Though the socio-emotional significance of psychiatric diagnoses and the frequency of transitions between diagnostic classifications are widely acknowledged, minimal research reveals how “diagnostic shifts” are subjectively experienced by psychiatric service-users.This study investigated how adult service-users make sense of diagnostic shifts and their impacts on one's life.Twenty-seven people with self-reported experiences of diagnostic shifts opted into this qualitative study. Virtual narrative interviews invited participants to share their “diagnosis stories.” Interview transcripts were analyzed using narrative thematic analysis to identify common and divergent experiences across participants.Interpretations of Diagnostic Shifts and Diagnosis-Specific Factors. Regarding the former, analysis produced a typology of three possible interpretations of diagnostic shifts, which were linked with consistently different antecedents, experiences and consequences. The latter dimension captured how experiences of diagnostic shifts also hinged on the unique meanings ascribed to the specific diagnoses gained and lost, particularly in relation to their perceived severity, stigma, personal associations, and related communities.Diverse experiences of diagnostic shifts were related: diagnostic shifts could both promote and undermine clinical trust, therapeutic engagement and self-understanding. The analysis suggested that shared and divergent experiences could be attributed to two dimensions of narratives: participants' Findings revealed how diagnostic shifts can be experienced as both traumatic and life-enhancing, depending on their social and subjective context. Understanding the range and predictors of variable experiences of diagnostic shifts is vital for sensitive clinical practice and communication. Mental health and neurodevelopmental difficulties manifest on a continuum, with considerable individual variability in the severity and expression of symptoms experienced. Yet most mental health science and practice depends on classification of psychological difficulties into discrete diagnostic categories, which typically have poor temporal and inter-rater reliability . One bypResearch with clinical and community samples shows most psychiatric diagnoses have limited longitudinal continuity –6. In prSince times of transition illuminate otherwise inconspicuous aspects of the status quo, diagnostic reforms are also an ideal platform to advance sociological understandings of the ways diagnosis affects personal and social lives –11. The Receiving a psychiatric diagnosis can involve both positive and negative socio-emotional impacts: while some welcome diagnoses as facilitating validation and self-insight, others find diagnoses threaten and devalue their self-concept , 15. At Thus, people invest social and emotional significance in the diagnoses they are ascribed, with different diagnostic labels carrying variable meanings. It is therefore plausible that revision of an established diagnosis has broad repercussions beyond clinical settings. A previous study confirmed that in child and adolescent mental health contexts, diagnostic shifts had major practical, social and emotional ramifications for young people and families . A revisThis lack of evidence on how adult service-users respond to diagnostic shifts is of pressing significance. Systems of psychiatric diagnosis are currently in flux: the long-established categorical approach to diagnosis, implemented through standardized manuals such as the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), is under increasing challenge from alternative formulation, precision and dimensional approaches to clinical assessment –22. ThesQuestions regarding service-user experiences are ideally suited to qualitative research methods, which generate in-depth insight into the range of subjective perspectives on a given phenomenon . These pParticipants were recruited using online convenience sampling that circulated mass invitations to opt into the study. Adverts for a study of “lived experience of diagnostic shifts in adult mental health” were placed in social media groups and online messaging boards focused on mental health issues. To diversify recruitment outlets, adverts targeted online networks involving different countries and diagnostic groupings. Stated eligibility criteria included age between 18 and 65, capacity to consent, ability to converse in English, and self-identification as having experienced a change of psychiatric diagnosis. No incentives were offered. Those interested in participating emailed the researcher, who confirmed eligibility, sought informed consent to participate, and arranged an interview time.Thirty-eight people contacted the research team expressing interest in or queries about the research. Following withdrawal of those who did not meet inclusion criteria or opted not to proceed, twenty-seven people took part in an interview. Twelve participated from the USA, five the UK, five Ireland, two Norway, and one each from Canada, Poland, and the Netherlands. Participant ages ranged from 24 to 56 (average = 33) years. Twenty-one identified their gender as female, four male and two non-binary. Eighteen participants reported employment in diverse occupations, alongside one retired, four unemployed and four student participants. Ethical approval was provided by the University College Dublin Human Research Ethics Committee. As data collection was international and occurred during the COVID-19 pandemic (February-April 2021), interviews took place using Zoom videoconferencing softwareInterviews were recorded, transcribed, and imported into NVivo 12 for narrative thematic analysis . A codinn = 9) transcripts were each coded by two independent analysts (n = 7) codes showing “nearly perfect” (κ > 0.8), 41.5% (n = 17) “substantial” (κ = 0.6-0.79), 24.2% (n = 10) “moderate” (κ = 0.4-0.59) and 17.1% (n = 7) “fair” (κ = 0.2-0.39) agreement, and none scoring in the “slight” (κ < 0.2) range. Researchers resolved specific coding disagreements through team discussion and tightened the definitions of codes with “moderate” or “fair” agreement. The final coding-frame was then applied to all remaining transcripts by a single coder. Other quality assurance measures included keeping a detailed ‘audit trail', transparent reporting of analytic steps, supporting analytic conclusions with illustrative data excerpts, and attention to discrepant or minority cases . Depending on the interpretation applied, consistently different antecedents, experiences and consequences of that shift were narrated  or missed diagnosis .Cases of misdiagnosis generally involved core symptoms, which were originally attributed to one underlying disorder but later remapped to another.it was a swap. Pretty much saying, like I feel that all the symptoms that brought you to your incorrect BPD diagnosis were actually like PTSD, presenting in like similar ways. And that he felt the more accurate diagnosis was PTSD. [P1]Cases of missed diagnosis typically involved symptoms originally being overlooked. This was attributed to numerous factors, including overshadowing by more salient problems , clinical carelessness, or participants withholding pertinent information .I told her, yeah everything and that's when she first was like, so you've had a lot of trauma […] I can see now how that diagnosis would have never come up, yeah, in any past therapeutic relationship or psychiatric relationship, because they never, I never felt comfortable and also they don't take the time to really find that out. [P13]In some cases of diagnostic shifts involving misdiagnosis or missed diagnosis, the shift was independently initiated by a clinician after routine re-evaluation.I had around six or more, maybe more, hours of evaluation […] they kind of took the time to go through all the questionnaires and then I was diagnosed with borderline personality disorder. [P17]More frequently, a diagnostic correction was actively sought by the participant. Participants sometimes requested re-evaluation based on a vague sense their previous diagnosis did not fully explain their difficulties. In other cases, participants strongly suspected they qualified for a specific missed diagnosis and lobbied for its application. Some reported a long quest for this diagnosis, involving multiple generalist and specialist services.I was going to another psychiatrist, but then still in the public system. I told her that I wanted this diagnosis […] She didn't give it to me, she didn't feel confident enough and specialist enough. So I went to the head psychiatrist in that clinic. He did not want to give me that diagnosis either. He suggested, like did you consider borderline? […] so I did what people told me to which was to find a specialized– specialist who specializes in adult ADHD. […] I was well prepared, because, you know, I've been thinking this about myself for ten years and she gave me a diagnosis. [P4]Some participants who believed they had been misdiagnosed requested its formal retraction.I went in, like you're prepared for a fight. Like, where I had to be like, I don't think I have it, and this is my reason why, here's my slideshow, and like testimonials from like my friends. [P6]Participants recalled trepidation prior to clinical encounters where they challenged their diagnostic status. This apprehension was sometimes vindicated by dismissive professional responses.It was very nerve-wracking. I was very nervous that I would get the default answer of “get off the Internet”. […] then I brought up complex PTSD. And then they laughed and they're like, that's just too new and that's, no, that's not a thing, that's just fancy PTSD. And I'm like, no, I'm pretty sure that's an official diagnosis. [P3]In almost all cases framed as misdiagnosis or missed diagnosis, participants saw the diagnosis they held at interview as appropriate. Generally, participants were more comfortable with their current than previous diagnoses.life's just been a lot easier since I had a decent diagnosis. [P16]Relief was a common response to a diagnostic shift viewed as the correction of a previous misdiagnosis. Relief typically arose from feeling one had a better explanation of one's life and challenges.now that I have a different diagnosis, it actually makes me feel better. It's like, oh, you know, it's not my chemistry, there's nothing wrong with my chemistry, my brain, I'm not bipolar. There's nothing wrong with my personality, I'm not borderline. […] It's just like everything fit together for the first time, like it all made sense. [P13]For those who felt their correct diagnosis had been delayed, relief was mixed with regret and anger regarding “lost time” for understanding and intervention.I'm really pissed off. I've had to suffer all this time because no one was prepared to actually sit down and give me that diagnosis […] You're fighting a battle against depression, when you're fighting the wrong battle. […] You know, over the years of not understanding, that not making sense is just… well, it's quite traumatic. [P16]Participants who proactively sought a diagnostic shift described a sense of agency and empowerment when it was confirmed.I sought this one out myself, so it was like it was me driving it […] so it felt good how it happened. [P2]However, when diagnostic corrections were unexpectedly introduced by a clinician, immediate responses sometimes involved embarrassment or shame.I think for that diagnostic shift, there was like maybe… a sense of worry? Like it was the first one I had kind of experienced and I felt, almost a little bit embarrassed, like “oh my God, they think I was lying”. [P1]Negative responses to diagnostic shifts could be alleviated by clinical communication that involved the participant in diagnostic decision-making.he took the time to really, really explain […] the reason for the diagnostic shift, so why I may have presented as someone with BPD or why he believed that I didn't have it. […] So for me that was a really, really positive experience because it was the first time that I really understood what was going on for me. [P1]Numerous participants characterized a delayed or corrected diagnosis as a transformative moment, altering the trajectory of their lives.it's given me… I'd say like a new lease of life, but you know, I'm a lot more comfortable with myself. […] It was like somebody switched the light on. The end of the dark period […] that diagnosis is everything. [P16]Corrected diagnoses could transform lives through access to more effective treatment.one thing I just, that I think is so exciting about going through a new diagnosis is you've been treated for one thing, and now you're going to be treated for something else, and you have so many new treatment options and tools available to you. [P19]However, experience of misdiagnoses or missed diagnoses could compromise trust in both individual clinicians and standard diagnostic procedures.I agree with that diagnosis, but I think my main problem is like, I doubt it all the same, because I'm like, you've got it wrong before. [P6]Corrected diagnoses often sparked a retrospective reframing of one's life, shedding new light on past experiences. This autobiographical reflection could reconstitute one's self-concept, improving self-esteem or mitigating self-judgement.I didn't perceive my problems with that procrastination like attention problems. I mean, at this time I believed in a very, very heavy moral evaluation, like when you're not making an effort, you're not doing the work, then it's laziness, right? I grew up thinking of myself as lazy. Took some time to unlearn that. […] there was a lot of validation, definitely, a lot of stuff coming together, chronological. A lot of saved self-esteem, like you know, I'm not inferior, I'm not lazy. [P4]However, the self-disruption caused by a corrected diagnosis could also leave people feeling disoriented.I got another framework to look at myself. That's perhaps the most confusing part, you know, how the frameworks change and what parts of you you consider normal, your personality, and what are, you know, more of expression of some difficulties that are connected to diagnosis. So what parts of me were… yeah. That was really hard for me to reconcile. [P17]Certain diagnostic shifts were characterized as gradual evolution rather than abrupt conversion. Participants attributed these shifts to the accumulation of clinical evidence, which informed progressively more sensitive diagnostic decisions. The final diagnosis was simply the logical end-point of this process.I suppose I just saw the change as an evolution of the technical picture, do you know, so it's not like I thought the adjustment disorder was wrong because it wasn't at the time, it was fine, and you know it was part of the picture…. and then okay, so it was becoming a bit more clear that it was more than an adjustment disorder and then, you know, depression seemed to fit at that stage. [P23]Diagnostic evolutions were typically precipitated by the emergence or disclosure of symptoms qualitatively different from the original clinical presentation. Sometimes these new symptoms were identified during a crisis episode, often involving hospitalization and/or new treating clinicians.I had got to the health center and they had said, well, you need to be in the hospital. When I was there, they also discovered some like psychosis and like paranoia and hallucinations. And so they changed my diagnosis to… they said I was having a mixed episode and they changed my diagnosis to bipolar II. [P10]Diagnoses could also evolve due to wider institutional developments. For example, multiple participants reported their diagnostic classifications had changed due to revision of diagnostic manuals, with the change of nomenclature experienced as perplexing.actually I hate that term […] emotionally unstable person, I absolutely hate it. If, I have to admit, if that had been the name of the disorder back when I had been diagnosed, I think I would have had a much stronger feelings of like being diagnosed with it. […] I would find it really invalidating to have been given a diagnosis of emotionally unstable personality disorder. [P22]Those who characterized their diagnostic shift as a progressive evolution generally saw this as a normative experience, or the way psychiatric diagnosis typically occurs. Personally, participants were largely indifferent to the shift.they usually start with adjustment disorder, it's kind of like what they start with before they have to put a diagnosis on it usually. So I don't know how long she had that but I just know that, you know, that's what they put when they first meet you. And then had, had me as depression and then generalized anxiety disorder and eating disorder not otherwise specified. [P18]Evolving diagnosis narratives often involved ambiguity around a participant's exact diagnostic status at particular points in their trajectory.he also said he thought I had borderline personality ‘tendencies', is the word he used with me, but so borderline personality tendency, I guess, I was diagnosed with and I never saw, like I never asked for written confirmation about the diagnosis, I just took it as it was. [P2]Such ambiguity was sometimes attributed to a perceived reticence among clinicians about giving diagnoses, which was not necessarily shared by service-users.I think that like my therapist […] he's uncomfortable with that diagnosis […] a lot of the frustration for me is that I think therapists have a lot of anxiety over things and over how patients might feel about diagnoses, but they never actually asked us how we feel about diagnosis, they assume. […] I didn't really care what my diagnosis is. [P22]The gradual, contiguous nature of diagnostic evolutions generally made these shifts comprehensible to participants, which fostered self-understanding.I could tell that there was something more going on, besides just the depression, and so I was like… Okay, that doesn't seem to fit so well anymore, but now, this new one, like okay, yeah. Like I read about it in the DSM and everything, yeah, this explains better what I was going through. [P10]Relative to corrected misdiagnoses, diagnostic evolutions were typically seen as less transformative, and did not necessarily alter treatment pathways.I think it just better explained what was going on. It was more… I mean it barely changed my– I don't think it changed my treatment at all, like, I was on the same medication, it was just a clarification. [P9]Diagnostic evolutions were usually not attributed to clinical error. Rather, the original diagnoses were seen as sensible given available information, and accurately updating in response to new evidence.these kinds of issues that I have in emotional regulation could be easily described by both ADHD and PTSD […] I think that it made sense to diagnose me with borderline personality disorder before they got to know my whole history. [P17]Evolving diagnoses therefore did not provoke the same crises of clinical trust evident in mis- or missed diagnoses. Trust was particularly promoted when diagnostic evolutions were negotiated collaboratively and transparently.I switched therapists and it was kind of like, well it's been a while, let's talk about this, like. Well she saw me for a while and she's like, I'd like to put down generalized anxiety, that feels like it's really just kind of the fit for you like at this point. Like how do you feel about that? [P21]A narrative of proliferating diagnoses applied to a subset of participants, who received between 5 and 10 diagnoses across successive diagnostic episodes. These participants sometimes experienced retractions of certain diagnosis. However, several also reported an understanding that multiple successive diagnoses remained on their clinical records, despite some ceasing to require active clinical attention.no one has taken off the unspecified or OCD despite my clear signs of autism, ADHD, depression and anxiety. I still have the two unspecified and OCD as open diagnoses. They're not locked down, they're not removed either. Just nobody has touched since I got them. […] They mostly have just ignored it. And that is a bit weird I think. [P12]Typically, those who experienced proliferating diagnoses had cycled through multiple different clinicians. A new clinician could disagree with former diagnoses, and either replace or supplement them with new diagnoses.I switched back to another psychiatrist that was recommended to me by my therapist. After meeting with him, he did not agree with borderline, the BPD diagnosis, so he actually went back to bipolar II. [P14]Participants reported that clinicians often failed to explain how a new diagnosis related to prior diagnoses, which were left untouched on their clinical records. However, it was also possible for prior diagnoses to be explicitly retracted by a new clinician, or for diagnoses to be “lost” in the move between clinicians.the borderline just kind of fell off when I changed doctors […] I think the only reason that actually left my file is that I changed doctors and I don't think they got the notes from my previous doctor. [P9]While self-sought diagnostic shifts were less common in narratives of proliferating diagnoses, some participants reported that certain clinicians afforded them considerable agency in determining their diagnosis.she just said do your own research kinda, see how you feel about it, see if it fits and then pretty much like if you feel like it fits, then we'll go with that, and if you don't feel, like if it's no, we won't. So it was very strange to me that, like I was almost put in charge of diagnosing myself. [P14]This was not universal; during other diagnostic episodes, participants felt like passive observers of professionals' decisions.she wrote like borderline, question mark and then that's what they ran with. […] it was very confusing because there was no, like I couldn't see any of the documents and I couldn't like talk to her about it and she didn't talk to me about it. So yeah, just kind of felt like it came out of nowhere. [P5]Like evolving diagnoses, proliferating diagnoses were associated with some ambiguity. Participants sometimes struggled to remember or expressed uncertainty about points in their diagnostic trajectory.I was diagnosed with major depression, manic depression, I don't know. At one stage they diagnosed me as three different types of depression, personality disorders, complex PTSD, lots of different labels that they just kept throwing at me and every time I'd say there was something else wrong with me they'd just label it with… personality disorder was a big one for a while. [P16]Some participants positioned one particular diagnosis as a landmark revelation, describing relief when that was confirmed.For me, the diagnosis was simply a confirmation that allowed me to say to other professionals that I am autistic without being told “you can't possibly know that” […] What the diagnosis did was change how I felt about myself—for the first time, I was able to truly forgive myself for executive functioning difficulties, social difficulties, and extreme clumsiness. [P26]However, a long list of regularly changing diagnoses caused confusion and frustration.I'd go away and think, okay well yeah, I'm depressed and I'm like this because this happened and trying to sort of identify, trying to put the jigsaw together but being given the wrong pieces, never getting anywhere. And when you'd go to them again, they'd give you a different piece. And that wrecks your head for six months, it just doesn't fit together. And then you'd go back and they'd give you a different puzzle, and you go away to try and get together all the new puzzle, but it doesn't make sense, it doesn't make anything better. [P16]Having one's diagnosis constantly mutate could be demoralizing. Several participants internalized their diagnostic complexity to infer that they were uniquely damaged.experiencing a series of diagnostic shifts and like none of them fully feeling like they made sense really made me feel like ‘oh I'm just so broken, like they just can't figure out like what's going on', you know? Like maybe there's a hopeless cause. [P1]Socially, frequent changes to one's diagnosis denied people a clear diagnostic group with which to identify, and were difficult to explain to others.I did tell some of the closest people in my life […] because it was relevant at the time but I'm not sure I would continue to tell about it. I think… I'm not sure, perhaps it was my impression that it made them a little bit more skeptical toward me, some of them. Because it was, you know, a huge change from borderline to, you know, PTSD and ADHD, yeah, ADHD… perhaps like if I was shoplifting the diagnosis, you know. They didn't say that but I kind of…. They were confused about the changes. They didn't really understand why. [P17]Experience of proliferating diagnoses often undermined clinical trust. Exposure to differences of opinion across professionals and time cultivated doubt in the validity of psychiatric diagnoses, making them seem random or arbitrary. Some withdrew from clinical settings as a result.they just kept throwing diagnoses at me that… I was kind of along for the ride, like I started to lose trust in them, because the longer I went in the more, the more like big diagnoses they were giving me. […] at that point, I had just officially given up completely, and like, I will figure out my mental health on my own. I'm not going back to a doctor. [P3]Similarities and disparities in participants' experiences were not entirely attributable to whether diagnostic shifts were characterized as proliferating, evolving, or mis-/missed diagnoses. Cutting across all three interpretations, participants raised the significance of the exact diagnostic labels involved. The second thematic dimension captures how responses to a diagnostic shift hinged on the unique meanings ascribed to the specific diagnoses gained and lost. Certain diagnoses were seen as more clinically serious than others. For example, psychotic and personality disorders were viewed as more pervasive, permanent, and disruptive than affective or anxiety disorders. Revised diagnoses perceived as less bleak than the originals elicited relief.really relieved because I felt like, oh, this means that I'm not going to be depress–like depressed my whole life. Like I can, I do have, my body does have the ability to feel happy and joy and feel resilient. And even if it's not in that big way of the hypomanic feeling, like I was really excited that I wasn't just going to be depressed forever. And I knew that depression was going to be part of, it's going to be part of my life forever, but I really felt just this huge sense of relief that that wasn't going to be the only feeling. [P19]Conversely, diagnoses seen to represent increases in clinical severity prompted despair.something like depression and anxiety you hear about all the time. And then obviously like the portrayals of people with psychosis in the media are like always a lot more dramatic and I kind of had, in my head, that that was like something totally incurable and that I was just crazy and that like nobody could relate to me. And that basically my prognosis was really bad because of that diagnosis. So I think it was– is more disheartening. [P1]Yet despite such discouragement, some participants found validation in clinical confirmation that their challenges were more serious (and hence achievements more significant) than originally acknowledged.I mean the prognosis for it, schizoaffective is definitely worse so it's kind of like… when I first heard that diagnosis applied to me, I was sort of like, “Oh, like that's a disappointment.” […] it's worse, but then it's also like, okay I'm–I'm overcoming this so I feel like that's sort of like a sense of… success I guess? [P10]The issue of diagnosis-specific stigma arose in all interviews. Narratives implied a “stigma hierarchy” with some diagnoses perceived as more stigmatizing than others. Participants welcomed shifts that reduced stigma exposure and struggled with shifts to diagnoses carrying greater amounts of stigma.there's so much stigma attached to BPD and I really wasn't, wasn't comfortable having that diagnosis. And say even now, like, I like to make the point that I was undiagnosed with that later. Like I think there's just so much stigma attached to that particular disorder. [P1]Participants were acutely aware of the stereotypes attached to new diagnoses, and abhorred the projection of these stereotypes onto oneself.it was awful. It was like everything, everything I had worked toward in recovery to understand that there isn't this black bad person inside me […] then to sit with people who are misinterpreting you every hour of every day and thinking you're being bold or however they think of borderline people. And you know, even when I'd be trying to eat my meals, I'd feel like, oh God they're looking at me, like, ‘ugh would she ever just eat, she hasn't got a real problem with food', you know, that she's just attention-seeking or whatever, like you know. And yeah, so it was really, really, really disturbing and it kind of took away my motivation to get well. [P25]There were some suggestions that stigma also affected clinical practice around particular diagnoses. For instance, four participants reported a discovery that a personality disorder diagnosis had been ascribed to them without their knowledge, suspecting clinicians wished to spare them the presumed stigma.I did an outpatient programme which was when they told me I was diagnosed with borderline because I didn't know before. When the psychologist diagnosed me, I just, she didn't tell me anything or whatever, so it was in my medical record […] I was like […] so shocked. I was like, wait what? And no one thought to talk to me about that? […] I kind of had the feeling that, like, I was the last to know. And like yeah, made me feel like a little bit infantilised. [P5]Beyond sociocultural stigma, certain diagnoses could also hold personalized meanings that mediated responses to diagnostic shifts. For example, shifts to diagnoses that were shared with relatives confronted participants with a vivid exemplar of the daily reality of living with that diagnosis.my mom and I were shopping for shoes and she was just like, yeah your dad has that. And I'm like, what? She told me these horrible stories about what it was like to be married to him—they're divorced—what it was like to be married and his like psychotic breaks with reality. I was like, what? I still remember that, I just started crying, I'm awful. [P13]Diagnoses could also hold idiosyncratic implications in occupational contexts. For example, one health professional was particularly uneasy about her diagnosis of ADHD, which among several diagnoses uniquely jeopardized her professional reputation.I would probably have the most stigma internally around ADHD. That's the one I don't disclose. [P23]Experiences of a diagnostic shift were additionally shaped by the associations friends and family held with a particular diagnosis. Participants reported both positive and negative social responses to disclosure of a diagnostic shift, depending on the meaning a diagnostic label held within one's social circle.I talked to my spouse at the time. […] he was very much like, well only the military gets PTSD. So at that point, I just learned to just keep it all to myself. [P3]the people I hang out with, they don't give a… they don't give a sh*t about BPD. [P8]By re-classifying individuals from one category to another, revised diagnoses could both open and close access to communities of similarly diagnosed others. Such diagnostically-bounded communities were often platforms for valued social identities. This was particularly salient for neurodevelopmental diagnoses such as ASD and ADHD.Depression is weird in a way, that if I had some other friends who had depression, I didn't relate to them at all. […] it's like everybody has a different depression. And with ADHD it's the exact opposite. […] It's crazy how easily we connect with ADHD. [P4]Diagnostic shifts that presented opportunities to form bonds with similar others were experienced as emotionally rewarding and practically helpful.the point when I finally saw other people that were dealing with similar things—that really informed me a lot. So I think that that's very helpful. [P15]Conversely, participants struggled with diagnostic shifts that erased the shared classification at root of valued social bonds.I like contacted the service-user network and like went along there and also […] my mom was like, privately she told me that […] that was the same diagnosis that she had had. And so I was like, oh everything's making sense and I like started to feel like, oh this is like something that fits for me. […] I got a call from her [doctor] and she was like, “oh my supervisor has reviewed my diagnosis and she doesn't think it's like, it's right for you” […] it was really, really difficult […] it was just like invalidation. [P24]However, embrace of the social identities attached to particular diagnoses was not universal. Diagnostic shifts that challenged existing identities, or that led people into social settings where they felt they did not belong, were difficult to absorb.it can take away… your identity becomes ingrained with the diagnosis and then, when you are reconsidering another one it's like, well then, who am I? You lose that sense of self. [P13]Though the socio-emotional significance of diagnostic classifications and the frequency of shifts between such classifications are widely acknowledged, minimal research has explored how diagnostic shifts are subjectively experienced by service-users. The current study represents the first to investigate how adult service-users make sense of diagnostic shifts and their impacts on one's life. Interviews with people with first-hand experience of diagnostic shifts revealed common features in their narratives, as well as salient points of divergence. Many of these patterns mapped onto a typology of interpretations of diagnostic shifts: diagnostic shifts were experienced differently, depending on their framing as evolving, proliferating or mis-/missed diagnoses. Also critical in determining diagnostic shift experiences were the specific diagnoses involved, and the unique meanings these classifications held in participants' personal and social ecosystems.Results contribute to the literature by revealing the importance of the interpretations service-users develop to understand the reasons behind their diagnostic shifts. The diagnostic shifts that saw smoothest adjustment were those characterized as evolving diagnoses. As these shifts were seen to follow from the emergence of new symptoms or accumulation of clinical evidence, they did not require nullifying previous diagnoses as “wrong.” This escape from binary “correct/incorrect” framings softened these shifts' impact: evolving diagnoses were not typically framed as overhauling one's life, though could yield subjective benefits in increasing self-understanding. In contrast, diagnostic shifts attributed to clinical errors in missing or misdiagnosing symptoms were cast as transformative in participants' lives. Mis- or missed diagnoses' perceived correction was typically welcomed by participants, both for emotional validation and alignment of more effective treatment. However, consistent with previous research , 32, 33,Narratives of proliferating diagnoses had perhaps the most negative implications for self-concept, social relations and clinical trust. Participants who had cycled through many different diagnoses, typically delivered by numerous clinicians, were confused and demoralized by their experiences. Whereas some participants adapted by fixating on one particular diagnosis as a watershed revelation, others developed an impression of diagnoses as arbitrary labels. While this could be interpreted as an appropriately critical perspective on the ontological status of categorical diagnoses , 22, it Results also showed how, beyond the distinctive patterns associated with the various interpretations of diagnostic shifts, experiences were contingent on the specific diagnoses involved. Shifts from one diagnosis to another brought relative advantages and disadvantages, depending on the unique meanings attached to each. Shifts connoting an increase in severity caused trepidation, while reductions in perceived severity caused relief. Participants welcomed re-classifications that reduced their stigma exposure, and resisted diagnoses that triggered pejorative stereotypes. Some compensation for stigma was available in the marshaling of diagnoses as bases for communities and social identities, but participants regretted shifts that removed them from valued communities. Moreover, specific diagnoses could have highly personalized associations within participants' social networks, which also mediated responses to diagnostic shifts. While much previous research has demonstrated the diagnostic specificity of sociocultural representations of mental illness –19, thisThese findings regarding the diagnostic specificity of adults' responses to clinical reclassifications echo those from the only previous study of lived experiences of diagnostic shifts, which focused on children and their parents . As in tvia a “self-fulfilling prophecy” effect . The patients/participants provided their written informed consent to participate in this study.CO'C contributed to conception and design of the study and wrote the first draft of the manuscript. CO'C and CS collected the data. CO'C, CS, and CY contributed to the qualitative analysis. All authors contributed to manuscript revision, read, and approved the submitted version.This research was supported by a grant from University College Dublin awarded to CO'C. Funders had no role in the design of, conduct of or decision to publish the research.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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The current qualitative study tests the pathway model in another Canadian province. We purposefully recruited 27 humanitarian migrants from 13 countries in four global regions, between April and December 2019, in two Ontario cities (Toronto and Ottawa). Four focus group discussions were facilitated in English, Arabic, Spanish, and Dari. Analysis revealed barriers to care similar to the Quebec study: Waiting time, financial, and language barriers. Further, participants were unsatisfied with the IFHP’s benefits package. Our data produced two new pathways for the model: transnational dental care and self-medication. In conclusion, the dental care needs of humanitarian migrants are not currently being met in Canada, forcing participants to resort to alternative pathways outside the conventional dental care system.The burden of oral diseases and need for dental care are high among refugees and asylum seekers (humanitarian migrants). Canada’s Interim Federal Health Program (IFHP) provides humanitarian migrants with limited dental services; however, this program has seen several fluctuations over the past decade. An earlier study on the experiences of humanitarian migrants in Quebec, Canada, developed the  By mid-2020, the number of displaced people globally had exceeded 80 million . Among tGlobally, the burden of oral diseases is high in humanitarian migrants, followed by a high need for dental care . In CanaUniversal oral health coverage will be achieved when all individuals have access to needed oral health services without financial hardship . Dental dental care pathways of humanitarian migrants model, showing four pathways: A conventional pathway to the dental clinic, a pathway to the clinic through non-dental health professionals, a pathway to the dental clinic through non-healthcare providers, and seeking advice and medication from abroad instead of seeking help in a health clinic in Canada.The Migrant Oral Health Project (MOHP) is a Canadian research team concerned with the oral health of humanitarian migrants. In 2019, Keboa and other MOHP members used focused ethnography to investigate how humanitarian migrants experienced and accessed dental care in Montreal, Quebec . InformeIn that previous study, the participants were covered for basic dental care by the federally-funded Interim Federal Health Program (IFHP). This program, which has undergone several modifications in the past decades, provides humanitarian migrants with basic health services, including dental, until they become eligible for provincial or territorial health insurance. One goal of Keboa et al.’s study was to understand what participants felt about the dental coverage provided by the IFHP, which had been severely reduced in 2012 and 2014 .The aim of our current study, which is part of a larger mixed-methods research program , was twoWe purposefully recruited humanitarian migrants from global regions that corresponded to Keboa et al.’s sample: Middle East, Central and South America, South Asia, and Africa. Participants were recruited from three community organizations providing services to humanitarian migrants: one in Ottawa, and two in Toronto. We used brief information sessions with potential participants and word-of-mouth to recruit participants. Using purposeful sampling, we invited participants who had arrived in Canada as refugees or asylum seekers (referred to as ‘refugee claimants’ in Canada), were 18 years old and above, and had previous experience with the dental care system in Canada. We purposefully sought a sample varied in age, gender, and country of origin. Participants were compensated for travel expenses and their time.We developed our initial semi-structured interview guide from the main findings of Keboa et al.’s study. Focus group discussions were preceded by a short questionnaire gathering participants’ sociodemographic information. Focus group topics included: Oral health knowledge, hygiene habits, and past experiences with the dental care system in Canada. After an initial conversation, we explicitly brought in the dental care pathway model to the discussion, to encourage participants to reflect on their personal experiences and challenge, and to enhance the model. We adapted our questions as we proceeded with iterative analysis during data generation.We held four focus groups, one each in English, Spanish, Arabic, and Dari. Data were generated between April 2019 to December 2020. We chose focus groups as our method to provide participants with an opportunity to exchange views and discuss ideas, and help us understand how humanitarian migrants seek care for oral health issues. Team members facilitated the English and Arabic focus group discussions  and trained a Spanish-speaking and a Dari-speaking facilitator for the remainder. All facilitators were migrants to Canada, and one was a refugee. The focus group discussions lasted between 45 and 90 min. All discussions were held in private rooms in each of the three community organizations. Fortunately, while data generation was interrupted by the COVID-19 pandemic, we reached data sufficiency prior to lockdown.The focus groups were audio-recorded, and recordings were stored on a secure server. Recordings were transcribed verbatim and translated to English for analysis. Our study included multiple investigators from different backgrounds to foster reflexivity and dialogue. We began our analysis by building a deductive coding structure based upon the interview guide and the dental care pathway model. We then proceeded with both deductive and inductive analysis, with one team member going line-by-line to build codes that enhanced or challenged the coding structure. After completing a comprehensive review of all data, codes were merged into themes and shared with the broader team for discussion and confirmation. This article adheres to the Standards for Reporting Qualitative Research (SRQR) guidelines .The study was approved by the University of Toronto’s Research Ethics Board (RIS Protocol No. 36911). Written informed consent was obtained from all participants. The facilitator explained the participants’ rights, the procedures to be undertaken, purpose of the study, expected duration of study, potential risks and benefits of participation and confidentiality of personal identification, in the participants’ language of preference.We begin the results by describing the participants’ profiles, and their experiences with facilitators and barriers to dental care access. Following, we describe how the data contributes two additional dental care pathways and outcomes of care to Keboa et al.’s model.We held four focus group discussions with 27 participants from thirteen countries: Palestine, Syria, Iraq, Mexico, El Salvador, Honduras, Venezuela, Afghanistan, Iran, Eritrea, Somalia, Nigeria, and the Democratic Republic of the Congo. Participants’ age ranged from 28 to 62 years. Most participants were women (65%), unemployed (78%), completed high school or more (80%), and had an annual income that is below minimum wage (78%). As described in “The centre of all body functions is the mouth. So, the hygiene for oral cavity has to be kept in mind.” She then recited a poem by the Persian poet Saadi: “If one organ is in pain, other organs are not at peace as well.” (48-year-old Iranian woman).Many of the participants spoke of oral health as a fundamental component of overall health. As one participant said: Participants showed a solid understanding of the importance of oral health. The phrase ‘good oral health’ was described with oral hygiene habits, such as brushing teeth regularly, visiting a dentist for dental check-ups, and using dental floss; ‘poor oral health’ was commonly described as bad breath, bleeding gums, missing and crowded teeth.They get the best treatment here.” (41-year-old Mexican woman).For children, mothers reported that ‘good oral health’ meant brushing teeth after breastfeeding. Overall, child dental care was not a concern for participants: ““I think we are more alert because it is very expensive [to treat dental problems] so we take all the precautions.” He added: “In our countries, we don’t give them too much importance but once we are here, we want to prevent [dental disease] with cleaning and dental tools because we don’t want anything bad to happen. And if it does, we have to have [have] at least $1000 saved just in case.”Participants’ felt that their knowledge of oral hygiene habits did not change after arriving in Canada; however, they reflected that their practices did. They said they are now more careful about following good hygiene measures in Canada because of an anticipated difficulty in dental care access. A man in his 40s from Venezuela said: Overall, participants’ understanding of the importance of oral health, their overall knowledge of oral health and hygiene, and their awareness of the local dental care system made them likely to identify their need for dental care.“General health coverage [by IFHP] is good, but for dentistry it is lacking. This being a country for refugees, there is a big shortage.” A Somali woman reflected that IFHP is not generally accepted: “I have [IFHP insurance] for one year. Then they say this one [IFHP] cannot cover you.” A Nigerian woman was also concerned about the coverage: “To remove, or to shape your teeth, or to polish, is expensive.”Finances were considered a major barrier by all participants, and cost was commonly the first issue raised. In particular, participants were unsatisfied with the IFHP benefit package available to them. As a young Syrian woman said, “I had insurance [IFHP] at that time, I consulted the dentist. My friends referred me to a dentist in [a Toronto] area. But it was really very expensive. As I mentioned before, only one root canal treatment [not covered by IFHP] cost 1200 dollars.”A middle-aged Afghani woman summed up the issues: “We used to visit a dentist every 3 to 4 months, but when we decided to migrate it turned out to be very expensive [in Canada]. Therefore, from going every 4 months now we will only go once a year.” (41-year-old Venezuelan man).Financial barriers also affected the frequency of dental visits by participants. Regular visits to dentists for preventive reasons were reported as common practice in their home countries, but in Canada, the behavior has become infrequent for some, and absent for most: “If I tell the dentist that it is an emergency, I will still have to wait for at least 20 days for my appointment.”Participants complained about the long time they had to wait before they could schedule an appointment. They followed the conventional pathway in the model; yet, theydid not always receive care within a window of time they felt was reasonable. As a woman from Afghanistan said, “The first time I went, they gave me a 2 months appointment and eventually I forgot I had that appointment.” (30-year-old Nigerian woman).Others reported that long waiting time was a barrier because they found it difficult to keep track of their appointments. As newcomers, they were overwhelmed by the list of appointments to which they had to attend. As a result, they were not able to obtain the treatment they needed: “A barrier is the language and technical words that we don’t know, and which make communication difficult.” Others have also echoed a similar concern.Language barriers were found to contribute to a reduced satisfaction with services provided. A 41-year-old Venezuelan man said: “The first problem I had was with the receptionist because she said I needed a translator even though I told her I understood. Another woman helped me, she was kinder, filled out my forms and gave me an appointment.” (37-year-old Mexican man).“The first thing I had to do is to fill out all the paperwork and I felt like it was overwhelming.” (41–year-old Venezuelan woman).“We had to ask someone else outside [the organization] because nobody helped us there.” A Mexican participant highlighted the same concern, saying: “For example, we asked our case worker about where to go for a dental appointment and she said that we had to find out on our own.”Some participants received information on navigating the system from the newcomer organizations with which they were registered. Their experiences of this support varied, however; some were satisfied, while others felt that they did not receive useful information. A young Honduran man said that: Together, these barriers culminated in the creation of two new pathways in the dental pathway model, as well as new outcomes to the care received .transnational dental care. Given the prohibitive cost of treatment, combined with trust in familiar dental services, participants compared local dental care unfavorably to the care they received in their home countries:The first new pathway is “In my country, we have better access and [treatment] is cheaper.” (56-year-old Venezuelan woman).“In my country there isn’t much protocol; here you have to go through many steps.” (31-year-old Venezuelan man).“In Egypt and Syria, dentists are very clever.... the filling does not come out.” (27-year-old Syrian woman).“I had a crown done for me back home in Iraq before 2003. Until today, it is the same colour, the same colour as my teeth.” (47-year-old Iraqi woman).“There are some people that I know who said they would buy an air ticket purposely to fix their teeth. They had a big problem with their teeth. I heard them, they said we pay for an air ticket, and we get to see our family also, and still, it will be cheaper than treating our teeth in Canada.”Thus, participants said they were prepared to travel outside Canada, when immigration laws allowed, to receive dental treatment. This sentiment was summed up by a middle-aged Iraqi woman: self-medication. Some participants sought to treat themselves, often as a temporary remedy to their pain, until they could afford professional care. A young Afghani woman spoke of using “garlic to relieve the pain” while waiting for care; a Mexican man spoke of “pain killers” being cheaper, and thus more accessible, than dental care.The second new pathway is “I was told I would have to pay $1500 for the extractions. I have other expenses to do and that is why I suspended that for the moment, but to come to this point it took me almost the year that I’m here.”The prohibitive cost of dental treatment was found to influence the decisions made by the participants. Some participants opted to decline the recommended treatment, and this is referred to as ‘No Care’ in the original model. One participant explained: “I have my own translator, but even with that it has been really hard. He made all the appointments, he called, he asked everywhere, and we haven’t found a solution yet because I have a jaw disorder, so they told me that I have to pay $3000 and that is where we stopped. I have insomnia and headaches.” (37-year-old Honduran woman).Another participant, after receiving help with navigating the appointment system, was not able to receive the needed treatment: ‘Complete care’ is when a participant received the whole treatment as recommended by the dental care provider. The second and new outcome was to opt for ‘partial treatment’: Here, the care was received, but was incomplete. This outcome is summarized by a 35-year-old Salvadorian man as follows:An addition to the pathway model  from our“They did two fillings but one of then was very deep. When they did it, I think they touched the nerve… that in a week I couldn’t bear the pain. Three weeks passed, I went to see the dentist, he told me it was sensitivity and that I had to go somewhere else to get it fixed because he couldn’t. He gave me a card, so he referred me to another doctor where I had to pay. I had the pain for a month, I had to pay for a root canal treatment $1400 and I haven’t come back for the crown yet because it is another $900.”“re-glued the front denture.”: “When I arrived in Toronto my daughter was looking for a job to make ends meet. She found a job with a dentist. She told him about my situation so he told her that she can bring me to the clinic. He was kind and fixed my teeth at no cost. He said that this was a temporary solution and that in about a year they might come off again.”Similarly, an older Palestinian woman reported that a dentist Our focus groups suggest that humanitarian migrants arrive in Canada with an awareness of when they needed to seek professional dental care; this awareness facilitated their care seeking. However, once seeking care, they were met with waiting time, financial, and language barriers. As a result, some study participants opted to receive only partial care, some self-medicated, and many considered transnational treatment as a viable option to accessing care in the future.These results confirm, as well as extend, Keboa et al.’s 2016) earlier work in important ways. To begin, the participants’ oral health knowledge and practices confirm that the personal identification of the need for treatment serves as a valid starting point for the dental care model. Further, while the IFHP program had been amended in 2016, providing more benefits than for participants in the Montreal study, participants were still unsatisfied with the coverage. A systematic review and meta-analysis found that covering individuals with dental insurance has a significant effect on increasing utilization in dental care . Further16 earlieScreening migrating populations when they enter their host country is a powerful tool to promote oral health. Refugee populations are disproportionately affected by common oral diseases , and uposic) to their country of origin” [the Longitudinal Survey of Immigrants to Canada 2001–2005 and found that immigrants lacking dental insurance and those reporting dental problems were more likely to report transnational dental care utilization [Transnational dental care was not reported in the Montreal study. Our participants reported their interest in traveling outside Canada to get affordable treatment. This strategy has been described as “immigrants seeking dental care across national borders in the form of dental tourism or while travelling. Our participants’ self-medication behavior was not necessarily informed from abroad, however. Self-medication, which has been defined in the literature as “the taking of drugs, herbs or home remedies on one’s own initiative, or on the advice of another person, without consulting a doctor”  is, therSelf-medication can be a dangerous practice because using some medicines without medical guidance may result in inappropriate, incorrect, or undue therapy, missed diagnosis, delays in treatment, pathogen resistance and increased morbidity . HoweverAlthough our study participants described waiting time and language as barriers seemingly disconnected from financial barriers, we believe that these experiences were connected. Participants had to wait because only a limited number of dental clinics provided services that were covered by IFHP. In addition, since financial barriers to dental care access are shared by Canadians at large, and in particular, low-income individuals, we understand that humanitarian migrants’ experiences may be shared by other Canadians. However, humanitarian migrants are forced to leave their country to escape war, persecution, or natural disaster, and therefore are more vulnerable to developing severe dental problems. Thus, they need timely access to dental care in their new home.As with any study, our study has important strengths and limitations. To begin, our work builds on the findings of a previous study, providing further insight into the dental care experiences of humanitarian migrants in Canada. To the best of our knowledge, this is the first study to report on humanitarian migrants from Ontario. While we could not include participants from all countries of origin of humanitarian migrants arriving in Canada, we interviewed humanitarian migrants from the four main global regions of origin, and our focus groups were facilitated in the mother tongue of participants. The diversity in our study population provides much detailed information to understand complex issues. We acknowledge the limitation of qualitative study designs; as it is not possible to generalize the findings to the study population, our goal was to describe the experience of humanitarian immigrants. The use of focus group discussions was a productive choice as focus groups allow participants to jointly brainstorm and debate ideas, opinions, and recommendations.The dental needs of humanitarian migrants in Ontario are not being met by local dental services, and our participants were not satisfied with IFHP coverage. Although they had good oral health knowledge, access to dental care for our participants was hindered by financial barriers, waiting time, and challenges navigating the oral health system. Adding to the original pathway model, participants in our study opted to receive partial care, and endorsed self-medication and transnational dental care as additional dental care pathways.To date, our MOHP team has canvassed the perspective of humanitarian migrants from central Canada (Quebec and Ontario), the locations of the majority of humanitarian migrants. Future work should explore experiences of humanitarian migrants in Western and Eastern regions, and test the model in other countries with similar dental care systems.


In the contemporary robotizing knowledge economy, robots take increasing responsibility for accomplishing knowledge-related tasks that so far have been in the human domain. This profoundly changes the knowledge-creation processes that are at the core of the knowledge economy. Knowledge creation is an interactive spatial process through which ideas are transformed into new and justified outcomes, such as novel knowledge and innovations. However, knowledge-creation processes have rarely been studied in the context of human–robot co-creation. In this article, we take the perspective of key actors who create the future of robotics, namely, robotics-related students and researchers. Their thoughts and actions construct the knowledge co-creation processes that emerge between humans and robots. We ask whether robots can have and create knowledge, what kind of knowledge, and what kind of spatialities connect to interactive human–robot knowledge-creation processes. The article’s empirical material consists of interviews with 34 robotics-related researchers and students at universities in Finland and Singapore as well as observations of human–robot interactions there. Robots and humans form top-down systems, interactive syntheses, and integrated symbioses in spatial knowledge co-creation processes. Most interviewees considered that robots can have knowledge. Some perceived robots as machines and passive agents with rational knowledge created in hierarchical systems. Others saw robots as active actors and learning co-workers having constructionist knowledge created in syntheses. Symbioses integrated humans and robots and allowed robots and human–robot cyborgs access to embodied knowledge. Currently, robotization is sweeping globally through the knowledge economy, appearing in an increasing number of industries and across various cultures and places Bauer, . Robots Today, various robots are involved in the knowledge-creation processes in varied spaces, which is why knowledge creation is no longer an exclusively human domain. There are many kinds of robots, including industrial arms; vacuum cleaners; autonomous vehicles and other mobile robots on land, air, and water; service robots; humanoids; soft robotics such as robotics in fabric; robotics  integrated with a human body like exoskeletons and bionic limbs; and swarms of small robot agents  and focus on different types of human–robot interactions and related spatial aspects in knowledge-creation processes. According to the International Organization for Standardization  Can robots possess knowledge, and if so, what kind? (b) What are the relationships that humans and robots share in knowledge creation? (c) How does spatiality connect to the knowledge co-creation processes between robots and humans? The results are drawn from gathering and analyzing 34 interviews with robotics students and researchers as well as observations of human–robot interactions in lectures, seminars, and laboratory robot construction in one university in Finland and two universities in Singapore. Both countries are highly developed technologically and have advanced expertise in robotics. Thematic qualitative content analysis was applied to the material. Questions (a) and (b) are first answered conceptually by elaborating on various perspectives of knowledge, and second, empirically by analyzing human–robot interaction in knowledge-creation processes, including ways in which robots’ human developers discuss robots. Question (c) elaborates on the knowledge-creation theory further by analyzing spatiality’s role in knowledge co-creation processes between robots and humans. The article advances the current understanding of knowledge creation by introducing robots in it and the spatial dimension in human–robot knowledge co-creation.Humans and robots are actors in knowledge-creation processes. To elaborate the role of a robot, we apply Hayles’s  can progress human thinking and allow, afford, or block human action Latour, , p. 72; ty” Ash, , p. 15, In the knowledge-creation processes, robots differ from humans and simple objects. For humans, learning “is a part of all activity” and humans flexibly adjust their knowledge to different situations  create knowledge in particular places  subjects.The empirical materials included thematic interviews with eight researchers and 26 students in robotics, observations of human–robot interactions, and a field diary the first author kept. The research received ethical approval by the university Ethics Committee in Finland (Statement 2/2019). All of the interviewees were contacted via an e-mail with information attached about the research and a privacy notice. The interviews were organized only with the participants who were willing to participate, and all of the participants were given the opportunity to read and comment on the manuscript before its submission for publication.Each interview took about 30 − 60 min. The topics included human–robot interactions and knowledge dimensions related to robots. Two important notions were considered throughout the analysis Table . First, In addition to the interviews, the first author visited the University of Tampere six times for 11 total days to observe two robotics courses (September 2018 − January 2019). The author participated in lectures, demonstrations, and seminars and observed students working in two robotics labs. In the first course, students formed project teams to design, build, and program a robot to deliver a task. They enhanced or combined existing robots in the lab. The students worked both independently and with the help of supervisors in the lab. The class frequently gathered with the teachers to discuss their progress and challenges. The second course combined lectures and lab work to program robots in teams. In Singapore, the first author received a tour of two robotics laboratories..” The analysis included three stages. First, the relevant themes were identified and summarized in a table . Second, new columns were added to summarize the content as key concepts  that were used to construct the general categories . Third, the diary was applied to compare the observation and interview findings and elaborate on the reasons for similarities and dissimilarities.The interviews were held in English or Finnish and transcribed verbatim into text for analysis through qualitative content analysis  of all interviewees, a robot can possess knowledge. Eight participants believed that robots could not possess knowledge, while five referred to knowledge very generally.[Robots are a] combination of motors, sensors, and code that is based on the data they produce. That [code] creates physical movement as the final outcome. (Student 4/Tampere)[An] electronic device […] can move […][it has] some sensors and actuators. It need[s] to have something to take information and it need[s] to be able to do something with that information. (Student 8/Tampere)When looking at the interviewees’ views on robots and robots’ abilities to possess knowledge more closely, two perspectives are visible. First is to see robots as only (stupid) machines that can possess knowledge from the rationalist perspective (16 interviewees). In this view, robots were defined as material devices that manipulate tangible objects and move in physical spaces. A robot was “a stupid device created by human beings” (Student 16/Tampere) and a “separate thing from a nonphysical artificial intelligence since it ‘must’ exist” (Student 17/Tampere). Robots have sensors , control systems , and move physically as one of their outcomes:Like what is the environment […] a human can know the alphabets, or know that this thing in here is a cupboard, […] [a] robot can know these kinds of things, too. (Student 6/Tampere)If the robot has been taught that pike is a fish, it knows that a pike is a fish. (Student 17/Tampere)Information experience about their environment […] will happen if A, B, C, and D are true. (Researcher 2/Singapore)In this group, 10 (of 16) interviewees believed that robots can have knowledge. Four thought that robots could not know “like we do” (Student 15/Singapore) because their “engineering is not that developed yet” (Student 14/Singapore). Robots cannot justify their knowledge or “explain why [their chosen] action is the best” (Researcher 2/Tampere). Such an understanding of robots’ knowledge (and its lack) is rational and similar to the view among artificial intelligence engineers in the 1990s . Furthermore, knowledge was seen as separate, extractable, and transferable from the humans’ and robots’ bodies.do something. And that something doesn't have to be a physical motion. It can be when you enter a building, it's dark, then the lights turn on by [themselves]. (Researcher 4/Singapore)To be a robotic system, it doesn't really need to have motion per se, but it needs to The second perspective was to consider the robots from a more collaborative view: as active actors or co-workers that could learn (17 interviewees). Knowledge in this group was considered from constructive perspective. Robots often were defined in relation to humans via comparison or co-evolution. These interviewees recognized robots and humans as becoming more like each other: “Robotics is understanding how we (humans) perform, behave, and think” (Student 15/Tampere). Robots’ (as only machines) simple materiality and physical motion were contested, and a few students accepted also purely digital robots as robots . Robot’s digital immaterial “brains” were considered as an entity that could be  inserted into a material form: “We can treat them all as robots […] the computer is a robot. If we just grab electronic arms and legs and put them together, it's a robot” (Student 10/Singapore). The machines’ “brains” could form an actor network and collectively act upon the physical space Ahn, : To be aWe represent the process through mathematics. […] robots in artificial neural networks [...] [interpret] what’s going on over many data sets. So, this is possibly the closest parallel […] between robot knowledge and human knowledge. (Student 6/Singapore)In this group, 11 (of 17) interviewees thought that robots could have knowledge. Four thought they could not for similar reasons as those who considered robots as only machines. One aspect consisted of the explicit elements of knowledge, here in comparison to humans:Learned, observed, and shared: Knowledge can be used for reasoning and decision-making or to extract new information. (Researcher 1/Tampere)Knowledge is understanding […] how things work, […] It doesn’t mean truth. It’s a way to describe, but there may be alternative ways to describe it. (Researcher 14/Singapore)The interviewees who viewed robots as learning co-workers emphasized knowledge from a constructionist and processual perspective, which consisted of learning, understanding, making sense, and reasoning. This was generally related to tacit and subjective elements of knowledge:about the physical space, whereas the robot as a learning co-worker learned to become an autonomous actor in a physical or digital space. The former referred to coded space through using code to give that space function. The latter referred to code/space in which space emerged through the robots’ function. Such autonomy required robots to learn, interact with their environment, and react on the go: “even [if] a new event or new decision is coming, he can take this on his own. Based on previous experience, he has gathered on this working’” (Student 11/Tampere). Thus, such robots could form collaborative spatial practices with humans in knowledge-creation processes.Those who considered robots as only machines described robots’ ability to have knowledge Although these interviewees considered robots as learning co-workers, they saw a hierarchy between humans and robots because humans created the programs that allowed the robots to learn. However, robots sometimes initiated communication with humans and brought them uncertainty and surprises. Such a robot “should do something that you don’t tell it to do’” (Student 5/Tampere), so that “you don’t know how the robot is going to behave” (Researcher 4/Singapore). Here, knowledge can be considered embodied in the practices of individual humans and robots and knowledge can move between the bodies of humans and robots.Human–robot interaction was connected to three knowledge co-creation processes with different dimensions of space—code/space, coded space, and redefined relational space—that emerged from relations among humans, robots, and cyborgs. Sometimes, the interviewees distinguished between digital and material, such as in programming (code) versus its actual realization (robots using the code). In other cases, material and digital were integrated into one space. Most of the interviewees discussed allocating work between humans and robots in terms of a system or synthesis, but they also provided examples of symbiosis Table .Table 2HRobots can do work that is repeatable, programmable, [and] easy, [but] not funny. (Student 7/Singapore)Like the surgery robots, they only repeat the moves of the human as accurately as possible. (Student 4/Tampere)In systems, robots are “only a machine” the creative engineer controls. Robots and humans have different and separated knowledge. In humans’ knowledge, the emphasis is on tacit and subjective elements needed to create “novelty,” justify knowledge, understand emotions and deep communication, and connect robots’ routine work to the knowledge-creation process. Human creativity, in general, was considered to exceed the robots’ agency Rose, , p. 782.must produce the right outcome that humans observe and what must be understandable through the code. If these were not true, the robot could not be trusted to repeat the activity. Human–robot systems require engineer coding experts.The knowledge-creation process has been transformed to meet a controlled code/space. As a result, both work and workspaces have been reorganized into a sequential order of stages, production lines, and specific activities together. Such learning co-workers include cognitive assemblage In synthesis, humans and robots form connected units of actors that can create knowledge  Hayles,  and soci Hayles, , p. 194.Humans and robots are co-workers that learn from each other. This makes the hierarchy (mostly) disappear from their interaction, thus expanding the robots’ role in the knowledge co-creation process. In addition, people without coding expertise can create knowledge with robots. The emphasis changes from rational knowledge in code/space to merging digital and material in the human–robot interaction. The knowledge creation emphasizes the communicative dimension in code/space and coded space. Robots can participate in novel creation and justify and move knowledge from themselves to humans.Anything can go wrong, so can we really release them? […] In factories, […] things are deterministic, so we are used to [telling] robots and machines to be perfect, don´t do mistakes. When they come outside, things are dynamic, they are uncertain. […] No matter how perfect they are they will get into accidents. […] If somebody just jumps in the front of the car, [the] car has initial speed so it can't be stopped no matter how intelligent you are. (Researcher 3/Tampere)The work of the students who were building and programming robots included moments when the strict rules and control of the laboratory space were bypassed. Students played with robots, improvised and built grippers with shoelaces, combined robots to explore and extend their activities, and imitated their behavior to understand the reasons and gain suggestions for their unexpected actions. Robots’ activities triggered ideas about how to develop the project further. However, releasing the robots from controlled laboratories could have led to unexpected and risky outcomes. The ongoing ability to identify, interpret, and react to events requites robots’ constructionist knowledge, instead of the rational knowledge that prevails in human–robot systems.The closer the interaction with humans, the more difficult it is. [...] [This is a] very high level on human–robot collaboration because you are literally touching the robot. (Student 6/Singapore)In symbiosis, robots become  part of humans, and humans and robots integrate into each other as cyborgs. Humans “are no longer contained—or even defined—by the boundaries of their skins” Hayles, , p. 2. AThe experience of using exoskeletons is a process of “embodiment” re-enabling the body and its abilities  in Finland and Singapore. This is one of the first studies to connect robots and knowledge creation, thus it is an important contribution to understand empirically and theoretically the changing knowledge and knowledge-creation processes in the robotizing knowledge economy currently being constructed  in which humans and robots had particular roles. In their visions, the human’s roles vary from that of top-down controller (systems) to mutual co-worker (synthesis) and integrated cyborg (symbiosis). In systems, humans are in control and perceived to pass to robots all necessary knowledge of mundane tasks. In synthesis, humans and robots collaborate and co-creatively learn from each other. In symbiosis, humans and robots become integrated and extend their skills beyond the limitations of pure humans and pure robots in the knowledge-creation processes. Moreover, each relation revealed different  understandings of knowledge and different roles of humans and robots in spatial knowledge co-creation processes. Identifying these relations contributes to the call for better understanding not only robots’ agency, but also humans’ changing agency Rose, .Second, the article revealed that the most common framework of current human–robot interactions among the interviewees was to understand knowledge as rational and hierarchical. In human–robot systems, humans (engineers) control robots. This is based on rational knowledge and has for long been common among artificial intelligence and robot developers , then not all robots’ human co-workers would need to speak the code’s language. However, “computers can never step outside the code, reflect on the code, and contribute their own observations” (Salzogni et al., Third, the article brought a novel perspective to the spatiality of knowledge-creation processes (Hautala & Jauhianen,


In their recent paper, AW Thille et al. look for an association between sleep assessed by polysomnography (PSG) performed in the afternoon and the night after extubation and the occurrence or not of respiratory failure/reintubation. .n = 15) versus abnormal sleep (n = 37) as in sleep in case of respiratory failure (n = 12) versus no respiratory failure (n = 40). So, the initial hypothesis supporting that work is not confirmed. Beyond these results, some comments can be made: Fundamentally that study is a physiological one aiming to positively rely sleep disturbances to respiratory performances and consequently to weaning outcome. But, the study was performed in a clinical setting, which obliges to offer the patients every validated treatment to guarantee the better outcome. Like that, NIV was applied, excepted during the PSG, in 50% of the patients raising a double risk. Firstly, to deprive of the NIV benefit during PSG recording (16 h); secondly, when applied to hide the potential role of sleep. That can be seen as an example of the difficulties in conducting physiological study and build its design in real life of clinical conditions.Sleep visual analysis and scoring is a heavy task and have limitations as it appears in one study allowing comparison between visual and numeric analysis . ParticuIn the previous studies , 5 PSG wThese authors, according to their previous works, have an actual interest and expertise both in weaning and sleep in ICU by PSG , 3. In p


In the original article, there was a mistake in Hypothesis 3 and in the Discussion.In Introduction, Purpose of the Present Research, Hypothesis 3 , the word “depression” should be replaced by “ED symptomatology”. The corrected paragraph is shown below.Hypothesis 3. . Self-esteem and anxiety might serve as mediators in a sequential mediation model between EI and ED symptoms; that is, EI positively predicts self-esteem, leading to lower levels of anxiety, further decreasing ED symptomatology.Similarly, in Discussion, Paragraph 2, the word “depression” should also be replaced by “ED symptomatology”. The corrected paragraph is shown below.The results of path analyses showed that self-esteem and anxiety play a fully sequential mediating role between EI and ED symptomatology, suggesting that EI was positively linked to higher self-esteem and lower anxiety, which in turn predicted lower levels of ED symptoms. The findings support the notion that EI decreases ED symptoms indirectly, suggesting that higher self-esteem and decreased anxiety may be possible underlying mechanisms through which emotional abilities contribute to reducing ED symptoms. These results are consistent with previous studies that found a mediating role for anxiety in the relationship between EI and ED (Hambrook et al., The authors apologize for these errors and state that they do not change the scientific conclusions of the article in any way. The original article has been updated.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The number of older women living with HIV in Africa is growing, and their health outcomes may be adversely impacted by social frailty, which reflects deficits in social resources that accumulate over the lifespan. Our objective was to adapt a Social Vulnerability Index (SVI) originally developed in Canada for use in a study of older women living with or without HIV infection in Mombasa, Kenya.We adapted the SVI using a five-step process: formative qualitative work, translation into Kiswahili, a Delphi procedure, exploration of potential SVI items in qualitative work, and a rating and ranking exercise. Four focus group discussions (FGD) were conducted (three with women living with HIV and one with HIV-negative women), and two expert panels were constituted for this process.Themes that emerged in the qualitative work were physical impairment with aging, decreased family support, a turn to religion and social groups, lack of a financial safety net, mixed support from healthcare providers, and stigma as an added burden for women living with HIV. Based on the formative FGD, the expert panel expanded the original 19-item SVI to include 34 items. The exploratory FGD and rating and ranking exercise led to a final 16-item Kenyan version of the SVI (SVI-Kenya) with six domains: physical safety, support from family, group participation, instrumental support, emotional support, and financial security.The SVI-Kenya is a holistic index to measure social frailty among older women in Kenya, incorporating questions in multiple domains. Further research is needed to validate this adapted instrument. In sub-Saharan Africa, approximately 1 in 8 persons living with HIV infection (PLWH), including 1 in 10 adults receiving antiretroviral therapy (ART), are aged 50 or older . This olIn Kenya, a country where over a third of the population still lives in poverty, HIV care is free but care for other medical conditions is harder to access; consequently, families and other social contacts are critical sources of support for women’s overall health and psychosocial needs –9. In thThe Social Vulnerability Index (SVI) developed by Andrew and colleagues has been used to investigate associations between social frailty and health outcomes including cognitive decline and mortality , 13. VerIn preparation for a study of social frailty among HIV-positive and HIV-negative women aged 40 and older living in Mombasa, Kenya, we aimed to investigate the relevance of the SVI items in this context and identify any new items women and their providers would consider more relevant. While Bunt et al. adapted the SVI for use in the Dutch context, we felt a modified process was needed in Kenya to take literacy and the cultural context into account, leading to a unique adapted instrument . In thisWe based our approach initially on a stepwise process used by Bunt and colleagues for adaptation of the SVI for use in the Netherlands . In addiBased on the information, motivation, behavioral skills (IMB) adherence model of Fisher and colleagues , we deveTwo experienced Kenyan professional translators fluent in English and Kiswahili separately translated the 19-item SVI as used by Armstrong and colleagues  into KisWe formed a group of 5 experts  fluent in both English and Kiswahili who were selected based on their expertise on the health and social situation of older Kenyan women. This group was convened in October 2019 for a detailed review the 19-item SVI using a Delphi procedure. The experts were asked to consider each SVI item in the context of their own lived experience and in relation to findings from the formative FGD results, which were presented in summary form. Ideas for items not currently included in the SVI that were important in the Kenyan context  were suggested and discussed. Items which were agreed to be potentially important were added to a working document with all items being considered for the adapted version, referred to as the “SVI-Kenya.”Based on the input from our expert committee, we developed a new topic guide to examine the concept of social frailty in further depth in two additional FGDs among women aged 40 and over, one with women living with HIV and the other with HIV-negative women. This topic guide broke the different potential SVI-Kenya items into several domains to enable discussion of similar concepts, including living situation, family, other relationships, general support, socializing, and physical impairment. These FGDs were conducted in late 2019 and early 2020, and were recorded, transcribed, and reviewed by the study team prior to reconvening the expert panel.The final step of our adaptation process was to cull the expanded list of SVI-Kenya items. Our panel was joined by a female Kenyan clinician with > 5 years of experience providing care to women of a variety of ages (BO) and the Kenyan sociobehavioral scientist (GW) who conducted the FGD. After presentation of the preliminary results of the two FGD conducted in step four to explore women’s views on social frailty, these 7 individuals were asked to rate the importance of each of the candidate SVI-Kenya items on a scale of 1–5, with importance rated as 1 being “very important,” 2 “important,” 3 “neutral,” 4 “unimportant,” and 5 being “should be removed. In addition, panel members were asked to rank the items within each domain from most to least important, assigning 1 to the highest ranked item, 2 to the next most important, etc. Only items with an average importance rating less than 2 were considered for retention. For parsimony, averaged rankings were then used to select only the most highly ranked items within a given domain by group consensus.All four recorded FGDs were transcribed verbatim and translated into English. An iterative process was employed to identify themes related to social frailty and health. Transcripts were first read several times by the three investigators  to understand the content and reflect on the research objective. A draft codebook was developed and refined throughout the inductive coding process. The three investigators applied the first draft of the codebook separately to each transcript. They discussed areas where the codebook needed refinement, until consensus was reached, and the codebook updated. A second round of coding was then done on all transcripts by the three investigators, using the final codebook. Atlas.ti  and manual coding were both used on to analyze the transcripts. Content analysis was employed to organize emergent themes and sub-themes.Table Below, we present the key themes that emerged in the qualitative work: physical impairment with aging, decreased family support, a turn to religion and social groups, lack of a financial safety net, mixed support from healthcare providers, and stigma as an added burden for women living with HIV.“It is true that as you age the energy that you had reduces. You can’t accomplish the chores that you once did, the speed you had. Now you feel that you are fatigued, your knees are hurting.” – HIV-negative woman, FGD 3Hypertension and diabetes were the most common non-communicable diseases reported. Cognitive complaints included memory loss.“I can keep keys in a place then begin to look for them everywhere and I can’t find them yet am all alone, and everyone has gone to school … only to find them when I am looking for something else. I told myself age is catching up with me” – HIV-positive woman, FGD 4There was such general sharing of physical complaints and health concerns that one woman asked:“Is old age sickness?” – HIV-positive woman, FGD 2Participants described several health concerns that they attributed to the aging process. Common physical complains included body pains and arthritis.Apart from not having husbands, some of us don’t even have other people whom we live with.” – HIV-positive woman, FGD 1“For many, children had moved away after they grew up and were not always supportive, although some continued to visit.“An old lady is supposed to be assisted, but nowadays there is no assistance forthcoming from the children, unlike in the days gone by when women used to be assisted.” – HIV-positive woman, FGD 4“For some women their children have rented for them houses and they live apart, but they come around to pay them visits” – HIV-negative woman, FGD 3In contrast, women who still had children or grandchildren at home found this to be an important source of motivation and satisfaction:“I take care of my child. If it were not for that I would just die” – HIV-positive woman, FGD 2Participants reported changes in their household make-up as they aged, which led to isolation. Many had had spouses who had died or marriages that had dissolved. One woman stated:“When one gets old that is when one gets too involved in church matters simply because most of her tasks are gone so it’s her and the church.” – HIV-positive woman, FGD 4There are meetings organized on Tuesdays, Wednesdays, there are some organized by pastors, there are those organized by women to talk about issues of life, so you can get to learn something you didn’t know. You get to learn a lot.” – HIV-negative woman, FGD 3““Merry-go-round” groups in which women regularly contributed a small sum to a fund that was paid out to members on a rotating basis were common and helped meet financial needs. While these social support groups were helpful to most women, some women described gossip and back-biting that led them to not participate.“There are no groups because you go and get filled with useless talk until when you get out you don’t even understand yourself.” – HIV-positive woman, FGD 2Religious and social groups served as sources of support for participants. Many women reported becoming more religious and participating in church groups.“I hear if you go there, they ask for your ID card and if they look at ID, they say you do not qualify.” – HIV-positive woman, FGD 4The financial challenges some women experienced led to them not being able to afford more than one meal a day. This led to stress and worry:“You can only sleep if you know that you have someone who can provide for you. But for us, if you are aging and you don’t have someone who will provide for you, you start losing sleep.” – HIV-negative woman, FGD 3Most participants felt that it was not easy for older women to get help from others when needed. Many said that women must support themselves through work and save money for the future. Government support was minimal and difficult to access:There are clinics such as this one where they offer health talks; those too work as you educate them in a language they understand” –HIV-negative woman, FGD 3“Most women found providers to be sources of motivation and support as they navigated their chronic health problems. While interacting with the health system was mostly positive, however, some women complained of not being taken seriously:“You see like me, I used to be very sick quite often, and I saw some arrogance. It’s like I had gone there so many times and they were tired of me. Such that when you go there … the doctor says you are not sick … You see, you are ignored...you are ignored and your body is very weak, you are sick.” – HIV-positive woman, FGD 1For others, the utility of seeking care was limited by their financial ability to pay for visit fees and medications:“For that you need to see the doctor and if you don’t have the money to see the doctor so that you can get help … . and on that I still haven’t sought help.” – HIV-negative woman, FGD 3For many women, healthcare providers and clinics were described as the greatest source of support:Someone will know that truly I have been infected. She will go and tell other people all over in the village.” – HIV-positive woman, FGD 2“Notably, no women mentioned physical impairments caused by HIV itself, and some women said the challenges that women with and without HIV face as they age are similar.“They don’t have HIV but struggling with all the other diseases, so we are all the same, I don’t see a difference.” – HIV-positive women, FGD 4Some distinct challenges were reported by women living with HIV. Stigma was common in the community and most women preferred to keep their HIV status a secret. Women feared that if their HIV status became known, people would talk about them, and they would become isolated.Table During the first expert panel meeting (step three), three variables were removed from the SVI draft by the expert panel: marital status, working or volunteering, and having close friends. Regarding marital status, the panel felt this should be collected as a sociodemographic variable but did not think it was informative for evaluating social frailty, given how frequently married couples in Kenya live in separate places for economic reasons. Working in formal employment or as a volunteer was considered very unusual for older women in Kenya, who rarely work in the formal economy and are too poor to volunteer. The item on having close friends was felt to be redundant with the question on how many people one felt close to, so was removed from consideration.In terms of added variables, a question on ability to read was added to the physical impairment domain, to capture both literacy and vision deficits. In the safety domain, the SVI item on whether most people can be trusted led to a discussion of how physical safety was more important and a basic need. In the family support domain, living in a home for older persons was added for discussion; while such institutions exist in Kenya, the panel considered this a living situation of last resort and said it was rare. In the group participation domain, “merry-go-round” groups were specified and a question on attending religious services added. Regarding the instrumental and emotional support questions, the panel added having someone take you to the doctor and feeling loved, respectively. Finally, given the very low income of most older women in Kenya, several items on financial security were added.In the final expert panel (step five), ratings and rankings were collected in a spreadsheet, with the physical impairment and safety domains grouped together as “barriers” in a single domain. One panel member’s data were excluded because she clearly did not understand the exercise despite assistance. After average importance ratings were calculated, 7 items rated at 2 or higher were removed from consideration. Once this was done, the items with the highest rankings within a given domain were retained. In only one case was an exception made in determining the final items: the question “In the last 12 months, how often did you run out of money for your basic needs?” was retained instead of the question “Do you receive a pension or other regular income?” despite a higher ranking, in order to capture financial hardship despite a pension or other regular income, which was relatively unusual. Table Due to the lack of a standardized, validated tool to measure social frailty in older adults in East Africa, we sought to adapt an existing measure to the Kenyan context. In reviewing the literature on social vulnerability, we identified the theoretical framework described by Bunt and colleagues as likely to be relevant . Bunt anThe process we used to adapt the SVI included qualitative work exploring the lived experiences of older Kenyan women. The themes we identified suggest that as women age and develop health conditions that limit their physical abilities, they are often also struggling with decreased family support and a lack of financial security. Those who have supportive families or support from religious and social groups fared better. This finding is in keeping with a study of older adults living in Nairobi slums, in which women were found to have more and stronger social ties than men, which put them at an advantage as physical impairments eventually reduced women’s ability to do chores . As in oWorking with the panel of experts, we expanded the original 19-item SVI to include additional items the experts thought important and drop items less relevant in Kenya. While the final domains for the SVI-Kenya are similar to those of the original SVI, hearing and vision were deemed less important barriers than concerns about physical safety, and so physical safety rather than impairment is included in the SVI-Kenya. Of note, gender-based violence is common in Kenya and has reportedly increased during the COVID-19 pandemic . SimilarWe are currently using the SVI-Kenya in a cross-sectional study in an urban setting comparing 150 women over age 40 living with HIV to 150 women living without HIV. The study’s objectives are to characterize social frailty using the SVI-Kenya and a social network survey, to evaluate associations between SVI scores and both clinical frailty measured with the Rockwood 7-point Clinical Frailty Scale and disability measured with the World Health Organization Disability Assessment Schedule (WHODAS)-12, version 2 , 24. We The strength of the current work is its grounding in Social Production Function theory and use of the SVI, which has demonstrated associations with increasing age, female sex, and adverse outcomes including clinical frailty, cognitive decline, and mortality in other settings , 25, 26.Overall, the SVI-Kenya promises to be a useful instrument for the assessment of social frailty among older women in Mombasa, Kenya. To our knowledge, it is the only measure of social frailty that has been adapted specifically for use in sub-Saharan Africa, the region most impacted by the HIV pandemic and one in which older adults, especially women, could use additional support. If the SVI proves to perform well in practice and to be correlated with other social support and frailty measures in our ongoing study in Kenya, it could be used more widely, and adapted to specific settings as needed.