disasters and wartime attacks. all were rebuilt and rebounded. at the start of the 19th century, "such resilience became a nearly universal fact" about urban settlements around the world (vale & campanella, 2004, p. 1) . looking at these cities today as well as warsaw, berlin, hamburg and new orleans, it seems this recuperative tendency is very strong (see also schneider & susser, 2003) . in the hiroshima museum that now exists at the exact point where the bomb fell, there is a 360-degree photograph of the zone around that point, taken a few days after the attack. except for a few piles of ruins, there is nothing but rubble as far as the eye can see in every direction. there were statements made that this would be the scene at that location for decades. but a visitor to the museum today can see in the windows behind the circular photograph, many signs of a bustling city and its population (for a description of the museum see webb, 2006) . hiroshima did receive much help and aid to rebuild. but the city came back in ways that observers at the time of impact did not foresee. early efforts to understand and to cope with disasters and crises were generally of an ad hoc nature. with the strong development of science in the 19th century, there was the start of understanding the physical aspects of natural disasters, and these had some influence on structural mitigation measures that were undertaken. however, the systematic social science study of crises and disasters is about a half-century-old (fritz, 1961; kreps, 1984; quarantelli, 1988 quarantelli, , 2000 schorr, 1987; wright & rossi, 1981) . in short, there is currently a solid body of research-generated knowledge developed over the last half century of continuing and ever increasing studies around the world in different social science disciplines. to be sure, such accounts and reports are somewhat selective and not complete. there are now case studies and analytical reports on natural and technological disaster (and to some extent on other crises) numbering in the four figures. in addition, there are numerous impressions of specific behavioral dimensions that have been derived from field research (for summaries and inventories see alexander, 2000; cutter, 1994; dynes, demarchi, & pelanda, 1987; dynes & tierney, 1994; farazmand, 2001; helsloot, boin, jacobs, & comfort, 2012; mileti, 1999; oliver-smith, 1999; perry, lindell, & prater, 2005; rosenthal, boin, & comfort, 2001; rosenthal, charles, & 't hart, 1989; tierney, lindell, & perry, 2001; turner, 1978) . what are the distinctive aspects of the newer disasters and crises that are not seen in traditional ones? to answer this question, we considered what social science studies and reports had found about behavior in disasters and crises up to the present time. we then implicitly compared those observations and findings with the distinctive behavioral aspects of the newer disasters and crises. one issue that has always interested researchers and scholars is how to conceptualize disasters and crises. there is far from full agreement that all disasters and crises can be categorized together as being relatively homogeneous phenomena (quarantelli, 1998; perry & quarantelli, 2005) . this is despite the fact that there have been a number of attempts to distinguish between, among and within different kinds of disasters and crises. however, no one overall view has won anywhere near general acceptance among self-designated disaster and crisis researchers. to illustrate we will briefly note some of the major formulations advanced. for example, one attempt has been to distinguish between natural and technological disasters (erikson, 1994; picou & gill, 1996) . the basic assumption was that the inherent nature of the agent involved made a difference. implicit was the idea that technological dangers or threats present a different and more varying kind of challenge to human societies than do natural hazards or risks. most researchers have since dropped the distinction as hazards have come to be seen as less important than the social setting in which they appear. in recent major volumes on what is a disaster (quarantelli, 1998; perry & quarantelli, 2005) , the distinction was not even mentioned by most of the two dozen scholars who addressed the basic question. other scholars have struggled with the notion that there may be some important differences between what can be called "disasters" and "crises". the assumption here is that different community level social phenomena are involved, depending on the referent. thus, some scholars distinguish between consensus and conflict types of crises (stallings, 1988 tries to reconcile the two perspectives). in some research circles, almost all natural and most technological disasters are viewed as consensus types of crises (quarantelli, 1998) . these are contrasted with crises involving conflict such as are exemplified by riots, terrorist attacks, and ethnic cleansings and intergroup clashes. in the latter type, at least one major party is either trying to make it worse or to extend the duration of the crisis. in natural and technological disasters, no one deliberately wants to make the situation worse or create more damage or fatalities. now, there can be disputes or serious disagreements in natural or technological disasters. it is almost inevitable that there will be some personal, organizational and community conflicts as, for example, in the recovery phase of disasters, where scapegoating is common (bucher, 1957; drabek & quarantelli, 1967 cf. boin, mcconnell, & 't hart, 2008) . in some crises, the overall intent of major social actors is to deliberately attempt to generate conflict. in contrast to the unfolding sequential process of natural disasters, terrorist groups or protesting rioters not only intentionally seek to disrupt social life, they modify or delay their attacks depending on perceived countermeasures. apart from a simple observable logical distinction between consensus and conflict types of crises, empirical studies have also established behavioral differences. for example, looting behavior is distinctively different in the two types. in the typical disaster in western societies, almost always looting is rare, covert and socially condemned, done by individuals, and involves targets of opportunity. in contrast, in many conflict crises looting is very common, overt and socially supported, undertaken by established groups of relatives or friends, and involves deliberately targeted locations (quarantelli & dynes, 1969) . likewise, there are major differences in hospital activities in the two kinds of crises, with more variation in conflict situations. there are differences also in the extent to which both organizational and community-level changes occur as a result of consensus and conflict crises, with more changes resulting from conflict occasions (quarantelli, 1993) . finally, it has been suggested that the mass media system operates differently in terrorism situations and in natural and technological disasters (project for excellence in journalism, 1999 journalism, , 2001 . 3 both the oklahoma city bombing and the 9-11 world trade center attack led to sharp clashes between different groups of initial organizational responders. there were those who saw these happenings primarily as criminal attacks necessitating closure of the location as a crime 3 for a contrary view that sees terrorist occasions as more or less being the same as what behaviorally appears in natural and technological disasters (fischer, 2003) . scene, and those who saw them primarily as situations where priority ought to be on rescuing survivors. in the 9-11 situation, the clash continued later into the issues of the handling of dead bodies and debris clearance. all this goes to show that crises and disasters are socially constructed. whether it is by theorists, researchers, operational personnel, politicians or citizens, any designation comes from the construction process and is not inherent in the phenomena itself. this is well illustrated in an article by cunningham (2005) where he shows that a major cyanide spill into the danube river was differently defined as an incident, an accident, or a catastrophe, depending on how culpability was perceived and who was doing the defining. still other distinctions have been made. some advocate "crisis" as the central concept in description and analysis (see the chapter of boin, kuipers and 't hart in this handbook). in this line of thinking, a crisis involves an urgent threat to the core functions of a social system. a disaster is seen as "a crisis with a bad ending" (boin, 2005) . this is consistent with the earlier expressed idea that while there are many hazards and risks, only a few actually manifest themselves. but the crisis idea does not differentiate among the manifestations themselves as the consensus and conflict distinction does. this is not the place to try and settle conceptual disagreements and we will not attempt to do so. anyone in these areas of study should acknowledge that there are different views and different proponents should try to make their positions as explicit as possible so people do not continue to talk past one another. it is perhaps not amiss here to note that the very words or terms used to designate the core nature of the phenomena are etymologically very complex with major shifts in meaning through time. 4 we are far from having standardized terms and similar connotations and denotations for them. a conceptual question that has come increasingly to the fore in the last decade or so is the question: have new kinds of crises and disasters began to appear? we think it is fair to say that there are new types of risks and hazards. there are also structural changes in social settings. together, they raise the prospect of new types of disasters and crises. for example, we have seen the breakdown of modern transportation systems (think of the volcanic ash crisis that paralyzed air traffic in 2010; kuipers & boin, 2015) . there have been massive information system failures either through sabotage or as a result of technical breakdowns in linked systems. there have been terrorist attacks of a magnitude and scale not seen before. we are living with the prospect of widespread illnesses and health-related difficulties that appear to be qualitatively different from traditional medical problems. we have just lived through financial and economic collapses that cut across different social systems around the world. many of these "new" disruptions have both traditional and non-traditional features: think of the heat waves in paris (lagadec, 2004) and chicago (klinenberg, 2002) , the ice storms in canada (scanlon, 1998) , but also the genocide-like violence in africa and the former yugoslavia. the chernobyl radiation fallout (1986) led some scholars and researchers to start asking if there was not something distinctively new about that disaster. the fallout was first openly measured in sweden. officials were mystified in that they could not locate any possible radiation source in their own country. later radiation effects on vegetation eaten by reindeer past the arctic circle in northern sweden were linked to the nuclear plant accident in the soviet union. the mysterious origins, crossing of national boundaries, and the emergent involvement of 4 see safire (2005) who struggles with past and present etymological meanings of "disaster", "catastrophe", "calamity" and "cataclysm"; also see murria (2004) who looking outside the english language found a bewildering set of words used, many of which had no equivalent meanings in other languages. many european and transnational groups was not something researchers had typically seen together in other prior disasters. looking back, it is clear that certain other disasters also should have alerted all of us to the probability that new forms of adversity were emerging. in november 1986, water used to put out fire in a plant involving agricultural chemicals spilled into the river rhine. the highly polluted river went through switzerland, germany, france, luxembourg and the netherlands. a series of massive fire smog episodes plagued indonesia in 1997 and 1998. land speculations led to fire-clearing efforts that, partly because of drought conditions, resulted in forest fires that produced thick smog hazes that spread over much of southeast asia (barber & schweithelm, 2000) . these disrupted travel, which in turn affected tourism as well as creating respiratory health problems, and led to political criticism of indonesia by other countries as multi-nation efforts to cope with the problem were not very successful. both of these occasions had characteristics that were not typically seen in traditional disasters. in the original version of this chapter, we spoke about "trans-system social ruptures". this term was an extension of the earlier label of "social ruptures" advanced by lagadec (2000 lagadec ( , 2004 . the term "transboundary" has since become the more conventional way to describe crises and disasters that jump across different societal boundaries disrupting the social fabric of different social systems (ansell et al., 2010) . the two prime and initial examples we used in the original chapter were the severe acute respiratory syndrome (sars) and the sobig computer f virus spread, both of which appeared in 2003. the first involved a "natural" phenomenon, whereas the second was intentionally created. since there is much descriptive literature available on both, we here provide only very brief statements about these phenomena. the new infectious disease sars appeared in the winter of 2003. apparently jumping from animals to humans it originated in southern rural china, near the city of guangzhou. from there it moved through hong kong and southeast asia. it spread quickly around the world because international plane flights were shorter than its incubation period. at least 774 infected persons died. it hit canada with outbreaks in vancouver in the west and toronto far away in the east. in time, 44 persons died of the several hundred that got ill, and thousands of others were quarantined. the city's healthcare system virtually closed down except for the most urgent of cases with countless procedures being delayed or cancelled. the result was that there was widespread anxiety in the area resulting in the closing of schools, the cancellation of many meetings and, because visitors and tourists stayed away, a considerable negative effect on the economy (commission report, 2004, p. 28) . the commission report notes a lack of coordination among the multitude of private and public sector organizations involved, a lack of consistent information on what was really happening, and jurisdictional squabbling on who should be doing what. although sars vanished worldwide after june 2003, to this day it is still not clear why it became so virulent in the initial outbreak and why it has disappeared (yardley, 2005) . the sobig computer f virus spread in august 2003 (schwartz, 2003) . it affected many computer systems and threatened almost all computers connected to the internet. the damage was very costly. a variety of organizations around the world, public and private, attempted to deal with the problem. initially uncoordinated, there eventually emerged in an informal way a degree of informational networking on how to cope with what was happening (koerner, 2003) . 5 what can we generalize from not only these two cases, but also others that we looked at later 5 in may 2017, the so-called wannacry virus affected millions of computers across the world with ransomware. many hospitals were affected. (ansell et al., 2010) ? the characteristics we depict are stated in ideal-typical terms; that is, from a social science perspective, what the phenomena would be if they existed in pure or perfect form. first, the threat jumps across many international and national/political governmental boundaries. it crosses functional boundaries, jumping from one sector to another, and crossing from the private into public sectors (and sometimes back). there was, for example, the huge spatial leap of sars from a rural area in china to metropolitan toronto, canada. second, a transboundary threat can spread very fast. cases of sars went around the world in less than 24 hours with a person who had been in china flying to canada quickly infecting persons in toronto. the spread of the sobig f virus was called the fastest ever (thompson, 2004) . this quick spread is accompanied by a very quick if not almost simultaneous global awareness of the risk because of mass media attention. third, there is no known central or clear point of origin, at least initially, along with the fact that the possible negative effects at first are far from clear. this stood out when sars first appeared in canada. there is much ambiguity as to what might happen. ambiguity is of course a major hallmark of disasters and crises (turner, 1978) . it is more pervasive in transboundary crises as information about causes, characteristics and consequences is distributed across the system. fourth, there are potentially if not actual large number of victims, directly or indirectly. the sobig computer virus infected 30% of email users in china, that is about 20 million people and about three fourths of email messages around the world were infected by this virus (koerner, 2003) . in contrast to the geographic limits of most past disasters, the potential number of victims is often open ended in disruptions that span across boundaries. fifth, traditional "solutions" or approachesembedded in local and/or professional institutions will not always work. this is rather contrary to the current emphasis in emergency management philosophy. the prime and first locus of planning and managing cannot be the local community as it is presently understood. international and transnational organizations must typically be involved very early in the initial response (boin, ekengren, & rhinard, 2013) . the nation state may not even be a prime actor in the situation. sixth, although responding organizations and groups are major players, there is an exceptional amount of emergent behavior and the development of many informal ephemeral linkages. in some respects, the informal social networks generated, involving much information networking, are not always easily identifiable from the outside, even though they are often the crucial actors at the height of the crisis. in this section, we sketch several future scenarios that most likely would create transboundary disasters. even though some of the scenarios discussed might seem to be science fiction in nature, the possibilities we discuss are well within the realm of realistic scientific possibilities. the most obvious scenario revolves around asteroids or comets hitting planet earth (di justo, 2005) . this has, of course, happened in the past, but even more recent impacts found no or relatively few human beings around. there are two major possibilities with respect to impact (mcguire, 2000; wisner, 2004) . a landing in the ocean would trigger a tsunami-like impact in coastal areas. just the thinking of the possibility of how, when and where ahead of time coastal population evacuations might have to be undertaken, is a daunting thought. statistically less likely is a landing in a heavily populated area. but a terrestrial impact anywhere on land would generate very high quantities of dust in the atmosphere, which will affect food production as well as creating economic disruption. this would be akin to the tambora volcanic eruption in 1813, which led to very cold summers and crop failures (post, 1977) . the planning and management problems for handling something like this would be enormous. the explosion of space shuttle columbia scattered debris over a large part of the united states. this relatively small disastercompared to a comet or asteroid impactinvolved massive crossing of boundaries, a large number of potential victims, and could not be managed by local community institutions. the response required that an unplanned effort coordinating organizations that had not previously worked with one another and other unfamiliar groups, public and private (ranging from the us forest service to local red cross volunteers to regional medical groups), be informally instituted over a great part of the united states (beck & plowman, 2013; donahue, 2003) . a second scenario is the inadvertent or deliberate creation of biotechnological disasters. genetic engineering of humans or food products is currently in its infancy. the possible good outcomes and products from such activity are tremendous (morton, 2005) and are spreading around the world (pollack, 2005) . but the double-edged possibilities mentioned earlier are also present. there is dispute over genetically modified crops, with many european countries resisting and preventing their use and spread in their countries. while no major disaster or crisis from this biotechnology has yet occurred, there have been many accidents and incidents that suggest that this will be only a matter of time. for example, in 2000, starlink corn, approved only for animal feed is found in the food supply, such as taco shells and other groceries. the same year farmers in europe learned that that they had unknowingly been growing modified canola using mixed seed from canada. in 2001, modified corn was found in mexico even though it was illegal to plant in that country. that same year, experimental corn that had been engineered to produce a pharmaceutical that was found in soybeans in the state of nebraska. in several places, organic farmers found that it was impossible for them to keep their fields uncontaminated (for further details about all these incidents and other examples, see pollack, 2004) . noticeable is the leaping of boundaries and uncertainty about the route of spreading. it does not take much imagination to see that a modified gene intended for restricted use, could escape and create a contamination that could wreak ecological and other havoc. perhaps even more disturbing to some is genetic engineering involving human beings. the worldwide dispute over cloning, while currently perhaps more a philosophical and moral issue, does also partly involve the concern over creating flawed human-like creatures. it is possible to visualize not far-fetched worst-case scenarios that could be rather disastrous. it should be noted that even when there is some prior knowledge of a very serious potential threat, what might happen is still likely to be as ambiguous and complex as when sars first surfaced. this can be seen in the continuing major concern expressed in 2004 to mid-2005 about the possible pandemic spread of avian influenza, the so called "bird flu" (nuzzo, 2004; thorson & ekdahl, 2005) . knowledge of the evolution and spread of new pandemics, their effects and whether presently available protective measures would work, may well be very limited. knowledge that it might occur provides very little guidance on what might actually happen. it is possible to imagine the destruction of all food supplies for human beings either through the inadvertent or deliberate proliferation of very toxic biotechnological innovations for which no known barriers to spreading exists. these potential kinds of global disasters are of relatively recent origins and we may expect more such possibilities in the future. the human race is opening up potentially very catastrophic possibilities by innovations in nanotechnology, genetic engineering and robotics (barrat, 2013; joy, 2000; makridakis, 2017) . a potential is not an actuality. but it would be foolish from both a research as well as a planning and managing viewpoint to simply ignore these and other doomsday possibilities. the question might be asked if there is a built-in professional bias among disaster and crisis researchers and emergency planners to look for and to expect the worst (see mueller, 2004 for numerous examples). in the disaster and crisis area, this orientation is reinforced by the strong tendency of social critics and intellectuals to stress the negative. 6 it would pay to look at the past, see what was projected at a particular time, and then to look at what actually happened. the worldwide expectations about what would happen at the turn of the century to computers are now simply remembered as the y2k fiasco. it would be a worthy study to take projections by researchers about the future of ongoing crises and disasters, and then to look at what actually happened. in the 1960s, in the united states, scholars made rough analyses about the immediate future course of racial and university riots in the country. their initial appearances had not been forecasted. moreover, there was a dismal record in predicting how such events would unfold (no one seemed to have foreseen that the riots would go from ghetto areas to university campuses), as well as that they rather abruptly stopped. we should be able to do a better job than we have so far in making projections about the future. but perhaps that is asking more of disaster and crisis researchers than is reasonable. after all, social scientists with expertise in certain areas, to take recent examples, failed completely to predict or forecast the non-violent demise of the soviet union, the peaceful transition in south africa, or the development of a market economy in communist china (cf. tetlock, 2005) . a disaster or crisis always occurs in some kind of social setting. by social setting we mean social systems. these systems can and do differ in social structures and cultural frameworks. there has been a bias in disaster and crisis research towards focusing on specific agents and specific events. thus, there is the inclination of social science researchers to say they studied this or that earthquake, flood, explosion and/or radioactive fallout. at one level that is nonsense. these terms refer to geophysical, climatological or physical happenings, which are hardly the province of social scientists. instead, those focused on the social in the broad sense of the term should be studying social phenomena. our view is that what should be looked at more is not the possible agent that might be involved, but the social setting of the happening. this becomes obvious when researchers have to look at such happenings as the 2004 southeast asia tsunami or locust infestations in africa. both of these occasions impacted a variety of social systems as well as involving social actors from outside those systems. this led in the tsunami disaster to sharp cultural clashes regarding on how to handle the dead between western european organizations who came into look mostly for bodies of their tourist citizens, and local groups who had different beliefs and values with respect to dead bodies (scanlon, personal communication with first author). the residents of the andaman islands lived at a level many would consider "primitive". at the time of the 2004 tsunami in southeast asia, they had no access to modern warning systems. but prior to the tsunami, members of the tribal communities saw signs of disturbed marine life and heard unusual agitated cries of sea birds. this was interpreted as a sign of impending danger, so that part of the population got off the beaches and retreated inland to the woods and survived intact (icpac report, 2006) . there is a need to look at both the current social settings as well as certain social trends that influence disasters and crises. in no way are we going to address all aspects of social systems and cultural frameworks or their social evolution, either past or prospective. instead, we will selectively discuss and illustrate a few dimensions that would seem to be particularly important with respect to crises and disasters. what might these be? let us first look at existing social structures around the world. what differences are there in authority relationships, social institutions and social diversity? as examples, we might note that australia and the united states are far more governmentally decentralized than france or japan (bosner, 6 for example, rees (2004) , a cosmologist at cambridge university, gives civilization as we know it only a 50-50 chance of surviving the 21st century. schoff, 2004) . this affects what might or might not happen at times of disasters (it is often accepted that top-down systems have more problems in responding to crises and disasters). but what does it mean for the management of transboundary disruptions, which require increased cooperation between and across systems? will decentralized systems be able to produce "emergent" transboundary cooperation? as another example, mass media systems operate in rather different ways in china compared with western europe. this is important because to a considerable extent the mass communication system (including social media) is by far the major source of "information" about a disaster or a crisis. they play a major role in the social construction of disasters and crises. for a long time in the former soviet union, even major disasters and overt internal conflicts by way of riots were simply not openly reported (berg, 1988) . and only late in 2005 did chinese authorities announce that henceforth death tolls in natural disasters would be made public, but not for other kinds of crises (kahn, 2005) . another social structural dimension has to do with the range of social diversity in different systems (bolin & stanford, 2006) . social groupings and categories can be markedly different in their homogeneity or heterogeneity. the variation, for instance, can be in terms of life styles, class differences or demographic composition. the aging population in western europe and japan is in sharp contrast to the very young populations in most developing countries. this is important because the very young and the very old incur disproportionately the greatest number of fatalities in disasters. human societies also differ in terms of their cultural frameworks. as anthropologists have pointed out, they can have very different patterns of beliefs, norms, and values. as one example, there can be widely held different conceptions of what occasions disasters and crises. the source can be attributed to supernatural, natural, or human factors as indicated earlier. this can markedly affect everything from what mitigation measures might be considered to how recovery and reconstruction will be undertaken. norms indicating what course of action should be followed in different situations can vary tremendously. for example, the norm of helping others outside of one's own immediate group at times of disasters and crises ranges from full help to none. thus, although the kobe earthquake was an exception, any extensive volunteering in disasters was very rare in japan (for a comparison of the us and japan, see hayashi, 2004) . in societies with extreme cross-cultural ethnic or racial differences, volunteering to help others outside of one's own group at times of disasters or crisis is almost unknown. social structures and cultural frameworks of course are always changing. to understand future disasters and crises, it is necessary to identify and understand trends that may be operative with respect to both social structures and cultural frameworks. in particular, for our purposes, it is important to note trends that might be cutting across structural and cultural boundaries. globalization has been an ongoing force. leaving aside the substantive disputes about the meaning of the term, what is involved is at least the increasing appearance of new social actors at the global level. with respect to disaster relief and recovery, there is the continuing rise of transnational or international organizations such as un entities, the european union, religiously oriented groupings, and the world bank (boin et al., 2013) . with the decline of the importance of the nation state (guéhenno, 1995; mann, 1997) , more and new social actors, especially of an ngo nature, are to be anticipated. the rise of the information society has enabled the development of informal social networks that globally cut across political boundaries. this trend will likely increase in the future. such networks are creating social capital (in the social science sense) that will be increasingly important in dealing with disasters and crises. at the cultural level, we can note the greater insistence of citizens that they ought to be actively protected against disasters and crises (beck, 1999) . this is part of a democratic ideology that has spread around the world. that same ideology carries an inherent paradox: the global citizen may not appreciate government interference in everyday life, but expects government to show up immediately when acute adversity hits. finally, there has been the impact of the 9/11 attacks especially on official thinking not just in the united states but elsewhere also. this happening has clearly been a "focusing event" (as birkland, 1997 uses the term) and changed along some lines, certain values, beliefs and norms (smelser, 2004; tierney, 2005) . there is a tendency, at least in the us after 9/11, to think that all future crises and disasters will be new forms of terrorism. one can see this in the creation of the us department of homeland security, which repeated errors in approach and thinking that over 50 years of research have shown to be incorrect (e.g., an imposition of a command and control model, assuming that citizens will react inappropriately to warnings, seeing organizational improvisation as bad managing, see dynes, 2003) . these changes were accompanied by the downgrading of fema and its emphasis on mitigation (cohn, 2005) . valid or not, such ideas influence thinking about transboundary disasters and crises (and not just in the united states). the ideas expressed above and the examples used were intended to make several simple points. they suggest, for instance, that an earthquake of the same magnitude in france to one in iran will probably be reacted to differently. a riot in sweden will be a different phenomenon than one in myanmar. to understand and analyze such happenings requires taking into account the aspects just discussed. it is hard to believe that countries that currently have no functioning national government, such as somalia and the democratic republic of the congo or marginally operatives ones such as afghanistan, will have the same reaction to disasters and crises as societies with fully functional national governments. different kinds of disasters and crises will occur in rather different social settings. in fact, events that today are considered disasters or crises were not necessarily so viewed in the past. in noting these cross-societal and cross-cultural differences, we are not saying that there are no universal principles of disaster and crisis behavior. there is considerable research evidence supportive of this notion. we would argue, for example, that many aspects of effective warning systems, problems of bureaucracies in responding, the crucial importance of the family/household unit are roughly the same in all societies. to suggest the importance of cross-societal and cross-cultural differences is simply to suggest that good social science research needs to take differences into account while at the same time searching for universal principles about disasters and crises. this is consistent with those disaster researchers and scholars (e.g., oliver-smith, 1994) who have argued that studies in these areas have badly neglected the historical context of such happenings. of course, this neglect of the larger and particularly historical context has characterized much social science research of any kind (wallerstein, 1995) ; it is not peculiar to disaster and crisis studies. one trend that affects the character of modern crises and disasters is what we call the social amplifications of crises and disasters. pidgeon, kasperson, and slovic (2003) described a social augmentation process with respect to risk. to them, risk not only depends on the character of the dangerous agent itself but how it was seen in the larger context in which it appeared. the idea that there can be social amplification of risk rests on the assumption that aspects relevant to hazards interact with processes of a psychological, social, institutional, and cultural nature in such a manner that they can increase or decrease perceptions of risk (kasperson & kasperson, 2005) . it is important to note that the perceived risk could be raised or be diminished depending on the factors in the larger context, which makes it different from the vulnerability paradigm which tends to assume the factors involved will be primarily negative ones. we have taken this idea and extended it to the behaviors that appear in disasters and crises. extreme heat waves and massive blizzards are hardly new weather phenomena (burt, 2004) . there have recently been two heat waves, however, that have new elements in them. in 2003, a long lasting and very intensive heat wave battered france. nearly 15,000 persons died (and perhaps 22,000-35,000 in all of europe). particularly noticeable was that the victims were primarily socially isolated older persons. another characteristic was that officials were very slow in accepting the fact that there was a problem and so there was very little initial response (lagadec, 2004) . there was a similar earlier happening 1995 in chicago not much noticed until reported in a study seven years later (see klinenberg, 2002) . it exhibited the same features, that is, older isolated victims, bureaucratic indifference, and mass media uncertainty. at the other temperature extreme, in 1998, canada experienced an accumulation of snow and ice that went considerably beyond the typical. the ice storm heavily impacted electric and transport systems, especially around montreal. the critical infrastructures being affected created chain reactions that reached into banks and refineries. at least 66 municipalities declared a state of emergency. such a very large geographic area was involved that many police were baffled that "there was no scene", no "ground zero" that could be the focus of attention (scanlon, 1998) . there were also many emergent groups and informal network linkages (scanlon, 1999) . in some ways, this was similar to what happened in august 2003, when the highly interconnected eastern north american power grid started to fail when three transmission lines in the state of ohio came into contact with trees and short circuited (townsend & moss, 2005) . this created a cascade of power failures that resulted in blackouts in cities from new york to toronto and eventually left around 50 million persons without power, which, in turn, disrupted everyday community and social routines (ballman, 2003) . it took months of investigation to establish the exact path of failure propagation through a huge, complex network. telecommunication and electrical infrastructures entwined in complex interconnected and network systems spread over a large geographic area with multiple end users. therefore, localized disruptions can cascade into large-scale failures (for more details, see townsend & moss, 2005) . such power blackouts have occurred among others in auckland, new zealand in 1998 (newlove, stern, & svedin, 2002) ; in buenos aires in 1999 (ullberg, 2004); in stockholm in 2001 and in siberian cities in 2001 (humphrey, 2003 ; in moscow in 2005 (arvedlund, 2005 ; in brazil in 2009 (brooks, 2009); in bangladesh in 2014 (al-mahmood, 2014 , and in sri lanka in 2016 (lbo, 2016). all of these cases initially involved accidents or software and hardware failures in complex technical systems that generate severe consequences creating a crisis with major economic and often political effects. these kinds of crises should have been expected. a national research council report (1989) forecast the almost certain probability of these kinds of risks in future network linkages. blackouts can also be deliberately created either for good or malevolent reasons having nothing to with problems in network linkages. employees of the now notorious enron energy company, in order to exploit western energy markets, indirectly but deliberately took off line a perfectly functioning las vegas power plant so that rolling blackouts hit plant-dependent northern and central california with about a million residences and businesses losing power (egan, 2005) . in the earliest days of electricity in new york city, the mayor ordered the power cut off when poor maintenance of exposed and open wires resulted in a number of electrocutions of citizens and electrical workers (jonnes, 2004) . one should not think of blackouts as solely the result of mechanical or physical failures creating chain-like cascades. most disasters are still traditional ones. for example, four major hurricanes hit the state of florida in 2004. we saw very little in what we found that required thinking of them in some major new ways, or even in planning for or managing them. the problems, individual or organizational, that surfaced were the usual ones, and how to successfully handle them is fairly well known. more important, emergent difficulties were actually somewhat better handled than in the past, perhaps reflecting that officials may have had exposure to earlier studies and reports. thus, the warnings issued and the evacuations that took place were better than in the past. looting concerns were almost non-existent and less than ten percent indicated possible mental health effects. the pre-impact organizational mobilization and placement of resources beyond the community level was also better. the efficiency and effectiveness of local emergency management offices were markedly higher than in the past. not everything was done well. long known problematical aspects and failures to implement measures that research had suggested a long time ago were found. there were major difficulties in interorganizational coordination. the recovery period was plagued by the usual problems. even the failures that showed up in pre-impact mitigation efforts were known. the majority of contemporary disasters in the united states are still rather similar to most of the earlier ones. what could be seen in the 2004 hurricanes in florida was rather similar to what the disaster research center (drc) had studied there in the 1960s and the 1970s. as the electronic age goes beyond its birth and as other social trends continue, new elements may appear creating new problems that will necessitate new planning. if and when that happens, we may have rather new kinds of hurricane disasters, but movement in that direction will be slow. as the famous sociologist herbert blumer used to say in his class lectures a long time ago, it is sometimes useful to check whatever is theoretically proposed against personal experience. in 2005, an extensive snowstorm led to the closing of almost all schools and government offices in the state of delaware. this was accompanied by the widespread cancellations of religious and sport events. there was across the board disruption of air, road and train services. all of this resulted in major economic losses in the millions of dollars. there were scattered interruptions of critical life systems. the governor issued a state of emergency declaration and the state as well as local emergency management offices fully mobilized. to be sure, what happened did not fully rival what surfaced in the canadian blizzard discussed earlier. but it would be difficult to argue that it did not meet criteria often used by many to categorize disasters. what happened was not that different from what others and we had experienced in the past. in short, it was a traditional disaster. finally, at the same time we were thinking about the florida hurricanes and the delaware snowstorm, we also observed other events that many would consider disasters or crises. certainly, a bp texas plant explosion in 2005 would qualify. it involved the third largest refinery in the country. more than a hundred were injured and 15 persons died. in addition, there was major physical destruction of refinery equipment and nearby buildings were leveled. there was full mobilization of local emergency management personnel (franks, 2005) . at about the same time, there were landslides in the state of utah and california; a stampede with hundreds of deaths in a bombay, india temple, train and plane crashes in different places around the world, as well as large bus accidents; a dam rupture which swept away five villages, bridges and roads in pakistan; recurrent coal mine accidents and collapses in china; recurrent false reports in asia about tsunamis that greatly disrupted local routines; sinking of ferries with many deaths, and localized riots and hostage takings. at least based on press reports, it does not seem that there was anything distinctively new about these occasions. they seem to greatly resemble many such prior happenings. unless current social trends change very quickly in hypothetical directions (e.g., marked changes as a result of biotechnological advances), for the foreseeable future there will continue to be many traditional local community disasters and crises (such as localized floods and tornadoes, hostage takings or mass shootings, exploding tanker trucks or overturned trains, circumscribed landslides, disturbances if not riots at local sport venues, large plant fires, sudden discoveries of previously unknown very toxic local waste sites, most airplane crashes, stampedes and panic flights in buildings, etc.). mega-disasters and global crises will be rare in a numerical and relative sense, although they may generate much mass media attention. for example, the terrorist attacks in european cities (madrid in 2004; london in 2005; paris in 2015; brussels, nice, munich berlin in 2016; stockholm and manchester in 2017) were certainly major crises and symbolically very important, but numerically there are far more local train wrecks and car collisions everyday in many countries in the world. the more localized crises and disasters will continue to be the most numerous, despite the rise of transboundary crises and disasters. what are some of the implications for planning and managing that result from taking the perspective we have suggested about crises and disasters? if our descriptions and analyses of such happenings are valid, there would seem to be the need for new kinds of planning and preparation for the management of future crises and disasters (ansell et al., 2010) . non-traditional disasters and crises require some non-conventional processes and social arrangements. they demand innovative thinking "outside of the box" (boin & lagadec, 2000; lagadec, 2005) . this does not mean that everything has to be new. as said earlier, all disasters and crises share certain common dimensions or elements. for example, if early warning is possible at all, research has consistently shown that acceptable warnings have to come from a legitimately recognized source, have to be consistent, and have to indicate that the threat or risk is fairly immediate. these principles certainly pertain to the management of transboundary disruptions. actually, if traditional risks and hazards and their occasional manifestations were all we needed to be worried about, we would be in rather good shape. as already said several times, few threats actually manifest themselves in disasters. for example, in the 14,600 plus tornadoes appearing in the united states between 1952 and 1973, there were casualties in only 497 of them, and 26 of these occasions accounted for almost half of the fatalities (noji, 2000) . similarly, it was noted in 1993 that while about 1.3 million people had been killed in earthquakes since 1900, over 70% of them had died in only 12 occurrences (jones, noji, smith, & wagner, 1993, p. 19) . we can say that risks and hazards and their relatively rare manifestations in crises and disasters are being coped with much better than they ever were even just a half-century ago. for example, there has been a remarkable reduction in certain societies of fatalities and even property destruction in some natural disaster occasions associated with hurricanes, floods and earthquakes (see scanlon, 2004 for data on north america). in the conflict area, the outcomes have been much more uneven, but even here, for example, the recurrence of world wars seems very unlikely. but transboundary crises and disasters require some type of transboundary cooperation. for example, let us assume that a health risk is involved. if international cooperation is needed, who talks with whom about what? at what time is action initiated? who takes the lead in organizing a response? what legal issues are involved (e.g., if health is the issue, can health authorities close airports?)? there might be many experts and much technical information around; if so, and they are not consistent, whose voice and ideas should be followed? what should be given priority? how could a forced quarantine be enforced? what of ethical issues? who should get limited vaccines? what should the mass media be told and by who and when? at a more general level of planning and managing, we can briefly indicate, almost in outline form, a half dozen principles that ought to be taken into account by disaster planners and crisis managers. first, a clear connection should be made between local planning and transboundary managing processes. there usually is a low correlation between planning and managing, even for traditional crises and disasters. but in newer kinds of disasters and crises, there are likely to be far more contingencies. planning processes need to be rethought and enhanced to help policymakers work across boundaries. second, the appearance of new emergent social phenomena (including groups and behaviors) needs to be taken into account. there are always new or emergent groups at times of major disasters and crises, but in transboundary events they appear at a much higher rate. networks and network links have to be particularly taken into account. third, there is the need to be imaginative and creative. the response to hurricane katrina suggests how hard it can be to meet transboundary challenges. but improvisation can go a long way. a good example is found in the immediate aftermath of 9/11 in new york. in spite the total loss of the new york city office of emergency management and its eoc facility, a completely new eoc was established elsewhere and started to operate very effectively within 72 h after the attack. there had been no planning for such an event, yet around 750,000 persons were evacuated by water transportation from lower manhattan (kendra & wachtendorf, 2016; kendra, wachtendorf, & quarantelli, 2003) . fourth, exercises and simulations of disasters and crises must take into account transboundary contingencies. most such training and educational efforts along such lines are designed to be like scripts for plays. that is a very poor model to use. realistic contingencies, unknown to most of the players in the scenarios, force the thinking through of unconventional options. even more important, policymakers need to be explicitly trained in the management of transboundary crises and disasters. fifth, planning should be with citizens and their social groups, and not for them. there is no such thing as the "public" in the sense of some homogenous entity (blumer, 1948) . there are only individual citizens and the groups of which they are members. the perspective from the bottom up is crucial to getting things done. this has nothing to do with democratic ideologies; it has instead to do with getting effective and efficient planning and managing of disasters and crises. related to this is that openness with information rather than secrecy is mandatory. this runs against the norms of most bureaucracies and other organizations. the more information the mass media and citizens have, the better they will be able to react and respond. however, all this is easier said than done. finally, there is a need to start thinking of local communities in ways different than they have been traditionally viewed. up to now, communities have been seen as occupying some geographical space and existing in some chronological time. instead, we should visualize the kinds of communities that exist today are in cyberspace. these newer communities must be thought of as existing in social space and social time. viewed this way, the newer kinds of communities can be seen as very important in planning for and managing disasters and crises that cut across national boundaries. to think this way requires a moving away from the traditional view of communities in the past. this will not be easy given that the traditional community focus is strongly entrenched in most places around the world (see united nations, 2005) . but "virtual reality communities" will be the social realities in the future. assuming that what we have written has some validity, what new research should be undertaken in the future on the topic of future disasters and crises? in previous pages, we suggested some future studies on specific topics that would be worthwhile doing. however, in this section we want to outline research of a more general nature. for one, practically everything we discussed ought to be looked at in different cultures and societies. as mentioned earlier, there is a bias in our perspective that reflects our greater familiarity with and awareness of examples from the west (and even more narrowly western europe, the united states and canada). in particular, there is a need to undertake research in developing rather than only developed countries. and that includes at least some of these studies being undertaken by researchers and scholars from the very social systems that are being studied. the different cultural perspectives that would be brought to bear might be very enlightening, and enable us to see things that presently we do not see, being somewhat a prisoner of our own culture. second, here and there in this chapter, we have suggested that it is important to study the conditions that generate disasters and crises. but there has to be at least some understanding of the nature of x before there can be a serious turn to ascertaining the conditions that generate x. we have taken this first step in this chapter. future work should focus more on the generating conditions. a general model would involve the following ideas. the first is to look at social systems (societal, community and/or organizational ones), and to analyze how they have become more complex and tightly coupled. the last statement would be treated as a working hypothesis. if that turns out to be true, it could then be hypothesized that systems can break down in more ways than ever before. a secondary research thrust would be to see if systems also have developed ways to deal with or cope with threatening breakdowns. as such, it might be argued that what ensues is an uneven balance between resiliency and vulnerability. in studying contemporary trends, particular attention might be given to demographic ones. it would be difficult to find any country today where the population composition is not changing in some way. the increasing population density in high risk areas seems particularly important. another value in doing research on this topic is that much demographic data are of a quantitative nature. we mentioned financial and economic collapses cutting across different systems. how can financial collapse conceivably be thought of as comparable in any way to natural disasters and crises involving conflict? one simple answer is that for nearly a hundred years, one subfield of sociology has categorized, for example, panic flight in theater fires and financial panics as generic subtypes within the field of collective behavior (blumer, 1939; smelser, 1963) . both happenings involve new, emergent behaviors of a non-traditional nature. in this respect, scholars long ago put both types of behavior into the same category. although disaster and crisis researchers have not looked at financial collapses, maybe it is time that they did so. these kinds of happenings seem to occur very quickly, are ambiguous as to their consequences, cut across political and sector boundaries, involve a great deal of emergent behavior and cannot be handled at the community level. in short, what has to be looked for are genotypic characteristics not phenotypic ones (perry, 2004) . if whales, human beings, and bats can all be usefully categorized as mammals for scientific research purposes, maybe students of disasters should also pay less attention to phenotypic features. if so, should other disruptive phenomena like aids also be approached as disasters? our overall point, is that new research along the lines indicated might lead researchers to seeing phenomena in ways different than they had previously seen. finally, we have said little at all about the research methodologies that might be necessary to study transboundary ruptures. up to now, disaster and crisis researchers have argued that the methods they use in their research are indistinguishable from those used throughout the social sciences. the methods are simply applied under circumstances that are relatively unique (stallings, 2002) . in general, we agree with that position. but two questions can be raised. first, if social scientists venture into such areas as genetic engineering, cyberspace, robotics and complex infectious diseases, do they need to have knowledge of these phenomena to a degree that they presently do not have? this suggests the need for actual interdisciplinary research. social scientists ought to expand their knowledge base before venturing to study certain disasters and crises, especially the newer ones. there is something here that needs attention. in the sociology of science there have already been studies of how researchers from rather different disciplines studying one research question, interact with one another and what problems they have. researchers in the disaster and crisis area should look at these studies. our view is that the area of disasters and crises is changing. this might seem to 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disasters letter from the president. international sociological association newsletter 2 hydropolitics of the nile valley the popular culture of disaster: exploring a new dimension of disaster research handbook of disaster research the societal implications of a comet/asteroid impact on earth: a perspective from international development studies social science and natural hazards after its epidemic arrival, sars vanishes urban space as "field" aspects of late ottoman town planning after fire cities and catastrophes: coping with emergency in european history key: cord-032269-zhk5fyfc authors: gerard, françois; imbert, clément; orkin, kate title: social protection response to the covid-19 crisis: options for developing countries date: 2020-08-29 journal: nan doi: 10.1093/oxrep/graa026 sha: doc_id: 32269 cord_uid: zhk5fyfc the public health response to covid-19 in many countries has involved strict restrictions on movement and economic activity which threaten the livelihoods of economically vulnerable households. in response, governments are adopting emergency economic measures to provide households with some safety net. we provide an overview of the policies that could form a comprehensive social protection strategy in low-income and middle-income countries, with examples of specific policies that have been adopted. our core argument is that these countries can cast an emergency safety net with extensive coverage if they use a broader patchwork of solutions than higher-income countries. these strategies could include expanding their social insurance system, building on existing social assistance programmes, and involving local governments and non-state institutions to identify and assist vulnerable groups who are otherwise harder to reach. covid-19 has now reached low-income and middle-income countries. 1 the public health response in many countries has involved strict restrictions on movement and economic activity (e.g. closing workplaces, banning gatherings, restricting travel) and others are considering imposing similar policies. 2 domestic measures, as well as similar measures adopted globally, are likely to have an immediate negative impact on household incomes, and might threaten the livelihoods of households who are already vulnerable economically. 3 in response, governments are adopting emergency economic measures to provide households with some safety net. 4 we provide an overview of the policies that could form a comprehensive social protection strategy in developing countries, with examples of specific policies adopted around the developing world in recent days. our core argument is that middle-income and lower-income countries can cast an emergency safety net with extensive coverage if they use a broader patchwork of solutions than higher-income countries. these strategies could include: 1. expanding their social insurance system, which typically covers a much smaller share of the labour force than in higher-income countries; 2. building on existing social assistance programmes, which reach a large share of households in many developing countries; 3. involving local governments and non-state institutions to identify and assist vulnerable groups who may not be reached by (1) and (2). the debate on social protection responses occurs as countries face both a public health and a public finance crisis. first, governments have to design a public health response to mitigate or suppress the virus which balances provision of covid-19 health care against other health needs and which can be implemented in contexts where strict social distancing is not practical. 5 the strictness and duration of the restrictions imposed on mobility and economic activity will, to a large extent, determine the immediate impact on household incomes, and thus the scale of the social protection response needed to mitigate it. in turn, the support provided to help households could increase compliance with public health policies. 6 second, governments have to finance both health and economic measures, while experiencing shortfalls in tax revenues. many developing countries were already heavily indebted before the crisis, and investors have sold emerging market assets, making borrowing on the open market difficult. 7 without novel solutions to allow governments to borrow internationally and secure additional aid quickly, 8 the scale of their social protection response will be limited, and developing countries may not afford a public health response imposing strict restrictions on their economies. 9 low-income and middle-income countries share features that present specific challenges and opportunities for their social protection response, compared to higherincome countries. 11 1. the economic consequences of the crisis for households in developing countries will be severe. a larger share of workers are in occupations and industries less compatible with social distancing (e.g. construction, labour-intensive manufacturing, small retail). households have more limited access to credit and hold limited savings or buffer stock. their usual means of smoothing income shocks, casual work and migration, are not possible when economic activity and mobility are restricted. support from social networks is also more limited when everyone experiences a simultaneous shock, which in the case of a global crisis is true even of the most extended networks (e.g. international remittances). complying with public health guidelines will incur out-of-pocket costs (e.g. access to water in urban slums) that are high as a portion of available income. in this context, households may take short-term decisions out of necessity that leave them in long-term poverty, such as selling assets to finance food consumption. moreover, firms often face more severe liquidity constraints in developing countries, limiting their ability to keep paying their workers during the crisis. the need for government intervention is thus particularly severe in developing countries today. 2. yet, government programmes insuring against job or earnings loss have more limited scope in developing countries. first, a larger share of workers are in employment categories that are difficult to insure against such risks. many employees work for informal (i.e. unregistered) businesses, which may not contribute to existing social insurance programmes, while others work for formal businesses on informal contracts. the self-employed-whose 'regular' income is more difficult to assess even in richer countries-account for a larger share of employment, and many of them also carry out their activities informally. second, government programmes insuring workers against such risks are more limited in developing countries even for formal (i.e. registered) employees. for instance, the share of developing countries in which these workers are eligible for some form of unemployment insurance is much lower than in higherincome countries (see figure 1 ). existing social insurance programmes will thus be less effective in supporting workers in developing countries. 3. at the same time, many developing countries can build on large existing social assistance programmes. as figure 2 (a) shows, these cover a sizeable share of the population, including contexts where informal work and self-employment are the norm. these programmes take various forms, such as conditional or unconditional cash transfers, work guarantees, or the direct delivery of food and other necessities (see figure 2 (b)). they target poor households and are not necessarily designed to mitigate job loss or income shocks. they can be made more generous in this time of crisis. they can also provide a base for emergency assistance, e.g. they often rely on detailed registries and effective infrastructure for transferring resources. existing social assistance programmes thus provide invaluable mechanisms to provide emergency relief to many households. 4. some vulnerable populations are not easily covered by social insurance and are usually outside the populations targeted by social assistance programmes (e.g. informal workers with volatile incomes, migrant workers), making them particularly hard to reach in an emergency. however, local governments in many developing countries are in a good position to assess unmet needs and to deliver direct assistance. the same is true of a range of non-state actors (e.g. ngos, savings and loan associations, mutual insurance organizations), which are active in contexts where state capacity is limited (e.g. remote rural areas or urban slums). involving local actors, especially non-state ones, is an opportunity but also a challenge, as their efforts need to be coordinated, and they need to be monitored by both citizens and national governments. credible partners thus exist for central governments to help 'harder-to-reach' segments of the population, as long as their actions are in line with the national effort and are accountable to the public they serve. despite pervasive informality, formal employees constitute a major employment category in many developing countries, particularly in middle-income countries. moreover, these workers are possibly even less well prepared than their counterparts in richer countries to cope with the economic impact of the crisis. therefore, expanding the social insurance system to provide more support to formal employees could be an important pillar of the social protection strategy of developing countries, even if it will not be sufficient to reach all workers (e.g. informal workers). governments around the world have adopted new job retention schemes in the last few weeks. such schemes already existed in some countries (e.g. germany, italy), including developing countries (e.g. brazil), to help firms cope with temporary shocks (e.g. drop in demand, insolvency issues, natural disasters). they provide subsidies for temporary reductions in the number of hours worked, replacing a share of the earnings forgone by the worker due to the hours not worked, over a maximum period of time (a few weeks or months). their advantage in the current crisis is to avoid the destruction of existing jobs (giupponi and landais, 2018) , which should be viable again once the public health response is relaxed. subsidizing these jobs could allow firms to continue to operate, even if at some reduced level, without imposing large pay cuts. subsidizing the survival of jobs that must be temporarily suspended could also spare workers and firms the costs of finding a new job and replacing the worker, speeding up the economic recovery. the argument in favour of job retention schemes is strong for developing countries. without such schemes, many workers will be laid off with no unemployment insurance. moreover, setting up a new job retention scheme might be logistically easier than setting up an unemployment insurance programme, as governments could use firms as intermediaries to channel the income support to their workers. job retention schemes are also most valuable in labour markets where search frictions are high. recent research shows (i) that finding the right workers is a major challenge to firm growth in developing countries (hardy and mccasland, 2017) ; (ii) that workers struggle to find formal employment because of difficulties signalling their skills credibly to firms (abebe et al., 2020 , carranza et al., 2020 ; and (iii) that displaced formal employees take much longer to find a new formal job than in higher-income countries (gerard and gonzaga, 2016) . the destruction of existing jobs might thus have severe longer-term impacts on the size and productivity of developing countries' formal sectors, which are a key policy focus (levy, 2008) . some implementation details might be particularly important in developing countries: 12 • targeting. in thailand, a recent job retention scheme covers a fixed share of workers' monthly earnings; 13 in morocco, a new programme provides a fixed monthly amount to workers whose job must be temporarily suspended; 14 the amount received under the brazilian and south african schemes is not fixed, but the share of forgone earnings that it replaces is lower for higher-wage workers. 15 targeting the income support to low-wage workers can help more workers for a given budget and leave more financial resources to help other worker categories. however, it will require higher-wage workers to make relatively larger adjustments and increase the risk that their jobs will not survive the crisis. additionally, targeting support to low-wage workers may not necessarily target jobs for which search frictions are most important, which may slow down the economic recovery. • payment. in contrast to some pre-existing job retention schemes (e.g. in france), the above-mentioned schemes do not rely on firms advancing the payment of the earnings subsidy. firms in developing countries may not have enough liquidity to make such advances or may not trust the government to reimburse them quickly, disincentivizing participation (see levinsohn et al. (2014) on an earlier wage subsidy in south africa). • other firm contributions. job retention schemes sometimes require firms to contribute towards their workers' compensation beyond the hours actually worked (e.g. for larger firms in the brazil scheme). this could incentivize firms struggling to stay afloat to lay off their workers rather than to participate in the scheme. more generally, firms face other costs than their payroll and helping them cover these costs might be necessary for existing jobs to survive. several countries have implemented a range of policies in this regard, such as low-interest loans, rent moratoriums, or tax relief. 16 even with a job retention scheme, many workers will likely be laid off and developing countries with unemployment insurance programmes will be in a better place to support these workers. however, it might be important to adjust their programmes, such as by relaxing job search requirements and extending eligibility rules. for instance, in south africa, workers are usually eligible for 1 day of unemployment insurance for every 6 days of employment. in brazil, many workers must accumulate up to 12 months of employment to become eligible for any benefits. such rules could leave laid-off workers who have limited job tenure (e.g. less than a year) with little income support throughout this crisis and no other employment options in the short run. a policy that is more common than unemployment insurance in developing countries is mandatory severance payments that firms must pay to workers at layoff. the insurance value of such lump-sum payments is limited when workers cannot find new jobs quickly. moreover, firms facing severe reductions in cash-flow might struggle to pay what they owe to their workers and governments may need to provide firms with low-interest loans to fund severance pay obligations (gerard and naritomi, 2019) . governments could also consider topping up the severance amount and spreading its payment over time to avoid workers spending it too quickly after layoff. another common component of the social insurance system in developing countries is mandatory contributions by firms or workers to forced (illiquid) savings accounts for long-term objectives, e.g. to fund a complementary severance payment at layoff or a complementary pension at retirement. workers could be allowed to withdraw some amount from these accounts in the current crisis. for instance, the indian government recently allowed formal workers to withdraw up to 3 months' worth of salary (but no more than 75 per cent of the amount in the account) from their employee provident fund. 17 the benefits for workers from such early withdrawals might greatly exceed their costs, particularly for younger workers who will be able to replenish their forced savings accounts in coming years. finally, some countries have considered extending the logic of these social insurance programmes to formal (i.e. registered) self-employed workers. however, it is more challenging to determine (a) their 'usual' earnings level prior to the crisis and (b) the reduction in earnings caused by the crisis. these challenges will only be exacerbated in developing countries, as governments likely have less information about these workers' past or current earnings than in higher-income countries, even for self-employed workers who are formally registered. 18 in this context, developing country governments may be left with fewer options. • one option is to make unconditional monthly transfers of a fixed amount. for instance, the auxilio emergencial in brazil will provide self-employed workers with a monthly payment of 60 per cent of the minimum wage for the next 3 months. 19 it might be possible to design a more fine-grained payment scheme, e.g. based on some presumptive income varying across sectors of activity. however, the costs of designing a more complicated scheme might outweigh its benefits if it leads to long delays in disbursements (as in the uk 20 ). • a complementary option is to provide emergency low-interest credit lines for self-employed workers, allowing them to borrow a maximum amount to pay themselves in the coming months. such policies have been recently implemented in some countries to help small and medium firms pay their workers' wages throughout the crisis, 21 and could be extended to self-employed workers. repayment of loans could be made contingent on self-employed workers' future income or gross revenue crossing above a certain threshold, to mitigate concerns of taking on more debt at this time. social insurance programmes will fail to reach a large share of households in developing countries, in particular those mostly active in the informal sector of the economy. however, many of these households could be reached through social assistance programmes. for example, south africa's child support grant reaches many poor households who are in informal jobs and will not be covered by its job retention scheme. 22 maintaining these programmes throughout the crisis will already provide some minimal support to many affected households, although some of their rules might need to be adapted. these programmes could also be made temporarily more generous to compensate current beneficiaries for income losses. 23 finally, these programmes could be temporarily extended to new households, e.g. to households whose information was collected to target these programmes, and who were deemed ineligible. in practice, these programmes take many forms and their key features determine how they can be used in response to the crisis. the first feature is the type of assistance that these programmes provide. some programmes dispense cash; some provide in-kind assistance (e.g. food, fuel); others subsidize access to essential goods and services (e.g. health services, housing). in cases where supply chains are impacted or prices rise, in-kind provision will be most powerful, and public procurement will support producers as well. for instance, the indian government doubled the monthly foodgrain (wheat and rice) household allowance and added pulses to the ration provided by the public distribution system. 24 when households can buy goods and services at reasonable prices, cash transfers are quicker to implement and more fungible than in-kind transfers. many countries have temporarily topped up the amount received by the current beneficiaries of social assistance programmes. for instance, the indonesian government increased both the benefit amounts of its cash transfer programme (pkh) and the frequency of its payments (from quarterly to monthly). 25 kenya has increased the amount of its pension and orphan and vulnerable children's grant. 26 provision or delay payments, especially for utilities that are publicly owned (e.g. electricity bills or rents). indonesia has recently granted 3 months of free electricity to 24m customers with low power connections. the second feature is the conditionality of the social assistance. conditional cash transfers (cct) programmes are a popular form of income support in developing countries (e.g. mexico's prospera or brazil's bolsa familia). they make assistance conditional on a particular behaviour encouraged by the state, e.g. enrolling children at school or immunizing them. public works programmes are also often used for antipoverty relief in the developing world (e.g. india's mg-nregs or ethiopia's psnp). these conditions cannot be fulfilled at the time when countries have closed schools and public works sites because of safety, or when hospitals are overwhelmed. to provide social protection in the current crisis, cct and public works programmes need to become temporarily unconditional. removing conditionalities may be legally or politically difficult. for instance, india's relief package increases the wage for mg-nregs workers, but it makes no provision to make public work sites compatible with social distancing. other public works programmes, such as ethiopia's psnp (berhane et al., 2015) , already provide cash or food for those identified by communities as unable to work and could perhaps extend this feature to all programme recipients. the third feature of social assistance programmes is the population that they target. some programmes help specific socio-demographic groups (e.g. non-contributory social pensions for the elderly or grants for orphans and children). some provide relief to specific occupational groups (e.g. farmer drought relief funds). others are targeted according to economic indicators, such as transfer to households deemed poor based on their assets (e.g. indonesia's conditional cash transfer pkh). developing countries can leverage all their programmes simultaneously to provide assistance to a wide range of vulnerable groups. each of these programmes suffers from inclusion errors, with resources being diverted to non-eligible households or stolen by corrupt bureaucrats, and from exclusion errors, with eligible households deterred from applying (hanna and olken, 2018) . in these times of emergency, governments will have to rely on social assistance programmes, even if their targeting is not perfect. direct beneficiary payments, and transparency in how much is given to whom, may help keep 'fund leakages' under control (muralidharan et al., 2016; banerjee et al., 2016) . using existing programmes to extend assistance to new beneficiaries is possible, but requires both information on potential beneficiaries and payment infrastructure to reach them. some countries have built digital infrastructures linking governments and poor citizens for various programmes that can now be used for emergency payments (see rutkowski et al., 2020) . for example, chile has a national id-linked basic account for most poor people, which will be used to pay more than 2m low-income individuals a once-off grant. india also has sent money to jan dhan accounts linked to the adhaar id system, which were created to promote financial inclusion among the poor. other countries have detailed censuses to identify the poorest citizens for social assistance. these censuses can now be used to extend assistance to people who were initially deemed too well-off for assistance. for example, the peruvian programme bono yo me quedo en casa 27 offers an additional transfer equivalent to 50 per cent of the minimum wage to 2.7m poor households identified in a dataset created to target the peruvian juntos cct. beneficiaries can check their availability online, and payments are routed via a national bank. in countries in which no pre-existing databases are available, or where governments would not automatically enrol large parts of the population in emergency assistance programmes, they may prefer to ask people in need of assistance to opt in. for instance, pakistan has announced a relief package with large transfers to the poor, but the emergency programme requires people to self-identify as vulnerable and to text the existing social programme ehsass with their national identification number. enrolling new beneficiaries and paying them is a challenge in many settings. in noncrisis times, enrolling people and checking eligibility may be more effective to target the poorest than automatic enrolment (alatas et al., 2016) . but enrolment systems set up in times of emergency may not necessarily target the most vulnerable efficiently. 28 for instance, the state of bihar in india has announced a transfer to all migrant workers stranded in other states and plans to perform identity checks through a phone app. 29 households recorded in the cadastro unico-i.e. the brazilian census of the poor-will be eligible for the same auxilio emergencial as formal self-employed workers (see above), but the government also created a new website to extend coverage of this emergency assistance programme to informal workers at large. the use of these technologies may prevent individuals without a computer or smartphone from enrolling, unless complementary systems are set up. even if they successfully enrol, transferring money to these new beneficiaries can be difficult. relying on digital payment infrastructures is quicker and safer in an epidemic, but it might exclude particularly vulnerable households: globally, only 69 per cent of adults have any digital bank or mobile money account; only 30 per cent have received wages or government transfer payments directly to an account (findex, 2017) . in this context, it will be necessary to set up physical collection points or direct delivery systems for these households while still respecting social distancing measures. in peru, bank branches were overcrowded when recipients of the bono yo me quedo en casa programme came to cash their benefits. 30 a strategy based on expanding social insurance and building on existing social assistance programmes will likely leave important needs unmet. for instance, informal workers with volatile incomes (especially in urban areas) or with weak ties to their place of residence (e.g. migrant workers) are often beyond the reach of social insurance and usually outside the populations targeted by social assistance. a comprehensive social protection response could involve local governments and a range of non-state actors to collect better information on these unmet needs and to deliver targeted assistance. 28 state and municipal governments may play a complementary role to national governments, who often have the main mandate for social insurance and assistance. many developing countries have decentralized extensively over the last decades, and have devolved a range of government functions to lower echelons of government, including responsibilities related to social assistance. for example, the responsibility for implementing india's employment guarantee mg-nregs is devolved from the central government to the state, the district, the block, down to the gram panchayat, a local government of about 500 households. it is common for developing countries to elect or select a large cadre of leaders at very local levels. in kenya, each village of ~120-200 households has a volunteer village leader who reports to the lowest level of paid civil servant, the assistant chief, adjudicates disputes, and spreads information from the state (orkin and walker, 2020; walker, 2019) . these structures can play multiple roles during this crisis. first, local structures can channel information up to decision-making structures, which is important when travel is limited. information could be movements of people, price and availability of food, whether new social protection measures have been successfully implemented, and whether specific groups remain unexpectedly not covered. in food-insecure countries such as malawi and ethiopia, infrastructure has been built to collect local data on food security and channel food or cash to famine-affected areas 31 and public works programmes to food-insecure areas (berhane et al., 2015 , beegle et al., 2017 . similarly, for public health success against ebola, it was vital that local structures relayed data back to coordinating structures for better decisions. 32 second, local structures could be involved in the identification of individuals in dire need of additional support. they were often involved in the targeting of social assistance programmes pre-crisis, both in the gathering of information on vulnerable populations for higher levels of government and in the prioritization of assistance to the most needed. for example, censuses of the poor used to target cct programmes are typically updated by local administrations in latin american countries. rwanda is using local structures to target in-kind food security packages, which will complement its existing social protection scheme. vulnerable households are identified at the most local (isibo) level, with information on numbers of households relayed up to higher government structures. 33 to avoid exclusion errors, the capital city government set up a toll-free line for households who reported they missed out in the targeting. 34 these institutions have particular strengths that may complement a national government response. they may have funding or staff already in place at local level. local authorities often receive block grant funding to address locally identified needs, with local structures in place to monitor how it is allocated. funding could be temporarily 31 repurposed or these structures could be used to channel any additional funds granted. for example, the indian government allowed state governments to use disaster funds to provide shelter and food to migrant workers. 35 local governments also have networks of employees (e.g. for education, health, welfare) in contact with more remote communities and able to support them in accessing services. for example, south africa's network of early childhood community care givers primarily conducts health promotion and prevention activities; pre-crisis, government tapped this network to assist families in enrolling for child support grants (hatipoglu et al., 2018) . local governments often have better information on local needs and preferences, so may be more responsive. as a result, their decisions may have more legitimacy. for example, in indonesia, leaders allocating cash transfer benefits via community targeting did reasonably well in terms of targeting the poor. communities were also more satisfied with community targeting than an externally administered proxy means test (alatas et al., 2012) . they may also be more easily held accountable to communities and may feel pressure to be more responsive, provided the resources and functions devolved to them are clearly communicated to the public (gadenne, 2017; martinez, 2018) . for example, the state government of bihar (india) has felt pressure to extend its attention to migrants in this crisis, a segment of the population which it does not usually serve or respond to, and which was excluded from the central government relief package. on the other hand, local structures may be more open to capture. for example, after a serious drought in 2002 in ethiopia, community-based food transfers were targeted to households with less access to support from relatives or friends, but were also twice as likely to be targeted to households with close associates in official positions (caeyers and dercon, 2012) . a range of non-state institutions are also particularly active in giving voice to specific groups or serving populations beyond the reach of the state. depending on the context, these institutions may be in a unique position to gather information on the needs of specific groups, and/or be credible partners for delivering assistance in an emergency. there are a broad range of examples of such institutions. illegal urban settlements sometimes have recognized local leaders who facilitate access to state services and social benefits and are accountable to local populations (e.g. in urban india). 36 recognized local ngos also often provide a range of services and sometimes coordinate their efforts within a geographic area under an umbrella organization (e.g. in urban brazil 37 ); they may have years of experience being accountable to both their donors and their beneficiaries. international ngos (e.g. brac, oxfam) have a strong presence across a range of contexts. there are also private associations with specific purposes, which can, in some instances, have wide coverage. for example, 24 per cent of africans participated in community-organized savings groups (findex, 2014) . membership may be even higher in rural areas: 53 per cent of a rural kenyan sample were members of a rotating savings group (rosca) (orkin and walker, 2020) . in ethiopia, over 90 per cent of villagers in two separate samples are members of burial associations (dercon et al., 2006; bernard et al., 2014) . another type of private association are professional organizations, which may be active in sectors that employ many informal or poor workers. for example, india's relief package encourages building and other construction worker welfare funds to provide emergency assistance. 38 these institutions could play a range of roles. some will likely repurpose themselves to provide emergency assistance in the current crisis spontaneously, an effort that could be leveraged and complemented by governments. governments could leverage their infrastructure to gather information on the needs of their many beneficiaries. many have a network of workers in remote areas, who are already part of public health responses, e.g. an ngo trained community volunteers, religious leaders, and traditional healers in senegal to monitor for common diseases in their villages. 39 they could be used to recruit people into government programmes in environments where communication about new programmes is difficult. for instance, kenya used roscas to enrol participants into its new health insurance scheme (oraro and wyss, 2018) . india used national rural livelihood missions and their network of self-help groups (shg) to advertise and enrol people into many development programmes, such as rural sanitation (swachh bharat mission). it may be unusual to involve non-state actors directly in provision of state assistance, but unprecedented times may call for exploring new opportunities. although there may be justifiable concerns about a lack of accountability, institutions with a long history and broad base of membership may be particularly resistant to the capture of transfers (dercon et al., 2006) . they already need to be locally legitimate to sustain their work, as they have no formal legal authority and are regulated largely by social sanction (olken and singhal, 2011) . the most important concern is that community institutions remain inclusive in times of crisis and share broadly the emergency resources given to them (gugerty and kremer, 2008) . for example, rural communities need to provide support to returning migrants rather than banning them from coming home for fear of the contagion. another concern is that non-state institutions enrolled in social protection efforts need also be onboard with governments' public health strategy (e.g. some religious organizations have been promoting alternative ways of dealing with the pandemic 40 ). our analysis highlights that governments in developing countries will have to find creative solutions to build a comprehensive social protection response to the economic impacts of the covid-19 epidemic. job retention programmes already existed in some countries (e.g. brazil) and could be used more widely to protect employment in the formal sector. 41 some governments, as in chile or india, have leveraged id-linked bank accounts opened for financial inclusion purposes to provide direct support to the poor. even populations that live at the margins of social protection systems, like migrant workers in the informal sector who are not registered where they work, can be reached through associations that work with them (like the aajeevika bureau for internal migrants in india). yet, any government response will be imperfectly targeted, with important inclusion and exclusion errors. government responses based on social insurance programmes may reach many formal employees and registered self-employed (although coarsely), but will miss the informal sector, which is an important part of developing countries' workforce. social assistance programmes allow governments to broaden the base of their response, but their targeting is always specific to a particular dimension of poverty, and their delivery is often plagued with 'leakages'. involving local governments or non-state actors to help provide assistance presents clear opportunities, but also runs the risk of resources being diverted by local elites or used for clientelism. together, these policies may reach some households through several channels at once while leaving others with no direct support. however, in an emergency, the benefits from improving targeting and reducing leakages may not exceed the costs if an improved process leads to long delays in implementation. fortunately, even imperfectly targeted transfers will reach some 'left-behind' households through family, informal, or formal sharing structures. existing social protection transfers are often widely shared in families and extended networks even outside times of crisis. for instance, south african pensions received by grandparents benefit grandchildren (duflo, 2003) and young adults in the household (ardington et al., 2009) . households ineligible for progresa cash transfers still get loans and gifts from eligible households in the same village and have higher food consumption (angelucci and di giorgi, 2009 ). government could acknowledge explicitly that their emergency response will not reach all households and encourage beneficiaries to share their resources with others whom they identify as being in need, possibly subsidizing means of money transfers (e.g. reducing fees for bank or mobile money transfers 42 ). charitable giving could be encouraged in response to the crisis and channelled to vulnerable populations (e.g. zakat funds in muslim communities in bangladesh before ramadam 43 ). in fact, national funds run by governments and businesses have already raised record amounts in some countries. 44 the challenge of mitigating the economic effects of the pandemic is enormous. any solution will be flawed in many ways because speed is of the essence. but governments, donors, and civil societies have made major gains in the last 30 years in building infrastructure to reach the poorest. if internal and external financing can be found, developing countries can use this to create the economic space for an effective public health response. china has helped firms but does not seem to have protected employment (south china morning post transfer fees for kenya's popular mobile money system were recently waived, although for a public health reason (finextra defusing bangladesh's covid-19 time bomb thousands of ordinary south africans have contributed to the solidarity fund'). nigeria's similar version, run by the central bank, raised £33m in a week anonymity or distance? job search and labour market exclusion in a growing african city targeting the poor: evidence from a field experiment in indonesia indirect effects of an aid program: how do cash transfers affect ineligibles' consumption? labour supply responses to large social transfers: longitudinal evidence from south africa e-governance, accountability, and leakage in public programmes: experimental evidence from a financial management reform in india direct and indirect effects of malawi's public works programme on food security turning a shove into a nudge? a "labeled cash transfer" for education the implementation of the productive safety nets programme and the household asset building programme in the ethiopian highlands the future in mind: aspirations and forward-looking behaviour in rural ethiopia', working paper political connections and social networks in targeted transfer programmes: evidence from rural ethiopia', economic development and cultural change job search and hiring with two-sided information frictions covid-19 control in low-income settings and displaced populations: what can realistically be done?', working paper group-based funeral insurance in ethiopia and tanzania grandmothers and granddaughters: old-age pensions and intrahousehold allocation in south africa the global findex database 2014: measuring financial inclusion around the world the global findex database 2017: measuring financial inclusion and the fintech revolution tax me, but spend wisely? sources of public finance and government accountability informal labour and the efficiency cost of social programmes: evidence from the brazilian unemployment insurance programme', nber working paper, 22608. -naritomi subsidizing labour hoarding in recessions: the employment and welfare effects of short time work outside funding and the dynamics of participation in community associations universal basic incomes versus targeted transfers: anti-poverty programmes in developing countries are small firms labour-constrained: experimental evidence from ghana supporting the early childhood workforce at scale: community health workers in south africa wage subsidies and youth employment in south africa: evidence from a randomised control trial', working paper good intentions, bad outcomes: social policy, informality and economic growth in mexico sources of revenue and government performance: evidence from colombia building state capacity: evidence from biometric smartcards in india informal taxation how does membership in local savings groups influence the determinants of national health insurance demand? a cross-sectional study in kisumu cash transfers and community participation in public affairs: a village-level randomized controlled trial in kenya responding to crisis with digital payments for social protection: short-term measures with long-term benefits informal taxation and cash transfers: experimental evidence from kenya key: cord-026579-k3w8h961 authors: carr, paul r. title: shooting yourself first in the foot, then in the head: normative democracy is suffocating, and then the coronavirus came to light date: 2020-06-10 journal: postdigit sci educ doi: 10.1007/s42438-020-00142-3 sha: doc_id: 26579 cord_uid: k3w8h961 this text starts with the premise that ‘normative democracy’ has rendered our societies vulnerable and burdened with unaddressed social inequalities. i highlight three central arguments: (1) social media, and, consequently, citizen engagement are becoming a significant filter that can potentially re-imagine the political, economic, and social worlds, which increasingly bleed over to how we might develop and engage with ‘democracy’; to this end, i introduce a brief case study on the nefarious interpretation of the killing of jamal khashoggi in 2018 to underscore the tension points in normative democracy; (2) capitalism, or neoliberalism, needs to be more fully exposed, interrogated, and confronted if ‘normative, representative, hegemonic, electoral democracy’ is to be re-considered, re-imagined, and re-invented; the perpetuation of social inequalities lays bare the frailty of normative democratic institutions; (3) covid-19 has exposed the fault lines and fissures of normative democracy, illustrating here the ‘common sense’ ways that power imbalances are sustained, which leaves little room for social solidarity; i present herein the case of the economic/labor dynamic in quebec during the coronavirus. ultimately, i believe the quest to re-imagine a more meaningful, critically engaged democracy, especially during a context that is imbued with a political, economic, and public health crisis, cannot be delayed much longer. 2018; thésée, carr, duclos, and potwora 2018) , and contextualizes how we think (and act) about the subject. to further clarify this context of how normative democracy manifests itself, i highlight the following examples from my research projects with colleagues over the years, which involved studies in some 15 countries with roughly 5000 teacher education and educator participants (carr and thésée 2019) : & we found that the vast majority did not have a robust, significant democratic experience in their own education; & that this has affected how they consider democracy and education; & that social justice is, for many, a difficult and problematic area to cultivate in and through education owing to a weakly asserted, structured, and supported institutional culture based on normative democracy; & that most considered that the space for inclusive and critical engagement in and through education is constrained, limited, and fraught with obstacles; & that racialized participants had significantly higher levels of experience, conscientization, and engagement with, for example, racism, antiracism, and efforts to address racial inequities, which further underscores how normative democracy closes down fundamental debate, dialog, teaching and learning as well as transformative education while presenting the posture and framework of democracy. when democracy and education are considered to be naturally disconnected while not leaving room for a more critically engaged democracy, it is not difficult to imagine the suffocating nature of normative democracy. normative elections, the ones that have been so effectively presented by the usa as the backbone to any meaningful democracy, have been jettisoned into a cesspit of turmoil and intractable debate that often neglects problematizing some of the most intractable and germane issues (achen and bartels 2017; howe 2010; torcal and ramon montero 2013) . not everyone involved in elections is corrupt or corrupted, or is afflicted with unsightly motivations, and people who go to the polls are not simply sheep being led to the proverbial slaughterhouse. there is a great deal of complexity as to why we vote and why we hope that there will be some hope in participating in mainstream democracy, but the faith in electoral democracy is waning almost everywhere (torcal and ramon montero 2013; carr and thésée 2019 ). yet, these normative elections, which are often ordered to measure with the threat of massive (real and rhetorical) carpet-bombing and worse, if not realized, are replete with all kinds of paradoxical anti-democratic maneuvers, starting with who can be elected, how much money plays into the process, how media can control and shape the message, manipulation, and diversion is a fundamental component, how seeking to win is more a priority than seeking to build a meaningful democracy, and how capitalism is the enormous, indelicate, meandering proverbial 800pound gorilla in the room (amico 2020; carr and thésée 2019) . added to this is the role, the purpose, and place of education in supporting, cultivating, and building a critically engaged democracy as well as critically engaged citizen participation. it is extremely difficult to have one without the other (democracy without education, for example, or, rather, meaningful, critically engaged democracy without meaningful, critically engaged education). (see carr 2011, and carr and thésée 2019 , as well as the unesco chair dcmét website at uqo.ca/dcmet/ for an archive of publications.). and then, starting in late 2019, the world started to feel the indelible, intractable, and (in)visible perturbations of the coronavirus, which emanated in china, and has quickly disseminated throughout all regions, making it a global pandemic. the number of people affected, contracting the virus, and ultimately succumbing to it, is increasing daily at this time but there is much analysis and data-crunching indicating that, in many areas, after several weeks of self-distancing, hygienic measures, increasing testing, closing down all but 'essential services', and enhancing medical and health care measures, the 'curve' may be flattening. however, few people believe that the virus will disappear, nor that the cost, in terms of human life, will be entirely negligible. so what is the connection to democracy, capitalism (or perhaps more correctly neoliberalism), and covid-19? the vulnerabilities, inequalities, and fault lines that existed prior to the coronavirus have been exacerbated, and the virus has disproportionately impacted racialized, marginalized, and lower income communities. the contraction and death rates are higher, and the economic, labor, living, and social conditions have worsened, notably for already vulnerable communities. this pandemic, sadly, provides a tremendous and significant impetus to re-consider and re-calibrate our thinking around democracy (diamond 2020; roy 2020) . this text starts with the premise that 'normative democracy' has put us in a pickle, and that, although there are ways out if it, this will require breaking out of the glass box that has a great many of us believing that there is no alternative. i highlight three points related to democracy in this text, formulating the following central arguments: 1) social media and, consequently, citizen engagement are becoming a significant filter that can potentially re-imagine the political, economic, and social worlds (outside of and beyond normative democracy), which increasingly bleed over to how we might develop and engage with 'democracy' (garrett 2019) ; to this end, the advent of 'fake news' is a worthy subject to explore here because a functioning democracy, to a certain degree, is dependent on media/political literacy, critical engagement/participation, and the capacity to communicate, analyze, and disseminate nuanced perspectives, ideas, and information; i introduce a brief case study on the nefarious interpretation of the killing of jamal khashoggi in 2018 (bbc news 2019) to underscore the tension points in normative democracy; 2) capitalism, or neoliberalism, needs to be more fully exposed, interrogated, and confronted if 'normative, representative, hegemonic, electoral democracy' is to be re-considered, re-imagined, and re-invented (lydon 2017) ; the perpetuation of social inequalities lays bare the frailty of normative democratic institutions; 3) covid-19 has exposed the fault lines and fissures of normative democracy, illustrating here the 'common sense' ways that power imbalances are sustained, which leaves little room for social solidarity (human rights watch 2020); i present here a small case study of the economic and labor dynamic in quebec during the coronavirus. ultimately, i believe the quest to re-imagine a more meaningful, critically engaged democracy, especially during a context that is imbued with a political, economic, and public health crisis, cannot be delayed much longer. capitalism, in addition to acknowledged and unacknowledged hegemony, is central to this model or framework, and a natural order and superiority flows effortlessly through thinking and believing that this is the only way to be, exist and function. democracy 2.0, which considers more fluidly agency, power crystallizations, social justice, and individual as well as collectivist media and citizen engagement, is much messier than democracy 1.0, which connects more directly with normative, representative, hegemonic, and electoral machinations (carr, hoechsmann, and thésée 2018) . social media is an exemplary feature of this new environment and can help us draw out the fundamental question if greater media, communication, and online involvement can lead to more robust, critical democratic forms of citizen participation. elsewhere, with colleagues (carr, daros, cuervo, and thésée 2020) , i describe some of the overlapping components, processes, and concerns that help frame the context for social media, fake news, and citizen participation. it would appear that everyone today is somehow connected to social media, even if one does not have an account for one or many of the social networks that pervade, link and smother the socio-cultural landscape (keating and melis 2017) . there are networks for an untold array of information sharing and gathering. nouns have become verbs as in 'youtubbing,' 'blogging,' 'vlogging,' 'googling,' 'facebooking,' etc.. the reach is significant, and the digital imprints (and footprints) are equally commensurate (sun, wang, shen and zhang 2015) . one can do a search for a pair of shoes on amazon.com, and, magically, there will be ads for shoes on the personal facebook feed immediately afterward. algorithms are increasingly programming what we see, and aligning at least some of our attention on 'stuff,' for lack of a better word, where we might not otherwise be interested. this surveillance, usurpation and data-gathering was significantly exposed in 2018, with facebook being highlighted for a particularly negative watershed year (sutton 2018; wong and morris 2018) . among the litany of events, problems and phenomena that have plagued facebook, which are clearly not limited to this one, albeit prominent social network, were the following claims, findings and evidence, amongst other issues: algorithms connected to the 'negative effects to referral traffic,' unregulated ads that underscored the mueller investigation that has, as it focus, in large part, the russian involvement in the 2016 us presidential election, the cambridge analytica scandal that 'obtained the data of tens of millions of facebook users without their knowledge or consent to help build a powerful political influencing tool,' privacy and security issues, 'special data-sharing arrangements with tech manufactures like amazon, apple and samsung,' hacking of accounts, and regulation problems (sutton 2018) . (carr et al. 2020: 4) fake news has leaped into mainstream consciousness over the past few years as if it is the problem hampering democracy. emphasizing that fake news is rarely neatly packaged within a singular category, the report cited above cautions that deception needs to be interrogated at various times while viewing media messages. with the avalanche of fake accounts, fake (bot) users, and fake (or tampered with) algorithms, the terrain is fertile for fake news. this is especially the case if users, consumers, and citizens are conditioned to not question or verify what comes their way, are reluctant to disbelief 'official' sources, are ignorant, are disinterested, or are enveloped in turbulent news cycles with complex, nuanced, voluminous information, for which they are unable to decipher the diverse and divergent realities emanating from a particular situation, event, or reality (carr, daros, cuervo, and thésée 2020) . citizen participation requires critical engagement, and constructing media/political literacy, however defined, needs to be considered in order to better underpin meaningful forms of democracy (carr, cuervo, and daros 2019) . the hailstorm of misinformation, misdirection, and disinformation during the early phases of the coronavirus mirrors the general online landscape, serving as both a tremendous opportunity and a mud-slide concurrently, and highlighting the potential for meaningful solidarity as well as, conversely, marginalization and xenophobia (ali and kurasawa 2020) . i am also drawn to the nuanced layers that mackenzie and bhatt (2020) add to this debate, suggesting that '[b]ullshit is different from lying and it need not undermine trust, particularly when it is blatant'. (the literature around the notion and proliferation of 'bullshit' is linked to, and builds on, the work of harry g. frankfurt, notably the 2005 book aptly entitled on bullshit.) this is extremely relevant in contemporary times, given populist movements, xenophobic manifestations, and the denunciation of human rights, and the quest to diminish 'news' as being 'fake' as a basic principle emanating from some powerful leaders in the western world as well as elsewhere. at the same time, i acknowledge that the traditional media is anchored in biases and hegemonic trappings but am troubled that the 'fake news' caravan seeks to whitewash anything that may bring contrary dimensions to the debate, especially in relation to revealing, exposing, and countering mainstream narratives related to war, conflict, racism, inequalities, and the like. democracy 1.0 had a relatively controlled audience, whereas democracy 2.0 has let the floodgates open, and this means that there are now opportunities for critique, solidarity, and mobilization that may not have been as readily available previously, including diverse social movements that have taken off through social media (carr, daros, cuervo, and thésée 2020) . these social movements can be a force of change in society at the local, national, and global levels where governments and international institutions are unwilling, unable, or unmotivated to respond to the needs of the population. for instance, black lives matter (mundt, ross, and burnett 2018) , #metoo (botti et al. 2019) , occupy, and idle no more have all had a significant social media influence, and environmental, peace, and other movements have also been influential at diverse levels in mobilizing solidarity that surpasses cultural, linguistic, geographic, and political boundaries carty 2019) . within the quickly evolving media/social media landscape, i can think of what appear to be several major (media and/or social) events in recent times-noting full-well that by the time this article is published, they may not even be recognizable-including the khashoggi killing, the covington school student debacle, the parkland shooting, the kavanaugh nomination, the thai cave recue, the (british) royal wedding, the manifestations in haiti, the never-ending quest to build a 'wall/barrier/fence' between the usa and mexico, and the political/humanitarian crisis in venezuela, among many others. i apologize for the usa-centric focus here. as a canadian, i am fully cognizant of the depth and reach of usa tentacles, thinking, control, power, and influence in and on my own work, as well as on many others, even though i collaborate widely with colleagues in diverse jurisdictions and contexts, notably in latin america. the usa and its interests bleed over to every region of the world, and, although united statesians (the concept of 'american' is hotly contested and does not cover all of the peoples of the 'americas') may not be talking collectively (in a central way) about the world or may not be collectively immersed in ingratiating the usa into the infinite number of political and economic issues, concerns, and cultural representations of the other countries and peoples, the world is watching, listening, and being consumed by the behemoth of usa empire. the covid-19 pandemic also squarely places the usa within the core of the action, with daily pronouncements about blaming china, cutting off funding to the world health organization, downplaying the spread of the virus, boasting about how the virus has been beaten back, and spreading the political and economic reach of this country far and wide, in military, diplomatic, commercial, and (potentially) humanitarian ways. it seems as though the reality of this being a (global) pandemic, a far-reaching health crisis, is only partially the story, and the present manifestations in the usa of people demanding that 'isolation' be stopped, while so many are being infected and even dying, is almost incomprehensible, and social media concurrently exposes, denounces, disseminates, and provides an echo chamber for what is taking place. so i question what becomes news, indeed viral, and how does it become more than click-bait, algorithmic entertainment, the bouncing around in limited, like-minded networks, tepid sharing, and a platform for trolls? is it about numbers, the quantity of clicks, views, shares and reads, or something more substantive? at the same time, what are the true dimensions of the issue(s)? who frames it, how, and why, and to what end? what is omitted, downplayed, obfuscated, how and why? in the list of issues in the previous paragraph, we can think of many pitfalls, foibles, and problematic concerns as to what 'issues' look like in democracy 2.0. all issues are not simply a usa problem, but connections to elites, hegemony, power differentials, and media framing are, i believe, worth establishing and interrogating. what is clear is that power differentials are at play in how fake news is constructed, disseminated, understood, and engaged with. the more volatile social media can push up against normative media in further determining how fake news can be projected, masked, embellished, and consumed. concerning the jamal khashoggi killing in october 2018 in istanbul (bbc news 2019), we can follow the usual process of focusing on hegemonic interests and avoiding contextual factors and backdrops. several significant and pivotal factors were down-or under-played in reporting on this tragedy. for example, the relationship to the saudi kingdom, human rights, billions upon billions of dollars in armaments sold to the saudis, the unimaginable assault by saudi arabia against yemen, and the impending famine and genocide in yemen as a result, women's rights, journalistic freedom, and an unending series of beheadings by the quasi-untouchable saudi regime. undoubtedly, information, discussion, debate, reports, and mobilization on all of these fronts can be located and advanced through social media, in spite of the mainstream, hegemonic vision. the point here is that central, controlled, and 'manufactured' debate, at least within a condensed and constrained optic and timeframe, shined a light on the actual killing of khashoggi in turkey, who did it, how, and why. yet, significantly, it was only weakly concerned with the other, what could/should be considered to be, highly pertinent and central issues that are/were intertwined within this quagmire. why such deference was paid to the saudi leadership in this case, when this same deference is not paid in many other instances, especially when the faulty regime is not an ally, is quite pertinent. the lack of historical, political, and economic context, combined with the propensity to avoid latching onto 'research', and a plurality of visions, perspectives, and experiences seem to be a predominant feature of how these stories crystallize. the khashoggi example, like others, contains an evolving set of circumstances and frames, as well as questions, and we are cognizant of how some segments of social media can provide differing narratives that can, consequently, re-shape the 'official' story. yet, the social media dimensions can also counter the formal hegemonic narrative, and this is where alternative forms of 'democracy' can start to take hold (jenkins, shresthova, gamber-thompson, kligler-velenchik, and zimmerman 2016) . why the more critical dimensions within the khashoggi case (or the venezuela situation or others, for that matter) were/are not more broadly taken up by democracy 1.0 relates, i believe, to the hegemonic shaping/framing of the issues. it is also combined with a weakly focused mainstream media, whose reach is now consumed within the 'fake news' bubble, and a still questionable place, at least among many formal political leaders and their business sector supports, of uncontrolled social movements and social media within formal political spheres. however, i do believe that this last factor-social movements and social media being a mobilizing force-is, and will continue to potentially be, central to conceptualizing, developing, cultivating, building, and elaborating a more decent, meaningful, robust, and critically engaged democracy, in spite of the status quo aiming to maintain and sustain its hegemonic place. social media movements can also lead to dictatorship, genocide, and an infringement of rights (sapra 2020) . for instance, gayo-avello (2015) hypothesizes that social media may contribute but is not the central feature to democratization: in short, social media is not a democratizing catalyzer per se. it is just one of many factors, in addition to great tactical tools, provided the conditions in the nondemocratic country are suitable. moreover, there are many variables which can negatively affect the outcome of any uprising, even without the regime tampering with social media. in other words, social media does not make people free; freedom requires people taking risks and organizing themselves. (gayo-avello 2015: 6) social media cannot magically lead to class consciousness, anti-racism, peace, and social solidarity. however, it may be able to provide an outlet and legs to important stories, events, and realities for people who were only previously loosely connected. this could have a dual effect of further questioning and delegitimizing normative democracy, and also providing space and voice for marginalized interests, perspectives, and arguments. social media is now indelibly a part of the citizen participation landscape. what is the point of living in a 'democracy' if you are one of those living in abject poverty, are homeless, and are working tirelessly to make ends meet but never achieve economic justice (ely yamin 2020)? of course, the notion of having the 'freedom' to pursue your dreams, as in 'the american dream', is sufficiently grounded within normative debates to ensure that questioning entrenched, systemic, institutional, deeply grounded social inequalities will be quickly snuffed out. within the usa context, amadeo (2019) highlights the increasing social inequalities as follows: structural inequality seems to be worsening. between 1979 and 2007, after-tax income increased 275% for the wealthiest 1% of households. it rose 65% for the top fifth. the bottom fifth only increased by 18%. that's true even adding all income from social security, welfare, and other government payments. during this time, the wealthiest 1% increased their share of total income by 10%. everyone else saw their share shrink by 1-2%. as a result, economic mobility worsened. the 2008 financial crisis saw the rich get richer. in 2012, the top 10% of earners took home 50% of all income. (amadeo 2019) powers, fischman, and berliner (2016) have highlighted how research on poverty and social inequalities is poorly understood or operationalized, which further underpins weak policy responses to entrenched and systemic problems. similarly, it is helpful to problematize how wealth has been accrued historically through genocide, slavery, imperialism, war and conflict, colonialism, and a host of racialized, sexist, and other machinations in addition to piketty's (2017) welldocumented treatise capital in the twenty-first century. mclaren (see pruyn and malott 2016) has highlighted marx's theory on surplus value and the limited mobility between the social classes, and the crushing blow of capital against labor; ultimately, the value of what is produced encounters hyper-inflation in the hands of investors, owners, and speculators without real production, which may seem locked into the days of children being exploited in coal mines over a century ago but there are still many parallels today. giroux (2016) has coined 'casino capitalism' to label the politicoeconomic system that enraptures the vast majority of formal, and to varying degrees, informal activity that underpin mass exploitation. he further elucidates the danger of continuing on the one-way neoliberal path before us: neoliberalism has put an enormous effort into creating a commanding cultural apparatus and public pedagogy in which individuals can only view themselves as consumers, embrace freedom as the right to participate in the market, and supplant issues of social responsibility for an unchecked embrace of individualism and the belief that all social relation be judged according to how they further one's individual needs and self-interests. matters of mutual caring, respect, and compassion for the other have given way to the limiting orbits of privatization and unrestrained self-interest, just as it is has become increasingly difficult to translate private troubles into larger social, economic, and political considerations. one consequence is that it has become more difficult for people to debate and question neoliberal hegemony and the widespread misery it produces for young people, the poor, middle class, workers, and other segments of societynow considered disposable under neoliberal regimes which are governed by a survival-of-the fittest ethos, largely imposed by the ruling economic and political elite. (giroux 2016) mclaren (see pruyn and malott 2016) and giroux (see giroux, sandin, and burdick, 2018) have also made a compelling case to interpret today's reality as a politicoeconomic context that is launching us into hyper-sophisticated forms of fascism. within this backdrop, i believe that there is a great need, as there always has been, to be more fully engaged with (and in) education, in political circles and in public debate, in general, in relation to the philosophy and operationalization of capitalism and, in particular, to the all-encompassing mercantilization of all public and private goods, services, and experiences enveloped within neoliberalism. the covid-19 context has expedited and underscored the slippery slope toward authoritarianism, stripping away rights while creating socio-economic cleavages that are even more serious than before . democracy 2.0 is tethered to democracy 1.0 conceptualizations of the world, but the door is (slightly) open to develop a new world, despite the titanic hegemonic vice-grip that maintains a stranglehold on education and public debate. as alluded to in the previous section, the collective 'we' are free to surf the web, consume, create, diffuse, comment, and cajole the other, whether the 'other' knows us, sees us, or cares about us or not. we are not frontally impeded from opening our eyes and ears. on the contrary, many movements have been stimulated from doing so-including the arab springalthough the aftermath re-captured regressive hegemonic features of what preceded it. the dilemma is that the corporate/business politico-economic (hegemonic) world has grown into this concurrently in-your-face and stealth, quickly-evolving, dynamic context seamlessly stamping its imprint in every way possible. the interplay between democracy 1.0 and democracy 2.0, thus, offers tremendous potential for citizen participation and engagement while, simultaneously, presenting the quicksand mirage that we may not be as 'free' as we think we are, or we may not be as 'engaged' as we think that we are. neoliberalism has many people around the world gasping for air. now mired in a pandemic that vacillates from signs of encouragement that the 'curve is flattening' to fears that 'community transmission' is rapidly spreading through asymptomatic contact, there is enormous stress about when there will be an effective vaccination, how the health context will play out, and, increasingly, when will the 'economy get back to normal.' at this point in time-although we are aware of massive numbers (the information is not hidden, anyway) of unnecessary deaths in 'developing' countries related to hunger, disease, poverty, and conflict-we can see the extreme concern within local, national, and international governments and institutions to get the economy working. while most of the world has emphasized 'social distancing' as a key measure to diminish the dissemination and transmission of covid-19, an eerily bizarre phenomenon has taken hold in the usa (wong, vaughan, quilty-harper, and liverpool 2020) . disparate, semi-organized protests against 'self-isolation' are taking place in diverse locations, often replete with a range of arms and placards enunciating the right to, among other things, 'haircuts' and to 'play golf.' is it pure insanity, a case of hubris beyond all limits, an anti-science ideology that needs to play out in every sector-including the environment-or complete indifference to human suffering? while the usa situation deeply underscores the anxiety and agitation around the health/economy dichotomy, i present below a brief illustration of the neoliberalization of the political and economic convergence through an example of the coronavirus in québec (canada). québec, a predominantly french-speaking province of 8.5 million people in canada, provides an interesting illustration of how a jurisdiction within a federal framework has worked to mobilize, sensitize, and activate a range of health, economic, political, and education measures to confront covid-19. there are daily press briefings, information sessions, directives, a vast media campaign, testimonies, and a host of consultations, which all serve to educate the public and to engage the citizenry concurrently. it would be disingenuous to simply criticize where there have been gaps and problems; the reality is that many people have worked diligently and courageously to create a sense of the gravity of the problem and to diminish the extent of the propagation of the virus. having a universal healthcare system has been, i believe, indispensable to understanding how to assess, allocate, distribute, and organize resources. this is not an individual problem but a vast, insidious collective one. it should be acknowledged as well that what we know is shifting and re-calibrating in real time, and decisions made on march 1 were questioned and re-assessed by march 7 and so on. moreover, what we know now cannot always be fully understood until later, and decisions that are taken in that light can lead to nefarious situations and the rampant spread of the virus. hindsight is 20/20 as the proverb goes so a fulsome diagnosis of what we are doing today will be more effectively critiqued once we are through to the other side of the pandemic. the situation in québec, one that is surely not unknown elsewhere, underscores the fragility of 'normative' democracy; this is, i believe, a question of normative democracy working the way that it does. one heart-wrenching issue that we are observing at this time is that the vast majority of deaths in québec, like elsewhere, is among those 70 years of age and older, and particularly the 80 + age-group. moreover, what many of us did not know or fully consider, the vast majority of deaths up until now within québec are among those who are in long-term care residences (in french, they are called cshlds), roughly 70%, which are essentially senior's residences for people with health issues. the transmission within these residences is extensive and rapid, with an increasing number of personnel, nurses, and doctors also being affected. one residence, for example, experienced an overwhelming amount of infection (herron, discussed below), and there are others that have also been deeply affected. one might say that there are two public health crises at this time: one for the general population and another for these particular residences with this specific group. on the one hand, the population is astonished, sickened, and in shock ('how could this happen?,' 'especially to "our elderly"?'). on the other hand, this was a serious politico-economic cocktail being mixed for a couple of decades, massaged through diverse political parties within the normative democracy that adjudicates such matters. (why was there such sustained neglect and under-funding? why was this not flagged as a serious catastrophe in the making?). i would like to underscore that this is not a problem of one person, one political party, one decision, one law, or one particular model: it is the consequence of systemic, institutional failure/negligence as well as the thinnest wedges of normative democracy carrying the day over the broader public interest and good. i briefly present some of the specific underlying conditions that lay the groundwork for what is playing out within this vulnerable population at this time: a lack of monitoring, under-paying workers, and diminished policy importance and planning. media accounts provide information on the tragedy unfolding before our eyes. in one case, at herron, in western montréal, the chsld there, which is privately owned, experienced serious staffing shortages, insufficient equipment, poor oversight, inadequate support from oversight bodies, and unacceptable communications with health authorities. mckenna (2020) provides a sense of the chaos and suffering there: nurses were getting sick, too: six out of the seven registered nurses on staff were experiencing covid symptoms, and of seven licensed practical nurses (lpns), only four were still healthy. (…). about a quarter of the orderlies (préposés aux bénéficiares, or patient attendants) had also stopped workingeither because they were experiencing covid symptoms or because they felt it was no longer safe to work at chsld herron. within weeks, a quarter of those patient attendants would test positive for covid-19. (…). bedridden residents were lying in sheets stained brown up to their necks in excrement, so long had it been since their diapers had been changed. some were dehydrated and unfed. (…). the head of professional services at the ciusss, dr. nadine larente, is the doctor who went to help. she told the french-language newspaper la presse the place was in chaos: one lpn and two patient attendants were trying to care for 130 residents. food trays had been placed on the floor, dishes untouched because residents with mobility issues could not reach them. (mckenna 2020). about double the number, proportionately, of seniors in québec opt for long-term care residences compared with the rest of the country, which could be a function of culture, policy, economics, and options available, and the rapidly aging québécois population is a further aggravating factor preparing the context (dougherty 2020). one expert (see lowrie 2020) noted that the spatial configuration 'with long corridors and residents sharing rooms, have a harder time isolating sick residents from uninfected ones, compared to residences with house-style layouts, where residents live in smaller wings' is another factor that helps explain the extreme transmission of the virus in chslds. with staff falling ill or refusing to come to work, there has been a massive campaign to recruit retired nurses and also to bring doctors and specialists into the overburdened long-term care system; the premier of the province has also asked for the military (over a thousand troops) to further provide support within these seniors' residences. social class and political power are fully intertwined in the quickly unraveling situation involving seniors' residences in québec. raising the minimum wage in québec, for example, was vigorously opposed by the present government and others along the way, fearful that employers, especially small businesses, could not afford it. while there is no maximum wage being regulated, those struggling with the minimum wage are often obligated to work two or three jobs, to seek assistance elsewhere, and face other severe challenges, including in relation to housing, childcare, education, and the cost of living. the chsld situation brought everything to a head, with it being clearly obvious that those designated as 'essential services' were often those being paid the least in society. the premier took the almost unprecedented measure of apologizing for underpaying workers when it became difficult and problematic to staff these residences: 'i know a lot of quebecers are asking themselves how we could have got ourselves in this situation,' a sombre legault said at his friday briefing, addressing the catastrophe unfolding in covid-19-stricken long-term seniors' residences (chslds). 'i myself have spent several days and nights asking what i should have done differently.' 'if i was able to redo one thing, i would have increased the wages of orderlies faster, even without the accord of the unions. i assume full responsibility. we entered this crisis ill equipped, and clearly the situation deteriorated for all kinds of reasons. the virus got in.' (authier 2020) . the premier also took a series of steps to increase pay for healthcare workers. as part of its effort to improve working conditions in the health-care system, quebec announced that nearly 300,000 employees in both the public and private sector will be getting temporary pay increases. workers who are in direct contact with the diseasesuch emergency-room professionals and nurses in coronavirus testing centreswill receive an 8 % boost in their salaries. those working in long-term care homes, known as chslds, will also be among the 69,000 workers to benefit from the 8 % raise…. another 200,000 people who work in the health-care system but aren't as directly exposed to the disease, such as the nurses who staff the 811 health line, will get a salary increase of 4 %. and workers in private long-term care homes, many of whom make little more than minimum wage, will get an additional $4 per hour. that measure appears designed to discourage these workers from quitting and staying home, to take advantage of federal financial assistance that's worth $2000 a month. (shingler, stevenson, and montpetit 2020) . one question that arises here is how these workers could have been underpaid for so long, and what the effect may have been, for them, the people receiving the care, the healthcare institutions and system, and society as a whole. did it dissuade qualified workers from pursuing careers or staying in them? what were the other priorities that negated remunerating fairly such indispensable and 'essential' workers? on the economic side of the ledger, how efficient is it to underpay some employees and over-compensate others who have not actually done the work or who are, ironically, considered to be disproportionately fundamental? is a 10:1 ratio for salaries at the top and the bottom reasonable or should it be 100:1 or 1000:1? in canada, in general, the wage differentials are less extreme and odious than the usa, but the issue of social (in)equality is also a significant concern there. one study (mishe and wolfe 2019) focused on usa compensation provides some backdrop to how public services and priorities can be disproportionately affected. ceo compensation is very high relative to typical worker compensation (by a ratio of 278-to-1 or 221-to-1). in contrast, the ceo-to-typical-worker compensation ratio (options realized) was 20-to-1 in 1965 and 58-to-1 in 1989. ceos are even making a lot more-about five times as much-as other earners in the top 0.1%. from 1978 to 2018, ceo compensation grew by 1007.5% (940.3% under the options-realized measure), far outstripping s&p stock market growth (706.7%) and the wage growth of very high earners (339.2%). in contrast, wages for the typical worker grew by just 11.9%. there is a lot of complexity to how covid-19 is analyzed, and comparing diverse sites/ jurisdictions/systems and how data are compiled and evaluated may not reveal the true breadth and scope of the reality. similarly, there are many moving parts and lots of people (remunerated and volunteer) involved and engaged, and there are also all kinds of activities aimed at supporting a solidified, vigorous response. my intention in presenting this case study is not to admonish or diminish those serious and important efforts. on the contrary, it is my hope that this pandemic will reveal a silver lining somewhere in that extreme vulnerabilities and shortcomings need to be rectified in order to ensure, as much as possible, that economics will not suffocate political considerations in the future. and i have not emphasized here the race, gender, and other pivotal underlying factors underpinning this pandemic, but they are also a significant piece of the puzzle. this text has underscored what 'democracy' we are trying to achieve, to cultivate, and to ingratiate. the focus and direction of my central arguments about the lack of bone fide democracy within a normative, mainstream political framework that preaches that we live in a developed democracy has, i believe, become accelerated and accentuated as a result of covid-19. i have highlighted some of the fundamental issues and problems with 'normative, representative, hegemonic, electoral democracy,' and also emphasized the pivotal contextual shifts and cornerstones embedded in democracy 1.0 as well as democracy 2.0. i have also made the case for more robust, critically-engaged citizen participation, which would require or, at the very least, benefit from new forms of education and media/political literacy. the social media equation was brought to light since it serves as an unruly, uncontrolled, and rapidly evolving microcosm of the world, its diversity, its problems, its challenges, and its potential. i was careful to not make a definitive declaration related to achieving democracy through the potentially transformative technologies that now shape how we live and function and relate to the world. despite everything, we are still mired in conflict(s), in inequitable power relations, and in 'democracies' that are not very 'democratic. ' we are still straddling democracy 1.0, in which formal political declarations are fabricated with partisan political interests at the fore, the stock market is seemingly central to everything, and business elites are catered to at every level. similarly, tax cuts-regardless of political stripe-figure into everything, political parties shamelessly line up to receive 'donations' (does anyone believe that they come with no strings attached?), tax breaks for companies must be considered as much as lower tax rates for the rich (does anyone believe that rich people will create more employment based on having more cash? if so, why are there so many off-shore accounts in tax-havens intended to not pay tax?), and (military) might is (still) right for many. the further the coronavirus expands, the more there is discussion about needing an economic balance to 'get back to normal,' and indicators such as the stock market are central to supposedly gaging what is happening (karabell 2020) . of course, there have been lots of (incremental) changes, and lots of new laws, policies, practices, and shifts in cultural norms that have benefitted, generally speaking, women, racialized minorities, the poor, and the vulnerable. yet, social inequalities, despite massive technological and others changes, not only persist but, in many regards, are increasing. how could this be when there is so much wealth? why do so many people leave their countries in complete desperation, why is there still so much military conflict-most of which goes unreported-why do so many problems of poverty and discrimination persist in the most vulgarly palpable ways, why is there such little global outrage over the state and fate of indigenous peoples (the loss of land, language, culture and autonomy), and why is the 'environment' not the priority? this very partial list of questions is noteworthy because neoliberalism is, definitely, an accelerator to many of the problems we are facing . to be clear here, this is not a binary proposition, and avoiding confronting real problems with real people will not address real suffering, oppression and marginalization (gray and gest 2018) . we might ask: why are there (recurrent, entrenched) problems when there are so many people, projects, forces, and movements fighting for a more decent, robust, and (even) alternative democracy 2.0, one that could place neoliberalism within a new, different and alternative landscape? how should hegemony be understood today when (many) people so freely believe that they have complete agency over their actions, thoughts and experiences, and when (many) people believe that voting is the (only) key? i would stress here that the binary capitalist-socialist, rich-poor binary is not the most productive lens through which to examine the complexity of such extreme power imbalances around the world. the debate around 'democracy,' i believe, needs to be more all-encompassing, involving all of the tentacles and blockages of neoliberalism into the class, race, gender, cultural, and other pivotal sociological markers of identity, and it also needs to carve out a place for how power works, is distributed and recreated. this debate needs to leave open the door for unknown questions and answers as well as (creative and alternative) processes and deliberations, accepting that the normative elections in place are most likely not very beneficial for most people, and, most definitely, the massive numbers of people who do not participate, willingly or unwillingly (van reybrouck 2017). it is important to connect the local with the global, as we can through covid-19. ely yamin (2020) provides a sense of the need to address global issues globally and to be leery of not considering the complexity of the linkages between complex problems. but that and many other challenges requires weaving human rights praxis-human rights for social change-into broader social movements, as well as working across disciplinary silos. the problems facing the rights movement are too complex for any one set of advocacy tools or any one field's expertise. of course, there is no single monolithic 'human rights community' just as there is no unified 'health and human rights community'. those tropes are used from the 'inside' to police the boundaries of orthodoxy and from the 'outside' to caricaturize sets of actors and strategies. yet, there are dangers of circling the wagons defensively around our professional tribes. the complexity of the challenges posed by rampant inequality, the spread of authoritarianism and illiberalism, distrust in multilateralism, and climate cataclysm call for embracing justified critiques and opening up to new ideas and perspectives-and uniting with labor, environmental and many other social justice movements. (ely yamin 2020) inspired by paulo freire's transformative work (freire 1970) , i would advocate for more openness and acceptance of political realities that shape our lived experiences as well as an extremely healthy dose of humility as means to being able to understand, engage with, and be with the 'other.' i explore more fully the interconnections and inspiration of freire's work with my colleague gina thésée (carr and thésée 2019) . the hard-wired, testosterone-induced, keep-fundraising-at-all-times political systems that have been put in place all over the place need to be re-imagined before they suffocate themselves and everyone else. people will slowly divest themselves from the voting game, leaving it as an empty shell filled with a bunch of white guys in suites. (yes, there are some openings for other identities in this equation but the game was made by and for these guys.) freire wrote of conscientization, and i believe that to get there, we need to focus on peace, not war, social, and cultural development as opposed to economic development, solidarity, and emancipation rather than exclusively on individual rights and liberties, and the recognition that we are (all) human beings. as human beings, we are not required to be racist (no baby is racist but we learn to be so), sexist (a totally learned behavior), classist (exploiting one's neighbor is not an obligation), kill one another (who gets killed anyway? the rich or the poor, and who are they? do we care?), or live with so much misery, hatred, and oppression. ultimately, we are in the same boat (or world) together. one could see the glass half full with lots of progress all over the place, and, yet, the empty side of the glass contains real people living through unimaginable (for the full side of the glass) realities; the wage discrepancies and gaps in the québec example exemplify this reality. the quest for a meaningful democracy aimed at both sides of the glass would be a more conducive option, and re-imagining democracy will require more fully and, even disproportionately, considering the empty side of the glass. taking a stand against democracy 1.0 and 'normative, representative, hegemonic, electoral democracy' is a necessary condition to moving forward for this re-imagined democracy. donkervoort (2020) underscores that the pandemic has been exploited by 'autocrats' but that citizens can resist and coalesce around global initiatives to weaken and confront hegemonic forces. this could mean enhanced civil society engagement across all boundaries with an eye to unmasking and dismantling the concentration of wealth and power. covid-19 has exposed the need for a different universe, not only in terms of public health but also, importantly, in relation to democracy and citizen engagement (roy 2020) . so while my foot, to return to the title, may be in taters, i'm hopefulindeed, it may be the only way out if this-that my head will not be the ultimate causality as we strive to either sustain or re-imagine a democracy that can not only take us out of a pandemic but, rather, into social solidarity that will remove our bodies and minds (and souls) from imminent disaster. open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. democracy for realists: why elections do not produce responsive government #covid19: social media both a blessing and a curse during coronavirus pandemic. the conversation structural inequality in america: how structural inequality stifles the american dream do democracy and capitalism really need each other? harvard business review the struggle for democracy in education: lessons from social realities covid-19 analysis: legault offers a mea culpa -but did he really have a choice? montreal gazette jamal khashoggi: all you need to know about saudi journalist's death the #metoo social media effect and its potentials for social change in europe. brussels: feps -foundation for european progressive studies does your vote count? critical 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exposing the plague of neoliberalism the new henry giroux reader: the role of the public intellectual in a time of tyranny silent citizenship: the politics of marginality in unequal democracies citizens adrift: the democratic disengagement of young canadians by any means necessary: the new youth activism as covid-19 spreads, listen to the stock market for now social media and youth political engagement: preaching to the converted or providing a new voice for youth? many factors behind covid-19 outbreaks hitting quebec's long-term care homes noam chomsky: neoliberalism is destroying our democracy: how elites on both sides of the political spectrum have undermined our social, political, and environmental commons. the nation why are american elections so long? orderlies worked without ppe, covid-19 patients wandered herron's halls for days after health agency took over lies, bullshit and fake news: some epistemological concerns ceo compensation has grown 940% since 1978: typical worker compensation has risen only 12% during that time. economic policy institute scaling social movements through social media: the case of black lives matter capital in the twenty-first century making the visible invisible: willful ignorance of poverty and social inequalities in the research-policy nexus this fist called my heart: the peter mclaren reader (volume i) the pandemic is a portal the last decade showed how social media could topple governments and make social change -and it's only getting crazier from here no one 'is more deserving,' says legault, raising wages of 300,000 health-care workers as covid-19 cases climb location information disclosure in location-based social network services: privacy calculus, benefit structure, and gender differences facebook's terrible, horrible, no good, very bad year: and youthought you had a rough conjuguer démocratie et éducation : perceptions et expériences de futurs-es enseignants-es du québec. citizenship education research journal/revue de recherche sur l'éducation à la citoyenneté political disaffection in contemporary democracies: social capital, institutions, and politics against elections: the case for democracy it's complicated: facebook's terrible 2018. the guardian covid-19 latest: cdc director warns us second wave could be even worse key: cord-024569-d9opzb6m authors: seo, mihye title: amplifying panic and facilitating prevention: multifaceted effects of traditional and social media use during the 2015 mers crisis in south korea date: 2019-07-26 journal: journal mass commun q doi: 10.1177/1077699019857693 sha: doc_id: 24569 cord_uid: d9opzb6m in the context of the 2015 middle east respiratory syndrome (mers) outbreak in south korea, this study examines the multifaceted effects of media use considering the current complex media environment. analysis of a two-wave online panel survey found that traditional media use had a positive influence on mers knowledge while social media use did not. however, knowledge did not facilitate preventive behaviors. in contrast, negative emotional responses due to media use stimulated desirable behaviors. furthermore, social media use directly influenced behavioral responses but traditional media use did not show the same effects. different functions of traditional and social media during an epidemic are discussed. changed that understanding considerably (petersen, hui, & zumla, 2015) . this unforeseen crisis induced not only morbidity and mortality but also fear and panic in korea. in fact, the panic epidemic caused more widespread damage than the disease itself by slowing the economy and interfering with people's daily routines. in times of crisis, the importance of the media is heightened. government and responsible organizations consider media to be an essential part of crisis management (reynolds & seeger, 2005) , and the public relies on the media to make sense of confusing or chaotic situations (tai & sun, 2007; zhang, kong, & chang, 2015) . given the importance of media in times of crisis, scholarly attention has been largely paid to the following questions: (a) how government and other organizations work (or should work) with media to prepare for and respond to crises and (b) how the media reports (or should report) on crises. relatively less attention, however, has been paid in existing research to examining informational, emotional, and behavioral consequences of individuals' media use in times of crisis. as the importance of social media has risen in general, its importance in the context of crises has also increased. evidence shows that many people turn to social media to seek crisis-related information, such as safety instructions and news updates (veil, buehner, & palenchar, 2011) , which stands to promote proper behavioral responses to facilitate effective crisis management. however, both researchers and practitioners caution that media-social media in particular-may create misperceptions and amplify public fears by fostering public panic and proliferating unverified information (kasperson, 1992) . in comparison to traditional media, social media use is particularly susceptible to the aforementioned concerns due to enhanced speed of information transmission and distinctive features of open access platforms (zeng, starbird, & spiro, 2016) . in the context of the 2015 mers outbreak in korea, this study provides an empirical examination of the multifaceted effects of media use in times of crisis in the complex and dynamic media environment of today. using two waves of online panel data collected at two different time points during the mers crisis, i investigate how individuals' traditional and social media use during the crisis produced various consequences, including increased mers knowledge, negative emotions such as fear and anxiety, and direct and indirect facilitation of mers preventive behaviors. i also scrutinize the differences in these effects caused by traditional and social media use. the term crisis is defined as "some breakdown in a system that creates shared stress" (coombs, 2014, p. 2) , which includes a very broad range of situations. an infectious disease outbreak is a typical example of crisis in the public health context. prior research has focused on how governments or other responsible organizations can achieve positive relationships with the public in managing a particular crisis. based on the organization-public relationship (opr) approach, scholars have theorized and investigated various (pre)conditions, attributes, and communication strategies of organizations to bring about positive relational outcomes with the public, such as satisfaction, commitment, trust, and mutual understanding (s.-u. yang, 2018) . with respect to the mers crisis in korea, s.-u. yang (2018) showed that the government's lack of dialogic competency negatively affected government-public relationships. those findings indicate that the korean government's lack of mutuality and openness weakened the credibility of its risk information, which produced negative relational consequences such as distrust and dissatisfaction and the intent to dissolve the relationship. cooperation with the media on the part of government and responsible organizations is a major portion of effective crisis management processes (coombs, 2014) . from a crisis management perspective, prior research has mainly focused on how to understand and work with the media to accomplish various goals (reynolds & seeger, 2005) . for instance, researchers have identified the kinds of communication strategies that work best to reduce public-relations damage and generate compliance with desired behaviors in hazardous situations (glik, 2007) . for instance, seeger, reynolds, and sellnow (2009) emphasized the importance of coordinating specific communication tasks for each crisis phase in the context of hurricane katrina and the h5n1 outbreak. based on the existing literature and case studies, scholars have also attempted to provide guidelines for best practices in crisis communication (veil et al., 2011) , which could also be used as evaluative criteria in crises (plattala & vos, 2012) . another line of research focuses on how media channels cover crises by analyzing the content of crisis reporting and discussing its implications. as manifested by terms such as disaster marathon (liebes, 1998) , the unexpected and impending nature of crises triggers media hype, which produces a prolific amount of reporting. much research has investigated the characteristics of crisis coverage (shih, wijaya, & brossard, 2008) . shih and colleagues (2008) , for instance, found that the coverage of epidemics showed common patterns across discrete diseases, such as a high eventbase and emphasis on newly identified cases and government actions. with respect to the mers crisis in korea, jin and chung (2018) performed semantic network analysis of korean and foreign media coverage of the crisis. they examined the most frequently used words (e.g., patient, hospital, infection, government, and case) and concluded that korean media focused heavily on the number of cases and the government's responses, consistent with shih and colleagues' findings (see kwon, 2016, for similar findings) . based on content analyses of crisis reporting, past research has also identified persistent problems in crisis reporting, such as excessiveness (rezza, marino, farchi, & taranto, 2004) , inaccuracy (auter, douai, makady, & west, 2016) , and sensationalism (moeller, 1999) . korean media's mers reporting was not exempt from sensational and excessive coverage of the contagious nature of the disease and patient counts (kim, 2016; kwon, 2016) . as population mobility and trade in goods and services have increased, newly emerging infectious diseases have become global public health concerns. some emerging infectious diseases have derived from a known infection, such as influenza, and have spread into new populations. the mers outbreak in korea can be understood as one such example. an outbreak of infectious disease causes not only human casualties but also massive economic harm. different from chronic health risks, infectious pandemics trigger spontaneous and intense media attention (posid, bruce, guarnizo, taylor, & garza, 2005) , which could create cascading effects in various public responses. however, relatively little empirical research has considered the various consequences of media use by individuals during a public health crisis. one of the most desirable public responses to a public health crisis is engaging in preventive behaviors (mitroff, 2004) . public adoption of precautionary behaviors is critical to preventing large outbreaks of infectious disease, particularly in densely populated countries such as korea. people need to behave in ways that prevent the spread of infectious disease and its consequences, and the media plays an important role in facilitating those behaviors (gammage & klentrou, 2011; zhang et al., 2015) . learning from media is one potential pathway to engagement in preventive behaviors (sayavong, chompikul, wongsawass, & rattanapan, 2015) . besides cognitive responses, another way to galvanize preventive behaviors could be through emotional responses, which could alarm people enough to take proper actions with respect to a given risk. research on risk and health communication has offered various theoretical models and empirical evidence for each approach (boer & seydel, 1996; griffin, dunwoody, & neuwirth, 1999 ). yet, there has been little research testing and comparing the two potential paths to preventive behaviors in the context of a pandemic crisis. first, media use could increase knowledge about a crisis, which could stimulate the public to enact preventive behaviors. the heavy emphasis on knowledge is largely drawn from the traditional knowledge deficit model of communication (rutsaert et al., 2014) , which claims that a lack of understanding is the major obstacle to reasonable public responses to a risk or crisis. therefore, it accentuates the scientific knowledge transfer from experts to the layperson and media have been regarded as a major conduit of knowledge transfer (hilgartner, 1990) . thus, when a crisis happens, government and responsible organizations attempt to work with media to disseminate crisis-related information, and the general public turns mainly to the media to acquire the information to deal with the atmosphere of uncertainty. despite that widespread expectation, relatively little empirical attention has been given to whether public crisis knowledge is indeed increased by media use or whether understanding of a crisis indeed facilitates preventive behaviors in times of crisis. media is known to be more suitable for diffusion of knowledge than other channels, such as interpersonal communication (price & oshagan, 1995) . prior research shows that media use increases health knowledge in the general public, which in turn encourages desirable health behaviors (gammage & klentrou, 2011; sayavong et al., 2015) . little empirical evidence, however, has been collected in the context of urgent public health crises such as epidemics. on the contrary, disaster studies have extensively examined individual and group responses to impending threats (e.g., natural disasters or terrorist attacks). according to that body of research, in the face of an impending threat, people become more sensitive to cues about social environments and engage in searches for information as a basis for protective behaviors (lindell & perry, 2004) . however, despite the known contribution of media channels to these disaster research models, media variables have received insufficient attention in explaining the behavioral responses of individuals to crises. second, media use could stimulate proper behavioral responses via mobilizing information (mi). in the health communication literature, mi is designed to encourage a specific health behavior (friedman & hoffman-goetz, 2003) . applied to a crisis context, mi offers specific "how to" and "where to" information, such as checklists for preparedness supplies, evacuation information, phone numbers or websites for further information, or specific instructions for precautionary behaviors, meant to encourage people to take specific actions (tanner, friedman, & barr, 2009) . facing a crisis, the public needs to learn about both the nature of the crisis and how to mitigate its effects and defend themselves (guion, scammon, & borders, 2007) . a handful of prior studies in the communication discipline have documented the direct and indirect effects of media use on preventive behaviors via knowledge in a crisis situation. ho (2012) , for example, found that attention to newspaper and television news increased public knowledge about the h1n1 pandemic. zhang et al. (2015) also found that media use potentially influenced h1n1 preventive behaviors through fear and perceived knowledge. the results of 36 national surveys in the united kingdom indicate that exposure to media coverage or advertising about swine flu increased the adoption of recommended preventive behaviors (g. rubin, potts, & michie, 2010) . lin and lagoe (2013) also showed that tv and newspaper use increased h1n1 risk perception and vaccination intent in media users. based on those discussions and findings, it is expected that media use will facilitate public understanding of an emerging infectious disease and encourage appropriate precautionary behaviors. media use in large-scale emergencies, however, still requires empirical scrutiny because of the many unexpected twists that characterize fluid crisis situations. human beings facing a crisis often experience a range of negative emotions. the intense uncertainty inherent to a crisis situation galvanizes fear, worry, and panic (sandman & lanard, 2003) . in the outbreak of an unfamiliar contagious disease, both the unknown cause and fatal outcome and the interruptions of daily routines and stigma could strengthen negative emotional responses (lee, kim, & kang, 2016) . prior research indicates that individuals often feel more threatened during crises than is warranted by the actual risk level (coombs & slovic, 1979) . according to social amplification theory, the risk people feel when facing a crisis could be amplified or weakened by exchanging various forms of information via the news media or informal networks (renn, burns, kasperson et al., 1992) . once a perceived risk is officially acknowledged, the distortion and exaggeration of information tend follow (song, song, seo, jin, & kim, 2017) , feeding a range of negative emotional responses. prior research has found that the media tends to overemphasize risk and sensationalize crises. for instance, the media overstresses the horrific symptoms of contagious diseases regardless of facts about the prevalence of those symptoms in a time of outbreak (moeller, 1999; ungar, 2008) . the media also tends to focus more on the spread of a disease and the body counts rather than scientific causes (d. rubin & hendy, 1977) . these types of sensationalism can produce disproportionate public fear and panic responses to infectious diseases. scholars such as muzzatti (2005) have gone a step further and demonstrated that the media can actually manufacture threats to public health. some prior works have examined the effects of media use on emotional reactions toward a crisis. hoffner, fujioka, ibrahim, and ye (2002) , for instance, found that people who learned about the september 11 terrorist attacks through mass media were more likely to report negative emotions than those who heard the news interpersonally. they attributed that difference to the nature of the live pictures and content in mass media crisis reporting. people's negative emotional responses as influenced by media use could lead to inappropriate behaviors, such as avoidance of precautionary behaviors or unnecessary or excessive behavioral reactions (liu, hammitt, wang, & tsou, 2005) . however, other convincing literature has claimed that emotions can trigger behavioral responses that are benign and adaptive (baumeister, vohs, dewall, & zhang, 2007) . negative emotional experiences can stimulate people to seek pertinent information (e.g., the risk information seeking and processing (risp) model, griffin et al., 1999) and encourage them to take preventive actions (e.g., protection motivation theory [pmt], boer & seydel, 1996) . unlike the cognition-based approach, which emphasizes the role of knowledge, these theoretical models focus on how negative emotions work as motivational drivers to guide people to protect themselves. empirical work has supported those claims by showing that negative emotion can drive positive behavioral responses, including adopting recommended health behaviors (ruiter, abraham, & kok, 2001) and engaging in information seeking (z. j. yang & kahlor, 2013) . as discussed, korean media coverage of the mers crisis did not deviate wildly from the patterns reported in the literature (kim, 2016; kwon, 2016) . the terms most frequently and centrally mentioned by the major news outlets mainly related to the contagious nature of the disease and patient counting (kwon, 2016) . sensational reporting and delivering government press releases without critical validation were also characteristic of the mers coverage (kim, 2016) . in addition, poor government handling of that crisis reduced the credibility of the information it provided (s.-u. yang, 2018) . against that backdrop, it is worth investigating the potential association between media use related to mers and the negative emotional responses of media users to determine the extent to which they influenced the behavioral responses of those users. along with traditional media channels such as television and newspapers, the importance of social media increases during large-scale events. these trends are particularly salient in the context of crises, which are traditionally marked by high levels of information seeking by the general population. evidence shows that people turn to social media during times of crisis to find information about safety instructions, news updates, and damage reports. increasingly, the public expects even official agents to respond to public requests via social media in times of emergency, concurrent with traditional crisis management (veil et al., 2011) . these heightened expectations are due in large part to perceptions of the benefits of social media for crisis communication. it is believed that social media can accelerate information dissemination in crisis situations by linking end users directly to critical information sources in real-time (hughes & palen, 2012) . during the 2009 h1n1 virus outbreak, people exchanged information and experiences through social media (chew & eysenbach, 2010) . social media, such as twitter, has been used to quickly share initial information and updates during various types of crises, as well as to encourage specific actions, such as volunteering and precautionary behaviors (potts, 2014) . the presence of social media as an information source becomes salient when traditional media provides limited information. for instance, tai and sun (2007) showed that, during the severe acute respiratory syndrome (sars) epidemic in 2003, chinese people turned to the internet and message services to find information unavailable from the traditional media, which operate under close censorship by the chinese government. likewise, at the beginning of the mers crisis, the korean government withheld the list of hospitals affected by mers, and the mainstream media adhered to the information embargo requested by the government. limited access to needed information fueled fear, so people turned to social media instead of traditional media outlets (kim, 2016) . social networking service (sns) users are likely to be exposed to messages that affect their perceptions and their use of preventive behaviors related to health risks and the crisis event. vos and buckner (2016) found that sns messages in the 2013 outbreak of the h7n9 virus consisted mainly of sense-making messages to educate users about the nature of the risk and efficacy messages to encourage appropriate responses. in a similar line, yoo, choi, and park (2016) found that receiving information about mers through sns directly encouraged mers preventive behavioral intentions. social media is filled not only with information but also emotional expressions (chew & eysenbach, 2010) . negative emotions are more likely than positive emotions to be floating around social media during an infectious outbreak, which could increase risk perception (choi, yoo, noh, & park, 2017) . for instance, song et al. (2017) found that negative emotions (e.g., anxiety or fear) prevailed in online boards and social media during the mers crisis. often, information intertwined with emotional markers travels around social media, and emotionally charged messages are more likely than purely informational posts to be shared and diffused (pfeffer, zorbach, & carley, 2014; stieglitz & dang-xuan, 2013) . s. choi, lee, pack, chang, and yoon (2016) mined internet media reports about mers in 2016 and examined their effects on public emotion expressed online, which they captured using a sentiment analysis. they mined all mers-related news articles from 153 media companies, including the comments about each one. in a time-series analysis, they found a flow from internet media to public fear. according to song et al. (2017) , negative emotion accounted for 80% of all posts throughout online networks, especially twitter, during the mers crisis. therefore, i have drawn the following four hypotheses. i expected that both traditional and social media use in times of crisis could directly and indirectly facilitate preventive behaviors (via mers knowledge) and negative emotional responses to the mers situation. emerging social media channels have reshaped the crisis information context, which potentially complicates the relationships among media use and informational, emotional, and behavioral responses in the general public. although social media has been considered a powerful tool for disseminating information, both researchers and practitioners have cautioned against the propensity of social media to proliferate inaccurate data, unverified rumors, and even malicious misinformation (zeng et al., 2016) . because information disseminated through social media is often unverified, identifying accurate data and valid sources can be challenging and could both undermine relevant knowledge and exacerbate the consequences of emotional and behavioral responses. together with the characteristics of open access platforms, this concern is heightened by the dynamic nature of crisis communication and information overload in times of crisis (zeng et al., 2016) . social media networks are mostly composed of acquaintances and thus share common characteristics with interpersonal channels. prior works have shown that interpersonal channels tend to show stronger effects on behavioral change than traditional media, mainly through normative pressure (price & oshagan, 1995) . in addition, social media generally deal with a rapid exchange of information, which could be more appropriate for short and clear mi than for scientific knowledge about a crisis. for instance, won, bae, and yoo (2015) conducted an issue word analysis of sns messages during the mers outbreak and reported the six most frequently mentioned words on sns at that time. two of the six words were mask and hand sanitizer, which are clearly related to preventive behaviors. the other four words were hospital, infection, coughing, and checkup, which are also at least indirectly related to preventive behaviors. however, a big data analysis examining online news sites found that posts about symptoms, government reaction, disease treatment, business impacts, and rumors ranked higher than prevention-related information (song et al., 2017) . therefore, the effects of social media use on crisis knowledge and preventive behaviors might differ from those of traditional media. in terms of emotional responses, social media and traditional media might also show some differences. social media is known for its ability to spread information in a speedy and viral manner, but that information tends to be integrated with emotions. furthermore, emotionally charged messages are more likely to be shared than neutral messages (pfeffer et al., 2014; stieglitz & dang-xuan, 2013) . recent works on the mers crisis have shown that about 80% of the buzzwords on social media during the mers crisis were negatively charged emotional words such as fear and anxiety (s. choi et al., 2017; song et al., 2017) . those works suggest that social media might be more likely than traditional media to magnify negative emotional responses. on the contrary, some prior works have found that people use social media for social support in crisis situations (y. choi & lin, 2009) . that phenomenon could lessen the negative emotional responses in social media users. therefore, it is worth investigating how the cognitive, emotional, and behavioral responses to social media use differ from those to traditional media use, which raises the following research question: are there any differences between traditional media use and social media use in terms of cognitive, emotional, and behavioral responses during the mers crisis? the proposed research model is based on the preceding discussion (see figure 1) . specifically, i expect that both traditional and social media use related to mers was associated with mers knowledge, and that it directly and indirectly encouraged mers preventive behaviors in media users. i also expect that traditional and social media use about the korean mers crisis stimulated negative emotional responses, which in turn influenced both precautionary and panic behaviors in media users. finally, i examine whether social media use showed informational, emotional, and behavioral consequences similar to those of traditional media use. the data for this study were obtained from a two-wave online panel survey. wave 1 survey was conducted in the first few days of june 2015, when hype about the mers situation was escalating, and wave 2 survey was conducted about 1 month later. the respondents were adult members of an online panel recruited and maintained by a survey company in seoul, korea. about 1 million online users compose the company's panel, and participants were randomly drawn from that list to meet the specified constraints (e.g., areas of residence based on census composition). the selected panel members received a soliciting e-mail from the company and had full liberty to decline participation. the first page of the online survey included an explanation of the study purpose and researcher contact information. study participants gave informed consent by clicking the start survey button. they were free to stop taking the survey at any time, and they received small monetary incentives (e.g., cash-equivalent points) from the company. a total of 1,187 members of the online panel participated in wave 1 survey. about 1 month later, the same respondents were recontacted by the survey company to participate in wave 2 survey. the number of participants who completed both waves 1 and 2 online surveys was 969, which is the final subject sample used for the analyses herein. the final sample was 50.7% male, with a mean age of 43.88 years (sd = 12.67). with regard to level of education, 50.5% of the sample had some level of college education or a bachelor's degree, 17.1% had a 2-year college degree, and 20.9% of the sample had some level of high school education or were graduates of high school. the median monthly household income was between 3,500,000 and 4,000,000 won. of the total sample, 64.4% were married, with an average of 1.7 children (sd = .84). traditional news use. traditional news use of mers-related content was measured based on media use frequency questions. specifically, on a 7-point scale (1 = never to 7 = very often), respondents were asked to measure how much they relied on tv news or tv news websites and newspapers and newspaper websites in the context of the korean mers crisis (r = .37, m = 4.20, sd = 1.25). social media use. social media use of mers-related content was measured using three 7-point scales (1 = never to 7 = very often) in wave 1 survey. the specific use behaviors were (a) seeking mers-related news or information using social media, (b) receiving mers-related news or information from others via social media, and (c) talking about mers with others via social media (î± = .79, m = 3.72, sd = 1.48). negative emotional reactions to the mers situation. negative emotional reactions to the mers situation were measured in both waves 1 and 2 surveys. on a 7-point scale (1 = not at all to 7 = feel strongly), respondents were asked to report how strongly they felt fear and anxiety about the mers situation (wave 1, r = .85, m = 5.42, sd = 1.47; wave 2, r = .85, m = 5.08, sd = 1.53). mers knowledge. mers knowledge was measured using six quiz-type questions in both waves 1 and 2 surveys. knowledge items covered mers symptoms, lethality, maximum latent period, and institutions where a formal diagnosis of mers could be made during the outbreak. for each question, correct answers were coded as 1, and incorrect answers were coded as 0. subsequently, the answers to those six questions were combined and used as the mers knowledge measure (wave 1, with scores ranging from 0 to 6, m = 3.09, sd = 1.17; wave 2, with scores ranging from 0 to 6, m = 3.75, sd = 1.26). wave 2 survey using five items. on a 7-point scale (1 = never to 7 = very often), respondents were asked how often they engaged in behaviors to prevent mers: wearing a mask when they were out, washing hands frequently, avoiding contact with people with mers symptoms, avoiding hospitals, and avoiding daily activities such as grocery shopping to avoid crowds (î± = .77, m = 4.18, sd = 1.43). before running the path model to test hypotheses, a confirmatory factor analysis (cfa) was conducted to test validity of the measurement model. two knowledge measures were excluded from cfa because measures were composed of all dichotomized items. model modification was not utilized: ï� 2 (67) = 301.95, p = .00; normed fit index (nfi) = .95; incremental fit index (ifi) = .96; comparative fit index (cfi) = .96; root mean square error approximation (rmsea) = .06 with 90% confidence interval (ci) = [.05, .07]. factor loadings ranged from .51 to .98 and two factor loadings were rather low of .56 (one of mers preventive behaviors) and .51 (newspaper use item). however all ave (average variance extracted) were higher than .50 and factor loadings were still within acceptable range (fornell & larcker, 1981) . therefore, all items remained. path analysis was conducted to test the hypotheses with latent variables and two observed knowledge variables. the tested model included two control variables from wave 1 data. specifically, mers knowledge and negative emotions about the mers situation measured in wave 1 controlled each of the wave 2 variables accordingly. the research model showed a reasonably good fit according to commonly used criteria (hu & bentler, 1999) : ï� 2 (90) = 359.76, p = .00; nfi = .96; ifi = .96; cfi = .96; rmsea = .056 with 90% ci = [.050, .062]. figure 2 presents the overall results with path coefficients of the hypothesized model. h1 predicted that the more individuals use traditional news media (h1a) and social media (h1b), the more mers knowledge they would acquire. as expected, mers knowledge increased with increasing use of mers-related traditional news media (î² = .13, p < .01), which supported h1a. on the contrary, mers-related social media use was not significantly associated with mers knowledge (î² = â��.04, ns), which did not support h1b. therefore, h1 was only partially supported. h2 predicted that two types of media use would be positively associated with negative emotional responses to the mers situation. results showed that the more traditional media one used, the more anxious and worried about mers one became (î² = .09, p < .05), which supported h2a. however, mers-related sns use and negative emotions was not significantly associated (î² = .05, ns), which failed to support h2b. therefore, h2 was also partially supported. the next set of hypotheses predicted that positive effects of mers knowledge (h3a) and negative emotional responses (h3b) on mers preventive behaviors. as predicted, negative emotional response was positively related to engagement in mers preventive behaviors (î² = .54, p < .001). on the contrary, mers knowledge was not significantly associated with mers preventive behaviors (î² = .05, ns). therefore, h3 was also partially supported. the final set of hypotheses expected that both traditional news media use (h4a) and social media use (h4b) would have direct positive effects on mers preventive behaviors. results showed that only social media use showed note. dotted arrows denote paths that are not statistically significant or only marginally significant. the numbers presented in figure 2 are the standardized path coefficients. all exogenous variables, including mers knowledge (w1) and negative emotions (w1), were correlated with one another. no error term was correlated. w1 = wave 1; w2 = wave 2; mers = middle east respiratory syndrome. *p < .05. **p < .01. ***p < .001. direct positive effects on mers preventive behaviors (î² = .23, p < .001) not traditional media use (î² = .05, ns). finally, rq1 asked whether traditional media use and social media use show any differences in terms of cognitive, emotional, and behavioral responses. results showed that individuals during the mers crisis showed different responses depending on two types of media use. with respect to cognitive responses, as reported above, only traditional media use was positively associated with mers knowledge. likewise, in terms of emotional responses, traditional news media use showed a positive association with negative emotional reactions. with respect to behavioral responses, only social media use showed significant positive direct effects on mers preventive behaviors. wald tests comparing the path coefficients confirmed that the difference between effects of social media and traditional media on behavioral responses (wald test = â��6.51, p < .001) was statistically meaningful. wald test result also validated that the difference in cognitive response between social and traditional media use was also statistically significant (wald test = â��2.29, p < .01). despite a consensus that the media play an important role in times of crisis, the informational, emotional, and behavioral effects of traditional and social media use by individuals have been understudied in previous research. using two sets of data collected at two different time points during the 2015 mers crisis in korea, i investigated how traditional and social media use influenced mers knowledge, fear and anxiety about the mers situation, and adoption of preventive behaviors. to reflect the complexity of today's media environment in times of crisis, i focused on potential differences between the effects of traditional and social media use. first, this study found that traditional media use and social media use have different effects. as expected, traditional media use galvanized public understanding of mers. the more people read newspapers and watched tv news about mers, the more knowledge they acquired about mers symptoms, lethality, and maximum latent period. social media use neither increased nor decreased mers knowledge. the role of social media in times of crisis has received growing attention, at least in part because of its potential for viral information transmission. however, i did not find significant cognitive effects from social media use. compared with traditional media, which mainly report information verified by expert sources (lowrey, 2004) , social media can not only convey knowledge but also disseminate false or unverified information during a crisis. the null effect of social media use on mers knowledge might thus result from the conflicting content of social media. this speculation, of course, should be verified with a robust empirical examination. second, i found that negative emotions played a prominent role in facilitating preventive behaviors in the mers crisis. experiencing fear and anxiety is a natural reaction when people are faced with a crisis. a lack of familiarity with newly emerging infectious diseases such as mers tends to deepen fear and anxiety (sandman & lanard, 2003) , and media use could amplify those emotional experiences (kasperson, 1992) . finding of this study also indicate that traditional media use increased negative emotional responses. the more media respondents consumed, the more fear and anxiety they felt about the mers situation. more importantly, i found that the negative emotional responses people experienced when facing a crisis caused them to protect themselves from mers instead of pushing them into illogical or destructive behaviors. the positive role of negative emotions in promoting adaptive behaviors is consistent with what theoretical frameworks such as pmt and risp suggest. however, most prior studies based on pmt have been developed and tested within the context of public health campaigns. compared with carefully designed campaign messages intended to scare people to act properly with respect to a given risk, media messages could more likely be crude and mixed with various intentions (e.g., sensational reports to secure audience attention). indeed, there is a lack of empirical research examining what kinds of crisis-specific responses could be elicited from the media individuals choose to use in times of crisis. in addition, risp research provides a useful theoretical framework to predict that negative emotions could motivate people to seek information about a risk. however, this framework did not pay attention to media use, which can lead to behavioral consequences such as preventive behaviors beyond information seeking. this study addressed these gaps in the literature by directly testing the roles of negative emotions and media as potential sources of those emotions during a pandemic, which has been rarely examined in previous studies. this finding has clear implications for governmental communication strategies and media reporting. this study's results suggest that it may not be effective crisis management to brush off negative emotions among the public as illogical overreactions. instead, admitting fears and anxiety people may feel and designing messages channeling those emotions into desirable health behaviors needs to be considered even in times of crisis. sympathizing with people's feelings can be an effective means to boost the evaluation of communicators' dialogic competency which was found to be positively related to information credibility and trust in the government during the mers endemic (s.-u. yang, 2018) , which in turn may promote government and media health message effectiveness. this seemingly positive role of negative emotions, however, does not advocate for sensationalizing crisis situations. instead, both government and media may consider applying knowledge about the potentially positive function of negative emotion to public communication during a crisis. for instance, risk and health communication research has developed guidelines on how to write a good fear appeal message in the public health campaign context. government and news media may consult with these guidelines to compose a message to help people to cope with an epidemic risk. third, the findings of this study indicate that the role of knowledge for preventive behaviors in the 2015 mers crisis was rather limited. only traditional media use significantly increased the public's knowledge about mers but the increased understanding did not facilitate precautionary behaviors. disseminating knowledge has been a top priority in times of crisis under the assumption that understanding could lead the public to protective behavioral responses. the results of this study imply that filling the deficit of knowledge may not be the most efficient way to promote behavioral responses. the findings here suggest that an emotional pathway may work more efficiently than cognitive drives in promoting the adoption of preventive behaviors during a public health crisis. however, it is also important to point out that the findings related to knowledge should be interpreted with caution in the context of the 2015 mers crisis. s.-u. yang (2018) noted that koreans in general tended to perceive the government's mutuality and openness in communication somewhat unfavorably, which often negatively affected government-public relationships. as s.-u. yang (2018) showed, the korean government's lack of mutuality and openness seems to have deteriorated the credibility of its risk information, which may have worsened the public's trust and satisfaction with the government. this unique situation might have lowered not only the credibility of government information but also the credibility of information from news media that relied heavily on the government for information. accordingly, the low credibility of public information on mers can explain the limited role of knowledge in promoting desirable behavioral responses. prior work examining a different epidemic crisis found that one material factor influencing preventive action was respondent opinion about authorities (quah & hin-peng, 2004) . my finding thus suggests that simple acquisition of disseminated scientific knowledge might not necessarily produce desirable behavioral responses from the public. it also implies that contextual factors, such as government dialogic competency, should be considered to fully grasp the role of knowledge in times of crisis. fourth, the findings of this study show that, unlike traditional media use, social media use produced strong direct behavioral responses during the mers crisis. traditional media use did not show direct effects on preventive behaviors. this distinction between social media use and traditional media use could be explained in the following two ways. first, compared with traditional media, which is known to be powerful in knowledge diffusion, the interpersonal channel has been considered effective on behavioral responses via the normative route (price & oshagan, 1995) . the role of normative pressure on behavioral adaptation has been well documented in the health communication literature (e.g., planned behavioral intention model, ajzen, 1991) . given that social media networks are mainly composed of acquaintances, it is possible that social media might have formed specific behavioral norms related to the mers crisis (e.g., avoidance of hospitals and crowded places). the other explanation is related to potential differences in the content of traditional media and social media. social media might have delivered more mi than traditional media. indeed, a prior work analyzing social media content during the mers crisis reported that preventive behavior-related terms (e.g., masks and hand sanitizers) were the most frequently mentioned words (won et al., 2015) . furthermore, the most needed information at the beginning of the mers crisis was the list of mers-affected hospitals, which the korean government had withheld. given the government's unwillingness to share the list of hospitals, the public resorted to social media to actively seek, exchange, and share the hospital-related information. that piece of information could single-handedly trigger one preventive behavior (i.e., avoiding specific hospitals to protect themselves). indeed, hospital was one of the terms most frequently used on social media during the mers crisis (won et al., 2015) . however, a big data analysis of traditional media reported that words such as infection, confirmed cases, and death were centrally located in traditional media content (kwon, 2016) . in short, compared with traditional media, social media might play an essential role in virally diffusing mi (specific behavioral information, including where not to go and what to do). given the importance of dialogic competency for effective crisis communication (s.-u. yang, 2018) , some technological features of social media may have enhanced communication mutuality and openness which the korean government and media lacked. communication through social media may allow users to share empathy and social support. at the same time, social media-mediated communication can be perceived as more accessible and open than media-mediated communication. strong mutuality and openness perceived through communication with network members on social media could have increased the credibility of mi which could have enhanced behavioral responses at least during the mers crisis in korea. another notable finding regarding social media is that social media did not generate public anxiety and fear, at least during the mers crisis in korea. this is quite an interesting finding because the korean government strongly criticized media, especially social media, for releasing unverified rumors and fears. the lack of association between social media use and negative emotional responses could be a result of canceling out effects. in other words, social media might induce fear and anxiety, but social media might effectively cancel out the negative emotions by providing wanted social supports or mi, which should be under solid empirical scrutiny in the future study. in the interest of future research, it is important to discuss some of the limitations of this study. the data are not based on a representative sample, which means the study findings must be interpreted with caution. for instance, online panels tended to include the younger and the more educated compared with the general population, which could influence the interpretation of the role of social media and traditional media use during the mers crisis in korea. the measurement of key variables also has limitations. for example, traditional media use was assessed only for newspaper and television. omitting radio and general internet use should be recognized as another major limitation of the study. also, using quiz-type questions to tap mers knowledge without close validation and planning might have contributed to the low correlation between the two mers knowledge measures, which also raises a concern about a test-retest error involved in the panel data. these measurement issues could produce errors, which would be carried into the hypothesized path model this study proposed. in addition, wave 1 data did not include mers preventive behavior measures, which made it impossible to control all the endogenous variables in wave 1 data. therefore, it is hard to argue that an ideal panel data analysis was conducted for testing the proposed hypotheses. with these limitations in mind, this study contributed to the scholarship by testing the predictions drawn from existing theories that have rarely been examined in the context of a real epidemic crisis. major scholarly focus in the communication field has been on how government and responsible organizations manage or should manage crises. shifting away from that focus, this study investigated the associations between individual media use and consequent responses which have been relatively understudied. the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. the author(s) received no financial support for the research, authorship, and/or publication of this article. mihye seo https://orcid.org/0000-0002-5734-3181 the theory of planned behavior. organizational behavior and human decision process circulating health rumors in the "arab world": a 12-month content analysis of news stories and reader commentary about middle east respiratory syndrome from two middle eastern news outlets how emotion shapes behavior: feedback, anticipation, and reflection, rather than direct causation predicting health behaviour: research and practice with social cognition models pandemics in 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model to pandemic influenza media coverage of public health epidemics: linking framing and issue attention cycle toward an integrated theory of print news coverage of epidemics social big data analysis of information spread and perceived infection risk during the 2015 middle east respiratory syndrome outbreak in south korea emotions and information diffusion in social media-sentiment of microblogs and sharing behavior media dependencies in a changing media environment: the case of the 2003 sars epidemic in china disaster communication on the internet: a focus on mobilizing information global bird flu communication: hot crisis and media assurance a work-in-process literature review: incorporating social media in risk and crisis communication social media messages in an emerging health crisis: tweeting bird flu issue words analysis according to the mers outbreak on sns middle east respiratory syndrome coronavirus (mers-cov)-republic of korea effects of government dialogic competency: the mers outbreak and implications for public health crises and political legitimacy what, me worry? the role of affect in information seeking and avoidance the effects of sns communication: how expressing and receiving information predict mers-preventive behavioral intentions in south korea media use and health behavior in h1n1 flu crisis: the mediating role of perceived knowledge and fear #unconfirmed: classifying rumor stance in crisis-related social media messages mihye seo (phd, the ohio state university) is an associate professor in the department of media and communication at sungkyunkwan university, seoul, south korea. her research focuses on media use and its influence on individuals' daily life and on community-building efforts. key: cord-016536-8wfyaxcb authors: ubokudom, sunday e. title: physical, social and cultural, and global influences date: 2012-02-20 journal: united states health care policymaking doi: 10.1007/978-1-4614-3169-5_6 sha: doc_id: 16536 cord_uid: 8wfyaxcb in chap. 5, we examined the technological environment of the health care policy-making system. specifically, we examined the classification, evolution, and diffusion of medical technology; the effects of medical technology on medical training and the practice of medicine; effects on medical costs, quality of care, and quality of life; effects on access to care; the ethical concerns raised by medical technology; and the practice of technology assessment. we concluded the chapter by observing that the growth of technology, as well as other human endeavors, affects other important aspects of our lives, most notably, the air we breathe, the food we eat, the generation of radioactive by-products and toxic chemicals, the manufacture of illicit drugs, and the generation of natural and man-made hazards. in other words, in addition to their effects on the health care system, technology and other human activities affect many other aspects of our lives that are associated with health. the who's defi nition of health as "a complete state of physical, mental, and social well-being, and not merely the absence of disease or infi rmity" (who 1948 ) , is primarily based on the wellness model. in this defi nition, emphasis is put on the fact that health is not merely the absence of disease, but also involves a social dimension. therefore, it also emphasizes the social and fi nancial support systems identifi ed in table 5 .1 of chap. 5 . this defi nition of health, as involving the combination of physical, mental, and social well-being led to the concept of the "health triangle." the health triangle left out the spiritual dimension of health, which has recently gained signifi cant attention in the literature due to a growing interest in the notion of holistic health. holistic health stresses the importance of all the things that make a person whole and complete. in addition to the three dimensions of the health triangle, of his analysis (szreter 2002 , p. 723) . subsequent studies revealed that the cessation of the large-scale redistribution of income and wealth from the very rich to the poorest in society had adverse effects on the health of the population. for example, when unhealthy behaviors and lifestyles were held as constant as possible, studies showed that people of lower socioeconomic status were more likely to die prematurely than were people of higher socioeconomic status (isaacs and schroeder 2004 , p. 1138; smith et al. 1996 , p. 486; davey smith et al. 1994 , p. 131) . the relationship between physical, social and cultural, and global environmental factors and health status is very well documented. in a letter to the editor of the jama , winkelstein ( 1993 winkelstein ( , p. 2504 argues that curative medical care, or those practices that are used for the care and rehabilitation of the sick, which involve most of the physical and designed social technologies listed in table 5 .1 of the previous chapter, is not the same as health care. medical care, as he defi nes it, makes only modest contributions to the health status of the population. on the contrary, the health status of the population is largely determined by a different set of factors that involve important physical, social, and economic components. these include preventive medicine, genetic predisposition, social and economic circumstances, environmental conditions, lifestyles and behaviors, and medical care (mckeown 1976 ; kannel et al. 1991 ; belloc and breslow 1972 , p. 409; bunker et al. 1989 ; bunker et al. 1995 , p. 305; marmot et al. 1991 marmot et al. , p. 1387 bell and standish 2005 , p. 339; mcginnis et al. 2002 , p. 78; wilkinson 1996 wilkinson , p. 1504 . we briefl y examine each of the identifi ed determinants of health below. preventive medicine seeks to minimize the occurrence of illness and disease. unlike the medical model that is reactive and seeks to contain disease and ill-health after they have occurred, preventive medicine is proactive and seeks to minimize the likelihood of the occurrence of disease and ill-health. generally, there are three areas or types of preventive measures, namely: primary prevention, secondary prevention, and tertiary prevention. primary prevention seeks to stop or minimize the development of disease or ill-health before it occurs. primary prevention may involve counseling against smoking, in order to prevent the development of chronic emphysema or chronic obstructive pulmonary disease (copd) and lung cancer. other primary interventions may include the promotion of an active lifestyle or exercise program, in order to minimize the likelihood of excess body fat and heart disease; driver education and mandatory seatbelt and motorcycle helmet laws, in order to reduce motor vehicle accidents and accidental head injuries; vaccinations for various forms of diseases and illnesses, such as measles and rubella, which can minimize the occurrence of early childhood diseases and mortality; and water purifi cation and sewage treatment programs that can minimize the occurrence of typhoid, cholera, and other waterborne diseases. secondary prevention involves the early detection and treatment of disease. health screenings and periodic and regular health examinations, such as hypertension screenings, mammograms, and pap smears, serve as examples of secondary prevention measures. these examples fall under the broad category of health promotion discussed in chap. 4 . the benefi ciaries of these programs are currently healthy people who are targeted to improve their health-related behaviors in order to minimize their chances of developing catastrophic and expensive illnesses. as was discussed in chap. 4 , secondary prevention measures are some of the most cost-effective steps employers take to lower their health benefi t costs ( coffi eld et al. 2001 , p. 1) . tertiary prevention measures involve steps taken to reduce the complications of diseases or illnesses, or to prevent further illnesses. they involve rehabilitative practices and the monitoring of the process of health care delivery. the infection control practices in hospitals and other improvements in the methods of health care delivery discussed in chap. 2 , under the postindustrial period of the evolution of the health care system, which are intended to reduce the occurrences of nosocomial infections and iatrogenic illnesses, are practical examples of tertiary prevention measures. other examples include patient education, nutrition counseling, and behavior modifi cation programs that seek to prevent the recurrence of disease and illness (timmreck 1994 , p. 17) . since the mid-1970s in the united states, there have been signifi cant reductions in heart disease, stroke, personal injury, and non-tobacco-related death rates foege 1993 , p. 2207; banta and jonas 1995 , p. 20) . similarly, the data presented in table 5 .3 of chap. 5 show signifi cant declines in death rates related to heart disease, cancer, stroke, infl uenza and pneumonia, chronic liver disease or cirrhosis, human immunodefi ciency virus (hiv) disease, suicide and homicides, from 1990 to 2006. these particular declines appear to be the result of preventive health measures, such as early screening, detection and treatment of hypertension, the provision and utilization of pneumonia and infl uenza vaccinations, moderate alcohol intake or abstinence, safe sex practices, suicide prevention and anger management programs, increased use of seatbelts and reductions in driving-underthe-infl uence episodes, smoking cessation, and the lowering of dietary fat and cholesterol. if, at least, some of the declines in mortality discussed above are due to preventive measures, the preventive strategy has yielded signifi cant gains in health. perhaps, it is this recognition of the importance of preventive services that led to the establishment of the us preventive services task force (uspstf) in 1984. most likely, it was the recognition of the crucial role that preventive medicine plays in enhancing population health that led to the convening of the uspstf in 1984 by the us public health service. the task force is a leading independent panel of nationally recognized nonfederal experts in prevention and evidencebased medicine. programmatic responsibility for the task force was transferred to the agency for health care research and quality (ahrq) in 1995 (uspstf procedure manual 2011 ). the uspstf is assigned the responsibility of making evidence-based recommendations that address primary and secondary preventive services targeting conditions that represent a substantial burden in the country, and that are provided in primary care delivery settings or made available through primary care referrals. the task force's recommendations are intended to improve clinical practice and promote the public health. tertiary prevention measures are outside the scope of the uspstf. even though the main audience for task force recommendations is the primary care provider, the recommendations are also used to guide programmatic, funding, and reimbursement decisions by policy-makers, managed care organizations, public and private payers, quality improvement organizations, research institutions, and consumers. beginning at the end of may 2007, the uspstf changed the grades it assigns to its recommendations. it assigns one of fi ve possible letter grades, a, b, c, d, or i, to each of its recommendations, including "suggestions for practice" associated with each grade. the agency also defi nes the levels of certainty regarding the net benefi t of each of its recommendations. the task force's 2009 reduction of the grade given for evidence quality from "b" to "c" for routine mammograms in women under the age of 50 years generated signifi cant controversy among health professionals and politicians (kinsman 2009 ) . in addition to the 2009 mammography recommendations stated above, the uspstf has recently recommended against screening for testicular cancer in adolescent or adult males (grade d recommendation) (uspstf 2011 , p. 483) . it has also concluded that there was insuffi cient evidence to assess the balance of benefi ts and harms of screening for bladder cancer in asymptomatic adults (moyer 2011 , p. 246) , and that prostate-specifi c antigen (psa) screening was associated with psychological harms, while its potential benefi ts remained uncertain (lin et al. 2008 , p. 192) . table 6 .1 shows the approach adopted by the agency in june 2007, to rank its recommendations. health is dependent upon biological factors. our predispositions to health or disease begin to take shape at the moment of conception. these predispositions are embedded in our genetic code. the genetic code guides the development of the proteins that determine our phenotypes (sizes, shapes, personalities, hair color, etc.) and genotypes or those aspects of our genetic codes that we cannot see, such as the biologic limit of our life expectancies (mcginnis et al. 2002 , p. 80; khoury et al. 1993 ; bell and standish 2005 , p. 339; starfi eld 1973 , p. 132; blum 1981 ; centers for disease control and prevention (cdc) 1979 ) . genetic factors predispose individuals to certain diseases. but although an individual may have a strong likelihood of developing a particular disease, this propensity to develop the disease is signifi cantly enhanced by environmental factors. for example, some studies demonstrate that there is a genetic basis for alcoholism (reich 1988 ) . but a person who has never taken a drink will not become an alcoholic. some triggers, in this case, the availability and consumption of alcohol, are necessary for the individual to progress from being genetically predisposed to alcoholism to actually (berkman and breslow 1983 ; burnett 1971 ; banta and jonas 1995 , p. 18; davis and webster 2002 , p. 13) . these examples suggest that the interaction between genetic factors and the environment in producing a particular disease is complex. while people have little or no control over their genetic makeups, the lifestyles and behaviors they freely choose and the surroundings where they live can have signifi cant infl uences on the likelihood of developing a particular disease to which they are genetically predisposed. to further the discussion of the infl uence of genetics on health, mcginnis et al. ( 2002 , p. 80) cite studies which show that although only about 2% of deaths in the united states may be attributed to purely genetic diseases, about 60% of late-onset disorders, such as diabetes, cardiovascular disease, and cancer, have some genetic component. for example, the brca1 gene accounts for only between 5 and 10% of breast cancers in the united states; only about 10% of colon cancers may be explained by genes, and only about 5% of elevated serum cholesterol levels may be explained by familial hyperlipidemia. similarly, studies of identical twins focusing on the occurrence of schizophrenia, and other twin studies examining the occurrence of dementia in older people, have found that about half of each might be explained by genetic factors. further, while about two-thirds of the risk of obesity might be genetic, the risk is expressed only with exposure to controllable lifestyle factors (baird 1994 , p. 133; muller 2000 , p. 7; panjukanta et al. 1998 , p. 369; kendler 1983 kendler , p. 1413 rowe and kahn 1998 ) . the institute of medicine (iom) ( 2003 , p. 20) reported that americans in 2003, compared with those who lived in 1900, were healthier, lived longer, and enjoyed lives that were less likely to be marked by injuries, ill health, or premature death. but the gains in health reported by the iom were not shared equally among the population of the united states. at the moment, as was also the case in 2003, gains in health status are not shared fairly or equally by all americans. americans with a good education, those who hold high-paying jobs, and those who live in serene and comfortable neighborhoods live longer and healthier lives than those with lower levels of education and income, and those who live in crime infested, overcrowded, and less comfortable and cohesive urban areas (isaacs and schroeder 2004 , p. 1137; bell and standish 2005 , p. 339; lantz et al. 1998 lantz et al. , p. 1703 navarro 2009 , p. 423; satcher 2010 , p. 6; williams 1990 , p. 81; metzler 2007 , p. 1; kilbourne et al. 2006 kilbourne et al. , p. 2113 berkman and lochner 2002 , p. 291) . there are several pathways through which social and economic circumstances affect health. those with good educational achievements are more likely to attain higher socioeconomic status than the poorly educated (angel et al. 2006 ; barr 2008 ; bartley 1994 ; mirowsky and ross 1986 , p. 23) . people of lower socioeconomic status die earlier and are more susceptible to undesirable life events than people on higher socioeconomic levels, a pattern that holds true in a progressive fashion from the poorest to the richest (mcleod and kessler 1990 , p. 162; adler et al. 1993 , p. 3140; adler and newman 2002 , p. 60; guralnik et al. 1993 , p. 110; mcdonough et al. 1997 mcdonough et al. , p. 1476 . this trend also holds whether one looks at education or occupation (national center for health statistics 1998 , p. 3; kaplan and keil 1993 , p. 1973 ). these differences are said to be due to the fact that people of higher socioeconomic status have healthier behaviors and lifestyles than those of lower socioeconomic status. people of higher socioeconomic status are less likely to smoke, and are far more likely to eat healthier foods and to engage in leisure-time physical exercise (national center for health statistics 2002 , p. 198; pratt et al. 1999 , p. s526; giles-corti and donovan 2002 , p. 601 ). according to isaacs and schroeder ( 2004 , p. 1138) , as a result of "a sedentary lifestyle and unhealthy eating habits, obesity and the diseases it fosters now characterize lower-class life." poor eating habits and a sedentary lifestyle alone do not explain the differences in health between high and low socioeconomic people. rather, another explanation for the differentials lies in the distribution of income or the income gradient between the low and high socioeconomic groups. in a study of white americans using 1980 census data, undertaken by smith et al. ( 1996 , p. 486) , men earning less than $10,000 per year were 1.5 times as likely to die prematurely as were those earning $34,000 or more. a similar study of british civil servants conducted about 2 years before the american study showed that when smoking and other risk factors were controlled for, those who were in the lowest employment category were more than twice as likely to die prematurely of cardiovascular disease as were those in the highest employment category (davey smith et al. 1994 , p. 131) . the fi ndings of these studies have led to the theory that inequitable distribution of income and wealth, or the socalled income and wealth gradient, causes poor health (sen 1992 (sen , p. 102, 1999 daniels et al. 2000 ; deaton 2002 , p. 13 ). as noted above, the relationship between health and income is referred to as a gradient. this terminology emphasizes the gradual relationship between the two variables. health improvements are directly related to improvements in income throughout the income distribution, and poverty has more than a "threshold" effect on health (deaton 2002 , p. 14) . the us national longitudinal mortality study (nlms) published by the national institutes of health (nih) ( 1992 ) showed that the proportional relationship between income and mortality was the same at all income levels, implying that the absolute reduction in mortality for each dollar of income was much larger at the bottom of the income distribution than at the top. apart from income, mortality is also known to decline with wealth, rank, and with social status (marmot et al. 1984 (marmot et al. , p. 1003 (marmot et al. , 1991 (marmot et al. , p. 1387 . similarly, studies also show marked differences in life expectancy by race and by geography or people's places of residence. for example, there is a 20-year gap in life expectancy between white men who live in the healthiest counties or localities and black men who live in the unhealthiest counties (murray et al. 1998 , p. 1; gittelsohn 1982 , p. 133; marmot 2006 marmot , p. 1304 kawachi and berkman 2003 ) . the brief discussion in this section points to the effects of numerous, and possibly interrelated, social and economic factors on health. income might affect health just as health might affect income; the distribution of income and wealth might affect health. similarly, education, race, minority status, geography, employment, housing, discrimination and social isolation, nutrition, lifestyle, stress, health practices, and coping skills might affect health. it does not appear to matter very much which of the above factors is stressed, especially since they are more likely to be interdependent than independent. disease risks exist, most often, along a continuum (rose 1994 ) . risks are rarely dichotomous. according to lochner ( 2002 , p. 2291) , there is no clear division between risk and no risk with regard to, for example, levels of blood pressure, cholesterol, alcohol or tobacco use, physical activity, diet and weight, etc. this gradient of risk also exists for many social and environmental conditions, such as socioeconomic status, social isolation, occupational and environmental exposure, and air quality. put differently, the numerous studies on the determinants of health that we are unable to fully summarize individually here for lack of space, point to the fact that even though the human and material resources at our disposal, the foods we eat, our levels of education, the houses we live in, the quality of the environments where we live and work, to name but a few, affect every person's health, the effects may vary in direction and scope from person to person, depending on the differences in their unique circumstances. improvement in environmental conditions is an important goal of the us government, as can be inferred from the emphasis on environmental quality outlined in healthy people 2010 . that document clearly states that factors in the physical and social environment play major roles in the health of individuals and communities. the physical environment is operationalized to include the air, water, and soil through which exposure to chemical, biological, and physical agents may occur. the physical environment can harm individual and community health, especially when individuals and communities are exposed to toxic substances, irritants, infectious agents, and physical hazards in homes, schools, and work sites. the physical environment can also promote good health, for example, by providing clean and safe places for people to work, exercise, and play ( healthy people 2010 , p. 19). therefore, the physical environment is perhaps one of the most important factors that should be considered when classifying the health status of an individual (wikipedia 2010 ) . environmental factors, such as air and water quality, exposure to pesticides and toxic waste, and housing conditions, have major effects on health and human development. for example, substandard air and water quality have been directly associated with diseases such as cancer, asthma, certain birth defects, and some neurological disorders (grant makers in health 2010 , p. 165) . similarly, many forms of cancer are associated with dioxin, polychlorinated biphenyls (pcbs), and mercury (friis 2007 ) . also, airborne particulate matter, tobacco smoke, and ground-level ozone, have been known to cause asthma attacks in children. exposure to lead, which can be found in peeling paint or in the soil and air in many poor communities, has been associated with impaired cognitive and behavioral development and low birth weight among children born to exposed mothers, and is also known to cause kidney damage (friis 2007 ) . in recognition of the danger of environmental contamination, bell and standish ( 2005 , p. 339 ) urge communities to act on their behalf to make changes in the policies that affect their physical, social, and economic environments. they state, plausibly, that "policy, place, and community" matter. combined, policy and community can alter or ameliorate the underlying forces that lie at the heart of the determinants of health. for example, they argue that policy determines the behaviors or things that are allowed, encouraged, discouraged, and prohibited. policy also determines whether industrial facilities will be sited near residential neighborhoods, how industrial facilities treat their neighbors; how dense neighborhoods will be; what materials can be used to build houses; who will live in a neighborhood; whether businesses can locate in a neighborhood; and whether there are tax or other incentives available for locating in a neighborhood (bell and standish 2005 , p. 340 ). in the developed communities or countries, environmental epidemiologists are concerned about such things as gene-environment interactions, environment-environment interactions, particulate air pollution, nitrogen dioxide, ground-level ozone, environmental tobacco smoke, radiation, lead, video display terminals, cellular telephones, and persistent organic pollutants (pops) that act as endocrine disruptors. exposure to these downstream or proximate environmental vectors (exposures that are closely related in time and space to the ill-effects they cause) affect both health and well-being (encyclopedia of public health 2010 ) . in the developing communities, the primary environmental determinants of health are said to involve biological agents in the air, water, and soil that account for most deaths. for example, diarrheal diseases acquired from contaminated food or water, malaria, intestinal parasitic infections, respiratory diseases caused by biological and chemical agents in both indoor and outdoor air, wreak havoc in the developing countries. these environmental hazards take a far greater toll on human life and suffering in absolute terms compared to those environmental vectors of concern in the developed countries (encyclopedia of public health 2010 ) . the above environmental vectors that cause havoc in the developing countries also abound in the poor localities of the united states and other developed countries. wealthy people are more likely to live in better homes and locations where they are less exposed to environmental risks than poor people (friis 2007 ; mcleod and kessler 1990 , p. 162; giles-corti and donovan 2002 , p. 601; shi and singh 2008 , p. 51; grant makers in health 2010 , p. 165) . for example, although the rates of asthma have been rising in the country, the disease affects low-income people disproportionately. whereas the national prevalence rate of childhood and adult asthma is put at about 7%, some african-american communities report about 25% of children suffering from asthma. also, puerto rican children are reported to have the highest prevalence of active asthma of any us ethnic or racial group. in california, latino children are reported to be hospitalized for asthma at a rate that is 10% greater than that of white children. obviously, environmental hazards are some of the reasons for these disparities ( healthy people 2010 ; joint center for political and economic studies and policylink 2004 , p. 6; flores et al. 2002 , p. 82) . despite the gains in environmental quality since the advent of the environmental movement in the 1970s, mainstream environmental policies neglected the problems identifi ed in low-income communities because the inhabitants of those areas lacked the political and economic resources to press for environmental justice. however, since its start around 1982, the environmental justice movement has resulted in the cleanup of hazardous waste sites, the redevelopment of brown-fi elds, the shutdown of incinerators, and the establishment of parks and conservation areas in low-income communities. additionally, in low-income communities, local pollution problems are being addressed, cleaner and more accessible means of public transportation are made available, and wild lands and unique habitats are being protected (faber and mccarthy 2001 ) . these changes are due to interest group pressure, the recognition of the externalities associated with environmental degradation, and the value of a clean environment to the health and well-being of all persons, rich and poor. mcginnis et al. ( 2002 , p. 82) contend that behavior choices constitute the single most important domain of infl uence over health prospects in the united states. lifestyle and behaviors involve many dimensions, including dietary choices, engagement in physical activity, sexual behavior and recreation, including the choice to smoke and to ingest alcohol, the wearing of motor vehicle seatbelts and motorcycle helmets, and other responsible behavior when operating motor vehicles. because lifestyle and behavioral factors are under the control of individuals, the public is very likely to defi ne lifestyle and behavioral health problems as being self-induced. the choices we make with regard to the many dimensions of lifestyle and behavior enumerated above have signifi cant impacts on personal and population health. for example, dietary factors have been associated with coronary heart disease and stroke; colon, breast, and prostate cancers; and diabetes (us department of health and human services 1988 ) . similarly, a sedentary lifestyle has been associated with increased risk for heart disease, osteoporosis, dementia, diabetes, and colon cancer (us department of health and human services 1996 ) . furthermore, research shows that diets rich in fruits and vegetables, low-fat dairy foods with reduced saturated and total fat, and low sodium diets can lower blood pressure (appel et al. 1997 (appel et al. , p. 1117 svetkey et al. 1994 , p. 285; sacks et al. 2001 , p. 3) . the primary differences between how we perceive behavioral change now from much earlier perceptions is the great awareness that individual behavior occurs in a social context (berkman and lochner 2002 , p. 292) , be it the place of work or abode, the family, the place of worship, the peer group, the school system, the stage of development, etc. for example, the results from the 2001 national youth risk behavior survey (yrbs) demonstrated that numerous high school students engaged in behaviors that increased their chances of dying from motor vehicle crashes, other unintentional injuries, homicide, and suicide. specifi cally, the survey results showed that 14.1% of those surveyed had rarely or never worn a seatbelt during the 30 days preceding the survey; 30.7% had ridden with a driver who had been drinking alcohol; 17.4% had carried a weapon during the 30 days preceding the survey; 47.1% had drunk alcohol during the 30 days preceding the survey; 23.9% had used marijuana during the 30 days preceding the survey; and 8.8% had attempted suicide during the 12 months preceding the survey (grunbaum et al. 2002 , p. 313) . the authors of the yrbs concluded that "priority health-risk behaviors, which contribute to the leading causes of mortality and morbidity among youths and adults, are often established during youth, extend into adulthood, are interrelated, and are preventable." the examination of the main causes of death in the united states, which we shall shortly discuss in the next section of this chapter, will shed further light on behavioral risk factors. meanwhile, suffi ce it to say that lifestyle and behavioral factors constitute some of the important determinants of health that health policy must seek to address. even though it is agreed that the contribution of medical care to improved health is not as pronounced as the other factors just examined, curative medical care-those practices, technologies, and organizations that society and the medical profession use to cure and rehabilitate the sick-is nonetheless a key determinant of health (blum 1981 ; cdc 1979 ) . the centers for disease control and prevention (cdc) estimate that only about 10% of premature deaths in the united states can be attributed to inadequate access to medical care, while the remaining 90% can be accounted for by individual lifestyle and behaviors (50%), genetic profi les (20%), and social and environmental conditions (20%) (cdc 1979 ) . the reason why medical care is the least important determinant of health is because it is reactive, not proactive-it waits for disease and illness to occur before intervening, so to speak. in other words, while individual and population health are somehow associated with having access to curative care, access to preventive services is of greater signifi cance. therefore, health can improve signifi cantly, and the prevalence of disease can decline dramatically, without effective medical care, due to the other determinants of health (sigerist 1970 , p. 46; mckeown 1976 , p. 93; banta and jonas 1995 , p. 19 ). this knowledge is very likely the reason why williams and jackson ( 2005 , p. 325 ) and isaacs and schroeder ( 2004 , p. 1141 ) advocate the broadening of the concept of health policy to include the other determinants of health that were not usually seriously considered when discussing health policy. this knowledge, too, is the primary reason for this chapter of the book. we can elaborate further on the importance and relevance of the determinants of health by linking them to the ten leading causes of death in the united states. where possible, the analysis will link the incidences of mortality reported in the country that are associated with each, some, or combinations of the determinants of health. table 6 .2 shows the ten leading causes of death in the united states for 2006 and 2007. we present, below, the ten leading causes of death in the country for 2006 and 2007 in order to attempt to link some of them to treatable or preventable behaviors and exposures. in other words, we shall attempt to show that most of the deaths can be associated with factors that mainly fall under the social, economic, environmental, and lifestyle and behavioral determinants of health that we have just discussed. most of the ten leading causes of death presented above are nongenetic and can be prevented or treated. diseases of the heart, cancers, cerebrovascular diseases or strokes, chronic lower respiratory diseases, unintentional injuries, diabetes, infl uenza and pneumonia, and infection-and high blood pressure-induced nephritis can be curtailed, prevented, or treated. for example, cigarette smoking is linked with an increased risk of heart disease, chronic lower respiratory disease, and cancer; obesity is a major health risk for diabetes, hypertension, coronary heart disease, and some forms of cancer; alcohol causes a wide variety of accidents and injuries, increases the risks for high blood pressure, irregularities of the heart, and stroke; fl u vaccines can minimize infl uenza deaths; and seeking treatment for infections can prevent septicemia. additionally, although there is a genetic basis for nephrosis and nephrotic syndrome, the conditions can occur as a result of infection (such as strep throat, hepatitis, or mononucleosis), use of certain drugs, and diabetes. furthermore, although age and family history are important risk factors for alzheimer's disease, longstanding high blood pressure and a history of head trauma are suspected risk factors for the disease as well mcginnis and foege ( 1993 , p. 2207) identifi ed and quantifi ed the major external or nongenetic factors that contributed to deaths in the united states in 1990. deaths associated with socioeconomic factors and access to medical care, although important contributors to the total deaths recorded in the country, were not included in the study because of the diffi culty quantifying them independent of the other factors reported in the study. about 10 years after the mcginnis and foege study, mokdad et al. ( 2004 mokdad et al. ( , p. 1238 ) used a similar methodology to quantify the nongenetic factors that contributed to deaths in 2000. the results of the two studies cited above showed that about half of all deaths that occurred in the united states in both 1990 and 2000 could also be attributed to a small number of largely controllable behaviors and exposures, including tobacco, diet and activity patterns, alcohol, microbial and toxic agents, fi rearms, sexual behavior, motor vehicle accidents, and illicit drug use. the results of the causes of death studies reported by mcginnis and foege and mokdad and his colleagues are consistent with the fi ndings of the 2001 national yrbs cited earlier in this chapter. the survey results showed that in the united states, 70.6% of all deaths among youth and young adults aged 10-24 years were due only to four causes: motor vehicle crashes, other unintentional injuries, homicide, and suicide. the deaths attributable to these causes among the identifi ed population group were 31.4, 12, 15.3, and 11.9%, respectively (grunbaum et al. 2002 , p. 313) . furthermore, substantial morbidity and social problems were said to result from the approximately 870,000 pregnancies that occurred each year among women 15-19 years (ventura et al. 2001 , p. 1) , and from the estimated million cases of sexually transmitted diseases (stds) that occurred each year among persons 10-19 years (institute of medicine 1997 ; eng and butler 1997 ) . similar to the studies on the actual causes of death in the united states in 1990 and 2000, the yrbs also found that the leading causes of mortality and morbidity among all age groups in the country were related to behaviors that contributed to unintentional injuries and violence, tobacco use, alcohol and other drug use, sexual behaviors that contributed to unintended pregnancies and stds, including hiv infection, unhealthy dietary behaviors, and sedentary lifestyles. in 2010, almost 10 years after the 2001 yrbs discussed above, the cdc quantifi ed the death rates among teenagers aged 12-19 years between 1999 and 2006. not surprisingly, the ten leading causes of death for the teenage population remained constant throughout the period. they were as follows: accidents or unintentional injuries, 48% of deaths; homicides, 13% of teenage deaths; suicide, 11%; cancer, 6%; and heart disease, 3%. further analysis showed that motor vehicle accidents accounted for almost three quarters (73%) of all deaths from unintentional injury; and that non-hispanic black males had the highest death rate among all teenagers, with homicide being the leading cause of death for them (minino 2010 ) . the determinants of health that have occupied our attention up to this point are not only affected by the broad national and personal factors we have identifi ed but are also affected by broad global or international factors (shi and singh 2008 , p. 53) . therefore, the rest of this chapter is devoted to examining the infl uences of global factors on the health care system and the health policymaking process. foreign policies involve the political relationships between countries and the outside world. foreign policy development generally concerns the protection of a country's national interests, usually defi ned in terms of security, economic prosperity, and ideological goals (lee et al. 2007 , p. 208) . increased globalization has led to the broadening of foreign policy concerns to include health. conversely, it is now recognized that international trade and fi nance, migration and population mobility, environmental change or global warming, the emerging and reemerging infectious disease paradigms, natural disasters, and global insecurity or terrorism have clear and observable consequences for human health (kassalow 2001 ; mcinnes and lee 2006 , p. 5; lee et al. 2007 , p. 208; katz and singer 2007 , p. 223; campbell-lendrum et al. 2007 , p. 235; fidler 2007 , p. 243; macpherson et al. 2007 , p. 200; labonte et al. 2009 ) . we shall briefl y examine how these components of globalizationinternational trade, population mobility, infectious diseases, global warming or climate change, and natural disasters and terrorism-affect countries' health care and policymaking systems generally, and the united states' health care and policymaking systems in particular. we begin with international trade. the principal agents of global international trade and fi nance include such international agencies as the world bank, the international monetary fund (imf), and the world trade organization (wto). it has been reported that the market-biased or effi ciency-oriented austerity policies these organizations promote or sponsor have resulted in reduced expenditures for social programs in developing countries, thereby impairing population health and slowing the advances in literacy, fertility reduction, and improved reproductive health of the women of the developing countries (kinnon 1998 , p. 397; gray 1998 ; watts 1997 ) . some specifi c examples of international trade and fi nance policies include the following: trade liberalization or the lowering of tariffs and other barriers to imports that has led to the doubling of the value of world trade from 24% of world gdp in 1960 to 48% in 2003 (world bank 2006 ; the reorganization of production and service provision across multiple national borders by multinational or transnational corporations, such as outsourcing or the pursuit of integration into global value chains, resulting in a global labor market (world bank 1995 , p. 2007 woodall 2006 ) ; the conditions attached to world bank and imf loans, and to the rescheduling of loan payments, including structural adjustment programs (saps); fi nancial liberalization, which exposes national economies to the uncertainties created by large and volatile short-term capital fl ows; the signifi cant growth in the world's urban population caused by transnational economic integration; the promotion of export-oriented agricultural development that does not consider the social and environmental consequences of such actions, which result from the pressures on governments around the world to increase export earnings (stonich and bailey 2000 , p. 23) ; and the promotion and reinforcement of a market-oriented concept of health sector reform that strongly favors private provision and fi nancing (petchesky 2003 ; koivusalo and mackintosh 2005 , p. 3). critics of the above international trade and fi nance policies argue that it is not at all clear that globalization leads to substantial poverty reduction. they point to the large-scale and extreme unequal distribution of wealth and income in the countries that have been identifi ed as "globalizers" witnessing rapidly growing economies. it is argued that even a little redistribution of income through progressive taxation and targeted social programs would go farther in terms of poverty reduction than many years of solid economic growth (jubany and meltzer 2004 ; paes de barros et al. 2002 ; de ferranti et al. 2004 ) . further, it is argued that as countries compete for foreign direct investment and outsourced production, the need to appear business-friendly may limit their ability to adopt and implement labor standards, occupational safety and health regulations, and other redistributive programs (cornia 2005 ) ; global integration of production may cause a sharp decline in the wages of, and demand for, low-skilled workers; large amounts of debt limit the ability of many developing and developed countries to meet other human needs related to health, education, water, public safety, sanitation, nutrition, etc.; globalization may lead to an intensifi cation of worldwide social relations which link distant localities in such a way that local happenings are shaped by events occurring many miles away, and vice versa (giddens 1990 , p. 64) ; much of the urbanization caused by international fi nance and trade policies occurs in countries that have limited resources to provide urban infrastructures; and the emphasis on private fi nancing and provision of health care leads to large-scale underinsurance and uninsurance in both the developed and developing countries (labonte and schrecker 2007 , p. 6) . globalization and the quest for exports are also blamed for increased smoking and tobacco-related mortality in the developing countries (murray and lopez 1997 , p. 1498) . also noteworthy is the escalation in the sale of weapons, much of it facilitated by western governments. the wars that have raged on and off in sub-saharan africa, latin america, and asia are tragic examples of the ill effects of aggressive weapon sales to these places (mcmichael and beaglehole 2000 , p. 497) . although the adverse effects of globalization discussed above tend to affect developing countries more than the united states, there are signifi cant adverse consequences of globalization for the united states as well. some of these include the perpetuation and exacerbation of the gap between the rich and the poor, a large public debt profi le that puts signifi cant pressure on social and other safety net policies and programs, the prevalence of uninsurance and underinsurance, job insecurity and reduced wages, the collapse of large manufacturing businesses, increased availability and demand for illicit drugs, and the emergence of new infectious diseases that spread more easily due to increased migration and population mobility (ubokudom and khubchandani 2010 , p. 20) . for example, american labor unions complain that the north american free trade agreement (nafta) with canada, mexico, and the united states, which came into force on january 1, 1994, has led to the loss of american jobs. job loss causes stress, loss of income and the fi nancial means to pay for medical care. from the onset, health issues were not at the heart or margins of foreign policy theory or practice for two reasons. first, the protection and promotion of population health did not factor into world leaders' calculations of what "competition in anarchy" (the condition from which foreign policy dynamics fl ow) required of their countries, nor was health for all seriously (as opposed to rhetorically) considered a pathway to a better world. second, those who were engaged in public health did not participate signifi cantly in discussions of foreign policy (fidler 2007 , p. 243) . therefore, there were only small and nonsubstantial linkages between health and foreign policy (harris 2004 , p. 171) . actions linking health issues or problems with foreign policy have been strongest when the potential impact on economic prosperity, national security, the environment, and development is severe. this has resulted in attention to health threats that are acute and severe, those that are projected to result in mass casualties, and those that are believed to be geographically widespread. in contrast, long-term health risks, or health risks that cause minor health problems, affect a limited number of people, or are not geographically widespread, attract little attention in relation to foreign policy. in other words, acute epidemic infections and major public health emergencies, such as natural or human-induced disasters, bioterrorism, and chemical and radiation accidents, have received signifi cant attention (fidler 2007 , p. 243; lee et al. 2007 , p. 208; katz and singer 2007 , p. 233) . a few specifi c examples of "attention-receiving" public health problems include the previously unknown human immunodefi ciency virus/acquired immunodeficiency syndrome (hiv/aids) which appeared in the united states in the early 1980s; the hantavirus, believed to have originated in korea; eastern equine encephalitis, which is found in the eastern and north-central united states, canada, parts of central and south america, and the caribbean islands; western equine encephalitis, which occurs primarily in the western and central united states, canada, and parts of south america; the polio virus that is believed to have originated in india in 2005; the spread of severe acute respiratory syndrome (sars) from china in 2003; and the 2009 outbreak of the deadly h1n1-swine flu-infl uenza believed to have originated in mexico (cdc 2009 ; shi and singh 2008 , p. 578; friis 2007 , p. 87) . in summary, many health problems, particularly infectious diseases, are widely recognized as global concerns that cross national and international boundaries. consequently, countries frequently include in their foreign policies strategies on these diseases that have the potential to threaten their domestic interests. this is likely to lead to higher prioritization, more attention, greater political support, and more funding. for example, in the united states, projections of the impact of hiv/ aids on the workforces of many countries, and the prevalence of hiv among military personnel in several regions of the world, contributed to the determination that hiv/aids was a security issue. similarly, awareness of the havocs caused by previous infl uenza pandemics and the economic impact of the small and short outbreak of sars led to serious preparations by the who and its member states for the next infl uenza pandemic (katz and singer 2007 , p. 234) . this understanding has led to many international agreements covering health and the environment, including the agreement on sanitary and phytosanitary measures, the international standards organization's classifi cation system for food labeling, the un framework convention on climate change, and the kyoto protocol, to name a few. data from the national aeronautics space administration (nasa) show that the earth's surface has warmed by about 0.66â°c between january and november 2010. that period was reported to be the warmest january-november in the nasa goddard institute for space studies (giss) analysis, which covers 131 years. the period was only a few hundredths of a degree warmer than 2005, so it is possible that the fi nal giss results for the full year, 2010, would be warmer or in the same range as 2005. further, the available data also show that the earth's surface has warmed by more than 0.8â°c over the past century and by about 0.6â°c in the past 3 decades (nasa 2010 ) . therefore, contrary to frequent assertions that global warming has slowed in the past decade, global warming has proceeded in the decade that ended in 2010 just as fast as it did in the prior 2 decades (nasa 2010 ) . the health hazards posed by climate change and global warming are inequitable, diverse, global, and probably irreversible over human time scales (patz et al. 2005 , p. 310; campbell-lendrum et al. 2007 , p. 235) . they include increased risks of extreme weather, such as fl oods and storms, fatal heat waves, long-term drought conditions in many areas of the world, surface water pollution and groundwater contamination, the melting of glaciers that supply freshwater to large population centers, salination of sources of agricultural and drinking water, increased rates of water extraction that may precipitate declines in supply, and creating a conducive environment for the global killers that are very sensitive to climatic conditions, such as malaria, diarrhea, and protein-energy malnutrition (campbell-lendrum et al. 2007 , p. 235; friis 2007 , p. 3) . as we noted under the actual causes of death, these three global killers cause many deaths in the united states; they are also said to account for about three million deaths worldwide each year (who 2004 ) . the relationship between migration, population mobility, and health is receiving renewed attention due to the emerging and reemerging infectious diseases that were discussed previously in this section. the health of both legal and illegal migrants to any country are affected by the determinants of health discussed earlier in this chapter, as well as by the risks that are present in their country of origin or that arise from the migration process itself (macpherson and gushulak 2001 , p. 390) . this is very true of the united states where a signifi cant portion of the annual population growth is due to migration. the effects of population mobility and migration on the country's health care system and the provision of health services are reported daily in the pages of newspapers. first, there is likely to be increased demand for services due to population growth, whether that growth is due to increased fertility rates or migration. for example, the exponential growth in medicaid expenditures in states that border mexico are said to be due to the increased demand for medical services by illegal immigrants as well as by the medical needs of an aging population. second, offi cials of the states that share boundaries with mexico complain about increased violent crimes committed by illegal immigrants, crimes that take a heavy toll on population health and health care expenditures. third, increased migration compels more health services planning, infrastructure maintenance, development and training of a diverse medical workforce to cater for the increasingly diverse population, and the establishment of public health programs for health promotion, health protection, and disease prevention (macpherson et al. 2007 , p. 200; cohen et al. 2002 , p. 90) . and, fourth, the opinion pages of newspapers carry citizens' letters that attribute the success of previous terrorist campaigns to the nearly open border policy the united states maintained prior to september 11, 2001 (9/11). since the 9/11 attacks, border security and entry visa requirements have been tightened. border control measures are now centered on inspecting and excluding goods, vessels, and people that pose serious health or terrorist threats to the united states. other countries have similar measures. the world has changed. indeed, the world has changed signifi cantly. while most people are actively planning on how to make their lives better, a few others are actively planning on how to destroy lives and settle political and ideological differences through acts of violence. no place and people are immune from the threats of violence, terrorism, and natural disasters. in the past 9 or 10 years, the united states has experienced disasters that have led to a rethinking of how to keep the population safe. the terrorist attacks in the united states on september 11, 2001, an unsuccessful attempt to initiate an anthrax epidemic in october 2001, and the devastation caused by hurricane katrina of the 2005 atlantic hurricane season led to signifi cant loss of lives and property and revealed defi ciencies in the public health and emergency response systems in the country. because of both underfunding and understaffi ng, and perhaps because the changes that have taken place in the world were not anticipated, the public health system was unable to develop or implement a comprehensive program of preparedness, prevention, response, and recovery (us general accounting offi ce 2003 ) . following the disasters, state, local, and federal public health agencies began to identify weaknesses in the nation's public health infrastructure and to reevaluate existing disaster response plans (baker and koplan 2002 , p. 15 ). the shortcomings revealed in the nation's disaster response plans elevated public health to an important national instrument for anticipating and dealing with terrorism, infectious disease outbreaks, and natural disasters. the guidance on responses to chemical, biological, radiological, nuclear, and explosive threats provided by the cdc, and by other national organizations and universities, helped individual state governments to develop statewide policies that took their unique concerns into account (ziskin and harris 2007 , p. 1584; shah 2006 shah , p. 1414 gebbie and turnock 2006 , p. 923) . public health plans to deal with terrorist threats, infectious diseases, and natural disasters now involve public health agencies at the federal, state, and local levels of government; other government and private agencies, such as the departments of justice and defense; the food and drug administration; private, public, and nonprofi t hospitals, clinics, and nursing homes; private and public practitioners, such as nurses and physicians; blood supply organizations, such as the american red cross; police and fi re departments; and individuals and groups throughout the country. as would be expected, expenditures for government public health activities, while still low relative to expenditures for medical care, rose from $47 billion in 2001 to about $69.4 billion in 2008, an increase of 47.6% from 2001 (centers for medicare and medicaid services (cms) 2010 ) . it remains to be seen if this enthusiasm for public health, demonstrated by increased funding since 2001, can be sustained. the law that is used as the basis for most of the new emergency preparedness measures is the homeland security act of 2002 . in addition to the strengthening of the public health infrastructure, the law also called for improved inspections of food products entering the united states. it calls for better measures to contain attacks on food and water supplies, to protect vital infrastructures, such as nuclear facilities, and to track biological materials anywhere in the country. further, the provisions of the law have been used to justify tough and controversial interrogation techniques, such as waterboarding. similarly, presidential executive order 13295, signed by george w. bush on april 4, 2003, authorizes the apprehension, detention, or conditional release of individuals with suspected communicable diseases, such as sars, cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, and viral hemorrhagic fevers such as ebola (the free dictionary 2008 ) . in summation, international trade and fi nance, infectious disease epidemics, global warming and climate change, population mobility, and natural disasters and terrorism signifi cantly affect the united states health care delivery and policymaking systems. in addition, medical technology and us health care professionals and consumers are also affected by global factors. for example, because the united states is widely believed to be the world leader in the development and utilization of high-technology medical protocols, foreign dignitaries come here for specialty care. also, nurses and foreign medical school graduates (fmgs) move to the united states to acquire licenses to practice in the country. this so-called brain drain causes shortages of medical practitioners in the developing countries and alleviates some of the shortages in the health professional shortage areas of the united states. furthermore, telemedicine allows us physicians to transmit radiological images to other countries where they are analyzed at lower costs. on the other hand, us consulting pathologists and radiologists provide their services to other parts of the world. also, advanced medical equipment and supplies that are abandoned here a few years after deployment are shipped to the developing and less technology-intensive developed countries at low costs. the high costs paid by us consumers are used to subsidize the low costs paid by the developing countries (ubokudom and khubchandani 2010 , p. 21) . this chapter has identifi ed the impacts of physical, social, cultural, and global factors on health and health policymaking. health can be defi ned under the medical or wellness models. the health status of the us population, or the population of any other country for that matter, is largely determined by factors that have important physical, social, and economic dimensions. these include preventive medicine, genetic disposition, social and economic circumstances, environmental conditions, lifestyles and behaviors, and medical care. these determinants of health are associated, in various degrees, with the real or actual causes of death in the country. research demonstrates that most of the deaths in the country are attributable to a small number of largely controllable behaviors and exposures, or due to factors that fall under the preventive, social, economic, environmental, and lifestyle and behavioral determinants of health. these determinants of health are not only affected by the broad national and personal factors identifi ed in the chapter, they are also affected by global or international factors, including trade and fi nance, outbreaks of infectious diseases, climate change, natural disasters, and the threats of terrorism and population mobility. but even though most of the deaths in the country are the result of social, cultural, economic, environmental, and global factors, medical care is also an important determinant of health that cannot be ignored. an insurance card is one of the important factors that infl uence access to medical services. consequently, the next chapter examines demographic factors, most especially americans' ability to access medical services, and the disparities in health among segments of the population. socioeconomic inequalities in health: no easy solution socioeconomic disparities in health: pathways and policies poor families in america's health care crisis a clinical trial of the effects of dietary patterns on blood pressure in why are some people healthy and others not? strengthening the nation's public health infrastructure: historic challenge, unprecedented opportunity in jonas's health care delivery in the united states health disparities in the united states: social class, race, ethnicity and health unemployment and ill health: understanding the relationship communities and health policy: a pathway for change relationship of physical health status and health problems health and ways of living: the alameda county study social determinants of health: meeting at a crossroads planning for health pathways to health: the role of social factors the role of medical care in determining health: creating an inventory of benefi ts genes, dreams, and realities global climate change: implications for international public health policy healthy people: the surgeon general's report on health promotion and disease prevention national health expenditure projections priorities among recommended clinical preventive services the case for diversity in the health care workforce policy reform and income distribution is inequality bad for our health explanations for socioeconomic differentials in mortality: evidence from britain and elsewhere the social context of science: cancer and the environment policy implications of the gradient of health and wealth inequality in latin america & the caribbean: breaking with history? the hidden epidemic: confronting sexually transmitted diseases green of another color: building effective partnerships between foundations and the environmental justice 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u.s. preventive services task force structure and processes trends in pregnancy rates for the united states, 1976-97: an update epidemics in history: disease, power and imperialism unhealthy societies: the affl iction of inequality social sources of racial disparities in health socioeconomic differences in health: a review and redirection men's health: chronic lower respiratory diseases world health organization (who). 1948. preamble to the constitution of the world health organization as adopted by the international health conference state health policy for terrorism preparedness key: cord-146850-5x6qs2i4 authors: gupta, abhishek; lanteigne, camylle; heath, victoria; ganapini, marianna bergamaschi; galinkin, erick; cohen, allison; gasperis, tania de; akif, mo; institute, renjie butalid montreal ai ethics; microsoft,; university, mcgill; commons, creative; college, union; rapid7,; global, ai; university, ocad title: the state of ai ethics report (june 2020) date: 2020-06-25 journal: nan doi: nan sha: doc_id: 146850 cord_uid: 5x6qs2i4 these past few months have been especially challenging, and the deployment of technology in ways hitherto untested at an unrivalled pace has left the internet and technology watchers aghast. artificial intelligence has become the byword for technological progress and is being used in everything from helping us combat the covid-19 pandemic to nudging our attention in different directions as we all spend increasingly larger amounts of time online. it has never been more important that we keep a sharp eye out on the development of this field and how it is shaping our society and interactions with each other. with this inaugural edition of the state of ai ethics we hope to bring forward the most important developments that caught our attention at the montreal ai ethics institute this past quarter. our goal is to help you navigate this ever-evolving field swiftly and allow you and your organization to make informed decisions. this pulse-check for the state of discourse, research, and development is geared towards researchers and practitioners alike who are making decisions on behalf of their organizations in considering the societal impacts of ai-enabled solutions. we cover a wide set of areas in this report spanning agency and responsibility, security and risk, disinformation, jobs and labor, the future of ai ethics, and more. our staff has worked tirelessly over the past quarter surfacing signal from the noise so that you are equipped with the right tools and knowledge to confidently tread this complex yet consequential domain. these past few months have been especially challenging, and the deployment of technology in ways hitherto untested at an unrivaled pace has left the internet and technology watchers aghast. artificial intelligence has become the byword for technological progress and is being used in everything from helping us combat the covid-19 pandemic to nudging our attention in different directions as we all spend increasingly larger amounts of time online. it has never been more important that we keep a sharp eye out on the development of this field and how it is shaping our society and interactions with each other. with this inaugural edition of the state of ai ethics we hope to bring forward the most important developments that caught our attention at the montreal ai ethics institute this past quarter. our goal is to help you navigate this ever-evolving field swiftly and allow you and your organization to make informed decisions. this pulse-check for the state of discourse, research, and development is geared towards researchers and practitioners alike who are making decisions on behalf of their organizations in considering the societal impacts of ai-enabled solutions. we cover a wide set of areas in this report spanning agency and responsibility, security and risk, disinformation, jobs and labor, the future of ai ethics , and more. our staff has worked tirelessly over the past quarter surfacing signal from the noise so that you are equipped with the right tools and knowledge to confidently tread this complex yet consequential domain. to stay up-to-date with the work at maiei, including our public competence building, we encourage you to stay tuned on https://montrealethics.ai which has information on all of our research. we hope you find this useful and look forward to hearing from you! wishing you well, abhishek gupta the state of ai ethics, june 2020 the debate when ethicists ask for rights to be granted to robots is based on notions of biological chauvinism and that if robots display the same level of agency and autonomy, not doing so would not only be unethical but also cause a setback for the rights that were denied to disadvantaged groups. by branding robots as slaves and implying that they don't deserve rights has fatal flaws in that they both use a term, slave, that has connotations that have significantly harmed people in the past and also that dehumanization of robots is not possible because it assumes that they are not human to begin with. while it may be possible to build a sentient robot in the distant future, in such a case there would be no reason to not grant it rights but until then, real, present problems are being ignored for imaginary future ones. the relationship between machines and humans is tightly intertwined but it's not symmetrical and hence we must not confound the "being" part of human beings with the characteristics of present technological artifacts. technologists assume that since there is a dualism to a human being, in the sense of the mind and the body, then it maps neatly such that the software is the mind and the robot body maps to the physical body of a human, which leads them to believe that a sentient robot, in our image, can be constructed, it's just a very complex configuration that we haven't completely figured out yet. the more representative view of thinking about robots at present is to see them as objects that inhabit our physical and social spaces. objects in our environment take on meaning based on the purpose they serve to us, such as a park bench meaning one thing to a skateboarder and another to a casual park visitor. similarly, our social interactions are always situated within a larger ecosystem and that needs to be taken into consideration when thinking about the interactions between humans and objects. in other words, things are what they are, because of the way they configure our social practices and how technology extends the biological body.our conception of human beings, then, is that we are and have always been fully embedded and enmeshed with our the state of ai ethics, june 2020 designed surroundings, and that we are critically dependent on this embeddedness for sustaining ourselves. because of this deep embedding, instead of seeing the objects around us merely as machines or on the other end as 'intelligent others', we must realize that they are very much a part of ourselves because of the important role they play in defining both our physical and social existence. some argue that robots take on a greater meaning when they are in a social context like care robots and people might be attached to them, yet that is quite similar to the attachment one develops to other artifacts like a nice espresso machine or a treasured object handed down for generations. they have meaning to the person but that doesn't mean that the robot, as present technology, needs to be granted rights. while a comparison to slaves and other disenfranchised groups is made when robots are denied rights because they are seen as 'less' than others, one mustn't forget that it happens to be the case that it is so because they are perceived as instruments and means to achieve an end. by comparing these groups to robots, one dehumanizes actual human beings. it may be called anthropocentric to deny rights to robots but that's what needs to be done: to center on the welfare of humans rather than inanimate machines. an interesting analogue that drives home the point when thinking about this is the milgram prison experiment where subjects who thought they had inflicted harms on the actors, who were a part of the experiment, were traumatized even after being told that the screams they heard were from the actors. from an outside perspective, we may say that no harm was done because they were just actors but to the person who was the subject of the experiment, the experience was real and not an illusion and it had real consequences. in our discussion, the robot is an actor and if we treat it poorly, then that reflects more so on our interactions with other artifacts than on whether robots are "deserving" of rights or not. taking care of various artifacts can be thought of as something that is done to render respect to the human creators and the effort that they expended to create it. discussion of robot rights for an imaginary future that may or may not arrive takes away focus and perhaps resources from the harms being done to real humans today as part of the ai systems being built with bias and fairness issues in them. invasion of privacy, bias against the disadvantaged, among other issues are just some of the few already existing harms that are being leveled on humans as intelligent systems percolate into the everyday fabric of social and economic life. the state of ai ethics, june 2020 from a for-profit perspective, such systems are poised and deployed with the aims of boosting the bottom line without necessarily considering the harms that emerge as a consequence. in pro-social contexts, they are seen as a quick fix solution to inherently messy and complex problems. the most profound technologies are those that disappear into the background and in subtle ways shape and form our existence. we already see that with intelligent systems pervading many aspects of our lives. so we're not as much in threat from a system like sophia which is a rudimentary chatbot hidden behind a facade of flashy machinery but more so from roomba which impacts us more and could be used as a tool to surveil our homes. taking ethical concerns seriously means considering the impact of weaving in automated technology into daily life and how the marginalized are disproportionately harmed. in the current dominant paradigm of supervised machine learning, the systems aren't truly autonomous, there is a huge amount of human input that goes into enabling the functioning of the system, and thus we actually have human-machine systems rather than just pure machinic systems. the more impressive the system seems, the more likely that there was a ton of human labor that went into making it possible. sometimes, we even see systems that started off with a different purpose such as recaptcha that are used to prevent spam being refitted to train ml systems. the building of ai systems today doesn't just require highly skilled human labor but it must be supplemented with mundane jobs of labeling data that are poorly compensated and involve increasingly harder tasks as, for example, image recognition systems become more powerful, leading to the labeling of more and more complex images which require greater effort. this also frames the humans doing the low skilled work squarely in the category of being dehumanized because of them being used as a means to an end without adequate respect, compensation and dignity. an illustrative example where robots and welfare of humans comes into conflict was when a wheelchair user wasn't able to access the sidewalk because it was blocked by a robot and she mentioned that without building for considering the needs of humans, especially those with special needs, we'll have to make debilitating compromises in our shared physical and social spaces. ultimately, realizing the goals of the domain of ai ethics needs to reposition our focus on humans and their welfare, especially when conflicts arise between the "needs" of automated systems compared to those of humans. what happens when ai starts to take over the more creative domains of human endeavour? are we ready for a future where our last bastion, the creative pursuit, against the rise of machines is violently snatched away from us? in a fitting start to feeling bereft in the times of global turmoil, this article starts off with a story created by a machine learning model called gpt-2 that utilizes training data from more than 8 million documents online and predicts iteratively the next word in a sentence given a prompt. the story is about "life in the time of coronavirus" that paints a desolate and isolating picture of a parent who is following his daily routine and feels different because of all the changes happening around them. while the short story takes weird turns and is not completely coherent, it does give an eerie feeling that blurs the line between what could be perceived as something written by a human compared to that by a machine. a news-styled article on the use of facial recognition systems for law enforcement sounds very believable if presented outside of the context of the article. the final story, a fictional narrative, presents a fractured, jumpy storyline of a girl with a box that has hallucinatory tones to its storytelling. the range of examples from this system is impressive but it also highlights how much further these systems have to go before they can credibly take over jobs. that said, there is potential to spread disinformation via snippets like the second example we mention and hence, something to keep in mind as you read things online. technology, in its widest possible sense, has been used as a tool to supplement the creative process of an artist, aiding them in exploring the adjacent possible in the creative phasespace. for decades we've had computer scientists and artists working together to create software that can generate pieces of art that are based on procedural rules, random perturbations of the audience's input and more. off late, we've had an explosion in the use of ai to do the same, with the whole ecosystem being accelerated as people collide with each other serendipitously on platforms like twitter creating new art at a very rapid pace. but, a lot of people have been debating whether these autonomous systems can be attributed artistic agency and if they can be called artists in their own right. the author here argues that it isn't the case because even with the push into using technology that is more the state of ai ethics, june 2020 automated than other tools we've used in the past, there is more to be said about the artistic process than the simple mechanics of creating the artwork. drawing on art history and other domains, there is an argument to be made as to what art really is -there are strong arguments in support of it playing a role in servicing social relationships between two entities. we, as humans, already do that with things like exchanging gifts, romance, conversation and other forms of social engagement where the goal is to alter the social relationships. thus, the creative process is more so a co-ownership oriented model where the two entities are jointly working together to create something that alters the social fabric between them. as much as we'd like to think some of the ai-enabled tools today have agency, that isn't necessarily the case when we pop open the hood and see that it is ultimately just software that for the most part still relies heavily on humans setting goals and guiding it to perform tasks. while human-level ai might be possible in the distant future, for now the ai-enabled tools can't be called artists and are merely tools that open up new frontiers for exploration. this was the case with the advent of the camera that de-emphasized the realistic paint form and spurred the movement towards modern art in a sense where the artists are more focused on abstract ideas that enable them to express themselves in novel ways. art doesn't even have to be a tangible object but it can be an experience that is created. ultimately, many technological innovations in the past have been branded as having the potential to destroy the existing art culture but they've only given birth to new ideas and imaginings that allow people to express themselves and open up that expression to a wider set of people. the state of ai ethics, june 2020 ranking and retrieval systems for presenting content to consumers are geared towards enhancing user satisfaction, as defined by the platform companies which usually entails some form of profit-maximization motive, but they end up reflecting and reinforcing societal biases, disproportionately harming the already marginalized. in fairness techniques applied today, the outcomes are focused on the distributions in the result set and the categorical structures and the process of associating values with the categories is usually de-centered. instead, the authors advocate for a framework that does away with rigid, discrete, and ascribed categories and looks at subjective ones derived from a large pool of diverse individuals. focusing on visual media, this work aims to bust open the problem of underrepresentation of various groups in this set that can render harm on to the groups by deepening social inequities and oppressive world views. given that a lot of the content that people interact with online is governed by automated algorithmic systems, they end up influencing significantly the cultural identities of people. while there are some efforts to apply the notion of diversity to ranking and retrieval systems, they usually look at it from an algorithmic perspective and strip it of the deep cultural and contextual social meanings, instead choosing to reference arbitrary heterogeneity. demographic parity and equalized odds are some examples of this approach that apply the notion of social choice to score the diversity of data. yet, increasing the diversity, say along gender lines, falls into the challenge of getting the question of representation right, especially trying to reduce gender and race into discrete categories that are one-dimensional, third-party and algorithmically ascribed. the authors instead propose sourcing this information from the individuals themselves such that they have the flexibility to determine if they feel sufficiently represented in the result set. this is contrasted with the degree of sensitive attributes that are present in the result sets which is what prior approaches have focused on. from an algorithmic perspective, the authors advocate for the use of a technique called determinantal point process (dpp) that assigns a higher probability score to sets that have higher spreads based on a predefined distance metric. how dpp works is that for items that the individual feels represents them well, the algorithm clusters those points closer together, for points that they feel don't represent them well, it moves those away from the ones that represent them well in the embedding space. optimizing for the triplet loss helps to achieve the goals of doing this separation. but, the proposed framework still leaves open the question of sourcing in a reliable manner these ratings from the individuals about what represents and doesn't represent them well and then encoding them in a manner that is amenable to being learned by an algorithmic system. while large-scale crowdsourcing platforms which are the norm in seeking such ratings in the machine learning world, given that their current structuring precludes raters' identities and perceptions from consideration, this framing becomes particularly challenging in terms of being able to specify the rater pool. nonetheless, the presented framework provides an interesting research direction such that we can obtain more representation and inclusion in the algorithmic systems that we build. in maryland, allstate, an auto insurer, filed with the regulators that the premium rates needed to be updated because they were charging prices that were severely outdated. they suggested that not all insurance premiums be updated at once but instead follow recommendations based on an advanced algorithmic system that would be able to provide deeper insights into the pricing that would be more appropriate for each customer based on the risk that they would file a claim. this was supposed to be based on a constellation of data points collected by the company from a variety of sources. because of the demand from the regulators for documentation supporting their claim, they submitted thousands of pages of documentation that showed how each customer would be affected, a rare window into the pricing model which would otherwise have been veiled under privacy and trade secret arguments. a defense that is used by many companies that utilize discriminatory pricing strategies using data sourced beyond what they should be using to make pricing decisions. according to the investigating journalists, the model boiled down to something quite simple: the more money you had and the higher your willingness to not budge from the company, the more the company would try to squeeze from you in terms of premiums. driven by customer retention and profit motives, the company pushed increases on those that they knew could afford them and would switch to save dollars. but, for those policies that had been overpriced, they offered less than 0.5% in terms of a discount limiting their downsides while increases were not limited, often going up as high as 20%. while they were unsuccessful in getting this adopted in maryland where it was deemed discriminatory, the model has been approved for use in several states thus showing that opaque models can be deployed not just in high-tech industries but anywhere to provide individually tailored pricing to extract away as much of the consumer surplus as possible based on the purportedly undisclosed willingness of the customer to pay (as would be expressed by their individual demand curves which aren't directly discernible to the producer). furthermore, the insurers aren't mandated to make disclosures of how they are pricing their policies and thus, in places where they should have offered discounts, they've only offered pennies on the dollar, disproportionately impacting the poorest for whom a few hundred dollars a year can mean having sufficient meals on the table. sadly, in the places where their customer retention model was accepted, the regulators declined to answer why they chose to accept it, except in arkansas where they said such pricing schemes aren't discriminatory unless the customers are grouped by attributes like race, color, creed or national origin. this takes a very limited view of what price discrimination is, harkening back to an era where access to big data about the consumer was few and far between. in an era dominated by data brokers that compile thick and rich data profiles on consumers, price discriminaton extends far beyond the basic protected attributes and can be tailored down to specificities of each individual. other companies in retail goods and online learning services have been following this practice of personalized pricing for many years, often defending it as the cost of doing in business when they based the pricing on things like zip codes, which are known proxies for race and paying capacity. personalized pricing is different from dynamic pricing, as seen when booking plane tickets, which is usually based on the timing of purchase whereas here the prices are based on attributes that are specific to the customer which they often don't have any control over. a 2015 obama administration report mentioned that, "differential pricing in insurance markets can raise serious fairness concerns, particularly when major risk factors are outside an individual customer's control." why the case of auto insurance is so much more predatory than, say buying stationery supplies, is that it is mandatory in almost all states and not having the vehicle insured can lead to fines, loss of licenses and even incarceration. transport is an essential commodity for people to get themselves to work, children to school and a whole host of other daily activities. in maryland, the regulators had denied the proposal by allstate to utilize their model but in official public records, the claim is marked as "withdrawn" rather than "denied" which the regulators claim makes no internal difference but allstate used this difference to get their proposal past the regulators in several other states. they had only withdrawn their proposal after being denied by the regulators in maryland. the national association of insurance commissioners mentioned that most regulators don't have the right data to be able to meaningfully evaluate rate revision proposals put forth by insurers and this leads to approvals without review in a lot of cases. even the data journalists had to spend a lot of time and effort to discern what the underlying models were and how they worked, essentially summing up that the insurers don't necessarily lie but don't give you all the information unless you know to ask the right set of questions. allstate has defended its price optimization strategy, called complementary group rating (cgr) as being more objective, and based on mathematical rigor, compared to the ad-hoc, judgemental pricing practices that have been followed before, ultimately citing better outcomes for their customers. but, this is a common form of what is called "mathwashing" in the ai ethics domain where discriminatory solutions are pushed as fair under the veneer of mathematical objectivity. regulators in florida said that setting prices based on the "modeled reaction to rate changes" was "unfairly discriminatory." instead of being cost-based, as is advocated by regulators for auto-insurance premiums because they support an essential function, allstate was utilizing a model that was heavily based on the likelihood of the customer sticking with them even in the face of price rises which makes it discriminatory. these customers are price-inelastic and hence don't change their demand much even in the face of dramatic price changes. consumer behaviour when purchasing insurance policies for the most part remains static once they've made a choice, often never changing insurers over the course of their lifetime which leads them to not find the optimal price for themselves. this is mostly a function of the fact that the decisions are loaded with having to judge complex terms and conditions across a variety of providers and the customers are unwilling to have to go through the exercise again and again at short intervals. given the opacity of the pricing models today, it is almost impossible to find out what the appropriate pricing should be for a particular customer and hence the most effective defense is to constantly check for prices from the competitors. but, this unduly places the burden on the shoulders of the consumer. google had announced its ai principles on building systems that are ethical, safe and inclusive, yet as is the case with so many high level principles, it's hard to put them into practice unless there is more granularity and actionable steps that are derived from those principles. here are the principles: â�¢ be socially beneficial this talk focused on the second principle and did just that in terms of providing concrete guidance on how to translate this into everyday practice for design and development teams. humans have a history of making product design decisions that are not in line with the needs of everyone. examples of the crash dummy and band-aids mentioned above give some insight into the challenges that users face even when the designers and developers of the products and services don't necessarily have ill intentions. products and services shouldn't be designed such that they perform poorly for people due to aspects of themselves that they can't change. for example, when looking at the open image dataset, searching for images marked with wedding indicate stereotypical western weddings but those from other cultures and parts of the world are not tagged as such. from a data perspective, the need for having more diverse sources of data is evident and the google team made an effort to do this by building an extension to the open images data set by providing users from across the world to snap pictures from their surroundings that captured diversity in many areas of everyday life. this helped to mitigate the problem that a lot of open image data sets have in being geographically skewed. biases can enter at any stage of the ml development pipeline and solutions need to address them at different stages to get the desired results. additionally, the teams working on these solutions need to come from a diversity of backgrounds including ux design, ml, public policy, social sciences and more. so, in the area of fairness by data which is one of the first steps in the ml product lifecycle and it plays a significant role in the rest of the steps of the lifecycle as well since data is used to both train and evaluate a system. google clips was a camera that was designed to automatically find interesting moments and capture them but what was observed was that it did well only for a certain type of family, under particular lighting conditions and poses. this represented a clear bias and the team moved to collect more data that better represented the situations for a variety of families that would be the target audience for the products. quickdraw was a fun game that was built to ask users to supply their quickly sketched hand drawings of various commonplace items like shoes. the aspiration from this was that given that it was open to the world and had a game element to it, it would be utilized by many people from a diversity of backgrounds and hence the data so collected would have sufficient richness to capture the world. on analysis, what they saw was that most users had a very particular concept of a shoe in mind, the sneaker which they sketched and there were very few women's shoes that were submitted. what this example highlighted was that data collection, especially when trying to get diverse samples, requires a very conscious effort that can account for what the actual distribution the system might encounter in the world and make a best effort attempt to capture their nuances. users don't use systems exactly in the way we intend them to, so reflect on who you're able to reach and not reach with your system and how you can check for blindspots, ensure that there is some monitoring for how data changes over time and use these insights to build automated tests for fairness in data. the second approach that can help with fairness in ml systems is looking at measurement and modeling. the benefits of measurement are that it can be tracked over time and you can test for both individuals and groups at scale for fairness. different fairness concerns require different metrics even within the same product. the primary categories of fairness concerns are disproportionate harms and representational harms. the jigsaw api provides a tool where you can input a piece of text and it tells you the level of toxicity of that piece of text. an example in the earlier version of the system rated sentences of the form "i am straight" as not toxic while those like "i am gay" as toxic. so what was needed to be able to see what was causing this and how it could be addressed. by removing the identity token, they monitored for how the prediction changed and then the outcomes from that measurement gave indications on where the data might be biased and how to fix it. an approach can be to use block lists and removals of such tokens so that sentences that are neutral are perceived as such without imposing stereotypes from large corpora of texts. these steps prevent the model from accessing information that can lead to skewed outcomes. but, in certain places we might want to brand the first sentence as toxic if it is used in a derogatory manner against an individual, we require context and nuance to be captured to make that decision. google undertook project respect to capture positive identity associations from around the world as a way of improving data collection and coupled that with active sampling (an algorithmic approach that samples more from the training data set in areas where it is under performing) to improve outputs from the system. another approach is to create synthetic data that mimics the problematic cases and renders them in a neutral context. adversarial training and updated loss functions where one updates a model's loss function to minimize difference in performance between groups of individuals can also be used to get better results. in their updates to the toxicity model, they've seen improvements, but this was based on synthetic data on short sentences and it is still an area of improvement. some of the lessons learned from the experiments carried out by the team: â�¢ test early and test often â�¢ develop multiple metrics (quantitative and qualitative measures along with user testing is a part of this) for measuring the scale of each problem â�¢ possible to take proactive steps in modeling that are aware of production constraints from a design perspective, think about fairness in a more holistic sense and build communication lines between the user and the product. as an example, turkish is a gender neutral language, but when translating to english, sentences take on gender along stereotypes by attributing female to nurse and male to doctor. say we have a sentence, "casey is my friend", given no other information we can't infer what the gender of casey is and hence it is better to present that choice to the user from a design perspective because they have the context and background and can hence make the best decision. without that, no matter how much the model is trained to output fair predictions, they will be erroneous without the explicit context that the user has. lessons learned from the experiments include: â�¢ context is key â�¢ get information from the user that the model doesn't have and share information with the user that the model has and they don't â�¢ how do you design so the user can communicate effectively and have transparency so that can you get the right feedback? â�¢ get feedback from a diversity of users â�¢ see the different ways in how they provide feedback, not every user can offer feedback in the same way â�¢ identify ways to enable multiple experiences â�¢ we need more than a theoretical and technical toolkit, there needs to be rich and context-dependent experience putting these lessons into practice, what's important is to have consistent and transparent communication and layering on approaches like datasheets for data sets and model cards for model reporting will aid in highlighting appropriate uses for the system and where it has been tested and warn of potential misuses and where the system hasn't been tested. the paper starts by setting the stage for the well understood problem of building truly ethical, safe and inclusive ai systems that are increasingly leveraging ubiquitous sensors to make predictions on who we are and how we might behave. but, when these systems are deployed in socially contested domains, for example, "normal" behaviour where loosely we can think of normal as that defined by the majority and treating everything else as anomalous, then they don't make value-free judgements and are not amoral in their operations. by viewing the systems as purely technical, the solutions to address these problems are purely technical which is where most of the fairness research has focused and it ignores the context of the people and communities where these systems are used. the paper serves to question the foundations of these systems and to take a deeper look at unstated assumptions in the design and development of the systems. it urges the readers, and the research community at large, to consider this from the perspective of relational ethics. it makes 4 key suggestions: â�¢ center the focus of development on those within the community that will face a disproportionate burden or negative consequences from the use of the system â�¢ instead of optimizing for prediction, it is more important to think about how we gain a fundamental understanding of why we're getting certain results which might be arising because of historical stereotypes that were captured as a part of the development and design of the system â�¢ the systems end up creating a social and political order and then reinforcing it, meaning we should involve a larger systems based approach to designing the systems â�¢ given that the terms of bias, fairness, etc evolve over time and what's acceptable at some time becomes unacceptable later, the process asks for constant monitoring, evaluation and iteration of the design to most accurately represent the community in context. at maiei, we've advocated for an interdisciplinary approach leveraging the citizen community spanning a wide cross section to best capture the essence of different issues as closely as possible from those who experience them first hand. placing the development of an ml system in context of the larger social and political order is important and we advocate for taking a systems design approach (see a primer in systems thinking by donna meadows) which creates two benefits: one is that several ignored externalities can be considered and second to involve a wider set of inputs from people who might be affected by the system and who understand how the system will sit in the larger social and political order in which it will be deployed. also, we particularly enjoyed the point on requiring a constant iterative process to the development and deployment of ai systems borrowing from cybersecurity research on how security of the system is not done and over with, requiring constant monitoring and attention to ensure the safety of the system. underrepresentation of disabilities in datasets and how they are processed in nlp tasks is an important area of discussion that is often not studied empirically in the literature that primarily focuses on other demographic groups. there are many consequences of this, especially as it relates to how text related to disabilities is classified and has impacts on how people read, write, and seek information about this. research from the world bank indicates that about 1 billion people have disabilities of some kind and often these are associated with strong negative social connotations. utilizing 56 linguistic expressions as they are used in relation to disabilities and classifying them into recommended and non-recommended uses (following the guidelines from anti-defamation league, acm sigaccess, and ada national network), the authors seek to study how automated systems classify phrases that indicate disability and whether usages split by recommended vs. non-recommended uses make a difference in how these snippets of text are perceived. to quantify the biases in the text classification models, the study uses the method of perturbation. it starts by collecting instances of sentences that have naturally occurring pronouns he and she. then, they replace them with the phrases indicating disabilities as identified in the previous paragraph and compare the change in the classification scores in the original and perturbed sentences. the difference indicates how much of an impact the use of a disability phrase has on the classification process. using the jigsaw tool that gives the toxicity score for sentences, they test these original and perturbed sentences and observe that the change in toxicity is lower for recommended phrases vs. the non-recommended ones. but, when disaggregated by categories, they find that some of them elicit a stronger response than others. given that the primary use of such a model might in the case of online content moderation (especially given that we now have more automated monitoring happening as human staff has been thinning out because of pandemic related closures), there is a high rate of false positives where it can suppress content that is non-toxic and is merely discussing disability or replying to other hate speech that talks about disability. to look at sentiment scores for disability related phrases, the study looks at the popular bert model and adopts a template-based fill-in-the-blank analysis. given a query sentence with a missing word, bert produces a ranked list of words that can fill the blank. using a simple template perturbed with recommended disability phrases, the study then looks at how the predictions from the bert model change when disability phrases are used in the sentence. what is observed is that a large percentage of the words that are predicted by the model have negative sentiment scores associated with them. since bert is used quite widely in many different nlp tasks, such negative sentiment scores can have potentially hidden and unwanted effects on many downstream tasks. such models are trained on large corpora, which are analyzed to build "meaning" representations for words based on co-occurrence metrics, drawing from the idea that "you shall know a word by the company it keeps". the study used the jigsaw unintended bias in toxicity classification challenge dataset which had a mention of a lot of disability phrases. after balancing for different categories and analyzing toxic and non-toxic categories, the authors manually inspected the top 100 terms in each category and found that there were 5 key types: condition, infrastructure, social, linguistic, and treatment. in analyzing the strength of association, the authors found that condition phrases had the strongest association, and was then followed by social phrases that had the next highest strongest association. this included topics like homelessness, drug abuse, and gun violence all of which have negative valences. because these terms are used when discussing disability, it leads to a negative shaping of the way disability phrases are shaped and represented in the nlp tasks. the authors make recommendations for those working on nlp tasks to think about the socio-technical considerations when deploying such systems and to consider the intended, unintended, voluntary, and involuntary impacts on people both directly and indirectly while accounting for long-term impacts and feedback loops. such indiscriminate censoring of content that has disability phrases in them leads to an underrepresentation of people with disabilities in these corpora since they are the ones who tend to use these phrases most often. additionally, it also negatively impacts the people who might search for such content and be led to believe that the prevalence of some of these issues are smaller than they actually are because of this censorship. it also has impacts on reducing the autonomy and dignity of these people which in turn has a larger implication of how social attitudes are shaped. the second wave of algorithmic accountability the article dives into explaining how the rising interest in ensuring fair, transparent, ethical ai systems that are held accountable via various mechanisms advocated by research in legal and technical domains constitutes the "first wave" of algorithmic accountability that challenges existing systems. actions as a part of this wave need to be carried out incessantly with constant vigilance of the deployment of ai systems to avoid negative social outcomes. but, we also need to challenge why we have these systems in the first place, and if they can be replaced with something better. as an example, instead of making the facial recognition systems more inclusive, given the fact that they cause social stratification perhaps they shouldn't be used at all. a great point made by the article is that under the veneer of mainstream economic and ai rationalizations, we obscure broken social systems which ultimately harm society at a more systemic level. the trolley problem is a widely touted ethical and moral dilemma wherein a person is asked to make a split-second choice to save one or more than one life based on a series of scenarios where the people that need to be saved have different characteristics including their jobs, age, gender, race, etc. in recent times, with the imminent arrival of self-driving cars, people have used this problem to highlight the supposed ethical dilemma that the vehicle system might have to grapple with as it drives around. this article makes a point about the facetious nature of this thought experiment as an introduction to ethics for people that will be building and operating such autonomous systems. the primary argument being that it's a contrived situation that is unlikely to arise in the real-world setting and it distracts from other more pressing concerns in ai systems. moral judgments are relativistic and depend on cultural values of the geography where the system is deployed. the nature paper cited in the article showcases the differences in how people respond to this dilemma. there is an eeriness to this whole experimental setup, the article gives some examples on how increasingly automated environments, devoid of human social interactions and language, are replete with the clanging and humming of machines that give an entirely inhuman experience. for most systems, they are going to be a reflection of the biases and stereotypes that we have in the world, captured in the system because of the training and development paradigms of ai systems today. we'd need to make changes and bring in diversity to the development process, creating awareness of ethical concerns, but the trolley problem isn't the most effective way to get started on it. most of us have a nagging feeling that we're being forced into certain choices when we interact with each other on various social media platforms. but, is there a way that we can grasp that more viscerally where such biases and echo chambers are laid out bare for all to see? the article details an innovative game design solution to this problem called monster match that highlights how people are trapped into certain niches on dating websites based on ai-powered systems like collaborative filtering. striking examples of that in practice are how your earlier choices on the platform box you into a certain category based on what the majority think and then recommendations are personalized based on that smaller subset. what was observed was that certain racial inequalities from the real world are amplified on platforms like these where the apps are more interested in keeping users on the platform longer and making money rather than trying to achieve the goal as advertised to their users. more than personal failings of the users, the design of the platform is what causes failures in finding that special someone on the platform. the creators of the solution posit that through more effective design interventions, there is potential for improvement in how digital love is realized, for example, by offering a reset button or having the option to opt-out of the recommendation system and instead relying on random matches. increasingly, what we're going to see is that reliance on design and other mechanisms will yield better ai systems than purely technical approaches in improving socially positive outcomes. the article presents the idea of data feminism which is described as the intersection between feminism and data practices. the use of big data in today's dominant paradigm of supervised machine learning lends itself to large asymmetries that reflect the power imbalances in the real world. the authors of the new book data feminism talk about how data should not just speak for itself, for behind the data, there are a large number of structures and assumptions that bring it to the stage where they are collated into a dataset. they give examples of how sexual harassment numbers, while mandated to be reported to a central agency from college campuses might not be very accurate because they rely on the atmosphere and degree of comfort that those campuses promote which in turn influences how close the reported numbers will be to the actual cases. the gains and losses from the use of big data are not distributed evenly and the losses disproportionately impact the marginalized. there are a number of strategies that can be used to mitigate the harms from such flawed data pipelines. not an exhaustive list but it includes the suggestion of having more exposure for technical students to the social sciences and moving beyond having just a single ethics class as a check mark for having educated the students on ethics. secondly, having more diversity in the people developing and deploying the ai systems would help spot biases by asking the hard questions about both the data and the design of the system. the current covid-19 numbers might also suffer from similar problems because of how medical systems are structured and how people who don't have insurance might not utilize medical facilities and get themselves tested thus creating an underrepresentation in the data. this recent work highlights how commercial speech recognition systems carry inherent bias because of a lack of representation from diverse demographics in the underlying training datasets. what the researchers found was that even for identical sentences spoken by different racial demographics, the systems had widely differing levels of performance. as an example, for black users, the error rates were much higher than those for white users which probably had something to do with the fact that there is specific vernacular language used by black people which wasn't adequately represented in the training dataset for the commercial systems. this pattern has a tendency to be amplifying in nature, especially for systems that aren't frozen and continue to learn with incoming data. a vicious cycle is born where because of poor performance from the system, black people will be disincentivized from using the system because it takes a greater amount of work to get the system to work for them thus lowering utility. as a consequence of lower use, the systems get fewer training samples from black people thus further aggravating the problem. this leads to amplified exclusionary behavior mirroring existing fractures along racial lines in society. as a starting point, collecting more representative training datasets will aid in mitigating at least some of the problems in these systems. algorithmic bias at this point is a well-recognized problem with many people working on ways to address issues, both from a technical and policy perspective. there is potential to use demographic data to serve better those who face algorithmic discrimination but the use of such data is a challenge because of ethical and legal concerns. primarily, a lot of jurisdictions don't allow for the capture and use of protected class attributes or sensitive data for the fear of their misuse. even within jurisdictions, there is a patchwork of recommendations which makes compliance difficult. even with all this well established, proxy attributes can be used to predict the protected data and in a sense, according to some legislations, they become protected data themselves and it becomes hard to extricate the non-sensitive data from the sensitive data. because of such tensions and the privacy intrusions on data subjects when trying to collect demographic data, it is hard to align and advocate for this collection of data over the other requirements within the organization, especially when other bodies and leadership will look to place privacy and legal compliance over bias concerns. even if there was approval and internal alignment in collecting this demographic data, if there is voluntary provision of this data from data subjects, we run the risk of introducing a systemic bias that obfuscates and mischaracterizes the whole problem. accountability will play a key role in evoking trust from people to share their demographic information and proper use of it will be crucial in ongoing success. potential solutions are to store this data with a non-profit third-party organization that would meter out the data to those who need to use it with the consent of the data subject. to build a better understanding, partnership on ai is adopting a multistakeholder approach leveraging diverse backgrounds, akin to what the montreal ai ethics institute does, that can help inform future solutions that will help to address the problems of algorithmic bias by the judicious use of demographic data. detection and removal of hate speech is particularly problematic, something that has been exacerbated as human content moderators have been scarce in the pandemic related measures as we covered here. so are there advances in nlp that we could leverage to better automate this process? recent work from facebook ai research shows some promise. developing a deeper semantic understanding across more subtle and complex meanings and working across a variety of modalities like text, images and videos will help to more effectively combat the problem of hate speech online. building a pre-trained universal representation of content for integrity problems and improving and utilizing post-level, self-supervised learning to improve whole entity understanding has been key in improving hate speech detection. while there are clear guidelines on hate speech, when it comes to practice there are numerous challenges that arise from multi-modal use, differences in cultures and context, differences in idioms, language, regions, and countries. this poses challenges even for human reviewers who struggle with identifying hate speech accurately. a particularly interesting example shared in the article points out how text which might seem ambiguous when paired with an image to create a meme can take a whole new meaning which is often hard to detect using traditional automated tooling. there are active efforts from malicious entities who craft specific examples with the intention of evading detection which further complicates the problem. then there is the counterspeech problem where a reply to hate speech that contains the same phrasing but is framed to counter the arguments presented can be falsely flagged to be brought down which can have free speech implications. the relative scarcity of examples of hate speech in its various forms in relation to the larger non-hate speech content also poses a challenge for learning, especially when it comes to capturing linguistic and cultural nuances. the new method proposed utilizes focal loss which aims to minimize the impact of easy-to-classify examples on the learning process which is coupled with gradient blending which computes an optimal blend of modalities based on their overfitting patterns. the technique called xlm-r builds on bert by using a new pretraining recipe called roberta that allows training on orders of magnitude more data for longer periods of time. additionally, nlp performance is improved by learning across languages using a single encoder that allows learning to be transferred across languages. since this is a self-supervised method, they can train on large unlabeled datasets and have also found some universal language structures that allow vectors with similar meanings across languages to be closer together. facial recognition technology (frt) continues to get mentions because of the variety of ways that it can be misused across different geographies and contexts. with the most recent case where frt is used to determine criminality, it brings up an interesting discussion around why techniques that have no basis in science, those which have been debunked time and time again keep resurfacing and what we can do to better educate researchers on their moral responsibilities in pursuing such work. the author of this article gives some historical context for where the state of ai ethics, june 2020 phrenology started, pointing to the work of francis galton who used the "photographic composite method" to try and determine characteristics of one's personality from a picture. prior, measurements of skull size and other facial features wasn't deemed as a moral issue and the removal of such techniques from discussion was done on the objection that claims around the localization of different brain functions was seen as antithetical to the unity of the soul according to christianity. the authors of the paper that is being discussed in the article saw only empirical concerns with the work that they put forth and didn't see any of the moral shortcomings that were pointed out. additionally, they justified the work as being only for scientific curiosity. they also failed to realize the various statistical biases introduced in the collection of data as to the disparate rates of arrests, and policing, the perception of different people by law enforcement, juries, and judges and historical stereotypes and biases that confound the data that is collected.thus, the labeling itself is hardly value-neutral. more so, the authors of the study framed criminality as an innate characteristic rather than the social and other circumstances that lead to crime. especially when a project like this resurrects class structures and inequities, one must be extra cautious of doing such work on the grounds of "academic curiosity". the author of this article thus articulates that researchers need to take their moral obligations seriously and consider the harm that their work can have on people. while simply branding this as phrenology isn't enough, the author mentions that identifying and highlighting the concerns will lead to more productive conversations. an increase in demand for workers for various delivery services and other gig work has accelerated the adoption of vetting technology like those that are used to do background checks during the hiring process. but, a variety of glitches in the system such as sourcing out-of-date information to make inferences, a lack of redressal mechanisms to make corrections, among others has exposed the flaws in an overreliance on automated systems especially in places where important decisions need to be made that can have a significant impact on a person's life such as employment. checkr, the company that is profiled in this article claims to use ai to scan resumes, compare criminal records, analyze social media accounts, and examine facial expressions during the interview process. during a pandemic, when organizations are short-staffed and need to make rapid decisions, checkr offers a way to streamline the process, but this comes at a cost. two supposed benefits that they offer are that they are able to assess a match between the criminal record and the person being actually concerned, something that can especially be fraught with errors in cases where the person has a common name. secondly, they are also able to correlate and resolve discrepancies in the different terms that may be used for crimes across different jurisdictions. a person spoke about his experience with another company that did these ai-powered background checks utilizing his public social media information and bucketed some of his activity into categories that were too coarse and unrepresentative of his behaviour, especially when such automated judgements are made without a recourse to correct, this can negatively affect the prospects of being hired. another point brought up in the article is that social media companies might themselves be unwilling to tolerate scraping of their users' data to do this sort of vetting which against their terms of use for access to the apis. borrowing from the credit reporting world, the fair credit reporting act in the us offers some insights when it mentions that people need to be provided with a recourse to correct information that is used about them in making a decision and that due consent needs to be obtained prior to utilizing such tools to do a background check. though it doesn't ask for any guarantees of a favorable outcome post a re-evaluation, at least it does offer the individual a bit more agency and control over the process. the toxic potential of youtube's feedback loop on youtube everyday, more than a billion hours of video are watched everyday where approximately 70% of those are watched by automated systems that then provide recommendations on what videos to watch next for human users in the column on the side. there are more than 2 billion users on the youtube platform so this has a significant impact on what the world watches. guillaume had started to notice a pattern in the recommended videos which tended towards radicalizing, extreme and polarizing content which were underlying the upward trend of watch times on the platform. on raising these concerns with the team, at first there were very few incentives for anyone to address issues of ethics and bias as it related to promoting this type of content because they feared that it would drive down watch time, the key business metric that was being optimized for by the team. so maximizing engagement stood in contrast to the quality of time that was spent on the platform. the vicious feedback loop that it triggered was that as such divisive content performed better, the ai systems promoted this to optimize for engagement and subsequently content creators who saw this kind of content doing better created more of such content in the hopes of doing well on the platform. the proliferation of conspiracy theories, extreme and divisive content thus fed its own demand because of a misguided business metric that ignored social externalities. flat earthers, anti-vaxxers and other such content creators perform well because the people behind this content are a very active community that spend a lot of effort in creating these videos, thus meeting high quality standards and further feeding the toxic loop. content from people like alex jones and trump tended to perform well because of the above reasons as well. guillaume's project algotransparency essentially clicks through video recommendations on youtube to figure out if there are feedback loops. he started this with the hopes of highlighting latent problems in the platforms that continue to persist despite policy changes, for example with youtube attempting to automate the removal of reported and offensive videos. he suggests that the current separation of the policy and engagement algorithm leads to problems like gaming of the platform algorithm by motivated state actors that seek to disrupt democratic processes of a foreign nation. the platforms on the other hand have very few incentives to make changes because the type of content emerging from such activity leads to higher engagement which ultimately boosts their bottom line. guillaume recommends having a combined system that can jointly optimize for both thus helping to minimize problems like the above. a lot of the problems are those of algorithmic amplification rather than content curation. many metrics like number of views, shares, and likes don't capture what needs to be captured. for example, the types of comments, reports filed, and granularity of why those reports are filed. that would allow for a smarter way to combat the spread of such content. however, the use of such explicit signals compared to the more implicit ones like number of views comes at the cost of breaking the seamlessness of the user experience. again we run into the issue of a lack of motivation on part of the companies to do things that might drive down engagement and hurt revenue streams. the talk gives a few more examples of how people figured out ways to circumvent checks around the reporting and automated take-down mechanisms by disabling comments on the videos which could previously be used to identify suspicious content. an overarching recommendation made by guillaume in better managing a more advanced ai system is to understand the underlying metrics that the system is optimizing for and then envision scenarios of what would happen if the system had access to unlimited data. thinking of self-driving cars, an ideal scenario would be to have full conversion of the traffic ecosystem to one that is autonomous leading to fewer deaths but during the transition phase, having the right incentives is key to making a system that will work in favor of social welfare. if one were to imagine a self-driving car that shows ads while the passenger is in the car, it would want to have a longer drive time and would presumably favor longer routes and traffic jams thus creating a sub-optimal scenario overall for the traffic ecosystem. on the other hand, a system that has the goal of getting from a to b as quickly and safely as possible wouldn't fall into such a trap. ultimately, we need to design ai systems such that they help humans flourish overall rather than optimize for monetary incentives which might run counter to the welfare of people at large. the article provides a taxonomy of communities that spread misinformation online and how they differ in their intentions and motivations. subsequently, different strategies can be deployed in countering the disinformation originating from these communities. there isn't a one-size-fits-all solution that would have been the case had the distribution and types of the communities been homogenous. the degree of influence that each of the communities wield is a function of 5 types of capital: economic, social, cultural, time and algorithmic, definitions of which are provided in the article. understanding all these factors is crucial in combating misinformation where different capital forms can be used in different proportions to achieve the desired results, something that will prove to be useful in addressing disinformation around the current covid-19 situation. the social media platform offers a category of pseudoscience believers which advertisers can purchase and target. according to the markup, this category has 78 million people in it and attempts to purchase ads targeting this category were approved quite swiftly. there isn't any information available as to who has purchased ads targeting this category. the journalist team was able to find at least one advertiser through the "why am i seeing this ad?" option and they reached out to that company to investigate and they found that the company hadn't selected the pseudoscience category but it had been auto-selected by facebook for them. facebook allows users the option to change the interests that are assigned to each user but it is not something that many people know about and actively monitor. some other journalists had also unearthed controversy-related categories that amplified messages and targeted people who might be susceptible to such kind of misinformation. with the ongoing pandemic, misinformation is propagating at a rapid rate and there are many user groups that continue to push conspiracy theories. other concerns around being able to purchase ads to spread misinformation related to potential cures and remedies for the coronavirus continue to be approved. with the human content moderators being asked to stay home (as we covered here) and an increasing reliance on untested automated solutions, it seems that this problem will continue to plague the platform. there isn't a dearth of information available online, one can find confirmatory evidence to almost any viewpoint since the creation and dissemination of information has been democratized by the proliferation of the internet and ease of use of mass-media platforms. so in the deluge of information, what is the key currency that helps us sift through all the noise and identify the signal? this article lays out a well articulated argument for how reputation and being able to assess it is going to be a key skill that people will need to have in order to effectively navigate the information ecosystem effectively. we increasingly rely on other people's judgement of content (akin to how maiei analyzes the ecosystem of ai ethics and presents you with a selection), coupled with algorithmically-mediated distribution channels, we are paradoxically disempowered by more information and paralyzed into inaction and confusion without a reputable source to curate and guide us. there are many conspiracy theories, famous among them that we never visited the moon, flat earth and more recently that 5g is causing the spread of the coronavirus. as rational readers, we tend to dismiss this as misinformation yet we don't really spend time to analyze the evidence that these people present to support their claims. to a certain extent, our belief that we did land on the moon depends on our trust in nasa and other news agencies that covered this event yet we don't venture to examine the evidence first-hand. more so, with highly specialized knowledge becoming the norm, we don't have the right tools and skills to even be able to analyze the evidence and come to meaningful conclusions. so, we must rely on those who provide us with this information. instead of analyzing the veracity of a piece of information, the focus of a mature digital citizen needs to be on being able to analyze the reputation pathway of that information, evaluate the agendas of the people that are disseminating the information and critically analyze the intentions of the authorities of the sources. how we rank different pieces of information arriving to us via our social networks need to be appraised for this reputation and source tracing, in a sense a second-order epistemology is what we need to prepare people for. in the words of hayek, "civilization rests on the fact that we all benefit from the knowledge that we do not possess." our cyber-world can become civilized by evaluating this knowledge that we don't possess critically when mis/disinformation can spread just as easily as accurate information. a very clear way to describe the problem plaguing the us response to the coronavirus, the phenomenon of truth decay is not something new but has happened many times in the past when trust in key institutions deteriorated and led to a diffused response to the crisis at hand, extending the recovery period beyond what would be necessary if there was a unified response. in the us, the calls for reopening the economy, following guidance on using personal protective equipment, and other recommendations is falling along partisan lines. the key factor causing this is how the facts and data are being presented differently to different audiences. while this epidemic might have been the perfect opportunity for bringing people together, because it affects different segments of society differently, it hasn't been what everyone expected it to be. at the core is the rampant disagreement between different factions on facts and data. this is exacerbated by the blurring of facts and opinions. in places like newsrooms and tv shows, there is an intermingling of the two which makes it harder for everyday consumers to discern fact from opinion. the volume of opinion has gone up compared to facts and people's declining trust in public health authorities and other institutions is also aggravating the problem. put briefly, people are having trouble finding the truth and don't know where to go looking for it. this is also the worst time to be losing trust in experts; with a plethora of information available online, people are feeling unnecessarily empowered that they have the right information, comparable to that of experts. coupled with a penchant for confirming their own beliefs, there is little incentive for people to fact-check and refer to multiple sources of information. when different agencies come out with different recommendations and there are policy changes in the face of new information, something that is expected given that this is an evolving situation, people's trust in these organizations and experts erodes further as they see them as flip-flopping and not knowing what is right. ultimately, effective communication along with a rebuilding of trust will be necessary if we're to emerge from this crisis soon and restore some sense of normalcy. the deepfake detection challenge: synthetic media is any media (text, image, video, audio) that is generated by an ai system or that is synthesized. on the other hand, non-synthetic media is one that is crafted by humans using a panoply of techniques, including tools like photoshop. detecting synthetic media alone doesn't solve the media integrity challenges, especially as the techniques get more sophisticated and trigger an arms race between detection and evasion methods. these methods need to be paired with other existing techniques that fact checkers and journalists already use in determining whether something is authentic or synthesized. there are also pieces of content that are made through low tech manipulations like the nancy pelosi video from 2019 which showed her drunk but in reality it was just a slowed down video. other such manipulations include simpler things like putting fake and misleading captions below the true video and people without watching the whole thing are misled into believing what is summarized in the caption. in other cases, the videos might be value neutral or informative even when they are generated so merely detecting something as being generated doesn't suffice. a meaningful way to utilize automated tools is a triaging utility that flags content to be reviewed by humans in a situation where it is not possible to manually review everything on the platform. while tech platforms can build and utilize tools that help them with these tasks, the adjacent possible needs of the larger ecosystem need to be kept in mind such that they can be served at the same time, especially for those actors that are resource-constrained and don't have the technical capabilities to build it themselves. the tools need to be easy to use and shouldn't have high friction such that they become hard to integrate into existing workflows. through open sourcing and licensing, the tools can be made available to the wider ecosystem but it can create the opportunity for adversaries to strengthen their methods as well. this can be countered by responsible disclosure as we'll cover below. for any datasets created as a part of this challenge and otherwise to aid in detection, one must ensure that it captures sufficient diversity in terms of environment and other factors and reflects the type of content that might be encountered in the world. the scoring rules need to be such that they minimize gaming and overfitting and capture the richness of variation that a system might encounter. for example most datasets today in this domain aim to mitigate the spread of pornographic material. they also need to account for the vastly different frequencies of occurrence of authentic and generated content. solutions in this domain involve an inherent tradeoff between pro-social use and potential malicious use for furthering the quality of inauthentic content. the release of tools should be done in a manner that enhances pro-social use while creating deterrents for malicious use. the systems should be stress-tested by doing red team-blue team exercises to enhance robustness because this is inherently an adversarial exercise. such challenges should be held often to encourage updating of techniques because it is a fast evolving domain where progress happens in the span of a few months. results from such detection need to be accessible to the public and stakeholders and explanations for the research findings should be made available alongside the challenge to encourage better understanding by those that are trying to make sense of the digital content. responsible disclosure practices will be crucial in enabling the fight against disinformation to have the right tools while deterring adversaries from utilizing the same tools to gain an advantage. a delayed release mechanism where the code is instantly made available to parties in a non-open source manner while the research and papers are made public with the eventual release of the code as well after a 6-12 months delay which would help with the detectors having a headstart over the adversaries. such detection challenges can benefit from extensive multi-stakeholder consultations which require significant time and effort so budget for that while crafting and building such challenges. some of the allocation of prize money should be towards better design from a ux and ui perspective. it should also include explainability criteria so that non-technical users are able to make sense of the interventions and highlights of fake content such as bounding boxes around regions of manipulations. the process of multi-stakeholder input should happen at an early stage allowing for meaningful considerations to be incorporated and dataset design that can be done appropriately to counter bias and fairness problems. finally, strong, trusting relationships are essential to the success of the process and require working together over extended periods to have the hard conversations with each other. it is important to have clear readings ahead of meetings that everyone has to complete so that discussions come from an informed place. spending time scoping and coming to clearer agreement about projects goals and deliverables at the beginning of the process is also vital to success. there is a distinction between misinformation and disinformation -misinformation is the sharing of false information unintentionally where no harm is intended whereas disinformation is false information that is spread intentionally with the aims of causing harm to the consumers. this is also referred to as information pollution and fake news. it has massive implications that have led to real harms for people in many countries with one of the biggest examples being the polarization of views in the 2016 us presidential elections. meaningful solutions to this will only emerge when we have researchers from both technical and social sciences backgrounds working together to gain a deeper understanding of the root causes. this isn't a new problem and has existed for a very long time, it's just that with the advent of technology and more people being connected to each other we have a much more rapid dissemination of the false information and modern tools enable the creation of convincing fake images, text and videos, thus amplifying the negative effects. some of the features that help to delve deeper into the study of how mis/disinformation spreads are: â�¢ democratization of content creation: with practically anyone now having the ability to create and publish content, information flow has increased dramatically and there are few checks for the veracity of content and even fewer mechanisms to limit the flow rate of information. â�¢ rapid news cycle and economic incentives: with content being monetized, there is a strong incentive to distort information to evoke a response from the reader such that they click through and feed the money-generating apparatus. â�¢ wide and immediate reach and interactivity: by virtue of almost the entire globe being connected, content quickly reaches the furthest corners of the planet. more so, content creators are also able to, through quantitative experiments, determine what kind of content performs well and then tailor that to feed the needs of people. â�¢ organic and intentionally created filter bubbles: the selection of who to follow along with the underlying plumbing of the platforms permits for the creation of echo chambers that further strengthen polarization and do little to encourage people to step out and have a meaningful exchange of ideas. â�¢ algorithmic curation and lack of transparency: the inner workings of platforms are shrouded under the veil of ip protections and there is little that is well-known about the manipulative effects of the platforms on the habits of content consumers. â�¢ scale and anonymity of online accounts: given the weak checks for identity, people are able to mount "sybil" attacks that leverage this lack of strong identity management and are able to scale their impact through the creation of content and dispersion of content by automated means like bot accounts on the platform. what hasn't changed even with the introduction of technology are the cognitive biases which act as attack surfaces for malicious actors to inject mis/disinformation. this vulnerability is of particular importance in the examination and design of successful interventions to combat the spread of false information. for example, the confirmation bias shows that people are more likely to believe something that conforms with their world-view even if they are presented with overwhelming evidence to the contrary. in the same vein, the backfire effect demonstrates how people who are presented with such contrary evidence further harden their views and get even more polarized thus negating the intention of presenting them with balancing information. in terms of techniques, the adversarial positioning is layered into three tiers with spam bots that push out low-quality content, quasi-bots that have mild human supervision to enhance the quality of content and pure human accounts that aim to build up a large following before embarking on spreading the mis/disinformation. from a structural perspective, the alternate media sources often copy-paste content with source attribution and are tightly clustered together with a marked separation with other mainstream media outlets. on the consumer front, there is research that points to the impact that structural deficiencies in the platforms, say whatsapp where source gets stripped out in sharing information, create not only challenges for researchers trying to study the ecosystem but also exacerbate the local impact effect whereby a consumer trusts things coming from friends much more so than other potentially more credible sources from an upstream perspective. existing efforts to study the ecosystem require a lot of manual effort but there is hope in the sense that there are some tools that help automate the analysis. as an example, we have the hoaxy tool, a tool that collects online mis/disinformation and other articles that are fact-checking versions. their creators find that the fact-checked articles are shared much less than the original article and that curbing bots on a platform has a significant impact. there are some challenges with these tools in the sense that they work well on public platforms like twitter but on closed platforms with limited ability to deploy bots, automation doesn't work really well. additionally, even the metrics that are surfaced need to be interpreted by researchers and it isn't always clear how to do that. the term 'deepfake' originated in 2017 and since then a variety of tools have been released such as face2face that allow for the creation of reanimations of people to forge identity, something that was alluded to in this paper here on the evolution of fraud. while being able to create such forgeries isn't new, what is new is that this can be done now with a fraction of the effort, democratizing information pollution and casting aspersions on legitimate content as one can always argue something was forged. online tracking of individuals, which is primarily used for serving personalized advertisements and monetizing the user behaviors on websites can also be used to target mis/disinformation in a fine-grained manner. there are a variety of ways this is done through third-party tracking like embedding of widgets to browser cookies and fingerprinting. this can be used to manipulate vulnerable users and leverage sensitive attributes gleaned from online behaviors that give malicious actors more ammunition to target individuals specifically. even when platforms provide some degree of transparency on why users are seeing certain content, the information provided is often vague and doesn't do much to improve the understanding for the user. earlier attempts at using bots used simplistic techniques such as tweeting at certain users and amplifying low-credibility information to give the impression that something has more support than it really does but recent attempts have become more sophisticated: social spambots. these slowly build up credibility within a community and then use that trust to sow disinformation either automatically or in conjunction with a human operator, akin to a cyborg. detection and measurement of this problem is a very real concern and researchers have tried using techniques like social network graph structure, account data and posting metrics, nlp on content and crowdsourcing analysis. from a platform perspective, they can choose to analyze the amount of time spent browsing posts vs. the time spent posting things. there is an arms race between detection and evasion of bot accounts: sometimes even humans aren't able to detect sophisticated social bots. additionally, there are instances where there are positive and beneficial bots such as those that aggregate news or help coordinate disaster response which further complicates the detection challenge. there is also a potential misalignment in incentives since the platforms have an interest in having higher numbers of accounts and activity since it helps boost their valuations while they are the ones that have the maximum amount of information to be able to combat the problem. this problem of curbing the spread of mis/disinformation can be broken down into two parts: enabling detection on the platform level and empowering readers to select the right sources. we need a good definition of what fake news is, one of the most widely accepted definitions is that it is something that is factually false and intentionally misleading. framing a machine learning approach here as an end-to-end task is problematic because it requires large amounts of labelled data and with neural network based approaches, there is little explanation offered which makes downstream tasks harder. so we can approach this by breaking it down into subtasks, one of which is verifying the veracity of information. most current approaches use human fact-checkers but this isn't a scalable approach and automated means using nlp aren't quite proficient at this task yet. there are attempts to break down the problem even further such as using stance detection to see if information presented agrees, disagrees or is unrelated to what is mentioned in the source. other approaches include misleading style detection whereby we try to determine if the style of the article can offer clues to the intent of the author but that is riddled with problems of not having necessarily a strong correlation with a misleading intent because the style may be pandering to hyperpartisanship or even if it is neutral that doesn't mean that it is not misleading. metadata analysis looking at the social graph structure, attributes of the sharer and propagation path of the information can lend some clues as well. while all these attempts have their own challenges and in the arms race framing, there is a constant battle between attack and defense, even if the problem is solved, we still have human cognitive biases which muddle the impacts of these techniques. ux and ui interventions might serve to provide some more information as to combating those. as a counter to the problems encountered in marking content as being "disputed" which leads to the implied truth effect leading to larger negative externalities, an approach is to show "related" articles when something is disputed and then use that as an intervention to link to fact-checking websites like snopes. other in-platform interventions include the change from whatsapp to show "forwarded" next to messages so that people had a bit more insight into the provenance of the message because there was a lot of misinformation that was being spread in private messaging. there are also third-party tools like surfsafe that are able to check images as people are browsing against other websites where they might have appeared and if they haven't appeared in many places, including verified sources, then the user can infer that the image might be doctored. education initiatives by the platform companies for users to spot misinformation are a method to get people to become more savvy. there have also been attempts to assign nutrition labels to sources to list their slant, tone of the article, timeliness of the article and the experience of the author which would allow a user to make a better decision on whether or not to trust an article. platforms have also attempted to limit the spread of mis/disinformation by flagging posts that encourage gaming of the sharing mechanisms on the platform, for example, downweighting posts that are "clickbait". the biggest challenges in the interventions created by the platforms themselves are that they don't provide sufficient information as to make the results scientifically reproducible. given the variety of actors and motivations, the interventions need to be tailored to be able to combat them such as erecting barriers to the rate of transmission of mis/disinformation and demonetization for actors with financial incentives but for state actors, detection and attribution might be more important. along with challenges in defining the problem, one must look at socio-technical solutions because the problem has more than just the technical component, including the problem with human cognitive biases. being an inherently adversarial setting, it is important to see that not all techniques being used by the attackers are sophisticated, some simple techniques when scaled are just as problematic and require attention. but, given that this is constantly evolving, detecting disinformation today doesn't mean that we can do so successfully tomorrow. additionally, disinformation is becoming more personalized, more realistic and more widespread. there is a misalignment in incentives as explored earlier in terms of what the platforms want and what's best for users but also that empowering users to the point of them being just skeptical of everything isn't good either, we need to be able to trigger legitimate and informed trust in the authentic content and dissuade them away from the fake content. among the recommendations proposed by the authors are: being specific about what a particular technological or design intervention means to achieve, breaking down the technological problems into smaller, concrete subproblems that have tractable solutions and then recombining them into the larger pipeline. we must also continue to analyze the state of the ecosystem and tailor defenses such that they can combat the actors at play. additionally, rethinking of the monetary incentives on the platform can help to dissuade some of the financially-motivated actors. educational interventions that focus on building up knowledge so that there is healthy skepticism and learning how to detect markers for bots, the capabilities of technology to create fakes today and discussions in "public squares" on this subject are crucial yet we mustn't place too much of a burden on the end-user that distracts them from their primary task which is interaction with others on the social network. if that happens, people will just abandon the effort. additionally, designing for everyone is crucial, if the interventions, such as installing a browser extension, are complicated, then one can only reach the technically-literate people and everyone else gets left out. on the platform end, apart from the suggestions made above, they should look at the use of design affordances that aid the user in judging the veracity, provenance and other measures to discern legitimate information vs. mis/disinformation. teaming up with external organizations that specialize in ux/ui research will aid in understanding the impacts of the various features within the platform. results from such research efforts need to be made public and accessible to non-technical audiences. proposed solutions also need to be interdisciplinary to have a fuller understanding of the root causes of the problem. also, just as we need tailoring for the different kinds of adversaries, it is important to tailor the interventions to the various user groups who might have different needs and abilities. the paper also makes recommendations for policymakers, most importantly that the work in regulations and legislations be grounded in technical realities that are facing the ecosystem so that they don't undershoot or overshoot the needs for successfully combating mis/disinformation. for users, there are a variety of recommendations provided in the references but notably being aware of our own cognitive biases and having a healthy degree of skepticism and checking information against multiple sources before accepting it as legitimate are the most important ones. disinformation is harmful even during times when we aren't going through large scale changes but this year the us has elections, the once in a decade census, and the covid-19 pandemic. malicious agents are having a field day disbursing false information, overwhelming people with a mixture of true and untrue pieces of content. the article gives the example of a potential lockdown and people reflecting on their experience with the boston marathon bombings including stockpiling essentials out of panic. this was then uncovered to have originated from conspiracy theorists, but in an environment where contact with the outside world has become limited and local touch points such as speaking with your neighbor have dwindled, we're struggling with our ability to combat this infodemic. social media is playing a critical role in getting information to people but if it's untrue, we end up risking lives especially if it's falsehoods on how to protect yourself from contracting a disease. but wherever there is a challenge lies a corresponding opportunity: social media companies have a unique window into discovering issues that a local population is concerned about and it can, if used effectively, be a source for providing crisis response to those most in need with resources that are specific and meaningful. when it comes to disinformation spreading, there isn't a more opportune time than now with the pandemic raging where people are juggling several things to manage and cope with lifestyle and work changes. this has increased the susceptibility of people to sharing news and other information about how to protect themselves and their loved ones from covid-19. as the who has pointed out, we are combating both a pandemic and an infodemic at the same time. what's more important is that this might be the time to test out design and other interventions that might help curb the spread of disinformation. this study highlighted how people shared disinformation more often than they believed its veracity. in other words, when people share content, they care more about what they stand to gain (social reward cues) for sharing the content than whether the content they're sharing is accurate or not. to combat this, the researchers embarked on an experiment to see if asking users to check whether something was true before sharing -a light accuracy nudge, would change their behaviour. while there was a small positive effect in terms of them sharing disinformation less when prompted to check for accuracy, the researchers pointed out that the downstream effects could be much larger because of the amplification effects of how content propagates on social media networks. it points to a potentially interesting solution that might be scalable and could help fight against the spread of disinformation. the who has mentioned the infodemic as being one of the causes that is exacerbating the pandemic as people follow differing advice on what to do. communication by authorities has been persistent but at times ineffective and this article dives into how one could enhance the visibility of credible information by governments, health authorities and scientists so that the negative impacts of the infodemic can be curbed. but, spewing scientific facts from a soapbox alone isn't enough -one is competing with all the other pieces of information and entertainment for attention and that needs to be taken into account. one of the key findings is that starting a dialogue helps more than just sending a one-way communiquã©. good science communication relies on the pillars of storytelling, cutting through the jargon and making the knowledge accessible. while online platforms are structured such that polarization is encouraged through the algorithmic underpinnings of the system, we should not only engage when there is something that we disagree with, instead taking the time to amplify good science is equally important. using platform-appropriate messaging, tailoring content to the audience and not squabbling over petty details, especially when they don't make a significant impact on the overall content helps to push out good science signals in the ocean of information pollution. clickbait-style headlines do a great job of hooking in people but when leading people into making a certain assumption and then debunking it, you stand the risk of spreading misinformation if someone doesn't read the whole thing, so in trying to make headlines engaging, it is important to consider what might be some unintended consequences if someone didn't read past the subtitle. science isn't just about the findings, the process only gets completed when we have effective communication to the larger audience of the results, and now more than ever, we need accurate information to overpower the pool of misinformation out there. there is a potential for ai to automate repetitive tasks and free up scarce resources towards more value-added tasks. with a declining business model and tough revenue situations, newsrooms and journalism at large are facing an existential crisis. cutting costs while still keeping up high standards of reporting will require innovation on the part of newsrooms to adapt emerging technologies like ai. for example, routine tasks like reporting on sports scores from games and giving updates on company earnings calls is already something that is being done by ai systems in several newsrooms around the world. this frees up time for journalists to spend their efforts on things like long-form journalism, data-driven and investigative journalism, analysis and feature pieces which require human depth and creativity. machine translation also offers a handy tool making the work of journalists accessible to a wider audience without them having to invest in a lot of resources to do the translations themselves. this also brings up the possibility of smaller and resource-constrained media rooms to use their limited resources for doing in-depth pieces while reaching a wider audience by relying on automation. transcription of audio interviews so that reporters can work on fact-checking and other associated pieces also helps bring stories to fruition faster, which can be a boon in the rapidly changing environment. in the case of evolving situations like the pandemic, there is also the possibility of using ai to parse through large reams of data to find anomalies and alert the journalist of potential areas to cover. complementing human skills is the right way to adopt ai rather than thinking of it as the tool that replaces human labor. the article gives an explanation for why truth labels on stories are not as effective as we might think them to be because of something called the implied truth effect. essentially, it states that when some things are marked as explicitly false and other false stories aren't, people believe them to be true even if they are outright false because of the lack of a label. fact checking all stories manually is an insurmountable task for any platform and the authors of the study mention a few approaches that could potentially mitigate the spread of false content but none are a silver bullet. there is an ongoing and active community that researches how we might more effectively dispel disinformation but it's nascent and with the proliferation of ai systems, more work needs to be done in this arms race of building tools vs increasing capabilities of systems to generate believable fake content. this paper by xiao ma and taylor w. brown puts forth a framework that extends the well studied social exchange theory (set) to study human-ai interactions via mediation mechanisms. the authors make a case for how current research needs more interdisciplinary collaboration between technical and social science scholars stemming from a lack of shared taxonomy that places research in similar areas on separate grounds. they propose two axes of human/ai and micro/macro perspectives to visualize how researchers might better collaborate with each other. additionally, they make a case for how ai agents can mediate transactions between humans and create potential social value as an emergent property of those mediated transactions. as the pace of research progress quickens and more people from different fields engage in work on the societal impacts of ai, it is essential that we build on top of each other's work rather than duplicating efforts. additionally, because of conventional differences in how research is published and publicized in the social sciences and technical domains, there's often a shallowness in the awareness of the latest work being done at the intersection of these two domains. what that means is that we need a shared taxonomy that allows us to better position research such that potential gaps can be discovered and areas of collaboration can be identified. the proposed two axes structure in the paper goes some distance in helping to bridge this current gap. ai systems are becoming ever more pervasive in many aspects of our everyday lives and we definitely see a ton of transactions between humans that are mediated by automated agents. in some scenarios, they lead to net positive for society when they enable discovery of research content faster as might be the case for medical research being done to combat covid-19 but there might be negative externalities as well where they can lead to echo chambers walling off content from a subset of your network on social media platforms thus polarizing discussions and viewpoints. a better understanding of how these interactions can be engineered to skew positive will be crucial as ai agents get inserted to evermore aspects of our lives, especially ones that will have a significant impact on our lives. we also foresee an emergence of tighter interdisciplinary collaboration that can shed light on these inherently socio-technical issues which don't have unidimensional solutions. with the rising awareness and interest from both social and technical sciences, the emerging work will be both timely and relevant to addressing challenges of the societal impacts of ai head on. as a part of the work being done at maiei we push for each of our undertakings to have an interdisciplinary team as a starting point towards achieving this mandate. most concerns when aiming to use technology within healthcare are along the lines of replacing human labor and the ones that are used in aiding humans to deliver care don't receive as much attention. with the ongoing pandemic, we've seen this come into the spotlight as well and this paper sets the stage for some of the ethical issues to watch out for when thinking about using ai-enabled technologies in the healthcare domain and how to have a discussion that is grounded in concrete moral principles. an argument put forth to counter the use of ai solutions is that they can't "care" deeply enough about the patients and that is a valid concern, after all machines don't have empathy and other abilities required to have an emotional exchange with humans. but, a lot of the care work in hospitals is routine and professionalism asks for maintaining a certain amount of emotional distance in the care relationship. additionally, in places where the ratio of patients/carers is high, they are unable to provide personalized attention and care anyways. in that respect, human-provided care is already "shallow" and the author cites research where care that is too deep actually hurts the carer when the patients become better and move out of their care or die. thus, if this is the argument, then we need to examine more deeply our current care practices. the author also posits that if this is indeed the state of care today, then it is morally less degrading to be distanced by a machine than by a human. in fact, the use of ai to automate routine tasks in the rendering of medical care will actually allow human carers to focus more on the emotional and human aspects of care. good healthcare, supposedly that provided by humans doesn't have firm grounding in the typical literature on the ethics of healthcare and technology. it's more so a list of things not to do but not positive guidance on what this kind of good healthcare looks like. thus, the author takes a view that it must, at the very least, respect, promote and preserve the dignity of the patient. yet, this doesn't provide concrete enough guidance and we can expand on this to say that dignity is a) treating the patient as a human b) treating them as a part of a culture and community and c) treating them as a unique human. to add even more concreteness, the author borrows from the work done in economics on the capabilities approach. this capabilities approach states that having the following 10 capabilities in their entirety is necessary for a human to experience dignity in their living: life, bodily health, bodily integrity, being able to use your senses, imaginations and thoughts, emotions, practical reasoning, affiliation, other species, play, and control over one's environment. this list applied to healthcare gives us a good guideline for what might constitute the kind of healthcare that we deem should be provided by humans, with or without the use of technology. now, the above list might seem too onerous for healthcare professionals but we need to keep in mind that healthcare to achieve a good life as highlighted by the capabilities approach things that are dependent on things beyond just the healthcare professionals and thus, the needs as mentioned above need to be distributed accordingly. the threshold for meeting them should be high but not so high that they are unachievable. principles are only sufficient for giving us some guidance for how to act in difficult situations or ethical dilemmas, they don't determine the outcome because they are only one element in the decision making process. we have to rely on the context of the situation and the moral surroundings of it. the criteria proposed are to be used in moral deliberation and should address whether the criterion applies to the situation, is it satisfied and is it sufficiently met (which is in reference to the threshold). with the use of ai-enabled technology, privacy is usually cited as a major concern but the rendering of care is decidedly a non-private affair, imagine a scenario where the connection facilitated by technology allows for meeting the social and emotional needs of a terminal patient, if there is a situation where the use of technology allows for a better and longer life, then in these cases there can be an argument for sacrificing privacy to meet the needs of the patient. ultimately, a balance needs to be struck between the privacy requirements and other healthcare requirements and privacy should not be blindly touted as the most important requirement. framing the concept of the good life with a view of restoring, maintaining and enhancing the capabilities of the human, one mustn't view eudaimonia as happiness but rather the achievement of the capabilities listed because happiness in this context would fall outside of the domain of ethics. additionally, the author proposes the care experience machine thought experiment that can meet all the care needs of a patient and asks the question if it would be morally wrong to plug in a patient into such a machine. while intuitively it might seem wrong, we struggle when trying to come up with concrete objections. as long as the patient feels cared for and has, from an objective standpoint, their care needs met, it becomes hard to contest how such virtual care might differ from real care that is provided by humans. if one can achieve real capabilities, such as the need to have freedom of movement and interaction with peers outside of their care confinement and virtual reality technology enables that, then the virtual good life enhances the real good life -a distinction that becomes increasingly blurred as technology progresses. another moral argument put forward in determining whether to use technology-assisted healthcare is if it is too paternalistic to determine what is best for the patient. in some cases where the patient is unable to make decisions that restore, maintain and enhance their capabilities, such paternalism might be required but it must always be balanced with other ethical concerns and keeping in mind the capabilities that it enables for the patient. when we talk about felt care and how to evaluate whether care rendered is good or not, we should not only look at the outcomes of the process through which the patient exits the healthcare context but also the realization of some of the capabilities during the healthcare process. to that end, when thinking about felt care, we must also take into account the concept of reciprocity of feeling which is not explicitly defined in the capabilities approach but nonetheless forms an important aspect of experiencing healthcare in a positive manner from the patient's perspective. in conclusion, it is important to have an in-depth evaluation of technology assisted healthcare that is based on moral principles and philosophy, yet resting more on concrete arguments rather than just the high-level abstracts as they provide little practical guidance in evaluating different solutions and how they might be chosen to be used in different contexts. an a priori dismissal of technology in the healthcare domain, even when based on very real concerns like breach of privacy in the use of ai solutions which require a lot of personal data, begets further examination before arriving at a conclusion. the article brings up some interesting points around how we bond with things that are not necessarily sentient and how our emotions are not discriminating when it comes to reducing loneliness and imprinting on inanimate objects. people experience surges in oxytocin as a consequence of such a bonding experience which further reinforces the relationship. this has effects for how increasingly sentient-appearing ai systems might be used to manipulate humans into a "relationship" and potentially steer them towards making purchases, for example via chatbot interfaces by evoking a sense of trust. the article also makes a point about how such behaviour is akin to animism and in a sense forms a response to loneliness in the digital realm, allowing us to continue to hone our empathy skills for where they really matter, with other human beings. with more and more of our conversations being mediated by ai-enabled systems online, it is important to see if robots can be harnessed to affect positive behaviour change in our interactions with each other. while there have been studies that demonstrate the positive impact that robots can have on influencing individual behaviour, this study highlighted how the presence of robots can influence human to human interactions as well. what the researchers found was that having a robot that displayed positive and affective behavior triggered more empathy from humans towards other humans as well as other positive behaviors like listening more and splitting speaking time amongst members more fairly. this is a great demonstration of how robots can be used to improve our interactions with each other. another researcher pointed out that a future direction of interest would be to see how repeated exposure to such robot interactions can influence behaviour and if the effects so produced would be long-lasting even in the absence of the robot to participate in the interactions. since time immemorial there has been a constant tussle between making predictions and being able to understand the underlying fundamentals of how those predictions worked. in the era of big data, those tensions are exacerbated as machines become more inscrutable while making predictions using ever-more higher-dimensional data which lies beyond intuitive understanding of humans. we try to reason through some of that high-dimensional data by utilizing techniques that either reduce the dimensions or visualize into 2-or 3-dimensions which by definition will tend to lose some fidelity. bacon had proposed that humans should utilize tools to gain a better understanding of the world around them -until recently where the physical processes of the world matched quite well with our internal representations, this wasn't a big concern. but a growing reliance on tools means that we rely more on what is made possible by the tools as they measure and model the world. statistical intelligence and models often get things right but often they are hostile to reconstruction as to how they arrived at certain predictions. models provide for abstractions of the world and often don't need to follow exactly the real-world equivalents. for example, while the telescope allows us to peer far into the distance, its construction doesn't completely mimic a biological eye. more so, radio telescopes that don't follow optics at all give us a unique view into distant objects which are just not possible if we rely solely on optical observations. illusions present us with a window into the limits of our perceptual systems and bring into focus the tension between the reality and what we think is the reality. "in just the same way that prediction is fundamentally bounded by sensitivity of measurement and the shortcomings of computation, understanding is both enhanced and diminished by the rules of inference." in language models, we've seen that end-to-end deep learning systems that are opaque to our understanding perform quite a bit better than traditional machine translation approaches that rest on decades of linguistic research. this bears some resemblance to searle's chinese room experiment where if we just look at the inputs and the outputs, there isn't a guarantee that the internal workings of the system work in exactly the way we expect them to. "the most successful forms of future knowledge will be those that harmonise the human dream of understanding with the increasingly obscure echoes of the machine." abhishek gupta (founder of the montreal ai ethics institute) was featured in fortune where he detailed his views on ai safety concerns in rl systems, the "token human" problem, and automation surprise among other points to pay attention to when developing and deploying ai systems. especially in situations where these systems are going to be used in critical scenarios, humans operating in tandem with these systems and utilizing them as decision inputs need to gain a deeper understanding of the inherent probabilistic nature of the predictions from these systems and make decisions that take it into consideration rather than blindly trusting recommendations from an ai system because they have been accurate in 99% of the scenarios. with increasing capabilities of ai systems, and established research that demonstrates how human-machine combinations operate better than each in isolation, this paper presents a timely discussion on how we can craft better coordination between human and machine agents with the aim of arriving at the best possible understanding between them. this will enhance trust levels between the agents and it starts with having effective communication. the paper discusses how framing this from a human-computer interaction (hci) approach will lead to achieving this goal. this is framed with intention-, context-, and cognition-awareness being the critical elements which would be responsible for the success of effective communication between human and machine agents. intelligibility is a notion that is worked on by a lot of people in the technical community who seek to shed a light on the inner workings of systems that are becoming more and more complex. especially in the domains of medicine, warfare, credit allocation, judicial systems and other areas where they have the potential to impact human lives in significant ways, we seek to create explanations that might illuminate how the system works and address potential issues of bias and fairness. however, there is a large problem in the current approach in the sense that there isn't enough being done to meet the needs of a diverse set of stakeholders who require different kinds of intelligibility that is understandable to them and helps them meet their needs and goals. one might argue that a deeply technical explanation ought to suffice and others kinds of explanations might be derived from that but it makes them inaccessible to those who can't parse well the technical details, often those who are the most impacted by such systems. the paper offers a framework to situate the different kinds of explanations such that they are able to meet the stakeholders where they are at and provide explanations that not only help them meet their needs but ultimately engender a higher level of trust from them by highlighting better both the capabilities and limitations of the systems. ai value alignment is typically mentioned in the context of long-term agi systems but this also applies to the narrow ai systems that we have today. optimizing for the wrong metric leads to things like unrealistic and penalizing work schedules, hacking attention on video platforms, charging more money from poorer people to boost the bottomline and other unintended consequences. yet, there are attempts by product design and development teams to capture human well-being as metrics to optimize for. "how does someone feel about how their life is going?" is a pretty powerful question that gives a surprising amount of insight into well-being distanced from what might be influencing them at the moment because it makes them pause and reflect on what matters to them. but, capturing this subjective sentiment as a metric in an inherently quantitative world of algorithms is unsurprisingly littered with mines. a study conducted by facebook and supported by external efforts found that passive use of social media triggered feelings of ennui and envy while active use including interactions with others on the network led to more positive feelings. utilizing this as a guiding light, facebook strove to make an update that would be more geared towards enabling meaningful engagement rather than simply measuring the number of likes, shares and comments. they used user panels as an input source to determine what constituted meaningful interactions on the platform and tried to distill this into the well-being metrics. yet, this suffered from several flaws, namely that the evaluation of this change was not publicly available and was based on the prior work comparing passive vs. active use of social media. this idea of well-being optimization extends to algorithmic systems beyond social media platforms, for example, with how gig work might be better distributed on a platform such that income fluctuations are minimized for workers who rely on it as a primary source of earnings. another place could be amending product recommendations to also capture environmental impacts such that consumers can incorporate that into their purchasing decisions apart from just the best price deals that they can find. participatory design is going to be a key factor in the development of these metrics; especially given the philosophy of "nothing about us without us" as a north star to ensure that there isn't an inherent bias in how well-being is optimized for. often, we'll find that proxies will need to stand in for actual well-being in which case it is important to ensure that the metrics are not static and are revised in consultation with users at periodic intervals. tapping into the process of double loop learning, an organization can not only optimize for value towards its shareholders but also towards all its other stakeholders. while purely quantitative metrics have obvious limitations when trying to capture something that is inherently subjective and qualitative, we need to attempt something in order to start and iterate as we go along. in a world where increasing automation of cognitive labor due to ai-enabled systems will dramatically change the future of labor, it is now more important than ever that we start to move away from a traditional mindset when it comes to education. while universities in the previous century rightly provided a great value in preparing students for jobs, as jobs being bundle of tasks and those tasks rapidly changing with some being automated, we need to focus more on training students for things that will take much longer to automate, for example working with other humans, creative and critical thinking and driving innovation based on insights and aggregating knowledge across a diversity of fields. lifelong learning serves as a useful model that can impart some of these skills by breaking up education into modules that can be taken on an "at will" basis allowing people to continuously update their skills as the landscape changes. students will go in and out of universities over many years which will bring a diversity of experiences to the student body, encouraging a more close alignment with actual skills as needed in the market. while this will pose significant challenges to the university system, innovations like online learning and certifications based on replenishment of skills like in medicine could overcome some of those challenges for the education ecosystem. individual actions are powerful, they create bottom-up change and empower advocates with the ability to catalyze larger change. but, when we look at products and services with millions of users where designs that are inherently unethical become part of everyday practice and are met with a slight shrug of the shoulders resigning to our fates, we need a more systematized approach that is standardized and widely practiced. ethics in ai is having its moment in the spotlight with people giving talks and conferences focusing on it as a core theme yet it falls short of putting the espoused principles into practice. more often than not, you have individuals, rank and file employees who go out of their way, often on personal time, to advocate for the use of ethical, safety and inclusivity in the design of systems, sometimes even at the risk of their employment. while such efforts are laudable, they lack widespread impact and awareness that is necessary to move the needle, we need leaders at the top who can affect sweeping changes to adopt these guidelines not just in letter but in spirit and then transmit them as actionable policies to their workforce. it needs to arrive at a point where people advocating for this change don't need to do so from a place of moral and ethical obligations which customers can dispute but from a place of policy decisions which force disengagement for non-adherence to these policies. we need to move from talk to action not just at a micro but at a macro scale. the wrong kind of ai? artificial intelligence and the future of labor demand do increasing efficiency and social benefits stand in exclusion to each other when it comes to automation technology? with the development of the "right" kind of ai, this doesn't have to be the case. ai is a general purpose technology that has wide applications and being offered as a platform, it allows others to build advanced capabilities on top of existing systems creating an increasingly powerful abstraction layer with every layer. according to the standard approach in economics, a rise in productivity is often accompanied with an increase in the demand for labor and hence a rise in wages along with standards of living. but, when there is a decoupling between the deployment of technology and the associated productivity accrual, it can lead to situations where we see more output but not a corresponding increase in the standards of living as the benefits accrue to capital owners rather than wage-earning labor which is distanced from the production lifecycle. this unevenness in the distribution of gains causes losses of jobs in one sector while increasing productivity in others, often masking effects at an aggregate level through the use of purely economic focused indicators like gdp growth rates. the authors expound on how the current wave of automation is highly focused on labor replacement driven by a number of factors. when this comes in the form of automation that is just as good as labor but not significantly better, we get the negative effects as mentioned before, that is a replacement of labor without substantial increases in the standards of living. most of these effects are felt by those in the lower rungs of the socio-economic ladder where they don't have alternate avenues for employment and ascent. a common message is that we just have to wait as we did in the case of the industrial revolution and new jobs will emerge that we couldn't have envisioned which will continue to fuel economic prosperity for all. this is an egregious comparison that overlooks that the current wave of automation is not creating simultaneous advances in technology that allow the emergence of a new class of tasks within jobs for which humans are well-suited. instead, it's increasingly moving into domains that were strongholds of human skills that are not easily repeatable or reproducible. what we saw in the past was an avenue made available to workers to move out of low skill tasks in agriculture to higher skill tasks in manufacturing and services. some examples of how ai development can be done the "right" way to create social benefits: â�¢ in education, we haven't seen a significant shift in the way things are done for close to 200 years. it has been shown that different students have different learning styles and can benefit from personalized attention. while it is infeasible to do so in a traditional classroom model, ai offers the potential to track metrics on how the student interacts with different material, where they make mistakes, etc., offering insights to educators on how to deliver a better educational experience. this is accompanied by an increase in the demand for teachers who can deliver different teaching styles to match the learning styles of students and create better outcomes. â�¢ a similar argument can be made in the field of healthcare where ai systems can allow medical staff to spend more time with patients offering them personalized attention for longer while removing the need for onerous and drudgery in the form of menial tasks like data entry. â�¢ industrial robots are being used to automate the manufacturing line often cordoning off humans for safety reasons. humans are also decoupled from the process because of a difference in the level of precision that machines can achieve compared to humans. but we can get the best of both worlds by combining human flexibility and critical thinking to address problems in an uncertain environment with the high degree of preciseness of machines by creating novel interfaces, for example, by using augmented reality. an important distinction that the authors point out in the above examples is that they are not merely the job of enablers, humans that are used to train machines in a transitory fashion, but those that genuinely complement machine skills. there are market failures when it comes to innovation and in the past, governments have helped mitigate those failures via public-private partnerships that led to the creation of fundamental technologies like the internet. but, this has decreased over the past two decades because of smaller amount of resources being invested by the government in basic research and the technology revolution becoming centered in silicon valley which has a core focus on automation that replaces labor, and with that bias and their funding of university and academic studies, they are causing the best minds of the next generation to have the same mindset. markets are also known to struggle when there are competing paradigms and once one pulls ahead, it is hard to switch to another paradigm even if it might be more productive thus leading to an entrenchment of the dominant paradigm. the social opportunity cost of replacing labor is lower than the cost of labor, pushing the ecosystem towards labor replacing automation. without accounting for these externalities, the ecosystem has little incentive to move towards the right kind of ai. this is exacerbated by tax incentives imposing costs on labor while providing a break on the use of capital. additionally, areas where the right kind of ai can be developed don't necessarily fall into the cool domain of research and thus aren't prioritized by the research and development community. let's suppose large advances were made in ai for health care. this would require accompanying retraining of support staff aside from doctors, and the high level bodies regulating the field would impose resistance, thus slowing down the adoption of this kind of innovation. ultimately, we need to lean on a holistic understanding of the way automation is going to impact the labor market and it will require human ingenuity to shape the social and economic ecosystems such that they create net positive benefits that are as widely distributed as possible. relying on the market to figure this out on its own is a recipe for failure. the labor impacts of ai require nuance in discussion rather than fear-mongering that veers between over-hyping and downplaying concerns when the truth lies somewhere in the middle. in the current paradigm of supervised machine learning, ai systems need a lot of data before becoming effective at their automation tasks. the bottom rung of this ladder consists of robotic process automation that merely tracks how humans perform a task (say, by tracking the clicks of humans as they go about their work) and ape them step by step for simple tasks like copying and pasting data across different places. the article gives an example of an organization that was able to minimize churn in their employees by more than half because of a reduction in data drudgery tasks like copying and pasting data across different systems to meet legal and compliance obligations. economists point out that white-collar jobs like these and those that are middle-tier in terms of skills that require little training are at the highest risk of automation. while we're still ways away from ai taking up all jobs, there is a slow march starting from automating the most menial tasks, potentially freeing us up to do more value-added work. with a rising number of people relying on social media for the news, the potential for hateful content and misinformation spreading has never been higher. content moderation on platforms like facebook and youtube is still largely a human endeavor where there are legions of contract workers that spend their days reviewing whether different pieces of content meet the community guidelines of the platform. due to the spread of the pandemic and offices closing down, a lot of these workers have been asked to leave (they can't do this work from home as the platform companies explained because of privacy and legal reasons), leaving the platforms in the hands of automated systems. the efficacy of these systems has always been questionable and as some examples in the article point out, they've run amok taking down innocuous and harmful content alike, seeming to not have very fine-tuned abilities. the problem with this is that legitimate sources of information, especially on subjects like covid-19, are being discouraged because of their content being taken down and having to go through laborious review processes to have their content be approved again. while this is the perfect opportunity to experiment with the potential of using automated systems for content moderation given the traumatic experience that humans have to undergo as a part of this job, the chasms that need to be bridged still remain large between what humans have to offer and what the machines are capable of doing at the moment. workplace time management and accounting are common practices but for those of us who work in places where schedules are determined by automated systems, they can have many negative consequences, a lot of which could be avoided if employers paid more attention to the needs of their employees. clopening is the notion where an employee working at a retail location is asked to not only close the location at the end of the day but also arrive early the next day to open the location. this among other practices like breaks that are scheduled down to the minute and on-call scheduling (something that was only present in the realm of emergency services) wreak havoc on the physical and mental health of employees. in fact, employees surveyed have even expressed willingness to take pay cuts to have greater control over their schedules. in some places with ad-hoc scheduling, employees are forced to be spontaneous with their home responsibilities like taking care of their children, errands, etc. while some employees try to swap shifts with each other, often even that becomes hard to do because others are also in similar situations. some systems track customer demand and reduce pay for hours worked tied to that leading to added uncertainty even with their paychecks. during rush seasons, employees might be scheduled for back to back shifts ignoring their needs to be with families, something that a human manager could empathize with and accommodate for. companies supplying this kind of software hide behind the disclaimer that they don't take responsibility for how their customers use these systems which are often black-box and inscrutable to human analysis. this is a worrying trend that hurts those who are marginalized and those who require support when juggling several jobs just to make ends meet. relying on automation doesn't absolve the employers of their responsibility towards their employees. while the dominant form of discussion around the impacts of automation have been that it will cause job losses, this work from kevin scott offers a different lens into how jobs might be created by ai in the rust belt in the us where automation and outsourcing have been gradually stripping away jobs. examples abound of how entrepreneurs and small business owners with an innovative mindset have been able to leverage advances in ai, coupling them with human labor to repurpose their businesses from areas that are no longer feasible to being profitable. precision farming utilizes things like drones with computer vision capabilities to detect hotspots with pests, disease, etc. in the big farms that would otherwise require extensive manual labor which would limit the size of the farms. self-driving tractors and other automated tools also augment human effort to scale operations. the farm owners though highlight the opaqueness and complexity of such systems which make them hard to debug and fix themselves which sometimes takes away from the gains. on the other hand, in places like nursing homes that get reimbursed based on the resource utilization rates by their residents, tools using ai can help minimize human effort in compiling data and let them spend more of their effort on human contact which is not something that ai succeeds on yet. while automation has progressed rapidly, the gains haven't been distributed equally. in other places where old factories were shut down, some of them are now being utilized by ingenious entrepreneurs to bring back manufacturing jobs that cleverly combine human labor with automation to deliver high-quality, custom products to large enterprises. thus, there will be job losses from automation but the onus lies with us in steering the progress of ai towards economic and ethical values that we believe in. the state of ai ethics, june 2020 what's next for ai ethics, policy, and governance? a global overview in this ongoing piece of work, the authors present the landscape of ethical documents that has been flooded with guidelines and recommendations coming from a variety of sectors including government, private organizations, and ngos. starting with a dive into the stated and unstated motivations behind the documents, the reader is provided with a systematic breakdown of the different documents prefaced with the caveat that where the motivations are not made explicit, one can only make a best guess based on the source of origin and people involved in its creation. the majority of the documents from the governmental agencies were from the global north and western countries which led to a homogeneity of issues that were tackled and the recommendations often touted areas of interest that were specific to their industry and economical make up. this left research and development areas of interest like tourism and agriculture largely ignored which continue to play a significant role in the global south. the documents from the former category were also starkly focused on gaining a competitive edge, which was often stated explicitly, with a potential underlying goal of attracting scarce, high-quality ai talent which could trigger brain drain from other countries that are not currently the dominant players in the ai ecosystem. often, they were also positioning themselves to gain an edge and define a niche for themselves, especially in the case of countries that are non-dominant and thus overemphasizing the benefits while downplaying certain negative consequences that might arise from widespread ai use, like the displacement and replacement of labor. for documents from private organizations, they mostly focused on self and collective regulation in an effort to pre-empt stringent regulations from taking effect. they also strove to tout the economic benefits to society at large as a way of de-emphasizing the unintended consequences. a similar dynamic as in the case of government documents played out here where the interests of startups and small and medium sized businesses were ignored and certain mechanisms proposed would be too onerous for such smaller organizations to implement this further entrenching the competitive advantage of larger firms. the ngos on the other hand seemed to have the largest diversity both in terms of the participatory process of creation and the scope, granularity, and breadth of issues covered which gave technical, ethical, and policy implementation details making them actionable. some documents like the montreal declaration for responsible ai were built through an extensive public consultation process and consisted of an iterative and ongoing approach that the montreal ai ethics institute contributed to as well. the ieee document leverages a more formal standards making approach and consists of experts and concerned citizens from different parts of the world contributing to its creation and ongoing updating. the social motivation is clearly oriented towards creating larger societal benefits, internal motivation is geared towards bringing about change in the organizational structure, external strategic motivation is often towards creating a sort of signaling to showcase leadership in the domain and also interventional to shape policy making to match the interests of those organizations. judging whether a document has been successful is complicated by a couple of factors: discerning what the motivations and the goals for the document were, and the fact that most implementations and use of the documents is done in a pick-and-choose manner complicating attribution and weight allocation to specific documents. some create internal impacts in terms of adoption of new tools, change in governance, etc., while external impacts often relate to changes in policy and regulations made by different agencies. an example would be how the stem education system needs to be overhauled to better prepare for the future of work. some other impacts include altering customer perception of the organization as one that is a responsible organization which can ultimately help them differentiate themselves. at present, we believe that this proliferation of ethics documents represents a healthy ecosystem which promotes a diversity of viewpoints and helps to raise a variety of issues and suggestions for potential solutions. while there is a complication caused by so many documents which can overwhelm people looking to find the right set of guidelines that helps them meet their needs, efforts such as the study being done in this paper amongst other efforts can act as guideposts to lead people to a smaller subset from which they can pick and choose the guidelines that are most relevant to them. the white paper starts by highlighting the existing tensions in the definitions of ai as there are many parties working on advancing definitions that meet their needs. one of the most commonly accepted ones frames ai systems as those that are able to adapt their behavior in response to interactions with the world independent of human control. also, another popular framing is that ai is something that mimics human intelligence and is constantly shifting as a goal post as what was once perceived as ai, when sufficiently integrated and accepted in society becomes everyday technology. one thing that really stands out in the definitions section is how ethics are defined, which is a departure from a lot of other such documents. the authors talk about ethics as a set of principles of morality where morality is an assemblage of rules and values that guide human behavior and principles for evaluating that behavior. they take a neutral stand on the definition, a far cry from framing it as a positive inclination of human conduct to allow for diversity in embedding ethics into ai systems that are in concordance with local context and culture. ai systems present many advantages which most readers are now already familiar given the ubiquity of ai benefits as touted in everyday media. one of the risks of ai-enabled automation is the potential loss of jobs, the authors make a comparison with some historical cases highlighting how some tasks and jobs were eliminated creating new jobs while some were permanently lost. many reports give varying estimates for the labor impacts and there isn't yet a clear consensus on the actual impacts that this might have on the economy. from a liability perspective, there is still debate as to how to account for the damage that might be caused to human life, health and property by such systems. in a strict product liability regime like europe, there might be some guidance on how to account for this, but most regimes don't have specific liability allocations for independent events and decisions meaning users face coverage gaps that can expose them to significant harms. by virtue of the complexity of deep learning systems, their internal representations are not human-understandable and hence lack transparency, which is also called the black box effect. this is harmful because it erodes trust from the user perspective, among other negative impacts. social relations are altered as more and more human interactions are mediated and governed by machines. we see examples of that in how our newsfeeds are curated, toys that children play with, and robots taking care of the elderly. this decreased human contact, along with the increasing capability of machine systems, examples of which we see in how disinformation spreads, will tax humans in constantly having to evaluate their interactions for authenticity or worse, relegation of control to machines to the point of apathy. since the current dominant paradigm in machine learning is that of supervised machine learning, access to data is crucial to the success of the systems and in the state of ai ethics, june 2020 cases where there aren't sufficient protections in place for personal data, it can lead to severe privacy abuses. self determination theory states that autonomy of humans is important for proper functioning and fulfillment, so an overreliance on ai systems to do our work can lead to loss of personal autonomy, which can lead to a sense of digital helplessness. digital dementia is the cognitive equivalent where relying on devices for things like storing phone numbers, looking up information, etc. will over time lead to a decline in cognitive abilities. the echo chamber effect is fairly well studied, owing to the successful use of ai technologies to promulgate disinformation to the masses during the us presidential elections of 2016. due to the easy scalability of the systems, the negative effects are multiplicative in nature and have the potential to become run-away problems. given that ai systems are built on top of existing software and hardware, errors in the underlying systems can still cause failures at the level of ai systems. more so, given the statistical nature of ai systems, behaviour is inherently stochastic and that can cause some variability in response which is difficult to account for. flash crashes in the financial markets are an example of this. for critical systems that require safety and robustness, there is a lot that needs to be done for ensuring reliability. building ethics compliance by design can take a bottom-up or top-down approach, the risk with a bottom-up approach is that by observing examples of human behaviour and extracting ethics principles from that, instead of getting things that are good for people, you get what's common. hence, the report advocates for a top-down approach where desired ethical behavior is directly programmed into the system. casuistic approaches to embedding ethics into systems would work well in situations where there are simple scenarios, such as in healthcare when the patient has a clear directive of do-not-resuscitate. but, in cases where there isn't one and where it is not possible to seek a directive from the patient, such an approach can fail and it requires that programmers either in a top-down manner embed rules or the system learns from examples. though, in a high-stakes situation like healthcare, it might not be ideal to rely on learning from examples because of skewed and limited numbers of samples. a dogmatic approach would also be ill-advised where a system might slavishly follow a particular school of ethical beliefs which might lead it to make decisions that might be unethical in certain scenarios. ethicists utilize several schools of thought when addressing a particular situation to arrive at a balanced decision. it will be crucial to consult with a diversity of stakeholders such that the nuances of different situations can be captured well. the wef is working with partners to come up with an "ethical switch" that will imbue flexibility on the system such that it can operate with different schools of thought based on the demands of the situation.the report also proposes the potential of utilizing a guardian ai system that can monitor other ai systems to check for compliance with different sets of ai principles. given that ai systems operate in a larger socio-technical ecosystem, we need to tap into fields like law and policy making to come up with effective ways of integrating ethics into ai systems, part of which can involve creating binding legal agreements that tie in with economic incentives.while policy making and law are often seen as slow to adapt to fast changing technology, there are a variety of benefits to be had, for example higher customer trust for services that have adherence to stringent regulations regarding privacy and data protection. this can serve to be a competitive advantage and counter some of the negative innovation barriers imposed by regulations. another point of concern with these instruments is that they are limited by geography which leads to a patchwork of regulation that might apply on a product or service that spans several jurisdictions. some other instruments to consider include: self-regulation, certification, bilateral investments treaties, contractual law, soft law, agile governance, etc. the report highlights the initiatives by ieee and wef in creating standards documents. the public sector through its enormous spending power can enhance the widespread adoption of these standards such as by utilizing them in procurement for ai systems that are used to interact with and serve their citizens. the report also advocates for the creation of an ethics board or chief values officer as a way of enhancing the adoption of ethical principles in the development of products and services. for vulnerable segments of the population, for example children, there need to be higher standards of data protection and transparency that can help parents make informed decisions about which ai toys to bring into their homes. regulators might play an added role of enforcing certain ethics principles as part of their responsibility. there also needs to be broader education for ai ethics for people that are in technical roles. given that there are many negative applications of ai, it shouldn't preclude us from using ai systems for positive use cases, a risk assessment and prudent evaluation prior to use is a meaningful compromise. that said, there are certain scenarios where ai shouldn't be used at all and that can be surfaced through the risk or impact assessment process. there is a diversity of ethical principles that have been put forth by various organizations, most of which are in some degree of accordance with local laws, regulations, and value sets. yet, they share certain universal principles across all of them. one concern highlighted by the report is on the subject of how even widely accepted and stated principles of human rights can be controversial when translated into specific mandates for an ai system. when looking at ai-enabled toys as an example, while they have a lot of privacy and surveillance related issues, in countries where there isn't adequate access to education, these toys could be seen as a medium to impart precision education and increase literacy rates. thus, the job of the regulator becomes harder in terms of figuring out how to balance the positive and negative impacts of any ai product. a lot of it depends on the context and surrounding socio-economic system as well. given the diversity in ethical values and needs across communities, an approach might be for these groups to develop and apply non-binding certifications that indicate whether a product meets the ethical and value system of that community. since there isn't a one size fits all model that works, we should aim to have a graded governance structure that has instruments in line with the risk and severity profile of the applications. regulation in the field of ai thus presents a tough challenge, especially given the interrelatedness of each of the factors. the decisions need to be made in light of various competing and sometimes contradictory fundamental values. given the rapid pace of technological advances, the regulatory framework needs to be agile and have a strong integration into the product development lifecycle. the regulatory approach needs to be such that it balances speed so that potential harms are mitigated with overzealousness that might lead to ineffective regulations that stifle innovation and don't really understand well the technology in question. ai is currently enjoying a summer of envy after having gone through a couple of winters of disenchantment, with massive interest and investments from researchers, industry and everyone else there are many uses of ai to create societal benefits but they aren't without their socio-ethical implications. ai systems are prone to biases, unfairness and adversarial attacks on their robustness among other real-world deployment concerns. even when ethical ai systems are deployed for fostering social good, there are risks that they cater to only a particular group to the detriment of others. moral relativism would argue for a diversity of definitions as to what constitutes good ai which would depend on the time, context, culture and more. this would be reflected in market decisions by consumers who choose products and services that align with their moral principles but it poses a challenge for those trying to create public governance frameworks for these systems. this dilemma would push regulators towards moral objectivism which would try and advocate for a single set of values that are universal making the process of coming up with a shared governance framework easier. a consensus based approach utilized in crafting the ec trustworthy ai guidelines settled on human rights as something that everyone can get on board with. given the ubiquity in the applicability of human rights, especially with their legal enshrinement in various charters and constitutions, they serve as a foundation to create legal, ethical and robust ai as highlighted in the ec trustworthy ai guidelines. stressing on the importance of protecting human rights, the guidelines advocate for a trustworthy ai assessment in case that an ai system has the potential to negatively impact the human rights of an individual, much like the better established data protection impact assessment requirement under the gdpr. additional requirements are imposed in terms of ex-ante oversight, traceability, auditability, stakeholder consultations, and mechanisms of redress in case of mistakes, harms or other infringements. the universal applicability of human rights and their legal enshrinement also renders the benefits of established institutions like courts whose function is to monitor and enforce these rights without prejudice across the populace. but they don't stand uncontested when it comes to building good ai systems; they are often seen as too western, individualistic, narrow in scope and abstract to be concrete enough for developers and designers of these systems. some arguments against this are that they go against the plurality of value sets and are a continued form of former imperialism imposing a specific set of values in a hegemonic manner. but, this can be rebutted by the signing of the original universal declaration of human rights that was done by nations across the world in an international diplomatic manner. however, even despite numerous infringements, there is a normative justification that they ought to be universal and enforced. while human rights might be branded as too individual focused, potentially creating a tension between protecting the rights of individuals to the detriment of societal good, this is a weak argument because stronger protection of individual rights has knock-on social benefits as free, healthy and well-educated (among other individual benefits) creates a net positive for society as these individuals are better aware and more willing to be concerned about societal good. while there are some exceptions to the absolute nature of human rights, most are well balanced in terms of providing for the societal good and the good of others while enforcing protections of those rights. given the long history of enforcement and exercises in balancing these rights in legal instruments, there is a rich jurisprudence on which people can rely when trying to assess ai systems. while human rights create a social contract between the individual and the state, putting obligations on the state towards the individual but some argue that they don't apply horizontally between individuals and between an individual and a private corporation. but, increasingly that's not the case as we see many examples where the state intervenes and enforces these rights and obligations between an individual and a private corporation as this falls in its mandate to protect rights within its jurisdiction. the abstract nature of human rights, as is the case with any set of principles rather than rules, allows them to be applied to a diversity of situations and to hitherto unseen situations as well. but, they rely on an ad-hoc interpretation when enforcing them and are thus subjective in nature and might lead to uneven enforcement across different cases. under the eu, this margin of appreciation is often criticized in the sense that it leads to weakening and twisting of different principles but this deferment to those who are closer to the case actually allows for a nuanced approach which would be lost otherwise. on the other hand we have rules which are much more concrete formulations and thus have a rigid definition and limited applicability which allows for uniformity but it suffers from inflexibility in the face of novel scenarios. yet, both rules and principles are complementary approaches and often the exercise of principles over time leads to their concretization into rules under existing and novel legal instruments. while human rights can thus provide a normative, overarching direction for the governance of ai systems, they don't provide the actual constituents for an applicable ai governance framework. for those that come from a non-legal background, often technical developer and designers of ai systems, it is essential that they understand their legal and moral obligations to codify and protect these rights in the applications that they build. the same argument cuts the other way, requiring a technical understanding of how ai systems work for legal practitioners such that they can meaningfully identify when breaches might have occurred. this is also important for those looking to contest claims of breaches of their rights in interacting with ai systems. this kind of enforcement requires a wide public debate to ensure that they fall within accepted democratic and cultural norms and values within their context. while human rights will continue to remain relevant even in an ai systems environment, there might be novel ways in which breaches might occur and those might need to be protected which require a more thorough understanding of how ai systems work. growing the powers of regulators won't be sufficient if there isn't an understanding of the intricacies of the systems and where breaches can happen, thus there is more of a need to enshrine some of those responsibilities in law to enforce this by the developers and designers of the system. given the large public awareness and momentum that built up around the ethics, safety and inclusion issues in ai, we will certainly see a lot more concrete actions around this in 2020. the article gives a few examples of congressional hearings on these topics and advocates for the industry to come up with some standards and definitions to aid the development of meaningful regulations. currently, there isn't a consensus on these definitions and it leads to varying approaches addressing the issues at different levels of granularity and angles. what this does is create a patchwork of incoherent regulations across domains and geographies that will ultimately leave gaps in effectively mitigating potential harms from ai systems that can span beyond international borders. while there are efforts underway to create maps of all the different attempts of defining principle sets, we need a more coordinated approach to bring forth regulations that will ultimately protect consumer safety. in containing an epidemic the most important steps include quarantine and contact tracing for more effective testing. while before, this process of contact tracing was hard and fraught with errors and omissions, relying on memories of individuals, we now carry around smartphones which allow for ubiquitous tracking ability that is highly accurate. but such ubiquity comes with invasion of privacy and possible limits on freedoms of citizens. such risks need to be balanced with public interest in mind while using enhanced privacy preserving techniques and any other measures that center citizen welfare in both a collective and individual sense. for infections that can be asymptomatic in the early days, like the covid-19, it is essential to have contact tracing, which identifies all people that came in close contact with an infected person and might spread the infection further. this becomes especially important when you have a pandemic at hand, burdening the healthcare system and testing every person is infeasible.an additional benefit of contact tracing is that it mitigates resurgence of the peaks of infection. r0 determines how quickly a disease will spread and is dependent on three factors (period of infection, contact rate and mode of transmission) out of which the first and third are fixed so we're only left with control over the contact rate.with an uptake of an application that facilitates contact tracing, the amount of reduction in contact rate is an increasing return because of the number of people that might come in contact with an infected person and thus, we get a greater reduction of r0 in terms of percentage compared to the percentage uptake of the application in the population. ultimately, reducing r0 to below 1 leads to a slowdown in the spread of the infection thus helping the healthcare system cope up with the sudden stresses that are brought on by pandemic peaks. one of the techniques that governments or agencies responsible for public health use is broadcasting in which the information of diagnosed carriers is made public via various channels but it carries severe issues like exposing private information of individuals and businesses where they might have been which can trigger stigma, ostracization and unwarranted punitive harm. it also suffers from the problem of people needing to access this source of information of their own volition and then self-identify (and remember correctly) if they've been in recent contact with a diagnosed carrier. selective broadcasting is a more restricted form of the above where information about diagnosed carriers is shared to a select group of individuals based on location proximity in which case the user's location privacy would have to be compromised and in another vector of dissemination, messages are sent to all users but filtered on device for their specific location and is not reported back to the broadcaster. but, the other second-order negative effects remain the same as broadcasting. both though require the download of an application which might decrease the uptake of it by people. unicasting is when messages are sent tailored specifically to each user and they require the download of an app which needs to be able to track timestamps and location and has severe consequences in terms of government surveillance and abuse. participatory sharing is a method where diagnosed carriers voluntarily share their information and thus have more data control but it still relies on individual action both on the sender and receiver and its efficacy is questionable at best. there is also a risk of abuse by malicious actors to spread misinformation and seed chaos in society via false alarms. private kit: safe paths is an open-source solution developed by mit that allows for contact tracing in a privacy preserving way. it utilizes the encrypted location trail of a diagnosed carrier who chooses to share that with public health agencies and then other users who are also using the solution can pull this data and via their own logged location trail get a result of they've been in close contact with a diagnosed carrier. in the later phases of development of this solution, the developers will enable a mix of participatory sharing and unicasting to further prevent possible data access by third parties including governments for surveillance purposes. risks of contact tracing include possible public identification of the diagnosed carrier and severe social stigma that arises as a part of that. online witch hunts to try and identify the individual can often worsen the harassment and include spreading of rumors about their personal lives. the privacy risks for both individuals and businesses have potential for severe harm, especially during times of financial hardship, this might be very troublesome. privacy risks also extend to non-users because of proximal information that can be derived from location trails, such as employees that work at particular businesses that were visited by a diagnosed carrier. it can also bring upon the same stigma and ostracization to the family members of these people. without meaningful alternatives, especially in health and risk assessment during a pandemic, obtaining truly informed consent is a real challenge that doesn't yet have any clear solutions. along with information, be it through any of the methods identified above, it is very important to provide appropriate context and background to the alerts to prevent misinformation and panic from spreading especially for those with low health, digital and media literacy. on the other hand, some might not take such alerts seriously and increase the risk for public health by not following required measures such as quarantine and social distancing. given the nature of such solutions, there is a significant risk of data theft from crackers as is the case for any application that collects sensitive information like health status and location data. the solutions can also be used for fraud and abuse, for example, by blackmailing business owners and demanding ransom, failing to pay which they would falsely post information that they're diagnosed carriers and have visited their place of business. contact tracing technology requires the use of a smartphone with gps and some vulnerable populations might not always have such devices available like the elderly, homeless and people living in low-income countries who are at high risk of infection and negative health outcomes. ensuring that technology that works for all will be an important piece to mitigating the spread effectively. there is an inherent tradeoff between utility from the data provided and the privacy of the data subjects. compromises may be required for particularly severe outbreaks to manage the spread. the diagnosed carriers are the most vulnerable stakeholders in the ecosystem of contact tracing technology and they require the most protection. adopting open-source solutions that are examinable by the wider technology ecosystem can engender public trust. additionally, having proper consent mechanisms in place and exclusion of the requirement of extensive third party access to the location data can also help allay concerns. lastly, time limits on the storage and use of the location trails will also help address privacy concerns and increase uptake and use of the application in supporting public health measures. for geolocation data that might affect businesses, especially in times of economic hardship, information release should be done such that they are informed prior to the release of the information but there is little else in current methods that can both protect privacy and at the same time provide sufficient data utility. for those without access to smartphones with gps, providing them with some information on contact tracing can still help their communities. but, one must present information in a manner that accounts for variation in health literacy levels so an appropriate response is elicited from the people. alertness about potential misinformation and educational awareness are key during times of crises to encourage people to have measured responses following the best practices as advised by health agencies rather than those based on fear mongering by ill informed and/or malicious actors. encryption and other cybersecurity best practices for data security and privacy are crucial for the success of the solution. time limits on holding data for covid-19 is recommended at 14-37 days, the period of infection, but for an evolving pandemic one might need it for longer for more analysis. tradeoffs need to be made between privacy concerns and public health utility. different agencies and regions are taking different approaches with varying levels of efficacy and only time will tell how this change will be best managed. it does present an opportunity though for creating innovative solutions that both allow for public sharing of data and also reduce privacy intrusions. while the insights presented in this piece of work are ongoing and will continue to be updated, we felt it important to highlight the techniques and considerations compiled by the openmined team as it is one of the few places that adequately capture, in a single place, most of the technical requirements needed to build a solution that respects fundamental rights while balancing them with public health outcomes as people rush to make ai-enabled apps to combat covid-19. most articles and research work coming out elsewhere are very scant and abstract in the technical details that would be needed to meet the ideals of respecting privacy and enabling health authorities to curb the spread of the pandemic. the four key techniques that will help preserve and respect rights as more and more people develop ai-enabled applications to combat covid-19 are: on-device data storage and computation, differential privacy, encrypted computation and privacy-preserving identity verification. the primary use cases, from a user perspective, for which apps are being built are to get: proximity alerts, exposure alerts, information on planning trips, symptom analysis and demonstrate proof of health. from a government and health authorities perspective, they are looking for: fast contact tracing, high-precision self-isolation requests, high-precision self-isolation estimation, high-precision symptomatic citizen estimation and demonstration of proof of health. while public health outcomes are at the top of the mind for everyone, the above use cases are trying to achieve the best possible tradeoff between economic impacts and epidemic spread. using the techniques highlighted in this work, it is possible to do so without having to erode the rights of citizens. this living body of work is meant to serve as a high-level guide along with resources to enable both app developers and verifiers implement and check for privacy preservation which has been the primary pushback from citizens and civil activists. evoking a high degree of trust from people will improve adoption of the apps developed and hopefully allow society and the economy to return to normal sooner while mitigating the harmful effects of the epidemic. there is a fair amount of alignment in the goals of both individuals and the government with the difference being that the government is looking at aggregate outcomes for society. some of the goals shared by governments across the world include: preventing the spread of the disease, eliminating the disease, protecting the healthcare system, protecting the vulnerable, adequately and appropriately distributing resources, preventing secondary breakouts, minimizing economic impacts and panic. the need for digital contact tracing is important because manual interventions are usually highly error prone and rely on human memory to trace how the person might have come in contact with. the requirement for high-precision self-isolation requests will avoid the need for geographic quarantines where everyone in an area is forced to self-isolate which leads to massive disruptions in the economy and can stall the delivery of essential services like food, electricity and water. the additional benefits of high-precision self-isolation is that it can help create an appropriate balance between economic harms and epidemic spread. high-precision symptomatic citizen estimation is a useful application in that it allows for more fine-grained estimation of the number of people that might be affected beyond what the test results indicate which can further strengthen the precision of other measures that are undertaken. a restoration of normalcy in society is going to be crucial as the epidemic starts to ebb, in this case, having proof of health that helps to determine the lowest risk individuals will allow for them to participate in public spaces again further bolstering the supply of essential services and relieving the burden from a small subset of workers who are participating. to service the needs of both what the users want and what the government wants, we need to be able to collect the following data: historical and current absolute location, historical and current relative position and verified group identity, where group refers to any demographic that the government might be interested in, for example, age or health status. to create an application that will meet these needs, we need to collect data from a variety of sources, compute aggregate statistics on that data and then set up some messaging architecture that communicates the results to the target population. the toughest challenges lie in the first and second parts of the process above, especially to do the second part in a privacy-preserving manner. for historical and current absolute location, one of the first options considered by app developers is to record gps data in the background. unfortunately, this doesn't work on ios devices and even then has several limitations including coarseness in dense, urban areas and usefulness only after the app has been running on the user device for some time because historical data cannot be sourced otherwise. an alternative would be to use wi-fi router information which can give more accurate information as to whether someone has been self-isolating or not based on whether they are connected to their home router. there can be historical data available here which makes it more useful though there are concerns with lack of widespread wi-fi connectivity in rural areas and tracking when people are outside homes. other ways of obtaining location data could be from existing apps and services that a user uses -for example, history of movements on google maps which can be parsed to extract location history. there is also historical location data that could be pieced together from payments history, cars that record location information and personal cell tower usage data. historical and current relative data is even more important to map the spread of the epidemic and in this case, some countries like singapore have deployed bluetooth broadcasting as a means of determining if people have been in close proximity. the device broadcasts a random number (which could change frequently) which is recorded by devices passing by close to each other and in case someone is tested positive, this can be used to alert people who were in close proximity to them. another potential approach highlighted in the article is to utilize gyroscope and ambient audio hashes to determine if two people might have been close together, though bluetooth will provide more consistent results. the reason to use multiple approaches is the benefit of getting more accurate information overall since it would be harder to fake multiple signals. group membership is another important aspect where the information can be used to finely target messaging and calculating aggregate statistics. but, for some types of group membership, we might not be able to rely completely on self-reported data. for example, health status related to the epidemic would require verification from an external third-party such as a medical institution or testing facility to minimize false information. there are several privacy preserving techniques that could be applied to an application given that you have: confirmed covid-19 patient data in a cloud, all other user data on each individual's device, and data on both the patients and the users including historical and current absolute and relative locations and group identifier information. private set intersections can be used to calculate whether two people were in proximity to each other based on their relative and absolute location information. private set intersection operates similarly to normal set intersection to find elements that are common between two sets but does so without disclosing any private information from either of the sets. this is important because performing analysis even on pseudonymized data without using privacy preservation can leak a lot of information. differential privacy is another critical technique to be utilized, dp consists of providing mathematical guarantees (even against future data disclosures) that analysis on the data will not reveal whether or not your data was part of the dataset. it asserts that from the analysis, one is not able to learn anything about your data that they wouldn't have been able to learn from other data about you. google's battle-tested c++ library is a great resource to start along with the python wrapper created by the openmined team. to address the need for verified group identification, one can utilize the concept of a private identity server. it essentially functions as a trusted intermediary between a user that wants to provide a claim and another party that wants to verify the claim. it functions by querying a service from which it can verify whether the claim is true and then serve that information up to the party wishing to verify the claim without giving away personal data. while it might be hard to trust a single intermediary, this role can be decentralized to provide for obtaining a higher degree of trust by relying on a consensus mechanism. building on theory from management studies by christensen et al. the authors of this article dive into how leaders of tech organizations, especially upstarts that are rapid in the disruption of incumbents should approach the accompanying responsibilities that come with a push into displacing existing paradigms of how an industry works. when there is a decoupling of different parts of the value chain in how a service is delivered, often the associated protections that apply to the entire pipeline fall by the wayside because of distancing from the end user and a diffusion of responsibility across multiple stakeholders in the value chain. while end users driven innovation will seek to reinforce such models, regulations and protections are never at the top of such demands and they create a burden on the consumers once they realize that things can go wrong and negatively affect them. the authors advocate for the leaders of the companies to proactively employ a systems thinking approach to identify different parts that they are disrupting, how that might affect users, what would happen if they become the dominant player in the industry and then apply lessons learned from such an exercise to pre-emptively design safeguards into the system to mitigate unintended consequences. many countries are looking at utilizing existing surveillance and counter-terrorism tools to help track the spread of the coronavirus and are urging tech companies and carriers to assist with this. the us is looking at how they can tap into location data from smartphones, following in the heels of israel and south korea that have deployed similar measures. while extraordinary measures might be justified given the time of crisis we're going through, we mustn't lose sight of what behaviors we are normalizing as a part of this response against the pandemic. russia and china are also using facial recognition technologies to track movements of people, while iran is endorsing an app that might be used as a diagnosis tool. expansion of the boundaries of surveillance capabilities and government powers is something that is hard to reign back in once a crisis is over. in some cases, like the signing of the freedom act in the usa reduced government agency data collection abilities that were expanded under the patriot act. but, that's not always the case and even so, the powers today exceed those that existed prior to the enactment of the patriot act. what's most important is to ensure that decisions policy makers take today keep in mind the time limits on such expansion of powers and don't trigger a future privacy crisis because of it. while no replacement for social distancing, a virus tracking tool putting into practice the technique of contact tracing is largely unpalatable to western democracies because of expectations of privacy and freedom of movement. a british effort underway to create an app that meets democratic ideals of privacy and freedom while also being useful in collecting geolocation data to aid in the virus containment efforts. it is based on the notion of participatory sharing, relying on people's sense of civic duty to contribute their data in case they test positive. while in the usa, discussions between the administration and technology companies has focused on large scale aggregate data collection, in a place like the uk with a centralized healthcare system, there might be higher trust levels in sharing data with the government. while the app doesn't require uptake by everyone to be effective, but a majority of the people would need to use it to bring down the rate of spread. the efficacy of the solution itself will rely on being able to collect granular location data from multiple sources including bluetooth, wi-fi, cell tower data, and app check-ins. a lot of high level cdc officials are advising that if people in the usa don't follow best practices of social distancing, sheltering in place, and washing hands regularly, the outbreak will not have peaked and the infection will continue to spread, especially hitting those who are the most vulnerable including the elderly and those with pre-existing conditions. on top of the public health impacts, there are also concerns of growing tech-enabled surveillance which is being seriously explored as an additional measure to curb the spread. while privacy and freedom rights are enshrined in the constitution, during times of crisis, government and justice powers are expanded to allow for extraordinary measures to be adopted to restore the safety of the public. this is one of those times and the us administration is actively exploring options in partnership with various governments on how to effectively combat the spread of the virus including the use of facial recognition technology. this comes shortly after the techlash and a potential bipartisan movement to curb the degree of data collection by large firms, which seem to have come to a halt as everyone scrambles to battle the coronavirus. regional governments are being imbued with escalated powers to override local legislations in an effort to curb the spread of the virus. the article provides details on efforts by various countries across the world, yet we only have preliminary data on the efficacy of each of those measures and we require more time before being able to judge which of them is the most effective. that said, in a pandemic that is fast spreading, we don't have the luxury of time and must make decisions as quickly as possible using the information at hand, perhaps using guidance from prior crises. but, what we've seen so far is minimal coordination from agencies across the world and that's leading to ad-hoc, patchy data use policies that will leave the marginalized more vulnerable. strategies that use public disclosure of those that have been tested positive in the interest of public health are causing harm to the individuals and other individuals that are close to them such as their families. as experienced by a family in new york, online vigilantes attempted to harass the individuals while their family pleaded and communicated measures that they had taken to isolate themselves to safeguard others. unfortunately, the virus might be bringing out the worst in all of us. an increasing number of tools and techniques are being used to track our behaviour online and while some may have potential benefits, for example, the use of contact tracing to potentially improve public health outcomes, if this is not done in a privacy-preserving manner, there can be severe implications for your data rights. but, barring special circumstances like the current pandemic, there are a variety of simple steps that you can take to protect your privacy online. these range from simple steps like using an incognito browser window which doesn't store any local information about your browsing on your device to using things like vpns which protect snooping of your browsing patterns even from your isp. when it comes to using the incognito function of your browser, if you're logged into a service online, there isn't any protection though it does prevent storing cookies on your device. with vpns, there is an implicit trust placed in the provider of that service to not store logs of your browsing activity. an even more secure option is to use a privacy-first browser like tor which routes your traffic requests through multiple locations making tracking hard. there is also an os built around this called tailsos that offers tracking protection from the device perspective as well not leaving any trace on the host machine allowing you to boot up from a usb. the eff also provides a list of tools that you can use to get a better grip on your privacy as you browse online. under the children's online privacy protection act, the ftc levied its largest fine yet of $170m on youtube last year for failing to meet requirements of limiting personal data collection for children under the age of 13. yet, as many advocates of youth privacy point out, the fines, though they appear to be large, don't do enough to deter such personal data collection. they advocate for a stronger version of the act while requiring more stringent enforcement from the ftc which has been criticized for slow responses and a lack of sufficient resources. while the current act requires parental consent for children below 13 to be able to utilize a service that might collect personal data, there is no verification performed on the self-declared age provided at the time of sign up which weakens the efficacy of this requirement. secondly, the sharp threshold of 13 years old immediately thrusts children into an adult world once they cross that age and some people are advocating for a more graduated approach to the application of privacy laws. given that such a large part of the news cycle is dominated by the coronavirus, we tend to forget that there might be censors at work that are systematically suppressing information in an attempt to diminish the seriousness of the situation. some people are calling github the last piece of free land in china and have utilized access to it to document news stories and people's first hand experiences in fighting the virus before they are scrubbed from local platforms like wechat and weibo. they hope that such documentation efforts will not only shed light on the reality and on the ground situation as it unfolds but also give everyone a voice and hopefully provide data to others who could use it to track the movement of the virus across the country. such times of crisis bring out creativity and this attempt highlights our ability as a species to thrive even in a severely hostile environment. there is a clear economic and convenience case to be made (albeit for the majority, not for those that are judged to be minorities by the system and hence get subpar performance from the system) where you get faster processing and boarding times when trying to catch a flight. yet, for those that are more data-privacy minded, there is an option to opt-out though leveraging that option doesn't necessarily mean that the alternative will be easy, as the article points out, travelers have experienced delays and confusion from the airport staff. often, the alternatives are not presented as an option to travelers giving a false impression that people have to submit to facial recognition systems. some civil rights and ethics researchers tested the system and got varying mileage out of their experiences but urge people to exercise the option to push back against technological surveillance. london is amongst a few cities that has seen public deployment of live facial recognition technology by law enforcement with the aim of increasing public safety. but, more often than not, it is done so without public announcement and an explanation as to how this technology works, and what impacts it will have on people's privacy. as discussed in an article by maiei on smart cities, such a lack of transparency erodes public trust and affects how people go about their daily lives. several artists in london as a part of regaining control over their privacy and to raise awareness are using the technique of painting adversarial patterns on their faces to confound facial recognition systems. they employ highly contrasting colors to mask the highlights and shadows on their faces and practice pattern use as created and disseminated by the cvdazzle project that advocates for many different styles to give the more fashion-conscious among us the right way to express ourselves while preserving our privacy. such projects showcase a rising awareness for the negative consequences of ai-enabled systems and also how people can use creative solutions to combat problems where laws and regulations fail them. there is mounting evidence that organizations are taking seriously the threats arising from malicious actors geared towards attacking ml systems. this is supported by the fact that organizations like iso and nist are building up frameworks for guidance on securing ml systems, that working groups from the eu have put forth concrete technical checklists for the evaluating the trustworthiness of ml systems and that ml systems are becoming key to the functioning of organizations and hence they are inclined to protect their crown jewels. the organizations surveyed as a part of this study spanned a variety of domains and were limited to those that have mature ml development. the focus was on two personas: ml engineers who are building these systems and security incident responders whose task is to secure the software infrastructure including the ml systems. depending on the size of the organization, these people could be in different teams, same team or even the same person. the study was also limited to intentional malicious attacks and didn't investigate the impacts of naturally occurring adversarial examples, distributional shifts, common corruption and reward hacking. most organizations that were surveyed as a part of the study were found to primarily be focused on traditional software security and didn't have the right tools or know-how in securing against ml attacks. they also indicated that they were actively seeking guidance in the space. most organizations were clustered around concerns regarding data poisoning attacks which was probably the case because of the cultural significance of the tay chatbot incident. additionally, privacy breaches were another significant concern followed by concerns around model stealing attacks that can lead to the loss of intellectual property. other attacks such as attacking the ml supply chain and adversarial examples in the physical domain didn't catch the attention of the people that were surveyed as a part of the study. one of the gaps between reality and expectations was around the fact that security incident responders and ml engineers expected that the libraries that they are using for ml development are battle-tested before being put out by large organizations, as is the case in traditional software. also, they pushed upstream the responsibility of security in the cases where they were using ml as a service from cloud providers. yet, this ignores the fact that this is an emergent field and that a lot of the concerns need to be addressed in the downstream tasks that are being performed by these tools. they also didn't have a clear understanding of what to expect when something does go wrong and what the failure mode would look like. in traditional software security, mitre has a curated repository of attacks along with detection cues, reference literature and tell-tale signs for which malicious entities, including nation state attackers are known to use these attacks. the authors call for a similar compilation to be done in the emergent field of adversarial machine learning whereby the researchers and practitioners register their attacks and other information in a curated repository that provides everyone with a unified view of the existing threat environment. while programming languages often have well documented guidelines on secure coding, guidance on doing so with popular ml frameworks like pytorch, keras and tensorflow is sparse. amongst these, tensorflow is the only one that provides some tools for testing against adversarial attacks and some guidance on how to do secure coding in the ml context. security development lifecycle (sdl) provides guidance on how to secure systems and scores vulnerabilities and provides some best practices, but applying this to ml systems might allow imperfect solutions to exist. instead of looking at guidelines as providing a strong security guarantee, the authors advocate for having code examples that showcase what constitutes security-and non-security-compliant ml development. in traditional software security there are tools for static code analysis that provide guidance on the security vulnerabilities prior to the code being committed to a repository or being executed while dynamic code analysis finds security vulnerabilities by executing the different code paths and detecting vulnerabilities at runtime. there are some tools like mlsec and cleverhans that provide white-and black-box testing; one of the potential future directions for research is to extend this to the cases of model stealing, model inversion, and membership inference attacks. including these tools as a part of the ide would further make it naturalized for developers to think about secure coding practices in the ml context. adapting the audit and logging requirements as necessitated for the functionality of the security information and event management (siem) system, in the field of ml, one can execute the list of attacks as specified in literature and ensure that the logging artifacts generated as a consequence are traced to an attack. then, having these incident logs be in a format that is exportable and integratable with siem systems will allow forensic experts to analyze them post-hoc for hardening and analysis. standardizing the reporting, logging and documentation as done by the sigma format in traditional software security will allow the insights from one analyst into defenses for many others. automating the possible attacks and including them as a part of the mlops pipeline is something that will enhance the security posture of the systems and make them pedestrian practice in the sdl. red teaming, as done in security testing, can be applied to assess the business impacts and likelihood of threat, something that is considered best practice and is often a requirement for supplying critical software to different organizations like the us government. transparency centers that allow for deep code inspection and help create assurance on the security posture of a software product/service can be extended to ml which would have to cover three modalities: ml platform is implemented in a secure manner, ml as a service meets the basic security and privacy requirements, and that the ml models embedded on edge devices meet basic security requirements. tools that build on formal verification methods will help to enhance this practice. tracking and scoring ml vulnerabilities akin to how they are done in software security testing done by registering identified vulnerabilities into a common database like cve and then assigning it an impact score like the cvss needs to be done for the field of ml. while the common database part is easy to set up, scoring them isn't something that has been figured out yet. additionally, on being alerted that a new vulnerability has been discovered, it isn't clear how the ml infrastructure can be scanned to see if the system is vulnerable to that. because of the deep integration of ml systems within the larger product/service, the typical practice of identifying a blast radius and containment strategy that is applied to traditional software infrastructure when alerted of a vulnerability is hard to define and apply. prior research work from google has identified some ways to qualitatively assess the impacts in a sprawling infrastructure. from a forensic perspective, the authors put forth several questions that one can ask to guide the post-hoc analysis, the primary problem there is that only some of the learnings from traditional software protection and analysis apply here, there are many new artifacts, paradigmatic, and environmental aspects that need to be taken into consideration. from a remediation perspective, we need to develop metrics and ways to ascertain that patched models and ml systems can maintain prior levels of performance while having mitigated the attacks that they were vulnerable to, the other thing to pay attention is that there aren't any surfaces that are opened up for attack. given that ml is going to be the new software, we need to think seriously about inheriting some of the security best practices from the world of traditional cybersecurity to harden defenses in the field of ml. all technology has implications for civil liberties and human rights, the paper opens with an example of how low-clearance bridges between new york and long island were supposedly created with the intention of disallowing public buses from crossing via the underpasses to discourage the movement of users of public transportation, primarily disadvantaged groups from accessing certain areas. in the context of adversarial machine learning, taking the case of facial recognition technology (frt), the authors demonstrate that harm can result on the most vulnerable, harm which is not theoretical and is gaining in scope, but that the analysis also extends beyond just frt systems. the notion of legibility borrowing from prior work explains how governments seek to categorize through customs, conventions and other mechanisms information about their subjects centrally. legibility is enabled for faces through frt, something that previously was only possible as a human skill. this combined with the scale offered by machine learning makes this a potent tool for authoritarian states to exert control over their populations. from a cybersecurity perspective, attackers are those that compromise the confidentiality, integrity and availability of a system, yet they are not always malicious, sometimes they may be pro-democracy protestors who are trying to resist identification and arrest by the use of frt. when we frame the challenges in building robust ml systems, we must also pay attention to the social and political implications as to who is the system being made safe for and at what costs. positive attacks against such systems might also be carried out by academics who are trying to learn about and address some of the ethical, safety and inclusivity issues around frt systems. other examples such as the hardening of systems against doing membership inference means that researchers can't determine if an image was included in the dataset, and someone looking to use this as evidence in a court of law is deterred from doing so. detection perturbation algorithms permit an image to be altered such that faces can't be recognized in an image, for example, this can be used by a journalist to take a picture of a protest scene without giving away the identities of people. but, defensive measures that disarm such techniques hinder such positive use cases. defense measures against model inversion attacks don't allow researchers and civil liberty defenders to peer into black box systems, especially those that might be biased against minorities in cases like credit allocation, parole decision-making, etc. the world of security is always an arms race whether that is in the physical or cyberspace. it is not that far-fetched to imagine how a surveillance state might deploy frt to identify protestors who as a defense might start to wear face masks for occlusion. the state could then deploy techniques that bypass this and utilize other scanning and recognition techniques to which the people might respond by wearing adversarial clothing and eyeglasses to throw off the system at which point the state might choose to use other biometric identifiers like iris scanning and gait detection. this constant arms battle, especially when defenses and offenses are constructed without the sense for the societal impacts leads to harm whose burden is mostly borne by those who are the most vulnerable and looking to fight for their rights and liberties. this is not the first time that technology runs up against civil liberties and human rights, there are lessons to be learned from the commercial spyware industry and how civil society organizations and other groups came together to create "human rights by design" principles that helped to set some ground rules for how to use this technology responsibly. researchers and practitioners in the field of ml security can borrow from these principles. we've got a learning community at the montreal ai ethics institute that is centered around these ideas that brings together academics and others from around the world to blend the social sciences with the technical sciences. recommendations on countering some of the harms centre around holding the vendors of these systems to the business standards set by the un, implementing transparency measures during the development process, utilizing human rights by design approaches, logging ml system uses along with possible nature and forms of attacks and pushing the development team to think about both the positive and negative use cases for the systems such that informed trade-offs can be made when hardening these systems to external attacks. in this insightful op-ed, two pioneers in technology shed light on how to think about ai systems and their relation to the existing power and social structures. borrowing the last line in the piece, " â�¦ all that is necessary for the triumph of an ai-driven, automation-based dystopia is that liberal democracy accept it as inevitable.", aptly captures the current mindset surrounding ai systems and how they are discussed in the western world. tv shows like black mirror perpetuate narratives showcasing the magical power of ai-enabled systems, hiding the fact that there are millions, if not billions of hours of human labor that undergird the success of modern ai systems, which largely fall under the supervised learning paradigm that requires massive amounts of data to work well. the chinese ecosystem is a bit more transparent in the sense that the shadow industry of data labellers is known, and workers are compensated for their efforts. this makes them a part of the development lifecycle of ai while sharing economic value with people other than the tech-elite directly developing ai. on the other hand, in the west, we see that such efforts go largely unrewarded because we trade in that effort of data production for free services. the authors give the example of audrey tang and taiwan where citizens have formed a data cooperative and have greater control over how their data is used. contrasting that, we have highly-valued search engines standing over community-run efforts like wikipedia which create the actual value for the search results, given that a lot of the highly placed search results come from wikipedia. ultimately, this gives us some food for thought as to how we portray ai today and its relation to society and why it doesn't necessarily have to be that way. mary shelly had created an enduring fiction which, unbeknownst to her, has today manifested itself in the digital realm with layered abstractions of algorithms that are increasingly running multiple aspects of our lives. the article dives into the world of black box systems that have become opaque to analysis because of their stratified complexity leading to situations with unpredictable outcomes. this was exemplified when an autonomous vehicle crashed into a crossing pedestrian and it took months of post-hoc analysis to figure out what went wrong. when we talk about intelligence in the case of these machines, we're using it in a very loose sense, like the term "friend" on facebook, which has a range of interpretations from your best friend to a random acquaintance. both terms convey a greater sense of meaning than is actually true. when such systems run amok, they have the potential to cause significant harm, case in point being the flash crashes the financial markets experienced because of the competitive behaviour of high frequency trading firm algorithms facing off against each other in the market. something similar has happened on amazon where items get priced in an unrealistic fashion because of buying and pricing patterns triggered by automated systems. while in a micro context the algorithms and their working are transparent and explainable, when they come together in an ecosystem, like finance, they lead to an emergent complexity that has behaviour that can't be predicted ahead of time with a great amount of certainty. but, such justifications can't be used as a cover for evading responsibility when it comes to mitigating harms. existing laws need to be refined and amended so that they can better meet the demands of new technology where allocation of responsibility is a fuzzy concept. ai systems are different from other software systems when it comes to security vulnerabilities. while traditional cybersecurity mechanisms rely heavily on securing the perimeter, ai security vulnerabilities run deeper and they can be manipulated through their interactions with the real world -the very mechanism that makes them intelligent systems. numerous examples of utilizing audio samples from tv commercials to trigger voice assistants have demonstrated new attack surfaces for which we need to develop defense techniques. visual systems are also fooled, especially in av systems where, according to one example, manipulating stop signs on the road with innocuous stripes of tape make it seem like the stop sign is a speed indicator and can cause fatal crashes. there are also examples of hiding these adversarial examples under the guise of white noise and other imperceptible changes to the human senses. we need to think of ai systems as inherently socio-technical to come up with effective protection techniques that don't just rely on technical measures but also look at the human factors surrounding them. some other useful insights are to utilize abusability testing, red-teaming, white hacking, bug bounty programs, and consulting with civic society advocates who have deep experience with the interactions of vulnerable communities with technology. reinforcement systems are increasingly moving from applications to beating human performance in games to safety-critical applications like self-driving cars and automated trading. a lack of robustness in the systems can lead to catastrophic failures like the $460m lost by knight capital and the harms to pedestrian and driver safety in the case of autonomous vehicles. rl systems that perform well under normal conditions can be vulnerable to adversarial agents that can exploit the brittleness of the systems when it comes to natural shifts in distributions and more carefully crafted attacks. in prior threat models, the assumptions for the adversary are that they can modify directly the inputs going into the rl agent but that is not very realistic. instead, here the authors focus more on a shared environment through which the adversary creates indirect impact on the target rl agent leading to undesirable behavior. for agents that are trained through self-play (which is a rough approximation of nash equilibrium), they are vulnerable to adversarial policies. as an example, masked victims are more robust to modifications in the natural observations by the adversary but that lowers the performance in the average case. furthermore, what the researchers find is that there is a non-transitive behavior between self-play opponent, masked victim, adversarial opponent and normal victim in that cyclic order. self-play being normally transitive in nature, especially when mimicking real-world scenarios is then no doubt vulnerable to these non-transitive styled attacks. thus, there is a need to move beyond self-play and apply iteratively adversarial training defense and population based training methods so that the target rl agent can become robust to a wider variety of scenarios. vehicle safety is something of paramount importance in the automotive industry as there are many tests conducted to test for crash resilience and other physical safety features before it is released to people. but, the same degree of scrutiny is not applied to the digital and connected components of cars. researchers were able to demonstrate successful proof of concept hacks that compromised vehicle safety. for example, with the polo, they were able to access the controller area network (can) which sends signals and controls a variety of aspects related to driving functions. given how the infotainment systems were updated, researchers were able to gain access into the personal details of the driver. they were also able to utilize the shortcomings in the operation of the key fob to gain access to the vehicle without leaving a physical trace. other hacks that were tried included being able to access and influence the collision monitoring radar system and the tire-pressure monitoring system which both have critical implications for passenger safety. on the focus, they found wifi details including the password for their production line in detroit, michigan. on purchasing a second-hand infotainment unit for purposes of reverse-engineering the firmware, they found the previous owner's home wifi details, phone contacts and a host of other personal information. cars store a lot of personal information including tracking information which, as stated on the privacy policy, can be shared with affiliates which can have other negative consequences like changes in insurance premiums based on driving behaviour. europe will have some forthcoming regulations for connected car safety but those are currently slated for release in 2021. we've all experienced specification gaming even if we haven't really heard the term before. in law, you call it following the law to the letter but not in spirit. in sports, it is called unsportsman-like to use the edge cases and technicalities of the rules of the game to eke out an edge when it is obvious to everyone playing the game that the rules intended for something different. this can also happen in the case of ai systems, for example in reinforcement learning systems where the agent can utilize "bugs" or poor specification on the part of the human creators to achieve the high rewards for which it is optimizing without actually achieving the goal, at least in the way the developers intended them to and this can sometimes lead to unintended consequences that can cause a lot of harms. "let's look at an example. in a lego stacking task, the desired outcome was for a red block to end up on top of a blue block. the agent was rewarded for the height of the bottom face of the red block when it is not touching the block. instead of performing the relatively difficult maneuver of picking up the red block and placing it on top of the blue one, the agent simply flipped over the red block to collect the reward. this behaviour achieved the stated objective (high bottom face of the red block) at the expense of what the designer actually cares about (stacking it on top of the blue one)". this isn't because of a flaw in the rl system but more so a misspecification of the objective. as the agents become more capable, they find ever-more clever ways of achieving the rewards which can frustrate the creators of the system. this makes the problem of specification gaming very relevant and urgent as we start to deploy these systems in a lot of real-world situations. in the rl context, task specification refers to the design of the rewards, the environment and any other auxiliary rewards. when done correctly, we get true ingenuity out of these systems like move 37 from the alphago system that baffled humans and ushered a new way of thinking about the game of go. but, this requires discernment on the part of the developers to be able to judge when you get a case like lego vs. move 37. as an example in the real-world, reward tampering is an approach where the agent in a traffic optimization system with an interest in achieving a high reward can manipulate the driver into going to alternate destinations instead of what they desired just to achieve a higher reward. specification gaming isn't necessarily bad in the sense that we want the systems to come up with ingenious ways to solve problems that won't occur to humans. sometimes, the inaccuracies can arise in how humans provide feedback to the system while it is training. ''for example, an agent performing a grasping task learned to fool the human evaluator by hovering between the camera and the object." incorrect reward shaping, where an agent is provided rewards along the way to achieving the final reward can also lead to edge-case behaviours when it is not analyzed for potential side-effects. we see such examples happen with humans in the real-world as well: a student asked to get a good grade on the exam can choose to copy and cheat and while that achieves the goal of getting a good grade, it doesn't happen in the way we intended for it to. thus, reasoning through how a system might game some of the specifications is going to be an area of key concern going into the future. the ongoing pandemic has certainly accelerated the adoption of technology in everything from how we socialize to buying groceries and doing work remotely. the healthcare industry has also been rapid in adapting to meet the needs of people and technology has played a role in helping to scale care to more people and accelerate the pace with which the care is provided. but, this comes with the challenge of making decisions under duress and with shortened timelines within which to make decisions on whether to adopt a piece of technology or not. this has certainly led to issues where there are risks of adopting solutions that haven't been fully vetted and using solutions that have been repurposed from prior uses that were approved to now combat covid-19. especially with ai-enabled tools, there are increased risks of emergent behavior that might not have been captured by the previous certification or regulatory checks. the problems with ai solutions don't just go away because there is a pandemic and shortcutting the process of proper due diligence can lead to more harm than the benefits that they bring. one must also be wary of the companies that are trying to capitalize on the chaos and pass through solutions that don't really work well. having technical staff during the procurement process that can look over the details of what is being brought into your healthcare system needs to be a priority. ai can certainly help to mitigate some of the harms that covid-19 is inflicting on patients but we must keep in mind that we're not looking to bypass privacy concerns that come with processing vast quantities of healthcare data. in the age of adversarial machine learning (maiei has a learning community on machine learning security if you'd like to learn more about this area) there are enormous concerns with protecting software infrastructure as ml opens up a new attack surface and new vectors which are seldom explored. from the perspective of insurance, there are gaps in terms of what cyber-insurance covers today, most of it being limited to the leakage of private data. there are two kinds of attacks that are possible on ml systems: intentional and unintentional. intentional attacks are those that are executed by malicious agents who attempt to steal the models, infer private data or get the ai system to behave in a way that favors their end goals. for example, when tumblr decided to not host pornographic content, creators bypassed that by using green screens and pictures of owls to fool the automated content moderation system. unintended attacks can happen when the goals of the system are misaligned with what the creators of the system actually intended, for example, the problem of specification gaming, something that abhishek gupta discussed here in this fortune article. in interviewing several officers in different fortune 500 companies, the authors found that there are 3 key problems in this domain at the moment: the defenses provided by the technical community have limited efficacy, existing copyright, product liability, and anti-hacking laws are insufficient to capture ai failure modes. lastly, given that this happens at a software level, cyber-insurance might seem to be the way to go, yet current offerings only cover a patchwork of the problems. business interruptions and privacy leaks are covered today under cyber-insurance but other problems like bodily harm, brand damage, and property damage are for the most part not covered. in the case of model recreation, as was the case with the openai gpt-2 model, prior to it being released, it was replicated by external researchers -this might be covered under cyber-insurance because of the leak of private information. researchers have also managed to steal information from facial recognition databases using sample images and names which might also be covered under existing policies. but, in the case with uber where there was bodily harm because of the self-driving vehicle that wasn't able to detect the pedestrian accurately or similar harms that might arise if conditions are foggy, snowy, dull lighting, or any other out-of-distribution scenarios, these are not adequately covered under existing insurance terms. brand damage that might arise from poisoning attacks like the case with the tay chatbot or confounding anti-virus systems as was the case with an attack mounted against the cylance system, cyber-insurance falls woefully short in being able to cover these scenarios. in a hypothetical situation as presented in a google paper on rl agents where a cleaning robot sticks a wet mop into an electric socket, material damage that occurs from that might also be considered out of scope in cyber-insurance policies. traditional software attacks are known unknowns but adversarial ml attacks are unknown unknowns and hence harder to guard against. current pricing reflects this uncertainty, but as the ai insurance market matures and there is a deeper understanding for what the risks are and how companies can mitigate the downsides, the pricing should become more reflective of the actual risks. the authors also offer some recommendations on how to prepare the organization for these risks -for example by appointing an officer that works closely with the ciso and chief data protection officer, performing table-top exercises to gain an understanding of potential places where the system might fail and evaluating the system for risks and gaps following guidelines as put forth in the eu trustworthy ai guidelines. there are no widely accepted best practices for mitigating security and privacy issues related to machine learning (ml) systems. existing best practices for traditional software systems are insufficient because they're largely based on the prevention and management of access to a system's data and/or software, whereas ml systems have additional vulnerabilities and novel harms that need to be addressed. for example, one harm posed by ml systems is to individuals not included in the model's training data but who may be negatively impacted by its inferences. harms from ml systems can be broadly categorized as informational harms and behavioral harms. informational harms "relate to the unintended or unanticipated leakage of information." the "attacks" that constitute informational harms are: behavioral harms "relate to manipulating the behavior of the model itself, impacting the predictions or outcomes of the model." the attacks that constitute behavioral harms are: â�¢ poisoning: inserting malicious data into a model's training data to change its behavior once deployed â�¢ evasion: feeding data into a system to intentionally cause misclassification without a set of best practices, ml systems may not be widely and/or successfully adopted. therefore, the authors of this white paper suggest a "layered approach" to mitigate the privacy and security issues facing ml systems. approaches include noise injection, intermediaries, transparent ml mechanisms, access controls, model monitoring, model documentation, white hat or red team hacking, and open-source software privacy and security resources. finally, the authors note, it's important to encourage "cross-functional communication" between data scientists, engineers, legal teams, business managers, etc. in order to identify and remediate privacy and security issues related to ml systems. this communication should be ongoing, transparent, and thorough. beyond near-and long-term: towards a clearer account of this paper dives into how researchers can clearly communicate about their research agendas given ambiguities in the split of the ai ethics community into near and long term research. often a sore and contentious point of discussion, there is an artificial divide between the two groups that seem to take a reductionist approach to the work being done by the other. a major problem emerging from such a divide is a hindrance in being able to spot relevant work being done by the different communities and thus affecting effective collaboration. the paper highlights the differences arising primarily along the lines of timescale, ai capabilities, deeper normative and empirical disagreements. the paper provides for a helpful distinction between near-and long-term by describing them as follows: â�¢ near term issues are those that are fairly well understood and have concrete examples and relate to rãªvent progress in the field of machine learning â�¢ long term issues are those that might arise far into the future and due to much more advanced ai systems with broad capabilities, it also includes long term impacts like international security, race relations, and power dynamics what they currently see is that: â�¢ issues considered 'near-term' tend to be those arising in the present/near future as a result of current/foreseeable ai systems and capabilities, on varying levels of scale/severity, which mostly have immediate consequences for people and society. â�¢ issues considered 'long-term' tend to be those arising far into the future as a result of large advances in ai capabilities (with a particular focus on notions of transformative ai or agi), and those that are likely to pose risks that are severe/large in scale with very long-term consequences. â�¢ the binary clusters are not sufficient as a way to split the field and not looking at underlying beliefs leads to unfounded assumptions about each other's work â�¢ in addition there might be areas between the near and long term that might be neglected as a result of this artificial fractions unpacking these distinctions can be done along the lines of capabilities, extremity, certainty and impact, definitions for which are provided in the paper. a key contribution aside from identifying these factors is that they lie along a spectrum and define a possibility space using them as dimensions which helps to identify where research is currently concentrated and what areas are being ignored. it also helps to well position the work being done by these authors. something that we really appreciated from this work was the fact that it gives us concrete language and tools to more effectively communicate about each other's work. as part of our efforts in building communities that leverage diverse experiences and backgrounds to tackle an inherently complex and muti-dimensional problem, we deeply appreciate how challenging yet rewarding such an effort can be. some of the most meaningful public consultation work done by maiei leveraged our internalized framework in a similar vein to provide value to the process that led to outcomes like the montreal declaration for responsible ai. the rise of ai systems leads to an unintended conflict between economic pursuits which seek to generate profits and value resources appropriately with the moral imperatives of promoting human flourishing and creating societal benefits from the deployment of these systems. this puts forth a central question on what the impacts of creating ai systems that might surpass humans in a general sense which might leave humans behind. technological progress doesn't happen on its own, it is driven by conscious human choices that are influenced by the surrounding social and economic institutions. we are collectively responsible for how these institutions take shape and thus impact the development of technology -submitting to technological-fatalism isn't a productive way to align our ethical values with this development. we need to ensure that we play an active role in the shaping of the most consequential piece of technology. while the economic system relies on the market prices to gauge what people place value on, by no means is that a comprehensive evaluation. for example, it misses out on the impact of externalities which can be factored in by considering ethical values as a complement in guiding our decisions on what to build and how to place value on it. when thinking about losses from ai-enabled automation, an outright argument that economists might make is that if replacing labor lowers the costs of production, then it might be market-efficient to invest in technology that achieves that. from an ethicist's perspective, there are severe negative externalities from job loss and thus it might be unethical to impose labor-saving automation on people. when unpacking the economic perspective more, we find that job loss actually isn't correctly valued by wages as price for labor. there are associated social benefits like the company of workplace colleagues, sense of meaning and other social structural values which can't be separately purchased from the market. thus, using a purely economic perspective in making automation technology adoption decisions is an incomplete approach and it needs to be supplemented by taking into account the ethical perspective. market price signals provide useful information upto a certain point in terms of the goods and services that society places value on. suppose that people start to demand more eggs from chickens that are raised in a humane way, then suppliers will shift their production to respond to that market signal. but, such price signals can only be indicated by consumers for the things that they can observe. a lot of unethical actions are hidden and hence can't be factored into market price signals. additionally, several things like social relations aren't tradable in a market and hence their value can't be solely determined from the market viewpoint. thus, both economists and ethicists would agree that there is value to be gained in steering the development of ai systems keeping in mind both kinds of considerations. pure market-driven innovation will ignore societal benefits in the interest of generating economic value while the labor will have to make unwilling sacrifices in the interest of long-run economic efficiency. economic market forces shape society significantly, whether we like it or not. there are professional biases based on selection and cognition that are present in either side making its arguments as to which gets to dominate based on their perceived importance. the point being that bridging the gap between different disciplines is crucial to arriving at decisions that are grounded in evidence and that benefit society holistically. there are also differences fundamentally between the economic and ethical perspective -namely that economic indicators are usually unidimensional and have clear quantitative values that make them easier to compare. on the other hand, ethical indicators are inherently multi-dimensional and are subjective which not only make comparison hard but also limit our ability to explain how we arrive at them. they are encoded deep within our biological systems and suffer from the same lack of explainability as decisions made by artificial neural networks, the so-called black box problem. why is it then, despite the arguments above, that the economic perspective dominates over the ethical one? this is largely driven by the fact that economic values provide clear, unambiguous signals which our brains, preferring ambiguity aversion, enjoy and ethical values are more subtle, hidden, ambiguous indicators which complicate decision making. secondly, humans are prosocial only upto a point, they are able to reason between economic and ethical decisions at a micro-level because the effects are immediate and observable, say for example polluting the neighbor's lawn and seeing the direct impact of that activity. on the other hand, for things like climate change where the effects are delayed and not directly observable (as a direct consequence of one's actions) that leads to behaviour where the individual prioritizes economic values over ethical ones. cynical economists will argue that there is a comparative advantage in being immoral that leads to gains in exchange, but that leads to a race to the bottom in terms of ethics. externalities are an embodiment of the conflict between economic and ethical values. welfare economics deals with externalities via various mechanisms like permits, taxes, etc. to curb the impacts of negative externalities and promote positive externalities through incentives. but, the rich economic theory needs to be supplemented by political, social and ethical values to arrive at something that benefits society at large. from an economic standpoint, technological progress is positioned as expanding the production possibilities frontier which means that it raises output and presumably standards of living. yet, this ignores how those benefits are distributed and only looks at material benefits and ignores everything else. prior to the industrial revolution, people were stuck in a malthusian trap whereby technological advances created material gains but these were quickly consumed by population growth that kept standards of living stubbornly low. this changed post the revolution and as technology improvement outpaced population growth, we got better quality of life. the last 4 decades have had a mixed experience though, whereby automation has eroded lower skilled jobs forcing people to continue looking for jobs despite displacement and the lower demand for unskilled labor coupled with the inelastic supply of labor has led to lower wages rather than unemployment. on the other hand, high skilled workers have been able to leverage technological progress to enhance their output considerably and as a consequence the income and wealth gaps between low and high skilled workers has widened tremendously. typical economic theory points to income and wealth redistribution whenever there is technological innovation where the more significant the innovation, the larger the redistribution. something as significant as ai leads to crowning of new winners who own these new factors of production while also creating losers when they face negative pecuniary externalities. these are externalities because there isn't explicit consent that is requested from the people as they're impacted in terms of capital, labor and other factors of production. the distribution can be analyzed from the perspective of strict utilitarianism (different from that in ethics where for example bentham describes it as the greatest amount of good for the greatest number of people). here it is viewed as tolerating income redistribution such that it is acceptable if all but one person loses income as long as the single person making the gain has one that is higher than the sum of the losses. this view is clearly unrealistic because it would further exacerbate inequities in society. the other is looking at the idea of lump sum transfers in which the idealized scenario is redistribution, for example by compensating losers from technology innovation, without causing any other market distortions. but, that is also unrealistic because such a redistribution never occurs without market distortions and hence it is not an effective way to think about economic policy. from an ethics perspective, we must make value judgments on how we perceive dollar losses for a lower socio-economic person compared to the dollar gains made by a higher socio-economic person and if that squares with the culture and value set of that society. we can think about the tradeoff between economic efficiency and equality in society, where the level of tolerance for inequality varies by the existing societal structures in place. one would have to also reason about how redistribution creates more than proportional distortions as it rises and how much economic efficiency we'd be willing to sacrifice to make gains in how equitably income is distributed. thus, steering progress in ai can be done based on whether we want to pursue innovation that we know is going to have negative labor impacts while knowing full well that there aren't going to be any reasonable compensations offered to the people based on economic policy. given the pervasiveness of ai and by virtue of it being a general-purpose technology, the entrepreneurs and others powering innovation need to take into account that their work is going to shape larger societal changes and have impacts on labor. at the moment, the economic incentives are such that they steer progress towards labor-saving automation because labor is one of the most highly-taxed factors of production. instead, shifting the tax-burden to other factors of production including automation capital will help to steer the direction of innovation in other directions. government, as one of the largest employers and an entity with huge spending power, can also help to steer the direction of innovation by setting policies that encourage enhancing productivity without necessarily replacing labor. there are novel ethical implications and externalities that arise from the use of ai systems, an example of that would be (from the industrial revolution) that a factory might lead to economic efficiency in terms of production but the pollution that it generates is so large that the social cost outweighs the economic gain. biases can be deeply entrenched in the ai systems, either from unrepresentative datasets, for example, with hiring decisions that are made based on historical data. but, even if the datasets are well-represented and have minimal bias, and the system is not exposed to protected attributes like race and gender, there are a variety of proxies like zipcode which can lead to unearthing those protected attributes and discriminating against minorities. maladaptive behaviors can be triggered in humans by ai systems that can deeply personalize targeting of ads and other media to nudge us towards different things that might be aligned with making more profits. examples of this include watching videos, shopping on ecommerce platforms, news cycles on social media, etc. conversely, they can also be used to trigger better behaviors, for example, the use of fitness trackers that give us quantitative measurements for how we're taking care of our health. an economics equivalent of the paper clip optimizer from bostrom is how human autonomy can be eroded over time as economic inequality rises which limits control of those who are displaced over economic resources and thus, their control over their destinies, at least from an economic standpoint. this is going to only be exacerbated as ai starts to pervade into more and more aspects of our lives. labor markets have features built in them to help tide over unemployment with as little harm as possible via quick hiring in other parts of the economy when the innovation creates parallel demands for labor in adjacent sectors. but, when there is large-scale disruption, it is not possible to accommodate everyone and this leads to large economic losses via fall in aggregate demand which can't be restored with monetary or fiscal policy actions. this leads to wasted economic potential and welfare losses for the workers who are displaced. whenever there is a discrepancy between ethical and economic incentives, we have the opportunity to steer progress in the right direction. we've discussed before how market incentives trigger a race to the bottom in terms of morality. this needs to be preempted via instruments like technological impact assessments, akin to environmental impact assessments, but often the impacts are unknown prior to the deployment of the technology at which point we need to have a multi-stakeholder process that allows us to combat harms in a dynamic manner. political and regulatory entities typically lag technological innovation and can't be relied upon solely to take on this mantle. the author raises a few questions on the role of humans and how we might be treated by machines in case of the rise of superintelligence (which still has widely differing estimates for when it will be realized from the next decade to the second half of this century). what is clear is that the abilities of narrow ai systems are expanding and it behooves us to give some thought to the implications on the rise of superintelligence. the potential for labor-replacement in this superintelligence scenario, from an economic perspective, would have significant existential implications for humans, beyond just inequality, we would be raising questions of human survival if the wages to be paid to labor fall below subsistence levels in a wide manner. it would be akin to how the cost of maintaining oxen to plough fields was outweighed by the benefits that they brought in the face of mechanization of agriculture. this might be an ouroboros where we become caught in the malthusian trap again at the time of the industrial revolution and no longer have the ability to grow beyond basic subsistence, even if that would be possible. authors of research papers aspire to achieving any of the following goals when writing papers: to theoretically characterize what is learnable, to obtain understanding through empirically rigorous experiments, or to build working systems that have high predictive accuracy. to communicate effectively with the readers, the authors must: provide intuitions to aid the readers' understanding, describe empirical investigations that consider and rule out alternative hypotheses, make clear the relationship between theoretical analysis and empirical findings, and use clear language that doesn't conflate concepts or mislead the reader. the authors of this paper find that there are 4 areas where there are concerns when it comes to ml scholarship: failure to distinguish between speculation and explanation, failure to identify the source of empirical gains, the use of mathematics that obfuscates or impresses rather than clarifies, and misuse of language such that terms with other connotations are used or by overloading terms with existing technical definitions. flawed techniques and communication methods will lead to harm and wasted resources and efforts hindering the progress in ml and hence this paper provides some very practical guidance on how to do this better. when presenting speculations or opinions of authors that are exploratory and don't yet have scientific grounding, having a separate section that quarantines the discussion and doesn't bleed into the other sections that are grounded in theoretical and empirical research helps to guide the reader appropriately and prevents conflation of speculation and explanation. the authors provide the example of the paper on dropout regularization that made comparisons and links to sexual reproduction but limited that discussion to a "motivation" section. using mathematics in a manner where natural language and mathematical expositions are intermixed without a clear link between the two leads to weakness in the overall contribution. specifically, when natural language is used to overcome weaknesses in the mathematical rigor and conversely, mathematics is used as a scaffolding to prop up weak arguments in the prose and give the impression of technical depth, it leads to poor scholarship and detracts from the scientific seriousness of the work and harms the readers. additionally, invoking theorems with dubious pertinence to the actual content of the paper or in overly broad ways also takes away from the main contribution of a paper. in terms of misuse of language, the authors of this paper provide a convenient ontology breaking it down into suggestive definitions, overloaded terminology, and suitcase words. in the suggestive definitions category, the authors coin a new technical term that has suggestive colloquial meanings and can slip through some implications without formal justification of the ideas in the paper. this can also lead to anthropomorphization that creates unrealistic expectations about the capabilities of the system. this is particularly problematic in the domain of fairness and other related domains where this can lead to conflation and inaccurate interpretation of terms that have well-established meanings in the domains of sociology and law for example. this can confound the initiatives taken up by both researchers and policymakers who might use this as a guide. overloading of technical terminology is another case where things can go wrong when terms that have historical meanings and they are used in a different sense. for example, the authors talk about deconvolutions which formally refers to the process of reversing a convolution but in recent literature has been used to refer to transpose convolutions that are used in auto-encoders and gans. once such usage takes hold, it is hard to undo the mixed usage as people start to cite prior literature in future works. additionally, combined with the suggestive definitions, we run into the problem of concealing a lack of progress, such as the case with using language understanding and reading comprehension to now mean performance on specific datasets rather than the grand challenge in ai that it meant before. another case that leads to overestimation of the ability of these systems is in using suitcase words which pack in multiple meanings within them and there isn't a single agreed upon definition. interpretability and generalization are two such terms that have looser definitions and more formally defined ones, yet because papers use them in different ways, it leads to miscommunication and researchers talking across each other. the authors identify that these problems might be occurring because of a few trends that they have seen in the ml research community. specifically, complacency in the face of progress where there is an incentive to excuse weak arguments in the face of strong empirical results and the single-round review process at various conferences where the reviewers might not have much choice but to accept the paper given the strong empirical results. even if the flaws are noticed, there isn't any guarantee that they are fixed in a future review cycle at another conference. as the ml community has experienced rapid growth, the problem of getting high-quality reviews has been exacerbated: in terms of the number of papers to be reviewed by each reviewer and the dwindling number of experienced reviewers in the pool. with the large number of papers, each reviewer has less time to analyze papers in depth and reviewers who are less experienced can fall easily into some of the traps that have been identified so far. thus, there are two levers that are aggravating the problem. additionally, there is the risk of even experienced researchers resorting to a checklist-like approach under duress which might discourage scientific diversity when it comes to papers that might take innovative or creative approaches to expressing their ideas. a misalignment in incentives whereby lucrative deals in funding are offered to ai solutions that utilize anthropomorphic characterizations as a mechanism to overextend their claims and abilities though the authors recognize that the causal direction might be hard to judge. the authors also provide suggestions for other authors on how to evade some of these pitfalls: asking the question of why something happened rather than just relying on how well a system performed will help to achieve the goal of providing insights into why something works rather than just relying on headline numbers from the results of the experiments. they also make a recommendation for insights to follow the lines of doing error analysis, ablation studies, and robustness checks and not just be limited to theory. as a guideline for reviewers and journal editors, making sure to strip out extraneous explanations, exaggerated claims, changing anthropomorphic naming to more sober alternatives, standardizing notation, etc. should help to curb some of the problems. encouraging retrospective analysis of papers is something that is underserved at the moment and there aren't enough strong papers in this genre yet despite some avenues that have been advocating for this work. flawed scholarship as characterized by the points as highlighted here not only negatively impact the research community but also impact the policymaking process that can overshoot or undershoot the mark. an argument can be made that setting the bar too high will impede new ideas being developed and slow down the cycle of reviews and publication while consuming precious resources that could be deployed in creating new work. but, asking basic questions to guide us such as why something works, in which situations it does not work, and have the design decisions been justified will lead to a higher quality of scholarship in the field. the article summarizes recent work from several microsoft researchers on the subject of making ai ethics checklists that are effective. one of the most common problems identified relate to the lack of practical applicability of ai ethics principles which sound great and comprehensive in the abstract but do very little to aid engineers and practitioners from applying them in their day to day work. the work was done by interviewing several practitioners and advocating for a co-design process that brings in intelligence on how to make these tools effective from other disciplines like healthcare and aviation. one of the things emerging from the interviews is that often engineers are few and far between in raising concerns and there's a lack of top-down sync in enforcing these across the company. additionally, there might be social costs to bringing up issues which discourages engineers from implementing such measures. creating checklists that reduce friction and fit well into existing workflows will be key in their uptake. for a lot of people who are new to the field of artificial intelligence and especially ai ethics, they see existential risk as something that is immediate. others dismiss it as something to not be concerned about at all. there is a middle path here and this article sheds a very practical light on that. using the idea of canaries in a coal mine, the author goes on to highlight some potential candidates for a canary that might help us judge better when we ought to start paying attention to these kinds of risks posed by artificial general intelligence systems. the first one is the automatic formulation of learning problems, akin to how humans have high-level goals that they align with their actions and adjust them based on signals that they receive on the success or failure of those actions. ai systems trained in narrow domains don't have this ability just yet. the second one mentioned in the article is achieving fully autonomous driving, which is a good one because we have lots of effort being directed to make that happen and it requires a complex set of problems to be addressed including the ability to make real-time, life-critical decisions. ai doctors are pointed out as a third canary, especially because true replacement of doctors would require a complex set of skills spanning the ability to make decisions about a patient's healthcare plan by analyzing all their symptoms, coordinating with other doctors and medical staff among other human-centered actions which are currently not feasible for ai systems. lastly, the author points to the creation of conversation systems that are able to answer complex queries and respond to things like exploratory searches. we found the article to put forth a meaningful approach to reasoning about existential risk when it comes to ai systems. a lot of articles pitch development, investment and policymaking in ai as an arms race with the us and china as front-runners. while there are tremendous economic gains to be had in deploying and utilizing ai for various purposes, there remain concerns of how this can be used to benefit society more than just economically. a lot of ai strategies from different countries are thus focused on issues of inclusion, ethics and more that can drive better societal outcomes yet they differ widely in how they seek to achieve those goals. for example, ai has put forth a national ai strategy that is focused on economic growth and social inclusion dubbed #aiforall while the strategy from china has been more focused on becoming a global dominant force in ai which is backed by state investments. some countries have instead chosen to focus on creating strong legal foundations for the ethical deployment of ai while others are more focused on data protection rights. canada and france have entered into agreements to work together on ai policy which places talent, r&d and ethics at the center. the author of the article makes a case for how global coordination of ai strategies might lead to even higher gains but also recognizes that governments will be motivated to tailor their policies to best meet the requirements of their countries first and then align with others that might have similar goals. reproducibility is of paramount importance to doing rigorous research and a plethora of fields have suffered from a crisis where scientific work hasn't met muster in terms of reproducibility leading to wasted time and effort on the part of other researchers looking to build upon each other's work. the article provides insights from the work of a researcher who attempted a meta-science approach to trying to figure out what constitutes good, reproducible research in the field of machine learning. there is a distinction made early on in terms of replicability which hinges on taking someone else's code and running that on the shared data to see if you get the same results but as pointed out in the article, that suffers from issues of source and code bias which might be leveraging certain peculiarities in terms of configurations and more. the key tenets to reproducibility are being able to simply read a scientific paper and set up the same experiment, follow the steps prescribed and arrive at the same results. arriving at the final step is dubbed as independent reproducibility. the distinction between replicability and reproducibility also speaks to the quality of the scientific paper in being able to effectively capture the essence of the contribution such that anyone else is able to do the same. some of the findings from this work include that having hyperparameters well specified in the paper and its ease of readability contributed to the reproducibility. more specification in terms of math might allude to more reproducibility but it was found to not necessarily be the case. empirical papers were inclined to be more reproducible but could also create perverse incentives and side effects. sharing code is not a panacea and requires other accompanying factors to make the work really reproducible. cogent writing was found to be helpful along with code snippets that were either actual or pseudo code though step code that referred to other sections hampered reproducibility because of challenges in readability. simplified examples while appealing didn't really aid in the process and spoke to the meta-science process calling for data-driven approaches to ascertaining what works and what doesn't rather than relying on hunches. also, posting revisions to papers and being reachable over email to answer questions helped the author in reproducing the research work. finally, the author also pointed out that given this was a single initiative and was potentially biased in terms of their own experience, background and capabilities, they encourage others to tap into the data being made available but these guidelines provide good starting points for people to attempt to make their scientific work more rigorous and reproducible. the push has been to apply ai to any new problem that we face, hoping that the solution will magically emerge from the application of the technique as if it is a dark art. yet, the more seasoned scientists have seen these waves come and go and in the past, a blind trust in this technology led to ai winters. taking a look at some of the canaries in the coal mine, the author cautions that there might be a way to judge whether ai will be helpful with the pandemic situation. specifically, looking at whether domain experts, like leading epidemiologists endorse its use and are involved in the process of developing and utilizing these tools will give an indication as to whether they will be successful or not. data about the pandemic depends on context and without domain expertise, one has to make a lot of assumptions which might be unfounded. all models have to make assumptions to simplify reality, but if those assumptions are rooted in domain expertise from the field then the model can mimic reality much better. without context, ai models assume that the truth can be gleaned solely from the data, which though it can lead to surprising and hidden insights, at times requires humans to evaluate the interpretations to make meaning from them and apply them to solve real-world problems. this was demonstrated with the case where it was claimed that ai had helped to predict the start of the outbreak, yet the anomaly required the analysis from a human before arriving at that conclusion. claims of extremely high accuracy rates will give hardened data scientists reason for caution, especially when moving from lab to real-world settings as there is a lot more messiness with real-world data and often you encounter out-of-distribution data which hinders the ability of the model to make accurate predictions. for ct scans, even if they are sped up tremendously by the use of ai, doctors point out that there are other associated procedures such as the cleaning and filtration and recycling of air in the room before the next patient can be passed through the machine which can dwindle the gains from the use of an unexplainable ai system analyzing the scans. concerns with the use of automated temperature scanning using thermal cameras also suffers from similar concerns where there are other confounding factors like the ambient temperature, humidity, etc. which can limit the accuracy of such a system. ultimately, while ai can provide tremendous benefits, we mustn't blindly be driven by its allure to magically solve the toughest challenges that we face. offering an interesting take on how to shape the development and deployment of ai technologies, mhlambi utilizes the philosophy of ubuntu as a guiding light in how to build ai systems that better empower people and communities. the current western view that dominates how ai systems are constructed today and how they optimize for efficiency is something that lends itself quite naturally to inequitable outcomes and reinforcing power asymmetries and other imbalances in society. embracing the ubuntu mindset which puts people and communities first stands in contrast to this way of thinking. it gives us an alternative conception of personhood and has the potential to surface some different results. while being thousands of years old, the concept has been seen in practice over and over again, for example, in south africa, after the end of the apartheid, the truth and reconciliation program forgave and integrated offenders back into society rather than embark on a kantian or retributive path to justice. this restorative mindset to justice helped the country heal more quickly because the philosophy of ubuntu advocates that all people are interconnected and healing only happens when everyone is able to move together in a harmonious manner. this was also seen in the aftermath of the rwanda genocide, where oppressors were reintegrated back into society often living next to the people that they had hurt; ubuntu believes that no one is beyond redemption and everyone deserves the right to have their dignity restored. bringing people together through community is important, restorative justice is a mechanism that makes the community stronger in the long run. current ai formulation seeks to find some ground truth but thinking of this in the way of ubuntu means that we try to find meaning and purpose for these systems through the values and beliefs that are held by the community. ubuntu has a core focus on equity and empowerment for all and thus the process of development is slow but valuing people above material efficiency is more preferable than speeding through without thinking of the consequences that it might have on people. living up to ubuntu means offering people the choice for what they want and need, rooting out power imbalances and envisioning the companies as a part of the communities for which they are building products and services which makes them accountable and committed to the community in empowering them. ethics in the context of technology carries a lot of weight, especially because the people who are defining what it means will influence the kinds of interventions that will be implemented and the consequences that follow. given that technology like ai is used in high-stakes situations, this becomes even more important and we need to ask questions about the people who take this role within technology organizations, how they take corporate and public values and turn them into tangible outcomes through rigorous processes, and what regulatory measures are required beyond these corporate and public values to ensure that ethics are followed in the design, development and deployment of these technologies. ethics owners, the broad term for people who are responsible for this within organizations have a vast panel of responsibilities including communication between the ethics review committees and product design teams, aligning the recommendations with the corporate and public values, making sure that legal compliance is met and communicating externally about the processes that are being adopted and their efficacy. ethical is a polysemous word in that it can refer to process, outcomes, and values. the process refers to the internal procedures that are adopted by the firm to guide decision making on product/service design and development choices. the values aspect refers to the value set that is both adopted by the organization and those of the public within which the product/service might be deployed. this can include values such as transparency, equity, fairness, privacy, among others. the outcomes refer to desirable properties in the outputs from the system such as equalized odds across demographics and other fairness metrics. in the best case, inside a technology company, there are robust and well-managed processes that are aligned with collaboratively-determined ethical outcomes that achieve the community's and organization's ethical values. from the outside, this takes on the meaning of finding mechanisms to hold the firms accountable for the decisions that they take. further expanding on the polysemous meanings of ethics, it can be put into four categories for the discussion here: moral justice, corporate values, legal risk, and compliance. corporate values set the context for the rest of the meanings and provide guidance when tradeoffs need to be made in product/service design. they also help to shape the internal culture which can have an impact on the degree of adherence to the values. legal risk's overlap with ethics is fairly new whereas compliance is mainly concerned with the minimization of exposure to being sued and public reputation harm. using some of the framing here, the accolades, critiques, and calls to action can be structured more effectively to evoke substantive responses rather than being diffused in the energies dedicated to these efforts. framing the metaphor of "data is the new oil" in a different light, this article gives some practical tips on how organizations can reframe their thinking and relationship with customer data so that they take on the role of being a data custodian rather than owners of the personal data of their customers. this is put forth with the acknowledgement that customers' personal data is something really valuable that brings business upsides but it needs to be handled with care in the sense that the organization should act as a custodian that is taking care of the data rather than exploiting it for value without consent and the best interests of the customer at heart. privacy breaches that can compromise this data not only lead to fines under legislation like the gdpr, but also remind us that this is not just data but details of a real human being. as a first step, creating a data accountability report that documents how many times personal data was accessed by various employees and departments will serve to highlight and provide incentives for them to change behaviour when they see that some others might be achieving their job functions without the need to access as much information. secondly, celebrating those that can make do with minimal access will also encourage this behaviour change, all being done without judgement or blame but more so as an encouragement tool. pairing employees that need to access personal data for various reasons will help to build accountability and discourage intentional misuse of data and potential accidents that can lead to leaks of personal data. lastly, an internal privacy committee composed of people across job functions and diverse life experiences that monitors organization-wide private data use and provides guidance on improving data use through practical recommendations is another step that will move the conversation of the organization from data entitlement to data custodianship. ultimately, this will be a market advantage that will create more trust with customers and increase business bottom line going into the future. towards the systematic reporting of the energy and carbon climate change and environmental destruction are well-documented. most people are aware that mitigating the risks caused by these is crucial and will be nothing less than a herculean undertaking. on the bright side, ai can be of great use in this endeavour. for example, it can help us optimize resource use, or help us visualize the devastating effects of floods caused by climate change. however, ai models can have excessively large carbon footprints. henderson et al.'s paper details how the metrics needed to calculate environmental impact are severely underreported. to highlight this, the authors randomly sampled one-hundred neurips 2019 papers. they found that none reported carbon impacts, only one reported some energy use metrics, and seventeen reported at least some metrics related to compute-use. close to half of the papers reported experiment run time and the type of hardware used. the authors suggest that the environmental impact of ai and relevant metrics are hardly reported by researchers because the necessary metrics can be difficult to collect, while subsequent calculations can be time-consuming. taking this challenge head-on, the authors make a significant contribution by performing a meta-analysis of the very few frameworks proposed to evaluate the carbon footprint of ai systems through compute-and energy-intensity. in light of this meta-analysis, the paper outlines a standardized framework called experiment-impact-tracker to measure carbon emissions. the authors use 13 metrics to quantify compute and energy use. these include when an experiment starts and ends, cpu and gpu power draw, and information on a specific energy grid's efficiency. the authors describe their motivations as threefold. first, experiment-impact-tracker is meant to spread awareness among ai researchers about how environmentally-harmful ai can be. they highlight that "[w]ithout consistent and accurate accounting, many researchers will simply be unaware of the impacts their models might have and will not pursue mitigating strategies". second, the framework could help align incentives. while it is clear that lowering one's environmental impact is generally valued in society, this is not currently the case in the field of ai. experiment-impact tracker, the authors believe, could help bridge this gap, and make energy efficiency and carbon-impact curtailment valuable objectives for researchers, along with model accuracy and complexity. third, experiment-impact-tracker can help perform cost-benefit analyses on one's ai model by comparing electricity cost and expected revenue, or the carbon emissions saved as opposed to those produced. this can partially inform decisions on whether training a model or improving its accuracy is worth the associated costs. to help experiment-impact-tracker become widely used among researchers, the framework emphasizes usability. it aims to make it easy and quick to calculate the carbon impact of an ai model. through a short modification of one's code, experiment-impact-tracker collects information that allows it to determine the energy and compute required as well as, ultimately, the carbon impact of the ai model. experiment-impact-tracker also addresses the interpretability of the results by including a dollar amount that represents the harm caused by the project. this may be more tangible for some than emissions expressed in the weight of greenhouse gases released or even in co2 equivalent emissions (co2eq). in addition, the authors strive to: allow other ml researchers to add to experiment-impact-tracker to suit their needs, increase reproducibility in the field by making metrics collection more thorough, and make the framework robust enough to withstand internal mistakes and subsequent corrections without compromising comparability. moreover, the paper includes further initiatives and recommendations to push ai researchers to curtail their energy use and environmental impact. for one, the authors take advantage of the already widespread use of leaderboards in the ai community. while existing leaderboards are largely targeted towards model accuracy, henderson et al. instead put in place an energy efficiency leaderboard for deep reinforcement learning models. they assert that a leaderboard of this kind, that tracks performance in areas indicative of potential environmental impact, "can also help spread information about the most energy and climate-friendly combinations of hardware, software, and algorithms such that new work can be built on top of these systems instead of more energy-hungry configurations". the authors also suggest ai practitioners can take an immediate and significant step in lowering the carbon emissions of their work: run experiments on energy grids located in carbon-efficient cloud regions like quebec, the least carbon-intensive cloud region. especially when compared to very carbon-intensive cloud regions like estonia, the difference in co2eq emitted can be considerable: running an experiment in estonia produces up to thirty times as much emissions as running the same experiment in quebec. the important reduction in carbon emissions that follows from switching to energy-efficient cloud regions, according to henderson et al., means there is no need to fully forego building compute-intensive ai as some believe. in terms of systemic changes that accompany experiment-impact-tracker, the paper lists seven. the authors suggest the implementation of a "green default" for both software and hardware. this would make the default setting for researchers' tools the most environmentally-friendly one. the authors also insist on weighing costs and benefits to using compute-and energy-hungry ai models. small increases in accuracy, for instance, can come at a high environmental cost. they hope to see the ai community use efficient testing environments for their models, as well as standardized reporting of a model's carbon impact with the help of experiment-impact-tracker. additionally, the authors ask those developing ai models to be conscious of the environmental costs of reproducing their work, and act as to minimize unnecessary reproduction. while being able to reproduce other researchers' work is crucial in maintaining sound scientific discourse, it is merely wasteful for two departments in the same business to build the same model from scratch. the paper also presents the possibility of developing a badge identifying ai research papers that show considerable effort in mitigating carbon impact when these papers are presented at conferences. lastly, the authors highlight important lacunas in relation to driver support and implementation. systems that would allow data on energy use to be collected are unavailable for certain hardware, or the data is difficult for users to obtain. addressing these barriers would allow for more widespread collection of energy use data, and contribute to making carbon impact measurement more mainstream in the ai community. the paper highlights four challenges in designing more "intelligent" voice assistant systems that are able to respond to exploratory searches that don't have clear, short answers and require nuance and detail. this is in response to the rising expectations that users have from voice assistants as they become more familiar with them through increased interactions. voice assistants are primarily used for productivity tasks like setting alarms, calling contacts, etc. and they can include gestural and voice-activated commands as a method of interaction. exploratory search is currently not well supported through voice assistants because of them utilizing a fact-based approach that aims to deliver a single, best response whereas a more natural approach would be to ask follow up questions to refine the query of the user to the point of being able to provide them with a set of meaningful options. the challenges as highlighted in this paper if addressed will lead to the community building more capable voice assistants. one of the first challenges is situationally induced impairments as presented by the authors highlights the importance of voice activated commands because they are used when there are no alternatives available to interact with the system, for example when driving or walking down a busy street. there is an important aspect of balancing the tradeoff between smooth user experience that is quick compared to the degree of granularity in asking questions and presenting results. we need to be able to quantify this compared to using a traditional touch based interaction to achieve the same result. lastly, there is the issue of privacy, such interfaces are often used in a public space and individuals would not be comfortable sharing details to refine the search such as clothing sizes which they can discreetly type into the screen. such considerations need to be thought of when designing the interface and system. mixed-modal interactions include combinations of text, visual inputs and outputs and voice inputs and output. this can be an effective paradigm to counter some of the problems highlighted above and at the same time improve the efficacy of the interactions between the user and the system. further analysis is needed as to how users utilize text compared to voice searches and whether one is more informational or exploratory than the other. designing for diverse populations is crucial as such systems are going to be widely deployed. for example, existing research already highlights how different demographics even within the same socio-economic subgroup utilize voice and text search differently. the system also needs to be sensitive to different dialects and accents to function properly and be responsive to cultural and contextual cues that might not be pre-built into the system. differing levels of digital and technical literacy also play a role in how the system can effectively meet the needs of the user. as the expectations from the system increase over time, ascribed to their ubiquity and anthropomorphization, we start to see a gulf in expectations and execution. users are less forgiving of mistakes made by the system and this needs to be accounted for when designing the system so that alternate mechanisms are available for the user to be able to meet their needs. in conclusion, it is essential when designing voice-activated systems to be sensitive to user expectations, more so than other traditional forms of interaction where expectations are set over the course of several uses of the system whereas with voice systems, the user comes in with a set of expectations that closely mimic how they interact with each other using natural language. addressing the challenges highlighted in this paper will lead to systems that are better able to delight their users and hence gain higher adoption. the paper highlights how having more translation capabilities available for languages in the african continent will enable people to access larger swathes of the internet and contribute to scientific knowledge which are predominantly english based. there are many languages in africa, south africa alone has 11 official languages and only a small subset are made available on public tools like google translate. in addition, due to the scant nature of research on machine translation for african languages, there remain gaps in understanding the extent of the problem and how they might be addressed most effectively. the problems facing the community are many: low resource availability, low discoverability where language resources are often constrained by institution and country, low reproducibility because of limited sharing of code and data, lack of focus from african society in seeing local languages as primary modes of communication and a lack of public benchmarks which can help compare results of machine translation efforts happening in various places. the research work presented here aims to address a lot of these challenges. they also give a brief background on the linguistic characteristics of each of the languages that they have covered which gives hints as to why some have been better covered by commercial tools than others.in related work, it is evident that there aren't a lot of studies that have made their code and datasets public which makes comparison difficult with the results as presented in this paper. most studies focused on the autshumato datasets and some relied on government documents as well, others used monolingual datasets as a supplement. the key analysis of all of those studies is that there is a paucity in the focus on southern african languages and because apart from one study, others didn't make their datasets and code public, the bleu scores listed were incomparable which further hinders future research efforts. the autshumato datasets are parallel, aligned corpora that have governmental text as its source. they are available for english to afrikaans, isizulu, n. sotho, setswana, and xitsonga translations and were created to build and facilitate open source translation systems. they have sentence level parallels that have been created both using manual and automatic methods. but, it contains a lot of duplicates which were eliminated in the study done in this paper to avoid leakage between training and testing phases. despite these eliminations, there remain some issues of low quality, especially for isizulu where the translations don't line up between source and target sentences. from a methodological perspective, the authors used convs2s and transformer models without much hyperparameter tuning since the goal of the authors was to provide a benchmark and the tuning is left as future work. additional details on the libraries, hyperparameter values and dataset processing are provided in the paper along with a github link to the code. in general the transformer model outperformed convs2s for all the languages, sometimes even by 10 points on the bleu scores. performance on the target language depended on both the number of sentences and the morphological typology of the language. poor quality of data along with small dataset size plays an important role as evidenced in the poor performance on the isizulu translations where a lowly 3.33 bleu score was achieved. the morphological complexity of the language also played a role in the state of the performance as compared to other target languages. for each of the target languages studied, the paper includes some randomly selected sentences to show qualitative results and how different languages having different structures and rules impacts the degree of accuracy and meaning in the translations. there are also some attention visualizations provided in the paper for the different architectures demonstrating both correct and incorrect translations, thus shedding light on potential areas for dataset and model improvements. the paper also shows results from ablation studies that the authors performed on the byte pair encodings (bpe) to analyze the impact on the bleu scores and they found that for datasets that had smaller number of samples, like for isizulu, having a smaller number of bpe tokens increased the bleu scores. in potential future directions for the work, the authors point out the need for having more data collection and incorporating unsupervised learning, meta learning and zero shot techniques as potential options to provide translations for all 11 official languages in south africa. this work provides a great starting point for others who want to help preserve languages and improve machine translations for low resources languages. such efforts are crucial to empower everyone in being able to access and contribute to scientific knowledge of the world. providing code and data in an open source manner will enable future research to build upon it and we need more such efforts that capture the diversity of human expression through various languages. presence of media cards, total interactions, history of engagement with the creator of the tweet, the user's strength of connection with the creator and the user's usage pattern of twitter. from these factors, one can deduce why filter bubbles and echo chambers form on the platform and where designers and technologists can intervene to make the platform a more holistic experience for users that doesn't create polarizing fractions which can promote the spread of disinformation. for the first time, there's a call for the technical community to include a social impact statement from their work which has sparked a debate amongst camps that are arguing to leave such a declaration to experts who study ethics in machine learning and those that see this as a positive step in bridging the gap between the social sciences and the technical domains. specifically, we see this as a great first step in bringing accountability closer to the origin of the work. additionally, it would be a great way to build a shared vernacular across the human and technical sciences easing future collaboration. we are impressed with all the work that the research and practice community has been doing in the domain of ai ethics. there are many unsolved and open problems that are yet to be addressed but our overwhelming optimism in the power of what diversity and interdisciplinarity can help to achieve makes us believe that there is indeed room for finding novel solutions to the problems that face the development and deployment of ai systems. we see ourselves as a public square, gathering people from different walks of life who can have meaningful exchanges with each other to create the solutions we need for a better future. let's work together and share the mic with those who have lived experiences, lifting up voices that will help us better understand the contexts within which technology resides so that we can truly build something that is ethical, safe, and inclusive for all. see you here next quarter, the state of ai ethics, june 2020 suckers list: how allstate's secret auto insurance algorithm squeezes big spenders algorithmic injustices towards a relational ethics social biases in nlp models as barriers for persons with disabilities the second wave of algorithmic accountability the unnatural ethics of ai could be its undoing this dating app exposes the monstrous bias of algorithms ( arielle pardes data is never a raw, truthful input -and it is never neutral racial disparities in automated speech recognition working to address algorithmic bias? don't overlook the role of demographic data ai advances to better detect hate speech algorithms associating appearance and criminality have a dark past beware of these futuristic background checks go deep: research summaries 30 the toxic potential of youtube's feedback loop study: facebook's fake news labels have a fatal flaw research summaries capabilities, and ai assistive technologies go wide: article summaries 50 ancient animistic beliefs live on in our intimacy with tech humans communicate better after robots show their vulnerable side at the limits of thought engineers should spend time training not just algorithms, but also the humans who use them using multimodal sensing to improve awareness in human-ai interaction different intelligibility for different folks aligning ai to human values means picking the right metrics why lifelong learning is the international passport to success (pierre vandergheynst and isabelle vonã¨che cardia you can't fix unethical design by yourself research summaries the wrong kind of ai? artificial intelligence and the future of labor demand ai is coming for your most mind-numbing office tasks tech's shadow workforce sidelined, leaving social media to the machines here's what happens when an algorithm determines your work schedule automation will take jobs but ai will create them research summaries what's next for ai ethics, policy, and governance? a global overview (daniel schiff a holistic approach to implement ethics in ai beyond a human rights based approach to ai governance: promise, pitfalls and plea go wide: article summaries 69 this is the year of ai regulations apps gone rogue: maintaining personal privacy in an epidemic maximizing privacy and effectiveness in covid-19 apps article summaries who's allowed to track my kids online? chinese citizens are racing against censors to preserve coronavirus memories on github can i opt out of facial scans at the airport? with painted faces, artists fight facial recognition tech research summaries adversarial machine learning -industry perspectives article summaries the deadly consequences of unpredictable code adversarial policies: attacking deep reinforcement learning specification gaming: the flip side of ai ingenuity doctors are using ai to triage covid-19 patients. the tools may be here to stay the future of privacy and security in the age of machine learning research summaries 95 towards a clearer account of research priorities in ai ethics and society integrating ethical values and economic value to steer progress in ai machine learning scholarship go wide: article summaries 104 microsoft researchers create ai ethics checklist with ml practitioners from a dozen tech companies why countries need to work together on ai quantifying independently reproducible machine learning be a data custodian, not a data owner research summaries towards the systematic reporting of the energy and carbon footprints of machine learning challenges in supporting exploratory search through voice assistants a focus on neural machine translation for african languages radioactive data: tracing through training using deep learning at scale in twitter's timeline (nicolas koumchatzky neurips requires ai researchers to account for societal impact and financial conflicts of interest in modern ai systems, we run into complex data and processing pipelines that have several stages and it becomes challenging to trace the provenance and transformations that have been applied to a particular data point. this research from the facebook ai research team proposes a new technique called radioactive data that borrows from medical science where compounds like baso4 are injected to get better results in ct scans. this technique applies minor, imperceptible perturbations to images in a dataset by causing shifts within the feature space making them "carriers".different from other techniques that rely on poisoning the dataset that harms classifier accuracy, this technique instead is able to detect such changes even when the marking and classification architectures are different. it not only has potential to trace how data points are used in the ai pipeline but also has implications when trying to detect if someone claims not to be using certain images in their dataset but they actually are. the other benefit is that such marking of the images is difficult to undo thus adding resilience to manipulation and providing persistence. prior to relevance based timeline, the twitter newsfeed was ordered in reverse chronological order but now it uses a deep learning model underneath to display the most relevant tweets that are personalized according to the user's interactions on the platform. with the increasing use of twitter as a source of news for many people, it's a good idea for researchers to gain an understanding of the methodology that is used to determine the relevance of tweets, especially as one looks to curb the spread of disinformation online. the article provides some technical details in terms of the deep learning infrastructure and the choices made by the teams in deploying computationally heavy models which need to be balanced with the expediency of the refresh times for a good experience on the platform. but, what's interesting from an ai ethics perspective are the components that are used to arrive at the ranking which constantly evolves based on the user's interaction with different kinds of content.the ranked timeline consists of a handful of the tweets that are the most relevant to the user followed by others in reverse chronological order. additionally, based on the time since one's last visit on the platform, there might be an icymi ("in case you missed it") section as well. the key factors in ranking the tweets are their recency, key: cord-002774-tpqsjjet authors: nan title: section ii: poster sessions date: 2017-12-01 journal: j urban health doi: 10.1093/jurban/jti137 sha: doc_id: 2774 cord_uid: tpqsjjet nan food and nutrition programs in large urban areas have not traditionally followed a systems approach towards mitigating food related health issues, and instead have relied upon specific issue interventions char deal with downstream indicators of illness and disease. in june of 2004, the san francisco food alliance, a group of city agencies, community based organizations and residents, initiated a collahorarive indicator project called rhe san francisco food and agriculture assessment. in order to attend to root causes of food related illnesses and diseases, the purpose of the assessment is to provide a holistic, systemic view of san francisco\'s food system with a focus on three main areas that have a profound affect on urban public health: food assistance, urban agriculture, and food retailing. using participatory, consensus methods, the san francisco food alliance jointly developed a sec of indicators to assess the state of the local food system and co set benchmarks for future analysis. members collected data from various city and stare departments as well as community based organizations. through the use of geographic information systems software, a series of maps were created to illustrate the assets and limitations within the food system in different neighborhoods and throughout the city as a whole. this participatory assessment process illustrates how to more effectively attend to structural food systems issues in large urban areas by ( t) focusing on prevention rather than crisis management, (2) emphasizing collaboration to ensure institutional and structural changes, and (3) aptly translating data into meaningful community driven prevention activities. to ~xplore the strategies to overcome barriers to population sample, we examined the data from three rapid surveys conducted at los angeles county (lac). the surveys were community-based partic· 1patory surveys utilizing a modified two-stage cluster survey method. the field modifications of the method resulted in better design effect than conventional cluster sample survey (design effect dose to that if the survey was done as simple random sample survey of the same size). the surveys were con· ducte~ among parents of hispanic and african american children in lac. geographic area was selected and d1.v1ded int.o small c~usters. in the first stage, 30 clusters were selected with probability proportionate to estimated size of children from the census data. these clusters were enumerated to identify and develop a list of households with eligible children from where a random sample was withdrawn. data collectmn for consented respondents involved 10-15 minutes in-home interview and abstraction of infor· ma~ion from vaccine record card. the survey staff had implemented community outreach activities designed to fost~r an~ maintain community trust and cooperation. the successful strategies included: developing re.lat1on .w.1th local community organizations; recruitment of community personnel and pro· vide them with training to conduct the enumeration and interview; teaming the trained community introduction: though much research has been done on the health and social benefits of pet ownership for many groups, there have been no explorations of what pet ownership can mean to adults who are marginalized, living on fixed incomes or on the street in canada. we are a community group of researchers from downtown toronto. made up of front line staff and community members, we believe that community research is important so that our concerns, visions, views and values are presented by us. we also believe that research can and should lead to social change. method: using qualitative and exploratory methods, we have investigated how pet ownership enriched and challenged the lives of homeless and transitionally housed people. our research team photographed and conducted one-on-one interviews with 11 pet owners who have experienced home· lessncss and live on fixed incomes. we had community participation in the research through a partnership with the fred vicror centre camera club. many of the fred victor centre camera club members have experienced homelessness and being marginalized because of poverty. the members of the dub took the photos and assisted in developing the photos. they also participated in the presenta· tion of our project. results: we found that pet ownership brings important health and social benefits to our partici· pants. in one of the most poignant statements, one participant said that pet ownership " ... stops you from being invisible." another commented that "well, he taught me to slow down, cut down the heavy drugs .. " we also found that pet ownership brings challenges that can at times be difficult when one is liv· ing on a fixed income. we found that the most difficult thing for most of the pet owners was finding affordable vet care for their animals. conclusion: as a group, we decided that research should only be done if we try to make some cha.nges about what we have learned. we continue the project through exploring means of affecting social change--for example, ~eti.tions and informing others about the result of our project. we would like to present our ~mdmgs and experience with community-based participatory action resea.rch m an oral. presentarton at yo~r conference in october. our presentation will include com· mumty representation ~f. both front-hne staff and people with lived experience of marginalization and homdessness. if this is not accepted as an oral presentation, we are willing to present the project m poster format. introduction the concept of a healthy city was adopted by the world health organization some time ago and it includes strong support for local involvement in problem solving and implementation of solutions. while aimed at improving social, economic or environmental conditions in a given community, more significantly the process is considered to be a building block for poliq reform and larger scale 'hange, i.e. "acting locally while thinking globally." neighbourhood planning can he the entry point for citizens to hegin engaging with neighbours on issues of the greater common good. methods: this presentation will outline how two community driven projects have unfolded to address air pollution. the first was an uphill push to create bike lanes where car lanes previously existed and the second is an ongoing, multi-sectoral round table focused on pollution and planning. both dt•monstrate the importance of having support with the process and a health focus. borrowing from traditions of "technical aid"• and community development the health promoter /planner has incorporated a range of "determinants of health" into neighbourhood planning discussions. as in most urban conditions the physical environment is linked to a range of health stressors such as social isolation, crowding, noise, lack of open space /recreation, mobility and safety. however typical planning processes do not hring in a health perspective. health as a focus for neighbourhood planning is a powerful starti_ng point when discussing transportation planning or changing land-uses. by raising awareness on determmants of health, citizens can begin to better understand how to engage in a process and affect change. often local level politics are involved and citizens witness policy change in action. the environmental liaison committee and the dundas east hike lanes project resulted from local level initiatives aimed at finding solutions to air pollution -a priority identified hy the community. srchc supported the process with facilitation and technical aid. _the processs had tangible results that ultimately improve living conditions and health. •tn the united kmgdom plannm in the 60's established "technical aid" offices much like our present day legal aid system to provide professional support and advocacy for communities undergoing change. p2-15 (c) integrating community based research: the experience of street health, a community service agency i.aura cowan and jacqueline wood street health began offering services to homeless men and women in east downtown ~oronto in 1986. nursing stations at drop-in centres and shelters were fo~lowed by hiv/aids prevent10~, harm reduction and mental health outreach, hepatitis c support, sleeping bag exchange, and personal tdennfication replacement and storage programs. as street health's progi;ams expanded, so to~ did the agency:s recognition that more nee~ed t~ be done to. address the underl~ing causes of, th~ soct~l and economic exclusion experienced by its clients. knowing t.h~t. a~voca~y ts. helped by . evtd~nce , street he.alt~ embarked on a community-based research (cbr) initiative to 1dent1fy commumty-dnven research priorities within the homeless and underhoused population. methods: five focus groups were conducted with 46 homeless people, asking participants to identify positive and negative forces in their lives, and which topics were important to take action on and learn more about. findings were validated through a validation meeting with participants. results: participants identified several important positive and negative forces in their lives. key positive forces included caring and respectful service delivery, hopefulness and peer networks. key negative forces included lack of access to adequate housing and income security, poor service delivery and negative perceptions of homeless people. five topics for future research emerged from the process, focusing on funding to address homelessness and housing; use of community services for homeless people; the daily survival needs of homeless people and barriers to transitioning out of homelessness; new approaches to service delivery that foster empowerment; and policy makers' understanding of poverty and homelessness. conclusions: although participants expressed numerous issues and provided much valuable insight, definitive research ideas and action areas were not clearly identified by participants. however, engagement in a cbr process led to some important lessons and benefits for street health. we learned that the community involvement of homeless people and front-line staff is critical to ensuring relevance and validity for a research project; that existing strong relationships with community parmers are essential to the successful implementation of a project involving marginalized groups; and that an action approach focusing on positive change can make research relevant to directly affected people and community agency staff. street health benefited from using a cbr approach, as the research process facilitated capacity building among staff and within the organization as a whole. p2-16 (c) a collaborative process to achieve access to primary health care for black women and women of colour: a model of community based participartory research notisha massaquoi, charmaine williams, amoaba gooden, and tulika agerwal in the current healthcare environment, a significant number of black women and women of color face barriers to accessing effective, high quality services. research has identified several issues that contribute to decreased access to primary health care for this population however racism has emerged as an overarching determinant of health and healthcare access. this is further amplified by simultaneous membership in multiple groups that experience discrimination and barriers to healthcare for example those affected by sexism, homelessness, poverty, homophobia and heterosexism, disability and hiv infection. the collaborative process to achieve access to primary health care for black women and women of colour project was developed with the university of toronto faculty of social work and five community partners using a collaborative methodology to address a pressing need within the community ro increase access to primary health care for black women and women of colour. women's health in women's hands community health centre, sistering, parkdale community health centre, rexdale community health centre and planed parenthood of toronto developed this community-based participatory-action research project to collaboratively barriers affecting these women, and to develop a model of care that will increase their access to health services. this framework was developed using a process which ensured that community members from the target population and service providers working in multiculrural clinical settings, were a part of the research process. they were given the opportunity to shape the course of action, from the design of the project to the evaluation and dissemination phase. empowerment is a goal of the participatory action process, therefore, the research process has deliberately prioritized _ro enabling women to increase control over their health and well-being. in this session, the presenters will explore community-based participatory research and how such a model can be useful for understanding and contextualizing the experiences of black women and women of colour. they will address. the development and use of community parmerships, design and implementation of the research prorect, challenges encountered, lessons learnt and action outcomes. they will examine how the results from a collaborative community-based research project can be used as an action strategy to poster sessions v61 address che social determinants of women health. finally the session will provide tools for service providers and researchers to explore ways to increase partnerships and to integrate strategies to meet the needs of che target population who face multiple barriers to accessing services. lynn scruby and rachel rapaport beck the purpose of this project was ro bring traditionally disenfranchised winnipeg and surrounding area women into decision-making roles. the researchers have built upon the relationships and information gachered from a pilot project and enhanced the role of input from participants on their policy prioriries. the project is guided by an advisory committee consisting of program providers and community representatives, as well as the researchers. participants included program users at four family resource cencres, two in winnipeg and two located rurally, where they participated in focus groups. the participants answered a series of questions relating to their contact with government services and then provided inpuc as to their perceptions for needed changes within government policy. following data analysis, the researchers will return to the four centres to share the information and continue che discussion on methods for advocating for change. recommendations for program planning and policy development and implementation will be discussed and have relevance to all participants in the research program. women's health vera lefranc, louise hara, denise darrell, sonya boyce, and colleen reid women's experiences with paid and unpaid work, and with the formal and informal economies, have shifted over the last 20 years. in british columbia, women's employability is affected by government legislation, federal and provincial policy changes, and local practices. two years ago we formed the coalition ior women's economic advancement to explore ways of dealing with women's worsening economic situations. since the formation of the coalition we have discussed the need for research into women's employabilicy and how women were coping and surviving. we also identified how the need to document the nature of women's employability and reliance on the informal economy bore significanc mechodological and ethical challenges. inherent in our approach is a social model of women's health that recognizes health as containing social, economic, and environmental determinants. we aim to examine the social contexc of women's healch by exploring and legitimizing women's own experiences, challenging medical dominance in understandings of health, and explaining women's health in terms of their subordination and marginalizacion. through using a feminist action research (far) methodology we will explore the relationship between women's employability and health in 4 communities that represent bricish columbia's social, economic, cultural/ethnic, and geographic diversities: skidegate, fort st . .john, lumhy, and surrey. over the course of our 2 year project, in each community we will establish and work with advisory committees, hire and train local researchers, conduct far (including a range of qualitative methods), and support action and advocacy. since the selected communities are diverse, the ways that the research unfolds will 1·ary between communities. expected outcomes, such as the provision of a written report and resources, the establishment of a website for networking among the communities, and a video do.:umentary, are aimed at supporting the research participants, coalition members, and advisory conuniuces in their action efforts. p2t 9 (c) health & housing: assessing the impact of transitional housing for people living with hiv i aids currently, there is a dearth of available literature which examines supporrive housing for phas in the canadian context. using qualitative, one-on-one interviews we investigace the impact of transitional housing for phaswho have lived in the up to nine month long hastings program. our post<'r pr<·senta-t1on will highlight research findings, as well as an examination of transitional housing and th<· imp;kt it has on the everyday lives of phas in canada. this research is one of two ground breaking undertakings within the province of ontario in which fife house is involved. p2-20 (c) eating our way to justice: widening grassroots approaches to food security, the stop community food centre as a working model charles l.evkoe food hanks in north america have come co play a central role as the widespread response to growing rates of hunger. originally thought to be a short term-solution, over the last 25 years, they have v62 poster sessions be · · · 1· d wi'thi'n society by filling the gaps in the social safety net while relieving govemcome mst1tut1ona 1ze . . . t f the ir responsibilities. dependent on corporate donations and sngmauzmg to users, food banks men so th' . ·11 i i . are incapable of addressing the structural cause~ of ~u~ger. 1s pres~ntation w1 e~~ ore a ternanve approaches to addressing urban food security while bmldmg more sustamabl.e c~mmumt1es. i:nrough the f t h st p community food centre, a toronto-based grassroots orgamzanon, a model is presented case 0 e 0 h'l k' b 'id · b that both responds to the emergency food needs of communities w 1 e wor mg to. u1 ~ sustama le and just food system. termed, the community food centre model. (cfc), ~he s~op is worki?g to widen its approach to issues of food insecurity by combining respectful ~1rect service wit~ com~~mty ~evelop ment, social justice and environmental sustainability. through this approach, various critical discourses around hunger converge with different strategic and varied implications for a~ion. as a plac~-based organization, the stop is rooted within a geographical space and connected directly to a neighbourhood. through working to increase access to healthy food, it is active in maintaining people's dignity, building a strong and democratic community and educating for social change. connected to coalitions and alliances, the stop is also active in organizing across scales in connection with the global food justice movement. inner city shelter vicky stergiopoulos, carolyn dewa, katherine rouleau, shawn yoder, and lorne tugg introduction: in the city of toronto there are more than 32,000 hostel users each year, many with mental health and addiction issues. although shelters have responded in various ways to the health needs of their clients, evidence on the effectiveness of programs delivering mental health services to the home· less in canada has been scant. the objective of this community based research was to provide a forma· tive evaluation of a multi-agency collaborative care team providing comprehensive care for high needs clients at toronto's largest shelter for homeless men. methods: a logic model provided the framework for analysis. a chart review of 56 clients referred over a nine month period was completed. demographic data were collected, and process and outcome indicators were identified for which data was obtained and analyzed. the two main outcome measures were mental status and housing status 6 months after referral to the program. improvement or lack of improvement in mental status was established by chart review and team consensus. housing outcomes were determined by chart review and the hostel databases. results: of the clients referred 75% were single and 98% were unemployed. forty four percent had a psychiatric hospitalization within the previous two years. the prevalence of severe and persistent men· tal illness, alcohol and substance use disorders were 60%, 26% and 37% respectively. six months after referral to the program 37% of clients had improved mental status and 41 % were housed. logistic regression controlling for the number of general practitioner and psychiatrist visits, presence of person· ality or substance use disorder and treatment non adherence identified two variables significantly associ· ated mental status improvement: the number of psychiatric visits (or, 1.92; 95% ci, 1.29-2.84) and treatment non adherence (or, 0.086; 95% ci, 0.01-0.78). the same two variables were associated with housing outcomes. history of forensic involvement, the presence of a personality or substance use disorder and the number of visits with a family physician were not significantly associated with either outcome. conclusions: despite the limitations in sample sire and study design, this study can yield useful informa· tion to program planners. our results suggest that strategies to improve treatment adherence and access to mental health specialists can improve outcomes for this population. although within primary care teams the appropriate collaborative care model for this population remains to be established, access to psychiatric follow up, in addition to psychiatric assessment services, may be an important component of a successful program. mount sinai hospital (msh) has become one of the pre-eminent hospitals in the world by contributing to the development of innovative approaches to effective health care and disease prevention. recently, the hospital has dedicated resources towards the development of a strategy aimed at enhancing the hospital's integration with its community partners. this approach will better serve the hospital in the current health care environment where local health integration networks have been struck to enhance and support local capacity to plan, coordinate and integrate service delivery. msh has had early success with developing partnerships. these alliances have been linked to programs serving key target populations with _estabhshe~. points of access to msh. recognizing the need to build upon these achievements to remain compe~mve, the hospital has developed a community integration strategy. at the forefront of this strategy is c.a.r.e (community advisory reference engine): the hospital's compendium of poster sessions v63 community partners. as a single point of access to community partner information, c.a.r.e. is more than a database. c.a.r.e. serves as the foundation for community-focused forecasting and a vehicle for inter and intra-organizational knowledge transfer. information gleaned from the catalog of community parmers can be used to prepare strategic, long-term partnership plans aimed at ensuring that a comprehensive array of services can be provided to the hospital community. c.a.r.e. also houses a permanent record of the hospital's alliances. this prevents administrative duplication and facilitates the formation of new alliances that best serve both the patient and the hospital. c.a.r.e. is not a stand-alone tool and is most powerful when combined with other aspects of the hospital's community integration strategy. it iscxpected that data from the hospital's community advisory committees and performance measurement department will also be stored alongside stakeholder details. this information can then be used to drive discussions at senior management and the board, ensuring congruence between stakeholder, patient and hospital objectives. the patient stands to benefit from this strategy. the unique, distinct point of reference to a wide array of community services provides case managers and discharge planners with the information they need to connect patients with appropriate community services. creating these linkages enhances the patient's capacity to convalesce in their homes or places of residence and fosters long-term connections to neighborhood supports. these connections can be used to assist with identifying patients' ongoing health care needs and potentially prevent readmission to hospital. introduction: recruiting high-risk drug users and sex workers for hiv-prevention research has often been hampered by limited access to hard to reach, socially stigmatized individuals. our recruitment effom have deployed ethnographic methodology to identify and target risk pockets. in particular, ethnographers have modeled their research on a street-outreach model, walking around with hiv-prevention materials and engaging in informal and structured conversations with local residents, and service providers, as well as self-identified drug users and sex workers. while such a methodology identifies people who feel comfortable engaging with outreach workers, it risks missing key connections with those who occupy the margins of even this marginal culture. methods: ethnographers formed a women's laundry group at a laundromat that had a central role as community switchboard and had previously functioned as a party location for the target population. the new manager helped the ethnographers invite women at high risk for hiv back into the space, this time as customers. during weekly laundry sessions, women initiated discussions about hiv-prevention, sexual health, and eventually, the vaccine research for which the center would be recruiting women. ra.its: the benefits of the group included reintroducing women to a familiar locale, this time as customers rather than unwelcome intruders; creating a span of time (wash and dry) to discuss issues important to me women and to gather data for future recruitment efforts; creating a location to meet women encountered during more traditional outreach research; establishing the site as a place for potential retention efforts; and supporting a local business. women who participated in the group completed a necessary household task while learning information that they could then bring back to the community, empowering them to be experts on hiv-prevention and vaccine research. some of these women now assist recruitment efforts. the challenges included keeping the group women-only, especially after lunch was provided, keeping the membership of the group focused on women at risk for hiv, and keeping the women in the group while they did their laundry. conclusion: public health educators and researchers can benefit from identifying alternate congregation sites within risk pockets to provide a comfortable space to discuss hiv prevention issues with high-risk community members. in our presentation, we will describe the context necessary for similar research, document the method's pitfalls and successes, and argue that the laundry group constitutes an ethical, respectful, community-based method for recruitment in an hiv-prevention vaccine trial. p3-0t (c) upgrading inner city infrastructure and services for improved environmental hygiene and health: a case of mirzapur in u.p. india madhusree mazumdar in urgency for agricultural and industrial progress to promote economic d.evelopment follo_wing independence, the government of india had neglected health promotion and given less emphasis on infrastructure to promote public health for enhanced human pro uct1v_ity. ong wit r~p1 m astrucrure development, which has become essential if citie~ are to. act ~s harbmger.s of econ~nuc ~owth, especially after the adoption of the economic liberalization policy, importance _is a_lso ~emg g1ve.n to foster environmental hygiene for preventive healthcare. the world health orga~1sat10~ is also trj:'1!1g to help the government to build a lobby at the local level for the purpose by off~rmg to mrroduce_ its heal.thy city concept to improve public health conditions, so as to reduce th_e disease burden. this pape~ 1s a report of the efforts being made towards such a goal: the paper descr~bes ~ c~se study ?f ~ small city of india called mirzapur, located on the banks of the nver ganga, a ma1or lifeline of india, m the eastern part of the state of uttar pradesh, where action for improvement began by building better sanitation and environmental infrastructure as per the ganga action plan, but continued with an effort to promote pre· ventive healthcare for overall social development through community participation in and around the city. asthma physician visits in toronto, canada tara burra, rahim moineddin, mohammad agha, and richard glazier introduction: air pollution and socio-economic status are both known to be associated with asthma in concentrated urban settings but little is known about the relationship between these factors. this study investigates socio-economic variation in ambulatory physician consultations for asthma and assesses possible effect modification of socio-economic status on the association between physician visits and ambient air pollution levels for children aged 1 to 17 and adults aged 18 to 64 in toronto, canada between 1992 and 2001. methods: generalized additive models were used to estimate the adjusted relative risk of asthma physician visits associated with an interquartile range increase in sulphur dioxide, nitrogen dioxide, pm2.5, and ozone, respectively. results: a consistent socio-economic gradient in the number of physician visits was observed among children and adults and both sexes. positive associations between ambient concentrations of sul· phur dioxide, nitrogen dioxide and pm2.5 and physician visits were observed across age and sex strata, whereas the associations with ozone were negative. the relative risk estimates for the low socio-«onomic group were not significantly greater than those for the high socio-economic group. conclusions: these findings suggest that increased ambulatory physician visits represent another component of the public health impact of exposure to urban air pollution. further, these results did not identify an age, sex, or socio-economic subgroup in which the association between physician visits and air pollution was significantly stronger than in any other population subgroup. eco-life-center (ela) in albania supports a holistic approach to justice, recognizing the environ· mental justice, social justice and economic justice depend upon and support each other. low income cit· izens and minorities suffer disproportionately from environmental hazards in the workplace, at home, and in their communities. inadequate laws, lax enforcement of existing environmental regulations, and ~ea.k penalties for infractions undermine environmental protection. in the last decade, the environmental 1ust1ce m~ve~ent in tirana metropolis has provided a framework for identifying and exposing the links ~tween irrational development practices, disproportionate siting of toxic facilities, economic depres· s1on, and a diminished quality of life in low-income communities and communities of color. the envi· ~onmental justice agenda has always been rooted in economic, racial, and social justice. tirana and the issues su.rroun~ing brow~fields redevelopment are crucial points of advocacy and activism for creating ~ubstantia~ social chan~~ m low-income communities and communities of color. we engaging intensively m prevcnnng co'.'1mumnes, especially low income or minority communities, from being coerced by gov· ernmenta~ age_nc1es or companies into siting hazardous materials, or accepting environmentally hazard· ous_ practices m order to create jobs. although environmental regulations do now exist to address the environmental, health, and social impacts of undesirable land uses, these regulations are difficult to poster sessions v65 enforce because many of these sites have been toxic-ridden for many years and investigation and cleanup of these sites can be expensive. removing health risks must be the main priority of all brown fields action plans. environmental health hazards are disproportionately concentrated in low-income communities of color. policy requirements and enforcement mechanisms to safeguard environmental health should be strengthened for all brownfields projects located in these communities. if sites are potentially endangering the health of the community, all efforts should be made for site remediation to be carried out to the highest cleanup standards possible towards the removal of this risk. the assurance of the health of the community should take precedence over any other benefits, economic or otherwise, expected to result from brownfields redevelopment. it's important to require from companies to observe a "good neighbor" policy that includes on-site visitations by a community watchdog committee, and the appointment of a neighborhood environmentalist to their board of directors in accordance with the environmental principles. vancouver 1976-2001 michael buzzelli, jason su, and nhu le this is the second paper of research programme concerned with the geographical patterning of environmental and population health at the urban neighbourhood scale. based on the vancouver metropolitan region, the aim is to better understand the role of neighbourhoods as epidemiological spaces where environmental and social characteristics combine as health processes and outcomes at the community and individual levels. this paper builds a cohort of commensurate neighbourhoods across all six censuses periods from 1976 to 2001, assembles neighbourhood air pollution data (several criterion/health effects pollutants), and providing an analysis to demonstrate how air pollution systematically and consistently maps onto neighbourhood socioeconomic markers, in this case low education and lone-parent families. we conclude with a discussion of how the neighbourhood cohort can be further developed to address emergent priorities in the population and environmental health literatures, namely the need for temporally matched data, a lifecourse approach, and analyses that control for spatial scale effects. solid waste management and environment in mumbai (india) by uttam jakoji sonkamble and bairam paswan abstract: mumbi is the individual financial capital of india. the population of greater mumbai is 3,326,837 and 437 sq. km. area. the density of population 21, 190 per sq. km. the dayto-day administration and rendering of public services within gr. mumbai is provided by the brihan mumbai mahanagar palika (mumbai corporation of gr. mumbai) that is a body of 221 elected councilors on a 5-year team. mumcial corporation provides varies conservancy services such as street sweeping, collection of solid waste, removal and transportation, disposal of solid waste, disposal of dead bodies of animals, construction, maintance and cleaning of urinals and public sanitary conveniences. the solid waste becoming complicated due to increase in unplanned urbanization and industrialization, the environment has deteriorated significantly due to inter, intra and international migration stream to mumbai. the volume of inter state migration to mumbai is considerably high i.e. 20.89 lakh and international migrant 0.77 lakh have migrated to mumbai. present paper gives the view on solid waste management and its implications to environment and health. pollution from a wide varity of emission, such as from automobiles and industrial activities, has reached critical level in mumbai, causing respiratory, ocular, water born diseases and other health problems. sources of generation of waste are -household waste, commercial waste, institutional waste, street sweeping, silt removed from drain/nallah/cleanings. disposal of solid waste in gr. mumbai done under 1 incineration 2. processing to produce organic manure. 3. vermi-composting 4. landfill the study shows that the quantity of waste disposal of through processing and conversion to organic ~anure is about 200-240 m.t. per day. the processing is done by a private agency m/s excel industries ltd. who had set up a plant at the chincholi dumping ground in western mumbai for this purpose. the corporation is also disposal a plant of its waste mainly market waste through the environment friendly, natural pro-ces~ known as vermi-composing about 100 m.t. of market waste is disposed of in this manner at the various sites. there are four land fill sites are available and 95 percent of the waste matter generated m mumbai is disposed of through landfill. continuous flow of migrant and increa~e in slum population is a complex barrier in the solid waste management whenever community pamc1pat1on work strongly than only we can achieved eco-friendly environment in mumbai. persons exposed to residential craffic have elevated races of respiratory morbidity an~ ~ortality. since poverty is an important determinant of ill-health, some h~ve argued that t~es~ assoc1at1ons may relate to che lower socioeconomic status of those living along ma1or roads. our ob1ect1ve was to evaluate the association between traffic intensity at home and hospital admissions for respiratory diagnoses among montreal residents older than 60 years. morning peak traffic estimates from the emmej2 montreal traffic model (motrem98) were used as an indicator of exposure to road traffic outside the homes of those hospitalised. the influence of socioeconomic status on the relationship between traffic intensity and hospital admissions for respiratory diagnoses was explored through assessment of confounding by lodging value, expressed as the dollar average over road segments. this indicator of socioeconomic status, as calculated from the montreal property assessment database, is available at a finer geographic scale than socioeconomic information accessible from the canadian census. there was an inverse relationship between traffic intensity estimates and lodging values for those hospitalised (rho -0.23, p 3160 vehicles during che 3 hour morning peak), even after adjustment for lodging value (crude or 1.35, cl95% 1.22-1.49; adjusted or 1.13, cl95% 1.02-1.25). in montreal, elderly persons living along major roads are at higher risk of being hospitalised for respiratory illnesses, which appears not simply to reflect the fact that those living along major roads are at relative economic disadvantage. the paper argues that human beings ought to be at the centre of the concern for sustainable development. while acknowledging the importance of protecting natural resources and the ecosystem in order to secure long term global sustainability, the paper maintain that the proper starting point in the quest for urban sustainability in africa is the 'brown agenda' to improve che living and working environment of che people, especially che urban poor who face a more immediate environmental threat to their health and well-being. as the un-habitat has rightly observed, it is absolutely essential "to ensure that all people have a sufficient stake in the present to motivate them to take part in the struggle to secure the future for humanity.~ the human development approach calls for rethinking and broadening the narrow technical focus of conventional town planning and urban management in order to incorporate the emerging new ideas and principles of urban health and sustainability. i will examine how cities in sub-saharan africa have developed over the last fifty years; the extent to which government policies and programmes have facilitated or constrained urban growth, and the strategies needed to achieve better functioning, safer and more inclusive cities. in this regard i will explore insights from the united nations conferences of the 1990s, especially local agenda 21 of the rio summit, and the istanbul declaration/habitat agenda, paying particular attention to the principles of enablement, decentralization and partnership canvassed by these movements. also, i will consider the contributions of the various global initiatives especially the cities alliance for cities without slums sponsored by the world bank and other partners; che sustainable cities programme, the global campaigns for good governance and for secure tenure canvassed by unhabit at, the healthy cities programme promoted by who, and so on. the concluding section will reflect on the future of the african city; what form it will take, and how to bring about the changes needed to make the cities healthier, more productive and equitable, and better able to meet people's needs. heather jones-otazo, john clarke, donald cole, and miriam diamond urban areas, as centers of population and resource consumption, have elevated emissions and concentrations of a wide range of chemical contaminants. we have developed a modeling framework in which we first ~stimate the emissions and transport of contaminants in a city and second, use these estimates along with measured contaminant concentrations in food, to estimate the potential health risk posed by these che.micals. the latter is accomplished using risk assessment. we applied our modeling framework to consider two groups of chemical contaminants, polycyclic aromatic hydrocarbons (pah) a.nd the flame re~ardants polybrominated diphenyl ethers (pbde). pah originate from vehicles and stationary combustion sources. ~veral pah are potent carcinogens and some compounds also cause noncancer effects. pbdes are additive flame retardants used in polyurethane foams (e.g., car seats, furniture) 105fer sessions v67 and cl~ equipm~nt (e.g., compute~~· televisio~s). two out of three pbdes formulations are being voluntarily phased by mdustry due to rmng levels m human tissues and their world-wide distribution. pbdes have been .related to adv.erse neurological, developmental and reproductive effects in laboratory ijlimals. we apphed our modelmg framework to the city of toronto where we considered the southcattral area of 21 by 21 km that has a population of 1.3 million. for pah, local vehicle traffic and area sources contribute at least half of total pah in toronto. local contributions to pbdes range from 57-85%, depending on the assumptions made. air concentrations of both compounds are about 10 times higher downtown than 80 km north of toronto. although measured pah concentrations in food date to the 1980s, we estimate that the greatest exposure and contribution to lifetime cancer risk comes from ingestion of infant formula, which is consistent with toxicological evidence. the next greatest exposure and cancer risk are attributable to eating animal products (e.g. milk, eggs, fish). breathing downtown air contributes an additional 10 percent to one's lifetime cancer risk. eating vegetables from a home garden localed downtown contributes negligibly to exposure and risk. for pbdes, the greatest lifetime exposure comes through breast milk (we did not have data for infant formula), followed by ingestion of dust by the toddler and infant. these results suggest strategies to mitigate exposure and health risk. p4-01 (a) immigration and socioeconomic inequalities in cervical cancer screening in toronto, canada aisha lofters, rahim moineddin, maria creatore, mohammad agha, and richard glazier llltroduction: pap smears are recommended for cervical cancer screening from the onset of sexual activity to age 69. socioeconomic and ethnoracial gradients in self-reported cervical cancer screening have been documented in north america but there have been few direct measures of pap smear use among immigrants or other socially disadvantaged groups. our purpose was to investigate whether immigration and socioeconomic factors are related to cervical cancer screening in toronto, canada. methods: pap smears were identified using fee codes and laboratory codes in ontario physician service claims (ohip) for three years starting in 1999 for women age 18-41 and 42-66. all women with any health system contact during the three years were used as the denominator. social and economic factors were derived from the 2001 canadian census for census tracts and divided into quintiles of roughly equal population. recent registrants, over 80% of whom are expected to be recent immigrants to canada, were identified as women who first registered for health coverage in ontario after january 1, 1993. results: among 397,967 women age 18-41 and 328,885 women age 42-66, 55.3% and 55.5%, rtspcctively, had pap smears within three years. low income, low education, recent immigration, visible minority and non-english language were all associated with lower rates (least advantaged quintile:most advantaged quintile rate ratios were 0.84, 0.90, 0.81, 0.85, 0.83, respectively, p < 0.05 for all). similar gradients were found in both age groups. recent registrants comprised 22.5% of women and had mm;h lower pap smear rates than non-recent registrants (37.2 % versus 63. 7% for women age 18-41 and 35.9% versus 58.2% for women age 42-66). conclnsions: pap smear rates in toronto fall well below those dictated by evidence-based practice. at the area level, immigration, visible minority, language and socioeconomic characteristics are associated with pap smear rates. recent registrants, representing a largely immigrant group, have particularly low rates. efforts to improve coverage of cervical cancer screening need to be directed to all ~omen, their providers and the health system but with special emphasis on women who recently arrived m ontario and those with social and economic disadvantage. challeges faced: a) most of the resources are now being ~pent in ~reventing the sprea.d of hiv/ aids and maintaining the lives of those already affected. b) skilled medical ~rs~nal are dymg under· mining the capacity to provide the required health care services. ~) th.e comphcat1o~s of hiv/aids has complicated the treatment of other diseases e.g. tbs d) the ep1dem1c has led. to mcrease number of h n requiring care and support. this has further stretched the resources available for health care. orp a s d db . . i methods used on our research: 1. a simple community survey con ucte y our orgamzat1on vo · unteers in three urban centres members of the community, workers and health care prov~ders were interviewed ... 2. meeting/discussions were organized in hospitals, commun.ity centre a~d with government officials ... 3. written questionnaires to health workers, doctors and pohcy makers m th.e health sectors. lessors learning: • the biggest-health bigger-go towards hiv/aids prevention • aids are spreading faster in those families which are poor and without education. •women are the most affected. •all health facilities are usually overcrowded with hiv/aids patients. actions needed:• community education oh how to prevent the spread of hiv/aids • hiv/aids testing need to be encouraged to detect early infections for proper medical cover. • people to eat healthy • people should avoid drugs. implications of our research: community members and civic society-introduction of home based care programs to take care of the sick who cannot get a space in the overcrowded public hospitals. prl-v a te sector private sector has established programs to support and care for the staff already affected. government provision of support to care-givers, in terms of resources and finances. training more health workers. introduction: australian prisons contain in excess of 23,000 prisoners. as in most other western countries, reliance on 'deprivation of liberty' is increasing. prisoner numbers are increasing at 7% per annum; incarceration of women has doubled in the last ten years. the impacts on the community are great -4% of children have a parent in custody before their 16th birthday. for aboriginal communities, the harm is greater -aboriginal and/or torres strait islanders are incarcerated at a rate ten times higher than other australians. 25% of their children have a parent in custody before their 16th birthday. australian prisons operate under state and territory jurisdictions, there being no federal prison system. eight independent health systems, supporting the eight custodial systems, have evolved. this variability provides an unique opportunity to assess the capacity of these health providers in addressing the very high service needs of prisoners. results: five models of health service provision are identified -four of which operate in one form or another in australia: • provided by the custodial authority (queensland and western australia)• pro· vided by the health ministry through a secondary agent (south australia, the australian capital territory and tasmania) • provided through tendered contract by a private organization (victoria and northern territory) • provided by an independent health authority (new south wales) • (provided by medics as an integral component of the custodial enterprise) since 1991 the model of the independent health authority has developed in new south wales. the health needs of the prisoner population have been quantified, and attempts are being made to quantify specific health risks /benefits of incarceration. specific enquiry has been conducted into prisoner attitudes to their health care, including issues such as client information confidentiality and access to health services. specific reference will be made to: • two inmate health surveys • two inmate access surveys, and • two service demand studies. conclusions: the model of care provision, with legislative, ethical, funding and operational independence would seem provide the best opportunity to define and then respond to the health needs of prisoners. this model is being adopted in the united kingdom. better health outcomes in this high-risk group, could translate into healthier families and their communities. p4-04 (a) lnregrated ethnic-specific health care systems: their development and role in increasing access to and quality of care for marginalized ethnic minorities joshua yang introduction: changing demographics in urban areas globally have resulted in urban health systems that are racially and ethnically homogenous relative to the patient populations they aim to serve. the resultant disparities in access to and quality of health care experienced by ethnic minority groups have been addressed by short-term, instirutional level strategies. noticeably absent, however, have been structural approaches to reducing culturally-rooted disparities in health care. the development of ethnic-specific h~alth car~ systems i~ a structural, long-term approach to reducing barriers to quality health care for eth· me mmonty populations. methods: this work is based on a qualitative study on the health care experiences of san francisco chinatown in the united states, an ethnic community with a model ethnic-specific health care infrastrucrure. using snowball sampling, interviews were conducted with key stakeholders and archival research was conducted to trace and model the developmental process that led to the current ethnic-specific health care system available to the chinese in san francisco. grounded theory was the methodology ijltd to analysis of qualitative data. the result of the study is four-stage developmental model of ethnic-specific health infrastrueture development that emerged from the data. the first stage of development is the creation of the human capital resources needed for an ethnic-specific health infrastructure, with emphasis on a bilingual and bicultural health care workforce. the second stage is the effective organization of health care resources for maximal access by constituents. the third is the strengthening and stability of those institutional forms through increased organizational capacity. integration of the ethnic-specific health care system into the mainstream health care infrastructure is the final stage of development for an ethnic-specific infrastructure. conclusion: integrated ethnic-specific health care systems are an effective, long-term strategy to address the linguistic and cultural barriers that are being faced by the spectrum of ethnic populations in urban areas, acting as culturally appropriate points of access to the mainstream health care system. the model presented is a roadmap to empower ethnic communities to act on the constraints of their health and political environments to improve their health care experiences. at a policy level, ethnic-specific health care organizations are an effective long-term strategy to increase access to care and improve qualiiy of care for marginalized ethnic groups. each stage of the model serves as a target area for policy interventions to address the access and care issues faced by culturally and linguistically diverse populations. users in baltimore md: 1989-2004 noya galai, gregory lucas, peter o'driscoll, david celentano, david vlahov, gregory kirk, and shruti mehta introduction: frequent use of emergency rooms (er) and hospitalizations among injection drug users (idus) has been reported and has often been attributed to lack of access to primary health care. however, there is little longitudinal data which examine health care utilization over individual drug use careers. we examined factors associated with hospitalizations, er and outpatient (op) visits among idus over 14 years of follow-up. methods: idus were recruited through community outreach into the aids link to lntravenous experience (alive) study and followed semi-annually. 2,551 who had at least 2 follow-up visits were included in this analysis. outcomes were self-reported episodes of hospitalizations and er/op visits in the prior six months. poisson regression was used accounting for intra-person correlation with generalized estimation equations. hits: at enrollment, 73% were male, 95% were african-american, 33% were hiv positive, median age was 35 years, and median duration of drug use was 15 years. over a total of 37,512 visits, mean individual rates of utilization were 11 per 100 person years (py) for hospitalizations and 123 per 100 py for er/op visits. adjusting for age and duration of drug use, factors significantly associated with higher rates of hospitalization included hiv infection (relative incidence [ri(, 1.4), female gender (ri, 1.2), homelessness (ri, 1.6), as well as not being employed, injecting at least daily, snorting heroin, havmg a regular source of health care, having health insurance and being in methadone mainte.nance treatment (mmt). similar associations were observed for er/op visits except for mmt which was not associated with er/op visits. additional factors associated with lower er/op visits were use of alcohol, crack, injecting at least daily and trading sex for drugs. 10% of the cohort accounted for 45% of total er/op visits, while 11 % of the cohort never reported an op visit during follow-up. . . . lgbt) populations. we hypothesized that prov1dmg .appomtments .for p~t1~nts w1thm 24 hours would ensure timely care, increase patient satisfaction, and improve practice eff1c1ency. further, we anticipated that the greatest change would occur amongst our homeless patients.. . methods: we tested an experimental introduction of advanced access scheduling (usmg a 24 hour rule) in the primary care medical clinic. we tracked variables inclu~ing waiting ti~e fo~ next available appointment; number of patients seen; and no-show rates, for an eight week penod pnor to and post introduction of the new scheduling system. both patient and provider satisfaction were assessed using a brief survey (2 questions rated on a 5-pt scale). results and conclusion: preliminary analyses demonstrated shorter waiting times for appointments across the clinic, decreased no-show rates, and increased clinic capacity. introduction of the advanced access scheduling also increased both patient and provider satisfaction. the new scheduling was initiated in july 2005. quantitative analyses to measure initial and sustained changes, and to look at differential responses across populations within our clinic, are currently underway. introduction: there are three recognized approaches to linking socio-economic factors and health: use of census data, gis-based measures of accessibility/availability, and resident self-reported opinion on neighborhood conditions. this research project is primarily concerned with residents' views about their neighborhoods, identifying problems, and proposing policy changes to address them. the other two techniques will be used in future research to build a more comprehensive image of neighborhood depri· vation and health. methods: a telephone survey of 658 london, ontario residents is currently being conducted to assess: a) community resource availability, quality, access and use, b) participation in neighborhood activities, c) perceived quality of neighborhood, d) neighborhood problems, and e) neighborhood cohesion. the survey instrument is composed of indices and scales previously validated and adapted to reflect london specifically. thirty city planning districts are used to define neighborhoods. the sample size for each neighborhood reflects the size of the planning district. responses will be compared within and across neighborhoods. data will be linked with census information to study variation across socio-eco· nomic and demographic groups. linear and gis-based methods will be used for analysis. preliminary results: the survey follows a qualitative study providing a first look at how experts involved in community resource planning and administration and city residents perceive the availability, accessibility, and quality of community resources linked to neighborhood health and wellbeing, and what are the most immediate needs that should be addressed. key-informant interviews and focus groups were used. the survey was pre-tested to ensure that the language and content reflects real experiences of city residents. the qualitative research confirmed our hypothesis that planning districts are an acceptable surrogate for neighborhood, and that the language and content of the survey is appropriate for imple· mentation in london. scales and indices showed good to excellent reliability and validity during the pre· test (cronbach's alpha from 0.57-0.96). preliminary results of the survey will be detailed at the conference. conclusions: this study will help assess where community resources are lacking or need improve· ment, thus contributing to a more effective allocation of public funds. it is also hypothesized that engaged neighborhoods with a well-developed sense of community are more likely to respond to health programs and interventions. it is hoped that this study will allow london residents to better understand the needs and problems of their neighborhoods and provide a research foundation to support local understandmg of community improvement with the goal of promoting healthy neighborhoods. p4-08 (a) hiv positive in new york city and no outpatient care: who and why? hannah wolfe and victoria sharp introduction: there are approximately 1 million hiv positive individuals living in the united sta!es. about. 50% of these know their hiy status and are enrolled in outpatient care. of the remaining 50 yo, approx~mately half do not know their status; the other group frequently know their status but are not enrolled m any .sys~em of outpatient care. this group primarily accesses care through emergency departments. when md1cated, they are admitted to hospitals, receive acute care services and then, upon poster sessions v71 di5'harge, disappear from the health care system until a new crisis occurs, when they return to the emergency department. as a large urban hiv center, caring for over 3000 individuals with hiv we have an active inpatient service ".'ith appr~xi~.ately 1800 discharges annually. we decided to survey our inpatients to better charactenze those md1v1duals who were not enrolled in any system of outpatient care. results: 18% of inpatients were not enrolled in regular outpatient care: 2% at roosevelt hospital and 35% at st.luke\'s hospital. substance abuse and homelessness were highly prevalent in the cohort of patients not enrolled in regular outpatient care. 84% of patients not in care (vs. 33% of those in care) were deemed in need of substance use treatment by the inpatient social worker. 74% of those not in care were homeless (vs. 15% of those in care.) patients not in care did not differ significantly from those in me in terms of age, race, or gender. patients not in care were asked "why not:" the two most frequent responses were: "i haven't really been sick before" and "i'd rather not think about my health. conclusions: this study suggests that there is an opportunity to engage these patients during their stay on the inpatient units and attempt to enroll them in outpatient care. simple referral to an hiv clinic is insufficient, particularly given the burden of homelessness and substance use in this population. efforts are currently underway to design an intervention to focus efforts on this group of patients. p4.q9 (a) healthcare availability and accessibility in an urban area: the case of ibadan city, nigeria in oder to cater for the healthcare need of the populace, for many years after nigeria's politicl independence, empphasis was laid on the construction of teaching, general, and specialist hospital all of which were located in the urban centres. the realisation of the inadequacies of this approach in adequately meeting the healthcare needs of the people made the country to change and adopt the primary health care (phc) system in 1986. the primary health care system which is in line with the alma ata declaration of of 1978, wsa aimed at making health care available to as many people as possible on the basis of of equity and social justice. thus, close to two decades, nigeria has operated primary health care system as a strategy for providing health care for rural and urban dwellers. this study focusing on urban area, examimes the availabilty and accessibility of health care in one of nigeria's urban centre, ibadan city to be specific. this is done within the contest of the country's national heath policy of which pimary health care is the main thrust. the study also offers necessary suggestion for policy consideration. in spite of the accessibility to services provided by educated and trained midwifes in many parts of fars province (iran) there are still some deliveries conducted by untrained traditional birth attendants in rural parts of the province. as a result, a considerable proportion of deliveries are conducted under a higher risk due to unauthorised and uneducated attendants. this study has conducted to reveal the pro· portion of deliveries with un-authorized attendants and some spatial and social factors affecting the selection of delivery attendants. method: this study using a case control design compared some potentially effective parameters indud· ing: spatial, social and educational factors of mothers with deliveries attended by traditional midwifes (n=244) with those assisted by educated and trained midwifes (n=258). the mothers interviewed in our study were selected from rural areas using a cluster sampling method considering each village as a cluster. results: more than 11 % of deliveries in the rural area were assisted by traditional midwifes. there are significant direct relationship between asking a traditional birth attendant for delivery and mother age, the number of previous deliveries and distance to a health facility provided for delivery. significant inverse relationships were found between mother's education and ability to use a vehicle to get to the facilities. conclusion: despite the accessibility of mothers to educated birth attendants and health facilities (according to the government health standards), some mothers still tend to ask traditional birth attendants for help. this is partly because of unrealistic definition of accessibility. the other considerable point is the preference of the traditional attendants for older and less educated mothers showing the necessity of changing theirs knowledge and attitude to understand the risks of deliveries attended by traditional and un-educated midwifes. p4-12 (a) identification and optimization of service patterns provided by assertive community treatment teams in a major urban setting: preliminary findings &om toronto, canada jonathan weyman, peter gozdyra, margaret gehrs, daniela sota, and richard glazier objective: assertive community treatment (act) teams are financed by the ontario ministry of health and long-term care (mohltc) and are mandated to provide treatment, rehabilitation and support services in the community to people with severe and persistent mental illness. there are 13 such teams located in various regions across the city of toronto conducting home visits 1-5 times per week to each of their approximately 80 respective clients. each team consists of multidisciplinary health professionals who assist clients to identify their needs, establish goals and work toward them. due to complex referral patterns, the need for service continuity and the locations of supportive housing, clients of any one team are often found scattered across the city which increases home visit travel times and decreases efficiency of service provision. this project examines the locations of clients in relation to the home bases of all 13 act teams and identifies options for overcoming the geographical challenges which arise in a large urban setting. methods: using geographic information systems (gis) we geocoded all client and act agency addresses and depicted them on location maps. at a later stage using spatial methods of network analysis we plan to calculate average travel rimes for each act team, propose optimization of catchment areas and assess potential travel time savings. resnlts: initial results show a substantial scattering of clients from several act teams and substan· rial overlap of visit travel routes for most teams. conclusions: reallocation of catchment areas and optimization of act teams' travel patterns should lead to substantial savings in travel times, increased service efficiency and better utilization of resourc_~· ~e l'<!tenri~i modifications to catchment areas must be conducted with appropriate attention to specific clients servtce needs, service continuity and applicable regulations by the mohl tc. venice lido is a popular island within and outside italy because it hosts the international cinema festival yearly. only few people remember the island for its hospital, which, in the fifties, was one of the most important hospitals in italy and in europe, being a modern center for wind-, sun-and thermal-therapy. since the sixties, its fame became to drop away, since its structure was no longer adequate for the evolving medicine science. at the end of the seventies all the wards were moved into a new big building in the same area. at present the hospital is made up by about forty 'pavilions' (mostly partially used or empty) and a big building, disseminated in a 10 hectares area, on the sea front, on the 500 m long beach. the aim of my research is to suggest a realistic solution, sustainable on the functional use of the area according to basic local needs and economically realizable. i used a philological and multi-disciplinary method, more in detail: -from historical documents, i found what was the very first call of the property and how it adapted to the needs of the demographic development and the sanitary supply over time; -by contacting some operators from different fields, i realized which functions were suitable to the buildings in existence, to the population's needs and to the present sanitary supply. moreover the planning idea considers: -the debate going on between local people who strongly want to preserve the property, and die ones who want to renew it by different new opportunities; and -the regional sanitary politics, aiming at rationalizing the regional hospitals dislocation, and the budget needs. this plan analyzes and proposes some new alternative solutions to satisfy different needs. the different activities will be dealt out and the environmental fall will be limited as much as possible. after having analyzed its basic call, considered its environmental peculiarities and its position, verified the emerging needs of the local population, the plan proposes 5 different activities: the hospital; the social-rehabilitation center; the elderly house; the thermal center; the residential center; and other activities. such a plan wants to share in the solution of a basic problem by giving architectonic and functional dignity to an historical completely degraded area and by starting again a social-economical broken off process, by bringing in venice lido some fresh necessary elements for its so wished new throw. p4-14 (c) dilemma of free health care in spokane, wa david bunting introduction: the paper reports on the activities of project access spokane [pas], a physician sponsored initiative to provide uncompensated health care to low income, uninsured residents of spokane county wa. program providers included all county hospitals, over 600 physicians, other medical professionals, and specialized clinics. each prescription requires only a $4 co-payment. sponsored and administered by the county medical society, pas is funded by local and national foundations, private corporations, municipalities, civic organizations and individuals. method: the paper is based on a first year assessment report funded by pas, using hcfa [health care financing administration] insurance claim data documenting utilization rates, disease categories and donated charge information and patient cares [centralized applications, referrals and enrollment status) data. results: while essentially free for enrollees, the program involved real costs. an administrative organization to refer over 700 patients to any of over 800 providers had to be developed and staffed, using both paid and unpaid personnel. methods to identify potential patients and veri.fy eligibility. had to ~devised. patient appointments and transportation had to be scheduled and monitored. pu~hc relanons, provider solicitations and fundraising activities were continuous. information requirements regarding program operation were also significant. data reporting the volume. ~nd value of dona~ed medical services were necessary to demonstrate accomplishments and attr~ct addmon~l support. providers required assurances their contributions were both significant and eqmtable. funding sources sought evidence that their support had important consequences. however, generating this ~~ta proved difficult. many providers failed to submit appropriate insurance claims forms because .of a~dmonal donated effort and administrative cost, thereby not only reducing their own apparent conmbut1ons but also the overall significance of the program. conclusions: during its initial year, the estimated cost to deliver free health care was ~bout 5500 per enrollee. the lesson is that without an elaborate administrative structure and record keeping s.yst~~· efforts to provide free health care probably will fail. eligible enrollees c~n not be ~parated from in~hgi ble ones, care will not be accessed or delivered in an efficient manner, neither fundmg nor ~upport "". 1 11 be offered without evidence of tangible benefits, and providers will withdraw if they perceive mequ1table tteannent. v74 p4-1s (c) mobility in prostitution and the impact of health therese van der helm and henk sulman poster sessions introduction: many of the estimated 8.000 commer~ial ~ex wor~ers (c~w)in a'.'1~terdam ~~me from developing countries and eastern europe. to gain ins~ght mto their workmg and_ hvmg condinons the intermediary project (ip) at the municipal health serv1~e _contacts these women via ?utreach work on regular basis. since the new brothel law in october 2000 1s 1~troduc~d, ~sw ~rom outside the eu and who have no dutch residence permit are not allowed to work m prost1tut10n. smee then, many of these csw therefore have gone "underground." the consequences of the new law in the netherlands will be discussed with regard to the accessibility of csw and their risk for stl/hiv acquisition and unplanned pregnancies. methods: topics during outreach work are the interventions to increase the knowledge of safe sex and birth control for csw. written information is handed out in relevant languages and with addresses of health and social services. in conversations with the women, it appeared that many are not aware of these services. to provide easier access to health care for women, staff of the ip carries out free sti control csw working places, in windows brothels and sex houses. also, women are offered vaccination against hepatitis b (hbv). results: from january 2004 till july 2005 we approached 900 csw for first contact. one third was dutch; others were from developing countries, other eu countries and eastern europe. 350 sti consul· rations were done among non-iv drug using sex workers, of whom 50 % was dutch. of these, 2 % was diagnosed with syphilis, 1 % with gonorrhea, and 9% with chlamydia. of 234 women tested for hiv, none were infected. due to the high turnover of csw in .brothels, most wnmen were tested only once. among 845 csw tested for hbv -of whom one third is dutch -22 % had antibodies for hbv, 12 were carrier of hbv, most of whom came from hbv endemic areas. conclusions: sti control and hbv vaccination in brothels is an important support in health care. our findings suggest that csw do not play an important role in the transmission of sti. many csw are highly mobile and often not aware of the existing health and social services. continuous outreach is important to remain in contact with this mobile population. regulations in the new brothel law should not hamper contacts with (illegal) csw. heart disease (cho) is projected to become the leading cause of death. studies conducted in europe and the united states have proven a higher rate of cho in south asians who have migrated from south asia, most notably india, pakistan and bangladesh. approximately 50% of all heart attacks among south asian men occur under the age of 55; 25% of them occur under the age of 40-unheard of in any other population. associated risk factors such as diabetes, high blood pressure and cholesterol are also com· mon in this group. the population of south asians residing in nyc has more than doubled over the past decade to over 300,000, the majority being young, working-class and with limited health care access. many south asian men are employed as taxi drivers (4 out of 10 nyc taxi drivers are from south asial, working daily12 hour plus shifts. methods: acknowledging that this vulnerable, at-risk group was unavailable for outreach through conventional venues, three of the hospitals of the new york city health and hospital corporation, (elmhurst, queens and bellevue) conducted a one day outreach effort at nyc's jfk international air· ~rt's taxi holdin~ ar~a, ~here over one thousand taxis regularly assemble. bringing an outreach event directly to the taxi dnvers workplace, a tent was set up where cardiovascular-related health screenings, in~luding bl~ pressure, sugar, cholesterol, body mass index (bmi), were provided. results were shared with and explamed to the drivers and each participant received a south asian health education brochure. a total of 84 taxi drivers who identified as south asian were involved. rau/ts: participants were all male, ranging from 20 to 61 years; mean age, 41.5. screenings revealed 57% hypertensive; 46% had cholesterols over 200; 26% blood glucose over 160; 91 % had a bmi greater than 25. conc~on: a unique outreach activity, adapting to logistical, occupational limitations, is pre· se~ted. on-site f~back and explanation of results, reiterating and reinforcing the concern that south asia~. men are at mcreased danger for early coronary heart disease, and the dissemination of a culturally sensmve and r~levant brochure, may heighten awareness of prevailing cardiac risk factors in this immi· grant community. p4-17 (c) the community-hospital integration program framework: community-hospital panoenhips to improve the population's health john stevenson, richard blickstead, ann-marie marcolin, and sandi kendal v75 introduction: st. josephs health centre is a catholic community teaching hospital located in the heart of southwest toronto. st. joseph\'s was founded from a community-expressed need for hospital services, and since then has stayed committed to fostering a healthy community through collaboration and parmership. st. joseph's has developed an innovative model, the community-hospital integration program (chip), to strengthen st. joseph's partnerships with community stakeholders, and facilitates the building of links between community needs, service provision, and public policy outcomes to improve the health and wellness of the diverse neighbourhoods they together serve. methods: development of the chip framework st. joseph's health centre developed the chip framework through a multidisciplinary approach that included extensive international literature reviews, consultations, and key informant interviews with community service agencies and academics. to ensure active community voice, st. joseph's has hosted a number of community consultations including a community outreach forum attended by over ninety representatives from 68 community partners. results: the chip framework the chip framework aims to improve the health and wellness of the urban communities served by st. josephs health centre through four intersecting pillars: • raising community voices provides an infrastructure and process that supports community stakeholder input into health care service planning, decision-making, and delivery by the hospital and across the continuum of care; • sharing reciprocal capacity promotes healthy communities through the sharing of our intellectual and physical capacity with our community partners; • cultivating integration initiatives facilitates vertical, horizontal, and intersectoral integration initiatives in support of community-identified needs and gaps; and • facilitating healthy exchange develops best practices in community integration through community-based research, and facilitates community voice in informing public policy. the chip framework drives the complex inter-relationships between community-hospital engagement, reciprocal capacity-building, integration initiatives, and community-based research and evaluation, to create an interconnected network of health care services. the fluidity and simplicity of this framework, and its dedication to balancing community needs and hospital mandate, posits the st. josephs health centre's chip model as an integral component in building healthy and thriving communities. p4-18 (c) home based care promotion: improving acess to quality services and livelihood in the face of aids home based care is a service provided to persons affected/living with hiv/aids, a menu of care/support services at home/community. it is a prominent alternative approach. in uganda, hospital bed ocupacny is high, patient health care worker ratio deteriorating. empowering communities offers solutions to the problems; adressing cost, effectiveness of care. hiv/aids demands changes in attitudes, behaviour, approaches which is enhanced in home/community settings. for example art requires high levels of adherecnce, which medical workers have vety little opportunity to enforce. it also demands other support mechanisims in terms of nutrition, personal displine, etc which work best in stigma free environments. hence the relevance of home based care. this paper highlights the gaps that call for increased action in terms of home based care, examples of whre it has worked key challenges and recommendations for the future. p4-19 (c) health care for one ... health care for alli katharina kovacs burns introduction: at the surface, it appears that every person in canada _has. ~ccess to a publicly funded health care system. those living in urban centers should have the best ava1l~b1hty, chmce, and access to a variety of health care services because of the distribution of health care services, fac1lmes, and health professionals in concentrated in urban centers. this is not true for everyone -people with low income or who are homeless experience the challenges of social exclusion and being marginalized: there are many factors at play making it difficult for the latter group of people to access health care. service they need,.when they need them. health care is not as accessible or inclusive as intended. the quesuon to be explore.cl 1~: if health care is available and accessible to one person, what makes it not available to all people? the ~1gmfic~nce of having marginalized people accessing health care and other services includes e~hanced quality of hfe and decreased risks associated with being homeless, and cost savings in ion~ ter~ w1rh acute health care. methodology: community-based participatory research is applied m a case study on health care access and challenges experienced by low income and homeless people in one urban centre, edmonton, edmonton, and their challenges. the data is being gathered and ana_lyzed usmg basic m1x~d methods. results: the results will focus on how services can be more mtegrated and accessible to all people with low income and who are homeless. there will also be discussion about specific perceptions of not only the service providers but also of people with low income an~ who are homeless~ and vario~s decision makers. the results will be compared to the literature regardmg health care services access mother urban centers in canada and elsewhere. conclusions: recommendations will need to address social exclusion and other factors which can make health care and other services more available to all people in the community. the implications for health care will also be discussed. additional information will be gathered in the next phases of the study to develop a community services access model. p4-20 (c) availability and access exemplified: a case study beth hayhoe and ruth ewert introduction: access to health care in canada requires either the correct documentation or money. street youth have neither. in addition, health services in canada are designed by adults for adults. youth in general are often wary of having trust in adults with respect to their health concerns and frequently feel misunderstood. street youth are even more mistrustful of adults and public organizations, making their contact with health care professionals minimal. this combined with their risky behaviours and dangerous environment creates a population at risk for numerous health issues but with no place to have them investi· gated. at our non-government, not for profit health service designed specifically to provide a broad range of health care to street youth, professional services are provided almost entirely by volunteers. methods: using a retrospective analysis of the 11 years of data gathered from this organization and reviewing the initial reasons gathered from youth about their needs, the success of the health centre was examined. results: all the things youth had listed as being important in a health centre have been implemented, and even more things have been added to improve the breadth and quality of services offered. the use of the health centre has increased by more than six times since its opening in 1994. in addition, tens of thousands of visits have been paid to the health centre, costing the government and taxpayers nothing. as far as we know there is nothing else in canada that offers so many diverse and innovative services to youth in need. conclusion: it is clear from this case, that health care targeted at the needs of specific disadvan· taged populations can successfully provide them with appropriate health care. a model of accessible health care for marginalized populations can easily be developed for high impact and low cost from this successful case. toronto is one of the most ethno-racially diverse cities in the world of the estimated 2,529,280 toronto residents, 24% (597,218) live in scarborough population growth in scarborough is faster than toronto. scarborough's population increased by 6% from 1996 to 2001 while toronto increased only by 4%. toronto's population is projected to increase by 10% (252 000) in 2011 while scarbor· ough's will increase by 12%. (census canada 2001) low income, pove;ty, seniors, hidden homeless, new~omers to canada, the uninsured, are just a few of the issues concerning health care in our community. health care needs in scarborough are greatly impacted by diversity of ethnic and racial groups, poverty and settlement issues. this paper will share how the scarborough hospital (tsh) an urb~n communir_y hospital cares f~~ it~ community. tsh recognizes: •the changing community• b_arriers t~ accessing care • lnequalmes m health care the hospital in caring for its community pro· v1~es services that '!'e~e cu~turally, racially, and linguistically sensitive to our community. the paper will share the hospitals unique program on access and equity. the paper will share the needs in scar· borough and tsh's response to these needs: working in partnership with the local health committee, i:ne scarborough homeless co.mminee, the scarborough network of immigrant services organiza· nons a~d others. 1:'1e paper will also share the many initiatives this urban community hospital has taken viz. community and home programs in service areas such as mental health, haemodialysis day care, t~~ home oxyg~n program, the palliative at-home program, and above all support for the volunteer clinic for the uninsured. j"'"1tllu:lion: in canada's universal health care system it is generally assumed that everyone has equal access to health care. however, some immigrant groups in canada have historically been uninswed. these groups include failed refugee claimants, those overstaying their visas, and new immigrants in transition who are waiting to become eligible for health insurance. some estimates have suggested that at the present time there may be as many as one hundred thousand undocumented and thus uninsured immigrants in toronto alone. understandably, information on the characteristics of this marginalized population is very limited, since undocumented immigrants tend to have little contact with formal institutions. knowledge of the demographic characteristics of this population may aid in the development of health and social programs to better identify and meet the needs of undocumented immigrants in toronto. we conducted a review of all undocumented, uninsured patients, 15 years of age or older at access alliance multicultural community health centre (aamchc) between 1994 and 2004. demographic information such as age, gender, preferred language, length of time living in canada, selfreported education level and household income were recorded. rmdts: 72% of all adult patients at access alliance were undocumented and uninsured. 80% were under40years of age (with a median age of 30 years), 72% were women and only 19% spoke english. this group lived in canada for an average period of 2.2 years before they were first seen at aamchc. 74% of undocumented clients reported having completed at least a secondary or post-secondary education. 81% had self-reported household incomes of less than 20,000$/year, while 97% of households reported earning less than $30,000/year. the mean income per person in an average household was 425$/month. conchuions: uninsured individuals at aamchc were predominantly young females with limited knowledge of the english language. despite having attained a high level of education most were living well below the poverty line. recognition of these characteristics may assist in the development of health and social programs that are better adapted to meet the needs of undocumented immigrants. p4-23 (c) sharing expertise: a role for the hospital lactation consultant in the community. badrgrmuul: st. michael's hospital is a tertiary care hospital that serves a large inner city population in downtown toronto. in order to provide care to this population, the hospital has developed a number of unique outreach roles. one such role was developed to work with pregnant and breastfeeding women living in regent park, a social housing complex located near the hospital. the population of regent park includes new immigrants, refugees and the socially disadvantaged. approach: the outreach lactation consultant provides care, as part of the canada prenatal nutrition program, in the community prenatally, in the hospital during their inpatient stay and postnatally when they return to the community. the continuity of care enhances the probability of long term successful breastfeeding. aside from the health benefits of breastmilk, breastfeeding is especially important for women who are financially needy and must depend on food banks for formula. . . lason learned: aher two years of partnership, the relationship between the an-hospital ~stpar tum experience for breastfeeding mothers and the community postpartum support, the breastfeeding rate ~thin this community is high. the professional support and visibility of the 1:8ctation consultant, both m the hospital and in the community, contributes to the support of breastfee~m~.. . in light of ongoing funding constraints, this ha1son between hospital and community could be at risk and discontinued. in light of the benefits to the mother/baby dyad, the lactation consultant as a community partner in the canada prenatal nutrition program should be safeguarded. . lldpodiu:tion: although the importance of adequate health care in pregna~cy is well recognised, ethnic disparities in utilization of prenatal care still exist in many western coun~~es. a fun~amental factor in these disparities may be language proficiency, as it influences women's ab1hty. to ob~m and understand health information, to find the way in the health care system and to communicate with health care v78 poster sessions providers. we investigated the role of language proficiency in use and knowledge of folic acid as aspect of prenatal care in an urban multi-ethnic pregnancy c?hort. . . design: prospective cohort study. setting and parnc1pants: amsterdam ~regnant women attending obstetric care providers for their first antenatal visit (n= 8050). country of birth defined ethnicity: the netherlands, surinam, antilles, turkey, morocco, ghana, other non-~est~m (nw) and other western (w) country. main outcome measures: knowledge about and use of.fohc a~d (fa) supplements in pregnancy, and determinants of these in diffe~~t ethnic ~~ups. deterrrunants mcl~ded age, ed~ tion, parity, pregnancy intention and dutch prof1c1ency. stansncs: ~2 to co~p~re e~c groups, stranfied logistic regression (forward stepwise method) to explore determmants "'.'thm ethmc groups .. use of fa supplements was significantly lower among ghanaian, moroccan, turkish and other nw women (21%to41 %) than among dutch (86%) or other w women (78%). use amongsurinames and antillean women was intermediate (51%and60%). ethnic differences in fa knowledge were similar. knowledge was the strongest determinant of use in all ethnic groups, with odds ratios (ors) ranging from 10.9 to 42.0. language proficiency was the strongest determi~a~t of kno~ledge in ethnic groups with a mother tongue different from dutch (ors good vs. low proficiency ranging from 3.2 ro 16.0). educational level had a modifying role, as shown by an interaction effect between education and language proficiency in the nw group. here, the odds of having fa knowledge given a high education and good dutch proficiency was 20 times the odds given a good proficiency but low education. conclusions: appropriate periconceptional use of folic acid supplements in non-western ethnic groups is low, reflecting an absence of knowledge that is largely determined by the inability to speak and understand the language of the habitual country. tailored interventions using communication channels most likely to address (pregnant) women from ethnic minority groups are necessary. apan from specific interventions, our results are in support of strong incentives on language education despite current political debate. introduction: recent research suggests living in an economically disadvantaged neighborhood is asso· ciated with decreased likelihood of undergoing mammography and increased risk of late-stage breast can· cer diagnosis. long distances and travel times to facilities offering low-or no-cost mammography may be imponant barriers to adherence to mammography screening recommendations for residents of economically disadvantaged neighborhoods. the purpose of this study was to examine whether facilities providing low-and no-cost screening mammography were less spatially accessible in low-income neighborhoods in chicago, and the extent to which the relationship between neighborhood income and the spatial accessibility of facilities varied by the proponion of african-american residents in the neighborhood. methods: the sample consisted of 343 chicago neighborhoods. for each neighborhood, we con· structed three measures of the spatial accessibility of facilities: street network distance to the nearest facility, public transportation travel time to the nearest facility, and shortest automobile travel time to a facility. using 2000 decennial census data, we characterized the neighborhoods according to proportion of residents with incomes below the poverty line, proportion of residents in each of four raciavethnic groups (african-american, latino, white, and other), and population density. we used ordinary least squares (ols) and spatial exogenous lag regression to examine relationships. model 1 estimated the relationship between neighborhood poverty and the spatial accessibility of facilities, adjusting for raciaveth· nic composition and population density. model 2 added a multiplicative interaction term between neighborhood poverty and african-american. restllts: we identified deven facilities that provided low-or no-cost screening mammography to chicago residents in 2004. we found that the distance and travel times via automobile and public trans· portation to facilities generally decreased as neighborhood poveny increased. however, we also found that the ~egative associations between neighborhood poverty and two of the spatial accessibility mea· sures -distance and public transportation travel time -were less strong in neighborhoods with the highest proponions of african-american residents. among neighborhoods in the highest tertile for poveny, th~ mean distance and mean public transportation travel time to facilities were over twice as long in neighborhoods in the highest tertile than in those in the lowest tenile of african-american residents. . ~ persistent socioeconomic and racial/ethnic disparities in breast cancer stage at diagno-s11 ~nd su~1val suggest that ensuring an equitable distribution of affordable mammography is a worth-w~e policy .goal. the ~~dy sugges~ that ~ture investigations should consider both neighborhood soc1oecono1d1c charactensbes and rac1avethmc composition when examining the spatial distribution of health resources. , 2004) . epidemiological data suggest tha~ hiv prevalence among msm is over 1 % in some metropolitan cities, such .as beijing (ibid.). due to widespread homophobia in chinese society, however, this population remains invisible within current health/social services. lack of research on sexuality, specifically homosexuality, has impaired our understanding of health and health practices of chinese msm. focusing on the illness experiences of chinese msm with hiv/aids, this paper explores the socio-cultural impacts of hiv/ aids on this group. the data used for this paper were collected through semi-constructed in-depth face-toiace interviews with 21 adult plwhas (including 11 msm) in beijing, china. with the permission of the participants, the interviews were audio-taped or recorded in notes. the transcribed interviews and interview notes were analyzed by using n-vivo, a software program for qualitative data analysis. this phenomenological study aimed to understand the experiences chinese plwhas (including msm) from their own perspectives. results: it is found that the illness experiences of chinese msm with hiv/aids are profoundly shaped by the socio-cultural meanings of homosexuality, which are further complicated by the dominant discourses on hiv/aids in china. at a macro level, homophobia in the larger society has decreased the capability of this group to respond to this epidemic in a more efficient way. at a meso level, aids-phobia within the chinese msm circuits has prevented this group from openly confronting this disease and offering support to those who are already affected by it. at a micro level, however, these hiv-infected/ affected msm have tried their best to locate spaces to live and to construct hope for their future lives despite various barriers within family, community, and the larger society. this study suggests that facilitating chinese msm's response to the aids crisis urgently requires bridging awareness, commitment, knowledge and resources both within and without this group. it also illustrates the importance of understanding homosexuality in the local context of hiv i aids, which will be helpful for developing culturally sensitive hiv/aids programs for this population on the community, national and international levels. introduction: having a regular family doctor (rfd) is known to be positively correlated with a good medical follow up, including access to preventive and/or chronic care. inversely, a lack of primary care may lead to high rates of avoidable hospitalizations, especially among poor people and/or in underserved neighbourhoods. in such a matter, a recent comparative study showed that paris was better ranged than other cities, such as nyc, tokyo or london. nevertheless, despite a quasi universal health insurance and a high density of general practitioners, a noticeable fraction of the paris population does not have any regular physician and we aimed to understand who they are and for what reasons rhey don't have any rfd. mdbods: cross sectional population survey among a random sample of households in 2 ~nderpriv ileged neighbourhoods in paris inner city, performed in 2003, using a face-to-face quest10nna1re collecr-1ng more than 400 social and health characteristics. ruults: a quarter (26.3 %) of rhe study popularion did not have any rfd. this proporrion was iignificantly higher among male (or= 2.00, 95%ci = [ 1.41-2.781), younger (e.g. or 18 -29/> .s l _= 4._oo, 95"1.ci = (2.13-7.69)), and/or unemployed (or =2.01, 95%ci = ij .21-3.3411_ people. in multtvanate analysis, after a full adjustment on gender, age, health status, health insura~ce, income, occupat10n and tducation level, we observed significant associations between having no rfd and: ~arrtal and_ pare~t hood status (e.g. or single no kids/in couple+kids = 2.12, 95%ci = ( 1.26-3.59()~ quality of relattonsh1ps with neighbours (or bad/good= 3 .82, 95%ci = [ 1.84-7.94)), and length of residence m the neighbourhood (with a dose/effect statistical relationship). . co11clusion: gender, age, employment status, mariral and parenthood stat~s as well as ~e1gh bourhood anchorage seem to be major predictors of having a rfd, even when um.versa! health i~sur ance has reduced most of financial barriers. in urban contexts, where residential migrattons and single lift (or family ruptures) are frequent, specific information may be conducted to encourage people to ket rfd. :tu~y tries to assess the health effects and costs and also analyse the availability and accessibility to health care for poor. . methods: data for this study was collected by a survey on 300 households of the local community living near the factories and 100 households where radiation hazard w~s n?~ present. ~~art from mor· bidity status and health expenditure, data was collected ~n access, a~ail~b1.hty and eff1c1ency of healrh care. a discriminant analysis was done to identify the vanables that d1scnmmate between the study and control group households in terms of health care pattern. a contingent valuation survey was also undertaken among the study group to find out the factors affecting their willingness to pay for health insurance and was analysed using logit model. results: the health costs and indebtedness in families of the study group was high as compared to control group households and this was mainly due to high health expenditure. the discriminant analysis showed that expenditure incurred by private hospital inpatient and outpatient expenditure were significant variables, which discriminated between the two types of households. the logit analysis showed !hat variables like indebtedness of households, better health care and presence of radiation induced illnesses were significant factors influencing willingness to pay for health insurance. the study showed that study group households were dependent on private sector to get better health care and there were problems with access and availability at the public sector. conclusion: the study found out that the quality of life of the local community is poor due to health effects of radiation and the burden of radiation induced illnesses are so high for them. there is an urgent need for government intervention in this matter. there is also a need for the public sector to be efficient to cater to the needs of the poor. a health insurance or other forms of support to these households will improve the quality for health care services, better and fast access to health care facilities and reduces the financial burden of the local fishing community. the prevalence of substance abuse is an increasing problem among low-income urban women in puerto rico. latina access to treatment may play an important role in remission from substance abuse. little is known, however, about latinas' access to drug treatment. further, the role of social capital in substance abuse treatment utilization is unknown. this study examines the relative roles of social capital and other factors in obtaining substance abuse treatment, in a three-wave longitudinal study of women ages 18-35 living in high-risk urban areas of puerto rico, the inner city latina drug using study (icldus). social capital is measured at the individual level and includes variables from social support and networks, familism, physical environment, and religion instruments of the icdus. the study also elucidates the role of treatment received during the study in bringing about changes in social capital. the theoretical framework used in exploring the utilization of substance abuse treatment is the social support approach to social capital. the research addresses three main questions: ( t) does social capital predict parti~ipating in treatment programs? (2) does participation in drug treatment programs increase social capital?, and (3) is there a significant difference among treatment modalities in affecting change in ~ial capital? the findings revealed no significant association between levels of social capital and gettmg treatment. also, women who received drug treatment did not increase their levels of social capital. the findings, however, revealed a number of significant predictors of social capital and receiving drug ~buse treatment. predictors of social capital at wave iii include employment status, total monthly mcoi:rie, and baseline social capital. predictors of receiving drug abuse treatment include perception of physical health and total amount of money spent on drugs. other different variables were associated to treatment receipt prior to the icldus study. no significant difference in changes of social capital was found among users of different treatment modalities. this research represents an initial attempt to elucidate the two-way relationship between social capital and substance abuse treatment. more work is necessary to unden~nd. ~e role of political forces that promote social inequalities in creating drug abuse problems and ava1lab1hty of treatment; the relationship between the benefits provided by current treatment poster sessions v81 sctrings and treatment-seeking behaviors; the paths of recovery; and the efficacy and effectiveness of the trtaanent. and alejandro jadad health professionals in urban centres must meet the challenge of providing equitable care to a population with diverse needs and abilities to access and use available services. within the canadian health care system, providers are time-pressured and ill-equipped to deal with patients who face barriers of poverty, literacy, language, culture and social isolation. directing patients to needed supportive care services is even more difficult than providing them with appropriate technical care. a large proportion of the population do not have equitable access to services and face major problems navigating complex systems. new approaches are needed to bridge across diverse populations and reach out to underserved patients most in need. the objective of this project was to develop an innovative program to help underserved cancer patients access, understand and use needed health and social services. it implemented and evaluated, a pilot intervention employing trained 'personal health coaches' to assist underserved patients from a variety of ethno-linguistic, socio economic and educational backgrounds to meet their supportive cancer care needs. the intervention was tested with a group of 46 underserved cancer patients at the princess margaret hospital, toronto. personal coaches helped patients identify needs, access information, and use supportive care services. triangulation was used to compare and contrast multiple sources of quantitative and qualitative evaluation data provided by patients, personal health coaches, and health care providers to assess needs, barriers and the effectiveness of the coach program. many patients faced multiple barriers and had complex unmet needs. barriers of poverty and language were the easiest to detect. a formal, systematic method to identify and meet supportive care needs was not in place at the hospital. however, when patients were referred to the program, an overwhelming majority of participants were highly satisfied with the intervention. the service also appeared to have important implications for improved technical health care by ensuring attendance at appointments, arranging transportation and translation services, encouraging adherence to therapy and mitigating financial hardship -using existing community services. this intervention identified a new approach that was effective in helping very needy patients navigate health and social services systems. such programs hold potential to improve both emotional and physical health out· comes. since assistance from a coach at the right time can prevent crises, it can create efficiencies in the health system. the successful use of individuals who were not licensed health professionals for this purpose has implications for health manpower planning. needle exchange programs (neps) have been distributing harm reduction materials in toronto since 1990. counterfit harm reduction program is a small project operated out of a community health centre in south-east toronto. the project is operated by a single full-time coordinator, one pan-rime mobile outreach worker and two peers who work a few hours each week. all of counterfit's staff, peers, and volunteers identify themselves as active illicit drug users. yet the program dis~rib utes more needles and safer crack using kits and serves more illicit drug u~rs t~an the comb1~e~ number of all neps in toronto. this presentation will discuss the reasons behind this success, .s~1f1cally the extended hours of operation, delivery models, and the inclusion of an. extremely marg1~ahzed community in all aspects of program design, implementation and eva.luat1?n. ~ounterfit was recently evaluated by drs. peggy milson and carol strike, two leading ep1dem1olog1st and researchers in the hiv and nep fields in toronto and below are some of their findings: "the program has experienced considerable success in delivering a high quality, accessible and well-used program .... the pro· gram has allowed (service users) to become active participants in providing. services to others and has resulted in true community development in the best sense. " ... counterf1t has ~~n verr succe~sful attracting and retaining clients, developing an effective peer-based model an.d assisting chen~s ~1th a vast range of issues .... the program has become a model for harm red~ctmn progr~ms withm the province of ontario and beyond." in june 2004, the association of ?ntano co~mumty heal~~ <:en· ires recognized counterfit's acheivements with the excellence m community health initiatives award. in kenya, health outcomes and the performance of government health service~ have det~riorated since the late 1980s, trends which coincide with a period of severe resource constramts necessitated by macro-economic stabilization measures after the extreme neo-liberalism of the 1980s. when the govern· ment withdrew from direct service provision as reform trends and donor advocacy suggested, how does it perform its new indirect role of managing relations with new direct health services providers in terms of regulating, enabling, and managing relations with these health services providers? in this paper therefore, we seek to investigate how healthcare access and availability in the slums of nairobi has been impacted upon by the government's withdrawal from direct health care provision. the methodology involved col· leering primary data by conducting field visits to 8 health institutions located in the slum areas of kibera and korogocho in nairobi. purposive random sampling was utilized in this study because this sampling technique allowed the researcher(s) to select those health care seekers and providers who had the required information with respect to the objectives of the study. in-depth interviews using a semi-structured ques· tionnaire were administered ro key informants in health care institutions. this sought to explore ways in which the government and the private sector had responded and addressed in practical terms to new demands of health care provision following the structural adjustment programmes of the 1990s. this was complemented by secondary literature review of publications and records of key governmental, bilateral and multilateral development partners in nairobi. the study notes a number of weaknesses especially of kenya's ministry of health to perform its expected roles such as managing user fee revenue and financial sustainability of health insurance systems. this changing face of health services provision in kenya there· fore creates a complex situation, which demands greater understanding of the roles of competition and choice, regulatory structures and models of financing in shaving the evolution of health services. we rec· ommend that the introduction of user fees, decentralization of service provision and contracting-out of non-clinical to private and voluntary agencies require a new management culture, and new and clear insri· tutional relationships. experience with private sector involvement in health projects underlines the need not only for innovative financial structures to deal with a multitude of contractual, political, market and risks, but also building credible structures to ensure that health services projects are environmentally responsive, socially sensitive, economically viable, and politically feasible. purpose: the purpose of this study is to examine the status of mammography screening utilization and its predictors among muslim women living in southern california. methods: we conducted a cross-sectional study that included 202 women aged ::!: 40 years. we col· leered data using a questionnaire in the primary language of the subjects. the questionnaire included questions on demography; practices of breast self-examination (bse) and clinical breast examination (cbe); utilization of mammography; and family history of breast cancer. bivariate and multiple logistic regression analyses were performed to estimate the odds ratios of mammography use as a function of demographic and other predictor variables. . results: among the 202 women, 78% were married, 68% were 40-50 years old, and 20% had family h1story of breast cancer. thirty-two percent of the participating women never practiced bse and 32% had not undergone cbe during the past two years. the data indicated that 46% of the women did not have mammography in the last two years. logistic regression analysis showed that age (0r=5.1, 95% confi· dcnc~ interval (cl)=l.8-14.2), having clinical breast examination (0r=24.9, 95% cl=8.4-73.7), and practtce of self-breast examination (0r=2.6, 95% cl= 1.1-6.2), were strong predictors of mammography use . . conclusions: the data point to the need for intervention targeting muslim women to inform and motivate th.cm a~ut practices for early detection of breast cancer and screening. further studies are needed to investigate the factors associated with low utilization of mammography among muslim women population in california. we conducted a review of the scientific literature and° government documents to describe ditnational health care program "barrio adentro" (inside the neighborhood). we also conducted qualiurivt interviews with members of the local health committees in urban settings to descrihe the comm unity participation component of the program. rtsmlts: until recently, the venezuelan public health system was characterized by a lack or limited access w health care (70% of the population) and long waiting lists that amounted to denial of service. moit than half of the mds worked in the five wealthiest metropolitan areas of the country. jn the spring oi2003, a pilot program hired 50 cuban mds to live in the slums of caracas to provide health care to piople who had previously been marginalized from social programs. the program underwent a massive expansion and in only two years 20,000 cuban and 6,500 venezuelan health care providers were working acmss the country. they provide a daily average of 20-40 medical consultations and home visits, c1lly out neighborhood rounds, and deliver health prevention initiatives, including immunization programs. they also provide generic medicines at no cost to patients, which treat 80% of presenting ill-ij!m, barrio adentro aims to build 8,000 clinics (primary care), 1,200 diagnostic and rehabilitation ctnrres (secondary care), and upgrade the current hospital infrastructure (tertiary care). local health committees survey the community to identify needs and organize a variety of lobby groups to improve dit material conditions of the community. last year, barrio adentro conducted 3.5 times the medical visits conducted by the ministry of health. the philosophy of care follows an integrated approach where btalrh is related to housing, education, employment, sports, environment, and food security. conclusions: barrio adentro is a unique collaboration between low-middle income countries to provide health care to people who have been traditionally excluded from social programs. this program shows that it is possible to develop an effective international collaboration based on participatory democracy. low-income americans are at the greatest risk of being uninsured and often face multiple health concerns. this evaluation of the neighborhood health initiative (nh!), an organization which uses multiple programmatic approaches to meet the multiple health needs of clients, reflected the program's many activities and the clients' many service needs. nh! serves low-income, underserved, and hard-to-reach residents in the des moines enterprise community. multiple approaches (fourth-generation evaluation, grounded theory, strengths-and needs-based) and methods (staff and client interviews, concept mapping, observations, qualitative and quantitative analysis) were used to achieve that reflection. results indicate good targeting of residents in the 50314 zip code and positive findings in the way of health insurance coverage and reported unmet health needs of clients. program activities were found to match client nttds, validating the organization\'s assessment of clients. important components of nhi were the staff composition and that the organization had become part of both the formal and informal networks. nhi 1 1 positioned as a link between the target population and local health and social sc:rvice agencies, working to connect residents with services and information as well as aid local agencies in reaching this underserved population. p4-36 (c) welfare: definition by new york city maribeth gregory for an individual who resides in new york city, to obtain health insurance under the medicaid policy one must fall under certain criteria .. (new york city's welfare programs 2003) if the individual _is on ssi or earns equal to or less than $934 per month, he is entitled to receive no more than $5,600 m resources. a family the size of two would need to earn less than $942 per month to qualify for no greater than ss,650 worth of medicaid benefits. a family of three would qualify for $5,650 is they earned less than $942 per month and so on. introduction: the vancouver gay communiry has a significant number of asian descendan!l. because of their double minority status of being gay and asian, many asian men who have sex with men (msm) are struggling with unique issues. dealing with racism in both mainstream society and the gay communiry, cultural differences, traditional family relations, and language challenges can be some of their everyday srruggles. however, culturally, sexually, and linguistically specific services for asian msm are very limited. a lack of availability and accessibiliry of culturally appropriate sexual health services isolates asian msm from mainstream society, the gay community, and their own cultural communities, deprives them of self-esteem, and endangers their sexual well-being. this research focuses on the qualita· tive narrative voices of asian msm who express their issues related to their sexualiry and the challenges of asking for help. by listening to their voices, practitioners can get ideas of what we are missing and how we need to intervene in order to reach asian msm and ensure their sexual health. methods: since many asian msm are very discreet, it is crucial to build up trust relationships between the researcher and asian msm in order to collect qualitative data. for this reason, a community based participatory research model was adopted by forming a six week discussion group for asian msm. in each group session, the researcher tape recorded the discussion, observed interactions among the participants, and analyzed the data by focusing on participants' personal thoughts, experiences, and emotions for given discussion topics. ra11lts: many asian msm share challenges such as coping with a language barrier, cultural differ· ences for interpreting issues and problems, and westerncentrism when they approach existing sexual health services. moreover, because of their fear of being disclosed in their small ethnic communities, a lot of asian msm feel insecure about seeking sexual health services when their issues are related to their sexual orientation. conclflsion: sexual health services should contain multilingual and multicultural capacities to meet minority clients' needs. for asian msm, outreach may be a more effective way to provide them with accessible sexual health services since many asian msm are closeted and are therefore reluctant to approach the services. building a communiry for asian msm is also a significant step toward including them in healthcare services. a communiry-based panicipatory approach can help to build a community for asian msm since it creates a rrust relationship between a worker and clients. p4-38 (c) identifying key techniques to sustain interpretation services for assisting newcomers isolated by linguistic and cultural barriers from accessing health services s. gopi krishna lntrodaetion: the greater toronto area (gta) is home to many newcomer immigrants and other vulnerable groups who can't access health resources due to linguistic, cultural and systemic barriers. linguistic and cultural issues are of special concern to suburbs like scarborough, which is home to thousands of newcomer immigrants and refugees lacking fluency in english. multilingual community ~nterpreter. service~ (mcis) is a non-profit social service organization mandated to provide high quality mterpretanon services. to help newcomers access health services, mcis partnered with the scarborough network of immigrant serving organizations (sniso) to recruit and train volunteer interpreters to accompany clienrs lacking fluency in english and interpret for them to access health services at various locati?ns, incl~~ing communiry ~c:-lth centres/social service agencies and hospitals. the model envisioned agencies recruin~ and mcis ~.mm.g and creating an online database of pooled interpreter resources. this da.tabase, acces&1bl~ to all pama~~g ?rganization is to be maintained through administrative/member · ship fees to. be ~1d by each parnapanng organization. this paper analyzes the results of the project, defines and identifies suc:cases before providing a detailed analysis for the reasons for the success . . methods:. this ~per~ q~ntitative (i.e. client numben) and qualitative analysis (i.e. results of key •~ormant m~rv1ews with semce ~sers and interpreters) to analyze the project development, training and 1mplementanon phases of the project. it then identifies the successes and failures through the afore· mentioned analysis. poster sessions vss resljts: the results of the analysis can be summarized as: • the program saw modest success both ia l?lllls of numbers of clients served as well as sustainability at various locations, except in the hospital iririog. o the success of the program rests strongly on the commitment of not just the volunteer interprmr, but on service users acknowledgments through providing transponation allowance, small honororia, letter of reference etc. • the hospital sustained the program better at the hospital due to the iolume and nature of the need, as well as innate capacity for managing and acknowledging volunceers. collc/llsion: it is possible to facilitate and sustain vulnerable newcomer immigrants access to health !ul'ices through the training and commitment of an interpreter volunteer core. acknowledging volunteer commitment is key to the sustenance of the project. this finding is important to immigration and health policy given the significant numbers of newcomer immigrants arriving in canada's urban communities. nity program was established in 1993 to provide support to people dying at home, especially those who were waiting for admission to the resi<lential hospice. with the advent of haart and corresponding challenges for people living with hiv/aids in the community, the community program has developed a unique case management approach. this model features an interdisciplinary team providing a clientdrivcn service. the case manager provides continuity of care to clients in a variety of settings both within and outside of the health care system. a case study is used to demonstrate how formal and informal networks of support facilitate efficient and appropriate resource utilization to promote client health. this case study demonstrates the value of consistent coordination with a client who has complex physical, spiritual, substance use and mental health needs. the authors will show how they liaised with the housing authority, police, social services as well as the family physician, clinic staff and a hospital emergtncy room to ensure this client did not fall between the cracks. tarek hussain recognition of the importance of community involvement and sectoral cooperation in health and !ocial services, formalized in alma-ata declaration in 1978, was reinforced at riga meeting held at the mid·point between alma-ata and the year 2000. then at the 20th anniversary of alma-ata declaration, ir was declared that 'primary health care is everybody's business'. health does not exist in isolation. health cannot be defined only as an outcome of 'medical care' but also as one of 'social action'; the responsibility of disease prevention and health promotion rests not only on governments, but also with don·govemmentorgan izations, the community, and individuals. the major accomplishment to date may be that rhere is growing realization in the health sector that community involvement is more than a political right-it is absolute necessary. lessons have learned during the implementation of disease-specific l'cltical programmes, such as cdd, ari, and epi; first, integrated and holistic approaches to childcare art needed, and second, the need for community involvement has become evident. imc! is a broad inte-gra1ed strategy with an overall objective contributing to reducing child morbidity and mortality in developing countries. and one of the imci components, 'community !mci', which is now broadening ~s an entry point for child-focused community development initiatives. community jmcl/c~1ld health is ~n mtcgrated approach to the promotion of key family and community practices that have impact on: child growth and development, disease prevention, home care for sick, malnourished child~en, a.nd care-seekmg behavior and compliance with advice and treatment. the presentation addres~es, m brief, the ~evel opinent of community !mci, operational aspect of community/im cl, key strategies and tools ava1la~le for implementation of c/imci. the paper draws some successful programme examples on working logether for imc! with the community in various countries which had substantial benefns on programme outcomes. p4-4 t (c) healthy child screening: an innovative service initiative ann-marie marcolin and joyce allen . introduction: with mounting attention for creative and integrated models of c~re .that are populallon and community focused, the healthy child screening initiative achiev.es t~ese pnncipl~s and more! . • parkdale high park rotary (sponsorship) the heal~h ~h1ld scree?1?g is a ~opl~-centred model of care. agency and professional sector-specific silos are ehmmated, ~rov1dmg f~~1hes wit~ one-sto~ access to primary prevention services in a local school gym! children at nsk are rece1vmg early mtervent10n and appropriate referrals to the right care provider, at the right time a~d in t~e right place. further, with a complimentary focus on prevention, the program serves to keep at nsk children healthy. healthy child screening results: the service model is developed around four distinct phases: 1) planned outreach; 2) coordinated intake and registration; 3) interdisciplinary screening; and 4) targeted referral. since the fall 2003 and through six collaborative healthy child screenings 158 children ranging in age from 2 to 6 have benefited from this unique service model of care. conclusion: the presentation will provide practical information on the development and implementation of the model. there will also be a focus on lessons learned in building community service provider-hospital relationships. according to statistics canada (2001) 49% of the toronto population was born outside of canada and 21 % were new immigrants. immigrants often arrive in canada in superior health compared to the canadian born population, but they lose this health advantage over time. changes in immigrant health status over time may be attributed to a variety of factors including barriers to accessing and receiving care as well as limitations in the mainstream health service organizations and their approaches to health care delivery (hyman, 2001 ) . for example, immigrant women are less likely to receive pap tests, which places them at a greater risk for developing cervical cancer. similarly, immigrant women receive less mammography screening than their canadian counterparts. the immigrant women's health centre mobile health unit (mhu) was created as an alternative care delivery model to address the need for increased accessibility as well as culturally and linguistically appropriate reproductive health care. toronto western hospital and the immigrant women's health centre have formed a collaborative partnership which incorporates a primary care nurse practitioner and lay ethnocultural counselors providing care on the mhu. currently, a qualitative ethnonursing study is underway to understand the unique experiences of women using the mhu for their reproductive health care as well as the perspectives of the mhu health care providers. based on a literature review and preliminary findings from provider and participant interviews, the proposed presentation will address the themes of health status for immigrant and refugee women, accessibility issues as well strategies to improve their reproductive health care. we will discuss benefits as well as limitations to health care provision using this alternative service delivery model. michael carden, brian edlin, andrew talal, elizabeth getter, and marla shu lntrod.ction: to date most active drug users have not had access to treatment for hepatitis c virus (hcv) infection and substantial barriers continue to exist that interfere with treatment availability for this population. methods: active illicit drug users interested in pursuing hcv care and treatment were recruited in partnership w~th co~munity-based organizations (cbo's) in new york city. baseline data were collected on quahty of hfe, substance use patterns, depression, health care utilization, hcv health beliefs and other relev.ant variables. medical evaluations were conducted, including liver biopsy when indicated, an~ treatment ts ~ffered when no contraindications are present. participants also receive psychiatric evaluahons to determme the appropriateness of interferon treatment. renlts: fifteen individuals have been recruited to date and received an initial medical evaluation. the mean age was 40 years and _the average age of initial heroin or cocaine use was 16.8. eight (53%) ha~ been homeless at least once m the last 6 months and s (33%) were homeless for most or all of this penod. fourteen (93%) had a history of injection drug use with the mean age at first injection being 21 111s1frsewons v87 ,an. elrven persc.!ns (79%) reported inje~~ng .heroin or cocaine within the last 30 days while the .wing four (21 l'o) reported regular non-m1ect1on use of cocaine and street-obtained benzodiazepines. sijiy seven percent of the sample (n= 10) reported ever being referred to hcv treatment while 2 ( t 3 % ) ftponeddiattreann~nt had been offered by~ ~e.dical provider. none had ever received a liver biopsy or araanent. most believed that hcv was a s1gmf1cant threat to their health (80%) and that there was a pm)dchance they would eventually die if their hepatitis c was not treated (67%). though 7 individuals 147%1 believed that there was no cure for hcv, 13 (87%) reported that they would initiate treatment if i was recommended by their doctor. thirteen (87%) had a current psychiatric diagnosis including «pmsion, anxiety disorder, schizophrenia, schizoaffective disorder, and borderline and antisocial persooaliry disorders. among eight individuals who had the beck depression inventory administered, the mean score was 29.75. attendance rates were 83% (83/100) at scheduled medical and psychiatric 1ppointments and 50% (2/4) at liver biopsy. <andtuions: active drug users, despite experiencing multiple psycho-social problems, can be mgaged in hcv care using a multidisciplinary approach, but require intensive follow-up support. hcv aunnent of active drug users should not be dismissed. n-44 (c) antiretroviral therapy in mv infected infants: when to initiate therapy an african experience kingsley okonkwo, ademola adeyemo, israel sokeye, and nwaife umeike /""°""ction: as technology for early diagnosis of human immunodeficiency virus [hiv] improves, m to commence highly active antiretroviral therapy [haarn is yet to be fully evaluated. this prospective study describes our initial experience with early haart in hiv infected nigerian infants and rqions the outcome. we also analyzed the socioeconomic implications of early haart therapy in infants in the african setting. method: hiv infected infants were started on haart before 6 months and followed up at 4 mkly intervals.we monitored baseline and 3 monthly cd4 . conclusion: initial results suggest early haart before 6 months resulted. in improv~d out~ome in african children. treatment appears to be as effective as in developed counmes. in. a~nca as. m most developing countries with limited resources it is possible and effective to use haart m 1~~ants if p~oper llloniroring facilities are available. however the occurrence of long-term drug related tox1c1ty and mk of emergence of resistant viral strains create need for further evaluation of haart in infants. background: most risk factors for cardiovascular disease (cvd) can be mitigated through ~th clinical interventions and lifestyle change. we used data from a telephone survey of new york city (nyc) adults to characterize health care access and healthy behavior among those with three or more cvd risk factors. methods: the study population included respondents to the nyc community health survey 2002 (n= 9,674) self-reporting~ 3 of the following: smoking, diabetes, high cholesterol level, high blood pres· sure, body mass index >25, and age >45 (males) or >55 (females) (n=2,439). results: based on self-report, an estimated 1.447,000 (24%) of nyc adults have~ 3 or more cvd risk factors. this population is 51 % male, 47% white, 25% black, and 53% with s 12 years of education. most report good access to health care, indicated by having health insurance (95%), regular doctor (89%), their blood pressure checked within last 6 months (91 %), and their choles· terol checked within the past year (90% ). only 29% reported getting at least 20 minutes of exercise ~ 4 times per week and only 9% eating ~ 5 servings of fruits and vegetables the previous day. among current smokers, 59% attempted to quit in past 12 months, but only 32% used medication or counseling. implications: these data suggest that most nyc adults known to be at high risk for cvd have access to regular health care, but most do not engage in healthy lifestyle or, if they smoke, attempt effective quit strategies. more clinic-based and population-level interventions are needed to support lifestyle change among those at high risk of cvd. introduction: recently, much interest has been directed at "obesogenic" (obesity-promoting) (swinburn, egger & raza, 1998) built environments, and at geographic information systems (gis) as a tool for their exploration. a major geographical concept is accessibility, or the ease of moving from an origin to a destination point, which has been recently explored in several health promotion-related stud· ies. there are several methods of calculating accessibility to an urban feature, each with its own strengths, drawbacks and level of precision that can be applied to various health promotion research issues. the purpose of this paper is to describe, compare and contrast four common methods of calculating accessibility to urban amenities in terms of their utility to obesity-related health promotion research. practical and conceptual issues surrounding these methods are introduced and discussed with the intent of providing health promotion researchers with information useful for selecting the most appropria1e accessibility method for their research goal~ ~ethod: this paper describes methodological insights from two studies, both of which assessed the neighbourhood-level accessibility of fast-food establishments in edmonton, canada -one which used a relatively simple coverage method and one which used a more complex minimum cos1 method. res.its: both methods of calculating accessibility revealed similar patterns of high and low access to fast-food outlets. however, a major drawback of both methods is that they assume the characteristics of the a~e~ities and of the populations using them are all the same, and are static. the gravity potential method is introduced as an alternative, since it is ·capable of factoring in measures of quality and choice. a n~mber of conceptual and pr~ctical iss~es, illustrated by the example of situational influences on food choice, make the use of the gravity potential model unwieldy for health promotion research into sociallydetermined conditions such as obesity. co.nclusions: i~ ~ommended that geographical approaches be used in partnership with, or as a foun~ation for, ~admonal exploratory methodologies such as group interviews or other forms of commumty consultation that are more inclusive and representative of the populations of interest. qilhl in los angeles county ,,..ia shaheen, richard casey, fernando cardenas, holman arthurs, and richard baker ~the retinomax autorefractor has been used for vision screening of preschool age childien. ir bas been suggested to be used and test school age children but not been validated in this age poup. ob;taiw: to compare the results of retinomax autorefractor with findings from a comprehensive i!' examination using wet retinoscopy for refractive error. mllhods: children 5-12 years old recruited from elementary schools at los angeles county were iaml with snellen's chart and the retinomax autorefractor and bad comprehensive eye examination with dilation. the proportion of children with abnormal eye examination as well as diesensitiviry and specificity of the screening tools using retinomax autorefractor alone and in combinalion wirh snellen's chart. results of the 258 children enrolled in the study (average age= 8.5± 2.1 years; age range, 5-12 years), 6?% had abnormal eye examination using retinoscopy with dilation. for the lerinomax, the sensitivity was 85% (95% confidence interval [ci] 78%-90%), and the specificity was 31% (95% ci, 22%-41 o/o). simultaneous testing using snellen's chart and retinomax resulted in gain in 111sitiviry (94%, 95% cl= 89, 97), and loss in specificity (28%, 95% cl= 19%-38%). the study showed that screening school age children with retinomax autorefractor could identify most cases with abnormal vision but would be associated with many false-positive results. simuhaneous resting using snellen's chart and retinomax maximize the case finding but with very low specificiry. mdhotjs: a language-stratified, random sample of 2366 members of the college of family physicians of canada received a confidential survey. the questionnaire collected data on socio-demographic characteristics, medical training, practice type, setting and hcv-related care practices. the self-adminisratd questionnaire was also made available to participants for completion on the internet. batdti: response proportion was 33%. median age was 41 years (47% female) and the proporlionoffrench questionnaires was 26%. approximately 88% had completed family medicine residency lllining in canada; median year of training completion was 1995. sixty-seven percent, 38% and 29% work in private offices/clinics, community hospitals and emergency departments, respectively. regarding ~practices, 94% had ever requested a hcv test and 87% of physicians had screened for hcv iafrction in rhe past 12 months· median number of tests was 10. while 17% reported having no hcv-uaed patients in their practic~, 44% had 1-5 hcv-infected patients. regarding the level of hcv care provided, 4.3% provide ongoing advanced hcv care including treatment and dose monitoring for ctmduions: in this sample of canadian family physicians, most had pro~ided hcv screening. to •least one patient in the past year. less than half had 1-5 hcv-infected patients and 41 % provide ~:relared care the role of socio-demographic factors, medical training as wel_i as hcv ca~e percep-lldas 10 rhe provision of appropriate hcv screening will be examined and described at the time of the canference. '4-50 (c) healthcare services: the context of nepal meen poudyal chhetri """1tl.ction healthcare service is related with the human rights and fundamental righ~ of the ci~ ciaaiuntry. however, the growing demand foi health care services, quality heal~care service, accessib1b~ id die mass population and paucity of funds are the different but interrelated issues to .be ~ddressed. m nepat.1n view of this context, public health sector in nepal is among other sectors, which is struggling -.i for scarce resources. . . . nepal, the problems in the field of healthcare servic~s do not bnut ~o the. paucity of faads and resources only, but there are other problems like: rural -urban imbalance, regional unbalance, poster sessio~ f the ll ·m1 ·ted resources poor healthcare services, inequity and inaccessibility of the poor management o , . poor people of the rural, remote and hilly areas for the healthcare services and so on.. . . . · . i f ct the best resource allocation is the one that max1m1zes t e sum o m ivi ua s u11 · ea t services. n a , · h d' ·b · · · h . ·t effi.ciency and efficient management are correlated. it might be t e re istn utmn of mes. ence, equi y, . . . . 1 . income or redistribution of services. moreover, maximizanon of available resources, qua tty healthcare services and efficient management of them are the very important and necessary tools and techmques to meet the growing demand and quality healthcare services in nepal. p4-51 (a) an jn-depth analysis of medical detox clients to assist in evidence based decision making xin li, huiying sun, ajay puri, david marsh, and aslam anis introduction: problematic substance use represents an ever-increasing public health challenge. in the vancouver coastal health (vch) region, there are more than 100,000 individuals having some probability of drug or alcohol dependence. to accommodate this potential demand for addiction related services, vch provides various services and treatment, including four levels of withdrawal management services (wms). clients seeking wms are screened and referred to appropriate services through a central telephone intake service (access i). the present study seeks to rigorously evaluate one of the services, vancouver detox, a medically monitored 24-bed residential detox facility, and its clients. doing so will allow decision makers to utilize evidence based decision-making in order to improve the accessibility and efficiency of wms, and therefore, the health of these clients. methods: we extract one-year data (october 1, 2003 -september 30, 2004 from an efficient and comprehensive database. the occupancy rate of the detox centre along with the clients' wait time for service and length of stay (los) are calculated. in addition, the effect of seasonality on these variables and the impact of the once per month welfare check issuance on the occupancy rate are also evaluated. results: among the 2411 clients (median age 40, 65% male) who were referred by access! to vancouver detox over the one-year period, 1448 were admitted. the majority (81 %) of those who are not admitted are either lost to follow up (i.e., clients not having a fixed address or telephone) or declined service at time of callback. the median wait time was 1 day [q3-ql: 3-1], the median los was 5 days iq3-qt: 6-3], and the average bed occupancy rate was 83%. however, during the threeday welfare check issue period the occupancy rate was lower compared to the other days of the year 175% vs. 84%, p conclusion: our analysis indicates that there was a relatively short wait time at vancouver detox, however 40% of the potential clients were not served. in addition, the occupancy rate declined during the welfare check issuance period and during the summer. this suggests that accessibility and efficiency at vancouver detox could be improved by specifically addressing these factors. background: intimate partner violence (ipv) is associated with acute and chronic physical and men· tal health outcomes for women resulting in greater use of health services. yet, a vast literature attests to cultural variations in perceptions of health and help-seeking behaviour. fewer studies have examined differences in perceptions of ipv among women from ethnocultural communities. the recognition, definition, and understanding of ipv, as well as the language used to describe these experiences, may be different in these communities. as such, a woman's response, including whether or not to disclose or seek help, may vary according to her understanding of the problem. methods: this pilot study explores the influence of cultural factors on perceptions of and responses to ipv among canadian born and immigrant young women. in-depth focus group interviews were con· ducted with women, aged 18 to 24 years, living in toronto. open-ended and semi-structured interview questions were designed to elicit information regarding how young women socially construct jpv and where they would go to receive help. interviews were transcribed, then read and independently coded by the research team. codes were compared and disagreements resolved. qualitative software qsr n6 was used to assist with data management. . ruu~ts_: res~nses_abo~t what constitutes ipv were similar across the study groups. when considering specific ab.us1ve ~1tuanons and types of relationships, participants held fairly relativistic views about ipv, especially with regard to help-seeking behaviour. cultural differences in beliefs about normaive m;ile/femal~ relations. familial.roles, and customs governing acceptable behaviours influenced partictpants perceptions about what 1n1ght be helpful to abused women. interview data highlight the social l05ter srnfons v91 11111 suucrural _impact these factors ha:e on you?g women and provide details regarding the dynamics of cibnocultur~ m~uences on help-~eekmg behav10ur: t~e ro~e of such factors such as gender inequality within rtlaoo?sh1ps and t_he ~erce1ved degree of ~oc1al 1solat1on and support nerworks are highlighted. collc~ the~ findmgs unde~score the _1mporta_nc_e of understanding cultural variations in percrprions of ipv ~ relanon to ~elp-seekmg beha~1':'ur. th1s_mformation is critical for health professionals iodiey may connnue developmg culturally sensmve practices, including screening guidelines and protorol s. ln addition, _this study demonstr~tes that focus group interviews are valuable for engaging young romen in discussions about ipv, helpmg them to 'name' their experiences, and consider sources of help when warranted. p4-s3 (a) health problems and health care use of young drug users in amsterdam .wieke krol, evelien van geffen, angela buchholz, esther welp, erik van ameijden, and maria prins /11trod11ction: recent advances in health care and drug treatment have improved the health of populations with special social and health care needs, such as drug users. however, still a substantial number dots not have access to the type of services required to improve their health status. in the netherlands, tspccially young adult drug users (yad) whose primary drug is cocaine might have limited access to drugrreatment services. in this study we examined the history and current use of (drug associated) treatmmt services, the determinants for loss of contact, and the current health care needs in the young drug mm amsterdam study (yodam). methods: yodam started in 2000 and is embedded in the amsterdam cohort study among drug mm. data were derived from y ad aged < 30 years who had used cocaine, heroin, ampheramines and i or methadone at least 3 days a week during the 2 months prior to enrolment. res11lts:of 195 yao, median age was 27 years (range: 18-30 years), 72% was male and 83% had 1dutch nationality at enrolment. nearly all participants (97%) reported a history of contact with drug llt.lnnent services (methadone maintenance, rehabilitation clinics and judicial treatment), mental health car? (ambulant mental care and psychiatric hospital) or general treatment services (day-care, night-care, hdp for living arrangements, work and finance). however, only 61 % reported contact in the past six l!xlllths. this figure was similar in the first and second follow-up visit. among y ad who reported no current contact with the health care system, 87% would like to have contact with general treatment serl' icts. among participants who have never had contact with drug treatment services, 67% used primarily cocaine compared with 22% and 8% among those who reported past or current contact, respectively. saied on the addiction severity index, 70% reported at least one mental health problem in the past 30 days, but only 11 % had current contact with mental health services. concl11sion: results from this study among young adult drug users show that despite a high contact rm with health care providers, the health care system seems to lose contact with yao. since 87% indicatt the need of general treatment services, especially for arranging house and living conditions, health m services that effectively integrate general health care with drug treatment services and mental health care might be more successful to keep contact with young cocaine users. mtthods: respondents included adults aged 18 and over who met dsm-iv diagn?snc criteria for an anxiety or depressive disorder in the past 12 months. we performed two sets of logisnc regressmns. thtdichotomous dependent variables for each of the regressions indicated whether rhe respondenr_vis-ud a psychiatrist, psychologist, family physician or social worker in the _past_ 12 months. no relationship for income. there was no significant interaction between educatmn an mco~:· r: ::or respondents with at least a high school education to seek help ~rom any of the four servic p were almost twice that for respondents who had not completed high school. th . d ec of analyses found che associacion becween educacion and use of md-provided care e secon s · · be d · · ·f· ly 1 ·n che low income group for non-md care, the assoc1anon cween e ucatlon and was s1gm icant on -· . . . . use of social workers was significant in both income groups, but significant only for use of psychologists in che high-income group. . . . conclusion: we found differences in healch service use by education level. ind1v1duals who have nor compleced high school appeared co use less mental he~lt~ servi~es provided ~y psyc~iatrists, psycholo· gists, family physicians and social workers. we found limited e.v1dence _suggesting the influence of educa· tion on service use varies according to income and type of service provider. results suggesc there may be a need to develop and evaluate progr~ms.designe~ to deliver targeted services to consumers who have noc completed high school. further quahtanve studies about the expen· ence of individuals with low education are needed to clarify whether education's relationship with ser· vice use is provider or consumer driven, and to disentangle the interrelated influences of income and education. system for homeless, hiv-infected patients in nyc? nancy sahler, chinazo cunningham, and kathryn anastos introduction: racial/ethnic disparities in access to health care have been consistently documented. one potential reason for disparities is that the cultural distance between minority patients and their providers discourage chese patients from seeking and continuing care. many institucions have incorporated cultural compecency craining and culturally sensicive models of health care delivery, hoping co encourage better relacionships becween patients and providers, more posicive views about the health care system, and, ulcimacely, improved health outcomes for minority patients. the current scudy tests whether cultural distance between physicians and patients, measured by racial discordance, predicts poorer patient attitudes about their providers and the health care system in a severely disadvantaged hiv-infected population in new york city that typically reports inconsistent patterns of health care. methods: we collected data from 396 unscably housed black and latino/a people with hiv who reported having a regular health care provider. we asked them to report on their attitudes about their provider and the health care system using validated instruments. subjects were categorized as being racially "concordant" or "discordant" with their providers, and attitudes of these two groups were compared. results: the sample consisted of 256 (65%) black and 140 (35%) latino/a people, who reported having 80 (20%) black physicians, 49 (12%) latino/a physicians, 167 (42%) white physicians, and 100 (25%) physicians of another/unknown race/ethnicity. overall, 260 (75%) subjects had physicians of a different race/ethnicity than their own. racial discordance did not predict negative attitudes about rela· tionship with providers: the mean rating of a i-item trust in provider scale (lo=high and o=low) was 8.0 for both concordant and discordant groups, and the mean score in 13-icem relationship with provider scale (4=high and !=low) was 3.5 for both groups. however discordance was significantly associated with distrust in che health care syscem: che mean score on a 7-icem scale (5=high discrust and l=low distrust) was 3.4 for discordant group and 3.0 for che concordant group (t= 2.66, p= 0.008). we further explored these patterns separacely in black and lacino/a subgroups, and using different strategies ro conceptualize racial/ethic discordance. conclusions: in this sample of unscably housed black and latino/a people who receive hiv care in new york city, having a physician from the same racial/ethnic background may be less important for developing a positive doctor-patient relationship than for helping the patients to dispel fear and distrust about the health care system as a whole. we discuss the policy implications of these findings. ilene hyman and samuel noh . .abstract objectiw: this study examines patterns of mental healthcare utilization among ethiopian 1mm1grants living in toronto. methods: a probability sample of 342 ethiopian adults ( 18 years and older) completed structured face-to-face interviews. variables ... define, especially who are non-health care providers. plan of analysis. results: approximately 5% of respondents received memal health services from mainstream healthcare providers and 8% consulted non-healthcare professionals. of those who sought mental health services from mainstream healthcare providers, 3.1 % saw family physicians, 2.1 % visited a psychiatrist. and 0.6% consulted other healthcare providers. compared with males, a significantly higher proportion 1gsfer sessions v93 ri ftlnales consulted non-healthcare_ professionals for emotional or mental health problems (p< 0.01 ). tlbile ethiopian's overall use of mamstream healthcare services for emotional problems (5%) did not prlydiffer from the rate (6%) of the general population of ontario, only a small proportion ( 12.5%) rjerhiopians with mental health needs used services from mainstream healthcare providers. of these, !oj% received family physicians' services, 4.3 % visited a psychiatrist, and 2.2% consulted other healthll/c providers. our data also suggested that ethiopian immigrants were more likely to consult tradioooal healers than health professionals for emotional or mental health problems ( 18.8% vs. 12.5% ). our bivariate analyses found the number of somatic symptoms and stressful life events to be associated with an increased use of medical services and the presence of a mental disorder to be associated with a dfcreased use of medical services for emotional problems. however, using multivariate methods, only die number of somatic symptoms remained significantly associated with use of medical services for emooonal problems. diu#ssion: study findings suggest that there is a need for ethnic-specific and culturally-appropriate mrcrvention programs to help ethiopian immigrants and refugees with mental health needs. since there ~a strong association between somatic symptoms and the use family physicians' services, there appears robe a critical role for community-based family physicians to detect potential mental health problems among their ethiopian patients, and to provide appropriate treatment and/or referral. the authors acknowledge the centre of excellence for research in immigration and settlement (ceris) in toronto and canadian heritage who provided funding for the study. we also acknowledge linn clark whose editorial work has improved significantly the quality of this manuscript. we want to thank all the participants of the study, and the ethiopian community leaders without whose honest contributions the present study would have not been possible. this paper addresses the impact of the rationalization of health-care services on the clinical decision-making of emergency physicians in two urban hospital emergency departments in atlantic canada. using the combined strategies of observational analysis and in-depth interviewing, this study provides a qualitative understanding of how physicians and, by extension, patients are impacred by the increasing ancmpts to make health-care both more efficient and cost-effective. such attempts have resulted in significantly compromised access to primary care within the community. as a consequence, patients are, out of necessity, inappropriately relying upon emergency departments for primary care services as well as access to specialty services. within the hospital, rationalization has resulted in bed closures and severely rmricted access to in-patient services. emergency physicians and their patients are in a tenuous position having many needs but few resources. furthermore, in response to demands for greater accountability, physicians have also adopted rationality in the form of evidence-based medicine. ultimately, ho~ever, rationality whether imposed upon, or adopted by, the profession significantly undermines physu.:1ans' ability to make decisions in the best interests of their patients. johnjasek, gretchen van wye, and bonnie kerker introduction: hispanics comprise an increasing proportion of th.e new york city (nyc) populanon !currently about 25%). like males in the general population, h1spamc males (hm) have a lower prrval,nce of healthcare utilization than females. however, they face additional access barriers such as bnguage differences and high rates of uninsurance. they also bear a heavy burden of health problems lllehasobesity and hiv/aids. this paper examines patterns of healthcare access and ut1hzat1on by hm compared to other nyc adults and identifies key areas for intervention. . . . 148 9 01 5 8 9 01 and older are significantly lower than the nhm popu anon . 10 v. . 10, p<.05), though hi\' screening and immunizations are comparable between the two groups. conclusion: findings suggest that hm have less access t? healthcare than hf or nhm. hown1r, hm ble to obtain certain discrete medical services as easily as other groups, perhapsdueto!rtor are a hm. i i . subsidized programs. for other services, utilization among 1s ower. mprovmg acc~tocareinthis group will help ensure routine, quality care, which can lead to a greater use of prevennve services iii! thus bener health outcomes. introduction: cancer registry is considered as one of the most important issues in cancer epidemiology and prevention. bias or under-reporting of cancer cases can affect the accuracy of the results of epidemiological studies and control programs. the aim of this study was to assess the reliability of the regional cancer report in a relatively small province (yasuj) with almost all facilities needed for c3llcll diagnosis and treatment. methods: finding the total number of cancer cases we reviewed records of all patients diagnoicd with cancer (icd 140-239) and registered in any hospital or pathology centre from1999 until 2001 i n yasuj and all (5) surrounding provinces. results: of 504 patients who were originally residents of yasui province, 43.7% wereaccoulll!d for yasuj province. the proportion varies according to the type of cancer, for exarnplecancetsofdiglstive system, skin and breast were more frequently reported by yasuj's health facilities whereas cancmoi blood, brain and bone were mostly reported by neighbouring provinces. the remaining cases (56.3%1 were diagnosed, treated and recorded by neighbouring provinces as their incident cases. this is partly because of the fact that patients seek medical services from other provinces as they believed that the facil. ities are offered by more experienced and higher quality stuffs and their relative's or temporary acooiii' modation addresses were reported as their place of residence. conclusion: measuring the spatial incidence of cancer according to the location of report ortht current address affected the spatial statistics of cancer. to correct this problem recording the permanm! address of diagnosed cases is important. p4-60 (c). providing primary healthcare to a disadvantaged population at a university-run commumty healthcare facility tracey rickards the. c:ommuni~y .h~alth ~linic (chc) is a university sponsored nurse-managed primary bealthwt (p~c:l clime. the clm1c is an innovative model of healthcare delivery in canada that has integrated tht principles of phc ser · · h' . vices wit ma community development framework. it serves to provide access to phc services for members of th · · illi · dru is ii be . . e community, particularly the poor and those who use or gs, we mg a service-learning facil'ty f d · · · · · · d rionll h . . .,m.:. · t · . meet c ient nee s. chmc nursing and social work staff and srudents r·--· ipa em various phc activities and h .l.hont" less i . f . outreac services in the local shelters and on the streels to'"" popu auon o fredericton as well th chc · model iii fosterin an on oi : . • e promotes and supports a harm reduction . · local d!or an~ h ng ~art:ersh1p with aids new brunswick and their needle exchange program, w1tha ing condoms and :xu:t h:~~~e e~aint~nance therapy clients, and with the clie~ts themselves ~_r; benefits of receiving health f ucation, a place to shower, and a small clothing and food oai~· care rom a nurse p · · d d · --""~'i"· are evidenced in th r research that involved needsaans mvo ves clients, staff, and students. to date the chc has unacn-1 · sessment/enviro i . d ; •• '""""1ll eva uanon. the clinic has also e . d nmenta scan, cost-benefit analysis, an on-go...,,1"".'i'~ facility and compassionate lea x~mme the model of care delivery' focusing on nursing roles wi~ cj rmng among students. finally, the clinic strives to share the resu•p v95 . -arch with the community in which it provides service by distributing a bi-monthly newsletter, and plllicipating in in-services and educational sessions in a variety of situations. the plan for the future is coolinued research and the use of evidence-based practice in order to guide the staff in choosing how much n~ primary healthcare services to marginalized populations will be provided. n-61 (c) tuming up the volume: marginalized women's health concerns tckla hendrickson and betty jane richmond bdrotbu:tion: the marginalization of urban women due to socio-economic status and other determinants negatively affects their health and that of their families. this undermines the overall vitaliry of urban communities. for example, regarding access to primary health care, women of lower economic surus and education levels are less likely to be screened for breast and cervical cancer. what is not as widely reported is how marginalized urban women in ontario understand and articulate their lack of access to health care, how they attribute this, and the solutions that they offer. this paper reports on the rnults of the ontario women's health network (owhn) focus group project highlighting urban women's concerns and suggestions regarding access to health care. it also raises larger issues about urban health, dual-purpose focus group design, community-based research and health planning processes. mdhods: focus group methodology was used to facilitate a total of 30 discussions with 55 urban and 54 rural women across ontario from 2003 to 2005. the women were invited to participate by local women's and health agencies and represented a range of ages, incomes, and access issues. discussions focussed on women's current health concerns, access to health care, and information needs. results were analyzed using grounded theory. the focus groups departed from traditional focus group research goals and had two purposes: 1) data collection and dissemination (representation of women's voices), and 2) fostering closer social ties between women, local agencies, and owhn. the paper provides a discussion and rationale for a dual approach. rax/ts: the results confirm current research on women's health access in women's own voices: urban women report difficulty finding responsive doctors, accessing helpful information such as visual aids in doctors' offices, and prohibitive prescription costs, in contrast with rural women's key concern of finding a family doctor. the research suggests that women's health focus groups can address access issues by helping women to network and initiate collective solutions. the study shows that marginalized urban women are articulate about their health conctrns and those of their families, often understanding them in larger socio-economic frameworks; howtver, women need greater access to primary care and women-friendly information in more languages and in places that they go for other purposes. it is crucial that urban health planning processes consult directly with women as key health care managers, and turn up the volume on marginalized women's voices. women: an evaluation of awareness, attitudes and beliefs introduction: nigeria has one of the highest rates of human immunodeficiency virus ihivi seroprrvalence in the world. as in most developing countries vertical transmission from mother to child account for most hiv infection in nigerian children. the purpose of this study was ro. determine the awareness, attitudes and beliefs of pregnant nigerian women towards voluntary counseling and testing ivct! for hiv. mnbod: a pre-tested questionnaire was used to survey a cross section '.>f.240 pregnant women ~t 2 (lrlleral antenatal clinics in awka, nigeria. data was reviewed based on willingness to ~c~ept or re1ect vct and the reasons for disapproval. knowledge of hiv infection, routes of hiv transm1ssmn and ant1rnroviral therapy iart) was evaluated. hsults: 72% of the women had good knowledge of hiv, i 5% had fair knowledge while 1.1% had poor knowledge of hiv infection.48% of the women were not aware of the association of hreast milk feeding and transmission of hiv to their babies. majority of the women 87% approved v~t while 13% disapproved vct, 93% of those who approved said it was because vct could ~educe risk of rransmission of hiv to their babies. all respondents, 100% who accepted vc.i ~ere willing to be tnted if results are kept confidential only 23% accepted to be tested if vc.t results w.111 be s~ared w1.th pinner and relatives 31 % attributed their refusal to the effect it may have on their marriage whale 69 '-gave the social 'and cultural stigmatization associated with hiv infection for their r~fusal.s 9 % wall accept vct if they will be tested at the same time with their partners.81 ~0 of ~omen wall pref~r to breast feed even if they tested positive to hiv. women with a higher education diploma were 3 times v96 more likely to accept vct. knowledge of art for hiv infected pregnant women as a means of pre. vention of maternal to child transmission [pmtct) was generally poor, 37% of respondents wm aware of art in pregnancy. conclusion: the acceptance of vct by pregnant women seems to depend on their understanding that vct has proven benefits for their unborn child. socio-cultur al factors such as stigmatizationof hiv positive individuals appears to be the maj_or impedi~ent towards widespread acceptanee of ycr in nigeria. involvemen t of male partners may 1mpro~e attitudes t~wa~ds vct:the developmentofm novative health education strategies is essential to provide women with mformanon as regards the benefits of vct and other means of pmtct. p4-63 (c) ethnic health care advisors in information centers on health care and welfare in four districts of amsterdam arlette hesselink, karien stronks, and arnoud verhoeff introduction : in amsterdam, migrants report a "worse actual health and a lower use of health care services than the native dutch population. this difference might be partly caused by problems migrants have with the dutch language and health care and welfare system. to support migrants finding their way through this system, in four districts in amsterdam information centers on health care and welfare were developed in which ethnic health care advisors were employed. their main task is to provide infor· mation to individuals or groups in order to bridge the gap between migrants and health care providers. methods: the implementat ion of the centers is evaluated using a process evaluation in order to give inside in the factors hampering and promoting the implementat ion. information is gathered using reports, attending meetings of local steering groups, and by semi-structu red interviews with persons (in)directly involved in the implementat ion of the centers. in addition, all individual and groupcontaets of the health care advisors are registered extensively. results: since 2003 four information centers, employing 12 ethnic health care advisors, are implemented. the ethnicity of the health care advisors corresponds to the main migrant groups in the different districts (e.g. moroccan, turkeys, surinamese and african). depending on the local steering groups, the focus of the activities of the health care advisors in the centers varies. in total, around 2000 individual and 225 group educational sessions have been registered since the start. most participants were positive about the individual and group sessions. the number of clients and type of questions asked depend highly on the location of the centers (e.g. as part of a welfare centre or as part of a housing corporation). in all districts implementa tion was hampered by lack of ongoing commitment of parties involved (e.g. health care providers, migrant organization s) and lack of integration with existing health care and welfare facilities. discussion: the migrant health advisors seem to have an important role in providing information on health and welfare to migrant clients, and therefore contribute in bridging the gap between migrants and professionals in health care and welfare. however, the lack of integration of the centers with the existing health care and welfare facilities in the different districts hampers further implementation . therefore, in most districts the information centres will be closed down as independent facilicities in the near future, and efforts are made to better connect the position of migrant health advisor in existing facilities. the 2005 who report ranks the philippines as ninth among 22 countries with a high tb prevalence. about a fourth of the country's population is infected, with majority of cases coming from the lower socioeconomic segments of the community. metro manila is not only the economic and political capital of the philippines but also the site of major universities and educational institutions. initial interviews with the school's clinicians have established the need to come up with treatment guidelines and protocols for students and personnel when tb is diagnosed. these cases are often identified during annual physical examinations as part of the school's requirements. in many instances, students and personnel diagnosed with tb are referred to private physicians where they are often lost to follow-up and may have failure of treatment due to un monitored self-administered therapy. this practice ignores the school clinic's great potential as a tb treatment partner. through its single practice network (spn) initiative, the philippine tuberculosis initiatives for the private sector (philippine tips), has established a model wherein school clinics serve as satellite treatment partners of larger clinics in the delivery of the directly observed treatment, short course (dots) protocol. this "treatment at the source" allows school-based patients to get their free government-suppl ied tb medicines from the clinic each day. it also cancels out the difficulty in accessing medicines through the old model where the patient has to go to the larger clinic outside his/her school to get treatment. the model also enables the clinic to monitor the treatment progress of the student and assumes more responsibility over their health. this experience illustrates how social justice in health could be achieved from means other than fund generation. the harnessing of existing health service providers in urban communities through standardized models of treatment delivery increases the probability of treatment success, not only for tb but for other conditions as well. p4-66 (c) voices for vulnerable populations: communalities across cbpr using qualitative methods martha ann carey, aja lesh, jo-ellen asbury, and mickey smith introduction: providing an opportunity to include, in all stages of health studies, the perspectives and experiences of vulnerable and marginalized populations is increasingly being recognized as a necessary component in uncovering new solutions to issues in health care. qualitative methods, especially focus groups, have been used to understand the perspectives and needs of community members and clinical staff in the development of program theory, process evaluation and refinement of interventions, and for understanding and interpreting results. however, little guidance is available for the optimal use of such information. methods: this presentation will draw on diverse experiences with children and their families in an asthma program in california, a preschool latino population in southern california, a small city afterschool prevention program for children in ohio, hiv/aids military personnel across all branches of the service in the united states, and methadone clinic clients in the south bronx in new york city. focus groups were used to elicit information from community members who would not usually have input into problem definitions and solutions. using a fairly common approach, thematic analysis as adapted from grounded theory, was used to identify concerns in each study. next we looked across these studies, in a meta-synthesis approach, to examine communalities in what was learned and in how information was used in program development and refinement. results: while the purposes and populations were diverse, and the type of concerns and the reporting of results varied, the conceptual framework that guided the planning and implementation of each study was similar, which led to a similar data analysis approach. we will briefly present the results of each study, and in more depth we will describe the communalities and how they were generated. conclusions: while some useful guidance for planning future studies of community based research was gained by looking across these diverse studies, it would be useful to pursue a broader examination of the range of populations and purposes to more fully develop guidance. background: the majority of studies examining the relationship between residential environments and cardiovascular disease have used census derived measures of neighborhood ses. there is a need to identify specific features of neighborhoods relevant to cardiovascular disease risk. we aim to 1) develop methods· data on neighborhood conditions were collected from a telephone survey of s,988 fesi· dents in balth:.ore, md; forsyth county, nc; and new york, ny. a sample of 120 of the i.ni~~l l'elpondents was re-interviewed 2-3 weeks after the initial interview t~ measure the tes~-~etest rebab1~1ty of ~e neighborhood scales. information was collected across seven ~e1ghborho~ cond1~ons (aesth~~ ~uah~, walking environment, availability of healthy foods, safety, violence, social cohesion, and acnvmes with neighbors). neighborhoods were defined as census tracts or homogen~us census tra~ clusters. ~sycho metric properties.of the neighborhood scales were accessed by ca~cu~~.ng chronba~h s alpha~ (mtemal consistency) and intraclass correlation coefficients (test-r~test reliabilmes) .. pear~n s .corre~anons were calculated to test for associations between indicators of neighborhood ses (tncludmg d1mens1ons of race/ ethnic composition, family structure, housing, area crowding, residential stability, education, employment, occupation, and income/wealth) and our seven neighborhood scales. . chronbach's alphas ranged from .73 (walking environment) to .83 (violence). intraclass correlations ranged from .60 (waling environment) to .88 (safety) and wer~ high~~~ .7~ for ~urout of the seven neighborhood dimensions. our neighborhood scales (excluding achv1hes with neighbors) were consistently correlated with commonly used census derived indicators of neighborhood ses. the results suggest that neighborhood attributes can be reliably measured. further development of such scales will improve our understanding of neighborhood conditions and their importance to health. childhood to young adulthood in a national u.s. sample jen jen chang lntrodfldion: prior studies indicate higher risk of substance use in children of depressed mothers, but no prior studies have followed up the offspring from childhood into adulthood to obtain more precise estimates of risk. this study aimed to examine the association between early exposure to maternal depl'elsive symptoms (mds) and offspring substance use across time in childhood, adolescence, and young adulthood. methods: data were obtained from the national longitudinal survey of youth. the study sample includes 4,898 mother-child/young adult dyads interviewed biennially between 1992 and 2002 with children aged 4 to 16 years old at baseline. data were gathered using a computer-assisted personal interview method. mds were measured in 1992 using the center for epidemiologic studies depression scale. offspring substance use was assessed biennially between 1994 and 2002. logistic and passion regression models with generalized estimation equation approach was used for parameter estimates to account for possible correlations among repeated measures in a longitudinal study. rnlllta: most mothers in the study sample were whites (42%), urban residents (79%), had a mean age of 31 years with at least a high school degree (82%). the mean child age at baseline was 9 years old. offspring cigarette and alcohol use increased monotonically across childhood, adolescence, and young adulthood. differential risk of substance use by gender was observed. early exposure to mds was associated with increased risk of cigarette (adjusted odds ratio (aor) = 1.52, 95% confidence interval (0): 1.12, 2.08) and marijuana use (aor = 1.46, 95% ci: 1.02, 2.08), but not with alcohol use across childhood, adolescence, and young adulthood, controlling for a child's characteristics, socioeconomic status, ~ligiosity, maternal drug use, and father's involvement. among the covariates, higher levels of father's mvolvement condluion: results from this study confirm previous suggestions that maternal depressive symptoms are associated with adverse child development. findings from the present study on early life experi-e~ce have the potential to inform valuable prevention programs for problem substance use before disturbances become severe and therefore, typically, much more difficult to ameliorate effectively. the ~act (~r-city men~ health study predicting filv/aids, club and other drug transi-b~) study 15 a multi-level study aimed at determining the association between features of the urban enyjronment mental health, drug use, and risky sexual behaviors. the study is randomly sampling foster sessions v99 neighborhood residents and assessing the relations between characteristics of 36 ethnographically defined urban neighborhoods and the health outcomes of interest. a limitation of existing systematic methods for evaluating the physical and social environments of urban neighborhoods is that they are expensive and time-consuming, therefore limiting the number of times such assessments can be conducted. this is particularly problematic for multi-year studies, where neighborhoods may change as a result of seasonality, gentrification, municipal projects, immigration and the like. therefore, we developed a simpler neighborhood assessment scale that systematically assessed the physical and social environment of urban neighborhoods. the impact neighborhood evaluation scale was developed based on existing and validated instruments, including the new york city housing and vacancy survey which is performed by the u.s. census bureau, and the nyc mayor's office of operations scorecard cleanliness program, and modified through pilot testing and cognitive testing with neighborhood residents. aspects of the physical environment assessed in the scale included physical decay, vacancy and construction, municipal investment and green space. aspects of the social environment measured include social disorder, social trust, affluence and formal and informal street economy. the scale assesses features of the neighborhood environment that are determined by personal (e.g., presence of dog feces), community (e.g., presence of a community garden), and municipal (e.g., street cleanliness) factors. the scale is administered systematically block-by-block in a neighborhood. trained research staff start at the northeast corner of an intersection and walk around the blocks in a clockwise direction. staff complete the scale for each street of the block, only evaluating the right side of the street. thus for each block, three or more assessments are completed. we are in the process of assessing psychometric properties of the instrument, including inter-rater reliability and internal consistency, and determining the minimum number of blocks or street segments that need to be assessed in order to provide an accurate estimate of the neighborhood environment. these data will be presented at the conference. obj«tive: to describe and analyze the perceptions of longterm injection drug users (idus) about their initiation into injecting. toronto. purposive sampling was used to seek out an ethnoculturally diverse sample of idus of both genders and from all areas of the city, through recruitment from harm reduction services and from referral by other study participants. interviews asked about drug use history including first use and first injecting, as well as questions about health issues, service utilization and needs. thematic analysis was used to examine initiation of drug use and of injection. results: two conditions appeared necessary for initiation of injection. one was a developed conception of drugs and their (desirable) effects, as suggested by the work of becker for marijuana. thus virtually all panicipants had used drugs by other routes prior to injecting, and had developed expectations about effects they considered pleasureable or beneficial. the second condition was a group and social context in which such use arose. no participants perceived their initiation to injecting as involving peer pressure. rather they suggested that they sought out peers with a similar social situation and interest in using drugs. observing injection by others often served as a means to initiate injection. injection served symbolic purposes for some participants, enhancing their status in their group and marking a transition to a different social world. concl111ion: better understanding of social and contextual factors motivating drug users who initiate injection can assist in prevention efforts. 10 ma!onty of them had higher educational level (57%-highschool or higher).about 20.2 yo adffiltted to have history of alcohol & another 12.4% had history of smoking. only 3.2% people were on hrt & 3.1 % were receiving steroid. majority of them (81.2) did not have history of osteoporosis. 13.6% have difficulty in ambulating. only 8.8% had family history of osteoporosis. bmd measurements as me~sured by dual xray absorptiometry (dexa) were used for the analysis. bmd results were compare~ w1~ rbc folate & serum vitamin b12 levels. no statistical significance found between bmd & serum v1taffiln b12 level but high levels of folate level is associated with normal bmd in bivariate and multivariate analysis. conclusion: in the studied elderly population, there was no relationship between bmd and vitamin b12; but there was a significant association between folate levels & bmd. introduction: adolescence is a critical period for identity formation. western studies have investigated the relationship of identity to adolescent well-being. special emphasis has been placed on the influence of ethnic identity on health, especially among forced migrants in different foreign countries. methodology: this study asses by the means of an open ended question identity categorization among youth in three economically disadvantaged urban communities in beirut, the capital of lebanon. these three communities have different histories of displacement and different socio-demographic makeup. however, they share a history of displacement due to war. results and conclusion: the results indicated that nationality was the major category of identification in all three communities followed by origin and religion. however, the percentages that self-identify by particular identity categories were significantly different among youth in the three communities, perhaps reflecting different context in which they have grown up. mechanical heart valve replacement amanda hu, chi-ming chow, diem dao, lee errett, and mary keith introduction: patients with mechanical heart valves must follow lifelong warfarin therapy. war· farin, however, is a difficult drug to take because it has a narrow therapeutic window with potential seri· ous side effects. successful anticoagulation therapy is dependent upon the patient's knowledge of this drug; however, little is known regarding the determinants of such knowledge. the purpose of this study was to determine the influence of socioeconomic status on patients' knowledge of warfarin therapy. methods: a telephone survey was conducted among 100 patients 3 to 6 months following mechan· ical heart valve replacement. a previously validated 20-item questionnaire was used to measure the patient's knowledge of warfarin, its side effects, and vitamin k food sources. demographic information, socioeconomic status data, and medical education information were also collected. results: sixty-one percent of participants had scores indicative of insufficient knowledge of warfarin therapy (score :s; 80%). age was negatively related to warfarin knowledge scores (r= 0.27, p = 0.007). in univariate analysis, patients with family incomes greater than $25,000, who had greater. than a grade 8 education and who were employed or self employed had significantly higher warfarm knowledge scores (p= 0.007, p= 0.002 and p= 0.001 respectively). gender, ethnicity, and warfar~n therapy prior to surgery were not related to warfarin knowledge scores. furthermore, none of t~e. m-hospital tea~hing practices significantly influenced warfarin knowledge scores. however, panic1~ants who _rece1v~d post discharge co~unity counseling had significantly higher knowledge scores tn comp~r1son with those who did not (p= 0.001 ). multivariate regression analysis revealed that und~r~tandmg the ~oncept of 1?ternational normalized ratio (inr), knowing the acronym, age and receiving ~ommum1!' counseling after discharge were the strongest predictors of warfarin kn~wledge. s~1oeconom1c status was not an important predictor of knowledge scores on the multivanate analysis. poster sessions v101 ~the majority of patients at our institution have insufficient knowledge of warfarin therapy.post-discharge counseling, not socioeconomic status, was found to be an important predictor of warfarin knowledge. since improved knowledge has been associated with improved compliance and control, our findings support the need to develop a comprehensive post-discharge education program or, at least, to ensure that patients have access to a community counselor to compliment the in-hospital educatiop program. brenda stade, tony barozzino, lorna bartholomew, and michael sgro lnttotl#ction: due to the paucity of prospective studies conducted and the inconsistency of results, the effects of prenatal cocaine exposure on functional abilities during childhood remain unclear. unlike the diagnosis of fetal alcohol spectrum disorder, a presentation of prenatal cocaine exposure and developmental and cognitive disabilities does not meet the criteria for specialized services. implications for public policy and services are substantial. objective: to describe the characteristics of children exposed to cocaine during gestation who present to an inner city specialty clinic. mnbods: prospective cohort research design. sample and setting: children ages 5 to 15 years old, referred to an inner city prenatal substance exposure clinic since november, 2003. data collection: data on consecutive children seen in the clinic were collected over an 18 month period. instrument: a thirteen (13) page intake and diagnostic form, and a detailed physical examination were used to collect data on prenatal substance history, school history, behavioral problems, neuro-psychological profile, growth and physical health of each of the participants. data analysis: content analysis of the data obtained was conducted. results: twenty children aged 6 to 14 years (mean= 9.8 years) participated in the study. all participants had a significant history of cocaine exposure and none had maternal history or laboratory (urine, meconium or hair) exposure to alcohol or other substances. none met the criteria of fetal alcohol spectrum disorder. all were greater than the tenth percentile on height, weight, and head circumference, and were physically healthy. twelve of the children had iqs at the 19th percentile or less. for all of the children, keeping up with age appropriate peers was an ongoing challenge because of problems in attention, motivation, motor control, sensory integration and expressive language. seventy-four percent of participants had significant behavioral and/or psychological problems including aggressiveness, hyperactivity, lying, poor peer relationships, extreme anxiety, phobias, and poor self-esteem. conclusion: pilot study results demonstrated that children prenatally exposed to cocaine have significant learning, behavioural, and social problems. further research focusing on the characteristics of children prenatally exposed to cocaine has the potential for changing policy and improving services for this population. methods: trained interviewers conducted anonymous quantitative surveys with a random sample (n= 148) of female detainees upon providing informed consent. the survey focused on: sociodemographic background; health status; housing and neighborhood stability and social resource availability upon release. results: participants were 70% african-american, 16% white, 9% mixed race and 5% native american. participants' median age was 37, the reported median income was <s2,000 year, and 53% reported receiving a high school diploma or equivalent. women reported a number of health conditions rypical of underserved populations, including asthma (42%), sexually transmitted infections (39%), high blood pressure (19%), hcv (14%), diabetes (5%) and hiv (4%). nearly half (46%) did not anticipate having a place to stay for at least 30 days upon release. factors significantly associated housing stability upon release were: high family support score (adjusted odds ratio [aor) 6.15; 95% confidence interval (95% cl) 1.76, 21.61), high neighborhood stability score (aor 4.41; 95% cl 1.25, 15.52), wanting a commercial sex worker (csw) support group (aor 0.25; 95% cl 0.10, 0.62); and identifying as bisexual (aor 0.24; 95% cl 0.07, 0.75). women desired employment (95%), housing (84%), education (77%), drug treattnent (74%), help with custody of children (31 %), childcare (28%), and domestic violence suppon (20%) services. conclusions: female detainees represent one of urban centers' most marginalized pcjpwatioos. short periods of detention represent a unique opportunity for _interven?~ns bri~ co~s and public health institutions. service providers should collaborate ~1th local ~ails to .p~de a con1111uwnof care for female detainees upon release that includes transportation , housing, residential drug treallllcnt, employment, education, family reunification, childcare and domestic viol~nce su~rt. ~pecial attenlion is warranted to lesbian and bisexual women and csws, who may be especially margmalized &om family and service-based support networks. introduction: "health care and ethnic minority immigrants" examines how health care policy dil· ferences between canada and the united states impact the health-related hardships, access and use of preventative care, and health outcomes of urban ethnic minority immigrants in both countries. methods: the findings of this paper build on the results of my qualitative comparative study of hotel workers in vancouver, bc and seattle, wa that revealed greater health related hardships for similarly matched employees in seattle compared to vancouver. in this paper, i examine the generalizability of these findings at the cross-national level for similar ethnic minority immigrant groups. i compare the impact of health care policy differences on specific groups that have emigrated to cities in both canada and the united states. these include immigrants from china, viemam, philippines, west indies, africa, sri lanka, pakistan, and latin america. comparative statistical analysis -utilizing rel· evant data from statistics canada and the u.s. census -reveal the extent to which health policy differ· ences help explain how current health policy in the united states disadvantages urban ethnic minority immigrants. results: many ethnic minority immigrants are a part of the working poor, a group which disproportionately lacks health insurance coverage in the united states. their position in the labour market makes them most vulnerable to exclusion from health care services. the data reveals how current u.s. health policy creates barriers for recently arrived ethnic minority immigrants to access health insurance and care. it remains difficult to ascribe health outcome differences directly to policy differences because of the challenge in disentangling the complex interacting interventing variables, including income inequality, that determine health outcomes. yer suggestive evidence suggests that health policy in the united states is harming the health of urban ethnic minority immigrants. the current health policy regime in the united states harms the health access, care, and outcomes of urban ethnic minority immigrants. comparing the fortunes of similar immigrants in cana· dian and u.s. cities reveals these patterns of disadvantage and some of their consequences. these barriers are an understudied factor in the sociological literature on "segmented assimilation" and social exclu· sion. the paper ends with policy recommendatio ns to improve access to health care among ethnic minor· ity immigrants in both countries, with the goal of reducing health related hardships, and improving health outcomes. mass index deyu pan, richard baker, and keith norris badtgrou~ over the past 3 decades, there has been dramatic increase in prevalence of obesity in the us population. however, the relationship between obesity and the prevalence of cardiovascular dis· ease (cv~) risk factors in different race/ethnic groups over time is not well known. . ik~rgn: _we use 2 cross-sectional , nationally representative surveys: national health and nutri· t10nal examination survey (nhanes iii 1988 -1994 (n= 14 029) and nhanes 1999 nhanes -2002 , including white, black, and hispa~ic races who were no~preg~ant, aged 20 to 74 years. res11lt1: the preval~nce of high cholesterol level (~ 240 mg/dl), untreated high blood pressure (2: l40/90 mm hg) an~ diabetes were calculated according to bmi group (lean, <25; overweight, 25-29; and obese, 2: 30) for different race/ethnicity groups. over the approximately 10 years period (from 1988l ~94 ~o [1999] [2000] [2001] [2002] , reducrion in 3 cvd risk factors in non-hispanic white has been observed. for mmonty race/~hnicity groups, black and hispanic, there had been increases in prevalence in high blood fa pressure and diabetes. the lean group experienced larger increase in prevalence of those cvd risk ctors. . fo~~ the prevalence in cvd risk factors over time had reduced in most of the bmi ca1egoes r t e w ~~e population. however, for black and hispanic, prevalence of 2 of 3 cvd risk factors ave generauy uncreased, especially in overweight and obese groups. methods: strategies identified to achieve these goals include: developing meaningful neighbourhood and district boundaries for comparing health information, providing free access to neighbourhood health profiles (including relevant data at the smallest level for which valid rates could be calculated); mapping relationships of inequality at a variety of nested levels; providing a range of formats (maps, tables) to meet the needs of users; providing technical support; seeking user input to advance and improve the site; and conducting workshops to foster access and use of data for decision-making , advocacy and collaboration. an evaluation strategy is being developed to assess the efforts and impact of these strategies. a preliminary assessment of the results of the first six months of activity will be completed in october 2005. results: significant differences in health are shown at all the geographic levels indicating success in developing the boundaries. results tabulated for the first six months use of the site include: site visits; media use; reference/acknow ledgement of the site in other documents; number of contacts through presentations and workshops; feedback from users identifying strengths and limitations; and, response from health decision makers. members of the partnership are identifying additional tools and services to further support actions that reduce health inequalities. the assessment will be used to develop more specific goals, targets and monitoring mechanisms. conclusions: our experience with paper-based health profiles indicates that they have been used extensively for program planning and advocacy. the greater availability of information in a publiclyavailable web-based format is expected to translate into even greater usefulness and wider application. the web site has had considerable usage to date, extensive media coverage. site users and workshop participants have provided positive feedback and suggestions for next steps. the six month review will be available in october 2005. in india, more than 4 and a half people are hiv-positive and half a million have aids. india currently has the largest number of positive people in the world, oumumbering south africa and accounting for nearly one tenth of the global hiv/aids prevalence. the world bank predicts that by 2015, there will be 35 million hiv/aids cases in india. the central challenge facing hiv prevention efforts in south asia today is learning how to respond to the societal determinants of vulnerability to hiv. hiv/aids is an issue largely engulfed by social stigma. stigma and discrimination are often considered the foremost barriers to effective poster sess10ns v104 prevention and care initiatives. stigma can make a person afraid of disclosing their status~ ~yone el se, and may make them feel depressed or alone. stigma can .also le~d to poor adherence to medicanon, ~ likelihood to access health and social services, and less desire to hve. hiv+ men and women may beafraidtotd! their co-workers that they have hiv for fear of their reactions or for fear of losing their jobs. in a study 1 conducted of people living with hiv/aids in delhi, india ov~r. 2003-~, many respo~ts shared their experiences of discrimination in their families, in their communmes, an~ m health ~e settmgs. these findings will be shared in the workshop, and will be compa~ed to m~ ex~nences workmg as an ~ co~l~ at the center for aids prevention studies in san francisco, cahforma and congreso de lannos unidos m philadelphia, pennsylvania. the workshop will include an overview of hiv/aids in urban contexts in tht united states (los angeles, san francisco, new york, philadelphia) and south asia (delhi, hyderabad, chennai). differences in methods for outreach, prevention and treatment efforts between devdoped world and developing world contexts will be discussed. a large portion of the workshop will be centered on discussion. participants will engage in an exercise to categorize their ideas of stigma. the workshop will also include a powerpoint presentation on the quantitative data gathered from the survey. the number of homeless and runaway youth is increasing in toronto, which is currently home to 3 out of 4 youth in the gt a who live alone, and it is the preferred locale for the street-involved and homeless youth. the city's youth population is expected to grow by nearly 20% by 2011, the school dropout rate is rising, and there are is a paucity of empirical data on what works with these at-risk youth. over a two-year period, (2002) (2003) (2004) , youthlink-inner city, conducted an evaluation of the impact of a harm reduction program aimed at reducing street youth's risk of contracting/infecting others with the hep c virus, which has both short-term and long-term deleterious effects. demographic data from 102 street-youth, along with resources/services used, employment methods, type and frequency of drug use, health status, police contacts, and their views of program impact were analyzed using a standardized sur· vey. additionally, focus groups with youth, agency staff and community key informants were conducted, as well as in-depth interviews with three youth, over a sixth-month period. this paper details study results, which both inform both practice and future study about what works, why it works, and how best to work with these vulnerable youth. sho~ed .that the wasteland in this area was contaminated by as cd zn pb cu simultaneously. the con-ta~matton of as ~d was quit significant. the contamination problems and environmental issues in this region are very. serious. the awareness on environmental and health issues was investigated by spot survey and analysis. overall awareness among the residents in the region is very poor. the measures must be taken to assu~e t~e .sustainable economy development by local and central gorvernments. keywords nandan guangx1; mmmg area; environmental awareness. concern like, epileptic fits, vision problems, earache, cough of more than 3 weeks and urinary problems. ninety-five subjects did not take bath regularly and 42 were exposed to sex. the health problems identified are only of a particular point of time and it may be difficult to interpret the depth of "iceberg" of the street children's world also draw the health-illness continuum. periodic interaction and follow-up is very difficult as they generally disappear from the research setting due to their frequent mobility for survival measures. as per the prediction of the iceberg theory, only some problems may have been identified, larger problems in respect to their health may not have been identified. in spite of various limitations, this attempt had proven that, it is possible to enter the street children world, explore the iceberg of illnesses, and establish data of health-illness continuum through an effective nursing agency. it is recommended to deworm these children, provide nutritional education, establish "condom corners" and "street children help line" in the city and urban slum areas and undertake action research on their health. malnutrition is a serious problem in developing countries like bangladesh. malnutrition causes a great deal of child suffering. malnutrition is one of the major causes of morbidity and mortality among the child. the aim of present study was to investigate the nutritional status and its relation to socioeconomic conditions of urban disadvantaged child of under five years age. nutritional status was determined by anthropoemetric measurement(heig ht, weight, mid-arm circumference etc.). determination of total protein and serum albumin were done for biochemical examination. haematological examination was done by blood haemoglobin profile estimation by cynmethhaemoglob in method and determination of haematocrit value or packed cell volume (pcv). stool examination for ova of hook worm, round worm, trichuris species and other species were also done. relevant information on socioeconomic characteristics was recorded by interviewing the house hold head using pretested questionnaire. our study demonstrated that nutritional status of the children are positively correlated with family income, parents level of formal education and negatively related to the family size. the effect of family income on the nutritional status, haematological and biochemical indices of urban disadvantaged child under five will be discussed in detail which will help us to determine proper way of utilization of health care facilities exists in developing countries. introduction: with the increase in morbidity and reduction in mortality and with the introduction of highly active antiretroviral therapy (haart), there is increasing focus on the determinants of healthrelated quality of life (hrqol) in hiv-infection. the focus on the present study is to examine the relationship between social support, depression, and hiv disease severity, and the extent to which these variables impact on hrqol in adult men with hiv-infection. methods: as part of a larger ongoing natural history study focusing on the neurobehavioural complications of hiv and aids, we administered questionnaires to assess depression (beck depression inventory), social support, and hrqol (mos-hiv) to 366 adult men with hiv-infection. a structured interview was used to collect health information and data on hiv disease severity. physical and mental health summary scores (phs and mhs) were derived through principal components analysis. participants were grouped according to level of social support: "well supported" (n= 180), "moderately supported" (n=90), "little or ineffective support" (n=96). analysis of variance was conducted to assess the effects of three levels of perceived social support, depression status (present vs absent), and hiv disease severity (aids vs non-aids) on mental and physical health dimensions of hrqol. potential interaction effects were also evaluated. results: social support was found to have a significant effect on both mhs and phs. presence of depression was found to have a significant effect on mhs but not phs. hiv disease severity (presence of aids diagnosis) was found to have a significant effect on phs but not mhs. manov a analyses revealed no significant interactions effects. conclusions and implications: level of social support, presence of depression and hiv disease severity were shown to have independent effects on hrqol. feeling "well supported" appears to have significant benefits for mental and physical health. biological indicators of hiv disease appear to have a selective impact on physical health while presence of depression is related to significant reductions in mental health. the development and evaluation of behavioural interventions to improve perceived social support network and depression will likely result in significant improvements in health outcomes of adults with hiv and aids. introduction: ongoing medical advances have greatly enhanced the longevity of penons living with aids (plwa). however, for certain subgroups living with hiv/aids, including, members of minority groups, women and the economically underprivilege d, aids outcomes have not changed so favorably. one obvious factor to consider when explaining disparities in aids outcomes is the environ· ment within which an individual resides. few studies of aids outcomes have focused on how commu· nity setting influences the effectiveness of care delivery. the principle research questions were: 1) what is the relationship between the locations of areas with concentrations of pl wa and the distribution of both primary and ancillary service providers? 2) how has the widespread availability of haart (after 1996) impacted aids outcomes at the community level? 3) how do aids mortality and fatality rates vary when related community characteristics, such as household income, ethnic mix, and geographic access to primary and ancillary hiv/aids services are considered? we examine this issue across residential communities in the los angeles area. methods: los angeles county's comprehensive aids service providers database (compiled and maintained by aids project los angeles) was geo-referenced and distances between weighted mean population centers and the nearest hiv/aids service providers were calculated to provide a measure of access which was then merged with aids diagnosis and mortality data along with relevant socioeconomic and population indicators and for analysis using bivariate and multivariate statistics at the zip code level. results: there is a growing disparity in hiv/aids outcomes between low-income minority areas and affluent non-minority areas in the post-haart era (p = 0.002). ancillary aids services such as case management and counseling and testing are located near the places where low income hiv/aids service consumers are likely to live (p =.000). in spite of having more access to ancillary services low income areas continue to be associated with smaller decreases post-haart aids mortality rates (p=0.301). conclusions: given the increasing disparities in aids outcomes between lower and upper income communities in the post -haart era, more specific research into the capacities of aids services providers and the efficiency of their interventions is required. although it is clear that ancillary services are operating in the areas of greatest need, their effectiveness remains limited. understanding the reasons for t~is, be they lack of adequate resources for inner city service providers, failure to reach target popula· tmns or other causes, requires additional research. in 20?3, y.out~ who were able to speak either french or english and had been absent from their parent's/ c~regivers ~es.1dence for at least three consecutive nights took part in the survey which consisted of inter· viewer-adm1ms tered question~aires. p.arti~i~an~s were recruited from drop in centres in 7 cities across <?-nada.y~uth self-report as either using in1ect1on or non-injection drugs. statistical analyses were car· r1ed out using sas version 8. the 'home' is a contested site for many women living in urban areas. women living in poverty and using illicit drugs are largely excluded from participation in dominant 'home-base' gender roles of wife and mother because of economic disadvantage. they thus 'make home' in ways that are specific to their everyday experiences. while research has established links between housing, health and drug use, this literature does not tend to consider the meanings that home may have within the lives of women who lack access to adequate tenured living spaces. this presentation reports the findings of my master's thesis work. using grounded theory methodology within a poststructuralist feminist conceptual framework, i conducted in-depth, open-ended interviews with 11 women living in the toronto area. the women were recruited from within the community through posters at different social service agencies (e.g., drop-in centres, community health centres). they were asked to describe their housing experiences and what home meant to them over the course of their lives. through the data analysis process, a substantive theory of 'making home' for women living in poverty and using illicit drugs emerged. the central concept of making home is a continual process of learning about and interacting with the environment. the process of making home entails different subprocesses: finding home (knowing what is available and accessible, and accessing home), adaptation, and leaving home. the different meanings of home that women developed from their experiences and knowledge emerged as critical components for the process of making home. the women i interviewed were very mobile and experienced constant change with regards to home. home was not considered only in relation to physical living space. home could be made within a relationship or with regards to a possession. while dominant meanings of home relation to tenured living spaces are generally positive, my research indicated that home could also be a negative context. the presentation will describe my research process and findings as well as the theoretical and policy implications of my results. in the western democracies, social citizenship bundles the right to social provision (defined as a share of the social good, not necessarily proportionate to the market value of a citizen's contribution) with participation in the paid labour force. for this reason, social citizenship rights, which usually involve some kind of redistributive measures, are a key mechanism by which states ensure economic equality, or at least, economic equality of opportunity, but are also a mechanism of social exclusion. social rights are inscribed around a single kind of relationship, that which exists between a male family breadwinner and the paid labor market; those who make economic contributions that fall outside this relationship -such as unpaid care-work, or, work that occurs in shadow or underground economiesare to a greater or lesser degree barred from accessing citizen-based social provisions. furthermore, social provision that occurs outside of the breadwinner/market-eco nomy dyad is very often meanstested and is accompanied by regulatory state apparatuses (this includes a range of social services, from welfare payments, to child-care subsidies, to disability pensions). social citizenship is thus stratified; the legal relationship that is at the heart of social citizenship acts as a form of social closure against claims for a share of the social good made by those who are 'lesser' citizens than others. of particular interest in this paper is how citizenship inequalities translate into inequalities in the social provisions that emerge from economic participation: the right to safety on the job, protection from employer harassment, protection from the vagaries of the market as well the right to adequate, comprehensive, and appropriate health services. drawing on mixed methods, longitudinal data from adult sex workers (n= 170) located in two research sites with different social welfare regimes -one in canada and one in the u.s. -we examine the consequences of working in a "shadow" or "underground" economy on various facets of health and access to health services, taking into consideration the mediating role that citizenship constructs and social welfare regimes play in accessing other key social and economic determinants of health. methods: the study population included methadone patients (re)admitted at the mhs in the period from 1/1/1996 to 31/1/2002, born in the netherlands, morocco, surinam, dutch antilles or turkye, and officially registered in the population register of amsterdam. the population register was used to ascer· rain the vital status. causes of death were provided by the central bureau of statistics. mortality was categorised as hiv related, directly drug related (overdose) and other.mortality. results: the methadone patients had the following characteristics: 38 years of age at entry; 81% male; 37% ethnic minority; 37% ever injected. in total, 9558 personyear (py) of observation time and 173 deaths (18% hiv related, 14% overdose; 57% other) were observed. hence, the crude mortality rate was 18/1000 py (95% ci 16-21/1000 py). the percentage of (ever) injectors was higher among the native dutch than among the ethnic minorities, 51 % and 14 % respectively. higher rates were observed among native dutch drug users compared to those belonging to an ethnic minority (age adjusted hazard ratio (hr) 1.9 (95% ci 1.4-2.7). the age adjusted hr of (ever) injecting drug users versus non injecting users was 3.0 (95% cl 2.2-4.1 ). after additional adjustment for route of administration a non significant difference between the dutch and ethnic minorities remained (hr 1.3, 95% cl 0.9-1.9, p-value 0.151. conclusion: the mortality rate among the heroin users in amsterdam is strongly affected by the high prevalence of non-injecting drug use. moreover, this study confirms that differences in mortality between the native dutch and the ethnic minorities is related to differences in route of administration. the ongoing reduction of injecting drug use (due tot selctieve mortality, and switching route ofadministration and popularity of crack cocaine) may lead to a further reduction of mortality rates among heroin users in amsterdam. interventions preventing the initiation of injecting should be encouraged. . introduction: food insecurity is an inequality that is central in the lives of many low-income cana· d1ans. people lack food security when regular access to nutritious food is limited or variable due to high prices'. low income, lack of transportation or inadequate food distribution, or they become disadvan· taged m other w~ys through the acquisition of food. a group comprising academics, health profession· als, and commumty workers who have experience in food insecurity, developed a pilot study in ottawa that sought to und~rstand the lived experience of food insecurity. the study also used the united states department of agriculture (usda) community food security module. methods: a series of group meetings determined the best research approaches; questionnaires and consent forms were developed by a working group. twenty-three self-identified food insecure respon· dents were interviewed. the data were analysed using frequency distributions· the food security module was coded according to the usda coding guide, and open-ended responses w~re coded using a grounded approach. renlts: preliminary results from our pilot study have given the research team cause for considerable concern. out of 14 households without children, 11 experienced food insecurity with hunger; 5 ~ere at the severe l~vel. out of 9 households with children, 7 experienced food insecurity with hunger. ~•rst person reflecnons commonly featured feelings of depression low self-esteem and despair. participants' account tha d . an 1 cu ty gettmg to the store, severely limited putting knowledge and skills mto practice. l'oster sessions v109 conclusion: based on these early findings, our research team is looking to challenge what appear to be assumptions about poverty and food insecurity and for best ways to use this information. some policy approaches and interventions that encourage people to eat better and exercise more, may be missing the mark for low-income individuals, and may serve to maintain food insecurity. future research will build on this pilot. with methods augmentation, and a comprehensive knowledge dissemination plan, we hope co contribute to research and policy frameworks at all levels. ps-25 (a) mental health and the corrections system: population-based analyses in urban, semi-urban, and rural settings julian somers, robert watts, and michelle patterson introduction: according to recent epidemiological research, rates of mental disorders vary considerably across countries and across regions within countries. nevertheless, rates of mental disorders (including substance use disorders) are consistently higher in populations involved in the corrections sys-1em. courts have long recognized the heavy burden of mental illness within their purview, and have developed innovative programs to better manage the needs of such individuals. the majority of these innovations (e.g., specialized courts) exist in urban settings. however, few studies have examined the degree of variability in rates of different mental disorders between courts in urban and other settings (e.g., semi-urban, rural). variability between courts in different settings, if present, holds implications for needs-based resource planning. the present study was conducted as part of a long-term inter-ministerial collaboration in british columbia (bc). analyses were conducted on linked administrative data regarding population health and correctional services. a database was constructed including all individuals sentenced in bc in a single year (n=49,142). corrections records were matched to records of health services utilization (hospital and outpatient services) for mental disorders and substance use disorders in the years preceding sentencing. services for mental health and substance-related problems were aggregated into three groups: severe mental illness (smi); less-severe mental illness (lsmi); alcohol/other drug (ad). courts were grouped, based on their annual volumes, inro three categories: "urban"; "semi-urban" and "rural." rates of service use for mental disorders were compared between groups for 1-year and 5-years preceding sentencing. results: there were significant differences in the rates of mental disorders in courts of different size (urban, semi-urban, rural) . however, differences between the rates of disorders within each of these groups exceeded the discrepancies between groups. comparatively high and low rates of disorders were observed in courts of each size. moreover, the courts with the highest rates of certain disorders (e.g., ad) did not have the highest rates of other types of mental disorders (e.g., smi). conclusions: rates of mental disorders differed significantly among the annual populations sentenced across courts in bc. urban courts (which process comparatively large numbers of people) have implemented services to address the needs of the mentally ill. the present analyses strongly suggest that program development should be closely linked to the demonstration of need. the results caution that a uniform approach to court programs for the mentally ill is likely to be inefficient, over-supplying services in some settings and underestimating need in others. results: public settings used for injection are characterized by highly unhygienic conditions, the presence of unsafely disposed syringes, limited availability of sterile syringes and a lack of sterile water for injecting. a number of unsafe injection practices observed were common among public injectors. the presence of police officers nearby and the potential of assault by street predators fostered rushed injecting among those consuming drugs in public spaces. the ecological features of these environments encourage unhygienic and unsafe injecting practices, heighten risk for overdose and the transmission of blood borne viruses. introduction: approximately 13% of women experience depression in the first weeks or months after giving birth. although it has been argued that postpartum depression (ppd) is a culture-bound p~ nomenon, experienced only in western, industrialized countries, recent international research studies have confirmed that the prevalence of ppd is similar around the world. however, little is known about variables that may influence the experience of ppd in women from diverse cultures and immigrant women. research is needed to identify the role culture may play in the presentation of ppd (i.e., types of symptoms most commonly reported), how women from various racial, ethnic and cultural backgrounds perceive and attribute their symptoms of ppd, and finally, how culture can be appropriately addressed in ppd treatment programs. method: to examine the role of culture in ppd, semi-structured interviews and self-report question· naires were administered to clients of the women's health centre of st. joseph's health centre, tor· onto. participants were identified as either first generation canadians (relative newcomen) (n=8) or second generation canadian (parents were immigrants to canada) (n=6). data were collected qd these two groups of women based on: severity of depression, symptom presentation, perceived role of social supports and culturally-specific traditions, and barriers and responses to treatment. the interview data were analyzed using qualitative methods (thematic content analysis), and the following themes were identified: 1) stress about passing on their culture to their children, 2) lack of social support and feelings of isolation, 3) perceived importance or lack of importance of cultural based tra· ditions, 4) conflicts with family members. about cultural traditions and beliefs, 5) mental health stigma within ethnic communities and beyond, 6) race-and sex-based discrimination, and 7) language barriers. conclrllion: identifying the role culture plays in the presentation of ppd, and how women from diverse backgrounds perceive and attribute their symptoms of ppd, is critical in order to establishcultur· ally appropriate guidelines for treatment options. furthermore, information gathered from this study can be used to develop policies and resources for delivering culturally competent care for newcomer wo~ who are dealing with ppd as well as the issues around acculturation (i.e., language barriers, racism). llus is of particular importance for urban health centers which provide postpartum care to diverse groups of women, and particularly recent immigrants or newcomers. ps-~8 (al. contaminated 'therapeutic landscape': perceptions of the aamjiwnaang fint nation keyln smith and isaac luginaah . in~: this. paper pres;ents the findings of an ongoing study among the aamjiwnaang f!rst nanon. aam11wnaang is located m the heart of samia's 'chemical valley', surrounded by cherrucal ~(ants such as esso, imperial oil, shell, suncor energy, and canada's largest hazardous waste disposal sate. safety kleen. this fint nation community is located within the st. clair river •area of concem'. as destgna~ by health canada for the population of samia and the surrounding region. although this comm_umty, by way of. its proximity to the numerous chemical plants is already exposed to high levels pollu~on, recent che?ucal dumping in ~mjiwnaang, as well as a failed proposal for another ethanol plant m the community, only helped to mtensify community concerns about potential health impacts of exposure. research on the cultural beliefs and traditions of first nation communities has established that th~ ~isting rel~tionship between first nations people and 'mother earth' is not only physical, but also_ spmtual. in this study we explore how the complex relationship between the aamjiwnaang first naaon and 'mother earth' be ha · · · i .. may c ngmg 111 a contammated 'therapeutic' landscape. the study a so ~lores h?w aam11wnaang residents are coping with these changes and with the probable conramina· boa of their community. ra!jts: aamjiwnaang residents acknowledge that they are living in a contaminated environment and are being impacted by emissions from the surrounding 'chemical valley' especially for future generations, and have expressed concerns that members of the community and mother earth are 'sick' as a result of this exposure. while moving from that 'place' has been discussed, residents have strong personal and generational connections to the land and insist however, that aamjiwnaang is their 'home' and will remain that way despite growing community concerns about the impact from industry. the contribution of this study lies in the direct involvement of community leadership in designing and conducting this research and distributing the results to further local policy development regarding community concerns on the reserve. background: truck driver are at very high risk for drug abuse because the factor contributing to drug abuse among driver are multiple. it is important to gain an understanding of the key factors that contributing to drug abuse among truck drivers. methods: seventy-truck driver aged 25-35 years were conveniently selected from the population. all the participants were male. an interview schedule was developed in the light of literature data and data were collected by personal interview with informed consent in selected urban area of eastern part of nepal. results: a considerable percentage of truck driver have less knowledge about drug abuse, its effect on body and their complication. majority of the participants (90%) explained that lack of education, financial crisis were leading factors of drug abuse. the average numbers of respondents were believed that lack of meaning in life, marital disharmony. friendship with drug abuser, stress, tiredness, modernization of life pattern and freedom from the home pressure were the influencing risk factors to drug abuse. conchuion: this study reveals those truck drivers are at risk in urban area for developing drugs abuse, mostly influenced by social and environmental factors. hence, these groups should undergo certain educational programme to prevent not only drug abuse, but also prevent transmission of infectious disease among these groups. introduction: food insecurity is an inequality that is central in the lives of many low-income canadians. our group of university researchers, health professionals, and community developers conducted a study in ottawa with community workers who work with people identified as food insecure. the purpose of the study was to understand the nature of their work, and their perspectives, perceptions and experiences of the causes and consequences of food insecurity. (a parallel study was conducted with food insecure participants). methods: sampling was through local knowledge of organizations involved in the provision of food to community members. written permission for the researchers to contact workers in confidence was obtained from each organization. thirteen in-depth interviews were conducted. the interviews consisted of a number of open-ended questions. the data were collated, and analysed using a grounded approach. results: workers interviewed represented organizations that offered diverse programming and methods of food distribution intended to address the needs of the community. the provision of food was seen as a necessary response to address hunger that arose for the majority from poverty caused by low income, or levels of government income support and safety nets that were insufficient to support food requirements. workers reported that food requirements varied according to different. ethnic backgrounds, ages of recipients and family configurations, and with food preferences, and d'.etary (health) requirements. workers' observations of the effects of insufficient food on adults and children such as depression, low energy and non-participation or social disengagement matched those of food insecure respondents. food insecurity was cited as "another srressor among the mountain of problems." overall, workers presented a picture of a silent, stigmatized, poor population including children, and a lack of advocacy to address the issues. be tha th · ·ty the results suggest that workers and organizations, like the commuruty mem rs t ey msecun • · · · · f ilab'l' f food · t d ·n thei·r ab1'l1'ty to address food insecurity. l1m1tanons m terms o ava 11ty o , serve, are restnc e 1 . . funding, and donations appeared to set the para?1eters of pr~g:am r.espon~ to commuruty food msecurity. workers were concerned with program des1g": and a~m1mstranon that m general addr~d hunger on an emergency short-term basis, although food msecunty was long-ter_m for ~any. sustainable solutions that include knowledge translation strategies, and health and social pohcy responses were suggested and will be explored in future research that hopes to build on this pilot. background: socioeconomic deprivation as well as low levels of soc!al s.uppoi:r have .been associated with poor outcomes following cardiac surgery. pre-operative depression m ~anents with coron~ry artery disease awaiting cabg ranges from 27-47% and is an independent predictor of post-operanve mortality. since st. michael's hospital has a large inner city population, this study was designed to determine the both the prevalence of depressive symptomatology (ds) in patients awaiting cabg as well as its relationship with socioeconomic status (ses) and social support. methods: consecutive patients referred for isolated cabg were invited to complete the centre for epidemiological studies depression scale (ces-d) as well as a social support scale and a life stressors inventory. a ces-d score of 2: 16 represents mild ds and a score of 2:27 represents moderate to severe ds. participants also recorded information on functional status, perceived progression of heart failure, demographic and ses variables. all participants with ces-d scores 2: 16 were considered to have ds. results: of the 75 patients (75%) who returned the survey, 22 (29.3%) of participants had a ces-d score 2: 16 with 8 (10.7%) of those having scores suggestive of severe depression. females and those with ongoing medical concerns tended to have more ds (p= 0.06 and p= 0.07 respectively). age was not related to ds. perceived worsening of symptoms and increased ccs angina class were significantly related to the presence of ds (p= 0.03 and p= 0.03 respectively) but not the number of diseased heart vessels. satisfaction with personal relationships including having someone to confide in (p=0.01), feeling lonely (p= 0.04) and not having a partner (p= 0.007) were significantly related to ds. being very upset by a recent breakup in the immediate family was also significantly related to ds (p= 0.02). having greater than a grade 9 education was the only ses variable related to ds (p=0.06). multivariate logistic regression suggested that not being partnered and having low education were the most significant predictors of ds. conclnsion: pre-operative depression is present in at least one quarter of patients referred for cabg. since ds is related to poor outcomes following cabg, single patients with few social supports and low education should be considered at high risk for ds. these findings support the need for the development of supportive interventions in patients at risk in order to decrease post-operative morbidity. this study examines the relationship between childhood sexual abuse, sexual assault during adolescence, and hiv-risk-related behaviours in a sample of 919 homeless youths. over the past decade, there has been increasing research devoted to the impact of childhood sexual abuse. some studies have suggested that the experience of childhood sexual abuse is associated with substance use and abuse, at· risk sexual behaviour and subsequent higher rates of hiv infection (ompad et al., 2005; cinq-mars et al., 2003; brown et al., 1997) . other studies have found that childhood abuse, especially sexual abuse, is c_o~n among stree~ youth (noell et al. 1999 ). this study compares sexually abused males and females livtng on the street ~th non-sexually abused street youth, with regards to unsafe sexual behaviours and e~ures to potmnal t:dv sources (e.g., tattooing, body piercing and injection drug use). the hypothe-sis oft~ ~nt study is that the prevalence of hn-risk-related behaviours will be higher among street youth vtctuns of sexual abuse than those who have not been sexually abused. the sample includes 919 youths aged 13 to 25 who met specific criteria's for itinerancy (649 male and 270 female, with a mean ~of 19.4 y· and a standard deviation of 2.9). they were recruited through five organisations working ~th~ you~ and were~ of an ongoing cohort study. all youth completed a 45 to 60 minute ques· ~onnaue on their sexual behaviours, use of drugs and alcohol and other hiv risk behaviours. oral spec· unens for hiv testing were. also collected. a total of 357 (38.9%) youth reported at least one incident of ~i •~use/assault (1~1 girls (67.0% of all the girls) and 176 boys (27.2% of all the boys]). preliminary descnpnve analyses pomt to sexually abused/assaulted youth showing the highest prevalence of sexual poster sessions v113 at-risk behaviours. for example, 43.3% of sexual abuse/assault victims have engaged in prostitution in their lives compared with 13.4% in the non-sexually abused/assaulted group. in addition, 42.6% of sexual abuse/assault victims reported having injected drugs, compared with 32.0% in the non-sexually abused/assaulted group. more statistical analyses will bring other significant factors to light, especially when we analyze separately those victim of childhood sexual abuse as compare to those victim of sexual assault after childhood. elucidating the risk factors for getting involved in hiv-risk-related behaviours is important for the development of comprehensive and appropriate prevention and treatment intervention strategies. introduction: new immigrants and refugees to canada frequently emigrate from regions of the world where intestinal parasitic infections with worms are endemic. of note, some of these parasites area capable of surviving for years to decades within a given host and can have life threatening consequences many years after initial infection. thus, early diagnosis and treatment of intestinal parasitic worms is considered important in high risk immigrant populations, however there remains a lack of consensus regarding the best method of accomplishing this. diagnosing worm infections through stool examinations is costly and has limited sensitivity, while presumptive treatment of all immigrants, although advocated by some, is expensive and results in healthy individuals being unnecessarily treated. herein, we examine the utility of a hematologic marker (i.e. peripheral blood eosinophilia) as a screening instrument to identify parasitic worm infections in new immigrants to toronto. we identified 192 adults, 15 years of age or older, who were screened for intestinal parasitic infections by stool examination as part of a recently developed screening protocol at a downtown toronto community health centre. we examined the prevalence of infections with worms and subsequently evaluated the impact of several demographic factors on the presence of worm infections. we also determined the sensitivity and specificity of peripheral blood eosinophilia (defined as greater than 500 eosinophils per ml) as a marker for intestinal parasitic worm infections. results: overall, 21 % of the 192 immigrants tested had evidence of at least one worm infection on a single stool examination, while 4% of such individuals bad infections with multiple worms concurrently. age did not appear to be associated with the presence of worms, however 29% of males had evidence of worm infections compared with 16% of females (p= 0.03). immigrants from asia, sub-saharan africa, and central america had the highest burden of overall infection. the sensitivity and specificity of peripheral blood eosinophilia for worm infections was 24% and 92% respectively. conclusions: one in five recent immigrants presenting to a community health centre in downtown toronto had evidence of at least one intestinal parasitic worm infection. the highest burden of illness was in men and in those emigrating from less developed regions of the world. peripheral blood eosinophilia is a poor screening test for worm infections however its presence is highly suggestive of the existence of worms in new immigrants. more than a decade ago, the journal of american college health recommended that a national study be conducted to measure the health status of african american college students, 'both health disparities and [their] positive healthful behaviors' (fennell, 1994) . it was later decided that when exploring the level of health risk behaviors for african american students, gender is an important variable and should be included in the research (fennell, 1997) . at historically black college and universities (hbcus) college health researchers must tackle gender disparities through highly-effective health promotion and disease prevention programs. the purpose of this review is to examine the literature that addresses the overarching health behaviors (i.e. risky sexual behavior, poor diet, smoking, physical inactivity, etc.) of african american men who attend hbcus. despite the various social, cultural, and academic benefits of african american students who attend hbcus, the number of research studies that adequately address their health and health behaviors is limited. studies indicate that african american men who attend hbcus are actively engaged in poor health behaviors. compared to females at hbcus, african american men are more likely to behave in ways that could result in injuries and the use tobacco, alcohol, and ~ther dru~. the city of toronto has recently proposed to conduct a street count of the homeless. like proposals that have come before, this most recent proposal is controversial among many homeless advocates and service providers because it is perceived as intrusive, likely to undercount the target population, and unnecessary for addressing the problem. advocates of the count view it as necessary to gauge the scope of the problem and advise city leaders about how to most effectively direct resources ro.the various homeless services. this paper first reviews the history of efforts to count homeless populat10ns m toronto, describing the motivations and arguments of people on both sides of the issue. second, the paper reviews the methodological complexities of counting homeless populations, describing approaches that use shelter-counts, administrative data and street observations. those interested in counts for toronto and elsewhere can benefit from this review of approaches that have been proposed and carried out in other municipalities. third, the paper proposes a new community-base d strategy that joins the skills of methodologists, local experts, and service providers to ensure a fair and accurate count. the method of systematic social observation avoids some of the problems of early counts by utilizing a repeated identification approach to minimize undercount bias. the method also has the advantage of involving and compensating homeless individuals for assisting with the street count estimates. the estimation approach can be implemented on a rolling basis throughout the year. drug transitions) is a multi-level study aimed at examining the associations between features of the urban environment and mental health, drug use, and risky sexual behaviors. research participants are being recruited in 36 new york city (nyc) neighborhoods. an essential first step in the implementation of this study was to delineate boundaries for each target neighborhood that could then be used to establish sampling frames and as key units of analytic interest. although many neighborhood studies rely on pre-established definitions (e.g. those used for the census or administrative purposes), such definitions do not always reflect contemporary settlement patterns. we felt that street level observations were a neces· sary component of the definition process. methods: the procedures used to delineate neighborhoods were: (1) development of census block maps of targeted areas; (2) review of land use maps and census tract data to ensure, prior to going into the field, tha.t particular blocks are residential and likely to have sufficient population for recruitment purposes; and (3) field vislts and observation in each of the targeted areas. field observations focused on: housing characteristics, including housing type and condition; characteristics of commercial areas, such as likely customer base (e.g. local or no~, socio-economic status and ethnicity of customers); pedestrian volume (including con· gregauons of people m parks and outside stores or residences); obstructions to pedestrian traffic (e.g. ma1or thoroughfares, multi-block industry or institutions); and maintenance and use of open spaces. results: in making the final decisions regarding neighborhood boundaries and the inclusion or exclusion of particular. blocks, we considered a broad range of factors including evidence of homogeneity an~ heterogeneity (socmeconomic, ethnic, housing type, environmental) across blocks within and blocks ad1acent to a nei.ghborhood, and across the 36 sample neighborhoods; the potential for efficient recruit· ment of appropriate particip.ants (i.e. sufficient local pedestrian traffic); and boundaries used in reporting census data (s? that population data can be used in our analysis). . altho~gh utilization of field observations for neighborhood definitions is relatively time consuming (ap~~ox1mately 2 hours for a 12 block area, with more diverse neighborhoods taking even longer), we annc1p~t~ that it will substantially improve the quality and consistency of our data gath· ~rmg ~nd analyse~. spec1f1c e?'amples from neighborhoods defined through this process will be given dur· m~ this presentatmn. we will also discuss the merits and limitations of characterizing neighborhoods usmg street level observations. has been no consideration for how social networks are associated with sse. the objective of this study was to identify personal and social network characteristics associated with being a recipient of sse. in this cross-sectional study, idus who injected in the past 6 months were recruited from syringe exchange programs in montreal, canada, between april 2004 and january 2005. information on each participant and on the persons with whom contact had occurred in the past month were elicited using a structured, interviewer-administe red questionnaire. participants provided detailed demographic and drug use information on up to 5 idu members with whom drugs or injecting materials were shared. using logistic regression, personal and network characteristics were examined in relation to receipt of sterile syringes. res.its: of 277 idus, 39% reported receiving sterile syringes in the past month from another idu. the sample mean age was 33 years (range 18-55), 73% male, 91 % caucasian, and 85% cocaine injectors. in multivariate analyses adjusted for age and gender, recipients of sterile syringes were more likely than non-recipients to share drugs after preparation (0r=2.39(1.06-5.42 )), to require help or to have helped inject another idu (or= 3.48(1.60-7.60)), to have asked someone to get sterile syringes from a syringe exchange program (or=2.54[1.20-5.40 )), to lend syringes (or=2.44[1.16-5.16) ) and to use drug preparation water that was previously used by another iou (0r=2.46(1.42-4.28) ) during the past 6 months. recipients also had a higher rate of change (p=0.01) of idus in their drug injecting network during the past month. with respect to social networks, 45% ( 171/348) of idu network members were providers of sterile syringes and were more likely than non-providers to inject everyday (or= 2.50( 1.51-4.15)). when stratified by their role as a sexual partner or as someone who provides support (e.g. friend, family member), further risk behaviours were observed in relation to sharing injecting materials with the participant. conclusion: recipients of sterile syringes and their idu network members had several high-risk behaviours for infection with bloodborne diseases. sse may afford an opportunity for the dissemination of other salutary behaviours such as information sharing on safe injecting practices between recipients and distributors. furthermore, drug injecting networks may be an avenue to reach idus who may not otherwise be exposed to preventive measures. there are numerous sources of stigma and labelling of mental and physical illness. first, the sociocultural dimension to stigma and labelling clearly influences patients, families, health care professionals and society's perception and treatment of illness. this creates multiple challenges related to illness identification and recovery, particularly in culturally diverse societies. second, the media is a major source of stigma and stereotyping with regard to a variety of mental and physical illnesses. despite increased public knowledge of many illnesses, studies have shown that stigma has intensified over the years in certain cases. a third element of stigma and labels appears with the use of diagnosis as a solution to human problems with the result that difficult to treat patients are repudiated and social issues are unaddressed. this presentation will serve to outline the development of stigma, various expressions of stigma, and consequences of stigma. it will provide some practical recommendations for the reduction of stigma related to mental and physical illness. purpose: to assess the knowledge, attitude, and practice about immunization for parent of 2-3 years old hispanic and african american children in los angeles county (lac). methods: we conducted two cluster surveys in lac. the sample was selected with probability proportionate to estimated size at the first stage and simple random sample of children at the second stage. data were collected through interview. we absuacted vaccine coverage data from immunization record card (irc) at home or from clinic records. the participation was 81 % in hispanics and 83% in african americans populations. irc was not available at home for 26% of african american and 16% of hispanic children. results: all parents perceived their children got all necessary vaccine~. fa~orable attitudes to.w~rd immunization were reported by 82 % of african american and 90% of h1s?amc parents. '.he m~1ority of the parents (90% african american and 95% hispanic) agreed that vaccines prevent senous d1se~ses among children. regarding vaccine safety, significantly more hispanic parents (91 %) than african american parents (75%) mentioned that vaccines are safe. introduction: cervical cancer has been shown to be preventable by papanicolau tests in heterosexual women; however, the utility of papanicolau test in lesbians is controversial. cervical cancer is caused by the human papillomavirus (hpv) which is transmitted by sexual _intercourse; howev_er, its' transmission by homosexual intercourse is also controversial. the goal of this study was to review the evidence for papanicolau tests in lesbians. methods: a pub med, ovid ( 1996 ovid ( to 2005 , and cochrane library search was performed using the mesh headings "homosexuality , female," "vaginal smears," and "papillomavirus, human." in pub med, the clinical queries feature was used with "diagnosis" and "broad, sensitive" filters. a google advanced search of the internet was conducted with the terms "lesbian," "cervical cancer," and "pap rest." the url was limited to ".ca," ".edu," or ".gov." results: the search yielded 8 original articles and 4 reviews, but no cochrane reviews. none of the publications were canadian. 111 website hits were found and selected websites were reviewed. studies showed that lesbians have fewer papanicolau tests than heterosexual women; however, many reported risk factors for cervical cancer, including multiple past or current sexual partners (male and female), early age of first coitus, history of sexually transmitted diseases, and cigarette smoking. hpv has been detected in 13-30% of lesbians and 6-19% of lesbians who have never had sex with men. case studies of abnormal papanicolau tests in lesbians who have never had sex with men have also been reponed. sexual transmission of hpv among lesbians can be explained by several factors: 1) 53-99% of lesbians have had sex with men and 21-30% of lesbians continue to have sex with men. 2) hpv may be transmitted by sexual behaviours among women, like digital-vaginal sex, digital-anal sex, oral sex, and the use of insertive sex toys. 3) hpv transmission requires only skin-to-skin contact. genital hpv has been identified on human fingers. some professional organizations, like the society of obstetricians and gynecologists of canada and the american cancer society, recognize the need for papanicolau tests in lesbians. other organizations, like the canadian cancer society, do not have official policy statements. the current ontario cervical screening program does not specifically address lesbians. conclusion: although the data was limited, most studies recommended that lesbians should receive papanicolau tests. the frequency of these tests was controversial. policy makers and professional organizations should address the needs of this special population and make specific recommendations . monique chaaya, ahia sibai, hiam chemaitelly, and zana el roueiheb . literature concerning the mental and physical effect of work at an old age is contradictory. in addinon, urban environments are physically and socially harsh with reduced potential for income generation and employment and increased potential for depression. the present paper is an attempt to study how do work, or lack of work, link to the experience of depression among older adults in underprivileged lebanese urban communities. the data comes from a cross-sectional survey, where 740 elderly residing in 3 underprivileged communities in beirut, including a palestinian refugee camp, were successfully inter-v1ewed through face-to-face interviews. logistic regression was performed to assess the effect of work on depression ad_justing for many other covariates. data showed that 17.5% of people aged 60 years and more were still workmg. there was a highly protective effect of work on depression in elderly males (or= 0.342, 95% cl= 0.128-0.909). the current study is the first of its kind in the arab region and more work shou_ld be _don_e in this area. it is important for the lebanese government to consider elderly rights for social mclus10n m terms of employment opportunities. amam nuru-jeter, nancy adler, and burton singer . l~u~on:_ the socioeconomic gradient is perhaps the most persistent and significant finding in social epidem1ological research. the insistent nature of the ses effect is evidenced by its significance after acc?untmg for ~umerous confounds. the significance and magnitude of the effect, however, varies by ::•al group. evidence_ o_f the relative effect of race and ses is inconclusive. further, less attention has f ~ ptid to the specific interactions of race and ses than to examinations of which is a better predictor 0 d ~ th. ~sues are further complicated by the explanatory complexity of the various measures of ses anl . owht ey relate to the health of various social groups. understanding the specific nature of these re a11ons ips 1s necessary for guiding he ith d · i 1· · h a an soc1a po mes and programs aimed at improving t e poster sessions v117 health of our most disadvantaged groups, and therefore population health, overall. this study examines the synergistic effects of ses with both race and gender in predicting group differences in mortality. methods: analyses use data from the national longitudinal mortality survey (n= 559, 715) for the years 1979, 1980, and 1981-85; and were linked to the national death index for deaths occurring through 1985. results were confirmed using data from the national mortality followback survey for people who died in 1986 (n= 13,491) and the 1986 national health interview survey (denominator). we used correlation analysis and the standardized mortality ratio to examine ses (education and income), race, and gender as predictors of group differences in changes in mortality. results: for the total population, analyses support the income gradient showing significant declines in mortality ratios from low to high income along the income strata. education shows a significant drop in mortality with completion of high school and completion of college, exhibiting a threshold rather than a gradient effect. compared to whites, blacks receive diminishing health returns for each subsequent level of income and education; with whites closely mirroring the total population in ses thresholds. similarly, compared to men, women do not experience the same health gains at comparable ses levels. for education, black men and women only show significant mortality declines upon completion of high school. the ses gradient operates differently among race and gender subgroups. threshold effects suggest resource gains in life opportunities at particular milestones along the ses gradient. further, ses matters less for blacks and women compared to whites and men suggesting differing implications for health and social policy aimed at reducing disparities. objective: we assessed the impact of diabetes in a large puerto rican community of chicago by measuring the prevalence of diagnosed diabetes and calculating the diabetes mortality rate. methods: we analyzed data from a comprehensive health survey conducted in randomly selected households in community areas. questions on diagnosed diabetes and selected risk factors were asked. in addition, mortality data were analyzed in order to calculate the age-adjusted diabetes mortality rate. when possible, rates were compared to those found in other studies. results: the diabetes prevalence located in this community (20.8%: 95% cl= 10.1 %-38.0%) is one of the highest ever reported for puerto ricans. for instance, it is more than three times higher than the prevalence for the us (6.1 %) and twice the prevalence for puerto ricans in new york ( 11.3%) and puerto rico (9.3%-9.6%). diagnosed diabetes was found to be significantly associated with obesity (p=0.023). the prevalence was particularly high among older people, females, those horn in the us, and those with a family history. the diabetes mortality rate (67.6 per 100,000 population) was more than twice the rate for all of chicago (31.2) and the us (25.4). conclusions: understanding why the diabetes and mortality rates for puerto ricans in this commu· nity are so much higher than those of other communities is imperative. collaboration between researchers, service providers and community members can help address the issues of diabetes education, early screening and diagnosis and effective treatment needed in this community. introduction: sars is a respiratory illness that is spread from person to person through dose contact. this infectious disease outbreak was unusual due to the high rate of infection among health care workers. the aim of the study is to explore the demographic and attitudinal determinants of psychological distress due to sars among health care workers of a toronto hospital. methods: a total of 997 adult participants completed questionnaires co assess psychological distress (impact of event scale -jes) and attitudes to sars. of these, 845 participants completed the questionnaire during the sars i outbreak, and 152 participants completed the questionnaire during the sars ii outbreak. participants also provided information on demographic variables, including occupation and exposure to sars. principal components analysis was used to derive eight attitudinal scales: fear: system, protection, prevention, job stress, stigma, instrumental coping, and psychological copm~. l111ear regression analyses were applied to evaluate the associations of the demographic and amtudmal variables, as well as time, with psychological distress. . . regression analyses showed that time and higher scores on fear, 1ob stress, stigma'. and instrumental coping were associated with a higher total ies score: (r2 =.30). contrary to expectations, none of the demographic variables was associated with total ies score. conclusion: the presence of psychological distress in health care workers is indicative of intrusive or avoidant responses to thoughts, feelings, and memories associated with the sars outbreak. this study shows that ( 1) fear for one's health and the he~lth of.others, (2) ex~erien~in~ job stress, (3)_tbe per· ception of stigma, (4) usage of instrumental copmg skills, ~n~ (5) t1m_e s1grufi~an~ly c~nmb~te to increased psychological distress in health care workers. potential mterventmns during mfecttous diseaie outbreaks in health care settings should be targeted to minimize the impact of these factors. purpose: the purpose of this study was to expand knowledge regarding feeding practices, know!· edge and nutritional beliefs of mothers currently residing in the dominican republic (dr). the rising incidence of obesity in children is a major national health concern and obesity in first and second-generation immigrant children also continues to rise. we know that parents (particularly mothers) shape children's early diet patterns and that immigrant mothers experience additional challenges related to acculturation and assimilation into a new culture, however there is a paucity of literature concerning the effect of immigrant adaptation to american culture on the nutrition of children. in addition, new immigrant knowledge about the causes of obesity and the resulting health implications for childhood obesity has not been assessed and reported. this qualitative study used focus group methodology to discuss views and practices related to the introduction of food for infants and feeding practices for young children, along with a discussion on knowledge and beliefs related to the causes and health implications of child· hood obesity. ten dominican mothers' of young children (birth to 6 years old) who reside in a small town in the western frontier area of the dr were participants in the focus group. results from this srudy will be compared to results from an identical study that will be conducted in fall 2005 with new immi· grant mothers from the dr to the boston area. we will compare feeding practices, beliefs and knowledge about nutrition for young children between these two groups. methods: using participatory principles, a focus group design was used to interview a group of mothers in the dr. the investigator along with a bilingual translator conducted the focus group. the session was tape recorded and is currently in the process of being transcribed and translated. transcribed data will be systematically analyzed themes will be identified. a qualitative data analysis software will be used to organize and code the data according to the specific aims of the study. supporting quotations will be selected to substrate each theme. lmpli~tions for urban health practice: an ultimate goal of this study is to lay a foundation for understanding the process of acculturation on feeding practices of mothers when they immigrate to the us. understanding beliefs, knowledge and feeding practices that mothers use with young children will help m ~he ~evelopment of culturally and linguistically appropriate educational strategies and materials for use m primary prevention of pediatric obesity. in canada more than seventy-five percent of immigrants choose to stay in three major urban centers of toronto, montreal and vancouver. approximately fifty percent of the immigrants eventually set· tie m ~~e greater tor<_>nto area. there is mounting evidence that the increasing immigrant population has a_ sigmfic~nt health disadvantage over canadian-born residents. this health disadvantage manifests particularly m the ma1"ority of 1"mm1"gr t h h d be · · h . . . . an s w o a en m canada for longer than ten years. this group as ~n associ~te~ with higher risk of chronic disease such as cardiovascular diseases. this disparity twccb n ma1onty of the immigrant population and the canadian-born population is of great importance to ur an health providers d" · i i · b as isproporttonate y arge immigrant population has settled in the ma1or ur an centers. generally the health stat f · · · · · · h h been . us 0 most 1mm1grants 1s dynamic. recent 1mm1grants w o av_e ant •;ffca~ada _for less ~han ~en years are known to have a health advantage known as 'healthy imm1• ~ants r::r · ~:s eff~ 1~ defined by the observed superior health of both male and female recent immiimmigrant participation in canadian society particularly the labour market. a new explanation of the loss of 'healthy immigrant effect' is given with the help of additional factors. lt appears that the effects of social exclusion from the labour market leading to social inequalities first experienced by recent immigrant has been responsible for the loss of healthy immigrant effect. this loss results in the subsequent health disadvantage observed in the older immigrant population. a study on patients perspectives regarding tuberculosis treatment by s.j.chander, community health cell, bangalore, india. introduction: the national tuberculosis control programme was in place over three decades; still tuberculosis control remains a challenge unmet. every day about 1440 people die of tuberculosis in india. tuberculosis affects the poor more and the poor seek help from more than one place due to various reasons. this adversely affects the treatment outcome and the patient's pocket. many tuberculosis patients become non-adherence to treatment due to many reasons. the goal of the study was to understand the patient's perspective regarding tuberculois treatment provided by the bangalore city corporation. (bmc) under the rntcp (revised national tuberculosis control programme) using dots (directly observed treatment, short course) approach. bmc were identified. the information was collected using an in-depth interview technique. they were both male and female aged between 4-70 years suffering from pulmonary and extra pulmonary tuberculosis. all patients were from the poor socio economic background. results: most patients who first sought help from private practitioners were not diagnosed and treated correctly. they sought help form them as they were easily accessible and available but they. most patients sought help later than four weeks as they lacked awareness. a few of patients sought help from traditional healers and magicians, as it did not help they turned to allopathic practitioners. the patients interviewed were inadequately informed about various aspect of the disease due to fear of stigma. the patient's family members were generally supportive during the treatment period there was no report of negative attitude of neighbours who were aware of tuberculosis patients instead sympathetic attitude was reported. there exists many myth and misconception associated with marriage and sexual relationship while one suffers from tuberculosis. patients who visited referral hospitals reported that money was demanded for providing services. most patients had to borrow money for treatment. patients want health centres to be clean and be opened on time. they don't like the staff shouting at them to cover their mouth while coughing. conclusion: community education would lead to seek help early and to take preventive measures. adequate patient education would remove all myth and conception and help the patients adhere to treatment. since tb thrives among the poor, poverty eradiation measures need to be given more emphasis. mere treatment approach would not help control tuberculosis. lntrod#ction: the main causative factor in cervical cancer is the presence of oncogenic human papillomavitus (hpv). several factors have been identified in the acquisition of hpv infection and cervical cancer and include early coitarche, large number of lifetime sexual partners, tobacco smoking, poor diet, and concomitant sexually transmitted diseases. it is known that street youth are at much higher risk for these factors and are therefore at higher risk of acquiring hpv infection and cervical cancer. thus, we endeavoured to determine the prevalence of oncogenic hpv infection, and pap test abnormalities, in street youth. ~tbods: this quantitative study uses data collected from a non governmental, not for profit dropin centre for street youth in canada. over one hundred females between the ages of sixteen and twentyfour were enrolled in the study. of these females, all underwent pap testing about those with a previous history of an abnormal pap test, or an abnormal-appearing cervix on clinical examination, underwent hpv-deoxyribonucleic (dna) testing with the digene hybrid capture ii. results: data analysis is underway. the following results will be presented: 1) number of positive hpv-dna results, 2) pap test results in this group, 3) recommended follow-up. . the results of this study will provide information about the prevalence of oncogemc hpv-dna infection and pap test abnormalities in a population of street youth. the practice implic~ tions related to our research include the potential for improved gynecologic care of street youth. in addition, our recommendations on the usefulness of hpv testing in this population will be addressed. methods: a health promotion and disease prevention tool was developed over a period of several years to meet the health needs of recent immigrants and refugees seen at access alliance multicultural community health centre (aamchc), an inner city community health centre in downtown toronto. this instrument was derived from the anecdotal experience of health care providers, a review of medical literature, and con· sultations with experts in migration health. herein we present the individual components of this instrument, aimed at promoting health and preventing disease in new immigrants and refugees to toronto. results: the health promotion and disease prevention tool for immigrants focuses on three primary health related areas: 1) globally important infectious diseases including tuberculosis (tb), hiv/aids, syphilis, viral hepatitis, intestinal parasites, and vaccine preventable diseases (vpd), 2) cancers caused by infectious diseases or those endemic to developing regions of the world, and 3) mental illnesses includiog those developing among survivors of torture. the health needs of new immigrants and refugees are complex, heterogeneous, and ohen reflect conditions found in the immigrant's country of origin. ideally, the management of all new immigrants should be adapted to their experiences prior to migration, however the scale and complexity of this strategy prohibits its general use by healthcare providers in industrialized countries. an immigrant specific disease prevention instrument could help quickly identify and potentially prevent the spread of dangerous infectious diseases, detect cancers at earlier stages of development, and inform health care providers and decision makers about the most effective and efficient strategies to prevent serious illness in new immigrants and refugees. lntrodmction: as poverty continues to grip pakistan, the number of urban street children grows and has now reached alarming proportions, demanding far greater action than presently offered. urbanization, natural catastrophe, drought, disease, war and internal conflict, economic breakdown causing unemployment, and homelessness have forced families and children in search of a "better life," often putting children at risk of abuse and exploitation. objectives: to reduce drug use on the streets in particular injectable drug use and to prevent the transmission of stds/hiv/aids among vulnerable youth. methodology: baseline study and situation assessment of health problems particularly hiv and stds among street children of quetta, pakistan. the program launched a peer education program, including: awareness o_f self and body protection focusing on child sexual abuse, stds/hiv/aids , life skills, gender and sexual rights awareness, preventive health measures, and care at work. it also opened care and counseling center for these working and street children ar.d handed these centers over to local communities. relationships among aids-related knowledge and bt:liefs and sexual behavior of young adults were determined. rea.sons for unsafe sex included: misconception about disease etiology, conflicting cultural values, risk demal, partner pressur~, trust and partner significance, accusation of promiscuity, lack of community endorsement of protecnve measures, and barriers to condom access. in addition socio-economic pressure, physiological issues, poor community participation and anitudes and low ~ducation level limited the effectiveness of existing aids prevention education. according to 'the baseline study the male children are ex~ to ~owledge of safe sex through peers, hakims, and blue films. working children found sexual mfor~anon through older children and their teachers (ustad). recommendation s: it was found that working children are highly vulnerable to stds/hiv/aids, as they lack protective meas":res in sexual abuse and are unaware of safe sexual practices. conclusion: non-fatal overdose was a common occurrence for idu in vancouver, and was associated with several factors considered including crystal methamphetamine use. these findings indicate a need for structural interventions that seek to modify the social and contextual risks for overdose, increased access to treatment programs, and trials of novel interventions such as take-home naloxone programs. background: injection drug users (idus) are at elevated risk for involvement in the criminal justice system due to possession of illicit drugs and participation in drug sales or markets. the criminalization of drug use may produce significant social, economic and health consequences for urban poor drug users. injection-related risks have also been associated with criminal justice involvement or risk of such involvement. previous research has identified racial differences in drug-related arrests and incarceration in the general population. we assess whether criminal justice system involvement differs by race/ethnicity among a community sample of idus. we analyzed data collected from idus (n = 1,084) who were recruited in san francisco, and interviewed and tested for hiv. criminal justice system involvement was measured by arrest, incarceration, drug felony, and loss/denial of social services associated with the possession of a drug felony. multivariate analyses compared measures of criminal justice involvement and race/ethnicity after adjusting for socio-demographic and drug-use behaviors including drug preference, years of injection drug use, injection frequency, age, housing status, and gender. the six-month prevalence of arrest was highest for whites (32%), compared to african americans (25%) and latinos (27% ), in addition to the mean number of weeks spent in jail in the past 6 months (7.0 vs. 5.8 and 4.2 weeks). these differences did not remain statistically significant in multivariate analyses. latinos reported the highest prevalence of a lifetime drug felony conviction (48%) and mean years of lifetime incarceration in prison (13.3 years), compared to african americans (48%, 10.7 years) and whites (34%, 6.9 years). being african american was independently associated with having a felony conviction and years of incarceration in prison as compared to whites. the history of involvement in the criminal justice system is widespread in this sample. when looking at racial/ethnic differences over a lifetime including total years of incarceration and drug felony conviction, the involvement of african americans in the criminal justice system is higher as compared to whites. more rigorous examination of these data and others on how criminal justice involvement varies by race, as well as the implications for the health and well-being of idus, is warranted. homelessness is a major social concern that has great im~act on th~se living.in urban commu?ities. metro manila, the capital of the philippines is a highly urbanized ar~ w.1t~ the h1gh~st concentration of urban poor population-an estimated 752,229 families or 3,005,857 md1v1duals. this exploratory study v122 is the first definitive study done in manila that explores the needs and concerns of street dwdlent\omc. less. it aims to establish the demographic profile, lifestyle patterns and needs of the streetdwdlersindit six districts city of manila to establish a database for planning health and other related interventions. based on protocol-guid ed field interviews of 462 street dwellers, the data is useful as a template for ref!!. ence in analyzing urban homelessness in asian developing country contexts. results of the study show that generally, the state of homelessness reflects a feeling of discontent, disenfranchisem ent and pow!!· lessness that contribute to their difficulty in getting out of the streets. the perceived problems andlar dangers in living on the streets are generally associated with their exposure to extreme weather condirioll! and their status of being vagrants making them prone to harassment by the police. the health needs of the street dweller respondents established in this study indicate that the existing health related servias for the homeless poor is ineffective. the street dweller respondents have little or no access to social and health services, if any. some respondents claimed that although they were able to get service from heallh centers or government hospitals, the medicines required for treatment are not usually free and are beyond their means. this group of homeless people needs well-planned interventions to hdp them improve their current situations and support their daily living. the expressed social needs of the sucet dweller respondents were significantly concentrated on the economic aspect, which is, having a perma· nent source of income to afford food, shelter, clothing and education. these reflect the street dweller' s need for personal upliftment and safety. in short, most of their expressed need is a combination of socioeconomic resources that would provide long-term options that are better than the choice of living on the streets. the suggested interventions based on the findings will be discussed. . methods: idu~ aged i 8 and older who injected drugs within the prior month were recruited in 2005 usmg rds which relies on referral networks to generate unbiased prevalence estimates. a diverse and mon· vated g~o~p of idu "seeds." were given three uniquely coded coupons and encouraged to refer up to three other ehgibl~ idu~, for which they received $5 usd per recruit. all subjects provided informed consent, an anonymous 1~t erv1ew and a venous blood sample for serologic testing of hiv, hcv and syphilis anti~!· results. a total of 213 idus were recruited in tijuana and 206 in juarez, of whom the maion!)' were .male < 9 .l.4% and 92.2%) and median age was 34. melhotls: using the data from a multi-site survey on health and well being of a random sample of older chinese in seven canadian cities, this paper examined the effects of size of the chinese community and the health status of the aging chinese. the sample (n=2,272) consisted of aging chinese aged 55 years and older. physical and mental status of the participants was measured by a chinese version medical outcome study short form sf-36. one-way analysis of variance and post-hoc scheffe test were used to test the differences in health status between the participants residing in cities representing three different sizes of the chinese community. regression analysis was also used to examine the contribution of size of the chinese community to physical and mental health status. rmdts: in general, aging chinese who resided in cities with a smaller chinese population were healthier than those who resided in cities with a larger chinese population. the size of the chinese community was significant in predicting both physical and mental health status of the participants. the findings also indicated the potential underlying effects of the variations in country of origin, access barriers, and socio-economic status of the aging chinese in communities with different chinese population size. the study concluded that size of an ethnic community affected the health status of the aging population from the same ethnic community. the intra-group diversity within the aging chinese identified in this study helped to demonstrate the different socio-cultural and structural challenges facing the aging population in different urban settings. urban health and demographic surveillance system, which is implemented by the african population & health research center (aphrc) in two slum settlements of nairobi city. this study focuses on common child illnesses including diarrhea, fever, cough, common cold and malaria, as well as on curative health care service utilization. measures of ses were created using information collected at the household level. other variables of interest included are maternal demographic and cultural factors, and child characteristics. statistical methods appropriate for clustered data were used to identify correlates of child morbidity. preliminary ratdts: morbidity was reported for 1,087 (16.1 %) out of 6,756 children accounting for a total of 2,691 illness episodes. cough, diarrhoea, runny nose/common cold, abdominal pains, malaria and fever made up the top six forms of morbidity. the only factors that had a significant associ· ation with morbidity were the child's age, ethnicity and type of toilet facility. however, all measures of socioeconomic status (mother's education, socioeconomic status, and mother's work status) had a significant effect on seeking outside care. age of child, severity of illness, type of illness and survival of father and mother were also significantly associated with seeking health care outside home. the results of this study have highlighted the need to address environmental conditions, basic amenities, and livelihood circumstances to improve child health in poor communities. the fact that socioeconomic indicators did not have a significant effect on prevalence of morbidity but were significant for health seeking behavior, indicate that while economic resources may have limited effect in preventing child illnesses when children are living in poor environmental conditions, being enlightened and having greater economic resources would mitigate the impact of the poor environmental conditions and reduce child mortality through better treatment of sick children. inequality in human life chances is about the most visible character of the third world urban space. f.conomic variability and social efficiency have often been fingered to justify such inequalities. within this separation households exist that share similar characteristics and are found to inhabit a given spatial unit of the 'city. the residential geography of cities in the third world is thus characterized by native areas whose core is made up of deteriorated slum property, poor living conditions and a decayed environment; features which personify deprivation in its unimaginable ma~t~de. there are .eviden~es that these conditions are manifested through disturbingly high levels of morbidity and mortality. ban · h h d-and a host of other factors (corrupt10n, msens1t1ve leaders 1p, poor ur 1ty on t e one an , . · 1 f · 1 · · th t ) that suggest cracks in the levels and adherence to the prmc1p es o socta 1usnce. ese governance, e c . . . . . ps £factors combine to reinforce the impacts of depnvat10n and perpetuate these unpacts. by 1den· grou o . ·1 "id . . bothh tifying health problems that are caused or driven by either matena _or soc1a e~nvanon or , t e paper concludes that deprivation need not be accepted as a way. of hfe a~d a deliberate effon must be made to stem the tide of the on going levels of abject poverty m the third world. to the extent that income related poverty is about the most important of all ramifications of po~erty, efforts n_iu_st include fiscal empowerment of the poor in deprived areas like the inner c~ty. this will ~p~ove ~he willingness of such people to use facilities of care because they are able to effectively demand 1t, smce m real sense there is no such thing as free medical services. ). there were 322 men with hiv-infection included in the present study (mean age and education of 41.8 (sd=8.4) and 13.9 (sd=2.7), respectively). a series of multiple regressions were used to examine the unique contributions of symptom burden (depression, cognitive, pain, fatigue), neuropsychologic al impairment (psychomotor efficiency), demographics (age and education) and hiv disease (cdc-93 staging) on iirs total score and jirs subscores: ( 1) activities of daily living (work, recreation, diet, health, finances); (2) psychosocial functioning (e.g., self-expression, community involvement); and (3) intimacy (sex life and relationship with partner). resnlts: total iirs score (r 2 "0.43) was associated with aids diagnosis (ii= 0.11, p <0.01) and symptoms of pain (ii= -0.14, p < 0.01 ), fatigue (ji = -0.34, p < 0.001) and cognitive difficulties (p =0.30, p < 0.001 ). for the three dimensions of the iirs, multiple regression results revealed: ( 1) activities of daily living (r2=0.42) were associated with aids diagnosis (ii =0.17, p < 0.01) and symptoms of pain <p =-0j6, p < 0.01 ), fatigue (ji = -0.31, p < 0.001) and cognitive difficulties (ji =0.32, p < 0.001 ); (2) psychosocial functioning (r2=0.31) was associated with was associated with symptoms of fatigue (ii= -0.25, p <0.001) and cognitive difficulties <ii =0.19, p <0.001); and (3) intimacy (r2=0.17) was related to was associated with symptoms of fatigue (ij = -0.17, p < 0.01) and cognitive difficulties (ii= 0.19, p < 0.001 ). methods: the sif evaluation methodology involves a comprehensive database located at the sif, a randomly selected p~o.spective coh~rt of sif users, and two pre-existing external control cohorts. . . ~ts: in addmon to reporting process data and descriptions of the sif users, we report on data indicating that the establishment of the sif has been independently associated with reductions in public ~':°g ~ (p <?.001), and syringe sharing (aor =0.3[95%ci: 0.1 _ 0.7); p =0.013) and other unsafe m1ecnon pract1_ces_ (p ~ 0.010), and increased uptake of detox services (log-rank p =0.017). as well, we report on da~ md1cat1ng that the sif has not prompted adverse changes in community drug use patterns. the vancouver sif has been well accepted by the target population, and while adve~ events s~c~ as overdoses have occurred, these events have been successfully managed. externally compiled data indicate that the sif has been associated with substantial declines in public disorder !'oster sessions v125 associated with injection drug use, syringe sharing, and increased uptake of detox services. as well, the establishment of the sif has not exacerbated community drug use patterns. ongoing evaluation activities wiu involve assessing the impact of the sif on a variety of outcomes, including infectious disease transmission, fatal overdose, and utilization of health and social services. city, brazil, 1996 -2002 maria cristina almeida, waleska caiaffa, renato assum;iio, and fernando proietti dengue cases were described according to time, space, intensity, age, gender, onset of symptoms, residence address and census tract. spatial distribution of two groups (children and women over 64 years old and men aged 20-59) were compared, under assumption that they have distinct behaviors regarding their displacement around the city. analysis included local moran index, ripley\\'s k function and recurrence of census areas over time. about 99,559 cases were identified in seven epidemic waves. concentration of cases in small areas, followed by a spread either in space or time suggested endemic patterns. regarding age-gender groups, distinct patterns suggested that residence might not be a good proxy in determining the local of infection for men aged 20-59. dengue is shifting to endemic pattern in this city and transmission may not be sole related to home environment, suggesting that additional spatial information must be couected aiming efficient control measures. murukan kandamuthan and subodh kandamuthan lnl7uduction: illness or disablement of a child may affect the economic functioning of a family as it alters the employment pattern and earnings of parents this paper tries to assess the health status and the quality of life of disabled children, and how generally, severe disablement in a child affected their fami-lies\' finances, and to quantify any such effects the problems faced by children in their home and to provide information relevant to the formation of criteria for new or increased cash support. methods: a case-control study was done in the thiruvananthapuram district, capital city of kerala by selecting a random sample of 300 families with severely disabled children below 15 years and a random sample of 300 normal children matched for age and occupation of the parents. comparative and subjective data were collected. money spent on children\'s medical care, loss of earnings of the parents, and other economic burden to the family due to the disability of the child in the family. a discriminant analysis along with univariate analysis was done to assess the factors that mostly differentiate the disabled and normal children. the mean expenditure of the families with a disabled child was rs. 852/-per month, which is significantly higher than the corresponding expenditure of rs. 389/-per month of families with normal child, (t= 16.86, p <.00001). of the disabled children, 81 % were not getting any social security payments and 90% had no special concessions for medical and other educational purposes. the analysis of income and expenditure pattern indicated that financial impact of disablement in a child on the family is significant. the discriminant model results revealed that medical expenditure was a significant variable that differentiated the disabled and normal child. the study found that the health status and quality of life of the disabled children were far from satisfactory. this in fact affected the economic status of the disabled children. in addition to reduced earnings, there are extra costs for disabled children for travel, domestic help, medical care, and health care expenditures (hospital care, physician services, dentistry, drugs and others) for disabled individuals. a strong case can be made for their long-term care by improving the financial support to such families possibly through the introduction of an allowance specially to compensate for the earnings lost by parents due to the disability of their children. widows in india are considered disadvantage group of population. because they are characterized by pangs of separation from spouse, and consequently they go through mental agony, social ~s?lation, and economic dislocation. in addition to these, poverty, landlessness, homelessness, malnutr1non etc. endure serious deterioration of their health. according to census 2001, there are 44 million women are widowed and one fourth live in urban areas. there is a noticeable increase of urban widows from the previous census (almost half). the paper examines the type of disability and chronic ailment borne among elderly widows (60 years and above). fifty second round of national sample survey aske~ the individuals three sets of questions regarding their health: their status of health, whether they are physically poster sessions v126 immobile, and whether or not they have had any specific chronic illnesses. although health infrastruc-1 1 ·1 ble 1 ·n urban setting in india as compared to rural counterpart, prevalence of tures are arge y ava1 a . . . . . h · ·11 · h h"gher 1 "n urban areas analysis shows 1omt problems m old age qmte common c romc 1 ness is muc 1 • . . and nearly 44 percent elderly widows are suffering from this ail'.11ent in urban areas. one-fifth of widows are suffering from high/low bp. heart disease, diabetes and urinary problems are much ~ore pre~alent in urban areas though disabilities is comparatively lower in urban areas. however, the d~fference is not statistically significant. disability with respect to vision is more pronounced and one third_ of the total respondents have problems regarding eyesight. one fifths ofdderly widows are _ha.rd of hearing. though disability increases with age, similar trend is not observed with respect to chr~mc illness. the percepnon of self-health among elderly becomes poorer as their age increases. the perceived health status need not be always corrected to objective indicators of health. it is noted that around 27 per~en~ of those perceived their health as "excellenr" or "very good" are found to be suffering from chrome disease of1omts and 17 percent have visual disability. to conclude an elderly widow living in urban areas have similar health problems as she jives in rural areas. this can be easily explained, as they were not made aware to seek treatment from health facility. in addition, the study shows that the economic conditions are deterrent factors for their illness. it is essential that intervention should be taken up improving their economic conditions so that wellbeing of this most vulnerable group of the society can be taken care of. heart failure is a disease that affects nearly 15 million people world wide. the united states alone accounts for one third of this population. blacks are stricken with heart failure twice as often as whites. men are more likely to develop chf than women, however since the majority of the chf population are seniors, there are actually more women than men. congestive heart failure (chf) has become a pandemic. as the baby boomer generation ages, the number of chf cases will rise dramatically. (young, j. & mills, r.,2004). after the age of 45, each proceeding decade doubles the incidence level of chf. the average person has a 1 in 5 chance of developing heart failure within their lifespan according to the framingham study (nih.gov). individuals aging 65 or older compose over half of the entire documented heart failure population. in this age group, chf is the leading cause of hospitalization. many patients are continuously readmitted. it is estimated that the chf population will increase by one million within the next 25 years. mortality was at 50% for a two year period and 70% for five years (young, j. & mills, r.,2004 ). data from: aha as technology evolves, the understanding of the nature of heart failure has become clearer. in the beginning of the 20th century heart failure was diagnosed as a condition that presented with edema (swelling) in the extremities caused by water retention. treatment in the beginning of the past cenrury was limited to abdominal drainage and diuretics. the discovery of the heart's insufficient pumping ability in heart failure patients lead to new surgeries and devices such as heart transplants and ventricular assist devices (bridge until transplant is available). ventricular hypertrophy often occurs before the development of heart failure. hypertrophy is the term given for cardiac remodeling. cardiac remodeling also includes chamber dilation (young, j. & mills, r.,2004) . chf financial burden the us healthcare financing administration has ranked chf as the highest cost illness in the diagnose-related area. direct costs related to chf in the us for 2004 were nearly $26 billion. these costs included hospital admissions, physician fees, home health aids and medications. indirect costs were over $2 billion in 2004. loss of jobs or death due to chf was the criteria for this category (young, j. & mills, r., 2004). . introduction: the injection drug user quality of life scale (iduqol) is a relatively new scale ~es1gned to capture the unique and individual circumstances that determine quality of life among injection drug users (idus). the 20 life areas comprising the instrument were based on the research literature an~ ~ocus group discussions with idus. the purpose of the present study was to evaluate the content validity of t.h~ iduqol using judgmental methods based on subject matter experts' (smes) ratings. content vah~1ty refers to the de~ee to which elements of an assessment tool are representative of the construct of interest and appropnate for a given population. methods: data were obtained from six smes, from the field of idu research and practice, who ~ere. asked t.o evaluate various aspects of the iduqol, including the title of the instrument, administraon instruchons, clarity of the names and descriptions of each life area, response format, scoring instruc-no~s and examples, record form and whether each life area should be included in the instrument. sme ratings were made using either 3 or 4 point scales. sm es were also given the opportunity to comment on poster sessions v127 each section and to suggest whether important life areas had been overlooked, were redundant, not relevant, or in need of revision. (cvi) and the ~v.erage ~eviation index (ad) were used to evaluate smes' agreement on ratings of the content vahd1ty vanables. both measures provided support for the content validity of various aspects of the iduqol, although results from the stricter ad index noted some areas of disagreement, including the description of particular life areas (e.g., being useful, drugs, sex), the inclusion of some life areas (e.g., drug treatment, education, independence and free choice), and the ease of the scoring instructions. the findings from this study provide (a) content validity evidence to support the use of the iduqol as well as (b) recommendations to suengthen both the instrument (e.g., improved descriptions for some items) and the accompanying administration and scoring manual (e.g., an easier scoring template). changes made to the instrument and its manual make the iduqol even easier for researchers, practitioners, and program evaluators to use as a way of assessing, and tracking changes over time or as a result of interventions in, quality of life in injection drug users. introduction: strict adherence to prescribed regimens is required to derive maximal benefit from highly active antireuoviral therapy (haart) in persons living with hiv/aids (phas). adherence is a key determinant of the degree and durability of viral suppression. adherence is also essential in reducing the spread of hiv and ensuring that today's treatments remain effective for as long as possible. the objective of this study is to conduct a systematic review of the research literature on the effectiveness of education and patient support strategies for improving adherence to haart. methods: a systematic search of the core databases was performed from january 1996 until may 2005. randomized controlled trials examining the effectiveness of education and patient support interventions to improve the adherence to haart were considered for inclusion. only those studies that measured adherence at a minimum of six weeks were included. study selection, quality assessments, and data abstraction were performed independently by two reviewers. results: study heterogeneity with respect to differing populations, interventions, outcomes, and length of follow-up did not allow for meta-analysis. we included 19 studies involving 2, 159 ph as. sample sizes ranged from 22 to 367. study duration ranged from a single session to a variable number of sessions delivered over one year. many of the interventions involved the provision of an educational component to improve adherence and often addressed strategies to overcome barriers to adherence and the development of problem-solving skills. they ranged from simple interventions (e.g., the provision of reminder devices) to complex interventions (e.g., cognitive-behavioural therapy delivered by licensed psychologists). eleven of the 19 studies demonstrated a statistically significant advantage associated with the described adherence intervention. the advantage associated with adherence outcomes does not seem to translate into the more clinically relevant outcome of viral suppression. only 4 out of 12 studies that reported virological or immunological results found a significant effect associated with the intervention. the studies had several methodological shortcomings. conclusions: there is a need for standardization and methodological rigour in the conduct of adherence trials. some interventions may have a significant impact on improving adherence. further research is required before any specific adherence improving strategy can confidently be incorporated into standard clinical practice. focus groups were used to collect data from a purposive sample of treatmentexperienced participants. focus group data were analyzed using a grou~ded t~eory appr~ach. i:ne themes identified from the interviews were used to identify the effects of ant1rerrov1rals on quality of hfe. the content of the mos-hiv was appraised against the themes identified from our analysis. participants also completed the mos-hiv survey and were asked whether the survey covered all important aspects of quality of life on antiretroviral medications. results: five key informant interviews and five focus groups with 38 participants were used to identify effects on quality of life that are not directly ~aptu~ed by_ the mos-hiv health survey. our~~ showed that our participants described quality of hfe as mvol~mg_ a set of ~rsonal trad~ffs ~stay alive. in most cases, worsened quality of life was traded-off for gams 1~ longevlty from ~~canon use. these eff~'ts or tradeoffs included: ( 1) downstream consequences of side effects and toxlanes; (2) loss of lrufe. pende~t decision-making privileges, (3) having to choose drugs over ~areer; (~)burden of medication-taking responsibilities; and (5) living life under a pretense and havmg to hide-the net effect of the tradeoffs, or "prices" to pay led to what was described as "longevity with hn without hope and future~. conclusion: our study highlights five major themes summarizing the impact of haart on quality on life, and suggests that currently used scales for measuring quality of life do not a~atd~ cap~e these findings and the associated consequences. the conceptual framework for measuring quality of bfe in hiv should be reconsidered in order to better capture the important effects of the medications on quality of life. this may involve widening the boundaries of the definition of health-related quality oflife to include aspects such as finances, employment, and housing. we should further consider the development of a haart adverse effect specific instrument, using a broad definition of adverse effect in order to capture all types of adverse impacts of hiv treatments on quality of life. introduction: measles (rubeola) is the most contagious vaccine preventable disease of humans. while cases of measles are uncommon in canada today, the disease continues to be a leading cause of morbidity and death in the developing world. as a result of human migration, measles cases still occur in canada, primari~ among immigrants, returning travelers, and other susceptible groups. canada's national advisory council on immunizations (naci) recommends that immigrants without records of measles immunization be considered for vac:cination since these individuals may not have been appropriately vaccinated in their native country. on rhe other hand, natural immunity to measles in immigrants is likely to be high given the high incidence of disease in developing parts of rhe world. thus it remains unclear if the most efficient strategy to achieve high levels of measles immunity in immigrants should entail initial serologic screening followed by vaccination of susceptible individuals or preemptive vaccination of all persons lacking immunization records. understanding the epidemiology of measles immunity in immigrant populations could help guide such decisions. . methods: we identified 527 adults, 15 years of age or older, who were screened for serologtc immunity to measles as part of a recently developed screening protocol at a downtown toronto community health centre. we subsequently determined if these individuals had any immunization records from their native country or from within canada. we then examined the relationship between several demographic factors and immunity to measles. results: 93% of immigrants had no prior immunization records. overall, 93% of the 527 immigrants rested for immunity to measles were found to be immune; 88% of those under the age of 20, 93% of those between 20 and 39 years of age, 99% of those between 40 and 59 years of age, and 100% of those 60 years of age or older. gender, education status, household income, and immigration status were nor ~ssoc1ated wirh immunity to measles. immunity to measles was lowest among immigrants from eastern europe (8~%), whil~ immigrants from other regions of the globe had greater than 90% immunity. c~lusrons: immigrants and refugees appear to have reasonably high levels of immunity to mea· sics, possibly related to natural infection wirh the measles virus. immigrants from eastern europe appear to have slightly. lower l~vel~ of immunity to the measles virus. universal screening for immunity to meales or preemptive vac:cmauon may both be inefficient public health strategies, however further research is needed to corroborate these findings. nancy r~ss, stephane tremblay, saeeda khan, daniel crouse, mark tremblay, and jean-marie berrhelor o~ve: the speed of the rise in obesity in places like canada suggests that rather than a shift in the gcncnc_ com~sirion of the population, the root of the obesity pandemic is an environment that suprrs ~besity. this paper examines the influence of neighbourhood and metropolitan characteristics. bour~lts:. while accounting. for individual socio-demographics and behaviours, residents of neighs with a large proportmn of poorly educated individuals had higher bmis than those living in poster sessions v129 neighbourhoods with more highly educated individuals (p <.01 ). residing in a neighbourhood with a high proportion of recent immigrants was associated with lower bmi for men (p<.01), but not women. neighbourhood dwelling density, a proxy for walkability, was not associated with bm! for either sex. metropolitan sprawl was associated with higher male bmi (p=.02) but the effect was negligible for women (p=.09). bmi was significantly lower for women (p<.01) living in a city in the province of quebec, even after accounting for the influence of individual and neighbourhood covariates. conclusions: bm! was strongly patterned by individual-level social position in urban canada. the incremental influence on bmi of neighbourhood related to the neighbourhood's social conditions and not to their physical form. metropolitan sprawl was associated with higher bm! for men, a group with longer car-dependent commutes than women. the findings suggest that both individuals and their environments (both social and physical) influence the distribution of bmi in urban populations. introduction: urban environments have been linked to a range of human health issues. in singapore, prevalence of end stage renal disease (esrd) is predicted to rise (2633 in 1999 to 6000 in 2010 , kidney international, vol.67, 2005 . the clinical and economic burden of esrd has promoted development of strategies aimed at preventing the development and progression of chronic kidney disease. these include population based screening programs such as the national kidney foundation, sin-gapore\'s (nkfs) "partnership for prevention."the program, aims to reduce incidence of esrd through comprehensive intervention and screening for early detection of urinary abnormalities, blood pressure (bp), and random blood glucose (rbg). objective of this study is to examine gender, race and age wise prevalence of elevated bp, rbg and proteinuria. methodology: this current analysis includes 575,438 subjects, age 18 to 86 years, who underwent screening during september 1999 and december 2004. participants were asked to give demographic information and the history of diseases. tests were given to get clinical information such as proteinuria, blood glucose, sbp, and dbp. blood pressure abnormalities were defined according to ]nc vi criteria. proteinuria was defined as the presence of 1 plus or greater protein (equivalent to> 30 mg/di) on dipstick analysis. results: there were 296, 116 (51.5%) males. racial distribution was chinese (78.8% ), malay (8.8% ), indians (8. 7%) and others (3. 7% ).among participants, who were apparently "healthy" (asymptomatic and without history of dm, ht, or kd), gender and race wise % prevalence of elevated (bp> 140/90), rbg (> 140 mg/di) and positive urine dipstick for protein was as follows male: (20.5;6.9; 3.5) female:(13.6;5.0;3. 2) chinese:( 17.1;6.0;3) malay: (19.4;7.3;5.6) indian:( 15.9;7.5;3.0) others: (15.4;4.5;2.9) total:(l 7.1, 6.1,3.2). percentage of participants with more than one abnormality were as follows. those with bp> 140/90mmhg, 14% also had rbg> 140mg/dl and 6.4% had proteinuria> i. those with rbg> 140mgldl, 11 % also had proteinuria> 1 and 35% had bp> 140/90mmhg. those with proteinuria> 1, 18% also had rbg> 140mg/dl, and 38% had bp> 140/90mmhg. conclusion: we conclude that sub clinical abnormalities in urinalysis, bp and rbg readings are prevalent across all genders and racial groups in the adult population. the overlap of abnormalities, point towards the high risk for esrd as well as cardiovascular disease. this indicates the urgent need for population based programs aimed at creating awareness, and initiatives to control and retard progression of disease. introduction: various theories have been proposed that link differential psychological vulnerability to health outcomes, including developmental theories about attachment, separation, and the formation of psychopathology. research in the area of psychosomatic medicine suggests an association between attachment style and physical illness, with stress as a mediator. there are two main hypotheses explored in the present study: ( t) that individuals living with hiv who were upsychologically vulne~able" at study entry would be more likely to experience symptoms of depression, anxiety and phys1ca! illness over. the course of the 9-month study period; and (2) life stressors and social support would mediate the relat10nship between psychological vulnerability and the psychological ~nd physical outcomes. . (rsles), state-trait anxiety inventory (stai), beck depr~ssi~n lnvento~ (bdi), and~ _21-item pbys~i symptoms inventory. we characterized participants as havmg psychological vulnerability and low resilience" as scoring above 35 on the raas (insecure attachment) or above 120 on the das (negative expectations about oneself). . . . . . " . . ,, . results: at baseline, 55% of parnc1pants were classified as havmg low resilience. focusmg on anxiety, the average cumulative stai score of the low-resilience group was significandy hi~e~ than that of the high-resilience group ( 18.45 sd= 10.6 versus 9.57 sd= 8.6; f(l,80)= 16.74, p <.001). similar results were obtained for bdi and physical symptoms (f( 1,80)= 14.65, p<.001 and f( 1,80)= 5.50, p<.05, respec· tively). after controlling for resilience, the effects of variance in life stres".°rs averaged over time wa~ a_sig· nificant predictor of depressive and physical symptoms, but not of anxiety. ho~e_ver, these assooan~s became non-significant when four participants with high values were removed. s1id1larly, after controlling for resilience, the effects of variance in social support averaged over time became insignificant. conclusion: not only did "low resilience" predict poor psychological and physical outcomes, it was also predictive of life events and social support; that is, individuals who were low in resilience were more likely to experience more life events and poorer social support than individuals who were resilient. for individuals with vulnerability to physical, psychological, and social outcomes, there is need to develop and test interventions to improve health outcomes in this group. rajat kapoor, ruby gupta, and jugal kishore introduction: young people in india represent almost one-fourth of the total population. they face significant risks related to sexual and reproductive health. many lack the information and skills neces· sary to make informed sexual and reproductive health choices. objective: to study the level of awareness about contraceptives among youth residing in urban and rural areas of delhi. method: a sample of 211 youths was selected from barwala (rural; n= 112) and balmiki basti (urban slums; n= 99) the field practice areas of the department of community medicine, maulana azad medical college, in delhi. a pre-tested questionnaire was used to collect the information. when/(calen· dar time), by 2, fisher exact and t were appliedxwhom (authors?). statistical tests such as as appropriate. result: nearly 9 out of 10 (89.1 %) youth had heard of at least one type of contraceptive and majority (81.5%) had heard about condoms. however, awareness regarding usage of contraceptives was as low as 9.4% for terminal methods to 39.3% for condom. condom was the best technique before and after marriage and also after childbirth. the difference in rural and urban groups was statistically signif· icant (p=.0001, give confidence interval too, if you provide the exact p value). youth knew that contra· ceptives were easily available (81 %), mainly at dispensary (68.7%) and chemist shops (65.4%). only 6.6% knew about emergency contraception. only advantage of contraceptives cited was population con· trol (42.6%); however, 3.8% believed that they could also control hiv transmission. awareness of side effects was poor among both the groups but the differences were statistically significant for pills (p=0.003). media was the main source of information (65%). majority of youth was willing to discuss a~ut contraceptive with their spouse (83.4%), but not with others. 51.2% youth believed that people in their age group use contraceptives. 35% of youth accepted that they had used contraceptives at least once. 81 % felt 2 children in family is appropriate, but only 59.7% believed in 3 year spacing. . conclusion: awareness about contraceptives is vital for youth to protect their sexual and reproduc· tive health .. knowledge about terminal methods, emergency contraception, and side effects of various contraceptives need to be strengthened in mass media and contraceptive awareness campaigns. mdbot:ls: 740 elderly aged 60+ were interviewed in 3 poor communities in beirut the capital of f:ebanon, ~e of which is a palestinia~. refugee camp. depression was assessed using the i 5-item geriat· nc depressi~n score (~l?s-15). specific q~estions relating to the 3 aspects of religiosity were asked as well as questions perta1rung to demographic, psychosocial and health-related variables. results: depression was prevalent in 24% of the interviewed elderly with the highest proportion being in the palestinian refugee camp (31 %). mosque attendance significantly reduced the odds of being depressed only for the palestinian respondents. depression was further associated, in particular communities, with low satisfaction with income, functional disability, and illness during last year. condiuion: religious practice, which was only related to depression among the refugee population, is discussed as more of an indicator of social cohesion, solidarity than an aspect of religiosity. furthermore, it has been suggested that minority groups rely on religious stratagems to cope with their pain more than other groups. implications of findings are discussed with particular relevance to the populations studied. nearly thirty percent of india's population lives in urban areas. the outcome of urbanization has resulted in rapid growth of urban slums. in a mega-city chennai, the slum populations (25.6 percent) face greater health hazards due to overcrowding, poor sanitation, lack of access to safe drinking water and environmental pollution. amongst the slum population the health of women and children are most neglected, resulting in burden of both communicable and non-communicable diseases. the focus of the paper is to present the epidemiology profile of children (below 14 years) in slums of chennai, their health status, hygiene and nutritional factors, the social response to health, the trends in child health and urbanization over a decade, the health accessibility factors, the role of gender in health care and assessment impact of health education to children. the available data prove that child health in slums is worse than rural areas. though the slum population is decreasing there is a need to explore the program intervention and carry out surveys for collecting data on some specific health implications of the slum children. objective: during the summer of 2003 there was a heat wave in central europe, producing an excess number of deaths in many countries including spain. the city of barcelona was one of the places in spain where temperatures often surpassed the excess heat threshold related with an increase in mortality. the objective of the study was to determine whether the excess of mortality which occurred in barcelona was dependent on age, gender or educational level, important but often neglected dimensions of heat wave-related studies. methods: barcelona, the second largest city in spain (1,582,738 inhabitants in 2003) , is located on the north eastern coast. we included all deaths of residents of barcelona older than 20 years that occurred in the city during the months of june, july and august of 2003 and also during the same months during the 5 preceding years. all the analyses were performed for each sex separately. the daily number of deaths in the year 2003 was compared with the mean daily number of deaths for the period 1998-2002 for each educational level. poisson regression models were fitted to obtain the rr of death in 2003 with respect to the period 1998-2002 for each educational level and age group. results: the excess of mortality during that summer was more important for women than for men and among older ages. although the increase was observed in all educational groups, in some age-groups the increase was larger for people with less than primary education. for example, for women in the group aged 65-74, the rr of dying for 2003 compared to 1998-2002 for women with no education was 1.30 (95%ci: 1.04-1-63) and for women with primary education or higher was 1.19 (95%ci: 0.90-1.56). when we consider the number of excess deaths, for total mortality (>=20 years) the excess numbers were higher for those with no education ( 17 5. 7 for women and 46. 7 for men) and those with less than primary education (112.5 for women and 11-2 for men) than those with more than primary edm:ation (75.0 for women and -10.3 for men). conclusion: age, gender and educational level were important in the 2003 barcelona heat wave. it is necessary to implement response plans to reduce heat morbidity and mortality. policies should he addressed to all population but also focusing particularly to the oldest population of low educational level. introduction: recently there has been much public discourse on homelessness and its imp~ct on health. measures have intensified to get people off the street into permanent housing. for maximum v132 poster sessions success it is important to first determine the needs of those to be housed. their views on housing and support requirements have to be considered, as th~y ar~ the ones affected. as few res.earch studies mclude the perspectives of homeless people themselves, httle is known on ho~ they e~penence the 1mpacrs on their health and what kinds of supports they believe they need to obtain housing and stay housed. the purpose of this study was to add the perspectives of homeless people to the discourse, based in the assumption that they are the experts on their own situations and needs. housing is seen as a major deter· minant of health. the research questions were: what are the effects of homelessness on health? what kind of supports are needed for homeless people to get off the street? both questions sought the views of homeless individuals on these issues. methods: this study is qualitative, descriptive, exploratory. semi-structured interviews were conducted with homeless persons on street corners, in parks and drop-ins. subsequently a thematic analysis was carried out on the data. results: the findings show that individuals' experiences of homelessness deeply affect their health. apart from physical impacts all talked about how their emotional health and self-esteem are affected. the system itself, rather than being useful, was often perceived as disabling and dehumanizing, resulting in hopelessness and resignation to life on the street. neither welfare nor minimum wage jobs are sufficient to live and pay rent. educational upgrading and job training, rather than enforced idleness, are desired by most initially. in general, the longer persons were homeless, the more they fell into patterned cycles of shelter /street life, temporary employment /unemployment, sometimes addictions and often unsuccessful housing episodes. conclusions: participants believe that resources should be put into training and education for acquisition of job skills and confidence to avoid homelessness or minimize its duration. to afford housing low-income people and welfare recipients need subsidies. early interventions, 'housing first', more humane and efficient processes for negotiating the welfare system, respectful treatment by service providers and some extra financial support in crisis initially, were suggested as helpful for avoiding homelessness altogether or helping most homeless people to leave the street. this study is a national homelessness initiative funded analysis examining the experiences and perceptions of street youth vis-a-vis their health/wellness status. through in-depth interviews with 140 street youth in halifax, montreal, toronto, calgary, ottawa and vancouver, this paper explores healthy and not-so healthy practices of young people living on the street. qualitative interviews with 45 health/ social service providers complement the analysis. more specifically, the investigation uncovers how street youth understand health and wellness; how they define good and bad health; and their experiences in accessing diverse health services. findings suggest that living on the street impacts physical, emotional and spiritual well·being, leading to cycles of despair, anger and helplessness. the majority of street youth services act as "brokers" for young people who desire health care services yet refuse to approach formal heal~h care organizational structures. as such, this study also provides case examples of promising youth services across canada who are emerging as critical spaces for street youth to heal from the ravages of ~treet cultur~. as young people increasingly make up a substantial proportion of the homeless population in canada, it becomes urgent to explore the multiple ways in which we can support them to regain a sense of wellbeing and "citizenship." p5-77 (c) health and livelihood implications of marginalization of slum dwellers in provision of water and sanitation services in nairobi city elizabeth kimani, eliya zulu, and chi-chi undie . ~ntrodfldion: un-habitat estimates that 70% of urban residents in kenya live in slums; yet due to their illegal status, they are not provided with basic services such as water sanitation and health care. ~nseque~tly, the services are provided by vendors who typically provide' poor services at exorbitant prices .. this paper investigates how the inequality in provision of basic services affects health and livelihood circumstances of the poor residents of nairobi slums . . methods: this study uses qualitative and quantitative data collected through the ongoing longitudmal .health and demographic study conducted by the african population and health research center m slum communities in n ·rob" w d · · · · ai 1. e use escnpnve analytical and qualitative techmques to assess h~w concerns relating to water supply and environmental sanitation services rank among the c~mmumty's general and health needs/concerns, and how this context affect their health and livelihood circumstances. results: water (32%) and sanitation (20%) were the most commonly reported health needs and also key among general needs (after unemployment) among slum dwellers. water and sanitation services are mainly provided by exploitative vendors who operate without any regulatory mechanism and charge exorbitantly for their poor services. for instance slum residents pay about 8 times more for water than non-slum households. water supply is irregular and residents often go for a week without water; prices are hiked and hygiene is compromised during such shortages. most houses do not have toilets and residents have to use commercial toilets or adopt unorthodox means such as disposing of their excreta in the nearby bushes or plastic bags that they throw in the open. as a direct result of the poor environmental conditions and inaccessible health services, slum residents are not only sicker, they are also less likely to utilise health services and consequently, more likely to die than non-slum residents. for instance, the prevalence of diarrhoea among children in the slums was 31 % compared to 13 % in nairobi as a whole and 17% in rural areas, while under-five mortality rates were 151/1000, 62/1000 and 113/1000 respectively. the results demonstrate the need for change in governments' policies that deprive the rapidly expanding urban poor population of basic services and regulatory mechanisms that would protect them from exploitation. the poor environmental sanitation and lack of basic services compound slum residents' poverty since they pay much more for the relatively poor services than their non-slum counterparts, and also increase their vulnerability to infectious diseases and mortality. since 1991 iepas've been working in harm reduction becoming the pioneer in latin america that brought this methodology for brazil. nowadays the main goal is to expand this strategy in the region and strive to change the drug policy in brazil. in this way harm reduction: health and citizenship program work in two areas to promote the citizenship of !du and for people living with hiv/aids offering law assistance for this population and outreach work for needle exchange to reduce damages and dissemination of hiv/aids/hepatit is. the methodology used in outreach work is peer education, needle exchange, condoms and folders distribution to reduce damages and the dissemination of diseases like hiv/aids/hepatitis besides counseling to search for basic health and rights are activities in this program. law attendance for the target population at iepas headquarters every week in order to provide law assistance that includes only supply people with correct law information or file a lawsuit. presentations in harm reduction and drug policy to expand these subjects for police chiefs and governmental in the last year attended 150 !du and 403 nidu reached and 26.364 needles and syringes exchanged. in law assistance 740 (420 people living with aids, 247 drug users, 43 inject drug users, 30 were not in profile) people attended. 492 lawsuits filed 218 lawsuits in current activity. broadcasting of the harm reduction strategies by the press helps to move the public opinion, gather supporters and diminish controversies regarding such actions. a majority number of police officer doesn't know the existence of this policy. it's still polemic discuss this subject in this part of population. women remain one of the most under seviced segments of the nigerian populationand a focus on their health and other needs is of special importance.the singular focus of the nigerian family welfare program is mostly on demographic targets by seeking to increase contraceptive prevalence.this has meant the neglect of many areas of of women's reproductive health. reproductive health is affected by a variety of socio-cultural and biological factors on on e hand and the quality of the service delivery system and its responsiveness on the other.a woman's based approach is one which responds to the needs of the adult woman and adolescent girls in a culturally sensitive manner.women's unequal access to resources including health care is well known in nigeria in which stark gender disparities are a reality .maternal health activities are unbalanced,focusi ng on immunisation and provision of iron and folic acid,rather than on sustained care of women or on the detection and referral of high risk cases. a cross-sectional study of a municipal government -owned hospitalfrom each of the 6 geo-political regions in igeria was carried out (atotal of 6 ce~ters) .. as _part ~f t~e re.search, the h~spital records were uesd as a background in addition to a 3-week mtens1ve mvesuganon m the obstemc and gynecology departments. . . . : little is known for example of the extent of gynecological morbtdtty among women; the little known suggest that teh majority suffer from one or more reproductive tr~ct infect~ons. although abortion is widespread, it continues to be performed under ilegal and unsafe condmons. with the growing v134 poster sessions hiv pandemic, while high riskgroups such ascomn;iercial sex workers and their clients have been studied, little has been accomplished in the large populat10ns, and particularly among women, regardmgstd an hiv education. . . conclusions: programs of various governmentalor non-governmental agen,c1es to mvolve strategies to broaden the narrow focus of services, and more importan~, to put wo~en s reproducnve health services and information needs in the forefront are urgently required. there is a n~d to reonent commuication and education activities to incorprate a wider interpretation of reproducnve health, to focus on the varying information needs of women, men, and youth and to the media most suitable to convey information to these diverse groups on reproductive health. introduction: it is estimated that there are 250-300 youths living on the streets, on their own with the assistance of social services or in poverty with a parent in ottawa. this population is under-serviced in many areas including health care. many of these adolescents are uncomfortable or unable to access the health care system through conventional methods and have been treated in walk-in clinics and emergency rooms without ongoing follow up. in march 2004, the ontario government provided the ct lamont institute with a grant to open an interdisciplinary and teaching medical/dental clinic for street youth in a drop-in center in downtown ottawa. bringing 5 community organizations together to provide primary medical care and dental hygiene to the streetyouths of ottawa ages 12-20, it is staffed by a family physician, family medicine residents, a nurse practitioner, 2 public health nurses, a dental hygienist, dental hygiene students and a chiropodist who link to social services already provided at the centre including housing, life skills programs and counselling. project objectives: 1. to improve the health of high risk youth by providing accessible, coordinated, comprehensive health and dental care to vulnerable adolescents. 2. to model and teach interdisciplinary adolescent care to undergraduate medical students, family medicine residents and dental hygiene students. methods: non-randomized, mixed method design involving a process and impact evaluation. data collection-qualitative:a) semi-structured interviews b) focus groups with youth quantitative:a) electronic medical records for 12 months b) records (budget, photos, project information). results: in progress-results from first 12 months available in august 2005. early results suggest that locating the clinic in a safe and familiar environment is a key factor in attracting the over 130 youths the clinic has seen to date. other findings include the prevalence of preventative interventions including vaccinations, std testing and prenatal care. the poster presentation will present these and other impacts that the clinic has had on the health of the youth in the first year of the study. conclusions: 1) the clinic has improved the health of ottawa streetyouth and will continue beyond the initial pilot project phase. 2) this project demonstrates that with strong community partnerships, it is possible meet make healthcare more accessible for urban youth. right to health care campaign by s.j.chander, community health cell, bangalore, india. introduction: the people's health movement in india launched a campaign known as 'right to health care' during the silver jubilee year of the alma ata declaration of 'health for all' by 2000 ad in collahoration with the national human rights commission (nhrc). the aim of the campaign was to establish the 'right to health care' as a basic human right and to address structural deficiencies in the pubic health care system and unregulated private sector . . methods: as part of the campaign a public hearing was organized in a slum in bangalore. former chairman of the nhrc chaired the hearing panel, consisting of a senior health official and other eminent people in the city. detailed documentation of individual case studies on 'denial of access to health care' in different parts of the city was carried out using a specific format. the focus was on cases where denial of health services has led to loss of life, physical damage or severe financial losses to the patient. results: _fourte_en people, except one who had accessed a private clinic, presented their testimonies of their experiences m accessing the public health care services in government health centres. all the people, e_xcept_ one person who spontaneously shared her testimony, were identified by the organizations worki_ng with the slum dwellers. corruption and ill treatment were the main issues of concern to the people. five of the fourteen testimonies presented resulted in death due to negligence. the public health cen· n:s not only demand money for the supposedly free services but also ill-treats them with verbal abuse. five of these fourteen case studies were presented before the national human right commission. the poster sessions v135 nhrc has asked the government health officials to look into the cases that were presented and to rectify the anomalies in the system. as a result of the public hearing held in the slum, the nhrc identified urban health as one of key areas for focus during the national public hearing. cond#sion: a campaign is necessary to check the corrupted public health care system and a covetous private health care system. it helps people to understand the structure and functioning of public health care system and to assert their right to assess heath care. the public hearings or people's tribunals held during the campaign are an instrument in making the public health system accountable. ps-82 (a) violence among women who inject drugs nadia fairbairn, jo-anne stoltz, evan wood, kathy li, julio montaner, and thomas kerr background/object ives: violence is a major cause of morbidity and mortality among women living in urban settings. though it is widely recognized that violence is endemic to inner-city illicit drug markets, little is known about violence experienced by women injection drug users (!du). therefore, the present analyses were conducted to evaluate the prevalence of, and characteristics associated with, experiencing violence among a cohort of female idu in vancouver. methods: we evaluated factors associated with violence among female participants enrolled in the vancouver injection drug user study (vidus) using univariate analyses. we also examined self-reported relationships with the perpetrator of the attack and the nature of the violent attack. results: of the 346 active iou followed between december 1, 2003 and may 6, 2005, 73 (21.1 %) had experienced violence during the last six months. variables positively associated with experiencing violence included: homelessness (or= 3.46, 95% ci: 1.66-7.21, p < 0.01), public injecting (or= 3.45, 95% ci: 1.43 -8.35, p < 0.01 ), frequent crack use (or= 2.99, 95% ci: 1. 72 -5.17, p < 0.01 ), recent incarceration (or =2.81, 95% cl: 1.38 -5.72, p < 0.01), receiving help injecting (or =2.77, 95% cl: 1.54-5.00, p < 0.01 ), shooting gallery attendance (or =2.46, 95% ci: 1.22 -4.93, p < 0.01 ), sex trade work (or =2.30, 95% cl: 1.35 -3.93, p < 0.01 ), frequent heroin injection (or= 1.96, 95% cl: 1.13 -3.40, p < 0.02), and residence in the downtown eastside (odds ratio [or] = 1.85, 95% ci: 1.09 -3.13, p < 0.02). variables negatively associated with experiencing violence included: being married or common-law (or =0.47. 95% ci: 0.25 -0.87, p < 0.02) and being in methadone treatment (or =0.53, 95% ci: 0.31 -0.91, p < 0.02). the most common perpetrators of the attack were acquaintances (48.0%), strangers (27.4%), police (9.6%), or dealers (8.2%). attacks were most frequently in the form of beatings (65.8%), robberies (21.9%), and assault with a weapon (13.7%). conclusion: violence was a common experience among women !du in this cohort. being the victim of violence was associated with various factors, including homelessness and public injecting. these findings indicate the need for targeted prevention and support services, such as supportive housing programs and safer injection facilities, for women iou. introduction: although research on determinants of tobacco use among arab youth has been carried out at several ecologic levels, such research has included conceptual models and has compared the two different types of tobacco that are most commonly used among the lebanese youth, namely cigarette and argileh. this study uses the ecological model to investigate differences between the genders as related to the determinants of both cigarette and argileh use among youth. methodology: quantitative data was collected from youth in economically disadvantaged urban communities in beirut, the capital of lebanon. results: the results indicated that there are differences by gender at a variety of ecological levels of influence on smoking behavior. for cigarettes, gender differences were found in knowledge, peer, family, and community influences. for argileh, gender differences were found at the peer, family, and community l.evels. the differential prevalence of cigarette and argileh smoking between boys and girls 1s therefore understandable and partially explained by the variation in the interpersonal and community envi.ronment which surrounds them. interventions therefore need to be tailored to the specific needs of boys and girls. introduction: the objective of this study was to assess the relationship between parents' employment status and children' health among professional immigrant families in vancouver. our target communmes v136 poster sessions included immigrants from five ethnicity groups: south korean, indian, chine~e, ~ussian, and irani~ with professional degrees (i.e., mds, lawyers, engineers, ma?~ger~, and uru~ers1ty professors) w11h no relevant job to their professions and those who had been hvmg m the studied area at least for 36 months. methodology: the participants were recruited by collaboration from three local community agencies and were interviewed individually during the fall of 2004. ra#lts: totally, 109 complete interviews were analyzed: 33 from south-east asia, 59 from south asia, 17 from russia and other eastern europe. overall, 14.5% were employed, 38.5% were underemployed, 46% indicated they were unemployed. overall, 58.5% were not satisfied with their current job. russians and other eastern europeans were most likely satisfied with their current job, while south-east asians were most satisfied from their life in canada. about 53% indicated that their spouses were not satisfied with their life in canada, while 55% believed that their children are very satisfied from their life in canada. in addition, around 30% said they were not satisfied from their family relationship in canada. while most of the responders ranked their own and their spouses' health status as either poor or very poor, jut 3% indicated that their first child's health was very poor. in most cases they ranked their children's health as excellent or very good. the results of this pilot study show that there is a need to create culturally specific child health and behavioral scales when conducting research in immigrant communities. for instance, in many asian cultures, it is customary for a parent either to praise their children profusely, or to condemn them. this cultural practice, called "saving face," can affect research results, as it might have affected the present study. necessary steps, therefore, are needed to revise the current standard health and behavioral scales for further studies by developing a new scale that is more relevant and culturally sensitive to the targeted immigrant families. metboda: database: 2003 national health survey (ministry of health www.msc.es). two thousand interviews were performed among madrid population (0.04% of the whole); 593 corresponded to older adults (0.04% of the 1. 7 million aged 50 years and over). study sample constitutes 95.3% (565 out of 593) of those older adults, who live in urban areas. demographic structure (by age and gender) of this population in relation to health services use (medical consultations, dentist visits, emergence services, hospitalisation) was studied using general linear model univariate procedure. a p0.005), while age was associated with emergence services use (26% of the population: 21 %, 28% and 45% of each age group) and hos~italisation (17% .oft~~ population: 13%, 20% and 31%, of each age ~oup) (p0.005) was fou~d with respect to dennst v1s1ts (18% vs 20%), medical consultations (29% vs 36%), and emergence services use (26% vs 26%), while an association (p= 0.005) was found according to hospitalisation (20% vs 16%). age. an~ g~der interaction effect on health services use was not found (p> 0.005), but a trend towards bosp1tal1sanon (p=0.04) could be considered. concl.uions: demographic structure of urban older adults is associated with two of the four health se~ices use studi~. a relation.ship ber_ween age. and hospital services use (emergence units and hospitalisanon), but not with ~ut-hosp1tal sei:vices (medical and dentist consultations), was found. in addition ro age, gender also contnbutes to explam hospitalisation. . sexua experiences. we exammed the prevalence expenences 10 relation to ethnic origin and other sociodemographic variables as wc1i as y1j7 die relation between unwanted sexual experiences, depression and agreuion. we did so for boys and prts separately. mdhods: data on unwanted sexual expcric:nces, depressive symptoms (ce.s-d), aggrc:uion (bohi-di and sociodemographic facron were collected by self-report quescionnairc:s administettd to 35 31 students in the: 2nd grade (aged 12-16) of secondary schools in amsterdam, the netherlands. data on the nature ol unwanted sexual experiences were collected during penonal interviews by trained schoolnursn. ltaijtj: overall prevalences of unwanted sexual experiences for boys and girls were 6.5% and 5.7% respectively. unwanted sexual experiences were more often ttported by turkish ( 17.1 %), moroc· an (10.4%) and surinamese/anrillian boys (7.4%) than by dutch boys (2.2%). moroccan and turkish girls, however, reported fewer unwanted sexual experiences (respectively 2.3 and 2.7%) than durch girls did (6.9%). depressive symptoms(or=4.6, cl=3.1-7.0) covert agression (0r•4.9, cl•3.2-7.7) and cmrt aggression (or= 2.6, cl• 1.6-4.4) were more common in girls with an unwanted sexual experi· met. boys with an unwanted sexual experience reported more depressive symptoms (or= 2.2; cl• i . .l· 3.9) and oven agression (or= 1.5, cl= 1.0-2.4) . of the reported unwanted sexual experiences rnpec· timy 17.5% and 73.5% were confirmed by male and female adolescents during a personal interview. cond11sion: we ..:an conclude that the prevalence of unwanted sexual experiences among turkish and moroccan boys is disturbing. it is possible that unwanted sexual experiences are more reported hy boys who belong to a religion or culture where the virginity of girls is a maner of family honour and talking about sexuality is taboo. more boys than girls did not confirm their initial disdosurc of an lllwalltc:d sexual experience. the low rates of disclosure among boys suggcsu a necd to educ.:atc hcahh care providen and others who work with migrant boys in the recognition and repomng of 1exu.il ... iction. viramin a aupplc:tmntation i1 at .h'yo, 1till far from tafl'eted 100%. feedinit pracn~:n panku· lerty for new born earn demand lot of educatton ernpha111 a• cxdu11ve hrealt fecdtnit for dnared rcnoj of 6 months was observtd in only 6.s% of childrrn thoulh colckturm w.11 givm 1n rn% of mwly horn ct.ildrm. the proportion of children hclow-2 waz (malnounshrdl .con" a• h!jh •• 42.6% anj "rt'i· acimy tc.. 11 compared to 1998 data. mother's ~alth: from all is 10 womm in ttprod~uvr •ill' poup, 83% were married and among marned w~ .\9% only w\"rt' u1mic wmr cnntr.-:cruve mt1h· odl 44% were married bdorc thc •ar of 18 yean and 27% had thnr ftnc prcicnancy hcftitt dlt' •icr nf 21 yean. the lt'f'vicn are not uutfactory or they arc adequate but nae unh1ed opumally. of thote' l'h mothen who had deliverrd in last one year, 80% had nailed 11ntmaral eum1nat1on 11 ira" oncc, .~o-... bad matt rhan four ttmn and ma1ortty had 1heir tetanus toxotd tnin,"t1or"'" nlht "'"'"· ljn1r11ned rn· win ronductrd 12.4% dchvcnn and 26% had home deh\'t'oc'i. ~md~: the tervtcn unbud or u111led are !tu than dnarame. the wr· l'kft provided are inadequate and on dechm reprcwnttng a looun1t ~p of h11hnto good coytti\#' ol wr· ncn. l!.ckground chanpng pnoriry cannoc be ruled out u °"" of thc coatnbutory bc10f. ps-ii ia) dcpn:wioa aad anuccy ia mip'mu ia awccr._ many de wn, witco tui~bmjer. jack dekker, aart·jan lttkman, wim gonmc:n. and amoud verhoeff ~ a dutch commumry-bucd icudy thawed 12-moarh•·prc:yalm«i al 17 .44'1. kw anx1· ay daorden and 13. 7% foi' dqrasion m anmttdam. nm .. 11p1tficantly hlllhn than dwwhrft .. dw ~thew diffamca m pttyalcnca att probably rdarcd to tlk' largr populanoa of napaan 111 ..\mturdam. <turkish 5%, moroccan 9%, and surinam 10%1. lndttd. ic'wt'll ltudla hatt ~ ~ high prevalena rata among migrant poupi in rbe ncdwrlands. howc'ytt au ttlluchn iuffenod from wry low raporne rara, or med screnung talel thac lack a ~y yabdarcd ~ in order to study the prevalence of depression and anxiety, and the (barriers to) use of mental health care among the different ethnic groups the following study was recently conducted: . the study consisted of a two-step approach. the first step was mcl~ded m the ~ h ith survey of 2004 (ahs), and consisted of three screening scales for depression and aruaety (klo, g::q-12 and mhl-5). in this survey all respondents were asked_ permission for~ second app~ 1:' 18t consisted of a structured interview containing the cidi for aruaety and depression, and questtollllalres on health care seeking, amongst others. all respondents who gave permission for a second approachwere invited by jetter for a suuctured interview with multilingual interviewers at home at a preset date and time in the following week. . in total, 439 dutch, 317 turkish, 322 moroccan and 124 surinam respondents took part in the ahs and gave permission for a second approach. in the second step, fo~ 21~ tur~h, 184m~roc can 87 surinamese and 320 dutch respondents, information from the extensive interview was available (res~nse rates between 60 and 70% ). since the data collection was completed only recently (june 2005), prevalence estimates can be presented at the conference for the first time. we have shown that with this approach it is feasible to achieve an acceptable response rate in a study on mental health among migrants. therefore we expect that this study will provide reli· able estimates of depression and anxiety in the turkish, moroccan and surinam migrants in amstw!3~· for the first time. in addition, insight into mechanisms underlying the differences between and within ethnic groups and into barriers to mental health care will provide pretexts for the improvement of pre· vention and mental health care for migrant groups. this study aimed to determine spatial patterns of mortality and morbidity of five major health problems in an urban environment: homicides, pregnancy among adolescents ((<20 years old), asthma hospitalization among young children(< 5 years old) and two mosquito-borne diseasesdengue and visceral leishmaniasis, during 1999-2003. all events were obtained through the city health database and, subsequently, geoproccsscd using the address of residence and the geographical and administrative division of the municipality, composed by 80 unit of planning (up), which in tum were formed, each one, by census tract units. two research questions were investigated: are there spatial patterns to the events dis· tribution, and moreover, are these patterns overlapping across space? we use thematic maps, index of comparative mortality/morbidity by up and the overlapped rank of the 20th worse up rates for each event. a spatial pattern of high rates of homicides, proportion of young mothers and hospitalization of asthma were overlapping in areas social and economically disadvantaged. for mosquito-borne diseases, high rates with great dispersion were found in unprivileged areas in contrast with very low rares among privileged ones. these results pointed toward a coexistence of heavier burden of diseases for those living in areas of the city where misery, poverty, lack of political public health may be modulating social health problems. a possible environmental intervention in one mosquito•bome disease might be playing a role in the occurrence of other. although with limitations, this study may provide useful information for a joint urban planning under the public perspective, articulated for use in health impact assessment. jalil safaei bdrod#aion: the association of socioeconomic status (ses), usually measured by income, and health status is an established result in bcalth studies. the poor and low income individuals have lower health sta· tus then_ those with higher incomes. in general. such finding has been usually obtained from sample surveys on speafic populations. a problem with many sample survey$ is that their results are not comparable aaoss ~ndaries as they may use different sampling methods, ask different questions, categorize the answers differently, or define groups differently. moreover, the sample data need to be standardized using the demographic: katurea of a ~ population. this study, however, uses the national population health survey (nphs) cycle 3 public use mictodata files which is based on a common survey template ·~~three~ area in canada, namely montreal, toronto, and vancouver. it also utili7.es the built-m stanclatdizaaon of the nphs data which accounts for its complex survey design. . ~:the stu~ usc:s two well-known measures of health inequalitythe relative index of meqaality and die concentranon indexto capture the extent of income related health inequality among poster sessions v139 urban female and male populations in each of the three metropolitan areas. personal income is classified into ten groups by the nphs with "no income" as the first group and "more than $60,000" as the last. health status is measured by three variables -having a chronic condition (chc), self assessed health (sah), and health utility index (hui) -using appropriate indices. alternative formulations are used to calculate the standard deviations of the estimated or calculated measures. the findings of the study suggest that the measured health inequality depends on the health measure used. for chc and hui the measured inequality indices do indicate poorer health for lower income individulas, however, they are not statistically insignificant. health inequalities are more pronounced when health is measured by sah. the results do not support any systematic ranking of the three metropolitan areas in terms of health inequalities. they do not reveal any systematic pattern of inequality between men and women, either. conclusions: despite the use of highly aggregated nphs data, income related health disparities are observed in the three metropolitan areas in canada. this is more the case with self perceived (sah) health. such disparities are preventable and call for broader health policies that address poverty and low income among other social determinants of health. introduction: the analysis of health indicators under the spatial perspective is configured as an important instrument in the detection of intra-urban differentials. this study aimed to examine the spatial distribution of the births occurred in belo horizonte, in 2001, analyzing the presence of spatial clusters of health indicators for newborns (rn) and their mothers, using data from the information system on live birth database (sinasc). method: for each covered area of the basic units of health (ubs), we calculated the proportion of: adolescent mothers, mothers with less than 8 years of schooling, first pregnancy, mothers with four or more pregnancies, dead babies born on previous pregnancies, stillbirths, cesarean section, less than four prenatal care attendance, moderate and severe hypoxemia in the 1st and 5th minutes of life, low or very low birth weight. we used empiric bayesian methods for smoothing the estimates. for spatial analysis, the indicators obtained from the global moran (i) index and local indicators of spatial association (lisa) were used. maps were built to allow the visualization of the spatial clusters. in all analysis, significance statistics was considered p~ 0.05. results: a total of 36, 12 7 births of residents in belo horizonte were registered in 200 i. the estimated bayesian proportions for the entire municipality was close to the one observed for all variables. analysis using lisa showed the presence of relevant spatial clusters for adolescent and low educated mothers, dead babies form previous pregnancies, cesarean section, low attendance to the prenatal care especially in area with low socio-demographic characteristics. three areas presented consistent clusters, with important spatial auto-correlation for almost all studied indicators. conclusion: the used methodology was configured as a great instrument of detection risk areas where clustering occurs. it can easily be incorporated in any surveillance system as a mechanism for controlling events related to births in the municipality. moreover, it can be applied to discriminate target areas for prompt public health interventions, such as improving health services access and the consolidation of better obstetric practices. introduction: gentrification, the displacement of low income and non-majority people out of longtime neighborhoods and residences is a global phenomenon. it has been identified as occurring in both developed and less developed countries and as inequality persists or increases, many communities are vulnerable to disruption and loss. while there may be some benefits to gentrification, these benefits are less likely to impact those who have been forced to move out of a gentrifying community or those who remain but economically stressed. . . . . this paper lays out a theoretical framework for 1dent1fymg and ~ddressm~. the_ health consequences of gentrification on residents living in a community prior .to o.r durmg gent~1~1cat.10n. by drawing on the literature of housing, sociology, health and urban plannmg, 1t places genmf1catt~n and neighborhood change into the context of other forces affecting th~ .hea.lth of vulnerable populations. it then proposes solutions to prevent or mitigate the impacts of genmf1cat1on. results: four main categories of consequences potentiallr re~ult from ~entr~fica~~n: !'°°r housing· related issues, spatial effects, mental health impacts and contr1bunons to racial ~spanttes m heal~. the housing issues include increased susceptibility to asthma, lead exposure, allergiesl~topy an~. acetdents/ injuries. spatial effects include reduced access to health ~are, reduce~ access to 1obslttadinonal food sources, decreased physical activity, and increased obesity. the __ pnmary mental health effects_ :ire increased stress increased risk of depression and disruption of trad1t1onal support networks. in addinon to the above he~lth issues, gentrification has the potential to increase racial disparities in health by reduc· ing access to long term and multi-culturally experienced health care provide~s. conclusions: public health practice provides a framework for addressmg the health consequences of gentrification. in this context primary prevention would involve preventing gentrification in the first place along with a renewed commitment to helping distressed communities a~~ im_proving the quality ~f life for long term residents. the next layer of meeting the challenges of gentrification would be to assjst long rime residents to stay in a community and thus potentially allowing them to participate in the bene~ts of gentrification (such as better public services). only if all these efforts fail -and these other prevennon strategies must be a priority, public policy should then work to help people and instirutions move to other communities through grants and the provision of alternative safe affordable housing and neighborhoods. sarah romans, marsha cohen, and tonia forte lnh'odlletion: there has been sustained interest in urban rural (ur) differences in mental health over the last 50 years of epidemiological research, with most studies reporting higher urban rates of mor· bidity, particularly when psychotic disorders have been studied. most recently, in britain, urban rates of non-psychotic disorder were greater than rural and semi-rural rates, both before and after the more adverse circumstances of urban dwellers were considered (paykel et al 2003) . surprisingly, there were no ur differences in help seeking. in canada, wang (2004) found greater urban rates for major depression only after he controlled for the confounding effects of race, immigration, employment and marital status, a result reminiscent of work from the us (blazer et 1985) . rural participants were less likely to have sought help for their mental health problems. in this study, we sought to examine urban/rural differences in rates of depression and help seeking in canada. method; data came from the 2000 canadian community health survey 1.2, a community survey conducted by statistics canada of people aged 15 and older, with the total sample size of 36,984 respon· dents, 77% response. analyses used weighted data; differences were assessed by chi-squared. ra.its: bivariate cross-tabulations showed a modest increase in 12 month depression rates for urban (5.4%) over rural (4.3%, p= 0.03) dwellers; there were no ur differences when the sample was examined separately by gender and age group ( 15-29, 30-44, 45-69) . in general, more urban (10.6%) than rural people (8. 7%, p= 0.002) had sought mental health treatment in the past year. there was no ur difference in helping seeking amongst those with depression (u 58.9%, r 50.1 % ns). amongst the whole population, helping seeking was gendered with more urban men accessing help (7.4%) than rural men (5.4%, p=0.004); this did not apply for women (13.7% vs 12.1% p=0.1). ~ons: the urban-rural demographic continues to generate intriguing findings, even recently when internal migration is common and people can seek out the environment most conducive to their health, ~th physical and mental. people with depression are a disadvantaged, frequently stigmatized group, with ~r quality of life a_nd often impaired function. unlike many other factors associated wi~h urban or rural hfe per se, depression can be treated. the low help seeking rates is a cause for concern, m both the ur~n and_ rural populations. it behooves researchers, policy makers and service planners to ensutt effective services are available for both humane and economic reasons. methods: using united states 2000 census income data, we assigned the 12 manhattan community districts to two major socioeconomic groups, manhattan i and ii. manhattan i is composed of community districts with average household incomes above the median for new york city; manhattan ii is those below. with public new york city department of health 1999 death records and 2000 us census data, we calculated a "standard" new york city population and estimated mortality rate distributions for manhattan i and ii. we then compared these age-adjusted actual mortality distributions with a standard t-test. results: we explored premature deaths using several cut-off points (before the ages of 65, 70, and 75), and with subcomparisons for males and females. every comparison showed the wealthier area, manhattan i, to have significantly lower premature mortality rates than the lower income manhattan ii. further, we compared age-adjusted mortality rates among the city's five boroughs, and found no significant differences based on local geography alone. conclusions: these findings suggest that in manhattan, characterized by its extremes of wealth and poverty, health status, as measured by premature mortality, does vary significantly with the local income level. in manhattan, the relative average income by community district varies as much as 4: 1. this ratio is greater than that found in the other cities we have studied: for example, the range among tokyo's kus is half that in manhattan, or about 2: 1. paris has shown the longest life expectancy and changing premature mortality rates. from our preliminary work, we expect to find less variation in premature mortality rates in comparable cities. this study will continue to explore the relationship of premature mortality rates and life expectancy to income levels and different health systems among wcp cities with a view to measuring health policy options. introduction: according to the world health organization (who), smoking-related illness is currently the world's second major cause of death, currently responsible for one out of ten adult deaths worldwide. the who's framework convention on tobacco control (fctc) aims to reduce tobaccorelated disease and deaths by changing national public policies. mexico, which, according to the who, had smoking prevalences of 32% among adults in 1998 and 23% among health care providers (hcps) in 1997, ratified the fctc in 2004. objective: to examine knowledge of and attitudes towards cigarette smoking and smoking cessation among hcps, and clinical practices regarding smoking cessation. methods: in june 2005, a convenience sample of hcps from one public clinic in urban oaxaca, mexico, part of mexico's national network of public health care clinics, were interviewed in spanish using a verbally administered questionnaire that was standard among all participants. during primary care outpatient visits, hcps were observed treating patients to assess the relative importance of smoking cessation as a health care priority. results: of the 18 hcps interviewed, including ten physicians, three nurses, and five medical students, 67% reported smoking regularly. all hcps reported assessing patients' history of smoking, knowledge of the health risks associated with smoking, and feeling qualified to discuss these risks with patients. all hcps reported counseling patients who currently smoked to quit. all hcps reported recommending nicotine replacement therapy (eg., patch and/or gum) and/or behavioral therapy (eg., psychologist, support groups) to patients who smoked. all hcps reported that there was no government funding for smoking cessation, and that all costs associated with smoking cessation were patients' out-of-pocket expenses. observation of hcp interaction with patients revealed that hcps always inquired about smoking history with new patients and rarely inquired about smoking history with returning patients. hcps were not observed counseling patients who reported current smoking on smoking cessation methods and its benefits. observation of the clinical environment suggested a focus on preventative child health (eg., immunization, water-borne illnesses), family planning, and chronic diseases (eg., diabetes, hypertension). conclusions: while the mexican government has made smoking cessation a public health priority and hcps report addressing smoking cessation, observation of hcps suggests: 1) smoking status is assessed only in new patients; and 2) smoking cessation methods are not addresse~. observ_atio~ of hcps and the clinical environment in a public clinic in oaxaca suggests that smoking cessation 1s of lower priority than other heath care issues. p6-04 (a) urban agriculture and food and nutrition security in kampala, uganda fiona yeudall, renee sebastian, abdelrahman lubowa, selahadin ibrahim, and donald cole introduction: urban agriculture is an important livelihood strategy contributing to household food security by increasing access and availability to food in urban settings (koc et al., 1999) . the purpose of poster sessions v142 rhis study was to examine relationships between child nutritional securiry outcomes, household food security, and urban agriculture activiries in kampala, uga~da. . . questionnaires assessing socio-demographic, farmmg and household food secunry (hfsi characreristics were administered to 270 households. food diversiry was ~lculate~ from ~e number of foods consumed over 24 hours for one child (2-5 years) per household. heigh~ weight,. nud-upper·ann· circumference (muac) and tricep skinfolds (tsf) were measured for the mdex child. z-sc.ores for height-for·age (haz), weighr-for-age (waz) and body mass index (zbmi) were ~~ulated usmg cen· rres for disease control and prevenrion reference data. z-scores for body composition measures were calculated using nhanes i and ii data for african americans. the lms method was used to c~.t for skewed z·score indices. all dara was checked for normaliry and univariable and backward mulnvanablc linear regression analysis conducted. ruwlts: household food securiry was significantly associated with wealth (b= 0. 71, p< 'a acre were more dependenr on assets for hfs. although sex of head of household was ~ot related to j-:ifs, it modi· fied relationships in rhar female headed households had greater food securtry when fai:mmg less than 1,4 acre compared ro male headed households, and vice versa. hfs was significantly associated with food diversiry (s=0.15, p). urbanization, especially in developing countries, has substantially increased the vulnerability of rhe mass of low-income urban dwellers. the livelihoods and quality of life for many of the poor espe· cially in larin america, asia, and africa, have deteriorated significantly over the years. urban areas are increasingly unable to provide for their populations, resulting in poverry, massive unemploymenr, job cuts, poor housing, lack of or poor public services, and a compromised health status. botswana, a country rhat lies in the sourhern parr of africa, has had its share of urban problems such as rhe mush· rooming of squarters and low-income urban sertlements. despite efforts to address the substandard living conditions in low-income urban areas, these problems have continued to grow. these living con· diuons are porenrially stressful to rhe residenrs and likely affects their health. the primary aim of the 11udy wa1 to examine the complex relationship between communiry-level stressors and interveners and health-related quality of life among residents of low-income neighborhoods in francistown, botswana. u1i"" a croa1-icctional quantitative design (both descriptive and explanatory) and using primarily cloae-mded interview• with a random sample of 388 residents, this study examined the role of chrome life 1trnson and environmental quality on overall health status qualiry of life) and the physical, psy· chological and level of independence domains of health. the major hypothesis of the study was that community-levrl stre1sor1 would influence health-related quality of life and that social capital would moderate these relationships. findings indicate that neighborhood quality is a powerful predictor of healrh 1tatu1 rhan socioeconomic status and individual life stressors. social capital was also found to he a 11111ificant positive predictor of healrh and also moderator of structural factors. social capital moderated the effects of low environmental quality on level of indrpendence and on physical health outcomn, but nor on psychological and global health outcomes. these findings suggest that as the environment get1 betttr. stresson are reduced, hence promoting berter health outcomes. the study ends with implication• for social justice, public health and social work practice, and research, focusing mostly on the ~ole of social capital and the environmental quality in predicting health outcomes. spt· cafically • anenhon should be focused on political and civic society's commitment for social justice and poveny alleviation, ~uction of the threat of insecuriry and violence; cultivating social capital and good governance; and improving the health and social environments, especially housing and environ· mental 1aiutanon to name a few. urban and other uprisings by non-elites that lead to transitions, can disrupt sexual and injection "risk" networks that transmit infectious diseases by changing mixing patterns. they can also weaken urban social networks, their associated protective norms and their informal social control mechanisms which can lead to increased sexual and drug risk behaviors and violence (fullilove 2004; wallace & wallace1998, aral 2002 , friedman & reid 2000 hankins et al 2002) . for example, the 1979 revolution and transition to theocratic rule, and subsequent urban and national conflicts, have been followed by many urban youth in iran engaging in clandestine high-risk sexual and drug behaviors. in palestine, conflicts and restrictions on movement have led to increased fatalities from chronic diseases due to limited access to hospitals and modern medical facilities (union of palestinian medical relief committees); and heroin use and violence-related blood exposure have also increased. social movements "from below" that are rooted both in urban social network dynamics and in underlying patterns of injustice can have both protective and risky effects. for example, the social movements that led to the collapse of the ussr and its dependent governments in other countries-with subsequent increases in sex trade, alcoholism, drug use, tuberculosis, hiv, stis, and mortality in many localities-were based originally on such city-based movements in eastern europe. their impacts on health were mediated by urban social dynamics and structures. some urban social movements have improved health by prevent· ing the spread of hiv, hepatitis and other diseases. examples include movements of (a) gays and lesbians and (b) drug users. these have been rooted in social networks that overlap with risk networks. theories of urban health should include social conflict as a core concept. mechanisms that generate conflicts and the pathways by which conflicts affect health should be a major part of urban health research agendas. p6-07 (c) demographic characteristics of people seen with tuberculosis in lagos state university teaching hospital (lasuth) chest clinic john bako, adewale akeredolu, and wale alabi tuberculosis has become a resurgent public health problem in recent times in the world. because resources are limited, control programmes frequently must target population at greatest risk. the purpose of this study was to study the demographic characteristics of people seen with tuberculosis in lagos state university teaching hospital. a total of 76 patients who have been both radiologically and bacteriologically confirmed tuberculosis patients were used for this study between january and march. 57 (75%) were males, while 19 (25%) were females. notable risk factors among patients with tuberculosis were overcrowding (46.1 % ), homelessness ( 11.8%) cigarette smoking (22.4% ), alcoholism (30.3%), non vaccination (25%), secondary contact (36.8%) and poor knowledge (92. l 'x,). man· agement history patterns among the patients were herbs ( 13.2 'yo), orthodox medicine ( .h . .l'x.). intervention targeting early-identified groups may be an effective way to reduce the incidence of tuber· culosis. such intervention should focus on health education, modification of life style and improvement of standard of living. p6-08 (c) profiles in urban health in 9 cities of the americas in the countries of the americas, there is an increasing migration of national and international populations to urban centers. this presentation will focus on some of the issues created by this influx of populations, the ways that 9 cities in 8 countries are dealing with them, and the efforts to promote local participation and solutions in management and decision-making. the methodology used to collect this information has been to draw upon and analyze information produced by the mayor's and ministry of health and development offices in each of the cities under consideration. an analysis of the impact of urbanization on health and health determinants will be presented. the information covers issues such as health status by geographic areas within the cities, highlighting issues such as marginality, barriers and physical, economic and cultural constructs and inequities in the delivery of and access to essential services (such as health, education, water, and basic sanitation). issues of governance and citizen participation will be highlighted to provide insight in~o the balance of power and mechanisms for decision-making at the local level. part of the analysis will show the relationship between democratic processes and social participation. public ~olicies will be reviewed to indicate those that are most beneficial in promoting health and overcoming barriers to it, as well as ways of capitalizing on local assets and resources. final~y, evidence of effectiveness of various strategies will be indicated. the presentation will conclude wuh suggesuons for future strategic directions to improve the quality of life and the promotion of health in large urban centers of the americas. introduction: much of the illicit drug in mexico is concentrated in northern border areas. the 2000 mile border between the u.s. and mexico is also characterized by migration; the border crossing between tijuana, baja california, mexico and san diego, california, u.s.a. is rep~rt~dl~ the busiest land border crossing in the world. we attempt to describe the migration scene among m1ect1on drug users (idus) m tijuana and investigate service needs. methods: migration trends were investigated in a cross-sectional study conducted from february to june 2005 among idus in tijuana. enrollment criteria included informed consent, being 18 years or older, and having injected drugs within the prior month. subjects were recruited by respondent-dnven sampling and were administered a quantitative survey and serology for hiv, hcv, and syphilis. logistic regression was used to compare idus who had migrated to the u.s. versus those who had not. results: of 222 idus enrolled, 91 % were male and median age and age at first injection were 35 and 20, respectively. drug combinations injected most frequently in the past 6 months were heroin (35%1 and crystal methamphetamine mixed with heroin (53%). of those enrolled, 212 responded to quesnons on migration and drug treatment and were included in this analysis. although 76% had resided in tijuana for at least 5 years, 70% of users were born outside of baja california. working outside of mexico was common, with 38% working abroad in the last 10 years (94% in u.s.), and 17% in the past year. in the last 6 months, 10% of idus had crossed the border to the u.s., with 57% crossing at least once per month. those working outside of mexico in the past year were less likely to have ever received substance abuse treatment, [29% vs. 53%, or 0.38, ] and were marginally less likely to have received drug treatment in the past 6 months [6% vs. 18 %, or 0.28, 95% ci (0.06-1.2)]. drug use patterns, age and gender did not differ between migrants and non-migrants, although migrants were more likely to report being in need of substance abuse treatment (68% vs. 57%, respectively). conclusions: migration is common among idus in tijuana. maintaining drug treatment regimens and determining how to best target education and services to a highly mobile population pose challenges to officials on both sides of the border. these data underscore the need to develop coordinated binational prevention and treatment efforts. introduction: despite the expanding literature on the important role public policy plays in influencing the broader determinants of the public\'s health, profound differences exist among jurisdictions in rhe attention placed upon such activities. we take an international perspective on health by examining rhe d?minant public _health paradigms of canada, usa, uk, and sweden and exploring how these paradigms shape public health practice. _method: we carefully analyze governmental and public health agencies documents to discern ~he dommant para~igms driving public health approaches and practices. we also consider the unique paht1· cal and economic contexts within each nation and consider how these contexts drive public health pahcy and approaches. . . ~u~: the canadian and usa public health communities -with some exceptions --focus upon m~ividuahzed approaches to risk management. in contrast, the uk and swedish public health scenes are oriented toward broader approaches to health determinants. we find that the extent to which govern· ments, public health agencies and public health workers concern themselves with public policy approaches £<_> ~ddress ~ro.ad~r .determinants of health depends upon the particular health parad'.~ adhered. ~o withm each 1urisd1ctton. and whether a paradigm is adopted depends upon the ideologi~a and pol~ncal context of each nation. nations such as sweden that have a long tradition of public policies promonng social jus~ce an~ equity are naturally receptive to evolving population health concepts. '[he usa represen~ a ~bey en~ro~~t where such is~ues are clear!~ subordinate. ., our findings mdicate that there 1s a strong political component that influences pubh ~ealth a~proaches and practi~ within the jurisdictions examined. the implications are that those seek· m~ to raise the broader detennmants of the public's health should work in coalition to raise these issues with non-health organizations and age · ca d d th · badrgrollnd: in developed countries, social inequalities in health have endured or even worsened comparatively throughout different social groups since the 1990s. in france, a country where access to medical and surgical care is theoretically affordable for everyone, health inequalities are among the high· est in western europe. in developing countries, health and access to care have remained critical issues. in madagascar, poverty has even increased in recent years, since the country wenr through political crisis and structural adjustment policies. objectives. we aimed to estimate and compare the impact of socio· economic status but also psychosocial characteristics (social integration, health beliefs, expectations and representation, and psychological characteristics) on the risk of having forgone healthcare in these 2 dif· fercnt contexts. methods: population surveys conducted among random samples of households in some under· served paris neighbourhoods (n= 889) and in the whole antananarivo city (n= 2807) in 2003, using a common individual questionnaire in french and malagasy. reslllts: as expected, the impact of socioeconomic status is stronger in antananarivo than in paris. but, after making adjustments for numerous individual socio-economic and health characteristics, we observed in both cities a higher (and statically significant) occurrence of reponed forgone healthcare among people who have experienced childhood and/or adulthood difficulties (with relative risks up to 2 and 3.s respectively in paris and antananarivo) and who complained about unhealthy living conditions. in paris, it is also correlated with a lack of trust in health services. coneluions: aside from purely financial hurdles, other individual factors play a role in the non-use of healthcare services. health insurance or free healthcare seems to be necessary hut not sufficienr to achieve an equitable access to care. therefore, health policies must not only focus on the reduction of the financial barriers to healthcare, but also must be supplemented by programmes (e.g. outreach care ser· vices, health education, health promotion programmes) and discretionary local policies tailored to the needs of those with poor health concern .. acknowledgments. this project was supported by the mal>io project and the national institute of statistics (instat) in madagascar, and hy the development research institute (ird) and the avenir programme of the national institute of health and medical research (inserm) in france. for the cities of developing countries, poverty is often described in terms of the living standard~ of slum populations, and there is good reason to believe that the health risks facing these populations are even greater, in some instances, than those facing rural villagers. yet much remains to be learned ahour the connections between urban poverty and health. it is not known what percentage of all urban poor live in slums, that is, in communities of concentrated poverty; neither is it known what proportion of slum residents are, in fact, poor. funhermore, no quantitative accounting is yet available that would sep· arare the health risks of slum life into those due to a househoid•s own poverty and those stemminic from poveny in the surrounding neighborhood. if urban health interventions are to be effectively targeted in developing countries, substantial progress must be made in addressing these cenrral issues. this paper examines poverty and children's health and survival using two large surveys, one a demographic and health survey fielded in urban egypt (with an oversampling of slums) and the other a survey of the slums of allahabad, india. using multivariate statistical methods. we find, in both settings: ( 11 substan· rial evidence of living standards heterogeneity within the slums; (21 strong evidence indicating that household-level poverty is an imponant influence on health; and (3) staristically significant (though less strong) evidence that with household living standards held constant, neighborhood levels of poverty adversely affect health. the paper doses with a discussion of the implications of these findings for the targeting of health and poverty program interventions. p6-13 (a) urban environment and the changing epidemiological surfacr. the cardiovascular ~ &om dorin, nigeria the emergence of cardiovascular diseases had been explained through the concomitants o_f the demographic transition wherein the prevalent causes of morbidity and monality ~hangr pr~mmant infectious diseases to diseases of lifestyle or chronic disease (see deck, 1979) . a ma1or frustration m the v146 poster sessions case of cvd is its multifactural nature. it is acknowledged that the environment, however defined is the d · f · t' b tween agents and hosts such that chronic disease pathogenesis also reqmre a me 1an o mterac ion e . spatio-temporal coincidence of these two parties. what is not clear is which among ~ever~( potennal fac· · h b pace exacerbate cvd risk more· and to what extent does the ep1dem1olog1cal trans1· tors m t e ur an s ' . . . . tion h othesis relevant in the explanation of urban disease outlook even the developmg cities like nigeri~: thesis paper explorer these within a traditional city in nigeria. . . . the data for the study were obtained from two tertiary level hospitals m the metropolis for 10 years (1991) (1992) (1993) (1994) (1995) (1996) (1997) (1998) (1999) (2000) . the data contain reported cases of cvd in the two facilities for the period. adopting a series of parametric and non-parametric statistics, we draw inferences between the observed cases of cvds and various demographic and locational variables of the patients. findings: about 28% of rhe cases occurred in 3 years (1997) (1998) (1999) coinciding with the last year of military rule with great instability. 55.3% occurred among male. 78.8% also occurred among people aged 31-70 years. these are groups who are also likely to engage in most stressful life patterns. ~e study also shows that 63% of all cases occurred in the frontier wards with minor city areas also havmg their •fair' share. our result conformed with many empirical observation on the elusive nature of causation of cvd. this multifactoral nature had precluded the production of a map of hypertension that would be consistent with ideas of spatial prediction. cvd -cardiovascular diseases. mumbai is the commercial capital of india. as the hub of a rapidly transiting economy, mumbai provides an interesting case study into the health of urban populations in a developing country. with high-rise multimillion-dollar construction projects and crowded slums next to each other, mumbai presents a con· trast in development. there are a host of hi-tech hospitals which provide high quality care to the many who can afford it (including many westerners eager to jump the queue in their healthcare systems-'medical tour· ism'), at the same time there is a overcrowded and strained public healthcare system for those who cannot afford to pay. voluntary organizations are engaged in service provision as well as advocacy. the paper will outline role of the voluntary sector in the context of the development of the healthcare system in mumbai. mumbai has distinct upper, middle and lower economic classes, and the health needs and problems of all three have similarities and differences. these will be showcased, and the response of the healthcare system to these will be documented. a rising hiv prevalence rate, among the highest in india, is a challenge to the mumbai public healthcare system. the role of the voluntary sector in service provision, advocacy, and empowerment of local populations with regards to urban health has been paramount. the emergence of the voluntary sector as a major player in the puzzle of urban mumbai health, and it being visualized as voices of civil society or communiry representatives has advantages as well as pitfalls. this paper will be a unique attempt at examining urban health in india as a complex web of players. the influence of everyday socio·polirical-cultural and economic reality of the urban mumbai population will be a cross cutting theme in the analysis. the paper will thus help in filling a critical void in this context. the paper will thus map out issues of social justice, gender, equiry, effect of environment, through the lens of the role of the voluntary sector to construct a quilt of the realiry of healthcare in mumbai. the successes and failures of a long tradi· tion of the active advocacy and participation of the voluntary sector in trying to achieve social justice in the urban mumbai community will be analyzed. this will help in a better understanding of global urban health, and m how the voluntary sector/ngos fir into the larger picture. ba~und: o~er. half _of n~irobi's 2.5 million inhabitants live in illegal informal settlements that compose 5 yo of the city s res1dent1al land area. the majority of slum residents lack access to proper san· iranon and a clean and adequate water supply. this research was designed to gain a clearer understand· mg of what kappr · · · h f . . opnate samtanon means or the urban poor, to determine the linkages between gender, hvehhoods, and access to water and sanitation, and to assess the ability of community sanitation blocks to meet water and sanitation needs in urban areas. m~tbojs_: _a household survey, gender specific focus groups and key informant interviews were conducted m maih saba, a peri-urban informal settlement. qualitative and quantitative research tools were u~ to asses~ the impact and effectiveness of community sanitation blocks in two informal settlements. results ropna e samtarmn me u es not only safe and clean latrines, but also provision ° adequate drainage and access to water supply for cleaning of clothes and homes. safety and cleanliness poster sessions v147 were priorities for women in latrines. levels of poverty within the informal settlements were identified and access to water and sanitation services improved with increased income. environmental health problems related to inadequate water and sanitation remain a problem for all residents. community sanitation blocks have improved the overall local environment and usage is far greater than envisioned in the design phase. women and children use the blocks less than men. this is a result of financial, social, and safety constraints. the results highlight the importance a need to expand participatory approaches for the design of water and sanitation interventions for the urban poor. plans need to recognize "appropriate sanitation" goes beyond provision of latrines and gender and socioeconomic differences must be taken into account. lessons and resources from pilot projects must be learned from, shared and leveraged so that solutions can be scaled up. underlying all the challenges facing improving water and sanitation for the urban poor are issues of land tenure. p6-16 (c) integrating tqm (total quality management), good governance and social mobilization principles in health promotion leadership training programmes for new urban settings in 12 countries/ areas: the prolead experience susan mercado, faren abdelaziz, and dorjursen bayarsaikhan introduction: globalization and urbanization have resulted in "new urban settings" characterized by a radical process of change with positive and negative effects, increased inequities, greater environmental impacts, expanding metropolitan areas and fast-growing slums and vulnerable populations. the key role of municipal health governance in mitigating and modulating these processes cannot be overemphasized. new and more effective ways of working with a wide variety of stakeholders is an underpinning theme for good governance in new urban settings. in relation to this, organizing and sustaining infrastructure and financing to promote health in cities through better governance is of paramount importance. there is a wealth of information on how health promotion can be enhanced in cities. despite this, appropriate capacity building programmes to enable municipal players to effectively respond to the challenges and impacts on health of globalization, urbanization and increasing inequity in new urban settings are deficient. the who kobe centre, (funded by the kobe group( and in collaboration with 3 regional offices (emro, searo, wpro) with initial support from the japan voluntary contribution, developed a health promotion leadership training programme called "prolead" that focuses on new and autonomous structures and sustainable financing for health promotion in the context of new urban settings. methodology: country and/or city-level teams from 12 areas, (china, fiji, india, japan, lebanon, malaysia, mongolia, oman, philippines, republic of korea, tonga and viet nam) worked on projects to advance health promotion infrastructure and financing in their areas over a 9 month period. tools were provided to integrate principles of total quality management, good governance and social mobili1.ation. results: six countries/areas have commenced projects on earmarking of tobacco and alcohol taxes for health, moblization of sports and arts organizations, integration of health promotion and social health insurance, organizational reforms, training in advocacy and lobbying, private sector and corporate mobilization and community mobilization. results from the other six areas will be reported in 01..;obcr. conclusions: total quality management, good governance and social mobilization principles and skills are useful and relevant for helping municipal teams focus on strategic interventions to address complex and overwhelming determinants of health at the municipal level. the prolead training programmes hopes to inform other processes for building health promotion leadership capacity for new urban settings. the impact of city living and urbanization on the health of citizens in developing countries has received increasing attention in recent years. urban areas contribute largely to national economies. however, rapid and unplanned urban growth is often associated with poverty, environmental degradation and population demands that outstrip service capacity which conditions place human health at risk. local and national governments as well as multi national organizations are all grappling with the challenges of urbanization. with limited data and information available, urban health characteristics, including the types, quantities, locations and sources in kampala, are largely unknown. moreover, there is n? basis for assessing the impact of the resultant initiatives to improve health ~onditions amo~g ~o":1":1um ties settled in unplanned areas. since urban areas are more than the aggregation ?f ~?pie w~th md_1v1dual risk factors and health care needs, this paper argues that factors beyond the md1v1dual, mcludmg the poster sessions v148 · i d h · i · ment and systems of health and social services are determinants of the health soc1a an p ys1ca environ . of urban populations. however, as part of an ongoing study? ~s pape~ .addresses the basic concerns of urban health in kampala city. while applying the "urban hvmg conditions and the urban heal~ pen· alty" frameworks, this paper use aggregated urban health d~ta t~ explore the role of place an~ 111st1tu· tions in shaping health and well-being of the population m kampala by understanding how characteristics of the urban environment and specific features of the city are causally related to health of invisible and forgotten urban poor population: results i~dica~e that a .range o~ urb~n he~l~h hazards m the city of kampala include substandard housing, crowdmg, mdoor air poll.ut1on, msuff1c1ent a~d con· taminated water, inadequate sanitation and solid waste management services, vector borne .diseases, industrial waste increased motor vehicle traffic among others. the impact of these on the envtronment and community.health are mutually reinforcing. arising out of the withdra"'.al of city pl~nning systems and service delivery systems or just planning failure, thousands of people part1cularl~ low-mc~me groups have been pushed to the most undesirable sections of the city where they are faced with ~ va_r1ety ~f envj· ronmental insults. the number of initiatives to improve urban health is, however, growing mvolvjng the interaction of many sectors (health, environment, housing, energy, transportation and urban planning) and stakeholders (local government, non governmental organizations, aid donors and local community groups). key words: urban health governance, health risks, kampala. introduction: the viability of urban communities is dependent upon reliable and affordable mass transit. in particular, subway systems play an especially important role in the mass transit network, since they provide service to vast numbers of ridersseven of the 95 subway systems worldwide report over one billion passenger rides each year. surprisingly, given the large number of people potentially affected, very little is known about the health and safety hazards that could affect both passengers and transit workers; these include physical (e.g., noise, vibration, accidents, electrified sources, temperature extremes), biological (e.g., transmission of infectious diseases, either through person-to-person spread or vector-borne, for example, through rodents), chemical (e.g., exposure to toxic and irritant chemicals and metals, gas emissions, fumes), electro-magnetic radiation, and psychosocial (e.g., violence, workstress). more recently, we need to consider the threat of terrorism, which could take the form of a mass casualty event (e.g., resulting from conventional incendiary devices), radiological attack (e.g., "dirty bomb"), chemical terrorist attack (e.g., sarin gas), or bioterrorist attack (e.g., weapons grade anthrax). given the large number of riders and workers potentially at risk, the public health implications are considerable. methods: to assess the hazards associated with subways, a structured review of the (english) litera· ture was conducted. ruults: based on our review, non-violent crime, followed by accidents, and violent crimes are most prevalent. compared to all other forms of mass transit, subways present greater health and safety risks. however, the rate of subway associated fatalities is much lower than the fatality rate associated with automobile travel (0.15 vs. 0.87 per 100 million passenger miles), and cities with high subway ridership rates have a 36% lower per capita rate of transportation related fatalities than low ridership cities (7.5 versus 11.7 annual deaths per 100,000 residents). available data also suggest that subway noise levels and levels of air pollutants may exceed recommended levels. . ~: there is a paucity of published research examining the health and safety hazards associated with subways. most of the available data came from government agencies, who rely on passively reported data. research is warranted on this topic for a number of reasons, not only to address important knowled~ gaps, but also because the population at potential risk is large. importantly, from an urban perspecnve, the benefits of mass transit are optimized by high ridership ratesand these could be adversely affu:ted by unsafe conditions and health and safety concerns. veena joshi, jeremy lim. and benjamin chua ~ ~rban health issues have moved beyond infectious diseases and now centre largely on chrome diseases. diabetes is one of the most prevalent non-communicable diseases globally. 9 % of adult ¥151 benefit in providing splash pads in more parks. given the high temperature and humidity of london summers, this is an important aspect and asset of parks. interviewed parents claimed to visit city parks anywhere between 1 to 6 days per week. corrduion: given that the vast majority of canadian children are insufficiently active to gain health benefits, identifying effective qualities of local parks, that may support and foster physical activity is essential. strategies to promote activity within children's environments are an important health initiative. the results from this study have implications for city planners and policy makers; parents' opinions of, and use of city parks provides feedback as to the state current local parks, and modifications that should be made for new ones being developed. this study may also provide important feedback for health promoters trying to advocate for physical activity among children. introdt1clion: a rapidly increasing proportion of urban dwellers in africa live below the poverty line in overcrowded slums characterized by uncollected garbage, unsafe water, and deficient sanitation and overflowing sewers. this growth of urban poverty challenges the commonly held assumption that urban populations enjoy better health than their rural counterparts. the objectives of this study are (i) to compare the vaccination status, and morbidity and mortality outcomes among children in the slums of nairobi with rural kenya, and (ii) to examine the factors associated with poor child health in the slums. we use data from demographic and health survey representative of all slum settlements in nairobi city carried out in 2000 by the african population & health research center. a total of 3,256 women aged 15-49 from 4,564 households were interviewed. our sample consists of 1,210 children aged 0-35 months. the comparison data are from the 1998 kenya demographic and health survey. the outcomes of interest include child vaccination status, morbidity (diarrhea, fever and cough) and mortality, all dichotomized. socioeconomic, environmental, demographic, and behavioral factors, as well as child and mother characteristics, are included in the multivariate analyses. multilevel logistic regression models are used. l'nlimin11ry rest1lts: about 32 % of children in the slums had diarrhea in the two weeks prior to the survey, compared to 16% of rural children. these disparities between the urban poor anj the rural residents are also observed for fever (64% against 42%), cough (46% versus 20%), infant mortality (91/ 1000 against 76/1000), and complete vaccination (48% against 64%). preliminary multivariate results indicate that health service utilization and maternal education have the strongest predictive power on child morbidity and mortality in the slums, and that household wealth has only minor, statistically insignificant effects. conclruion: the superiority of health of urban children, compared with their rural counterparts, masks significant disparities within urban areas. compared to rural residents, children of slum dwellers in nairobi are sicker, are less likely to utilize health services when sick, and stand greater risk to die. our results suggest policies and programs contributing to the attainment of the millennium development goal on child health should pay particular attention to the urban poor. the insignificance of socioeconomic status suggests that poor health outcomes in these communities are compounded by poor environmental sanitation and behavioral factors that could partly be improved through female education and behavior change communication. introduction: historic trade city surat with its industrial and political peace has remained a center of attraction for people from all the comers of india resulting in to pop.ulatio~ explosio~ a~d stressed social and service infrastructure. the topography,dimate and demographic profile of the city 1s threat to the healthy environment. aim of this analysis is to review the impact of managemt'nt reform on health indicators. method: this paper is an analysis of the changing profile of population, sanitary infr~s~rucrure, local self government management and public health service reform, secondary health stat1st1cs data, health indicator and process monitoring of 25 years. . . health of entire city and challenge to the management system. plague outbr~ak (1994) was the turning point in the history of civic service management including p~blic ~e~lth service management. ~ocal self government management system was revitalized by reg~lar_ field v1s1ts o~ al~ cadre~, _decentraltzanon of power and responsibility, equity, regular vigilant momtormg, commumcanon facility, ream_approach and people participation. reform in public health service management was throu_gh stan~~rd1zed intervention protocol, innovative intervention, public private partnership, community part1c1panon, academic and service institute collaboration and research. sanitation service coverage have reached nearer to universal. area covered by safe water supply reached to 98%(2004) from 40% (1991) and underground drainage to 97% (2004) from 17% ( 1991) the overhauling of the system have reflected on health indicators of vector and water born disease. malaria spr declined to 1.23 (2004) from 23.06'yo(!991) and diarrhea case report declined to 1963(2004) from 3431 (2004). except dengue fever in 2002 no major disease outbreaks are reported after 1991. city is recipient of international/national awards/ranking for these achievements. the health department have developed an evidence and experience based intervention and monitoring system and protocol for routine as well as disaster situation. the health service and management structure of surat city have emerged as an urban health model for the country. introduction: the center for healthy communities (chc) in the department of family and com· munity medicine at the medical college of wisconsin developed a pilot project to: 1) assess the know· ledge, attitudes, and behaviors of female milwaukee public housing residents related to breast cancer; 21 develop culturally and literacy appropriate education and screening modules; 3) implement the developed modules; 4) evaluate the modules; and 5) provide follow-up services. using a community-based participatory research model the chc worked collaboratively with on-site nurse case management to meet these objectives. methods: a "breast health kick off event" was held at four separate milwaukee public housing sites for elderly and disabled adults. female residents were invited to complete a 21-item breast health survey, designed to accommodate various literacy levels. responses were anonymous and voluntary. the survey asked women about their previous physical exams for breast health, and then presented a series of state· ments about breast cancer to determine any existing myths. the final part gathered information about personal risk for breast cancer, the highest level of education completed, and whether the respondents h;td ever used hormone replacement therapy and/or consumed alcohol. responses were collected for descriptive analysis. results: a total of 45 surveys (representing 18% of the total female population in the four sites) were completed and analyzed. 89% reported that they had a physical exam in the previous rwo years. 96% of respondents indicated they never had been diagnosed with breast cancer. 85% reported having had a mammogram and 87% having had a clinical breast exam. those that never had a mammogram reported a fear of what the provider would discover or there were not any current breast problems ro warrant an exam. 80% agreed that finding breast cancer early could lower the chance of dying of cancer. over 92% reported that mammograms were helpful in finding cancer. however, 27% believed that hav· ing a mammogram actually prevents breast cancer. 14% indicated that mammograms actually cause cancer and 16% reported that a woman should get a mammogram only if there is breast cancer in her family. conclusion: this survey indicates that current information about the importance of mammograms and clinical breast exams is reaching traditionally underserved women. yet there are still critical oppor· tunities to provide valuable education on breast health. this pilot study can serve as a tool for shaping future studies of health education messages for underserved populations. located in a yourh serv· ~ng agency m downtow~ ottawa, the clinic brings together community partners to provide primary medical care. and dent~i hygiene t? the street youths of ottawa aged 12-20. the primary goal of the project is to provide accessible, coordinated, comprehensive health and dental care to vulnerable adolescents. these efforts respond to the pre-existing body of evidence suggesting that the principle barrier in accessing such care for these youths are feelings of intimidation and vulnerability in the face of a complex healthcare system. the bruyere fhn satellite clinic is located in the basement of a downtown drop-in and brings together a family medicine physician and her residents, a dental hygienist and her 2nd year students, a nurse practitioner, a chiropodist and 2 public health nurses to provide primary care. the clinic has been extremely busy and well received by the youth. this workshop will demonstrate how five community organizations have come together to meet the needs of high risk youths in ottawa. this presentation will showcase the development of the clinic from its inception through its first year including reaction of the youths, partnerships and lessons learned. it will also focus on its sustainability without continued funding. we hope to have developed a model of service delivery that could be reproduced and sustained in other large cities with faculties of medicine. methods: non-randomized, mixed method design involving a process and impact evaluation. data collection-qualitative-a) semi structured interviews with providers & partners b)focus groups with youth quantitative a)electronic medical records for 12 months records (budget, photos, project information). results: 1) successfully built and opened a medicaudental clinic which will celebrate its 1 year anniversary in august. 2) over 140 youths have been seen, and we have had over 300 visits. conclusion: 1) the clinic will continue to operate beyond the 18 month project funding. 2) the health of high risk youth in ottawa will continue to improve due to increased access to medical services. p7-11 (a) health services -for the citizens of bangalore -past, present and future savita sathyagala, girish rao, thandavamurthy shetty, and subhash chandra bangalore city, the capital of karnataka with 6.5 million is the 6th most populous city in india; supporting 30% of the urban population of karnataka, it is considered as one of the fastest growing cities in india. known as the 'silicon valley of india', bangalore is nearly 500 years old. bangalore city corporation (bmp), is a local self government and has the statutory commitment to provide to the citizens of bangalore: good roads, sanitation, street lighting, safe drinking water apart from other social obligations, cultural development and poverty alleviation activities. providing preventive and promotive heahh services is also a specific component. the objective of this study was to review the planning process with respect to health care services in the period since india independence; the specific research questions being what has been the strategies adopted by the city planners to address to the growing needs of the population amidst the background of the different strategies adopted by the country as a whole. three broad rime ranges have been considered for analysis: the 1950s, 1970s and the 1990s. the salient results are: major area of focus has been on the maternal and child care with activities ranging from day-care to in-patient-care; though the number of institutions have grown from 5 to the current day 79, their distribution has been far from satisfactory; obtaining support from the india population projects 3 and 8 major upgradarions have been undertaken in terms of infrastructure; over the years, in addition to the dispensaries of modern system of medicine, local traditional systems have also been initiated; the city has partnered with the healthy cities campaign with mixed success; disease surveillance, addressing the problems related to the emerging non-communicable diseases including mental health and road traffic injuries are still in its infancy. isolated attempts have been made to address the risks groups of elderly care and adolescent care. what stands out remarkably amongst the cities achievements is its ability to elicit participation from ngos, cbos and neighbourhood groups. however, the harnessing of this ability into the health sector cannot be said totally successful. the moot question in all the above observed development are: has the city rationally addressed it planning needs? the progress made so far can be considered as stuttered. the analysis and its presentation would identify the key posirive elements in the growth of banglore city and spell a framework for the new public health. introduction: anaemia associated with pregnancy is a major public health problem all over the world. different studies in different parts of india shown prevalence of anaemia between 60-90%. anaemia remains a serious health problem in pregnancy despite of strong action taken by the government of india through national programmes. in the present study we identified th~ social beha~iors, responsible for low compliance of if a tablets consumption in pregnancy at community level and intervention was given with new modified behaviors on trial bases. . in vadodara urban. 60 anganwadies out of 289 were selected from the list by random sampling for tips (trials of improved practices) study. . . participants: 266 pregnant women (132, intervention group+ 134, control. group) registered m the above 60 anganwadies. study was conducted in to three phases: phase: 1. formative research and baseline survey (frbs). data was collected from all 266 pregnant women to identify behaviors that are responsible for low compliance of ifa tablets. both qualitative and quantitative data were collected. haemoglobin was estimated of all pregnant women by haemo-cue. phase: 2. phase of tips. behaviors were identified both social & clinical for low compliance of ifa tablets consumption in pregnancy from frbs and against those, modified behaviors were proposed to pregnant women in the intervention group on trial bases by health education. trial period of 6 weeks was given for trial of new behaviors to pregnant women in the interven· tion group. phase: 3. in this phase, feedbacks on behaviors tried or not tried were taken from pregnant women in intervention group. haemoglobin estimation was carried out again in all 266 pregnant women. at the end of the study, messages were formulated on the bases of feedbacks from the pregnant women. results: all pregnant women in the intervention group had given positive feedback on new modified behaviors after intervention. mean haemoglobin concentration was higher in intervention group (10.04±0.11 gm%) than control group (9.60±0.14 gm%). ifa tablets compliance was improved in intervention group (95.6%) than control group (78.6%). conclusion: all pregnant women got benefits after trial of new modified behaviors in the intervention group. messages were formulated from the new modified behaviors, which can be used for longterm strategies for anaemia control in the community. introduction: in order to develop a comprehensive mch handbook for pregnant women and to assess its effect among them, a pilot study was carried out at the maternal and child health training institute (mchti), in dhaka, bangladesh. methods: from mchti a sample of 600 pregnant women was selected and all subjects were women who were attending the first visit of their current pregnancy by using a random sampling method. of the 600 subjects, 240 women were given the mch handbook as case and 360 women were not given the handbook as control. data on pre and post intervention of the handbook from the 240 cases and 360 controls were taken from data recording forms between the 1st of november 2002 and 31st of october, 2003 and data was analysed by using a multilevel analysis approach. this was a hospital-based action (case-control) research, and was applied in order to measure the outcome of pre and post intervention following the introduction of the handbook. data was used to assess the effects of utilisation of the handbook on women's knowledge, practice and utilisation of mch services. results: this study showed that the change of knowledge about antenatal care visits was 77.1% among case mothers. knowledge of danger signs improved 49.2 %, breast feeding results 31.5%, vaccination 32.0% and family planning results improved 60.3% among case. results showed some positive changes in women's attitudes among case mothers and study showed the change of practice in antenatal care visits was .u.5% in the case. other notable changes were: change of practice in case mother's tetanus toxoid (ti), 55.2%; and family planning 41.2%. in addition, handbook assessment study indicated that most women brought the handbook on subsequent visits (83.3%), the handbook was highly utilised (i.e. it was read by 84.2%, filled-in by 76.1 %, and was used as a health education tool by 80.4%). most women kept the handbook (99.5%) and found it highly useful (78.0%) with a high client satisfaction rate of 88.0%. conclusion: pregnant women in the case group had higher knowledge, better practices, and higher utilisation of mch services than mothers in the control groups who used alternative health cards. if the handbook is developed with a focus on utilising a problem-oriented approach and involving the recomendations .of end~users, it is anticipated that the mch handbook will contribute significantly to ensuring the quahry of hfe of women and their children in bangladesh. after several meetmgs to identify the needs of the community, a faso clinic was opened at ncfs. health care professionals from smh joined with developmental and social service workers from ncfs to implement the faso diagnostic process and to provide culturally appropriate after-care. the clinic is unique in that its focus is the high risk urban aboriginal population of toronto. it accepts referrals of not only children and youth, but also of adults. lessons learned: response to the faso clinic at native child and family services has been overwhelming. aboriginal children with f asd are receiving timely diagnosis and interventions. aboriginal youth and adults who have been struggling with poveny, substance abuse, and homelessness are more willing to enter the ncfs centre for diagnosis and treatment. aboriginal infants prenatally exposed to alcohol born at st. michael's hospital or referred by other centres have access to the developmental programs located in both of the partnering agencies. the presentation will describe the clinic's development, and will detail the outcomes described, including interventions unique to the aboriginal culture. p7-15 (c) seeds, soil, and stories: an exploration of community gardening in southeast toronto carolin taran, sarah wakefield, jennifer reynolds, and fiona yeudall introduction: community gardens are increasingly seen as a mechanism for improving nutrition and increasing food security in urban neighbourhoods, but the evidence available to support these claims is limited. in order to begin to address this gap in a way that is respectful of community knowledge and needs, the urban gardening research opportunities workgroup (ugrow) project explored the benefits and potential risks of community gardening in southeast toronto. the project used a community-based research (cbr) model to assess community gardens as a means of improving local health. the research process included interviews, focus groups, and participant observation (documented in field notes). we also directly engaged the community in the research process, through co-learning activities and community events which allowed participants to express their views and comment on emerging results. most of the research was conducted by a community-based research associate, herself a community gardener. key results were derived from these various sources through line-by-line coding of interview transcripts and field note review, an interactive and iterative process which involved both academic and community partners. results: these various data sources all suggest that enhanced health and access to fresh produce are important components of the gardening experience. they also highlight the central importance of empowering and community-building aspects of gardening to gardeners. community gardens were thought to play a role in developing friendships and social support, sharing food and other resources, appreciating cultural diversity, learning together, enhancing local place attachment and stewardship, and mobilizing to solve local problems (both inside and outside the garden). potential challenges to community gardens as a mechanism for communiry development include bureaucratic resistance to gardens, insecure land tenure and access, concerns about soil contamination, and a lack of awareness and under· standing by community members and decision-makers of all kinds. conclusion: the results highlight many health and broader social benefits experienced by commu· nity gardeners. they also point to the need for greater support for community gardening programs, par· ticularly ongoing the ongoing provision of resources and education programs to support gardens in their many roles. this research project is supported by the wellesley central health corporation and the centre for urban health initiatives, a cihr funded centre for research development hased at the univer· sity of toronto. p7-16 (c) developing resiliency in children living in disadvantaged neighbourhoods sarah farrell, lorna weigand, and wayne hammond the traditional idea of targeting risk reduction by focusing on the development of eff~ctive coping strategies and educational programs has merit in light of the research reportmg_ that_ ~10lupl.e forms of problem behaviour consistently appear to be predicted by increasing exposure to 1den_uf1able risk factors. as a result, many of the disadvantaged child and youth studies have focused on trymg to better _unde.r· stand the multiple risk factors that increase the likelihood of the development of at nsk behaviour m ch1ldren/youth and the potential implications for prevention. this in turn has led t_o. the conclus1on that community and health programs need to focus on risk reduction by helpm~ md1v1duals develop more effective coping strategies and a better understanding of the limitations of cenam pathologies, problematic v156 poster sessions coping behaviours and risk factors potentially inheren~ in high needs co~unities. ~owever, another ai:ea of research has proposed that preventative interventions should cons1de~ .~rotecnve fa~ors alo~~ with reducing risk factors. as opposed to just emphasizing problems, vulnerab1ht1es, and deficits, a res1liencybased perspective holds the belief that children, youth and their families. have strengths, reso~ce.s and the ability to cope with significant adversity in ways that are not only effective, but tend to result m mcreased ability to constructively respond to future adversity. with this in mind, a participatory research project sponsored by the united way of greater toronto was initiated to evaluate and determine the resiliency profiles of children 8 -12 years (n = 500) of recent immigrant families living in significantly disadvantaged communities in the toronto area. the presentation will provide an overview of the identified protective factors (both intrinsic and extrinsic) and resiliency profiles in an aggregated format as well as a summary of how the children and their parents interpreted and explained these strength-based results. as part of the focus groups, current community programs and services were examined by the participants as to what might be best practices for supporting the development and maintaining of resiliency in children, families and communities. it was proposed that the community model of assessing resiliency and protective factors as well as proposed best strength-based practice could serve as a guide for all in the community sector who provide services and programs to those in disadvantaged neighbourhoods. p7-17 (c) naloxone by prescription in san francisco, ca and new york, ny emalie huriaux the harm reduction coalition's overdose project works to reduce the number of fatal overdoses to zero. located in new york, ny and san francisco, ca, the overdose project provides overdose education for social service providers, single-room occupancy hotel (sro) residents, and syringe exchange participants. the project also conducts an innovative naloxone prescription program, providing naloxone, an opiate antagonist traditionally administered by paramedics to temporarily reverse the effects of opiate overdose, to injection drug users (idus). we will describe how naloxone distribution became a reality in new york and san francisco, how the project works, and our results. the naloxone prescription program utilizes multiple models to reach idus, including sro-and street-based trainings, and office-based trainings at syringe exchange sites. trainings include information on overdose prevention, recognition, and response. a clinician conducts a medical intake with participants and provides them with pre-filled units of naloxone. in new york, funding was initially provided by tides foundation. new york city council provides current funding. new york department of mental health and hygiene provides program oversight. while the new york project was initiated in june 2004, over half the trainings have been since march 2005. in san francisco, california endowment, tides foundation, and san francisco department of public health (sfdph) provide funding. in addition, sfdph purchases naloxone and provides clinicians who conduct medical intakes with participants. trainings have been conducted since november 2003. to date, nearly 1000 individuals have been trained and provided with naloxone. approximately 130 of them have returned for refills and reported that they used naloxone to reverse an opiate-related overdose. limited episodes of adverse effects have been reported, including vomiting, seizure, and "loss of friendship." in new york, 400 individuals have been trained and provided with naloxone. over 30 overdose reversals have been reported. over half of the participants in new york have been trained in the south bronx, the area of new york with the highest rate of overdose fatalities. in san francisco, 570 individuals have been trained and provided with naloxone. over 96 overdose reversals have been reported. the majority of the participants in san francisco have been trained in the tenderloin, 6th street corridor, and mission, areas with the highest rates of overdose fatalities. the experience of the overdose project in both cities indicates that providing idus low-threshold access to naloxone and overdose information is a cost-effective, efficient, and safe intervention to prevent accidental death in this population. p7-18 (c) successful strategies to regulate nuisance liquor stores using community mobilization, law enforcement, city council, merchants and researchers tahra goraya presenta~ion _will discuss ~uccessful environmental and public policy strategies employed in one southen:1 cahf?rmna commumty to remedy problems associated with nuisance liquor stores. participants ~111 be given tools to understand the importance of utilizing various substance abuse prevention str~tegi~ to change local policies and the importance of involving various sectors in the community to a~_1st with and advocate for community-wide policy changes. recent policy successes from the commultles of pa~ad~na and altad~na will highlight the collaborative process by which the community mobilized resulnng m several ordmances, how local law enforcement was given more authority to monitor poster sessions v157 nonconforming liquor stores, how collaborative efforts with liquor store owners helped to remove high alcohol content alcohol products from their establishments and how a community-based organiz,uion worked with local legislators to introduce statewide legislation regarding the regulation of nuisance liquor outlets. p7-19 (c) "dialogue on sex and life": a reliable health promotion tool among street-involved youth beth hayhoe and tracey methven introduction: street involved youth are a marginalized population that participate in extremely risky behaviours and have multiple health issues. unfortunately, because of previous abuses and negative experiences, they also have an extreme distrust of the adults who could help them. in 1999, toronto public health granted funding to a non governmental, nor for profit drop-in centre for street youth aged 16-24, to educate them about how to decrease rhe risk of acquiring hiv. since then the funding has been renewed yearly and the program has evolved as needed in order to target the maximum number of youth and provide them with vital information in a candid and enjoyable atmosphere. methods: using a retrospective analysis of the six years of data gathered from the "dialogue on sex and life" program, the researchers examined the number of youth involved, the kinds of things discussed, and the number of youth trained as peer leaders. also reviewed, was written feedback from the weekly logs, and anecdotal outcomes noted by the facilitators and other staff in the organization. results: over the five year period of this program, many of youth have participated in one hour sessions of candid discussion regarding a wide range of topics including sexual health, drug use, harm reduction, relationship issues, parenting, street culture, safety and life skills. many were new youth who had not participated in the program before and were often new to the street. some of the youth were given specific training regarding facilitation skills, sexual anatomy and physiology, birth control, sexually transmitted infections, hiv, substance use/abuse, harm reduction, relationships and discussion of their next steps/future plans following completion of the training. feedback has been overwhelmingly positive and stories of life changing decisions have been reported. conclusion: clearly, this program is a successful tool to reach street involved youth who may otherwise be wary of adults and their beliefs. based on data from the evaluation, recommendations have been made to public health to expand the funding and the training for peer leaders in order ro target between 100-200 new youth per year, increase the total numbers of youth reached and to increase the level of knowledge among the peer leaders. p7-20 (c) access to identification and services jane kali replacing identification has become increasingly more complex as rhe government identification issuing offices introduce new requirements rhar create significant barriers for homeless people to replace their id. new forms of identification have also been introduced that art' not accessible to homekss peoplt-(e.g. the permanent resident card). ar rhe same time, many service providers continue to require identifi· cation ro access supports such as income, housing, food, health care, employment and employmt·nt training programs. street health, as well as a number of other agencies and community health centres, h,1, been assisting with identification replacement for homeless peoplt· for a number of years. the rnrrt·nr challenges inherent within new replacement requirements, as well as the introduction of new forn1' of identification, have resulted in further barriers homeless people encounter when rrring to access t:ssential services. street health has been highlighting these issues to government identification issuing offices, as well as policy makers, in an effort to ensure rhar people who are homeless and marginalized have ac'ess to needed essential services. bandar is a somali word for •·a safe place." the bandar research project is the product of the regent park community health centre. the research looks ar the increasing number of somali and afri· can men in the homeless and precariously house population in the inner city core of down~own toronto. in the first phase of the pilot project, a needs assessment was conducted to 1dennfy barners and issues faced by rhe somali and other african men who are homeless and have add1cr10ns issues. th_e second phase of rhe research project was to identify long rerm resources and service delivery mechamsms that v158 poster sessions would enhance the abiity of this population to better access detox, treatment, and post treatment ser· vices. the final phase of the project was to facilitate the development of a conceptual model of seamless continual services and supports from the streets to detox to treatment to long term rehabilitation to housing. "between the pestle and mortar" -safe place. p7-22 (c) successful methods for studying transient populations while improving public health beth hayhoe, ruth ewert, eileen mcmahon, and dan jang introduction: street youth are a group that do not regularly access healthcare because of their mis· trust of adults. when they do access health care, it is usually for issues severe enough for hospitalization or for episodic care in community clinics. health promotion and illness prevention is rarely a part of their thinking. thus, standard public health measures implemented in a more stable population do not work in this group. for example, pap tests, which have dearly been shown to decrease prevalence of cer· vical cancer, are rarely done and when they are, rarely followed up. methods to meet the health care needs and increase the health of this population are frequently being sought. methods: a drop-in centre for street youth in canada has participated in several studies investigating sexual health in both men and women. we required the sponsoring agencies to pay the youth for their rime, even though the testing they were undergoing was necessary according to public health stan· dards. we surmised that this would increase both initial participation and return. results: many results requiring intervention have been detected. given the transient nature of this population, return rates have been encouraging so far. conclusion: it seems evident that even a small incentive for this population increases participation in needed health examinations and studies. it is possible that matching the initial and follow-up incentives would increase the return rate even further. the fact that the youth were recruited on site, and not from any external advertising, indicates that studies done where youth trust the staff, are more likely to be successful. the presentation will share the results of the "empowering stroke prevention project" which incor· porated self-help mutual aids strategies as a health promotion methodology. the presentation will include project's theoretical basis, methodology, outcomes and evaluation results. self-help methodology has proven successful in consumer involvement and behaviour modification in "at risk," "marginalized" settings. self-help is a process of learning with and from each other which provides participants oppor· tunities for support in dealing with a problem, issue, condition or need. self-help groups are mechanisms for the participants to investigate existing solutions and discover alternatives, empowering themselves in this process. learning dynamic in self-help groups is similar to that of cooperative learning and peertraining, has proven successful, effective and efficient (haller et al, 2000) . the mutual support provided by participation in these groups is documented as contributory factor in the improved health of those involved. cognizant of the above theoretical basis, in 2004 the self-help resource centre initiated the "empowering stroke prevention project." the project was implemented after the input from 32 health organizations, a scan of more than 300 resources and an in-depth analysis of 52 risk-factor-specific stroke prevention materials indicated the need for such a program. the project objectives were:• to develop a holistic and empowering health promotion model for stroke prevention that incorporates selfhelp and peer support strategies. • to develop educational materials that place modifiable risk factors and lifestyle information in a relevant context that validates project participants' life experiences and perspectives.• to educate members of at-risk communities about the modifiable risk factors associated with stroke, and promote healthy living. to achieve the above, a diverse group of community members were engaged as "co-editors" in the development of stroke prevention education materials which reflected and validated their life experiences. these community members received training to become lay health promoters (trained volunteer peer facilitators). in collaboration with local health organizations, these trained lay health promoters were then supported in organizing their own community-based stroke prevention activities. in addition, an educational booklet written in plain language, entitled healthy ways to prevent stroke: a guide for you, and a companion guide called healthy ways to pre· vent stroke: a facilitator's guide were produced. the presentation will include the results of a tw<>tiered evaluation of the program methodology, educational materials and the use of the materials beyond the life of the project. this poster presentation will focus on the development and structure of an innovative street outreach service that assists individuals who struggle mental illness/addictions and are experiencing homelessness. the mental health/outreach team at public health and community services (phcs) of hamilton, ontario assists individuals in reconnecting with health and social services. each worker brings to the ream his or her own skills-set, rendering it extremely effective at addressing the multidimensional and complex needs of clients. using a capacity building framework, each ream member is employed under a service contract between public health and community services and a local grassroots agency. there are public health nurses (phn), two of whom run a street health centre and one of canada's oldest and most successful needle exchange programs, mental health workers, housing specialists, a harm reduction worker, youth workers, and a united church minister, to name a few. a community advisory board, composed of consumers and professionals, advises the program quarterly. the program is featured on raising the roors 'shared learnings on homelessness' website at www.sharedlearnings.ca. through our poster presentation participants will learn how to create effective partnerships between government and grassroots agencies using a capacity building model that builds on existing programs. this study aims to assess the effects of broadcasting a series of documentary and drama videos, intended to provide information about the bc healthguide program in farsi, on the awareness about and the patterns of the service usage among farsi-speaking communities in the greater vancouver area. the major goals of the present study were twofold; ( 1) to compare two methods of communications (direct vs. indirect messages) on the attitudes and perceptions of the viewers regarding the credibility of messengers and the relevance of the information provided in the videos, and (2) to compare and contrast the impact of providing health information (i.e., the produced videos) via local tvs with the same materials when presented in group sessions (using vcr) on participants' attitudes and perceptions cowards the bc healrhguide services. results: through a telephone survey, 545 farsi-speaking adults were interviewed in november and december 2004. the preliminary findings show that 53% of the participants had seen the aired videos, from which, 51 % watched at least one of the 'drama' clips, 8% watched only 'documentary' clip, and 41% watched both types of video. in addition, 27% of the respondents claimed that they were aware about the program before watching the aired videos, while 73% said they leaned about the services only after watching the videos. from this group, 14% said they called the bchg for their own or their "hildren's health problems in the past month. 86% also indicated that they would use the services in the future whenever it would be needed. 48% considered the videos as "very good" and thought they rnuld deliver relevant messages and 21 % expressed their wish to increase the variety of subjects (produ\:e more videos) and increase the frequency of video dips. conclusion: the results of this study will assist public health specialists in bc who want to choose the best medium for disseminating information and apply communication interventions in multi\:ultural communities. introduction: many theorists and practitioners in community-based research (cbr) and knowledge transfer (kt) strongly advocate for involvement of potential users of research in the development of research projects, yet few examples of such involvement exist for urban workplace health interventions. we describe the process of developing a collaborative research program. methods: four different sets of stakeholders were identified as potential contributors to and users of the research: workplace health policy makers, employers, trade unions, and health and safety associations. representatives of these stakeholders formed an advisory committee which met quarterly. over the 13 month research development period, an additional 21 meetings were held between resc:ar~h~rs and stakeholders. in keeping with participant observation approaches, field notes of group and md1v1~ ual meetings were kept by the two co-authors. emails and telephone calls were also documented. qu~h tative approaches to textual analysis were used, with particular attention paid to collaborattve v160 poster sessions relationships established (as per cbr), indicators of stakeholders' knowledge utilization (as per kt), and transformations of the proposed research (as per cbr). results: despite initial strong differences of opinion both among stakeho~ders .an~ between stakeholders and researchers, goodwill was noted among all involved. acts of rec~proc1ty included mu.rual sharing of assessment tools, guidance on data utilization to stakeho~der orga~1zat10ns, and suggestions on workplace recruitment to researchers. stakeholders demonstrated mcreases m concep~ual. un~erstand ing of workplace health e.g. they more commonly discussed more complex,. psychosocial md1cators of organizational health. stakeholders made instrumental use of shared materials based on research e.g. adapting their consulting model to more sophisticated dat~ analysis. sta~ehol?~rs recogni_zed the strategic use of their alliance with researchers e.g., transformational leadership trainmg as a~ inducement to improve health and safety among small service franchises. stakeholders helped re-define the research questions, dramatically changed the method of recruitment from researcher cold call to stakeholderbased recruitment, and strongly influenced pilot research designs. owing a great deal to the elaborate joint development process, the four collaboratively developed pilot project submissions which were all successfully funded. conclusion: the intensive process of collaborative development of a research program among stakeholders and researchers was not a smooth process and was time consuming. nevertheless, the result of the collaborative process was a set of projects that were more responsive to stakeholder needs, more feasible for implementation, and more broadly applicable to relevant workplace health problems. introduction: environmental groups, municipal public health authorities and, increasingly, the general public are advocating for reductions in pesticide use in urban areas, primarily because of concern around potential adverse health impacts in vulnerable populations. however, limited evidence of the relative merits of different intervention strategies in different contexts exists. in a pilot research project, we sought to explore the options for evaluating pesticide reduction interventions across ontario municipalities. methods: the project team and a multi-stakeholder project advisory committee (pac), generated a list of potential key informants (kl) and an open ended interview guide. thirteen ki from municipal government, industry, health care, and environmental organizations completed face to face or telephone interviews lasting 30-40 minutes. in a parallel process, a workshop involving similar representatives and health researchers was held to discuss the role of pesticide exposure monitoring. minutes from pac meetings, field notes taken during ki interviews, and workshop proceedings were synthesized to generate potential evaluation methods and indicators. results: current evaluation activities were limited but all kls supported greater evaluation effons beginning with fuller indicator monitoring. indicators of education and outreach services were imponant for industry representatives changing applicator practices as well as most public health units and environmental organizations. lndictors based on bylaw enforcement were only applicable in the two cities with bylaws, though changing attitudes toward legal approaches were being assessed in many communities. the public health rapid risk factor surveillance system could use historical baseline data to assess changes in community behaviour through reported pesticide uses and practices, though it had limited penetration in immigrant communities not comfortable in english. pesticide sales (economic) data were only available in regional aggregates not useful for city specific change documentation. testing for watercourse or environmental contamination might be helpful, but it is sporadic and expensive. human exposure monitoring was fraught with ethical issues, floor effects from low levels of exposure, and prohibitive costs. clinical episodes of pesticide exposure reported to the regional poison centre (all ages) or the mother risk program (pregnant or breastfeeding women) are likely substantial underestimates that would be need to be supplemented with sentinel practice surveillance. focus on special clinical populations e.g., multiple chemical sensitivity would require additional data collection efforts . . conc~ons: broad support for evaluation and multiple indicators were proposed, though con-s~raints associate~ with access, coverage, sensitivity and feasibility were all raised, demonstrating the difficulty of evaluating such urban primary prevention initiatives. interventionists. an important aim of the youth monitor is to learn more about the health development of children and adolescents and the factors that can influence this development. special attention is paid to emo· tional and behavioural problems. the youth monitor identifies high-risk groups and factors that are associated with health problems. at various stages, the youth monitor chancrs the course of life of a child. the sources of informa· tion and methods of research are different for each age group. the results arc used to generate various kinds of repons: for children and young persons, parents, schools, neighbourhoods, boroughs and the municipality of rotterdam and its environs. any problems can be spotted early, at borough and neigh· bourhood level, based on the type of school or among the young persons and children themselves. together with schools, parents, youngsters and various organisations in the area, the municipal health service aims to really address these problems. on request, an overview is offered of potentially suitable interventions. the authors will present the philosophy, working method, preliminary effects and future developments of this instrument, which serves as the backbone for the rotterdam local youth policy. social workers to be leaders in response to aging urban populations: the practicum partnership program sarah sisco, alissa yarkony, and patricia volland 1"'"1tliu:tion: across the us, 77.5% of those over 65 live in urban areas. these aging urban popu· lations, including the baby boomers, have already begun encounter a range of heahh and mental hcahh conditions. to compound these effects, health and social service delivery fluciuates in cities, whit:h arc increasingly diverse both in their recipients and their systems. common to other disciplines (medicine, nursing, psychology, etc.) the social work profession faces a shortage of workers who are well-equipped to navigate the many systems, services, and requisite care that this vast population requires. in the next two decades, it is projected that nearly 70,000 social workers will be required to provide suppon to our older urban populations. social workers must be prepared to be aging-savvy leaders in their field, whether they specialize in gerontology or work across the life span. mllhotu: in 2000, a study conducted at the new york academy of medicine d<>1:umcntcd the need for improved synchroniciry in two aspects of social work education, classroom instruction and the field experience. with suppon from the john a. hanford foundation, our team created a pilot proj~"t entitled the practicum pannership program (ppp) in 11 master's level schools of social work, to improvt" aginr exposure in field and classroom content through use of the following: i) community-university partnrr· ships, 2) increased, diverse student field rotations, ll infusion of competcn1."}'·drivm coursework, 41 enhancement of field instructors' roles, and 5) concentrated student recruitment. we conductt"d a prr· and post-test survey into students' knowledge, skills. and satisfaction. icarlja: surveys of over 400 graduates and field inltnk."tors rcflected increased numlk-n of .1rrm:y· univmity panncrships, as well as in students placed in aging agencin for field placements. there wa1 11 marked increase in student commitments to an aging specialization. onr year por.t·gradu:nion rcvealrd that 93% of those surveyed were gainfully employed, with 80% employed in the field of aginic. by com· bining curricular enhancement with real-world experiences the ppp instilled a broad exposurr for llu· dents who worked with aging populations in multiple urban settings. coltdtuion: increased exposure to a range of levels of practicr, including clinical, policy/ajvocaq, and community-based can potentially improve service delivery for older adulh who live in elfin, and potentially improve national policy. the hanford foundation has now elected to 1uppon cxpantion of the ppp to 60 schools nationwide (urban and rural) to complement other domntic initiatives to cnhalk"c" holistic services for older adults across the aging spectrum. bodrgnn.ntl: we arc a team of rcscarcbcn and community panncn working tcj8c(her to develop an in"itepth understanding of the mental health needs of homeless youth ~ages 16 to 24) (using qualiutivc and quantitative methods 8' panicipatory rncarch methods). it is readily apparmt that '-neless youth cxpcricnce a range of mental health problems. for youth living on the street, menul illnew may be either a major risk factor for homelessnal or may frequently emcsge in response to coping with rhe multitudinous stressors associated with homclcslllcsi including exposure to violence, prasutt to pamaplte in v162 poster sessions survival sex and/or drug use. the most frequent psychiatric diagnoses amongst the homeless gencrally include: depression, anxiety and psychosis. . . . the ultimate ob1ective of the pr~am of rei:e~ is to ~evelop a plan for intervention to meet the mental health needs of street youth. prior t_o pl~nnmg mtervenbons, .it is necessary to undertake a comprehensive assessment ~f mental health needs m this ~lnerable populanon. thus, the immediate objective of this research study is to undertake a comprehensive assessment of men· tal health needs. . . melbotlology: a mixed methodology triangulating qualitative, participatory acnon and quantitative methods will capture the data related to mental health needs of homeless youth. a purposive sample of approximately 60-80 subjecrs. ages 16 to 24, is currently being ~ted ~participate from the commu.nity agencies covenant house, evergreen centre fo~ srrc;et youth, turning p?1?t and street ~ serv~. youth living on the street or in short -term residennal programs for a mmimum of 1 month pnor to their participation; ages 16 to 24 and able to give infonned consent will be invited to participate in the study. o..tcomes: the expected outcome of this initial survey will be an increased understanding of mental health needs of street youth that will be used to develop effective interventions. it is anticipated that results from this study will contribute to the development of mental health policy, as well as future programs that are relevant to the mental health needs of street youth. note: it is anticipated that preliminary quantitative data (25 subjects) and qualitative data will be available for the conference. the authors intend to present the identification of the research focus, the formation of our community-based team, relevance for policy, as well as preliminary results. p7-31 (a) the need for developing a firm health policy for urban informal worken: the case of despite their critical role in producing food for urban in kenya, urban farmers have largely been ignored by government planners and policymakers. their activity is at best dismissed as peripheral eveo, inappropriate retention of peasant culture in cities and at worst illegal and often some-times criminal· ized. urban agriculture is also condemned for its presumed negative health impact. a myth that contin· ues despite proof to the contrary is that malarial mosquitoes breed in maize grown in east african towns. however, potential health risks are insignificant compared with the benefits of urban food production. recent studies too rightly do point to the commercial value of food produced in the urban area while underscoring the importance of urban farming as a survival strategy among the urban poor, especially women-headed households. since the millennium declaration, health has emerged as one of the most serious casualties consequent on the poverty, social exclusion, marginalisation and lack of sustain· able development in africa. hiv/aids epidemic poses an unprecedented challenge, while malaria, tuber· culosis, communicable diseases of childhood all add to the untenable burden. malnutrition underpins much ill-health and is linked to more than 50 per cent of all childhood deaths. kenya's urban poor people ~ace ~ h~ge burde~ of preventable and treatable health problems, measured by any social and bi~ medical md1cator, which not only cause unnecessary death and suffering, but also undermine econonuc development and damage the country's social fabric. the burden is in spite of the availability of suitable tools and re:c=hnology for prevention and treatment and is largely rooted in poverty and in weak healah •rstems. this pa~ therefore challenges development planners who perceive a dichotomy instead of con· tmuum between informal and formal urban wage earners in so far as access to health services is con· cemed. it i~ this gap that calls for a need to developing and building sustainable health systems among the urban mformal ~wellers. we recommend a focus on an urban health policy that can build and strengthen the capacity of urban dwellers to access health services that is cost-effective and sustainable. such ~ health poli<=>: must strive for equity for the urban poor, displaced or marginalized; mobilise and effect1~ely use sufficient sustainable resources in order to build secure health systems and services. special anenti_on. should ~ afforded hiv/aids in view of the unprecedented challenge that this epidemic poses to africa s economic and social development and to health services on the continent. methods: a review of the literature led us to construct three simple models and a composite model of exposure to traffic. the data were collected with the help of a daily diary of travel activities using a sample of cyclists who went to or come back from work or study. to calculate the distance, the length of journey, and the number of intersections crossed by a cyclist different geographic information systems (gis) were operated. statistical analysis was used to determine the significance between a measure of exposure on the one hand, and the sociodemographic characteristics of the panicipants or their geographic location on the other hand. restlltj: our results indicate that cyclists were significantly exposed to road accidents, no matter of where they live or what are their sociodemographic characteristics. we also stress the point that the fact of having been involved in a road accident was significantly related to the helmet use, but did not reduce the propensity of the cyclists to expose themselves to the road hazards. condlllion: the efforts of the various authorities as regards road safety should not be directed towards the reduction of the exposure of the vulnerable users, but rather towards the reduction of the dangers to which they could face. keywords: cyclist, daily diary of activities, measures of exposure to traffic, island of montreal. p7-33 (a) intra urban disparities and environmental health: some salient features of nigerian residential neighbourhoods olumuyiwa akinbamijo intra urban disparities and environmental health: some salient features of nigerian residential neighbourhoods abstract urbanization panicularly in nigerian cities, ponends unprecedented crises of grave dimensions. from physical and demographic viewpoints, city growth rates are staggering coupled with gross inabilities to cope with the consequences. environmental and social ills associated with unguarded rapid urbanization characterize nigerian cities and threaten urban existence. this paper repons the findings of a recent study of the relationship between environmental health across inrraurban residential communities of akure, south west nigeria. it discuses the typical urbanization process of nigerian cities and its dynamic spatial-temporal characteristics. physical and socio-demographic attributes as well as the levels and effectiveness of urban infrastructural services are examined across the core residential districts and the elite residential layouts in the town. the incidence rate of cenain environmentally induced tropical diseases across residential neighborhoods and communes is examined. salient environmental variables that are germane to health procurement in the residential districts, incidence of diseases and diseases parasitology, diseases prevention and control were studied. field data were subjected to analysis ranging from the univariate and bivariate analysis. inferential statistics using the chi-square test were done to establish the truthfulness of the guiding hypothesis. given the above, the study affirms that there is strong independence in the studied communities, between the environment and incidence of diseases hence health of residents of the town. this assertion, tested statistically at the district levels revealed that residents of the core districts have very strong independence between the environment and incidences of diseases. the strength of this relationship however thins out towards the city peripheral districts. the study therefore concludes that since most of the city dwellers live in urban deprivation, urban health sensitive policies must be evolved. this is to cater for the urban dwellers who occupy fringe peripheral sites where the extension of facilities often times are illegally done. urban infrastructural facilities and services need be provided as a matter of public good for which there is no exclusive consumption or access even for the poorest of the urban poor. many suffer from low-self esteem, shame and guilt about their drug use. in addition, they often lack suppon or encounter opposition from their panners, family and friends in seeking treatment. these personal barriers are compounded by fragmented addiction, prenatal and social care services, inflexible intake systems and poor communication among sectors. the experience of accessing adequate care between services can be overwhelming and too demanding. the toronto centre for substance use in pregnancy (t-cup) is a unique program developed to minimize barriers by providing kone-stop" comprehensive healthcare. t-cup is a primary care based program located in the department of family medicine at st. joseph\'s health centre, a community teaching hospital in toronto. the interdisciplinary staff provides prenatal and addiction services, case management, as well as care of newborns affected by substance use. regular care plan meetings are held between t-cup, labour and delivery nurses and social workers in the y164 poster sessions maternity and child care program. t-cup also connects "'.omen with. inpatient treatment programs and community agencies such as breaking the cycle, an on-site counselmg group for pregnant substance users. · f · d d h ith method: retrospective chart review, qualitative patient ~ans action stu ~· an ea care provider surveys are used to determine outcomes. primary outcomes mclude changes m maternal su~tance use, psychosocial status and obstetrical complications (e.g. pre-rupture of membrane, pre-eclampsia, placen· ral abruption and hemorrhage). neonatal measures ~~nsisted of .bir~h pa_rame~ers, length of h~spital st.ay and complications (e.g. feral distress, meconium stammg, resuscitation, 1aund1ce, hypoglycemia, seventy of withdrawal and treatment length). chart review consisted of all t-cup patients who met clinical cri· reria for alcohol or drug dependence and received prenatal and intra-partum care at st. joseph's from october 2003 to june 2005. participants in the qualitative study included former and current t-cup patients. provider surveys were distributed on-site and to a local community hospital. raulb: preliminary evaluation has demonstrated positive results. treatment retention and satisfaction rates were high, maternal substance use was markedly reduced and neonatal outcomes have shown to be above those reported in literature. conclusion: this comprehensive, primary care model has shown to be optimal in the management of substance use in pregnancy and for improving neonatal outcomes. future research will focus on how this inexpensive program can be replicated in other health care settings. t-cup may prove to be the optimal model for providing care to pregnant substance users in canada. lntrod11ction: cigarette smoking is one of the most serious health problems in taiwan. the prevalence of smoking in 2002 is 48.1 % in males 5.9% in females aged 18 years and older. although the government of taiwan passed a tobacco hazards control act in 1997, it has not been strongly enforced in many places. therefore, community residents have often reported exposure of second hand smoke. the purpose of the study was to establish a device to build up more smoke-free environments in the city of tainan. methods: unique from traditional intervention studies, the study used a healthy city approach to help build up smoke-free environments. the major concept of the approach is to build up a healthy city platform, including organizing a steering committee, setting up policies and indicators, creating intersectoral collaboration, and increasing community participation. first, more than 80 enthusiastic researchers, experts, governmental officers, city counselors and community leaders in tainan were invited in the healthy city committee. second, smoke-free policies, indicators for smoke-free environments, and mechanisms for inter-departmen· tal inspections were set up. third, community volunteers were recruited and trained for persuading related stakeholders. lastly, both penalties and rewards were used for help build up the environments. raults: aher two-year (2003 aher two-year ( -2005 execution of the project, the results qualitatively showed that smoke-free environments in tainan were widely accepted and established, including smoke-free schools, smoke-free workpla~es, smoke-free households, smoke-free internet shops, and smoke-free restaurants. smoke~s were. effectively educated not to smoke in public places. community residents including adults and children m the smoke-free communities clearly understand the adverse effects of environmental tobacco smoke and actively participated anti-smoking activities. conclruions: healthy city platform is effective to conquer the barrier of limited anti-smoking rc:sources. nor. only can it enlar:ge community actions for anti-smoking campaigns, but also it can provide par_merships for collaboratjon. by establishing related policies and indicators the effects of smoke· free environments can be susta1·ned a d th · · · ' · n e progression can be monitored m a commuruty. these issues are used ~· oi::c it~ goals, weuha identifies issues that put people's health at risk. presently, team com~u:c: ran ee~tion !earns. (iats) that design integrative solutions ~tesj'°~ g om six to fifteen members. methods in order to establish wo-poster sessions v165 projects for weuha, the following approach was undertaken: i. a project-polling template was created and sent to all members of the alliance for their input. each member was asked to identify thdr top two population groups, and to suggest a project on which to focus over a 12-18 month period for each identified population. 2. there was a 47% response to the poll and the top three population groups were identified. data from the toronto community health profile database were utilized to contextualize the information supplied for these populations. a presentation was made to the steering committee and three population-based projects were selected, leaders identified and iats formed. three population-based projects: the population-based projects and health care issues identified are: newcomer prenatal uninsured women; this project will address the challenges faced by providers to a growing number of non-insured prenatal women seeking care. a service model where the barrier of "catchments" is removed to allow enhanced access and improved and co-ordinated service delivery will be pilot-tested. children/obesity/diab etes: using a health promotion model this team will focus on screening, intervention, and promoting healthy lifestyles (physical activity and nutrition) for families as well as for overweight and obese children. seniors health promotion and circle of discharge: this team will develop an early intervention model to assist seniors/family unit/caregivers in accessing information and receiving treatment/care in the community. the circle of discharge initiative will address ways of utilizing community supports to keep seniors in the community and minimize readmissions to acute care facilities. results/expected outcomes: coordinated and enhanced service delivery to identified populations, leading to improved access, improved quality of life, and health care for these targeted populations. introduction: basic human rights are often denied to high-risk populations and people living with hiv/aids. their rights to work and social security, health, privacy, non discrimination, liberty and freedom of movement, marriage and having a family have been compromised due to their sero-positive status and risk of being positive. the spread of hiv/aids has been accelerating due to the lack of general human rights among vulnerable groups. to formulate and implement effective responses needs dialogue and to prevent the epidemic to go underground barriers like stigma need to be overcome. objective: how to reduce the situation of stigma, discrimination and human rights violations experienced by people living with hiv/aids and those who are vulnerable to hiv/aids. methodology and findings: consultation meetings were strm.-rured around presentations, field visits, community meetings and group work to formulate recommendations on how govt and ngos/cbos should move forward based on objective. pakistan being a low prevalence country, the whole sense of compl;u:enc.:y that individuals are not subject to situations of vulnerable to hiv is the major threat to an explosion in th•· epidemic, therefore urgent measures are needed to integrate human rights issues from the very start of the response. the protection and promotion of human rights in an integral component of ;tll responses to the hiv/aids epidemic. it has been recognized that the response to hiv/aios must he multi sectoral and multi faceted, with each group contributing its particular expertise. for this to occur along with other knowlcdg<" more information is required in human rights abuses related to hiv/ aids in a particular scenario. the ~·on sultarion meetings on hiv/aids and human rights were an exemplary effort to achieve the same ohj<..:tivc. recommendations: the need for a comprehensive, integrated and a multi-sectoral appro;u.:h in addressing the issue of hiv/aids was highlighted. the need social, cultural and religious asp•·ct' to he: prominently addressed were identified. it was thought imperative measures even in low prevalence countries. education has a key role to play, there is a need for a code of ethics for media people and h<"alth care providers and violations should be closely monitored and follow up action taken. p7-38 (c) how can community-based funding programs contribute to building community capacity and how can we measure this elusive goal? mary frances maclellan-wright, brenda cantin, mary jane buchanan, and tammy simpson community capacity building is recognized by the public health agency of canada (phac) as an important strategy for improving the overall health of communities by enabling communities to addre~s priority issues such as social and economic determinants of health. in 2004/2005 phac.:, alberta/nwf region's population health fund (phf) supported 12 community-based projects to build community capacity on or across the determinants of health. specifically, this included creating accessible and sup· portive social and physical environments as well as creating tools and processes necessary for healthy policy development and implementation. the objective of this presentation is to highlight how the community capacity building tool, developed by phac ab/nwf region, can demonstrate gains in v166 poster sessions · · the course of a pror· ect and be used as a reflective tool for project planning and community capacity over . . . . i · a art of their reporting requirements, 12 pro1ect sites completed the community caparny eva uanon. s p . . th t i ii i'd d . building tool at the beginning and end of their ~ne-year prorect. e oo ~o ects va 1 an reliable data in the context of community-based health prorects. developed through a vigorous ~nd collabora11ve research process, the tool uses plain languag~ to expl~re nine key f~atures o~ commuruty cap~city with 35 't ch with a section for contextual information, 26 of which also mdude a four-pomt raong 1 ems, ea f fu d · scale. results show an increase in community capacity over the course o the nde prorects. pre and post aggregate data from the one-year projects measure~ statistic.ally si~n~ficant changes for 17 of the 26 scaled items. projects identified key areas of commumty capacity bmldmg that needed strengthemng, such as increasing participation, particularly among people with low incomes; engaging community members in identifying root causes; and linking with community groups. in completing the tool, projects examined root causes of the social and economic determinants of health, thereby exploring social justice issues related to the health of their community. results of the tool also served as a reflec· cion on the process of community capacity building; that is, how the project outcomes were achieved. projects also reported that the tool helped identify gaps and future directions, and was useful as a project planning, needs assessment and evaluation tool. community capacity building is a strategy that can be measured. the community capacity building tool provides a practical means to demonstrate gains in community capacity building. strengthening the elements of community capacity building through community-based funding can serve as building blocks for addressing other community issues. needs of marginalized crack users lorraine barnaby, victoria okazawa, barb panter, alan simpson, and bo yee thom background: the safer crack use coalition of toronto (scuc) was formed in 2000 in response to the growing concern for the health and well-being of marginalized crack users. a central concern was the alarm· ing hepatitis c rate ( 40%) amongst crack smokers and the lack of connection to prevention and health ser· vices. scuc is an innovative grassroots coalition comprised of front-line workers, crack users, researcher! and advocates. despite opposition and without funding, scuc has grown into the largest crack specific harm reduction coalition in canada and developed a nationally recognized sarer crack kit distribution program (involving 16 community-based agencies that provide outreach to users). the success of our coalition derives from our dedication to the issue and from the involvement of those directly affected by crack use. setting: scuc's primary service region is greater toronto, a diverse, large urban centre. much ofour work is done in areas where homeless people, sex trade workers and drug users tend to congregate. recently, scuc has reached out to regional and national stakeholders to provide leadership and education. mandate: our mandate is to advocate for marginalized crack users and support the devdopmentof a com.p.rehensive harm reduction model that addresses the health and social needs facing crack users; and to fac1htare the exchange of information between crack users, service providers, researchers, and policy developers across canada. owrview: the proposed workshop will provide participants with an overview of the devdopment of scuc, our current projects (including research, education, direct intervention and consultation), our challenge~ and s~ccesses and the role of community development and advocacy within the coalition. pre-senter~ will consist of community members who have personal crack use experience and front-line work· ers-, sc.uc conducted a community-based research project (toronto crack users perspectives, 2005) , in w~ich 1 s focus groups with marginalized crack users across toronto were conducted. participants iden· t1f1ed health and social issues affecti h b · · · d " red . . ng t em, arrsers to needed services, personal strategies, an oue recommendations for improved services. presenters will share the methodology, results and recommen· datmns resulting from the research project. conc/usio": research, field observations and consultations with stakeholders have shown that cradck shmoke~s are at an. increased risk for sexually transmitted infections hiv/aids hepatitis c, tb an ot er serious health issues health · ff, · ' ' · · . · issues a ectmg crack users are due to high risk behavmurs, socio· economic factors, such as homeless d. · · · · d · 1 . 1 . ness, 1scrsmmat1on, unemployment, violence incarceraoons, an soc1a 1so at1on, and a lack of comprehe · h i h · ' ns1ve ea t and social services targeting crack users. · · sinct · s, owever arge remains a gross underesurnaoon. poster sessions v167 these are hospital-based reports and many known cases go unreported. however teh case, young age at first intercourse, inconsistent condom use and multiple partnersplace adolescents at high risks for a diverse array of stls, including hiv. about 19% of female nigerian secondary school students report initiating sexual intercourse before age 13 years. 39% of nigerian female secondary school students report not using a condom the last time they had sexual intercourse. more than 60% of urban nigerian teens report inconsistent condom use. methods: 371 adolescents were studied, ages 12 to 19, from benin city in edo state. the models used were mother-daughter(119), mother -son(99), father -son (87), and father-daughter(66). the effect of parent-child sexual communicationat baseline on child\'s report of sexual behavior, 6 to 12 months later were studied. greater amounts of sexual risk communication were asociated with markedly fewer episodes of unprotected sexual intercourse, reduced number of sexual partners and fewer episodes of unprotected sexual intercourse. results: this study proved that parents can exert more influence on the sexual knowledge attitudes and practise of their adolescent children through desired practises or rolemodeling, reiterating their values and appropriate monitoring of the adolescents\' behavior. they also stand to provide information about sexuality and various sexual topics. parental-child sexual communication has been found to be particularly influential and has been associated with later onset of sexual initiation among adolescents, less sexual activity, more responsible sexual attitudes including greater condom use, self efficacy and lower self -reported incidence of stis. conclusions: parents need to be trained to relate more effectively with their children/wards about issues related to sex and sexuality. family -based programs to reduce sexual risk-taking need to be developed. there is also the need to carry out cross-ethnicaland cross-cultural studies to identify how parent-child influences on adolescent sexual risk behavior may vary in different regions or countries, especially inthis era of the hiv pandemic. introduction: public health interventions to identify and eliminate health disparities require evidence-based policy and adequate model specification, which includes individuals within a socioecological context, and requires the integration of biosociomedical information. multiple public and private data sources need to be linked to apportion variation in health disparities ro individual risk factors, the health delivery system, and the geosocial environment. multilevel mapping of health disparities furthers the development of evidence-based interventions through the growth of the public health information network (phin-cdc) by linking clinical and population health data. clinical encounter data, administrative hospital data, population socioenvironmental data, and local health policy were examined in a three-level geocoded multilevel model to establish a tracking system for health disparities. nj has a long established political tradition of "home rule" based in 566 elected municipal governments, which are responsible for the well-being of their populations. municipalities are contained within counties as defined by the us census, and health data are linked mostly at the municipality level. marika schwandt community organizers from the ontario coaliti~n again~t pove~, .along ":ith ~edical practitioners who have endorsed the campaign and have been mvolved m prescnbmg special diet needs for ow and odsp recipients, will discuss the raise the rates campaign. the organizati~n has used a special diet needs supplement as a political tool, meeting the urgent needs o.f .poor ~ople m toront~ while raising the issues of poverty as a primary determinant of health and nutrtnous diet as a preventative health mea· sure. health professionals carry the responsibility to ensure that they use all means available to them to improve the health of the individuals that they serve, and to prevent future disease and health conditions. most health practitioners know that those on social assistance are not able to afford nutritious foods or even sufficient amounts of food, but many are not aware of the extra dietary funds that are available aher consideration by a health practitioner. responsible nurse practitioners and physicians cannot, in good conscience, ignore the special needs diet supplement that is available to all recipients of welfare and disabiliry (ow and odsp). a number of toronto physicians have taken the position that all clients can justifiably benefit from vitamins, organic foods and high fiber diets as a preventative health measure. we know that income is one of the greatest predictors of poor health. the special needs diet is a health promotion intervention which will prevent numerous future health conditions, including chronic conditions such as cardiovascular disease, cancer, diabetes and osteoporosis. many communiry health centres and other providers have chosen to hold clinics to allow many patients to get signed up for the supplement at one time. initiated by the ontario coalition against poverty, these clinics have brought together commu· niry organizers, community health centers, health practitioners, and individuals, who believe that poverty is the primary determinant of poor health. we believe that rates must be increased to address the health problems of all people on social assistance, kids, elders, people with hiv/aids -everyone. even in the context of understaffing, it could be considered a priority activity that has potentially important health promotion benefits. many clients can be processed in a two hour clinic. most providers find it a very interesting, rewarding undertaking. in 2004 the ontario coalition for social justice found that a toronto family with two adults and two kids receives $14,316. this is $21,115 below the poverty line. p7-43 (c) the health of street youth compared to similar aged youth beth hayhoe and ruth ewert . lntrod~on: street youth are at an age normally associated with good health, but due to their risky ~hav1ours and th~ conditions in which they live, they experience health conditions unlike their peer~ an more stable env1r~nments. in addition, the majority of street youth have experienced significant physical, sexual ~nd em.ot1onal abuse as younger children, directly impacting many of the choices they make around their physical and emotional health. we examined how different their health really is. . , methodl: using a retrospective analysis of the 11 years of data gathered from yonge street mis· 510~ 5 • evergreen health centre, the top 10 conditions of youth were examined and compared with national tren~s for similar aged youth. based on knowledge of the risk factors present in the group, rea· sons for the difference were examined. d' ~its: street youth experience more illness than other youth their age and their illnesses can bt . irect t ·~kc~ to the. conditions in which they live. long-term impacts of abus~ contribute to such signif· ~~nt t e t 0 d~slpl air that youth may voluntarily engage in behaviours or lack of self care in the hope at t cir 1ve~ w1 perhaps come to a quicker end. concl11non: although it has ion b k h th' dy clearly shows 3 d'fi . h g ee~ no~n t at poverty negatively affects health, ~siu be used to make ; erence m t .e health of this particular marginalized population. the infonnanon can relates to th . ecommendatio.ns around public policy that affects children and youth, especially as it e1r access to appropriate health care and follow up. p7-44 (cl why do urban children · b gt . tarek hussain 10 an adesh die: how to save our children? the traditional belief that urban child alid. a recent study (dhs d fr 17 r~n are better off than rural children might be no longer v urban migrants are highata th om h c~untn~s i demonstrates that the child survival prospects of rural· er an t ose m their r j · · ·grants. in bangladesh, currently 30 million 0 ~r~ 0~1gm and lower than those of urban non-idi million. health of the urban 1 ~ p~e are hvmg m urban area and by the year 2025, it would be so the popu at1on 1s a key a eals that urban poor have the worse h 1 h . concern. recent study on the urban poor rev ea t situation than the nation as a whole. this study shows that infant poster sessions v169 mortality among the urban poor as 120 per thousand, which are above the rural and national level estimates. the mortality levels of the dhaka poor are well above those of the rest of the city's population but much of the difference in death rates is explained by the experience of children, especially infants. analyzing demographic surveillance data from a large zone of the city containing all sectors of the population, research showed that the one-fifth of the households with the least possessions exhibited u5 child mortality almost three times as high as that recorded by the rest of the population. why children die in bangladesh? because their parents are too poor to provide them with enough food, clean water and other basic needs to help them avoid infection and recover from illness. researchers believed that girls are more at risk than boys, as mothers regularly feed boys first. this reflects the different value placed on girls and boys, as well as resources which may not stretch far enough to provide for everyone. many studies show that housing conditions such as household construction materials and access to safe drinking water and hygienic toilet facilities are the most critical determinants of child survival in urban areas of developing countries. the present situation stressed on the need for renewed emphasis on maternal and child healthcare and child nutrition programs. mapping path for progress to save our children would need be done strategically. we have the policies on hand, we have the means, to change the world so that every child will survive and has the opportunity to develop himself fully as a healthy human being. we need the political will--courage and determination to make that a reality. p7-45 (c) sherbourne health centre: innovation in healthcare for the transgendered community james read introduction: sherbourne health centre (shc), a primary health care centre located in downtown toronto, was established to address health service gaps in the local community. its mission is to reduce barriers to health by working with the people of its diverse urban communities to promote wellness and provide innovative primary health services. in addition to the local communities there are three populations of focus: the lesbian, gay, bisexual, transgendered and transexual communities (lgbtt); people who are homeless or underhoused; and newcomers to canada. shc is dedicated to providing health services in an interdisciplinary manner and its health providers include nurses, a nurse practitioner, mental health counsellors, health promoters, client-resource workers, and physicians. in january 2003 shc began offering medical care. among the challenges faced was how to provide responsive, respectful services to the trans community. providers had considerable expertise in the area of counselling and community work, but little in the area of hormone therapy -a key health service for those who want to transition from one gender to another. method: in preparing to offer community-based health care to the trans community it was clear that shc was being welcomed but also being watched with a critical eye. trans people have traditionally experienced significant barriers in accessing medical care. to respond to this challenge a working group of members of the trans community and health providers was created to develop an overall approach to care and specific protocols for hormone therapy. the group met over a one year period and their work culminated in the development of medical protocols for the provision of hormone therapy to trans individuals. results: shc is currently providing health care to 281 registered clients who identify as trans individuals (march 31 2005) through primary care and mental health programs. in an audit of shc medical charts (january 2003 to september 2004) 55 female-to-male (ftm) and 82 male-to-female (mtf) clients were identified. less than half of the ftm group and just over two-thirds of the mtf group presented specifically for the provision of hormones. based on this chart audit and ongoing experience shc continues to update and refine these protocols to ensure delivery of quality care. conclusion: this program is an example of innovative community-based health delivery to a population who have traditionally faced barriers. shc services also include counselling, health promotion, outreach and education. p7-46 (c) healthy cities for canadian women: a national consultation sandra kerr, kimberly walker, and gail lush on march 4 2005, the national network on environment and women's health held a pan-canadian consultation to identify opportunities for health research, policy change, and action. this consultation also worked to facilitate information sharing and networking between canadian women working as urban planners, policy makers, researchers, and service workers on issues pertaining to the health of women living in canadian cities. methods: for this research project, participants included front-line service workers, policy workers, researchers, and advocates from coast to coast, including francophone women, women with disabilities, racialized women, and other marginalized groups. the following key areas were selected as topics for du.bnes i1 alto kading .:auk of end·sugr ieaal clileue ia singapore, accounting for more than so% of new can singapore (nkfs) to embark on a prevention program (pp) 10 empo~r d1ahc 1j1u1f dieir condition bttter, emphasizing education and disease sdf·managemen1 lkilla a. essennal camponenn of good glycaemic control. we sought 10 explore the effects of a 1pecialijed edu.:a11on pro· pun od glycacmic conuol, as indicated by, serum hba ic values budine serum hba ic values were determined before un<k-rgmng the education progr ;am, which couisted of comprehensive dietary advice, ideal weight goals, and improving lipid profiln. serum hbaic values were obtained ar 3,6,9 months later to determine impact of the program. analy11• wu done uling paired !·tests significant reduction in hba le levels from 0 ro 9 month• was observed in females, chinese race, older age group(> so yean). ohew-ibmi ~ 27.nwm2, wai11 hip ratio> l),up to primary and above secondary level education and those having om urine iclt showed that increasing hbalc levels (9) had increasing urmary protein (38.± 117; .18 ±i ih so± 136) and crearinine (s2.s ± 64 7s ± 71; ioi± 7s) levels fbg rnults showed that the management nf d1abetn m the nkfs preven· tion programme is effec;rive. results also indicated 1har hba le leve11 have a linnr trend wnh unnary protein and creatinine which are imponant determinants of renal diseate tal family-focused cinical palbway1 promoce politivc outcollln for ua inner city canu allicy ipmai jerrnjm1 care llctivirits in preparation for an infanr'' dilchargr honlr, and art m1endnl lo improve effi.:k'fl.:tn of c.are. 11lere i11 paucity of tttran:h, and inconsi1trncy of rnulta on 1ht-•m!*-1 of f1m1ly·fc"-'uw d1nm 1a: to determinr whrthrr implrmentation of family.focuted c:pt 1n 1 ntnn.tt.tl unit w"n mg an inner city 1;ommunity drcl't'aki leftarh of lf•y (i.osi and rromclll'i family uo•fkllon and rt.1j1 nest for dikhargr. md6odt: family-focuk"d cpi 1041 data wm coll«ted for all infant• horn btrwttn 29 and 36 wft"k• 1t"lal111mi atr who wrtt .1dm111ed to the ntonatal unit lmgdl of -.y 111. 9 n. 14.8 day'o p c o.osi ind pma .11 d•mr., ho.nr 137.3 t 1.3 n. 36.4 ± i. i wb, p < o.os) wett n«01fiamly f.lfrt 1n the pre.(]' poup. ~11.fxtmon icofn for famihn wrre high. and families noctd thc:y wnr mott prepued to ah thrar t..lby "'-· thett was .a cosi uving of s 1,814 (cdn) per patient d1teharpd home 1n the pmi-cp poap c.-pated 10 the p"''lfoup· cortclaion· lmplrmrnr.rion of family·foanrd c:p. in a nrona1.1i umt tc"fyidi an 1nnn an com· muniry decre.ned length of'"'" mft with a high dcgrft of family uujamon, and wrre coll~nt at least 35% percent of the kathmandu population lives in slum like conditions with poor access to basic health services. in these disadvantaged areas, a large proportion of children do not receive treatment due to inaccessibility to medical services. in these areas, diarrhea, pneumonia, and measles, are the key determinants of infant mortality. protein energy malnutrition and vitamin a deficiency persists and communicable diseases are compounded by the emergence of diseases like hiv/aids. while the health challenges for disadvantaged populations in kathmandu are substantial, the city has also experienced various forms of innovative and effective community development health programs. for example, there are community primary health centers established by the kathmandu municipality to deliver essential health services to targeted communities. these centers not only provide equal access to health services to the people through an effective management system but also educate them hy organizing health related awareness programs. this program is considered one of the most effective urban health programs. the paper/presentation this paper will review large, innovative, and effective urhan health programs that are operating in kathmandu. most of these programs are currently run by international and national ngos a) early detection of emerging diseases in urban settings through syndromic surveillance: 911 data pilot study kate bassil of community resources, and without adequate follow-up. in november 2003 shelter pr.oviders ~et with hospital social workers and ccac to strike a working group to address some of th~ issues by mcre.asing knowledge among hospital staff of issues surrounding homelessness, and to build a stro?g workmg relationship between both systems in hamilton. to date the hswg has conducted four w~lkmg to~ of downtown shelters for hospital staff and local politicians. recently the hswg launched its ·~ool.k1t for staff working with patients who are homeless', which contains community resources and gu1dehnes to help with effective discharge plans. a scpi proposal has been submitted to incre~se the capacity of the hswg to address education gaps and opportunities with both shelters and hospitals around homelessness and healthcare. the purpose of this poster presentation is to share hamilton's experience and learnings with communities who are experiencing similar issues. it will provide for intera~tion around shared experiences and a chance to network with practitioners across canada re: best practices. introduction and objectives: canadians view health as the biggest priority for the federal government, where health policies are often based on models that rely on abstract definitions of health that provide little assistance in the policy and analytical arena. the main objectives of this paper are to provide a functional definition of health, to create a didactic model for devising policies and determining forms of intervention, to aid health professionals and analysts to strategize and prioritize policy objectives via cost benefit analysis, and to prompt readers to view health in terms of capacity measures as opposed to status measures. this paper provides a different perspective on health, which can be applied to various applications of health such as strategies of aid and poverty reduction, and measuring the health of an individual/ community/country. this paper aims to discuss theoretical, conceptual, methodological, and applied implications associated with different health policies and strategies, which can be extended to urban communities. essentially, our paper touches on the following two main themes of this conference: •health status of disadvantaged populations; and •interventions to improve the health of urban communities.methodology: we initially surveyed other models on this topic, and extrapolated key aspects into our conceptual framework. we then devised a theoretical framework that parallels simple theories of physkal energy, where health is viewed in terms of personal/societal health capacities and effort components.after establishing a theoretical model, we constructed a graphical representation of our model using selfrated health status and life expectancy measures. ultimately, we formulated a new definition of health, and a rudimentary method of conducting cost benefit analysis on policy initiatives. we end the paper with an application example discussing the issues surrounding the introduction of a seniors program.results: this paper provides both a conceptual and theoretical model that outlines how one can go about conducting a cost-benefit analysis when implementing a program. it also devises a new definition and model for health barred on our concept of individual and societal capacities. by devising a definition for health that links with a conceptual and theoretical framework, strategies can be more logically constructed where the repercussions on the general population are minimized. equally important, our model also sets itself up nicely for future microsimulation modeling and analysis.implications: this research enhances one's ability to conduct community-based cost-benefit analysis, and acts as a pedagogical tool when identifying which strategies provide the best outcome. p7-06 (a) good playgrounds are hard to find: parents' perceptions of neighbourhood parks patricia tucker, martin holmes, jennifer irwin, and jason gilliland introduction: neighbourhood opportunities, including public parks and physical activity or sports fields hav~ been. iden.tified as correlates to physical activity among youth. increasingly, physical activity among children 1s bemg acknowledged as a vital component of children's lives as it is a modifiable determinant of childh~d obesity. children's use of parks is mainly under the influence of parents; therefore, the purpose of this study was to assess parents' perspectives of city parks, using london ontario as a case study.m~~: this qualitative study targeted a heterogeneous sample of parents of children using local parks w1thm london. parents with children using the parks were asked for 5 minutes of their time and if willing, a s.hort interview was conducted. the interview guide asked parents for their opinion 'of city parks, particularly the one they were currently using. a sample size of 50 parents is expected by the end of the summer.results: preliminary findings are identifying parents concern with the current jack of shade in local parks. most parents have identified this as a limitation of existing parks, and when asked what would make the parks better, parents agree that shade is vital. additionally, some parents are recognizing the v170 poster sessions focused discussions during the consultation: 1. women in _poverty 2. women with disability 3. immi· grant and racialized women 4. the built and _physica_l environment. . . . . r its· participants voiced the need for integration of the following issues withm the research and policy :::na; t) the intersectional nature of urban women's health i~sues wh~ch reflects the reality of women's complex lives 2) the multisectional aspect of urban wo_m~n s health, 1ss~es, which reflects the diversity within women's lives 3) the interse~roral _dynamics within _womens hves and urban health issues. these concepts span multiple sectors -mdudmg health, educat10n, and economics -when leveraging community, research, and policy support, and engaging all levels of government.policy jmplicatiom: jn order to work towards health equity for women, plans for gender equity must be incorporated nationally and internationally within urban development initiatives: • reintroduce "women" and "gender" as distinct sectors for research, analysis, advocacy, and action. •integrate the multisectional, intersectional, and intersecroral aspects of women's lives within the framework of research and policy development, as well as in the development of action strategies. • develop a strategic framework to house the consultation priorities for future health research and policy development (for example, advocacy, relationship building, evidence-based policy-relevant research, priority initiatives}.note: research conducted by nnewh has been made possible through a financial contribution from health canada. the views expressed herein do not necessarily represent the views of health canada.p7-47 (c) drugs, culture and disadvantaged populations leticia folgar and cecilia rado lntroducci6n: a partir de un proyecto de reducci6n de daiios en una comunidad urbana en situ· aci6n de extrema vulnerahilidad surge la reflexion sobre el lugar prioritario de los elementos sociocuhurales en el acceso a los servicios de salud de diferentes colectivos urbanos. las "formas de hacer, pensar y sentir" orientan las acciones y delimitan las posibilidades que tienen los individuos de definir que algo es o no problema, asf como tambien los mecanismos de pedido de ayuda. el analisis permanenre del campo de "las culturas cotidianas" de los llamados "usuarios de drogas" aporta a la comprension de la complejidad del tema en sus escenarios reales, y colabora en los diseiios contextualizados de politicas y propuestas socio-sanitarias de intervenci6n, tornandolas mas efectivas.mitodos: esta experiencia de investigaci6n-acci6n que utiliza el merodo emografico identifica elementos socio estructurales, patrones de consumo y profundiza en los elementos socio-simb61icos que estructuran los discursos de los usuarios, caracterizandolos y diferenciandolos en tanto constitutivos de identidades socia les que condicionan la implementaci6n del programas de reduccion de daiios.resultados: los resultados que presentaremos dan cuenta de las caracteristicas diferenciadas v relaciones particulares ~ntre los consumidores de drogas en este contexto espedfico. a partir de este e~tudio de caso se mtentara co1?1enzar a responder preguntas que entendemos significativas a la hora de pensar intcrvcnciones a la med1da de poblaciones que comparten ciertas caracteristicas socio-culturales. (cuales serian las .motivaciones para el cambio en estas comunidades?, cque elementos comunitarios nos ayudan a i:nnstnur dema~~a? • cque tenemos para aprender de las "soluciones" que ellos mismos encuenrran a los usos problemat1cos? methods: our study was conducted by a team of two researchers at three different sites. the mapping consisted of filling in a chart of observable neighbourhood features such as graffiti, litter, and boarded housing, and the presence or absence of each feature was noted for each city block. qualitative observations were also recorded throughout the process. researchers analyzed the compiled quantitative and qualitative neighbourhood data and then analyzed the process of data collection itself.results: this study reveals the need for further research into the effects of physical environments on individual health and sense of well-being, and perception of investment in neighbourhoods. the process reveals that perceptions of health and safety are not easily quantified. we make specific recommendations about the mapping methodology including the importance of considering how factors such as researcher social location may impact the experience of neighbourhoods and how similar neighbourhood characteristics are experienced differently in various spaces. further, we discuss some of the practical considerations around the mapping exercise such as recording of findings, time of day, temperature, and researcher safety.conclusion: this study revealed the importance of exploring conceptions of health and well-being beyond basic physical wellness. it suggests the importance of considering one's environment and one's own perception of health, safety, and well-being in determining health. this conclusion suggests that attention needs to be paid to the connection between the workplace and the external environment it is situated in. the individual's workday experience does not start and stop at the front door of their workplace, but rather extends into the neighbourhood and environment around them. our procedural observations and recommendations will allow other researchers interested in the effect of urban environments on health to consider using this innovative methodology. introduction: responding ro protests against poor medical attention for sexually assaulted women and deplorable conviction rates for sex offenders, in the late 1970s, the ontario government established what would become over 30 hospital-based sexual assault care and treatment centres (sactcs) across the province. these centres, staffed around the clock with specially trained heath care providers, have become the centralized locations for the simultaneous health care treatment of and forensic evidence collection from sexually assaulted women for the purpose of facilitating positive social and legal outcomes. since the introduction of these centres, very little evaluative research has been conducted to determine the impact of this intervention. the purpose of our study was to investigate it from the perspectives of sexually assaulted women who have undergone forensic medical examinations at these centres.method: women were referred to our study by sactc coordinators across ontario. we developed an interview schedule composed of both closed and open-ended questions. twenty-two women were interviewed, face-to-face. these interviews were approximately one-to-two hours in length, and were transcribed verbatim. to date, 19 have been analyzed for key themes.results: preliminary findings indicate that most women interviewed were canadian born (79'yo), and ranged in age from 17 to 46 years. a substantial proportion self-identified as a visible minority ( 37'x.). approximately half were single or never married (47%) and living with a spouse or family of origin (53%). most were either students or not employed (68%). two-thirds (68%) had completed high school and onethird (37%) was from a lower socio-economic stratum. almost two-fifths (37%) of women perceived the medical forensic examination as revictimizing citing, for example, the internal examination and having blood drawn. the other two-thirds (63%) indicated that it was an empowering experience, as it gave them a sense of control at a time when they described feeling otherwise powerless. most (68%) women stated that they had presented to a centre due to health care concerns and were very satisfied ( 84 % ) with their experiences and interactions with staff. almost all (89%) women felt supported and understood.conclusions: this research has important implications for clinical practice and for appropriately addressing the needs of sexually assaulted women. what is apparent is that continued high-quality medical attention administered in the milieu of specialized hospital-based services is essential. at the same time, we would suggest that some forensic evidence collection procedures warrant reevaluation. the study will take an experiential, approach by chroruclmg the impa~ of the transition f m the streets to stabilization in a managed alcohol program through the techruque of narrative i~:uiry. in keeping with the shift in thinking in the mental health fie!~ ~his stu~y is based on a paradigm of recovery rather than one of pathology. the "inner views of part1c1pants hves as they portray their worlds, experiences and observations" will be presented (charm~z, 1991, ~· 38~)-"i?e p~ of the study is to: identify barriers to recovery. it will explore the exj?cnence of ~n~t1zanon pnor to entry into the program; and following entry will: explore the meanmg ~nd defirutto~s of r~overy ~~d the impact of the new environment and highlight what supports were instrumental m movmg pan1apants along the recovery paradigm.p7-st (a) treating the "untreatable": the politics of public health in vancouver's inner city introdudion: this paper explores the everyday practices of therapeutic programs in the treadnent of hiv in vancouver's inner city. as anthropologists have shown elsewhere, therapeutic programs do not siinply treat physical ailments but they shape, regulate and manage social lives. in vancouver's inner city, there are few therapeutic options available for the treatment of 1-ilv. public health initiatives in the inner city have instead largely focused on prevention and harm reduction strategies such as needle exchange programs, safe injection sites, and safer-sex education. epidemiological reports suggest that less than a quarter of those living with hiv in the downtown eastside (dtes) are taking antiretroviral therapies raising critical questions regarding the therapeutic economy of antiretrovirals and rights to health care for the urban poor.methods: this paper is drawn from ethnographic fieldwork in vancouver's otes neighborhood focusing on therapeutic programs for hiv treatment among "hard-to-reach" populations. the research includes participant-observation at inner city health clinics specializing in the treatment of hiv; semi· structured interviews with hiv positive participants, health care professionals providing hiv treatment, and administraton working in the field of inner city public health; and, lastly, observation at public meetings and conferences surrounding hiv treatment.r.awlts: hiv prevention and treatment is a central concern in the lives of many residents living in the inner city -although it is just one of many health priorities afflicting the community. concerns about drug resistance, cost of antiretrovirals, and illicit drug use means that hiv therapy for most is characterized by the daily observation of their medicine ingestion at health clinics or pharmacies. daily observed treatment (dot) is increasingly being adopted as a strategy in the therapeutic management of "untreatable" populations. dot programs demand a particular type of subject -one who is "compliant" to the rules and regimes of public health. over emphasis on "risky practices," "chaotic lives," and "~dh~rence" preve~ts the public health system from meaningful engagement with the health of the marginalized who continue to suffer from multiple and serious health conditions and who continue to experience considerable disparities in health.~ the ~ffec~s of hiv in the inner city are compounded by poverty, laclc of safe and affordable houamg, vanous 1llegal underground economies increased rates of violence and outbreaks of ~~~·~ly tr~nsmitted infections, hepatitis, and tuberculosi: but this research suggests 'that public health uunauves aimed at reducing health disparities may be failing the most vulnerable and marginal of citiztl1s. margaret malone 1~ vi~lence that occurs in families and in intimate relationships is a significant urban, ~unity, and pu~hc health problem. it has major consequences and far-reaching effects for women, ~~--renho, you~ sen1on, and families. violence also has significant effects for those who provide and ukllc w receive health care violence · · i · · . all lasses, · is a soc1a act mvolvmg a senous abuse of power. it crosses : ' : ' ~ 11 s;nden, ag~ ~ti~, cultures, sexualities, abilities, and religions. societal responseshali ra y oc:used on identificatton, crisis intervention and services for families and individuajs.promoten are only "-"--:-g to add h · ' · i in intimate relationshi with"-~"'.". ress t e issues of violence against women and vjoence lenga to consider i~ m families. in thi_s p~per, i analyze issues, propose strategies, and note c~· cannot be full -...l'-~ whork towards erad1canng violence, while arguing that social justice and equity y -.1ucvcu w en thett are people wh mnhod: critical social theory, an analysis that addresses culturally and ethnically diverse communities, together with a population health promotion perspective frame this analysis. social determinants of health are used to highlight the extent of the problem of violence and the social and health care costs.the ottawa charter is integrated to focus on strategies for developing personal skills, strengthening community action, creating supportive environments, devdoping healthy public policies, and re-orientating health and social services. attention is directed to approaches for working with individuals, families, groups, communities, populations, and society.ratdts: this analysis demonstrates that a comprehensive interdisciplinary, multisectoral, and multifaceted approach within an overall health promoting perspective helps to focus on the relevant issues, aitical analysis, and strategies required for action. it also illuminates a number of interacting, intersecting, and interconnecting factors related to violence. attention, which is often focused on individuals who are blamed for the problem of violence, is redirected to the expertise of non-health professionals and to community-based solutions. the challenge for health promoters working in the area of violence in families and in intimate relationships is to work to empower ourselves and the communities with whom we work to create health-promoting urban environments. social justice, equiry, and emancipatory possibilities are positioned in relation to recommendations for future community-based participatory research, pedagogical practices for health care practitioners, and policy development in relation to violence and urban health. the mid-main community health center, located in vancouver british columbia (bc), has a diverse patient base reflecting various cultures, languages, abilities, and socio-economic statuses. due to these differences, some mid-main patients experience greater digital divide barriers in accessing computers and reputable, government produced consumer health information (chi) websites, such as the bc healthguide and canadian health network. inequitable access is problematic because patient empowerment is the basis of many government produced chi websites. an internet terminal was introduced at mid-main in the summer of 2005, as part of an action research project to attempt to bridge the digital divide and make government produced chi resources useful to a broad array of patients. multi-level interventions in co-operation with patients, with the clinic and eventually government ministries were envisioned to meet this goal. the idea of implementing multi-level interventions was adopted to counter the tendency in interactive design to implement a universal solution for the 'ideal' end-user [ 1 ), which discounts diversity. to design and execute the interventions, various action-oriented and ethnographic methods were employed before and during the implementation of the internet terminal. upon the introduction of the internet terminal, participant observation and interviews were conducted using a motion capture software program to record a digital video and audio track of patients' internet sessions. this research provided insight into the spectrum of patients' capacities to use technology to fulfil their health information needs and become empowered. at the mid-main clinic it is noteworthy that the most significant intervention to enhance the usefulness of chi websites for patients appeared to be a human rather than a technological presence. as demonstrated in other ethnographic research of community internet access, technical support and capacity building is a significant component of empowerment (2). the mid-main wired waiting room project indicates that medical practitioners, medical administrators, and human intermediaries remain integral to making chi websites useful to patients and their potential empowerment. (1) over the past 5 years the environmental yo~th alliance has been of~ering a.youth as~t. mappin~ program which trains young people in community research and evaluation. wh1~st the positive expenenc~ and relationships that have developed over this time attest to the success of this program, no evaluations has yet been undertaken to find out what works for t.he youth, what ~ould be changed, and what long term outcomes this approach offers for the youth, their local community, and urban governance. these topics will be shared and discussed to help other community disorganizing and uncials governments build better, youth-driven structures in the places they live.p7-55 (a) the world trade center health registry: a unique resource for urban health researchers deborah walker, lorna thorpe, mark farfel, erin gregg, and robert brackbill introduction: the world trade center health registry (wfchr) was developed as a public health response to document and evaluate the long-term physical and mental health effects of the 9/11 disaster on a large, diverse population. over 71,000 people completed a wfchr enrollment baseline survey, creating the largest u.s. health registry. while studies have begun to characterize 9/11 bealth impacts, questions on long-term impacts remain that require additional studies involving carefully selected populations, long-term follow-up and appropriate physical exams and laboratory tests. wtchr provides an exposed population directory valuable for such studies with features that make ita unique resource: (a) a large diverse population of residents, school children/staff, people in lower man· hattan on 9/11 including occupants of damaged/destroyed buildings, and rescue/recovery/cleanup work· ers; (b) consent by 91 % of enrollees to receive information about 9/11-related health studies; (c) represenration of many groups not well-studied by other researchers; (c) email addresses of 62% of enrollees; (d) 30% of enrollees recruited from lists with denominator estimates; and (e) available com· parison data for nyc residents. wfchr strives to maintain up-to-date contact information for all enrollees, an interested pool of potential study participants. follow-up surveys are planned.methods: to promote the wtchr as a public health resource, guidelines for external researcher.; were developed and posted on (www.wtcregistry.org) which include a short application form, a twopage proposal and documentation of irb approval. proposals are limited to medical, public health, or other scientific research. researchers can request de-identified baseline data or have dohmh send information about their studies to selected wfchr enrollees via mail or email. applications are scored by the wtchr review committee, comprised of representatives from dohmh, the agency for toxic subst~nces and disease registry, and wtchr's scientific, community and labor advisory committees. a data file users manual will be available in early fall 2005.~suits: three external applications have been approved in 2005, including one &om a non-u.s. ~esearcher, all requesting information to be sent to selected wtchr enrollees. the one completed mail· mg~~ wtchr enrollee~ (o 3,700 wfc tower evacuees) generated a positive survey response rate. three additional researchers mtend to submit applications in 2005. wfchr encourages collaborations between researchers and labor and community leaders.conclusion: studies involving wtchr enrollees will provide vital information about the long· term health consequences of 9/11. wtchr-related research can inform communities, researcher.;, policy makers, health care providers and public health officials examining and reacting to 9111 and other disasters. t .,. dp'"f'osed: thi is presentation will discuss the findings of attitudes toward the repeat male client iden· 1 ie as su1e1 a and substance us'n p · · · · i · 'd . . -1 g. articipants will learn about some identified effective strategies or service prov1 ers to assist this group of i · f men are oft · d bl men. n emergency care settings, studies show that this group 0 en viewe as pro emaric patient d i r for mental health p bl h h 5 an are more ikely to be discharged without an assessmen 200!) ea 1 1 rofr ems t. an or er, more cooperative patients (forster and wu 2002· hickey er al., · r y resu ts om this study suggest th · · ' ' l · d tel' mining how best to h 1 . d 1 at negative amtudes towards patients, difficu nes e · as well pathways l_e_ p patientsblan ~ck of conrinuity of care influence pathways to mental health care. • uc\:ome pro emat1c when p ti k · che system. m a ems present repeatedly and become "get stuc id methods: semi-structured intervie d . · (n=5), ed nurses (n=5) other ed ;s were con ucted with male ed patients (n=25), ed phys1oans ' sta (n= 7) and family physicians (n= 7). patients also completed a poster sessions v175 diagnostic interview. interviews were tape-recorded, transcribed verbatim and managed using n6. transcripts were coded using an iterative process and memos prepared capture emergent themes. ethics approval was obtained and all participants signed a detailed informed consent form.introduction: urban settings are particularly susceptible to the emergence and rapid spread of nt•w or rare diseases. the emergence of infectious diseases such as sars and increasing concerns over the next influenza pandemic has heightened interest in developing and using a surveillance systt·m which detects emerging public health problems early. syndromic surveillance systems, which use data b,1scd on symptoms rather than disease, offer substantial potential for this by providing near-real-rime data which are linked to an automated warning system. in toronto, we are piloting syndromic data from the 911 · emergency medical services (ems) database to examine how this information can be used on an ongoing basis for the early detection of syndromes including heat-related illness (hri), and influenza-like-illness (ill). this presentation will provide an outline of the planned desi_gn of this system and proposed evaluation. for one year, 911 call codes which reflect heat-related illness or influenza-like-illness will be selected and searched for daily using software with a multifactorial algorithm. calls will he stratified by call code, extracted from the 911-ems database and transferred electronically to toronto public health. the data will be analyzed for clusters and aberrations from the expected with the realtime outbreak and disease surveillance (rods) system, a computer-based public health tool for the early detection of disease outbreaks. this 911-ems surveillance system will be assessed in terms of its specificity and sensitivity through comparisons with the well-established tracking systems already in place for hr! and ill. others sources of data including paramedic ambulance call reports of signs and . this study will introduce complementary data sources t~ the ed ch1e~ complamt an~ o~~rthe-counter pharmacy sales syndromic surveillance data currently bemg evaluated m ~ther ontar~o cltles. . syndromic surveillance is a unique approach to proactive(~ dete~tmg early c.hangesm the health status of urban communities. the proposed study aims to provide evidence of differential effectiveness through investigating the use of 911-ems call data as a source of syndromic surveillance information for hr! and ili in toronto. introduction: there is strong evidence that primary care interventions, including screening, brief advi<:e, treatment referral and pharmacotherapy are effective in reducing morbidity and mortality caused by substance abuse. yet physicians are poor at intervening with substance users, in part because of lack of time, training and support. this study examines the hypothesis that shared care in addictions will result in decreased substance use and improved health status of patients, as well as increased use of primary care interventions by primary care practitioners (pcps). methods: the addiction medicine service (ams) at st. joseph's health centre's family medicine department is in the process of being transformed from its current structure as a traditional consult service into a shared care model called addiction shared care (asc). the program will have three components: education, office systems and clinical shared care. as opposed to a traditional consult service, the patient will be booked with both a primary care liaison worker (pcl) and addictions physician. patients referred from community physicians, the emergency department and inpatient medical and psychiatric wards will be recruited for the study as well as pcps from the surrounding community. the target sample size is 100-150 physicians and a similar number of patients. after initial consult, patient will be recruited into the study with their consent. the shared-case model underlines the interaction and collaboration with the patient's main pcp. asc will provide them with telephone consults, advice, support and re-assessment for their patients, as well as educational sessions and materials such as newsletters and informational kits.results: the impact of this transition on our patient care and on pcp's satisfaction with the asc model is currently being evaluated through a grant provided by the ministry of health & long term care. a retrospective chart review will be conducted using information on the patient's substance use, er/clinic visits, and their health/mood status. pcp satisfaction with the program will be measured through surveys and focus groups. our cost-effectiveness analysis will calculate the overall cost of the program per patient..conclusion: this low-cost service holds promise to serve as an optimal model and strategy to improve outcomes and reduce health care utilization in addict patients. the inner city public health project introduction the inner city public health project (icphp) was desi.gned to explore new an~ innovative ways to reach marginalized inner city populations that par-t1c1pate m high health-nsk beha~1ors. much of this population struggles with poverty, addictions, mental illness and homelessness, creatmg barriers to accessing health services and receiving follow-up. this pro1ect was de~igned to evaluat~ .~e success of offering clinics in the community for testing and followup of communicable diseases uuhzmg an aboriginal outreach worker to build relationships with individuals and agencies. v1n(demographics~ history ~f testi~g ~nd immunization and participation in various health-risk behaviors), records of tesnng and 1mmumzat1ons, and mterviews with partner agency and project staff after one year.. results: t~e chr ~as i~strumental in building relationships with individuals and partner agencies ' .° the c~mmun_1~ re_sultmg m req~ests for on-site outreach clinics from many of the agencies. the increase m parnc1pat10n, the chr mvolvement in the community, and the positive feedback from the agen? staff de~onstrated that.the project was successfully creating partnerships and becoming increasingly integrated m the community. data collected from clients at the initial visit indicated that the project was reaching its target populations and highlighted the unique health needs of clients, the large unmet need for health services and the barriers that exist to accessing those services. ~usion: the outreach clinics were successful at providing services to target populations of high health-nsk groups and had great support from the community agencies. the role of the chr was critical to the success of the project and proved the value of this category of health care worker in an urban aboriginal population. the unmet health needs of this disadvantaged population support the need for more dedicated resources with an emphasis on reducing access barriers. building a caring community old strathcona's whyte avenue, a district in edmonton, brought concern about increases in the population of panhandlers, street people and homeless persons to the attention of all levels of government. the issue was not only the problems of homelessness and related issues, but feelings of insecurity and disempowerment by the neighbourhood residents and businesses. their concerns were acknowledged, and civic support was offered, but it was up to the community itself to solve the problem. within a year of those meetings, an adult outreach worker program was created. the outreach worker, meets people in their own environments, including river valley camps. she provides wrap-around services rooted in harm reduction and health promotion principles. her relationship-based practice establishes the trust for helping clients with appropriate housing, physical and/or mental health issues, who have little or no income and family support to transition from homelessness. the program is an excellent example of collaboration that has been established with the businesses, community residents, community associations, churches, municiple services, and inner-city agencies such as boyle street community services. statistics are tracked using the canadian outcomes research institute homes database, and feedback from participants, including people who are street involved. this includes an annual general meeting for community and people who are homeless. the program's holistic approach to serving the homeless population has been integral, both in creating community awareness and equipping residents and businesses to effectively interact with people who are homeless. through this community development work, the outreach worker engages old strathcona in meeting the financial and material needs of the marginalized community. the success of this program has been surprising -the fact is that homeless people's lives are being changed; one person at a time and the community has been changed in how they view and treat those without homes. over two years, the program has successfully connected with approximately seventy-five individuals who call old strathcona home, but are homeless. thirty-six individuals are now in homes, while numerous others have been assisted in obtaining a healthier and safer lifestyles by becoming connected with other social/health agencies. the program highlights the roots of homelessness, barriers to change and requirements for success. it has been a thriving program and a model that works by showing how a caring community has rallied together to achieve prosperous outcomes. the spn has created models of tb service delivery to be used m part~ers~1p with phannaceunca compa-. · · -. t' ns cooperatives and health maintenance orgamzanons (hmos). for example, the mes, c1v1c orgamza 10 , . · b tb d' · spn has established a system with pharmaceutical companies that help patients to uy me 1cmes at a special discounted rate. this scheme also allows patients to get a free one-_month's worth of~ dru_g supply if they purchase the first 5 months of their regimen. the sy_s~e~s were ~es1gned to be cm~pattble with existing policies for recording and documentation of the ph1hppme national tuberculosis program (ntp). aside from that, stakeholders were also encouraged to be dots-enabled through the use of m~nual~ and on-line training courses. the spn initiative offers an alternative in easing the burden of tb sc:rv1ce delivery from rhe public sector through the harnessing of existing private-sector (dsos). the learnmgs from the spn experience would benefit groups from other locales that _work no~ only on ~ but other health concerns as well. the spn experience showcases how well-coordinated private sector involvements help promote social justice in health delivery in urban communities.p7-63 (c) young people in control; doing it safe. the safe sex comedy juan walter and pepijn v. empelen introduction: high prevalence of chlamydia and gonorrhoea have been reported among migrants youth in amsterdam, originating from the dutch antilles, suriname and sub-sahara africa. in addition, these groups also have high rates of teenage-pregnancy (stuart, 2002) and abortions (rademakers 1995), indicating unsafe sexual behaviour of these young people. young people (aged 12 -30) from the so· called urban scene (young trendsetters in r&b/hip hop music and lifestyle) in amsterdam have been approached by the municipal health service (mhs) to collaborate on a safe sex project. their input was to use comedy as vehicle to get the message a cross. for the mhs this collaboration was a valuable opportunity to reach a hard-to-reach group.mdhods: first we conducted a need assessment by means of a online survey to assess basic knowledge and to similtaneously examine issues of interest concerning sex, sexuality, safer sex and the opposite sex. second, a small literature study was conducted about elements and essential conditions for succesful entertainment & education (e&e) (bouman 1999), with as most important condition to ensure that the message is realistic (buckingham & bragg, 2003) . third a program plan was developed aiming at enhancing the stl/hiv and sexuality knowledge of the young people and addressing communication and educational skills, by means of drama. subsequently a safe sex comedy show was developed, with as main topics: being in love, sexuality, empowerment, stigma, sti, hivand safer sex. the messages where carried by a mix of video presentation, stand up comedy, spoken word, rap and dance.results: there have been two safe sex comedy shows. the attendance was good; the group was divers' with an age range between 14 and 50 year, with the majority being younger than 25 year. more women than men attended the show. the story lines were considered realistic and most of the audients recognised the situations displayed. eighty percent of the audients found the show entertaining and 60% found it edm:arional. from this 60%, one third considers the information as new. almost all respondents pointed our that they would promote this show to their friends.con.clusion: the s.h<_>w reached the hard-to-reach group of young people out of the urban scene and was cons1d_ered entert~mmg, educational and realistic. in addition, the program was able in addressing important issues, and impacted on the percieved personal risk of acquiring an sti when not using condoms, as well as on basic knowledge about stl's. introduction: modernity has contributed mightily to the marginality of adults who live with mental illnesses and the subsequent denial of opportunities to them. limited access to social, vocational, educational, and residential opportunities exacerbates their disenfranchisement, strengthening the stigma that has been associated with mental illness in western society, and resulting in the denial of their basic human rights and their exclusion from active participation in civil society. the clubhouse approach tn recovery has led to the reduction of both marginality and stigma in every locale in which it has been implemented judiciously. its elucidation via the prism of social justice principles will lead to a deeper appreciation of its efficacy and relevance to an array of settings. methods: a review of the literature on social justice and mental health was conducted to determine core principles and relationships between the concepts. in particular, fondacaro and weinberg's (2002) conceptualization of social justice in community psychology suggests the desirability of the clubhouse approach in community mental health practice. a review of clubhouse philosophy and practice has led to the inescapable conclusion that there is a strong connection between clubhouse philosophy-which represents a unique approach co recovery--and social justice principles. placing this highly effective model of community mental health practice within the context of these principles is long overdue. via textual analysis, we will glean the principles of social justice inherent in the rich trove of clubhouse literature, particularly the international standards of clubhouse development.results: fondacarao and weinberg highlight three primary social justice themes within their community psychology framework: prevention and health promotion; empowerment, and a critical pnsp<"<·tive. utilizing the prescriptive principles that inform every detail of clubhouse development and th<" movement toward recovery for individuals at a fully-realized clubhouse, this presentation asserts that both clubhouse philosophy and practice embody these social justice themes, promote human rights, and empower clubhouse members, individuals who live with mental illnesses, to achieve a level of wdl-heing and productivity previously unimagined.conclusion: a social justice framework is critical to and enhances an understanding of the clubhouse model. this model creates inclusive communities that lead to opportunities for full partic1pil!ion 111 civil society of a previously marginalized group. the implication is that clubhouses that an· based on the international standards for clubhouse programs offer an effective intervention strategy to guarantee the human rights of a sizable, worthy, and earnest group of citizens. to a drastic increase in school enrollment from 5.9 million in 2002 to 7.5 million in 200.s. however, while gross enrollment rates increased to 104°/., in the whole country after the introduction of fpe, it remained conspicuously low at 62% in the capital city, nairobi. nairobi city's enrollment rate is lower .than thatof all regions in the country except the nomadic north-eastern province. !h.e.d1sadvantage of children bas_ed in the capital city was also noted in uganda after the introduction of fpe m the late 1990s_-many_ education experts in kenya attribute the city's poor performance to the high propornon of children hvmg m slums, which are grossly underserved as far as social services are concerned. this paper ~xammes the impact of fpe and explores reasons for poor enrollment in informal settlements m na1rob1 city. methods: the study utilizes quantitative and qualitative schooling data from the longitudinal health and demographic study being implemented by the african population and health research center in two informal settlements in nairobi. descriptive statistics are used to depict trends in enrollment rates for children aged 5-19 years in slum settlements for the period 2000-2005. results: the results show that school enrollment has surprisingly steadily declined for children aged 15-19 while it increased marginally for those aged 6-14. the number of new enrollments (among those aged 5 years) did not change much between 2001 and 2004 while it declined consistently among those aged 6-9 since 2002. these results show that the underlying reasons for poor school attendance in poverty-stricken populations go far beyond the lack of school fees. indeed, the results show that lack of finances (for uniform, transportation, and scholastic materials) has continued to be a key barrier to schooling for many children in slums. furthermore, slum children have not benefited from fpe because they mostly attend informal schools since they do not have access to government schools where the policy is being implemented.conclusion: the results show the need for equity considerations in the design and implementation of the fpe program in kenya. without paying particular attention to the schooling needs of the urban poor children, the millennium development goal aimed at achieving universal primary education will remain but a pipe dream for the rapidly increasing number of children living in poor urban neighborhoods.ps-04 (c) programing for hiv/aids in the urban workplace: issues and insights joseph kamoga hiv/aids has had a major effect on the workforce. according to !lo 35million persons who are engaged in some form of production are affectefd by hiv/aids. the working class mises out on programs that take place in communities, yet in a number of jobs, there are high risks to hiv infection. working persons sopend much of their active life time in workplaces and that is where they start getting involved in risky behaviour putting entire families at risk. and when they are infected with hiv, working people face high levels of seclusion, stigmatisation and some miss out on benefits especially in countries where there are no strong workplace programs. adressing hiv/aids in the workplace is key for sucessfull responses. this paper presents a case for workplace programing; the needs, issues and recommendations especially for urban places in developing countries where the private sector workers face major challenges.