The coronavirus disease 2019 (COVID-19) has received various distinct perspectives and responses at the local as well as global levels. The current study pays attention to local perspectives, which have appeared in the Sindh Province of Pakistan.Given the constraints of the pandemic, and using convenience sampling, we conducted 10 online group discussions, 7 one-on-one interviews, and 30 cellphone discussions from a small town of Sindh Province. We made every effort to make our sampling inclusive in terms of decisive sociocultural factors: gender, religion, level of formal education, and occupation/job. We obtained data from women, men, Muslims and non-Muslims, the formally educated and noneducated, government employees, and daily wage laborers. Moreover, to perform content analysis, we used social media such as WhatsApp and Facebook.Bāgrrī community who practice Hinduism are taking cow urine to deal with the virus. This study brings these perspectives to the center stage; yet, the results cannot be generalized across the country, or within the province. Moreover, the study situates these perspectives within the global and socio-cultural, economic, and political contexts and invites more in-depth studies to inquire why such perspectives emerge.We have found that some people consider COVID-19 a “political” game, “supernatural test” or “Western plot”. The given perceptions then guide further actions: either ignore or adopt the preventive measures or take supernatural preventive measures. Considering it as a test of God, Muslims perform prayers, while the We discuss different narratives concerning COVID-19 in a small town of Sindh Province. We maintain that documenting these various perspectives and analyzing their impacts on the preparedness programs is essential, yet understanding the causes behind the stated standpoints is equally essential, if not more so. Over time, infections rapidly escalated, and by the end of August 2020, the virus had infected around 30,000 people, of which over 6000 died. This spread led the government to impose “lockdown,” and then what the government called “smart” lockdown, which is the same as the “targeted” lockdowns imposed in the United States.2 Nevertheless, by the end of April 2021, the virus had infected around 826,000 people, of whom approximately 18,000 had died.In Pakistan, the Ministry of Health confirmed the first 2 coronavirus disease 2019 (COVID-19) infections on February 26, 2020: 1 person in Karachi and another in Islamabad. Within the next 15 days, the virus “officially” infected around 20 people, while the suspected number of infected people was around 470. The highest number of infections was in Sindh Province, followed by Gilgit-Baltistan.Owing to a rapid escalation of infection, the government re-imposed smart lockdown in 20 cities across the country, including the capital, Islamabad. By April 2021, as anticipated, what can be called the “third wave” of the pandemic caused a critical situation in Pakistan, despite the apparent efforts of the government to control the situation. These government efforts to contain the virus have included: early case detection and tracing and tracking contacts, communicating the risks of the virus to the public, physical distancing, quarantine, and isolation. Yet the novelty and scale of this disease, along with its uncertainty and ambiguity, have made it critical for health authorities to plan appropriate strategies and effective preparedness.The continuous worries and fears have also created a fertile environment for local perspectives to emerge; the local perspectives of laypeople from villages and from a small town of Pakistan’s Sindh Province constitute the subject matter of this paper. We will analyze these perspectives after situating them within global as well as sociocultural, economic, and political perspectives.Matiari District located in the Sindh Province of Pakistan. Located in the southeastern portion of the country, Sindh is geographically 1 of the largest of the 4 provinces of Pakistan. We collected our data using well-established anthropological research methods. To conduct anthropological research, one needs ample time to build rapport, mingle with interlocutors, develop tools, and gather data through methods as well as observation. Although the research for this paper did not encompass long-term ethnographic fieldwork on COVID-19, it does draw on our earlier long-term ethnographic fieldwork projects in Pakistan, mainly in Sindh Province, which we have been conducting since 2005: Inayat Ali (2005 to the present), Salma Saddique (from 2013 on), and Shabazz Ali (from 2012 on). The fieldwork projects of Inayat Ali , and Shabazz Ali (2014-2020) on health and illness provide background and context for this present paper.During May and June 2020, we carried out the study we report on here in a small town of the For the primary data collection in the village, we drew on Salma’s long-term fieldwork (2013-2020); for this particular project, Salma simply contacted her prior interlocutors. Given the constraints of the pandemic, and using convenience sampling, we conducted 10 online group discussions, 7 one-on-one interviews, and 30 cellphone discussions. We made every effort to make our sampling inclusive in terms of decisive sociocultural factors: gender, religion, level of formal education, and occupation/job. We obtained data from women, men, Muslims and non-Muslims, the formally educated and noneducated, government employees, and daily wage laborers. The purpose of this diverse sampling was to incorporate multiple and differing perspectives, as all these identities play pivotal roles in shaping the ideas and practices of the people in the selected locale.Moreover, to perform content analysis, we used social media such as WhatsApp and Facebook. This study is part of a project that was approved by Pakistan’s National Bioethics Committee (reference No.4-87/NBC-471-COVID-19-09/20/); it included an informal interview guide. This guide encompassed 14 central themes related to COVID-19, including the necessary socio-economic information about our interlocutors on which this paper draws. The intention behind using an informal interview guide was to avoid affecting the views of interlocutors, as well as not making them feel uncomfortable with a “formal” interview. To maintain ethical considerations, we sought verbal consent from our interlocutors and have anonymized their names. Again, our analyses of our current data on COVID-19 build on our above-noted ethnographic fieldwork projects in Pakistan, including in Sindh Province.3 As the number of affected people increased, people’s perceptions of COVID-19 also gradually changed. Everyone is affected by the pandemic directly or indirectly, yet some people still consider it to be “propaganda.” After identifying over 2300 reports on media and social media in 25 languages in around 87 countries, Islam and colleagues4 have gathered the following 56 different local narratives: rumors, conspiracy theories, and narratives showing stigma information about COVID-19 is circulating rapidly around the sociocultural landscape, Pakistan has its own, unique socioculturally rooted (mis)information and (mis)conceptions about COVID-19.igma see .7 For a non-COVID-related example of how rumors and conspiracy theories can spread in local areas, Inayat Ali reports that he repeatedly heard varying narratives in Sindh Province concerning an unfamiliar, aggressive, and dangerous small animal that appeared and attacked in 2016. This story held that:8the animal was an Indian conspiracy to cause havoc in Pakistan—someone imported them from an Indian zoo to deliberately set them free in Pakistan. The other held that the animal had emerged from an unknown area. As fear grew larger and stronger, villages started assigning duties to various individuals to provide 24-h security. People, especially children, were afraid to sleep. The male members stopped sleeping at an Otāq  or walking outside the house after sunset. Frequent announcements broke out about seeing the animal, which caused villagers to gather with their dogs and their weapons—rifles, pistols, axes, and sticks. These gatherings attracted the local media. A few deaths occurred, in which the bodies were said to contain “paw”-like marks, which added further fear into an already chaotic situation. Despite the fact that such an animal was never captured, the rumor continued unabated for over a month.While all of these perspectives are fascinating, herein we focus on Pakistan, as, although Islam and colleagues have paid significant attention to these varying narratives, they have not included anything from Pakistan. As in other countries, various local perspectives and narratives about COVID-19 have emerged in that country.8 The “Western plot” and “hidden interest” narratives became a reality when the media reported a fake vaccination drive that the American Central Intelligence Agency (CIA) organized in Pakistan’s Abbottabad city to locate Osama bin Ladin. This critical event was termed “vaccination suicide” as it significantly affected the Expanded Programme on Immunization (EPI); many vaccinators were attacked, and over a hundred were killed.8Similarly, multiple competing narratives have been surrounding vaccination campaigns, that is, that these campaigns contain “hidden interests” and are a “Western plot” to sterilize Muslim women, leading to vaccine refusals and resentment.9 Two highly prevalent narratives in Sindh Province were about treatment:Hyderabad to district Ddaharki, that shaving one’s head protects against the virus. As soon as this rumor traveled, many men (the shaving of a woman’s head is considered shameful) immediately shaved their heads—a very affordable preventive measure that costs only US5-10 cents. In 1 village of Sindh, over 50 men had their heads shaved. This rumor is a good example of how a society can come up with an easily accessible “cure” in the absence of a practical and effective health-care system.6A widespread rumor broke out in Sindh Province, from its district Likewise, various narratives surrounded COVID-19 to locate the “hidden agent” behind it. Some believed that either the United States or Big Pharma has “bioengineered” COVID-19. People also started circulating information about home remedies, eg, drinking garlic water , or “blowing hot air from a hair dryer through your nostrils”; or keeping one’s throat moist on the recommendations of the country’s health ministry.6After this baby’s miraculous birth, he started talking: “I will not survive. I am here to tell you something important about the current coronavirus, that the disease is deadly. I will die at noon and will bring the coronavirus with me,” said the child. It could kill everyone if a recommended measure was not taken. The measure was brewing green tea, and every person should drink 5 sips. The one who would drink these 5 sips would survive; the rest would die. “As long as my heart beats, I ask you to please drink tea.” After conveying this message, the child died.The second narrative emerged concerning an infant in the northern part of Sindh Province, which quickly spread in many districts with multiple forms but with the same idea as given below:Following the wide dissemination of this narrative, many laypeople got on their mobile phones to make calls and send messages to their family, friends, and acquaintances. Some even paid in-person visits to their neighbors to bring the great news of this miraculous treatment, showing the willingness of the locals to believe in the supernatural.6 Therefore, many believe that the government is “fabricating” the statistics, which is why the number of infected people is escalating. Some interlocutors believe that COVID-19 is a Yahudi Sazish (Jewish conspiracy) to stop Muslims from going to mosques. Those who do not believe that this pandemic exists freely go to markets and roam around. They believe that there is no reality in the coronavirus as presented in the media; they reason, “If COVID-19 exists, why we have not been affected?”In contrast, some local people believe that COVID-19 does not exist but is just a “political game” being played because the Pakistani government wants funds from high-income countries and from the International Monetary Fund (IMF). Inayat Ali discovered that many people in Sindh and Punjab Provinces believe that “the government is only imposing lockdowns to receive global attention for potential foreign aid and that there is no danger.”Matiari District —stated that:Our life is totally at risk. We are fearful of contracting the virus, as the pandemic has affected millions of people worldwide. Owing to that fear, there are people who even have a simple cough; they think they have contracted the virus. My uncle died due to heart failure. Since he had symptoms of COVID-19, he was brought for a test for this virus to a nearby hospital. On his way, he got heart failure because he was significantly under stress and fearful of contracting COVID-19. Consequently, he died when he was on the way to a hospital. He was worried, like many people in Sindh, to be tested for the coronavirus due to the attached fear that he will be put in quarantine.In contrast, some Pakistanis who do believe that it is real fear contracting it; hence, they have been maintaining self-quarantine. Sorath—a 35-y-old woman from Sindh Province working in a nongovernmental organization (NGO) in Matiari District, explained:COVID-19 has created an alarming situation for us. We must take precautions because we will also be dealing with it soon. It is better to make our body prepared and strong while eating a healthy diet and practicing physical distancing. The most important thing is to make our minds strong enough to deal with this critical disease.Moreover, some interlocutors perceived that the coronavirus is only dangerous when one does not follow the required measures, such as physical distancing, wearing masks, and using a sanitizer. If a person follows precautions, eats a healthy diet, and does not go outside, then s/he is safe from this virus. As Qudarat, who is in her late 40s and a gynecologist at a government hospital of One of our colleagues has tested positive for COVID-19; therefore, our organization has decided to conduct COVID-19 tests of all employees and communities who remained in physical contact with the employee in the last week. Nonetheless, due to fear, people are refusing to get the coronavirus tests. The underlying reason is that if they are tested positive, it will mean shame for the community and the government will not allow them to live with the family members, and we will be put in an isolation center. Yet some people consider it an opportunity: if tested positive, then they will be spared from work.Most interlocutors argued that they have not in actuality met anyone infected with COVID-19; however, they have constantly been reading and watching about them on social and print media. Thinking about COVID-19 has resulted in psychological depression in some people, as they feared that the government would enforce quarantine and isolate them from their families. And being diagnosed with COVID-19 may stigmatize them in the eyes of others. Habiba, a 29-y-old from the Matiari District, who also works in the private sector, shared that:As Habiba notes, for some people COVID-19 has emerged as an opportunity to get some free time to spend with their families; a colleague of Habiba, named Halima, who is in her late 30s from Matiari District, stated, “We want our COVID test to be positive because after declaring as positive, we will take a rest for a few days, as our organization will give us leave without pay. And, this way we will have time to spend time with family.”When the coronavirus infection was first confirmed in Pakistan, most people were following precautionary measures, such as wearing masks and gloves, observing physical distance during going outside from home. However, the current condition is critical because many people are not taking COVID-19 seriously anymore. People have become habituated to it by now.One year after we obtained our original data for this paper, the current situation of COVID-19 became more critical in Pakistan as people got used to the virus and become less or nonserious about protecting themselves from it. This criticality was hinted at almost a year ago by our interlocutor Sakeena, who is around 40 y old and works as a nurse at a private hospital in a town of Matiari District, was of the view that:6 found interpretations of COVID-19 as a supernatural act in Punjab Province, where laypeople considered the virus as the punishment of Allah, which occurred due to “the opening of cinemas in Saudi Arabia and general disbelief in God in the Global North, where everything is ‘too open,’ especially romance.” People believed that “Allah has shown us how powerful He is in that science is unable to deal with the pandemic.” Many Pakistanis hold the idea that their strong belief in Allah is the reason why the virus infections are significantly less in Pakistan than in the United States and Europe.6 For example, Asad Ali, age 45, who is a college teacher from Matiari District, argues:Jis Ka Ali Waris, Usay Kiya Kre Ga Coronavirus .COVID-19 is a punishment for unbelievers [this may be translated: those who do not practice Islam]. As we are followers of Ali (the son-in-law and cousin of the prophet Muhammad), we would not be infected by the virus under any circumstances. [In Urdu] Some people also have related the etiology of the pandemic to a supernatural act. Inayat AliNamāz (praying) and [reading the] Qurān. Once Allah is pleased with us, then the disease will soon end, as we are not able to prevent ourselves from the disease—only Allah can do so.None of us has a fear of coronavirus; instead, we are afraid of God. The occurrence of a disease and its cure is the will of Allah. Nobody except Allah would ever cause any disease to anyone. Despite that, we are living in the scientific world and cannot make or unmake an illness because it occurs by the decision of Allah. Presently, the coronavirus has been described by a religious leader and many people as a disease from Allah to test individuals and put them on the right track. Many people are stating that the coronavirus spread because people are not performing Similar are the views of Kamalan, who is around 60 y old from the same District with no formal education and a house worker, who stated:Mātta [a term that is used for Hindu goddess by the practitioners of Hinduism] is our goddess. Firstly, we made sweet bread and distributed it to children, and then the children offered the bread to a cow. After an hour, when the cow urinated, then we kept that urine in a metal jug and recited some Bhajjan [sacred song of Hinduism]. After that, every family member, irrespective of age and gender, washed their body with that urine. Furthermore, we also sprinkle urine on every space of our house. Our deliberation is that the virus will not affect us, with the blessing of our cow Mātta.We used to wash our bodies with cow urine as the cow Of interest, the Bāgarrī—a nomadic Hindu hunting and gathering community of Sindh—have adopted a distinct set of preventive measures. They have performed various rituals and have used cow urine for prevention because they consider cows to represent a goddess—which particular goddess depends on the specific Bāgarrī cultural group, as each group worships a different goddess. As Jadul, a 50-y-old Bāgarrī woman with no formal education who works as a wage laborer, shared:Gāūmūtrā (cow urine worship) program, hosted by Akhil Bharat Hindu Mahasabha. Hundreds of people attended this event and drank the urine, believing that this would immunize them against the virus. Other cultural groups have also used cow urine while considering it a sacred measure to deal with COVID-19. Holding a similar belief, members of All India Hindu Mahasabha (All India Hindu Union) organized a 11 These beliefs and perspectives are encoded in various narratives, eg, rumors and conspiracy theories, which are social phenomena that reflect people’s anxieties and fears.5People’s beliefs and perspectives are real, influence behavior, and help them to make sense of their lifeworlds.8Believing that there is no coronavirus reveals a contestation between different medical systems, and also demonstrates the mistrustful relationship between the government and the people, which, again, creates negative effects as people have become more careless in taking preventive measures against a disease they do not believe even exists. The deeper meanings of such perceptions can only be fully understood when they are placed within the historical context of colonization, poverty, corrupt or ineffective governance, and aid dependency.12 people started drinking alcohol excessively, and as a result, around 800 people died in Pakistan, and around 5900 in Iran.14 Some Americans died from drinking bleach because then-President Trump actually recommended it, and Asian Americans across the United States are being vilified, attacked, and even killed because to some, they incarnate the belief that the virus was deliberately imported to the United States from China. Former President Trump repeatedly referred to COVID-19 as the “China virus,” which apparently strengthened the association of Asians in general with the coronavirus in the minds of his followers, expressed through social-media hate speech and now actual attacks.15Some narratives can be downright dangerous. For example, based on a rumor that consuming highly concentrated alcohol disinfects the body and kills COVID-19,5 Such narratives may also exert positive effects. For example, linking the pandemic to the supernatural likely gave laypeople great hope that pleasing and worshiping Allah would help to prevent and cure the disease. For another example, Inayat Ali5 found that, at the beginning of the pandemic, rumors circulated in Pakistan that the government shot or set fire to COVID-19 infected people. These narratives made family members, particularly parents, to be highly concerned about the mobility of the younger generation so that they should stay at home.5 On the upside, these rumors might have caused people to intensify their efforts to avoid contagion by self-quarantining. Yet on the downside, such rumors caused many to avoid getting tested even if they were symptomatic.Rumors, conspiracy theories, and infection-associated stigmas may also negatively affect people’s willingness to comply with government preparedness programs to contain the virus.Bhajjan (Hindu religious songs) also gives hope to people that the virus will not infect them. According to Davis-Floyd and Laughlin, “ritual stands as a buffer between cognition and chaos”—between people’s ability and inability to cope with a stressful situation—because the performance of rituals can be calming and stabilizing.16 Thus, it is no wonder that people everywhere use rituals to stabilize themselves in times of crisis.16 Even the small daily rituals of handwashing, mask-wearing, and physical distancing give people a sense of confidence, while deeper rituals, such as performing prayers and large-scale ceremonies like the one described above that involves drinking cow urine, greatly enhance that sense of confidence.Thus, such local perspectives may both create panic and decrease fear. For example, believing that health and illness, including COVID-19, are determined by God allows people to release their anxieties and fears through prayers. Similarly, listening to the sacred songs of 17Knowledge, attitudes, and practices toward any disease play an integral role in shaping society’s readiness to accept behavioral changes. The lessons learned from the severe acute respiratory syndrome (SARS) outbreak are that knowledge and attitudes are associated with levels of panic and emotion, which further complicate measures to contain the spread of the disease.18 When facing new and challenging diseases causing epidemics and pandemics, we should consider these different perceptions and practices because they may affect how symptoms are recognized, access to care, treatment provided, and fear of stigmatization. Public health interventions should consider cultural beliefs and assumptions to ensure that the interventions are culturally appropriate for the community.20 It is crucial to avoid correlating the disease with questionable cultural causations, as this may lead to blaming specific populations for their high prevalence rate or to the stigmatizing of those infected.21These perceptions and practices are shaped by sociocultural, economic, and (geo-)political factors. Remaining distinct from society to society, they significantly impact an individual’s life, as is widely understood. Cross-cultural studies support that each specific culture has its own beliefs related to particular explanations for health and sickness.6We note that it is essential to conduct in-depth studies to generate a thorough understanding of these numerous perspectives: what do such narratives reveal and why do they emerge? Documenting them, their significant impacts, and their underlying causes, as we have done herein, is undoubtedly vital. Such documentation and analysis will lead us to those historical, sociocultural, economic, and political factors that significantly shape these seemingly irrational perspectives, which, in Pakistan and many other countries, develop in the presence of multiple and syndemic disparities, including lack of effective educational and health-care systems and to an inefficient and corrupt governmental regime.Because the perspectives surrounding COVID-19 are still developing, this study would be among those limited investigations that have focused on the local perspectives and practices on the disease in Pakistan. Moreover, analogous to other qualitative studies, this study has certain limitations. The sampling has certain limitations: (a) its type, that is, convenience sampling, (b) the number of interlocutors is small, (c) most of the interlocutors are women. Therefore, the results cannot be generalized to the entire country. Yet our study offers first-hand data and triggers further studies following the same lines in Pakistan. Moreover, it adds a perspective from Pakistan to other studies that have been documenting and analyzing different narratives around COVID-19 at a global level.Analogous to other countries, Pakistan has been overwhelmed by the pandemic. Because COVID-19 is still unfolding and there appears as yet (May 2021) no or not enough vaccines available in many countries, including Pakistan, and distinct perceptions, attitudes, and practices surrounding COVID-19 have emerged there, as elsewhere. We have described these in this paper, showing that the practices around COVID-19 in Pakistan range from harmless home remedies like drinking green tea to extremely harmful “preventive measures” like drinking oneself to death. We have also shown how local beliefs and attitudes about COVID-19 have strongly influenced behaviors in both positive and negative, rational and irrational, ways.Understanding local attitudes, beliefs, and practices and their underlying rationales could greatly help health officials to present science-based strategies for preventing infection in culturally appropriate and acceptable ways. For example, government protocols could recommend drinking green tea and performing rituals and prayers, harmless practices that carry great psychological benefits, while noting that the “beneficial” effects of such home remedies or large-scale ceremonies would be greatly enhanced by also wearing masks, hand-sanitizing, and physical distancing. In such ways, government standard operating procedures could be presented as a package that includes local remedies and honors local beliefs. This present research on Sindhis’ perceptions of COVID-19 can greatly aid in such efforts.


For instance topics related to meeting and job are found to be sticky, while negative thinking and emotion, and global events, like ‘school orientation’ were found to be less sticky even though they change rates over time. We evaluate CLD coefficient over both quantitative and qualitative tests, studied over 6 years of language on Twitter. We find CLD predicts the spread of tweets and friendship connections, scores converge with human judgments of lexical diffusion (r=0.92), and CLD coefficients replicate across disjoint networks (r=0.85). Comparing CLD scores can help understand lexical diffusion: positive emotion words appear more diffusive than negative emotions, first-person plurals (we) score higher than other pronouns, and numbers and time appear non-contagious.Lexical phenomena, such as clusters of words, disseminate through social networks at different rates but most models of diffusion focus on the discrete adoption of new lexical phenomena (i.e. new topics or memes). It is possible much of lexical diffusion happens via the changing rates of existing word categories or concepts  rather than new ones. In this study we introduce a new metric,  For instance, terms can be introduced, vanish, or change in meanings and applications over time . All sucResearchers are increasingly developing techniques to understand language change in the context of social networks, often termed ‘language diffusion’. Building on models of disease contagion, which are often seen as dichotomous events (infection or not), much of such work focuses on the diffusion of new terms . For example, researchers have analyzed lexical emergence in Twitter , 16, invThis gap is important because a majority of language utterances are in fact of the ordinary. lexical phenomena tend to follow a Zipfian distribution of frequencies where a large portion of the terms we use represent only a small portion of all possible terms . While tThe change in focus from the tail to the head of the distribution translates into important methodological distinctions: models intended for tracking new phenomena are often ill-suited for tracking diffusion of ordinary terms since they rely heavily on binary or discrete-variable metrics that often do not capture change in frequency by single users or nodes. In analogy to disease infection , term diContrastive Lexical Diffusion (CLD) Coefficient for quantifying content diffusion of ordinary lexical phenomena – lexical categories that make up most of our language and yet there is a gap in our understanding of their diffusion – over time with respect to the effect of friendship networks and accounting for population language. We evaluate this method by applying it to common clusters of words in social media, calculating the CLD coefficient of ordinary LDA topics. Evaluation is facilitated through showing the CLD coefficient (a single feature) is by itself quite predictive for many tasks such as like and retweet prediction as well as guess whether pairs of nodes are friends, in addition to agreement with human judges. Finally, we extend the model to other categories of language, the lexical Inquiry and Word Count categories and examining which common categories are more likely to spread among friends.In this study, we propose the 2The study of language change by itself has a rich history, which most of it has been done in a historical context by analyzing patterns of language change , 29, 42.Most previous work on lexical diffusion can be characterized as either studying: (1) new terms or (2) change in meanings of existing words, as well as by its network type: (1) geographical or (2) social/friendship. Importantly, little attention has been given to measuring and understanding the diffusion of ordinary lexical phenomena, which has an advantage of utility in downstream modeling applications since it covers a large area under the Zipfian distribution.Linguistic variance across geographic units is perhaps the most well documented. For example, Grieve et al. mapped lexical innovations to track the spread of new words on American Twitter . KulkarnLanguage itself is a form of information and information often propagates through social ties. For instance, Bakshy et al. studied the role of strong and weak ties in exposure to information diffusion . HoweverSuch works start with a process of capturing innovations – new terms emerging among a group of well-connected individuals. The next step examines diffusion: first, speakers (or writers) must come into contact with the new lexical phenomena; second, they must decide to use it , 11. Thifrequency of ordinary language units over people, and (2) we characterize language phenomena  using social networks rather than characterizing networks/nodes using language.Most measure diffusion as a function of the number of individuals (or nodes) who mention a specific phenomenon (rather than frequency of the phenomena), so it is perhaps intuitive that there are few works examining phenomena frequency. However, there are some exceptions. For example, frequency has been used to estimate latent trajectories of phenomena  and to c3core users of the sample. We acquired two independent networks of 3, 298 core users (development data) and 978 core users (replication data). Such data was directly scraped from Twitter using Twitter API.Language is a social behavior and each word we write or speak can be seen as a social activity , and difpast time span  tweets, including the text, creation date, number of likes and number of retweets, all written in English. This gave us a pool of 83 million original (non-retweet) tweets, split into two time spans with roughly equal number of tweets. 40 million created between 2013 to 2016 – our data for span see , and 43 4Frequency of language units change over time within a social network. We distinguish the individual, friends of the individual, and the general network population, in order to measure diffusion of language units themselves. We view this measure as defining a specific property of language units (rather than network nodes) that characterizes how much it “sticks” (or propagates) specifically over direct connections.Broadly, our approach is two fold. First, we measure language usage of people and their friends at two different time spans. Then, we compare language usage over the time spans, and in comparison to friends versus the general population. To capture language usage, we consider lexical features of the individual documents generated by the individual within the two time spans.Ln×m where n is the number of individuals, m is the number of topic features, and Lij is the value of topic j for individual i.While our method may generalize to many features, we focus on lexical categories, specifically clusters of semantically related words (topics). As the clusters themselves are not a focus of this work, we downloaded a pre-existing set of 2000 social media clusters extracted using Latent Dirichlet Allocation . Such topast: 2013–2016 and current: 2017–2018. For each individual, we then aggregate the features into the time spans, building Lp and Lc as language usage matrices for past and current respectively. Language change is then defined as ΔL = Lc − Lp.1We split each individuals’ documents (e.g. tweets) into 2 time spans, L, we then consider his/her friends’ language. Specifically, we calculate a vector for individual i’s friends, Fi, by averaging over friends’ language usage:Lj is the jth row of language usage matrix L, fr(i) is the set of individual i’s friends, and |fr(i)| is the cardinality of the set fr(i). Now, we can define friends’ language usage matrix Fn×m by vertically concatenating {Fi}:Having a vector representation of language change for the individual, i.e. Δbefore the change). This mirrors causal modeling in that the cause, here friends language, happens prior to its effect, here users’ current language [F is only derived for the past time span, and ΔF = F−Lp is thus the friends’ language difference.To arrive at a measure of lexical diffusion, as we will explain next, we need to compare the individual’s change in language to the friends’ past language  and (2) that between the individual in the past and their friends in the past (ΔF). Thus, if a particular lexical unit was catchy you would expect its ΔL and ΔF to covary, on average.After measuring language change we have two differences: (1) that between the individual in the F with ΔLper feature. We look at the Delta matrices column-wise and obtain the similarity of columns of these two matrices. For instance, ΔLj, which is jth column of matrix ΔL, represents change in topic j from past to current. Similarly, the ΔFj is jth column of ΔF represents friends’ language difference for topic j. Therefore, for each topic the similarity between vectors ΔFj and ΔLj shows the extent the usage of topic j has changed from past to current towards friends’ language. So, we need to exploit a measure to capture similarity between vectors. We use cosine similarity since the dimensions of these vectors represent individuals and we need a similarity measure that cannot be overtaken by just a few dimensions. Additionally, our vectors do not simply represent a point, but rather vectors that share an origin i.e. Lp.To find how much individual’s language evolve towards their friends’ language, we measure the similarity of ΔF and ΔL represents how much the individual’s language is changing toward their friends, it is possible that the individual is just matching a population-wide trend which is not specifically diffused through their friends. Thus, we control for language use of the whole population, the average language usage of all of the individuals, can be subject to change in the same way we defined friends’ language effect. We define vector p as follows:Lj is the jth row of language usage matrix L, and n is the number of individuals in the population. The population’s language usage matrix Pn×m is obtained by horizontally concatenating p, n times. The population’s language is the same no matter which individual we are calculating.While the similarity between Δcurrent language differs from individual’s past language, as ΔP = P − Lp. Unlike friends’ effect we want to consider population’s language at current time span to measure how much of individual’s language change deviated from population toward friends’ effect. Finally, for each topic j the cosine similarity between vectors ΔPj and ΔLj shows how much the change in usage of topic j over time is towards population’s language.We calculate population’s effect by finding how population’s j we quantify how much ΔLj changes more towards friends than towards population by comparing the two its cosine similarities. If friend’s similarity score is larger than that of population it means that topic changed more towards friends’ language rather than population’s language. Our final CLD coefficient, ψj, is thus:C is the cosine similarity of vectors x and y. The higher ψj value a topic gets, the more probable to spread it is among friendship relations.2Finally, for each topic core users. In this diagram, each axis represents a core user, and since we are plotting the diagram for a topic t, the projection of a point on an axis is the normalized usage frequency of topic t by the specified user. For instance, Lp is a point in this two dimensional space, where the first dimension is the usage frequency of t by user 1 in the past, and the second dimension is the usage frequency of t by user 2 in the past. Similarly, Lc represents topic usage frequency of user 1 and user 2 in current. The other two points in this diagram, F, and P, belong to topic t usage frequency for friends at past and population at current correspondingly. ΔL = Lc − Lp represents language change, here, only for topic t. 3 utilizes randomized experiments such as a Randomized Controlled Trial(RCT) [Correlation does not imply causation. In an ideal case, causal inferenceial(RCT) , in whicUnfortunately, randomly assigning “treatments” to people is not feasible nor ethical, rendering RCTs not possible in observational situations like ours as we cannot dictate who is friends with whom in life. However, observational studies need not be limited to simple correlational analyses . Analyti4 In other words, on average, if people did not encounter their friends’ language, each person’s current language would be randomly drawn around the average current language of the population. If the language is sticky, encountering friends’ language in the past would change individual’s current language from the population’s towards the friends’. Note that we do not assume that encountering with friends’ language in the social network has to be the only medium of influence. The diffusion may happen through offline or other contexts, where one’s online friends are only a sample of the population of language they encounter.To understand the extent to which CLD coefficient captures causality is related to causality (i.e. how likely influence is the mechanism behind stickiness), we consider both: (1) it’s analogy to RCTs, and (2) the Bradford-Hill criteria it covers. Analogous to RCTs, CLD views the treatment as the language of friends in the past, and considers its effect on individual’s current language, where by the average language of the population represents the control group.Consistency or reproducibility: we reproduce consistent CLD scores of word categories based on two separate networks. Specificity: we setup our experiments to rule out other possibilities of causation, e.g. considering intervals of 2 or 3 years removes the possibility of short term trends, or controlling for population’s language rules out the effect of overall language change on each specific word category. Temporality: the effect, current language (Lc), happens after the cause, friends’ past language (F), in time. Plausibility: we show agreement with human judges. Coherence: there is no serious conflict with the relationship of people’s language and that of their surroundings. Finally, Analogy: We show the analogy of lexical diffusion with Tweets’ spread through predicting number of likes and retweets. Previous well-accepted studies have covered 5 to 7 criteria. For example ronksley2011association’s study of alcohol and cardiovascular disease outcomes covered 5 criteria, aghajafari2013association’s study of vitamin D level and pregnancy and neonatal outcomes covered 6 criteria, and hu2013resolved covered 7 criteria in their study of sugar-sweetened beverage consumption and the prevalence of obesity and obesity-related diseases.Bradford Hill’s criteria for causation , includeOur work falls in line with this challenge of developing measures over observational data, where experiments are not possible, but which go beyond simple correlations providing evidence toward causality , 17, 36.55.1We conduct several experiments to validate the utility of CLD-coefficients. We consider the predictive validity and reliability of CLD coefficients over: (1) two tweet-level tasks (predicting number of likes and number of retweets), (2) a user-level task (predicting friendship connections), and (3) a lexeme-level (association with human judgment of diffusion). We also conducted (4) an assessment of the stability of the coefficient as a lexical property by comparing its calculation over two independent training sets of users/tweets.ψm) is taken as the aggregate of the CLD coefficient of the topics represented in the tweet as well as their prevalence:m is the message, ψt is the CLD coefficient of topic t, and pmt represents the normalized frequency of topic t in message m. We end up with a single score per tweet, which we test for its lone-ability to predict retweets and likes by comparing it to: 1) number of likes, 2) number of retweets and 3) spread of tweet: a combination of number of likes and retweets of a tweet as shown in St is the intended spread of tweet for tweet t. ‖rt‖ and ‖lt‖ are the number of retweets and likes of tweet t correspondingly, and Z(.) yields the mean centered and standard deviation normalization of the scores . The normalization (z-scoring) is per user, therefore the values of St are comparable among tweets of that specific user, and thus controls for the number of followers and other user-specific, non-lexical attributes that affect spread.Retweeting and liking tweets are two key mechanisms of influence over the twitter network. While many factors come in to play for liking and retweeting, lexical diffusion should be associated with greater spread. We evaluate how well the number of likes and retweets of a tweet can be predicted by looking at only the CLD coefficient of the topics of the tweet. The CLD coefficient of the whole treat , we repeated experiments using all the 2000 topics. As it is shown in r for CLD coefficient and lexical emergence. Such a decrease in performance supports the significance of being able to quantify diffusion of the most common (i.e. ordinary language).Results shown in r .5 Movingk topics with highest CLD scores, then calculate weighted Jaccard similarity of the test user’s topic representation with each of his/her potential friends. The potential friend with higher Jaccard similarity, will be selected as the predicted friend of that test user.People influence their friends’ behaviors in many different ways, including via language . Examinik, along with several different baselines . We also considered selecting k topics with lowest scores for CLD coefficient which should be worse if our method is valid. This result shows an steady improvement in accuracy of CLD_top for k from 10 to 200 (approximately the top 10%), but then accuracy starts to fall off with minimum (chance) accuracy from use of all 2000 topics. We can see that CLD_top outperforms all the other 6 baselines. While past studies showed friends language are similar to each other [A topic (cluster of words) is considered to be diffusive in long-term, if people are more likely to use its words long time (a year or so) after they read tweets from their friends that contain the topic’s word(s). For each pair of topics, annotators were shown the 10 most representative words from each, and asked to pick the topic that they assume to be more diffusive. Each pair was composed of a random selection of one topic from the top 50 and one from the bottom 50 according to CLD coefficient or, for comparison lexical emergence.The next experiment is a feature-level experiment that we conduct to compare the most and least diffusive topics according to human judgements. We asked a group of 5 graduate students with NLP-related expertise to compare 50 pairs of topics. We defined lexical diffusion for a topic as follows; 6 Still, taken in the context of our previous objective evaluations, we consider human subjective judgements as a complimentary piece of evidence for whether our proposed metric is capturing diffusion. Specifically, the human task consisted of distinguishing the top and bottom 50 most diffusive topics. Here the inter-rater agreement, which is the average agreement of judges with each other is is 0.712 while the average agreement with majority vote is 0.828, This shows while the annotators are not compliant with each other, their individual agreement with majority is relatively high.We next compare CLD coefficient with human judgements. Human judgements cannot be considered a gold-standard due to cognitive biases and difficulty of the task.Qualitatively, our CLD coefficient is intended to capture its “stickiness” – to become used in greater amount by a person when they encounter it more often from a friend. We took a multi-modal approach to evaluate the validity and utility of our measure. We considered human judgments, utility in predicting likes and retweets, and utility in capturing friendships.Evaluating the CLD coefficient on various prediction tasks, here we tend to find the reliability of our CLD coefficient. To do so, we run our method on the two disjoint networks that we explained in the Dataset section, to establish two sets of scores for the same group of 500 topics. We quantify reliability with two metrics, 1) Pearson-r correlation between these two sets of CLD coefficients 2) Jaccard similarity from the top 100 diffusive topics of each set of scores. 5.2We conducted three exploratory experiments to demonstrate the use of CLD Coefficient for gaining insights about other phenomena: 1) Exploring CLD coefficient of LIWC’s word-categories, 2) Exploring topics with high CLD coefficient vs. low CLD coefficient and 3) Finding the relation of CLD coefficient with Big Five personality traits.7 Results in We conducted an exploratory experiments to demonstrate the use of CLD Coefficient for gaining insights about lexical phenomena. Specifically, we looked at one of the most widely-used word category lexica, Linguistic Inquiry and Word Count (LIWC), which defines 74 categories of words with psychological relevance . LIWC is8 This corresponds with the idea that people either write about these events or not, not because their friends’ language but due to an external effect, the event itself.To get an idea what came out as scoring high or low in CLD coefficient, we depict the 5 topics with high CLD coefficient along with the 5 topics with low CLD coefficient in Since CLD coefficient is intended to capture linguistic units that change under the influence of friends (people), we expect they should diverge along personality traits of people. we looked language associated with the Big Five personality traits , which c9 A different way the approach is flexible is in the time resolution. While we focused on long-term language diffusion, CLD could be adapted to short-term diffusion by adjusting the time windows. This could aid in the study of short-term and long-term diffusion. As the introduction and evaluation of the approach, we focused on long-term frequency to make our validation scores reliable and well estimated.We presented a novel measure to obtain CLD score, focused extensively on its evaluation. However, there are many avenues for extensions by injecting other parameters. For instance, one could incorporate link weights over a network by using the weighted average of friend’s language.6lexical emergence, it has left a gap in understanding of diffusion as a frequency-based process covering changes in ordinary lexical units . We evaluated our CLD coefficient against indicators of influence , as well as for distinguishing friends from non acquaintances, and versus human judgments. While past studies showed friends language are similar to each other, we have deduced that such similarity is facilitated mostly among the most sticky topics. Comparing CLD score of topics with their personality scores revealed topics associated with emotionally stability are more probable to be more likely to spread through friends, while those characteristic of agreeableness and extroversion have less chance to stick in their friends language use. Furthermore, CLD coefficient of lexical categories suggested new lexical diffusion information such as positive emotion being more sticky than negative or plural first-person pronouns (e.g. we) being more likely to spread than singular first-persons (e.g. I) and second-persons (e.g. You). We see this introduction and evaluation of the novel CLD coefficient as enabling greater computational study of diffusion of the ordinary language.We have presented and evaluated a novel method to capture frequency-based diffusion of lexical phenomena through friendship networks over time, while controlling for population effects. While work on dissemination of language over social networks has begun to provide a rich understanding of


Pulmonary rehabilitation (PR) is an effective intervention for people with chronic respiratory diseases (CRD); however, its effects fade after 6–12 months. Community-based strategies might be valuable to sustain PR benefits, but this has been little explored. People with CRD, informal carers, and healthcare professionals (HCPs) were recruited from pulmonology appointments of two local hospitals, two primary care centres, and one community institutional practice and through snowballing technique. Focus groups were conducted using a semi-structured guide. Data were thematically analysed. Twenty-nine people with CRD , 5 informal carers , and 16 HCPs  were included. Three themes were identified: “Maintaining an independent and active lifestyle” which revealed common strategies adopted by people with “intrinsic motivation and professional and peer support” as key elements to maintain benefits, and that “access to information and partnerships with city councils’ physical activities” were necessary future steps to sustain active lifestyles. This study suggests that motivation, and professional and peer support are key elements to maintaining the benefits of PR in people with CRD, and that different physical activity options (independent or group activities) considering peoples’ preferences, should be available through partnerships with the community, namely city councils. Chronic respiratory diseases (CRD) are leading causes of mortality and years lived with disability worldwide . PulmonaEngaging people with CRD in maintenance PR programmes for indefinite periods of time might not be the optimal approach, as PR is a highly inaccessible intervention  and aimsAddressing this relevant issue, studies have been conducted exploring the benefits of maintenance exercise training programmes after PR; however, their effectiveness is still not clear . CommuniTo successfully implement such strategies, the needs and expectations of people with CRD and informal carers’ need to be considered and meet healthcare professionals’ (HCPs) goals. Nevertheless, their perspectives on long-term maintenance strategies for people with CRD are yet unknown. This study aimed to explore which maintenance strategies should be available for people with CRD in the community and how they should be provided, from the perspectives of people with CRD, informal carers, and HCPs.A qualitative exploratory study with focus groups (group interviews) was conducted. This study is nested in a larger project approved by three independent Ethic Committees . All participants provided written informed consent.The study is reported following the Consolidated Criteria for Reporting Qualitative Research (COREQ)  and the Participants from three stakeholder groups were recruited: people with CRD, informal carers, and HCPs. People with CRD and HCPs were recruited face-to-face using purposive sampling  from theInformal carers were recruited through people with CRD, using the snowballing technique . People HCPs were eligible if they had been directly involved in the implementation of PR programmes.The pulmonary rehabilitation programme prior to the focus groups followed the international recommendations and was “a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies” , that inSample size estimations in thematic analysis should consider the richness and complexity of data for addressing the research question rather than a specific number obtained with a power calculation . For medAll participants provided information regarding their age, gender, education level, marital status, and occupation.For people with CRD, height and weight were measured and data from spirometry were retrieved from medical records. Additionally, smoking status, use of long-term oxygen therapy, non-invasive ventilation, number of acute exacerbations and hospitalisations in previous year, and impact of the disease with COPD assessment test, were also collected.Informal carers were asked about the kinship with the person with CRD, geographical distance to their house, and duration of care provided.HCPs also provided their professional background, years of professional experience, and the setting of their workplace.Focus group interviews were conducted separately with each stakeholder group containing 6 to 12 participants  in a rooC.D. contacted participants, conducted five focus groups, transcribed all data, and analysed the data first. She is a female experienced physiotherapist, with a master’s degree in respiratory physiotherapy and clinical practice in assessing and treating people with CRD in a hospital. A.M. conceived the idea, drafted the interview guide, pilot-tested it, conducted two focus groups, reviewed the transcripts, was involved in data analysis and interpretation, and supervised C.D. during her master’s degree. A.M. is a female experienced respiratory researcher in pulmonary rehabilitation and qualitative studies who holds a PhD.Before the start of the study, there was no relationship established between the moderators and the participants. However, the interviewers presented themselves to the participants who were aware of their motivations for conducting the research. The interviewers had knowledge of the importance of PR and were aware of the challenges to maintain a healthy lifestyle. S.S.-M. is a female PhD candidate with a master’s degree in respiratory physiotherapy and experience in assessing and treating people with CRD, as well as in conducting qualitative studies. S.S.-M. analysed the data, interpreted it, and prepared the manuscript.E.M. reviewed the transcripts, was involved in data analysis and interpretation, and co-supervised C.D. during her master’s degree. E.M. is an experienced female nurse who collaborates with PR, conducts qualitative studies, and holds a PhD.C.J. is a female researcher that holds a PhD with extensive knowledge in PR and qualitative studies. C.J. analysed the data, interpreted it, and revised the manuscript. Descriptive statistics were computed using SPSS software .Qualitative data were analysed with inductive thematic analysis in 6 phases: transcription, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report . The focOne author (C.D.) generated the initial codes using organic coding and the codes were then merged and interpreted as themes, when there were common patterns within the data . During Trustworthiness, procedures of credibility, transferability, dependability, and confirmability were ensured , as recoAll people with CRD and HCPs agreed to participate. Only 5 of 29 informal carers contacted participated, as they did not perceive their input as valuable, or due to time unavailability. A total of 50 people  were included in the study. Seven focus groups  were conducted. Focus groups lasted on average 47 ± 15 (32–70) minutes. People with CRD were mostly male (76%), with COPD (83%), with a median age of 69 years old, and mostly of GOLD group B (48%). Informal carers were all females, with a median age of 69 years old, mostly spouses (80%). HCPs were mostly females (75%), with a median age of 36 years old, working mainly at hospitals (62.5%). Three themes explaining the perspectives of the different stakeholders were identified: “maintaining an independent and active lifestyle”, “intrinsic motivation and professional and peer support”, and “partnerships with city councils’ physical activities”. No differences in perspectives between stakeholder groups or subgroups within each stakeholder group were found. Several physical activities such as walking or doing house chores were identified as commonly used strategies adopted by people with CRD to keep the benefits of PR and an active lifestyle on their own. People expressed that activities such as walking, cycling, or vacuum cleaning made them feel physically active, which was crucial to maintaining their well-being. Additionally, they felt that physical activity could be done in several places, such as patients’ homes, community centres, and outdoors—taking advantage of green spaces with clean air. Nonetheless, all stakeholders felt that these activities should consider people’s preferences to help them maintain their motivation and prevent dropouts.“(…) I do physical activity at home, like vacuum cleaning, it’s also good for me. I also climb a lot of stairs at home.”—J., male, 61 y, COPD“Walking… I had no idea that it was so good for him, and he got excited with counting his steps.”—A., female, 53 y, informal carer“If the patient has a bicycle or likes to walk, we have to give positive reinforcement. We need to work with them while they’re here to try to figure out what they do and what they like.”—J., male, 33 y, MDParticipants thought one of the most important barriers to being physically active was the lack of motivation in people with CRD and that this was related with the lack of awareness or consciousness about their condition. People with CRD felt that some of them, when not fully aware of how the disease progresses, might neglect physical activities by thinking they are not needed. They expressed that it was necessary to make a commitment with a professional, so they would feel inhibited from missing the session. Informal carers also revealed that keeping people with CRD engaged in social physical activities or maintenance PR made them feel at ease and better themselves, by seeing their loved ones were feeling happier and capable of doing more tasks at home. All stakeholders felt that giving the power to choose the type of activity to people with CRD and performing group activities would foster their motivation and could help break their typical social isolation. Furthermore, people with CRD showed that they were often scared of having no professional monitoring and that doing the activities by themselves could be detrimental, as they were not confident on how to perform the movements correctly. All stakeholders felt that, to keep people with CRD motivated and feeling safe, the activities should integrate the family and be monitored by a qualified professional. They also expressed that frequent follow-up should be done, to provide feedback to people with CRD on the course of their disease and reaching their goals and make any necessary adjustments. “I have equipment at home, I do one day then I am one month without doing it, then I’ll do it again. This does absolutely nothing. Because there’s no motivation, and there’s fear, fear of doing it wrong.”—T., female, 69 y, COPD, “It’s for their own good. Theirs and ours. Because their well-being is our well-being.”—C., female, 69 y, informal carer“Maintaining frequent physical activity with supervision, that’s what we saw that works, because without supervision their motivation decreases, and they stop doing physical activity.”—A., female, 35 y, PhysiotherapistParticipants felt that to induce behavioural change in people with CRD, they should be empowered through access to information about the types and places of available activities, and through awareness of the importance of being physically active. Participants felt that community PR programmes should also be available, so patients could maintain the benefits of the first programme conducted in specialised institutions. They also thought that creating partnerships with city councils would be of value for both interested parties, as PR services could refer people with CRD to physical activities and city councils could identify people with CRD that should be integrated in PR. Additionally, participants felt that city councils would have the necessary resources to place qualified professionals in monitoring people with CRD, close to people’s homes, such as fire departments, parish councils’ facilities or primary care centres, to conduct different physical activities at reduced costs.“(…) but pulling them to where we are, our centre, our region. Because this cost a lot of money, right? The cars don’t move on water, it’s difficult to bear.”—F., male, 67 y, interstitial lung disease“But I think that primary care centres are the closest to people, so I think that it will have to be in primary care centres.”—C., female, 69 y, informal carer“The city councils, they have their own health departments now, and they know what institutions they have in the region. It would be good if we could ask them to disseminate our programme and they told us what activities exist and in what institutions. Because usually, every institution that exists in every council is funded by the city council.”—A., female, 33 y, PhysiotherapistThis study showed the perspectives of people with CRD, informal carers, and HCPs on maintenance strategies following a PR programme.Our findings revealed that stakeholders thought people with CRD could perform some physical activities without supervision, such as walking or house chores, to keep an independent and active lifestyle. Studies have found that people with CRD often adopt more active lifestyles after PR, through occupational and household activities, walking, or cycling . NeverthA recent review found weak evidence for the effectiveness of exercise programmes following PR in people with COPD . AuthorsThis study suggests motivation and peoples’ preferences to be the key propulsors to engage people in active lifestyles. Doing physical activities with peers under the supervision of an HCP were recognised in our study, but also by others as facilitators to keep people with CRD motivated and adherent to interventions ,9,10. MoCurrently, physical activities adapted for people with CRD in the community are scarce, and since monitoring was highly valued by participants, their interest of having maintenance PR programmes in the community  was not surprising. Other studies have also shown that having maintenance PR after a first programme is often a desire of people with CRD , and thaFinally, focus groups were a suitable methodology to gather stakeholders’ views as this topic was unexplored . An in-dThis study has some limitations. Although efforts were made to have a balanced sample, the recruitment of informal carers was insufficient, and their views might not be representative of this stakeholder group. Difficulties in recruiting loved ones have been previously acknowledged in other studies . FurtherThis study suggests that motivation, and peer and professional support are key elements to maintaining the benefits of PR in people with CRD, and that different options considering people’s preferences, such as independent activities  or group-based activities provided by city councils, should be available.


This study examined the relationship between the sense of coherence (SOC), which is conceptually the ability to successfully cope with stress, of Japanese junior high school students and their mothers, and investigated SOC-related factors among the students. We analyzed self-reported data from 134 junior high school students (aged 12–14 years) and their mothers (average age: 45.5 ± 4.1 years), based in an urban area of Japan. We found a weak correlation between the SOC total scores of female students and their mothers; further, few subscales showed weak correlations. However, the SOC of male students was not correlated with that of their mothers, including the three subcomponents that constitute the SOC. The results of multiple regression analysis indicated that the SOC of female students was negatively associated with ASD-related characteristics, sensitivity to evaluation, and avoidant help-seeking style, and positively associated with a sense of belonging to the school. However, male students’ SOC showed a negative relationship with excessive response to evaluation and a strong sense of parental control. To improve SOC in adolescents, it is necessary to consider their gender differences and support them, both at home and school. SOC is at the core of salutogenesis, which aims to elucidate, support, and strengthen salutary factors by considering how health is recovered, maintained, and enhanced. SOC can also help transform stress into a source of growth and development. According to Antonovsky2, individuals with a strong SOC are less likely to perceive everyday situations as being stressful. Put differently, a SOC helps agents select appropriate coping strategies more frequently, and consequently, experience fewer detrimental health effects associated with stress3. Conceptually, a SOC comprises three components: comprehensibility, manageability, and meaningfulness. Comprehensibility refers to the extent one can perceive internal and external stimuli as understandable. Meaningfulness implies that a person is engaged with something in life that is important to them on both an emotional and a cognitive level. Manageability focuses on available resources needed to meet an individual’s demands2. Previous studies indicate that factors such as a high economic status4, high educational background5, and stable family relationships, are all associated with a strong SOC6. Moreover, in recent years, it has been a topic of great research interest, primarily in Europe and the US, as well as in Japan8.Sense of coherence (SOC) was originally conceptualized by Antonovsky10, and studies have shown that a strong SOC provides psychological stability to adolescents, and helps them adjust to the school environment and society11. However, Antonovsky12 stated that SOC in adolescents is very vulnerable, and suggested that receiving trust and affection from teachers, friends, and family has a significant impact on the development thereof in adolescents. Antonovsky1 stated that family relationships are associated with SOC formation, including the possibility that involvement in decisionmaking at home may foster a SOC in children; however, he did not clearly indicate if a SOC is passed down in families as an inherited trait. A study by Omiya et al. showed that the SOC of high school female students and their mothers is correlated and that the behaviors of the mothers and female students in families may influence each other13. Clarifying the association and influence of a SOC among family members in vulnerable adolescents, may help elucidate how a SOC is nurtured in children. Additionally, clarifying these issues can help advise parents and children on appropriate behaviors at home to foster a strong SOC in children. To our knowledge, no study has examined the association between SOC in junior high school students and their parents.It is a predictor of depression and adjustment disorders14. Ishizu and Ambo15 also pointed out that, while children who are sensitive to others’ evaluation have high social skills and appear to be adapted to school, they are also likely to be over-adapted. The tendency for over-adaptation may be reflected in a high-achiever student who understands the intentions of others, and at the same time, shows a high tendency toward depression16. In such a case, even if there is a tendency toward depression, parents and teachers judge a student as adapted and find it difficult to recognize the child’s help-seeking behavior. It has also been observed that model students are hesitant to request help15. Therefore, it is necessary to examine the relationship between adolescents’ susceptibility to others’ evaluation, decreased mental health, and help-seeking attitudes.School is an integral part of an adolescent’s life; close friendships play a major role in adolescence and significantly affect an individual’s school life. The psychological characteristics associated with this developmental stage can increase one’s sensitivity to evaluation by others. In a previous study on adolescents, many participants reported experiencing social intimidation, making statements such as “I wonder what people think of me,” “I feel tense when interacting with people,” and “I cannot fit in groups”13. Since the characteristics of ASD are distributed on a continuum, the concept of a spectrum has been proposed17. This indicates that, while students with significantly high ASD characteristics receive a diagnosis, there are many children with ASD tendencies in regular classes, who do not18. In Japan, there are many cases where ASD is not diagnosed in childhood, and depression or adjustment disorder appears as a secondary disorder in adulthood20. Since a SOC is a predictor of depression and adjustment disorder10, it is necessary to examine the relationship between SOC and ASD in junior high school students, from the perspective of depression and suicide prevention; however, thus far, no study has examined ASD tendencies and a SOC in junior high school students attending regular classes.In school, students develop close relationships with each other through regular communication. They cannot develop friendships if they find it difficult to understand others’ intentions or have unsuccessful interactions; such experiences can lead to school refusal, depression, and bullying. In a study on high school students, Omiya et al. found that high levels of the communication-related characteristics of autism spectrum disorder (ASD) were associated with a weak SOC in male studentsThis study aimed to examine the relationship between a SOC of adolescents and their mothers, and to identify factors associated therewith in adolescents who are experiencing stress and difficulties at school. The participants were Japanese junior high school students and their mothers. To gain insight into the process of a SOC formation, we examined how the SOC of junior high school students was related to that of their mothers. We also examined the relationship between junior high school students' SOC and school- and family-related variables, personality tendencies and traits, and parenting styles.Based on Antonovsky’s theory, is there a correlation between the SOC of junior high school students (early adolescents) and the SOC of their mothers?What are the factors related to the SOC of Japanese junior high school students?The SOC of female junior high school students is correlated to their mothers’ SOC.Junior high school students’ SOC is related to their own personality traits , family factors (subjective parenting styles), and the way they perceive school life.21. Thus, research in Japan suggests that adolescents’ relationships with their mothers may significantly impact their emotional growth and development22. Consequently, in this study, we focused only on mothers.The participants were 320 first- and second-year students attending a junior high school in Tokyo, Japan (age range: 12–14 years) and their mothers. In Japan, the responsibilities of childcare fall heavily on mothers, as it has long been the social norm for fathers to focus primarily on work and spend long hours away from homeData were collected using an anonymous self-administered questionnaire survey, between January and March 2018. The questionnaires were distributed to the students by their class teachers and the students took home the questionnaires for their mothers. Students were asked to submit completed questionnaires using a collection box placed in their school, while the mothers were asked to return their questionnaires by mail. We received responses from 158 students, with a response rate of 49.4%. Responses from students were analyzed only if their mothers also responded to the questionnaire. Overall, 134 mothers (41.9%) returned completed questionnaires. Additionally, among the respondents, there were no cases where a mother had two children in the same school.This study complied with the rules of the Declaration of Helsinki and was conducted with the approval of the medical ethics review board of the University of Tsukuba . In accordance with ethical guidelines, we obtained written consent from each student’s parents regarding their participation in the survey, since the present sample comprised junior high school students. We explained that participation in the survey was voluntary and that withdrawing participation at any time would not be penalized. We distributed the questionnaire only to students who provided a handwritten signature from their parents to confirm their intention to participate. We set up a response section in each questionnaire for both the students and mothers to confirm their intention to participate and checked whether there was a statement of intention to participate. We also assigned a common number to each mother-student pair to conduct a joint analysis; however, we explained in writing that there was no match between the students’ names and their assigned numbers, thereby maintaining anonymity.Each student’s gender and age were recorded as basic demographic attributes. The students’ mothers were asked to provide their age, educational background, financial status, occupation, and marital status.23, and validated through a nationwide survey in Japan. In the original 29-item scale, responses are provided on a 7-point scale; however, in the SOC-13, the items are rated on a 5-point scale. Additionally, the SOC-13 contains three subscales: comprehensibility (5 items), manageability (4 items), and meaningfulness (4 items). Higher scores indicate higher health-generating and stress-coping ability. In this study, Cronbach’s alphas of the SOC-13 among students and mothers, were 0.835 and 0.860, respectively.To measure SOC, we used the Japanese version of the Sense of Coherence 13-item Scale (SOC-13), which is a shortened version of Antonovsky’s original 29-item scale. The SOC-13 was developed by Togari and Yamazaki24. This scale has three components: acceptance by students (five items), acceptance by teachers (four items), and sense of belonging (four items). The reliability and validity of the Japanese version have been previously confirmed25. Responses are provided on a 5-point Likert scale and summed to obtain a total score. In this study, Cronbach’s alpha for this scale was 0.790.To measure the students’ sense of school membership, we used the Japanese short version of the School Membership Scale, adapted from Goodenow’s Psychological Sense of School Membership Scale26, that measures two types of help-seeking styles: excessive help-seeking (seeking more help than is necessary) and avoidant help-seeking (rarely seeking help). The scale comprises eight items rated on a 7-point Likert scale. Scores are summed up to provide a total score. In this study, Cronbach’s alphas were 0.914 and 0.927, for excessive and avoidant help-seeking, respectively.We used a scale developed and validated by Nagai27 developed and validated the PAS, based on the Children’s Report on Parental Behavior28. The scale assesses parenting behavior by examining children’s perspectives. It comprises three subscales: acceptance , excessive psychological parental control , and monitoring . Items are scored using a 7-point Likert scale, with responses ranging from 1  to 7 (“very applicable”), and a total score is calculated by summing up all items. In the present study, Cronbach’s alphas for the three subscales were 0.915, 0.826, and 0.709, respectively.Utsumi29. This subscale assesses sensitivity to evaluation (caring about others’ opinions) and excessive response to evaluation (being sensitive to the words of others and being shocked and hurt by minor criticism), both of which are measured by seven items each, scored on a 5-point Likert scale. In this study, Cronbach’s alphas for sensitivity and excessive response to evaluation were 0.858 and 0.814, respectively.We used the interpersonal sensitivity subscale of the Interpersonal Sensitivity/Privileged Self Scale, developed by Muranaka et al.30, the AQ-J-10 is a self-reported scale that measures autism-related traits among individuals with an IQ of at least 85. Since its reliability and validity have been confirmed31, the AQ-J-10 is commonly used to screen for ASD in Japan. Responses are provided on a 4-point Likert scale. For each item, the scale is split into halves, indicating high and low autism tendencies. If a participant selects one of the two options from the “high autism tendency” half, they are awarded 1 point, and if they select one of the two options from the “low autism tendency” half, they receive no points. The cut-off for the AQ-J-10 is seven points; that is, a score of seven points or more indicates a strong ASD tendencies.Based on a questionnaire originally developed by Baron-Cohen et al.In the analysis, we first performed a simple tabulation for the attributes of the mothers and students. Specifically, we tabulated the distribution of grades and the number of male and female students (ratio). We conducted a simple aggregation of the mothers’ attributes and traits. We used matching data for the mother-student pairs. We calculated the average SOC score and its standard deviation for the students and mothers. Both SOCs were normally distributed. Next, we examined the students’ SOC by gender. We calculated the correlation coefficient between the subscale scores and total SOC score of the student and the SOC of the mother.Additionally, we examined whether the average score on the School Membership Scale , help-seeking style , and PAS score, differed between male and female students. We examined the PAS  and the AQ-J-10  scores by gender, using the t-test. Furthermore, we calculated the Spearman correlation coefficient between each variable for both genders.To examine gender differences in the factors related to a SOC, we performed a multiple regression analysis with SOC as the dependent variable. On calculating the correlation coefficient for each gender, we found a significant correlation for both genders for the School Membership Scale, help-seeking style, the PAS, interpersonal sensitivity, and the AQ-J-10. Therefore, we input these as explanatory variables. We used the SPSS 25.0  for data analysis.32.Among the students, 61.2% of the participants were female (Table p < 0.05). For the SOC subscales, the correlation between female students’ meaningfulness scores and mothers’ total SOC scores was 0.232 (p < 0.05); no other significant correlations were found. However, male students’ SOC scores were unrelated to their mothers’ SOC, and there was no correlation between male students’ SOC and their mothers’ responses for any of the other variables.Table p = 0.011), as well as higher sensitivity to evaluation scores (p = 0.039) and monitoring scores for PAS (p = 0.039). Meanwhile, male students scored significantly higher on the psychological control subscale of the PAS (p = 0.001) and the AQ-J-10 (p = 0.039) compared with female students.Table p < 0.01; avoidance: r = 0.398, p < 0.01) and scores on the School Membership Scale . However, female students’ AQ-J-10 scores were not correlated with any variable.Correlation coefficients for the student-related variables, stratified by gender, are shown in Table p = 0.012), sensitivity to evaluation , having ASD-related traits , and an avoidant help-seeking style . Among male students, the significant variables included a tendency toward an excessive response to evaluation , and feeling controlled by their parents . The adjusted R2 scores were 0.715 and 0.530 for the male and female students, respectively. Thus, these traits appear to be related to a weak SOC.In the multiple regression analysis Table  using st32; however, we could not confirm this finding in our sample. Togari et al.33, examined a SOC in mothers of high school students and found that mothers’ SOC affected their children’s SOC. Thus, it is unclear whether the difference between the present and previous results is because of age difference between the samples, differences between private and public schools , or the location of the schools.To our knowledge, this is the first study to examine the relationship between early adolescent students’ and their mothers’ SOC scores. Although we found a weak correlation between mothers and daughters in terms of parent–child SOC, this relationship was absent between mothers and sons, as we found no correlation between male students’ and their mothers’ SOC scores. This result may indicate that a SOC is not mutually shared among a family’s members. This study used a cross-sectional design, and therefore, causal relationships could not be determined; however, it is plausible that adolescents’ SOC may be affected by relationships and experiences occurring outside the family. Although not shown in the tables, the mothers’ high economic status and high educational background were not related to their children’s SOC. Interestingly, previous studies have found an association between a SOC and high socioeconomic status and educational background34 reported gender differences in children’s affinity for their parents, and this affinity was particularly strong in mother-daughter relationships. High levels of closeness between mothers and their daughters have long been reported in Japan35, and situations where the father is commonly absent are notable in this regard21. Further, male junior high school students have close psychological proximity with their fathers, who are their primary role models34. Consequently, the SOC of male students may be strongly related to that of their fathers. Thus, future research on the association between children’s and parents’ SOC should also include fathers.With regard to the association of a SOC between mothers and daughters, Egami and Nakata36. However, this result was not found in male students. This study showed that both male and female students who do not seek help, lack a sense of belonging to their school and do not feel accepted by their teachers. This suggests that teachers and families should pay closer attention to students who do not express their difficulties or emotions.As mentioned, female students exhibited higher scores for help-seeking behavior and sensitivity to evaluation, compared with male students Table . However20, even if they are experiencing difficulties, and feel that they are not accepted by other students, and therefore, do not have a safe space in the school. However, no variables were correlated with ASD-related traits among the female students, despite the fact that the association was found for men; this may suggest, paradoxically, that women with high ASD-related traits may find it challenging to seek help, because they believe they are not experiencing much difficulty. In other words, a female student with high ASD-related traits—and her teacher—may first realize that she is having difficulties only after the student develops a secondary disorder, such as depression or an adaptation disorder. Therefore, teachers and school nurses should carefully assess students with ASD-like traits.Furthermore, our findings showed that male students exhibited higher ASD-related traits (via the AQ-J-10) than female students. Research indicates that children who have higher ASD-related traits usually do not seek helpWe also obtained results on the correlations among children’s characteristics and interpreted them. However, it is clear that concerns regarding the theoretical justification of these findings still remain. One possible reason for this is that very few studies have examined the association between ASD tendencies and other characteristics in junior high school students attending regular schools. From the perspective of an enhanced SOC and to ensure proper development in adolescents, it is necessary to accumulate more research on the characteristics of adolescents in this age group.37, which was confirmed in this study. Although it is natural to be apprehensive about the opinions of others, there is a need to educate female students, both at school and at home, that one should not be overly concerned in this regard. Additionally, given that female students build relationships in consideration of their surroundings and the harmony therein, known in Japan as “reading the context”37, it is possible that female students with ASD-related traits commonly experience severe difficulties in friendships at school. Indeed, in this study, female students tended to seek help more when compared to male students. However, children with ASD often do not seek help when needed20. Moreover, female students were more likely to seek help than male students; however, female students who do not seek help in need, are less likely to be noticed by their teachers or parents. Furthermore, female students who are likely to have ASD, may not know how to seek help or who to seek help from, and might not even understand that they are facing difficulties. Therefore, it is important for teachers and parents to actively ask such female students, “Are you experiencing any difficulty?” Furthermore, teachers and parents should secure a place for them where they can communicate and express themselves freely.The results of the multiple regression analysis showed that, among female students, sensitivity to evaluation , ASD-related traits, and an avoidant help-seeking style were significantly and negatively associated with a SOC. Importantly, adolescent female students often show a strong tendency to care about others’ opinions38. Furthermore, Bando and Mori39 found that male students experience more social pressure, particularly when exposed to others’ opinions. Thus, attention should be paid to male students, especially those who are sensitive to the reactions of others, and teachers should closely observe how they respond to interactions with peers. In this study, among male students, the feeling of being controlled by their parents  was correlated with a weak SOC. Excessive attention from mothers, typified by statements such as “Have you finished your homework?” or “Stop using your smartphone” may be interpreted by male adolescents as “You are a helpless and useless child.” Relevant literature states that adolescents who rebel against attentive parents are likely to be healthier37. Thus, we suggest that schoolteachers should monitor obedient or quiet male students who have attentive mothers, as well as their mental health status. While mothers need to be attentive to their sons, it is also crucial to educate mothers on how to interact with their sons at home—for example, informing them that it is better not to repeatedly give detailed instructions to boys.For male students, there was a significant negative association between a SOC and a strong tendency toward excessive response to evaluation (shocked or hurt by minor criticism). Previous studies have reported that male students greatly value their relationships with peers and seniors40. Given that male students tend to be more immature compared to female students of the same age, it is possible that male students with ASD are not bothered by their communication skills, because they are part of groups having members with similar characteristics. However, they may face difficulties upon reaching a stage that requires social communication, such as high school and college. Thus, proper career guidance—based on personality characteristics—is important for preventing secondary disorders, such as depression.Regarding ASD-related traits, male students’ scores were higher than those of female students; however, there was no association with a SOC. Social development in adolescence occurs more rapidly in female than in male studentsA major limitation of this study is that we only surveyed one school in Japan. This is because our questionnaire—which was a parent–child survey—contained sensitive content, and therefore, it was difficult to gain cooperation from schools. The school nurses and teachers in the target school were eager to care for the students. Additionally, it was a public school with several academic achievements and where many students came from families with a high socioeconomic status; therefore, the present results should be generalized with caution. Another limitation was the low response rate. Ethical considerations were required because the sample comprised junior high school students—specifically, we were required to acquire written consent from the parents of each student. Thus, the submission rate of the written consent forms was the response rate. Failure to adequately explain the study to parents—because of time constraints—could have negatively affected the response rate. A higher number of participants would have allowed us to examine additional variables. Furthermore, the parents (mothers) who consented and participated in the study may have been a group of mothers with a strong SOC, who were interested and enthusiastic about their children's care and school life. This can be seen from the fact that the mothers' SOC scores were higher than those of their peers in the national sample. This population characteristic needs to be understood and considered when interpreting the results.In this study, we only included mothers, as they are considered to be the parent primarily involved in child-rearing in Japan. Although we found an association between female students’ and their mothers’ SOC, it is possible that a similar association between male students’ and their fathers’ SOC could have been observed, if fathers had been included in this investigation. To enable proper physical and psychological development in children, it may be necessary to provide fathers with recommendations on how to behave at home and interact with their children. Thus, further research regarding the role of fathers in adolescent SOC formation is necessary and warranted.The SOC of female junior high school students was slightly correlated with their mothers’ SOC. However, there was no correlation between male students’ SOC and mother-related variables. This may be due to the high affinity between mothers and daughters at home, in Japan. In the future, it will be important to consider the relationship between boys’ and their fathers’ SOC. Furthermore, although there were no gender differences in the SOC scores, such differences were found in other variables, such as ASD-related traits being higher in male students than in female students, and the latter seeking help more than the former. The multiple regression analysis showed that, among female students, factors such as ASD-related traits and an evasive help-seeking style were negatively related to a SOC. Given that many female students are usually active in seeking help, teachers and parents need to pay attention to quiet female students who do not seek help. At school, establishing a system of counseling and outreach can make it easier for students to receive help.Excessive response to evaluation and a strong sense of parental control were negatively related to a SOC among male students. Thus, persistent attention from mothers may reduce their sons’ SOC. It is important to observe male students who receive too much attention from their mothers and are quiet and obedient. Ultimately, the school and home environments both have different influences on adolescent boys and girls; thus, it is necessary to create environments that accommodate these gender differences within schools and homes.