The designation “gamer” is structurally bound to networked economies of digital play that are rewarded fiscally, socially, and publically, an order of play that is proving difficult to overturn. That girls and women have enjoyed at best marginal positions within video game cultures is by now well recognized, yet at the very same time is too easily dismissed in light of persuasively documented increases in the numbers of women who play. This article traces a large-scale transformation of ludic engagement from participation to spectatorship that parallels the professionalizing and commodifying of traditionally embodied sports, games, and play to demonstrate how new and emerging economies of gameplay, far from opening up the playing field, threaten a further entrenchment of gendered relations. It is aResearch on gender, race, sexuality, and gameplay has amply demonstrated the deeply sexist practices in the culture and industry surrounding video games cf. , p. 832.What is less well understood is how these inequities are, as Representation can only be properly analysed in relation to the actual concrete forms which meaning assumes, in the concrete practices of the signifying, “reading” and interpretation; and these require analysis of the material forms…in which symbolic meaning is circulated. (p. 9)We try to trace here the ways in which that focus by feminist and other scholars (ourselves included) on gender representation in video games has often neglected to study it as first and foremost an expression of larger and more powerful economic inequities. Feminist media scholarship has examined gender inequities in digital and social media consumption, use and commodification created in and through an emerging spectatorial economy of games and play. In a relatively short period of time, more and more people have tuned in to watch other people play. This is made most clear in the financially lucrative eSports contracts being awarded to mostly top male players in video game leagues  or the tTo better understand how material conditions for women, in particular, change when play becomes professionalized public performance, we need first to unpack what’s meant by “labor” in the immaterial, affective, and aspirational forms that characterize video game play. Then, we review the moniker “gamer” and the ways it has been used to galvanize a culture around gameplay which, even while celebrating democratic expansions of “participation,” actually retrenches gender-stratified economic privilege. Next, we examine cultures and economies that support professional play—through eSport tournaments and Twitch and YouTube broadcasters and subscribers—to show how gender inequalities are very much a part of the commodification of the ludic.It is beyond the scope of one short paper to detail the intricacies of labor’s transformations in the turn to the digital. It is necessary though, and helpful, to set out some terms relevant to a discussion of gender, labor, and video game cultures and industries. And while it might seem that, in a discussion of “digital work,” we overemphasize domestic labor, given this is neither a study of vacuuming or child-rearing, we do so to draw attention to continuities and convergences between those domestic practices and new forms of immaterial labor, both of which remain largely “women’s work.”Women’s work is the unpaid social, domestic, reproductive work that is distinguished from productive, commodified labor and was consigned for that reason to relative insignificance by Marx. More recently, the value of those forms of immaterial labor whose products are not commodities has been reconceived and reclaimed as a potent form of autonomous work to contest capitalism’s economic and ideological hegemony . In viewhas continued to consist of the kind of gendered domestic work that is “used up” even as it is carried out: the cooking of food, the caring for family members, the cleaning of the house, and the kind of work that has use value, but not exchange value. Both these reproductive and affective contributions by women “on the home front” support all other economic activities, and more fundamentally still, provide the workforce with its laborers, its human resources.It is along this trajectory that “participatory culture,” voluntary labor as a “gift economy,” the promotion of self-branding, and entrepreneurialism, and the valorization of “doing what you love” can be located. According to The contributions of bloggers, streamers, reviewers, YouTubers, network administrators, guild leaders, modders, and the whole gamut of mostly unpaid digital media content creators, including open source programmers, have directed renewed attention to these emergent forms of immaterial labor, but in ways which fail to engage with the enduring, very substantively material reality of women’s reproductive and domestic labor, whose immateriality is of a quite different order. We contend that what else drops out in the “movement out of the kitchen and into the Internet” is recognition of the complex interplay between traditional and informatized conceptions of immaterial labor, an interplay in which gender remains a driving force of inequality, and one that goes unacknowledged so long as the focus is placed on changed forms and functions of digital labor, with women’s work  being “d“Affective labor,” most simply put, is immaterial labor that produces “affects” whose distinctive contribution is the formation and maintenance of “collective subjectivities…socialities, and ultimately…society itself” , p.89. Tontological role for affective labor in contemporary capitalist society. “Biopolitical production,” he contends, “consists primarily in the labour involved in the creation of life—not in the activities of procreation but the creation of life precisely in the production and reproduction of affects” (p. 99). But from recognizing that the affective labor which can be only be accomplished through “human contact and proximity” can be accomplished through virtual contact and proximity as well as though material coembodiment, to arguing for “the creation of life precisely in the production and reproduction of affects” is a very big, and quite illogical, leap. So that even as Hardt clearly recognizes that “caring labour , is entirely immersed in the bodily, in the somatic” (p. 96), his argument ends by subsuming all forms of women’s work, including reproductive labor, within a category of affective labor which can be either actual or virtual. This is a category mistake. Affective labor may certainly create a “form of life,” but in its virtual forms, it does not create or sustain life—somebody still pushes the vacuum cleaner, somebody feeds the baby.Mobilizing and then inverting the Foucauldian notion of biopower to consider “the potential of labour as biopower, a biopower from below” (p. 100), Hardt argues an Placing primacy on digitally remediated forms of affective labor thus subordinates these gendered forms of work, which remain far away indeed from having “autonomous’ or subversive potential. As The professionalization of digital gameplay and the democratization of media content creation are immaterial, to be sure, but in fundamentally different ways from gendered immaterial and affective labor, which remain largely untouched by the purported transformations of the digital. That’s because digital content creation, which can have both use value (the pleasure of doing what one loves) and exchange value , does not, of course, contribute to the creation and support of the labor force. Those reproductive contributions of women’s work even today remain very much embodied and have in fact not been greatly assisted by digital technologies—the vacuuming still needs doing.Contemporary efforts to formulate a conception of immaterial labor that illuminates the perils and the promise of emerging forms of the (mostly) voluntary work of creative and cultural digital production still continue to elide the persistently gendered division of immaterial labor very much materially rendered, which remains prerequisite to digital content creation in the fundamental sense that its creators are embodied human beings whose very survival depends upon the uninterrupted provision of domestic labor—and that is still work done primarily by women, and without pay.The concept of affective labor exhibits a similarly slippery ambiguity, insofar as it fails to recognize that much affective work “in the bodily mode” cannot be reduced to or replaced by affective work accomplished virtually. That conceptual conflation in turn deflects attention from the ways digital media within a postindustrial information economy are produced collectively but selectively compensated along clearly gendered lines.Those newly professionalized forms of ludic labor have been inelegantly designated as “playbour”  and “proDrawing on in depth interviews with 18 young “fashion bloggers,” Mobilizing Duffy’s arguments to address video game play in particular helps make sense of how and why increasing the numbers of women who participate in remunerative play and content creation might not necessarily mean that game culture is becoming more inclusive or equitable. Just as game journalists and scholars encounter very different rewards and punishments for doing or writing the very same things, so game playbourers and prosumers occupy very different worlds even when they inhabit the very same times and places. The next section turns to identity and the identificatory politics that surround who is recognized as someone who plays video games.Both players and makers of video games have been embroiled publically in a battle since the fall of 2014 over the roles of women and others in video game’s culture and industries. The battleground? Online—Twitter, 4chan, reddit, and 8chan—where countless individuals mounted attacks against women who dare to make and critique video games. This public “war,” which at the time of writing in 2017 has somewhat lost its momentum, is referred to widely as Gamergate. Its histories and stories have been well rehearsed by academics and the mainstream press , coverinalso served to obscure who is remunerated and who benefits socially and economically from game making.Preceding Gamergate was a hashtag that trended on twitter for many months in 2012, #1reasonwhy (there aren’t more women in the games industry), where women tweeted the harassment that they had experienced from male colleagues and friends working in the industry. That led to a panel “#1reasonwhy” at the major industry “Game Developers Conference” (GDC) in San Francisco in which leading female figures in the industry discussed their own past experiences and proposed solutions to the problem. The point here is that there is a long history in video game cultures and industries regarding explicit sexual harassment and misogyny directed at women who work, play, and write about video games—nothing new here, in fact. Except that the groundswell of fury, one way or another, over “Gamergate,” a discourse of symptoms that pitches “gamers” against women, focuses critical attention on superficialities of identificatory politics, and has in that way served as a powerful distraction from interrogating more deeply the economic forces that structure and bind digital play, its players, and its industries. That is not to say that important cultural and social issues haven’t been raised in response to Gamergate, but more that it http://www.reddit.comr/GirlGamers), a Steam community publically supporting female gamers that has chat and forum rules to protect its members (https://steamcommunity.com/groups/GirlGamers), and then of course there are countless YouTube videos dedicated to the topic of “fake gamer girls”—who only want a date and can’t really play, and so on.This is expressed in discourses around gamers, gamer girls/z, girls who play games, and games for girls. “Gamer girls” are shorthand for girls and women who play games. It also has darker connotations beyond its simple referent—a gamer girl can be someone who just plays because her boyfriend plays, she is likely less skilled than male players, or “just holding the controller” for her “boyfriend,” and she is a loosely parodied, male gamer geek, fetish object—imagine a female that is both beautiful and skilled at playing video games. That last connotation is reinforced on YouTube and Twitter, where (mostly) young women upload images/videos that sometimes call into question that heteromale fantasy or, more often, simply reinforce it through posed images targeted to a male gaze. The Twitter hashtag #gamergirls is a good example of the messiness of the term—it has booty shots, carefully framed photos of attractive women playing, parodic calls to what a “real girl gamer is,” as well as invitations to play by women who are seeking other women to play with. There are many other examples of the use of gamer girls to demarcate women and girls who play video games—a subreddit is dedicated to the topic (Gamasutra (an online publication dedicated to games and game making), Time, Polygon, and The Guardian, among other prominent journalistic venues, wrote a piece entitled: “‘Gamers’ don’t have to be your audience. ‘Gamers’ are over.” In it, she argues that:‘Gamer’ isn’t just a dated demographic label that most people increasingly prefer not to use. Gamers are over. That’s why they’re so mad. These obtuse shitslingers, these wailing hyper-consumers, these childish internet-abusers—they are not my audience. They don’t have to be yours. (n.p.)https://newzoo.com/insights/articles/esports-revenues-2016-adjusted-upward-493m/). So here again we can see that in actual material terms, the market for digital games is diversifying, even as its core, white male player base is resisting. And that matters because underlying gamer girl as a discursive construct are material, social and economic inequities and inequalities that sequester gamer girls from the material and social rewards afforded to the malestream gamer.Gamer girl is a discursive construct that signals, at its most literal, that girls and by extension women are also gamers. However, much that label might seem to interrupt the perception that gamers are white, heterosexual men, the false gender binary gamer girl evokes sets girls/women and their gameplay apart from male gamers. That distinction appeared significant especially during the height of Gamergate when How to do Things with Videogames, Ian Bogost advances a similar argument to Alexander’s:we must face a humbling perhaps even disturbing conclusion about the media forms we love: they’re just not that special…as games broaden in appeal, being a “gamer” will actually become less common if being a gamer means consuming games as one’s primary media diet or identifying with videogames as a primary part of one’s identity…. Soon gamers will be the anomaly. If we’re very fortunate, they’ll disappear altogether. Instead we’ll just find people, ordinary people of all sorts. And sometimes those people will play videogames. And it won’t be a big deal, at all. (pp. 153–154)Wishes and wistfulness aside, both Bogost  and Alexander argue that the medium of the video game is fundamentally changed—that players of all types, ages, genders, sexualities, and ethnicities are exploring the medium of games, not just video games but online, mobile, educational, and alternative reality games (as the success of Pokemon Go clearly demonstrated). So let’s do away with gamers. Let’s free the medium from our narrow expectations, and open our minds to the vast possibilities games offer us when we domesticate their underlying mechanisms…. The real birth of the player must be at the cost of the death of the Gamer. (n.p.)These calls to move away from gamer constitute a deliberate linguistic intervention in video game culture. But this lexical shift matters only if we are also looking beyond discourse to shifts in the industry to see how gamer retains a powerful grip on game culture in its ties to burgeoning and financially lucrative industries—eSports and video game play streaming .In his Candy Crush player who doesn’t pay to play, or even an 80-year-old grandmother who streams her play on YouTube.The common discourse for referring to eSports professionals is not in contention though—and “professional gamers” refers, of course, first and foremost to male players. But what if those were just “professional eSports players”—that really could be anyone regardless of age, sex, gender, sexual orientation, or ethnicity. Referring to “players,” can mean anyone—someone who plays board games, or someone who is a level 600 https://newzoo.com/insights/markets/esports/).2 That total includes media rights, merchandise, tickets, advertising, sponsorship, and game publisher fees. eSports has an extremely large audience, online, and in person. In December 2016, Riot, the company behind the top played and top grossing game of 2016, League of Legends, reported that their eSports Championship Finals were viewed by 43 million people with 14.7 current viewers during the final match , among many others that are local and extra local in the United States, Canada, China, Mexico, Europe, and Korea. This global network of eSports leagues and their increasingly corporate sponsors, including game companies, is also now supported through “mainstream” sports coverage. Both ESPN and Yahoo launched in 2016 online sections—“verticals”—devoted to eSports , Electronic Sports League, Dreamhack, European Gaming League, as well as game-specific world championship leagues  to play as labor that has exchange value. There has not yet been an academic study we could locate that focuses on the economic impacts of eSports, whether on players, game companies, local and global tourism, and so on, so we do not yet have good data to answer the question of what the exchange value for playing eSports is. But it’s very clear that an important driver of eSports revenue is, simply, its viewers. As Engineering and Technology Magazine (http://www.esportsearnings.com/players), with the top male player earning over US$2.5 million in prize money alone. The top female player by comparison earned US$170,000 (http://www.esportsearnings.com/players).As viewership becomes increasingly important and tied to revenue streams , and givMagazine , Michaelhttps://newzoo.com/insights/markets/esports/), it is noteworthy that professional gaming remains male dominated, and very much a “boys club” that has worked hard over the past 15 years to have pro-gaming designated a “sport,” and one that is not welcoming to women. Competitive digital gameplay is a space that is vocally homophobic, misogynistic, and racist, which attempts to excuse its exclusionary utterances as simply “trash talk” , is often harassed and threatened with threats of rape while playing. She spoke in 2016 at the GDC along with Morgan Romine, arguing that female-only tournaments “are a necessary first step to creating a more inclusive esports culture”  can be economically and socially rewarding—for some anyway. 3 That is not to say there aren’t female and other Twitch streamers and YouTube commentators, but Prostigo overlooks the intersections of gender, sexuality, ethnicity, and ability in his analyses of labor in digital environments. What is often missing in accounts like Prostigo’s is who is supporting the production of such digital and affective labor—who supports the initial investment in technology? Overlooked here are important questions about the fundamental means of production: Who makes the entrepreneurial gamer possible? Who cooks the meals? Who pays the rent? How do we better make visible these practices? How can we as researchers and theorists, without endlessly repeating ourselves, uncover the ways in which hegemonic masculinities are “in play”? That is, those masculinities that are “most highly valued, legitimated and respected in society,” even as they “disempower women and…subordinate other men”  or the top YouTube video game commentators/Let’s Play video producers are, to date, primarily male, it’s a defensible assumption.her men” , p. 486.In masking the very exploitative mechanisms of labour that it fuels, DWYL is, in fact, the most perfect ideological tool of capitalism. It shunts aside the labour of others and disguises our own labour to ourselves. It hides the fact that if we acknowledge all of our work as work, we could set appropriate limits for it, demanding fair compensation and humane schedules that allow for family and leisure time. And if we did that, more of us could get around to doing what it is we really love. (n.p.)Too often overlooked in the valorization of digitally enabled opportunities for creative work and play in participatory media spheres are its imbrications with capitalism’s well-entrenched structures of exploitation and inequality  by spectatorship as by participation.equality . When as


Despite many health benefits of physical activity, nearly a third of the world’s adult population is insufficiently active. Technological interventions, such as mobile apps, wearable trackers, and Web-based social networks, offer great promise in promoting physical activity, but little is known about users’ acceptability and long-term engagement with these interventions.The aim of this study was to understand users’ perspectives regarding a mobile social networking intervention to promote physical activity.Participants, mostly university students and staff, were recruited using purposive sampling techniques. Participants were enrolled in a 6-month feasibility study where they were provided with a wearable physical activity tracker (Fitbit Flex 2) and a wireless scale (Fitbit Aria) integrated with a social networking mobile app . We conducted semistructured, in-depth qualitative interviews and focus groups pre- and postintervention, which were recorded and transcribed verbatim. The data were analyzed in Nvivo 11 using thematic analysis techniques.In this study, 55 participants were enrolled; 51% (28/55) were females, and the mean age was 23.6 (SD 4.6) years. The following 3 types of factors emerged from the data as influencing engagement with the intervention and physical activity: individual , social , and technological. In addition, automation and personalization were observed as enhancing the delivery of both individual and social aspects. Technological limitations were mentioned as potential barriers to long-term usage.Self-regulatory techniques and social factors are important to consider when designing a physical activity intervention, but a one-size-fits-all approach is unlikely to satisfy different users’ preferences. Future research should adopt innovative research designs to test interventions that can adapt and respond to users’ needs and preferences throughout time. Physical inactivity has been identified by the World Health Organization as a global public health problem, emerging as the fourth leading risk factor for global mortality . ResearcIt is widely acknowledged that behavior change is a challenging process. The success of behavior change depends not only on an individual but also on social and environmental factors ,5. BehavThe use of technology in the delivery of behavior change interventions has potential in promoting their success and diffusion. Notably, mobile health  interventions, involving mobile apps and wearable devices, can reach individuals continuously, enabling the self-monitoring of health and physical activity data  and the To date, a few qualitative studies have sought users’ attitudes and views on the use of mHealth technologies and Web-based social networks for physical activity promotion -22, withThis study is part of a larger mixed-methods feasibility study on the use of a social networking mobile app to promote physical activity and weight management . Given tThis study was conducted at Macquarie University . We recruited 55 participants, mostly university staff and students, using purposive sampling techniques through several channels, including posters around campus, website information, social media, and an email newsletter. Eligible participants were healthy adults with sufficient English to understand and participate in the study; aged between 19 and 35 years; who planned to be living in Sydney for the duration of the study; and owned a mobile phone (iOS or Android) with internet access. The exclusion criteria included pregnancy; body mass index (BMI) <17; prior history of eating disorders; or having diabetes or other comorbid conditions that could impact the study participation .For a 6-month period, participants were asked to use an intervention bundle (detailed below). Interviews were conducted pre- and postintervention, with the aim of assessing participants’ perspectives on the use of social networking and mHealth interventions to promote physical activity. Of 55 initial participants, 45 returned for the final interviews.The intervention bundle was composed of a mobile social networking app , a fitness tracker (Fitbit Flex 2), and short message service text messages and emails . The mobTo enable the automation of self-monitoring, the app was integrated with the Fitbit Flex 2 fitness tracker, through the Fitbit Application Programming Interface. Reminders to wear the trackers and check the app were sent to participants every 2 weeks in the form of short message service text messages and emails. Prior to study commencement, an interview guide  was deveIn the preintervention session, 55 participants attended a brief individual interview (10-15 minutes) in which they were asked about perceived facilitators and barriers to physical activity and their views on the potential advantages and disadvantages of the mobile app and wireless devices . The content of the preintervention interviews was summarized and used as prompts for discussion in the postintervention sessions.In the postintervention session, we conducted 32 individual interviews and 5 focus groups with 13 participants (20-45 minutes); data saturation was reached. While the interviews allowed us to understand individual perspectives, the focus groups enabled us to explore group differences and similarities ,28.At the postintervention sessions, participants talked about their experiences regarding the use of the intervention and provided suggestions on the devices and the intervention. Furthermore, semistructured interviews were conducted by 2 researchers with expertise in qualitative methods. Field notes were taken throughout the interviews.With participants’ consent, the interviews were recorded and transcribed verbatim, and transcripts were analyzed in Nvivo 11 . The data were analyzed using thematic analysis techniques . SpecifiWe found the following 3 types of factors emerging from the data as influencing user engagement with the intervention and physical activity levels: individual, social, and technological. At the individual level, participants mentioned that goal setting, self-monitoring, and feedback were important for their physical activity. At the social level, social comparison and the connection with other users in terms of familiarity and similarity were considered motivating. Finally, at the technological level, automation and personalization were considered to be facilitators, while technological limitations were observed as reducing user engagement. The following sections discuss each of these themes in detail, with illustrative quotations -3.Self-monitoring was deemed important by many users, as it increased their awareness of activity levels and performance, as well as enabled them to review their progress over time and better plan their exercise . By having multiple types of information about themselves, users felt they could get an overall view of their daily patterns, and how external factors  affected their health and well-being , quote 5Many participants expressed that they benefited from goal setting. They believed that setting a goal  kept them accountable for their physical activity performance and motivated them to reach that goal. Participants indicated that goal setting and self-monitoring complemented each other because, without self-monitoring, they would have no way of knowing whether their goals had been achieved , quote 6For many users, the feedback on progress toward goals was particularly encouraging; knowing that they were close to reaching their goals would motivate users to do more physical activity, while being notified of goal achievement gave them positive emotions . ParticSelf-monitoring of behaviorQuote 1: The important part for me is [keeping track] – I know I'm going beyond the average, like the normal number of steps for a person […] - it makes me more motivated. Quote 2: I could use the data, so I know how [many] steps for one run, or how long I take for one run. It helps me to evaluate how [many] runs I could actually do, or what should be my targets for next day. Quote 3: I climb now […] I'm actually looking for a watch or something that can measure altitude, it will be more interesting because I'd get to see how far I've climbed. Quote 4: [I do] martial arts, so it’s not so much running and movement. I want to have heartrate, it’d probably be a bit more useful. Quote 5: I realized because of work pressure, in fact, I’m doing two jobs right now […] my average sleep has gone down. Goal settingQuote 6: There was a goal to reach every day. It kept me motivated […]. I would feel bad if I'm not wearing the [Fitbit]. It was like an additional limb in my body sort of thing.” Quote 7: I want to set my own goals each day […]. Some days I'm more active than other days. On those days, I'll automatically reach 10,000 steps in […] one session alone. But if I changed [the goal] to 20,000 steps then […] it would not really [be] achievable on the days that I don't do that much physical activity. If you could tailor the steps per day, then the motivation would be continuous. Because the motivation only works if I get close up to the end. Feedback on behaviorQuote 8: Because I work long hours, I would reach 10,000 steps at like 10am. It always made me feel good when it vibrated and all the colors everywhere. I was like, yes! Quote 9: When I […] got 80% of my goal, [I would just] go aimlessly for a walk. So that was getting me to walk more. Solely because I was on 80% and I wanted that 100%. Quote 10: It sorts of guilt-tripped a bit. When I’d see it and I was like oh, I’d only done so many steps today. Participation from other users was important for people to engage with the social network component of the intervention. Many users described attrition as a “domino effect”—once a certain number of people stopped using the app or the wearable tracker, other users subsequently felt less motivated to use the technology Quote 2: I find competition helps me to regularly exercise often by going for runs with friends or family or competing in team sports.…Other people can see [your effort] and keep you accountable to your fitness goals. There’s also that element of showing off…and also being able to see how other people exercise and then try to match them. Quote 3: I probably look up more.…A lot of my days, I get up to 17,000 steps. So, I don’t look down, I’d look up and be like, “Oh, why are those people getting 21,000 steps? I need to get 21,000 steps.” Quote 4: I would obviously want my comparison to be done with somebody who is exactly like me, or similar in certain ways. It gives me some kind of happiness that I’m achieving my goals in comparison to this person. It’s like a competition. It’s like scoring 87 and the other person is scoring 84.…Then I would also want to know the person who has got a 96 and why did he get a 96?…If you want to achieve 100, you want to know where you went wrong and what did you do right. But I don’t want to compare with a person who got a 40. Quote 5: I was probably competing to the person closest in terms of kilometers that we were doing. It was interesting to see what they were doing and how they progress…. I tried to beat them every day. Quote 6: Being compared to other people was a bit shocking—I was [at] the end of the group, so it was a bit demotivating. Quote 7: If I’m having more steps than others, I feel motivated, and know that at least I keep myself healthy. Familiarity with other usersQuote 8: It’s like, I don’t really know anyone [in the study] and then…the fad of comparing yourself against people wears off; I did try and use it a little bit more, but it was just like because you don’t know anyone, you forget about it.…If it was in a group of my friends, we probably would’ve been checking it weekly. Quote 9: I guess not knowing what they do…—whether they worked or whether they were students— not knowing that, it’s a bit hard to…compare because there’s all these variables. Also, because I really didn’t know them, I didn’t feel obliged to try to motivate them at all in any way. I guess with friends—and if I got to know them at all— yeah, I might have done that. Quote 10: [I’d like to see] more information about the kind of fitness people are doing. For example, someone has done 20,000 steps in a day, which is a huge amount, then give me a basic idea of what that person has done to get to that goal. Quote 11: If everybody [had a] profile, maybe it [would be easier] to make friends. At the beginning I thought “Maybe I can [make a] friend and we can train together to lose some weight.” Similarity with other usersQuote 12: I think it would help if you had people…with a similar body type doing similar things that would suit you more. Quote 13: I like that you could go through and track people who were similar to you…. I went and found people with similar BMI. I’m happy to track myself against similar people and see how many steps [they’ve done]. Quote 14: Everyone’s goal might be different. So, you need to group people with similar goals together. …I would want to compare myself to somebody who [has similar goals] and is using it on a daily basis like me.” Quote 15: Having a goal section where people say whether they want to gain or lose weight would be good. Then all people who want to lose weight can get together and talk about it. Participation from other usersQuote 16: It was a bit like a domino effect, so after about two months you could see that 20 to 30 per cent had zero [steps]. It felt like people weren’t using the app, so there was no reason for me to use it as well. Quote 17: There’s no number of steps [from some people] sometimes. It can be a little demotivating when you see a lot of zeros…It’s like are they taking this seriously? Many participants found that using the wireless tracker and scale in combination with a mobile app offered many advantages. Specifically, wireless devices provided an automatic way for users to collect and self-monitor personal measurements, and their integration with the mobile app provided a user interface platform for participants to visualize those data and to review progress Quote 2: I like the [Fitbit] app. It integrates so well, so you wear your [tracker] and then [the app] tells you [how many] exercises you’ve done in a week, your steps, sleep. Quote 3: [Having health information] would be good, but it has to be personalized or customized to me, (…) my body type, […] not like a general advice like [what is] BMI etc. […] A lot of people can read about general information; but if it's personalized to you or customized to your needs, it's going to be more interesting and more reliable […]. Quote 4: I liked that at the end [of a fitness video], you can put a smiley face on how difficult it was. Based on my reaction, I want the app to give me recommendations on what types of exercises I should do. So, it was tailored to me, according on my reaction. Quote 5:Male: Whether to have one or multiple buddies, the choice depends on what works for the person. Maybe you can personalize it in some way. Maybe you can elect I want only one partner, or I want to be put in a group. Female: It is like gym training session, you can have private sessions, you can have small group sessions, or you can have a class session and you choose which one is best for you. The same with the app and your buddy. Technological barriers to continued usageQuote 6: The charge lasted three days, and because I had such a busy schedule, charging it again [was] such a big chore. So, it would then just sit for another week and I’d get a [reminder] email and then I would plug it in […]. I was doing so many things, so remembering to charge it became a challenge. Quote 7: After a first couple of months, it started to feel more like a chore to do. I got into the thinking “I had to [check the app] everyday” as opposed to “I want to do this every day to keep track of my weight”. Then university started, and things started getting busy. Quote 8: The battery was discharging very quickly. In the morning it was telling me that I had achieved my goals when I just started the day. Quote 9: I liked the social comparison feature in fit.healthy.me, but it’s hidden in several menus. I liked the Fitbit app better—the design is certainly more elegant. Quote 10: I checked the Fitbit app more than the fit.healthy.me app. I think the reason was because the Fitbit app was much sleeker, looks nicer and more inviting and easier to use. This study explored users’ perspectives regarding facilitators and barriers in using mobile social networking interventions to promote physical activity. The following 3 categories of influencing factors emerged: individual, social, and technological. At the individual level, behavior change techniques, such as goal setting, self-monitoring, and feedback, were suggested as important for user engagement in physical activity. At the social level, social comparison, familiarity, and similarity with other users were mentioned as motivating aspects. Finally, automation and personalization were highlighted as technological facilitators, enhancing the delivery of both individual and social aspects of the intervention. However, some technological limitations were also found to be barriers to user engagement.Our findings suggest that the success of a behavior change depends on a range of factors, including both individual and social aspects. These findings are in line with other behavior change theories, namely the social cognitive theory , and theIn line with our results, behavioral informatics interventions  can facilitate the delivery of both individual and social aspects in physical activity interventions . SpecifiOur users indicated that goal setting, self-monitoring of behavior, and feedback on behavior could encourage them to engage in physical activity, which is in line with previous qualitative studies ,19. IndeIn addition, previous research has suggested the need to examine which type of goal is best for motivating individuals to be more active and how technologies can best support monitoring those goals and providing feedback. The literature seems to suggest that small goals  are morThis study emphasized the role of social comparison, familiarity, and similarity with other users in a social networking intervention. First, our participants revealed different preferences regarding social comparison. This finding is in line with previous research, where it has been demonstrated that individual preferences might depend on their tendency to make upward or downward comparisons . Specififamiliarity and similarity were found to be important factors in a social networking intervention for physical activity. The importance of familiarity seems to be in line with previous literature, where researchers have demonstrated that existing social networks can greatly influence individual health behaviors [Second, ehaviors ,44, leveehaviors ,40,45-47ehaviors ,47, whicehaviors . Thus, aFurthermore, this study showed that similarity is important for motivation and engagement, highlighting the role of homophily  . NotablyThrough automation and personalization, multiple modes and features of technology can work synergistically to deliver a physical activity intervention with both individual and social factors ,50,51. TThis study has several strengths. We interviewed users after 6 months of experiencing the intervention, ensuring that our sample had an informed perspective. The combination of individual interviews and focus groups enabled us to capture both individual perspectives and social dynamics in a group setting, which are essential aspects to understand in a social networking intervention. The findings of this paper must be interpreted in light of some limitations. First, study recruitment was limited to a university setting with a young age group. Though the main purpose of qualitative studies is not to make generalizable claims , future This study highlights several important implications, including suggestions on the intervention design and new research avenues. Interventions for physical activity promotion should consider offering goal setting, self-monitoring, and feedback as a bundle, as these techniques have been shown to be both effective and acceptable to end users. Consequently, the design of mobile apps and wearable trackers need to effectively assist with real-time self-monitoring and provide consistent feedback to enable the achievement of goals . In addipersonalization. By identifying users’ behavioral patterns and preferences, researchers can design and deliver interventions at the right time, using the right channel and tone, and the most relevant content or services [Furthermore, this study highlights the importance of services ,56. Futuservices ,57.This study provides insights into the individual, social, and technological factors that influence user engagement with a mobile social networking app for physical activity promotion. Our findings reveal that self-regulatory behavior change techniques seem to be a necessary element in these interventions, and that aspects related to social comparison, existing social ties, and homophily should be considered in the development of the social network component. Future research should adopt innovative research designs to evaluate the effectiveness of these different components, as well as investigate the delivery of personalized interventions.


Background and Objectives: The complex concept of rational suicide, defined as a well-thought-out decision to die by an individual who is mentally competent, is even more controversial in the case of older adults. Materials and Methods: With the aim of better understanding the concept of rational suicide in older adults, we performed a systematic review of the literature, searching PubMed and Scopus databases and eventually including 23 published studies. Results: The main related topics emerging from the papers were: depression, self-determination, mental competence; physicians’ and population’s perspectives; approach to rational suicide; ageism; slippery slope. Conclusions: Despite contrasting positions and inconsistencies of the studies, the need to carefully investigate and address the expression of suicidal thoughts in older adults, as well as behaviours suggesting “silent” suicidal attitudes, clearly emerges, even in those situations where there is no diagnosable mental disorder. While premature conclusions about the “rationality” of patients’ decision to die should be avoided, the possibility of rational suicide cannot be precluded. Suicide is a global phenomenon accounting for 800,000 deaths worldwide every year . ConsideIn older age there is a high risk of unrecognized and untreated psychiatric illnesses ,7. In paAging may lead individuals to think back about their lives and to experience either feelings of integrity (if they feel their life has been meaningful) or despair (if they are unable to find meaning and achievement in their life) . MoreoveFurthermore, the current historical period is one marked by many new opportunities  which have allowed a rapid increase of life expectancy and longevity, but also by the difficulties and ambiguities in facing what these opportunities have brought about. Life support technologies currently enable the prolongment of critically ill patients’ life, often beyond a point where it can be experienced as meaningful and desirable . TherefoIn recent years, there has been much discussion (not only in the scientific community) about suicide and what has been named “rational suicide” in older adults. It is described as “rational” an action which is “sensible, appropriate, in keeping with one’s fundamental interests, and perhaps even admirable”. RationaThe concept of rational suicide is controversial and difficult to define, so that some suicidologists and psychologists consider it as an oxymoron. The debate about this topic is even more complicated by emerging and complex to define concepts such as those of “good” or “gentle death”, and of “silent suicide”, defined as the intention to kill oneself by nonviolent means such as refusal of food and liquids or noncompliance with essential medical treatment. Such means of promoting one’s death causes ambiguity in medical, clinical, personal, cultural, ethical, religious and historical interpretations . MoreoveGiven the ongoing debate about the possibility that a “rational suicide” exists, the concern represented by older adults’ suicide and the world population aging trend, we performed a systematic review of the literature about rational suicide in late life, with the primary aim to offer an overview and better understanding of the concept of rational suicide in older adults through a description of the main related topics emerged from the literature.We searched PubMed and Scopus databases from inception to April 16th and 19th 2019, respectively, with the following search keywords: rational AND suicid* AND (elderly OR older*). Two of the Authors  reviewed and screened eligible articles according to the PRISMA  flow diagram . Any disStudies were excluded if: (1) they were written in languages other than English; (2) their full-text was not available; (3) they were book chapters, commentaries and editorials/letters to the editor; (4) they were focused on euthanasia, PAD and PAS.For each study, we extracted: year, design, sample features, used rating scales, reasons mentioned for rational suicide, rational suicide criteria and/or definition, main results, and conclusions.The search retrieved 144 references; 24 full text articles were assessed for eligibility  and affect clinicians’ ability to identify psychopathology . For insTrying to find a balance between patients’ autonomy and clinicians’ responsibility, therapeutic nihilism and medical paternalism is necessary to face a phenomenon, which may be associated with increased longevity.Several authors have expressed concern that recognizing the right to die would too easily shift to “a climate enforcing a social, obligatory duty to die”, and novelists have well described this risk in science fiction stories such us Richard Matheson’s The Test (1958).Indeed, several of the selected papers mentioned the “slippery slope” argument, which is also debated in the end-of-life/euthanasia/PAS/PAD context and which refers to the possibility that acknowledging the right to die would eventually shift towards an obligation to die and/or lead older persons to feel guilty if they had no wish to end their life and decided not to commit suicide .However, it has to be underscored that, in the context of the euthanasia debate, no consensus has yet been reached about the presence of the slippery slope effect ,65.The aim of this review was to offer an overview and a better understanding of the concept of rational suicide in older adults.Opinions are not consistent about whether older adults’ wish to hasten death in the absence of a psychiatric disorder could be regarded as a rational choice. Suicide presenting in the absence of a clinically diagnosable depression  and occurring in cases of adverse conditions such as physical illness and aging has been considered “rational” from the perspective of respect for individual autonomy, and the rational assessment of utility . SuicideEven though Authors do not agree on the role of mental disorders in “rational suicide”, usually those who adhere to the conventional psychiatric opinion think that mental disorders are preeminent with regard to suicidal ideation and that suicide is a manifestation of psychiatric illness, hence they do not consider suicide as a rational option ,54. The Although life expectancy for those living in western societies is higher than ever before in human history, this has had the effect of making it difficult for medical professionals to find a balance between patients’ autonomy and clinicians’ responsibility, to admit when someone is dying and to know where to draw the line in terms of offering more treatment ,67. The Some valuable suggestions to face the problem of rational suicide emerge from the studies we assessed; for instance, Richman, quoted by Moore  underscoIt should be underscored that a limitation of this work is that, since the available literature was very uneven and, despite the selection criteria, mainly based on opinions and theoretical papers, the reported quantitative synthesis is limited. Furthermore, we cannot exclude that the choice of not including editorials and book chapters in the current review might have limited the access to potentially relevant material. Further original research studies may help to better understand this complex topic.In conclusion, despite contrasting positions and inconsistencies of the studies described in this review, what seems to emerge is that the expression of suicidal thoughts in older adults, as well as behaviours suggesting “silent” or indirect suicidal attitudes ,69, shou


Relatively little is known about the ease or difficulty with which women decide to have an abortion, and most research uses single-item measurements. We used a mixed methods approach to combine data from the Dutch Abortion and Mental Health Study  with data from a qualitative study about the decision process with a small subsample (n = 69) of the DAMHS study. We used the findings from the qualitative study to develop the Dimensions of Abortion Decision Difficulty [DADD] scale, and tested this scale among a larger sample of women who took part in the second wave of the cohort study (n = 264). Qualitative analyses revealed six dimensions of decision difficulty. The DADD scale was based on these six dimensions. Results from the DADD scale at follow-up reduced these to four dimensions: (1) unrealistic fears about the abortion and fantasies about the pregnancy; (2) decision conflict; (3) negative abortion attitudes; and (4) general indecisiveness. Decision conflict was the only dimension related to previous mental disorders. The findings suggest that the concept of decision difficulty seems multidimensional, rather than unidimensional. On a clinical level, it could be important to separate the more general fears, attitudes, and indecisiveness from strong decision conflict, because the latter might involve pressure of others, lack of decision ownership, and might be related to previous mental health. In the Netherlands, abortion is free, legal, and available up until 22 weeks of gestation; but at the same time the abortion rate is among the lowest in the world: about 8.6 in 1,000 women aged 15–45 per year have an abortion , 4; a USDespite its clinical relevance, decision difficulty is infrequently used as a concept in abortion research, and the terminology varies. Other related terms are ‘ambivalence’ –10, ‘doupost-abortion development of mental disorders  scale. Between December 2012 and November 2013, which was on average 2.7 years after the baseline quantitative interview, all women who had taken part in the first interview were approached for a follow-up quantitative interview, and the scale was tested among the whole cohort. The inclusion of participants in the three measurements is depicted in All interview meetings were held in a private setting, mostly in the respondent’s home. Prior to each interview, the study purposes and procedures were explained, and informed consent was obtained. Confidentiality, anonymous data handling, and the opportunity to withdraw from the interview were ensured. In the in-depth interview, it was stressed that we considered all kinds of reasons, thoughts, and feelings they might have had, as valid and accepted. Participants were encouraged to communicate the salient aspects of their experiences in their own words. All selected interviewers were female and over 25 years old. They received a two-day diagnostic interviewing training, followed up by at least two full test-interviews. The qualitative interviewers had to have extensive experience with qualitative interviewing. Qualitative interviews were audiotaped for transcription, which enabled regular peer supervision and standardization sessions between the interviewers. The mean duration of the interviews was around 2.5 h (baseline), around 1.5h (subsample), and 1.5h (follow-up). For each interview, participants received a gift card of 50 Euros. The study protocols were approved by the Dutch Medical Ethical Committee specialized in mental health METiGG in 2010. In 2012, the METiGG was abolished and the research protocols were transferred to the Central Committee on Research Involving Human Subjects (CCMO).The participants were recruited by clinical staff in Dutch abortion clinics. In the Netherlands, the large majority (around 90%) of abortions are performed in these specialized clinics . For repThe quantitative study enrolled 332 Dutch-speaking women 18 to 46 years old, obtaining an abortion  for an unwanted pregnancy, without clear fetal or maternal medical indications. At baseline, seven interviews could not be completed, leaving 325 participants for analysis. At follow-up, 264 participants (81.2%) were re-interviewed. Participant flow and results of a response analysis are described elsewhere , 17.The majority of the women (n = 272) in DAMHS gave consent to be contacted for the qualitative study. Because our main purpose was to investigate the concept of decision difficulty, we approached interested women based on their level of self-reported decision difficulty (high or low). The subsample consisted of 69 women who had had an abortion 4 to 7 months prior to the in-depth interview. The numbers of participants in the low and high decision difficulty groups were 47 and 22, respectively.The topic list for the qualitative interviews consisted of eight main topics, which are summarized in Decision difficulty was measured at baseline with one item (in Dutch: “In hoeverre heeft u over de abortus getwijfeld?”) on a five-point scale from ‘not at all’ to ‘to very large extent’. The Dutch concept of ‘twijfel’ cannot be translated into English directly, it is more neutral and less negative than ‘doubt’, and a bit more serious than ‘think about’. The closest translation in English would be “To what extent did you have difficulty with making the decision to have an abortion?” The respondents were explicitly asked to think about the pre-abortion period. Women were categorized into High Decision Difficulty (HDD) when they scored 4 or 5, and into Low Decision Difficulty (LDD) when they scored 1 or 2.‘Age’ was measured continuously; women were then categorized into three age groups. ‘Living alone’ was a dichotomous measure of living alone versus living together with a husband or cohabitating with a partner. Similarly, ‘children’ distinguished women with one or more children from those without any children. ‘Education level’ was measured in 8 categories, and then categorized in low = 1 (primary education or lower secondary education) and higher = 0 . Other measures were: ‘unemployed’ ; ‘religious’ , and ‘non-western ethnicity’: respondents in this category or at least one parent of the respondent were born in Turkey, the Caribbean, Africa, Asia (excluding Japan/ Indonesia) or Latin-America , which is the standard definition of Statistics Netherlands (CBS) .History of mental disorders was assessed at baseline with the Composite International Diagnostic Interview (CIDI) version 3.0, which was developed and validated for the WHO World Mental Health Survey Initiative , 20, andBased on the results of the qualitative analyses see  section,First, descriptive statistics were calculated. Chi-square tests were performed to test differences in background and mental health variables between women who experienced high decision difficulty and women who did not. Selection of participants for the qualitative subsample was also based on the single item decision difficulty. Qualitative interviews were transcribed verbatim and were imported in NVIVO9 software for coding and analysis . After tX2  = 7.68, p = .006, and of substance use disorders, X2  = 4.41, p = .04. HDD women also more often had later (second trimester) abortions than the others, X2  = 5.62, p = .02.Descriptive characteristics of the total baseline sample, as well as the subsample for the qualitative interviews, are displayed in Women in the HDD-group talked about individual as well as contextual dimensions that influenced their abortion decision. Women in the LDD-group did not always address these issues, or mentioned that they did not cause any difficulty deciding. Based on the analyses, we identified six dimensions of decision difficulty.A considerable number of women in the HDD-group felt happy and proud when they discovered that they were pregnant. Many of the HDD-women expressed a wish to have a child, but their unfavorable living circumstances or the status of the partner relationship made them debate whether to continue this pregnancy. They experienced strong ambivalent feelings. One HDD-participant revealed:It was all so two-sided. This is something I really want, I have a strong desire to have a child, so on the one hand you think ‘I really want it, but on the other hand, it’s his’. And that’s not what I wanted, not this way. I had very contradictory feelings, and of course that made it hard.Sometimes, women did not mention positive feelings, but described ‘maternal feelings’. The idea of having an abortion felt unnatural to those who described feelings of maternal attachment. Some women thought these positive/maternal feelings were hormonally determined. Some, who already had children and considered their family complete, recognized their maternal feelings from earlier wanted pregnancies. They noted that they could not feel as happy now as during their previous pregnancies. These mothers found the abortion decision hard as they realized that the fetus could grow up like their sons and daughters. They struggled with the question whether it was acceptable to not want this child while earlier pregnancies were welcomed.Women in the LDD-group less frequently reported positive/maternal feelings in response to the pregnancy compared to women in the HDD-group, even though most LDD-women also had a (future) wish to have a child or already had children and considered their family complete.HDD-women articulated several fears of adverse health or psychological consequences due to abortion. The most mentioned fear was feeling regret. Several women were concerned about potential risks associated with the abortion procedure, e.g., physical damage resulting in decreased fertility. Some  feared that they would never get another chance to become a mother. Fears about infertility were mainly prevalent among childless women. One HDD-participant stated:You can’t help being afraid that they’ll damage something inside you and that you’ll never get the chance to be pregnant again…[…] You think, this could be my only chance.A few HDD-women were afraid that they would suffer mental health problems due to the abortion. Apart from feared post-abortion consequences, HDD-women often feared adverse experiences  related to the abortion procedure. In contrast, none of the LDD-women talked about fearing negative consequences due to abortion, although many felt tense prior to the abortion procedure itself. This was, however, not a reason to reconsider their decision.Most HDD-women viewed the pregnancy decision as a choice ‘between life and death’. Many of them understood abortion as taking the life of a human being and therefore found it an objectionable, selfish action. Some were inclined to blame other women for not having taken responsibility for proper contraception. Some believed that other women engage in unprotected sex carelessly and regard abortion as a form of contraception. Consequently, these participants sought to separate themselves from other women having abortions.Many women set conditions under which they found abortion acceptable. Some found abortion only tolerable for women living in extremely adverse circumstances or in situations in which they could not be held responsible for getting pregnant . Except for one, none of the participants with a negative abortion view had become pregnant under such circumstances. The discrepancy with their own circumstances was seldom mentioned by participants directly. Rather, these women struggled with feelings of guilt and remorse towards the unborn child and/or towards women with an unfulfilled wish to have a child. They wondered if they were egocentric or were deflecting their responsibility by having an abortion. One HDD-participant stated:I felt strongly that I was denying life to a child. I kept thinking: ‘You need to take responsibility for your actions. You got pregnant and you’re 38, for goodness sake. You’re not 16 any more. You know how these things work. Dammit, I should have organized some birth control.Some emphasized that they had no choice other than abortion. They stressed that they would never consider an abortion in other circumstances. It took time to reconcile these women’s feelings of guilt, shame and moral conflict with the abortion decision. As such, a negative abortion view interfered with the decision-making. Similar to HDD-women, women in the LDD-group stressed women’s responsibility for preventing an unwanted pregnancy. Many blamed themselves for not having used proper birth control and sometimes felt ashamed and foolish for getting pregnant. However, these women did not link this responsibility to bringing this pregnancy to full term, whereas women in the HDD-group sometimes argued that a woman should continue her pregnancy if she had failed in contraception use. Some LDD-women spoke of abortion as taking responsibility for preventing a child from being born in unfavorable circumstances. One LDD-participant explained:If you are in a situation where you really cannot raise a child, I don’t think it’s selfish to do it. You have to make this choice for the child. After all, a child is on the way. And can I offer it anything? Do I want to offer it anything? What is there to offer it? And if there’s nothing to offer and everything is ‘No, No, No’, then it’s not selfish to say, ‘well, I won’t give you life just yet. Because this life that you would get now is not nice’.Compared to the LDD-group, women in the HDD-group were more often unable to distance themselves emotionally from the pregnancy. This inability to keep the pregnancy at distance manifested itself in several ways. Some of the HDD-women searched more often for information about the development of the fetus, whereas most LDD-women sought only practical information about abortion. A number of HDD-women reported that their attention was drawn to babies, mothers, baby clothes, cuddly toys etcetera. Some of them, especially those experiencing positive feelings, had fantasized about (their future life with) the potential child or about its looks and gender. One HDD-participant stated:I had images in my head, of a child playing, and all the nice things about it. The feeling that I had always wanted to be a mother—that came up really strongly, like ‘I want to keep it’…And because I wanted to imagine what it would be like to keep it, I kept having thoughts like ‘How would I manage here?’, ‘Where would I put the crib?’, and ‘What about the cats?’ […].HDD-women also more often considered the fetus as ‘a child’, ‘a baby’, whereas most women in the LDD-group abstracted the fetus and thought of it as ‘it’, ‘a clump of cells’, or ‘something’.HDD-women more frequently reported that the sexual partner was unsupportive or had put them under pressure to choose an abortion. A few HDD-women, especially the younger ones, experienced pressure from the parents to have an abortion. None of the women in the LDD-group experienced pressure from others.In both groups, most partners preferred an abortion. Especially HDD-women in an unstable relationship experienced lack of support from the partner and pressure towards abortion. Initially, these women tried to figure out if they could count on the man as a father and/or partner. The prospect of single motherhood scared them. As the decision process unfolded, their worries about the partner’s role in child-raising increased.Although less frequently observed, there were a few women in the HDD-group who felt pressured to have an abortion by their partner with whom they already had children. Particularly women who feared abandonment by their partner, expressed that they had no other option. A coercive or unsupportive partner behaved in various ways . One HDD-participant stated:He was shocked that I had such doubts. He hadn’t expected that at all. He was really angry…after I told him, told him in person, I didn’t see him again until the abortion. He was prepared to help me if I got rid of it, then he would come with me…he kept sending negative text messages, always giving reasons for why I couldn’t keep the child and that I would ruin his life and everything…In the LDD-group, the man’s preference for abortion was seldom experienced as negative. Especially in the case of a stable, lasting relationship, his preference was seen as affirmative of their own choice. The abortion decision was made harmoniously. One LDD-participant stated:I really felt our family was complete, and luckily my boyfriend felt the same. He had no interest in going back to nappies either. So we agreed on that immediately. The decision was truly a joint one between us.Women in the HDD-group more often characterized themselves as indecisive in general whereas almost none of the women in the LDD-group described themselves as such. Indecisive women found the abortion decision especially difficult given the irreversibility of the choice. They were also afraid to dismiss important matters in considering the options. They wished to be completely sure of their choice, but did not know how and when to reach that point. One HDD-participant stated:Deciding about a life, that’s something completely different, because your whole life changes. Some decisions can be reversed. But this decision is irreversible. It is Yes or No. There is no middle ground and of course I’m a ‘ditherer’ [indecisive person] anyway.To explore whether the six dimensions of decision difficulty would be supported in a larger group, the DADD scale was administered in the full cohort (n = 264). Mean scores on each of the items as well as item-item correlations are displayed in Explorative linear regression analyses were conducted for each of the four factors, with any mental disorder or the three disorder categories as predictors, and age, previous abortions and second trimester abortions as covariates. It was found that the first factor (‘fears and fantasies around abortion and pregnancy’) was only related to second trimester abortions . The second factor (‘decision conflict’) was strongly associated with a history of mental disorders . This factor was also inversely related to age  and previous abortions : the women scoring high on decision conflict where younger and more often were experiencing their first abortion. The fourth factor  was associated with a history of anxiety disorders . No further associations were found for the factors with mental health correlates, age, previous abortions or second trimester abortions.Both the qualitative and quantitative data in this study showed that abortion decision difficulty is a multidimensional concept. The in-depth interviews brought forward six substantive dimensions of decision difficulty. A combination of these individual and contextual dimensions were simultaneously present in decision-making among women who had experienced considerable difficulty deciding. The quantitative testing of these dimensions by means of a newly developed scale, reduced the number of dimensions to four: (1) unrealistic fears and fantasies around pregnancy (termination), (2) decision conflict, (3) negative abortion attitudes, and (4) general indecisiveness.Although decision difficulty has received relatively little attention in research, the present findings are in line with previous research. Literature suggests that fears and fantasies around abortion are commonly present in the decision-maker’s thinking . PerceivExploratory analyses showed that women who scored high on the dimension ‘decision conflict’ more often had a history of mental disorders, were younger, and less often had had previous abortions. These women experienced positive maternal feelings, and also more often experienced pressure by others; they expressed that the decision was not entirely their own. Qualitative interviews showed that women experiencing strong decision conflict often do not see themselves as active agents in the decision process, but rather experience that they ‘have no choice’. The quantitative findings show that these women are also more likely to have experienced mental disorders in the past. These results should be interpreted carefully; they do not imply that women with a mental disorder history are less capable of making these decisions. They also do not imply that women with these histories more often have abortions ‘against their will’. They merely show that there is an association between previous mental disorders and decision conflict, which might in turn be related to relationship stability or other important negative life events .The fourth dimension, general indecisiveness, was related to a history of anxiety disorders. Since anxiety disorders often involve ruminating and recurrence of  thoughts, it seems natural that being indecisive in general is related to this (and not abortion-specific). Unrealistic fears about the abortion and fantasies about the pregnancy, as well as negative abortion attitudes, came about as substantive concepts, but they were unrelated to mental disorders. In other words, these dimensions of decision difficulty are complicating the decision for many women, but they are not indicative of mental disorders.An interesting finding was that HDD women with negative abortion attitudes would often feel that abortion was only allowed under some strict and severe circumstances, yet almost none of them had become pregnant under these circumstances themselves. They did not mention the discrepancy between their moral beliefs and their own actions, but they did show strong feelings of guilt, shame and remorse, and often felt personally responsible for not having taken contraception properly. A negative abortion attitude, but also unrealistic fears about the abortion, could hamper the decision process. Where unrealistic fears about the abortion procedure can be challenged in counselling, women’s moral beliefs may often be left unaddressed. However, a negative abortion attitude could be indicative of a more difficult decision and abortion process. Fostering openness about abortion (and contraception) in the general population, but also in this specific group, could help women to see things more clearly when faced with an unwanted pregnancy.Our study aimed to deepen the understanding of the concept of decision difficulty around an abortion. A strength of the study is the rich mixed methods approach, using a longitudinal quantitative dataset as well as in-depth qualitative subset data. Moreover, we used the quantitative data to select cases for the qualitative interview, and subsequently, the qualitative findings served as input for the follow-up quantitative data collection. In this respect, quantitative and qualitative methods not only complemented each other, but they also provided enriching input and further improved the data collection .This study has some limitations as well. First, the retrospective nature of the study may have induced some recall bias. For ethical reasons, it was not possible to interview women before the abortion, therefore, the first measurement of decision difficulty was 3 to 6 weeks post-abortion. Women could have overestimated their own decision difficulty, for reasons of self-preservation, but they could also have underestimated it to remove cognitive dissonance after making the irreversible decision. There is no way to tell whether either type of bias was present, and we found that decision difficulty was fairly constant over time post-abortion. Second, the study sample of the quantitative study was slightly selective in terms of sociodemographics. Compared to the abortion population, the DAMHS quantitative sample was slightly older, higher educated, and more often of Western (Dutch) ethnicity . Thus, tOur findings have important methodological and clinical implications. At a methodological level, our findings suggest that a unidimensional construct does not do justice to measure the experience of abortion decision difficulty. Single-item measures do not fully capture this complex phenomenon, and important information could be lost. At the clinical level, the findings suggest that women who experience high decision conflict might need more time, attention, and assistance during the decision process. These women are more likely to have had mental disorders in the past, and they more often experience pressure of others to have the abortion. It could be important that counsellors address general fears and ideas about having an abortion, and ease, correct, or normalize these. Decision conflict could also be addressed, to investigate potential coercion or reproductive control . It is iS1 Fig(PDF)Click here for additional data file.S1 Appendix(PDF)Click here for additional data file.S2 Appendix(PDF)Click here for additional data file.