Previous research suggests that mindfulness meditation and psychedelic substances show promise as mental health interventions, but relatively little remains known about their potential impact on leadership outcomes.This study aimed to investigate if and how mindfulness meditation and psychedelic use may impact leadership among respondents with a management position as their primary role at work.Using samples representative of the US and UK adult populations with regard to sex, age, and ethnicity, this study used quantitative and qualitative methods to examine if and how mindfulness meditation and psychedelic use may impact leadership.n = 3,150), 1,373 reported having tried mindfulness meditation and 559 reported having tried psychedelics. In covariate-adjusted regression analyses, both lifetime number of hours of mindfulness meditation practice and greater psychological insight during respondents’ most intense psychedelic experience were associated with describing a positive impact on leadership , while qualitative analyses revealed nuances in the type of impacts mindfulness meditation and psychedelic use had on leadership. There were several subthemes  that were frequently reported with both mindfulness meditation and psychedelic use. There were also unique subthemes that were more commonly reported with mindfulness meditation  and psychedelic use , respectively.Among respondents with a management position as their primary role at work (Although causality cannot be inferred due to the research design, the findings in this study suggest potential complementary effects of mindfulness meditation and psychedelic use on leadership, which could inspire new approaches in leadership development. There have recently been anecdotal reports of individuals using altered states of consciousness for peak performance and leadership development . While tThe cultivation of mindfulness through meditation or other practices has been found to influence several outcomes related to leadership . For insWhile psychedelics are largely unexplored in the leadership literature, recent quantitative findings suggest that moderate-to-high doses of psychedelics—if administered in safe and supportive contexts—may also impact outcomes related to leadership see also , creativPrevious research indicates that there may be parallels between the neurophysiology and phenomenology of altered states induced by mindfulness meditation and psychedelic use . Other rN = 9,732), we used quantitative and qualitative analyses to examine if and how mindfulness meditation and psychedelic use may have influenced leadership among respondents with a management position as their primary role at work. The perceived impact of mindfulness meditation and psychedelic use, respectively, was also compared to better understand in what ways such self-reported effects might overlap and contrast with each other.To address the gaps in the literature, the present study aimed to investigate the perceived impact of mindfulness meditation and psychedelic experiences on leadership at work. Using samples representative of the US and UK adult populations with regard to sex, age, and ethnicity  and UK  residents who were 18 years or older. The study description did not mention psychedelics to avoid potential self-selection bias. The respondents were asked questions about demographic characteristics, employment status, mindfulness meditation, and psychedelic use. This study was part of a larger survey and respondents were paid £0.9 for completing the full survey. Study procedures were determined to be exempt from review by the Institutional Review Board at the University of Wisconsin–Madison.The respondents were recruited in August 2022, through Prolific Academic,All respondents were asked to report their age in years, gender , educational attainment , degree of religiosity , and political affiliation .All respondents were asked whether they were currently employed or not. The respondents who reported current employment were asked to select the response option that best described their primary role at work:Board MemberC-Level Senior ManagementOther ManagementNone of the aboveThe respondents were asked whether they had ever tried mindfulness meditation, including Vipassana, Zen Buddhist meditation, Mindfulness-Based Stress Reduction, and Mindfulness-Based Cognitive Therapy. Those who reported that they had ever tried mindfulness meditation were asked to estimate their total lifetime number of hours of mindfulness meditation practice . If respondents reported that they had ever tried mindfulness meditation and they had a management position as their primary role at work , they were also asked to write a few sentences describing if and how mindfulness meditation had impacted their leadership at work.The respondents were asked whether they had ever used drugs, including any of the following psychedelics: N,N-Dimethyltryptamine (DMT), ayahuasca, psilocybin, LSD, mescaline, peyote, or San Pedro. Those who reported that they had ever used psychedelics were asked to think back on their most intense experience using a psychedelic and complete the Psychological Insight Questionnaire (n = 3) and psychedelic use (n = 8) categories. However, sensitivity analyses were conducted with no impact on leadership and negative impact on leadership combined into one category. The logistic regressions included a number of control variables that broadly correspond with those used in a previous investigation (The responses were coded independently by two authors (OS and WO). First, each participant’s text description was coded primarily as (1) no impact on leadership, (2) positive impact on leadership, or (3) negative impact on leadership. If the text description was perceived as contradictory or did not clearly indicate a positive or negative impact on leadership, it was coded as no impact on leadership. Once the independent analyses were finished, inter-assessor verification was carried out to ensure that consensus was reached on the coded categories. Logistic regression was used to examine the association between the respondents’ lifetime number of hours of mindfulness meditation practice and the perceived impact of mindfulness meditation on leadership . Logistic regression was also used to examine the association between psychological insight during respondents’ most intense experience using a psychedelic and the perceived impact of psychedelics on leadership . The independent variables were z-scored to standardize values and make comparison easier. Negative impact on leadership was not evaluated in regression models due to low counts in both the mindfulness meditation . As shown in the table, 1,373 of respondents in a management position reported having tried mindfulness meditation , 559 reported having tried psychedelics , and 334 reported having tried both . A total of 396 responses on mindfulness meditation and leadership were coded as no impact (28.8%), 974 were coded as positive impact (70.9%), and 3 were coded as negative impact (0.2%). A total of 324 responses on psychedelics and leadership were coded as no impact (58.0%), 227 were coded as positive impact (40.6%), and 8 were coded as negative impact (1.4%).Based on the analysis of the text descriptions, we identified four main themes that emerged in the texts on both mindfulness meditation and psychedelic use: (1) wellbeing and health; (2) presence and awareness; (3) productivity and performance; and (4) interpersonal attitudes and behaviors. Each theme is described below and exemplified with quotations from the respondents. Due to low counts on negative impacts, such quotation examples are included under a general theme on negative impacts.The thematic analysis revealed that wellbeing and health was a common theme across many respondents who practiced mindfulness meditation. For example, many respondents described how mindfulness meditation had a calming effect on them and had also helped them to manage stress and anxiety, which positively impacted their sleep and wellbeing. This made them more effective in their leadership and more resilient at work, especially in the midst of challenging and stressful situations.“When I was feeling really stressed, mindfulness [meditation] helped me to feel more relaxed. This in turn helped me to sleep better and then be a better leader.” 34, Female, Other Management.“Mindfulness [meditation] helps me reduce my stress and anxiety levels generally. At work, this has helped me perform better as a leader in stressful situations. I’m able to approach difficult situations with more conscious thought.” 25, Male, Other Management.“As someone who has dealt with anxiety and depression over a lifetime, mindfulness meditation has become an essential part of my self-care toolbox. I meditate in the morning to calm my mind and body rather than getting hyped up on the minutia of what tasks lie ahead in the day. As my mind is cleared, I find I am better able to process the unexpected in my day without anxiety. I meditate in the evening essentially for the same reason, to clear my mind of the day’s stressors and prepare for a restful sleep. These practices have made me a much more effective leader at work because I find I am overall less stressed and far better able to give my team individual attention and listen to them fully. We have actually incorporated meditation at our workplace and many of my team members express thankfulness for the changes it has brought to their lives both in and outside of work.” 54, Female, Senior Management.“Mindfulness meditation makes me [calmer and more] focused at work. I can deal with situations in a controlled way and therefore can be the leader that others can be confident in following.” 42, Male, Senior Management.“[Mindfulness meditation] has put my mind at ease, making leading others easier and less stressful.” 20, Female, Board Member.Another common theme among respondents was greater presence and awareness as a result of mindfulness meditation. For instance, respondents frequently reported more decentering, less reactivity, and greater awareness of thoughts, feelings and behaviors. This supported them in their emotion regulation and self-understanding, which, in turn, had positive downstream effects on performance and interpersonal behavior at work.“Mindfulness meditation has helped me become more patient and understanding in my leadership at work. I am able to separate myself from uncomfortable emotions, such as anger and irritability. I try to become more mindful and observe what is actually going on without the filter of these emotions.” 30, Female, Other Management.“[Mindfulness meditation] helps me to remain observant of my thoughts and feelings in a way that promotes response rather than reaction and allows me to stay focused on important tasks.” 43, Male, Other Management.“I think [mindfulness meditation] has allowed me to become more aware of the impact of my actions and words. It has influenced the way I respond to my peers and to myself.” 44, Female, Other Management.“[Mindfulness meditation] helps de-stress and de-escalate my feelings and allows me to think critically about a situation instead of emotionally. Like when a subordinate makes a mistake that directly impacts me and my performance. A few minutes of mindful meditation lets me separate myself from my emotions and be able to coach my employee in a beneficial and logical way. It’s like it lets my logic and reason take over instead of emotion and feeling.” 41, Male, Other Management.“[Mindfulness] meditation has provided me with a better understanding of myself and my feelings. It has allowed me to be more accepting of change and differences between people. It has also allowed me to feel more confident around others which helps in leadership, especially when making presentations or leading a team.” 29, Female, Senior Management.“I use mindfulness [meditation] to enhance my effectiveness and performance including becoming more aware of my personal limits of performance. Specifically, enhanced levels of self-awareness, attention and emotion regulation were applied as mechanisms of change to improve my effectiveness.” 47, Male, C-Level.Mindfulness meditation was described by several respondents as a helpful tool for productivity and performance at work. While enhanced focus at work was widely mentioned as a result of mindfulness meditation, there were many other positive outcome descriptions, including improved priority-setting, problem-solving, creativity, and overall productivity for oneself and one’s team.“For me, I feel that my mindfulness [meditation has] broadened my perspectives on things, has helped me to encourage my team’s individual strengths to create better performance as a group, and has brought greater depth to my compassion.” 64, Female, Other Management.“Using mindfulness meditation, I’m able to control my anxiety and stay calm at work. This has helped me keep on task and has improved my overall productivity as a leader at work. I’m able to make good job-related decisions on a day-to-day basis.” 32, Male, Other Management.“Mindfulness meditation has [helped] in reducing stress and anxiety and makes me focus on things that really matter at work, which makes me effective in my leadership at work.” 30, Female, Other Management.“Mindfulness meditation has helped me to concentrate and be creative as a leader at work.” 36, Male, Senior Management.“I have used [mindfulness meditation] to calm down. I usually do it when I need to focus and be more productive at my work.” 48. Male, C-Level.Many respondents described how mindfulness meditation positively influenced their interpersonal attitudes and behaviors. While empathy, compassion and patience were mentioned regularly, there was also a recurring theme around a more collegial and egalitarian approach to leadership.“[Mindfulness meditation] helps me to be calm and not critical of others. I am able to lead with compassion.” 69, Female, Other Management.“My [mindfulness meditation] practice has enabled me to not be so stressed in leadership roles and to be able to lead compassionately, without forcing authority on my subordinates.” 59, Female, Other Management.“Mindfulness meditation has helped me become a gentle, more empathetic leader. I now enjoy collaborative projects, whereas before I had an individualistic approach to problem-solving. I actively listen to the needs of others within my organization, and take a more compassionate, hands-on approach to teaching, training, and leading - and I owe much of my professional growth to the daily practice of mindfulness meditation.” 39, Female, Other Management.“[Mindfulness meditation has] made me more aware of the importance of treating others with compassion and equality. [It has] made me calmer in the workplace and more able to deal with problems effectively.” 64, Male, Senior Management.“Mindfulness meditation has [helped] me be more empathetic and compassionate at work and develop a collegial approach to management. I do not use an autocratic management approach - that approach does not let employees develop to their full potential.” 79, Male, C-Level.“I feel [mindfulness meditation] made me more connected, focused and patient. The new, more compassionated way of leading and inspiring people seems to be contagious among co-workers.” 38, Male, Board Member.There were a few responses that were coded as negative impact, but no discernible themes emerged due to low counts.I do not know if I can really say that it has impacted my leadership at work. For me, [mindfulness] meditation causes bad memories to surface and then I dissociate, which I do not find too helpful. 49, Female, Other Management.It’s been completely useless. I found it more stressful to do it. I prefer physical exercise. 37, Male, C-Level.The thematic analysis revealed that wellbeing and health was a recurring theme among those who reported lifetime psychedelic use. For instance, many respondents reported developing a more loving and caring relationship toward themselves and healing from depression, anxiety, or past trauma. The increase in wellbeing and health, in turn, was described as helping the respondents to lead and help others at work.“It made me a much calmer and happier person.” 48, Female, Other Management.“My experience with psychedelics has contributed to my creativity and also helped reduce issues with depression which negatively impacted my leadership skills in the past.” 34, Male, Other Management.“My experience with [psychedelics] allowed me to grow as a human and really deal with all the pain I had experienced and trauma. Even though the growth was uncomfortable, it was necessary for me to reach my full potential and be there for others in a leadership role.” 21, Female, Other Management.“It has relieved stress when I [use psychedelics] occasionally, thus making me enjoy work much more.” 33, Male, Senior Management.“Psychedelics have made me more confident in dealing with who I am and all my good and bad parts. It made me put my guard down and stop being such a perfectionist and realize that it’s okay to make mistakes!” 27, Female, C-Level.“I have benefited from psychedelics by being able to work through past trauma and learning to love myself. That impacts my work because I feel more connected to people and the universe and I think that helps me to help my clients.” 50, Female, C-Level.There was a general theme around presence and awareness across respondents, in particular around self-understanding and psychological insight. The use of psychedelics was frequently reported to have led to more presence at work and a heightened awareness and understanding of oneself and others. This was often described as leading to more effective leadership.“I feel like trying [psychedelics] has impacted my leadership at work positively. I became more aware of my actions and thoughts. I was also able to understand other people more by experiencing something completely new.” 26, Female, Other Management.“It gave me better insight into who I am and how I operate. It showed me there are more important things than work.” 68, Male, Other Management.“I was better able to work calmly and slowly, even mindfully. I was keenly aware of myself and detached from the worries around me. I was connected on a deeper level to myself and my loved ones, pets, friends. I was a slower, more careful worker and a less stressed person overall.” 29, Female, Senior Management.“It allows me to find empathy in almost anything and anyone. I should add that I probably do a heroic dose every 4 months because it resets my brain. My apathy and depression go away and I am a much more present boss. Present is the key word.” 49, Male, Senior Management.The respondents commonly reported benefits of psychedelic use related to productivity and performance. For instance, several respondents attributed a greater capacity for creativity and out-of-the-box-thinking to their use of psychedelics, but there were also a few reports of enhanced focus and problem-solving.“Psychedelics improved my leadership skills by allowing me to be more creative and open-minded. I believe the use of such substances may improve the overall cognitive function of the brain.” 50, Male, Other Management.“Psychedelics have allowed me to be less biased and come from a place of common ground when working with subordinates and upper management alike. They have given me a sense of scale and of what really matters and of how to deal with issues in a manner appropriate to the magnitude of the issue.” 23, Male, Other Management.“My experiences with psychedelics [have] generally improved my leadership at work. It has allowed me to become more hyper focused and allowed me to see things in a new light. It has allowed me to become less stressed and work better in my organization.” 26, Male, Senior Management.“It made me examine myself and the world around me in more compassionate ways while recognizing personal complexities that contribute to effectiveness and productivity in a work setting. People are people, after all.” 31, Non-Binary Gender, C-Level.“It strengthened my ability to see a problem from the outside looking in. Having the skill to remove one’s self from a situation is paramount to finding an objective solution.” 48, Male, C-Level.“I’ve felt more open to creative ideas that I was previously unable to visualize. I’ve also been much more compassionate and empathetic since my first major trip. I feel as though these things have helped me become a better, more understanding leader.” 44, Male, C-Level.The interpersonal attitudes and behaviors theme was perhaps the most salient topic in relation to psychedelic use. Not only did respondents regularly mention compassion, empathy, forgiveness, and patience in relation to their coworkers and others, but the use of psychedelics was commonly reported to have facilitated a less hierarchical attitude toward colleagues and a closer bond—and more connectedness—with their teams at work.“It made me realize that we are all interconnected and one person’s actions will eventually effect everyone. I try to lead with compassion and flexibility. Since we are all connected, it makes no sense to be hard with someone.” 45, Female, Other Management.“It has provided a lasting perspective that I can consider, which is the truth that all people want love and validation. I can use this knowledge to build [up those] around me to grow as a team.” 26, Male, Other Management.“It has allowed me to see the bigger picture and not be harsh on employees. I realize everybody is needed for their different skills to make the wheels go round. Everybody plays their part and everybody is equal.” 38, Male, Other Management.“My experiences with psychedelics have only really affected my work as a leader in the sense that I believe they made me more compassionate, empathetic, and understanding. These qualities allow me to be a more effective leader by fostering an environment in which people can thrive and build their skills comfortably.” 26, Male, Other Management.“My previous experiences [with] psychedelics have fundamentally changed my interpersonal behavior by making me much more empathetic to other people’s perspectives. This has probably made a more tolerant manager than I would otherwise be.” 45, Male, Other Management.I think it opened me up to the possibility that I am not always right and that I do not have to be, so I am more open to feedback and constructive criticism. I understand that no one is above or below anyone, so I do not engage in hierarchical supervision behaviors or thoughts. 46, Female, Other Management.“I feel a greater sense of unity with my team members.” 29, Male, Senior Management.“It’s a while since I have done any psychedelics but I feel it gave me a greater understanding of life itself and one of those lessons is to not judge others so harshly throughout life. In the work environment it can get stressful and it’s easy to cast judgment but in the end we are all the same, going through our own problems that no one else knows anything about and sometimes this can impact the things we do or say. It’s difficult at times to have this understanding [or] take this approach in a managerial position but I believe it’s helped form a closer work relationship with my colleagues which in return has boosted performance in the business.” 36, Male, C-Level.There were a few responses that were coded as negative impact, but no discernible themes emerged due to low counts.It made my work harder and I wasn’t feeling good. 26, Male, Other Management.It has taken me quite a while to recover from the after effects, so it becomes difficult to focus on work. 26, Male, Other Management.Using representative samples of the US and UK adult populations with regard to sex, gender and ethnicity, this study applied quantitative and qualitative analyses to examine if and how mindfulness meditation and psychedelic use might impact leadership among respondents with a management position as their primary role at work. The quantitative analyses revealed that lifetime number of hours of mindfulness meditation practice was associated with a higher likelihood of describing a positive impact on leadership and greater psychological insight during respondents’ most intense psychedelic experience was associated with a higher likelihood of describing a positive impact on leadership. In the qualitative analyses, no discernible themes emerged from the responses coded as negative impact due to low counts, but the analyses assessing positive impact on leadership revealed four overarching themes that were common to both mindfulness meditation and psychedelic use: (1) wellbeing and health; (2) presence and awareness; (3) productivity and performance; and (4) interpersonal attitudes and behaviors. There were notable overlaps and differences within these themes when comparing mindfulness meditation and psychedelic use, which suggests that these two interventions may produce comparable and also complementary effects on leadership at work. While there were several subthemes  that were frequently reported with both mindfulness meditation and psychedelic use, there were a few that were relatively unique to mindfulness meditation and psychedelic use, respectively. For example, improved sleep was commonly reported among respondents who had engaged with mindfulness meditation, but sleep was not mentioned in any response among those who had used psychedelics. Another notable difference was the extent to which respondents who had engaged with mindfulness meditation reported stress reduction and calming effects as compared to those who had used psychedelics. It was, however, more common for respondents who had used psychedelics to report greater self-understanding and also positive changes in interpersonal attitudes and behaviors than those who had used mindfulness meditation. These identified overlaps and differences contribute to the emerging research literature on the potential complementary effects of mindfulness meditation and psychedelic use .There was a higher prevalence of responses coded as positive impact among respondents who reported mindfulness meditation practice (70.9% versus 40.6% of those who reported psychedelic use) and a higher (though still low) prevalence of responses coded as negative impact among respondents who reported lifetime psychedelic use (1.4% versus 0.2% of those who reported mindfulness meditation use). Such differences do not necessarily reflect a higher risk–benefit ratio for mindfulness meditation relative to psychedelic use in leadership development. It is possible, for example, that those who reported psychedelic use had taken these substances in unsupportive contexts, in low doses, or in combination with other substances, all of which could have influenced responses. The same could also be true for those who reported mindfulness meditation use.These findings must be considered in light of several limitations with the research design. First, although the responses were coded by two researchers independently, it is possible that the respondents themselves or other researchers would disagree with the coding of the responses. It may also have been useful to have utilized more than two researchers coding the responses to reduce potential bias. Second, the respondents were asked a single qualitative question about leadership and were not asked to provide additional details about their use of mindfulness meditation or psychedelics that could have been important to evaluate . No questions were asked, for example, about whether the use of mindfulness meditation or psychedelics preceded work experience in a management position, which would have been important to better understand temporal sequence. The single qualitative question also did not ask about the durability of the potential effects . Third, respondents who reported current employment were asked to select the response option that best described their primary role at work, but no additional questions were asked that could have been useful . Fourth, the findings cannot be used to infer causality, due to the cross-sectional design of the study. Fifth, the responses were collected from a single survey and were both retrospective and self-reported, which increases the likelihood of response biases . It is pWhile the findings in this study should be considered preliminary due to the limitations of the research design, the results suggest that mindfulness meditation and psychedelic use may produce comparable and also complementary effects on leadership at work. If replicated in future studies with more rigorous research designs , such findings could lead to the development of novel training programs that combine both mindfulness meditation and psychedelics to improve leadership at work.https://doi.org/10.6084/m9.figshare.23541459.v1.Data and code are available at figshare: Study procedures were determined to be exempt from review by the Institutional Review Board at the University of Wisconsin–Madison. The patients/participants provided their written informed consent to participate in this study.OS conceptualized and designed the study. OS and WO analyzed the data. OS wrote the manuscript, with comments from CS, SG, PH, and WO. All authors contributed to the article and approved the submitted version.OS was supported by Ekhaga Foundation and Olle Engkvist Foundation. SG was supported by a grant (K23AT010879) from the National Center for Complementary and Integrative Health. Support for this research was also provided by the University of Alabama at Birmingham School of Public Health, Swedish Research Council for Sustainable Development , Forte (2020–00977), and the University of Wisconsin–Madison Office of the Vice Chancellor for Research and Graduate Education with funding from the Wisconsin Alumni Research Foundation and with funding from the Wisconsin Center for Education Research.PH was on the scientific advisory board of Bright Minds Biosciences Ltd., Eleusis Benefit Corporation, and Reset Pharmaceuticals Inc. OS was a co-founder of Eudelics AB.The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


It is increasingly recognised by UK researchers and population health advocates that an important impetus to effective policy action to address health inequalities is activation of public dialogue about the social determinants of health and how inequalities might be addressed. The limited body of existing scholarship reaches varying conclusions on public preferences for responding to health inequalities but with consensus around the importance of tackling poverty. Young people's perspectives remain underexplored despite their increasingly visible role in activism across a range of policy issues and the potential impact of widening inequalities on their generation's health and wellbeing.Six groups of young people  from two UK cities (Glasgow and Leeds) were engaged in online workshops to explore views on health inequalities and potential solutions. Inspired by calls to employ notions of utopia, artist–facilitators and researchers supported participants to explore the evidence, debating solutions and imagining a more desirable society, using visual and performance art. Drawing together data from discussions and creative outputs, we analysed participants' perspectives on addressing health inequalities across four domains: governance, environment, society/culture and economy.Proposals ranged from radical, whole‐systems change to support for policies currently being considered by governments across the United Kingdom. The consensus was built around embracing more participatory, collaborative governance; prioritising sustainability and access to greenspace; promoting inclusivity and eliminating discrimination and improving the circumstances of those on the lowest incomes. Levels of acceptable income inequality, and how best to address income inequality were more contested. Individual‐level interventions were rarely presented as viable options for addressing the social inequalities from which health differences emanate.Young people contributed wide‐ranging and visionary solutions to debates around addressing the enduring existence of health inequalities in the United Kingdom. Their reflections signal support for ‘upstream’ systemic change to achieve reductions in social inequalities and the health differences that flow from these.An advisory group of young people informed the development of project plans. Participants shaped the direction of the project in terms of substantive focus and were responsible for the generation of creative project outputs aimed at influencing policymakers. In relation to addressing health inequalities, these processes could precede the generation of consensus around actionable solutions. In this study, we asked young people about their perceptions of health inequalities and potential alternative visions for fairer societies in which health inequalities are reduced. Specifically, the research presented here focuses on the following exploratory questions: 1—What do young people, drawn from across Glasgow and Leeds (United Kingdom), envisage a fairer society, in which health inequalities are reduced, would look like? 2—What are young people's perceptions of key policy domains for addressing inequalities and what actions do they support in reducing inequalities?Scott‐Samuel and colleagues propose that research exploring potential responses to health inequalities might be aided by engagement with notions of utopia.22.1By employing arts‐based research with young people, we aimed to provide safe and collaborative spaces (with artists and researchers) to discuss how health inequalities are generated and might be addressed. Developed largely in the tradition of participatory research, arts‐based approaches have been adopted across disciplines, including health,2.2Six groups of young people, three in Leeds and three in Glasgow, were recruited to participate in arts‐based workshops over 4 days  was impacted by pandemic‐related physical distancing measures in the United Kingdom, so workshops were online using the preferred video‐conferencing platforms of partner organisations. This pivot involved close consideration of the potential for digital exclusion and accessibility needs of participants, development of alternative engagement and facilitation approaches and rapid innovation in collaborative online art‐making activities. Materials  were posted to participants before the first workshop. Each day comprised three/four workshop sessions, with breaks between. Young people joined from private spaces, mostly their homes. Workshops were led by creative facilitators, drawing on activities, resources and topic guides co‐developed with researchers. Facilitators completed a short online training module in health inequalities as preparation for the project but had not previously engaged with evidence or policy discussion in the area. Their expertise was in creative engagement and facilitation with young people, and their role in the workshops was collaborative and supportive, rather than primarily focused on data collection. Researchers observed sessions, answered questions and offered facilitation support as needed.Following the first workshop series (Glasgow 1), session plans were refined based on facilitator, researcher and participant insights. In the five subsequent workshops, the first day was used to explore drivers of health inequalities while the remaining days focused on addressing inequalities. An indicative schedule for workshops is provided in Table Sessions included warm‐up games; group discussions, breakout discussions and interviews; engagement with research evidence and policy and responsive creative practice. Glasgow groups focused on visual arts and Leeds groups focused on performance arts according to the expertise of facilitators. Young people were supported to develop creative outputs through engagement with notions of utopia and alternative futures,2.4The creative activities, group discussions and interviews resulted in a diverse data set, including verbatim transcripts derived from recordings of 51 group and breakout discussions and 32 interviews, ethnographic notes, extracts of creative writing and visual and performance art . Text files were uploaded to NVivo 12 for coding. Lead and second authors read and reread all materials and developed an initial thematic network summarising visually the main themes and sub‐themes, and relationships between these.3Our analysis of young people's discussions and creative outputs shows engagement across wide‐ranging policy domains influencing health inequalities. We briefly discuss participants' conceptions of effective solutions, before considering their responses to the task of envisaging what a society in which health inequalities are much reduced might look like.3.1G2_P3: I knew that the mental health services in school wouldn't help at all, that the schools just don't listen, even though they said they did, but they just don't. And the [free Mindfulness] app would just be easily forgotten, just like if you were to download a game, play it for a bit, use it, then just forget about it and delete it. And, just, so protecting people's jobs relieves stress and just gives them a proper income, so they have money to live and have a house, the standard things that they need for living. Within and across groups, there was agreement on the need to address health inequalities, and broadly groups appeared to conceptualise health as socially determined. This may reflect, in part, responses to evidence participants encountered early in the workshops describing the nature and extent of the problem.Across discussions, participants' preferred actions to tackle health inequalities could be considered ‘upstream’ policy changes. Efforts to secure adequate living and working conditions for all, through systemic change, were frequently described as more likely to impact health inequalities than individually focused interventions. Indeed, young people's proposals align with expert characterisations of effective interventions as addressing causes rather than symptoms of health inequalities3.2Young people shared their creative visions for alternative futures in which health inequalities are reduced and developed a series of ‘policy asks’ for addressing social inequalities. Explanation of the mechanisms and pathways through which these linked to health varied across policy domains discussed. Similarly, progression from visions to policy asks varied: some participants stayed committed to alternative future visions throughout discussions, even if far removed from reality, while others progressed from utopian visions to proposals for refining current systems and policies as incremental steps towards a longer‐term vision.Our analysis categorised participants' reflections into four overlapping domains: governance; environment; society/culture and economy. We describe each of these in turn, providing illustrative examples of the visions described, noting underpinning values and proposals for action and considering consensus and diversity.3.2.1Facilitator: [L3_P2], in your utopia, what does power and responsibility look like?L3_P2: […] there wouldn't be a government, it would be sort of socialist, but not like…because there's, like, Communism, where everyone is the same, and you do everything the same. But it would be like, everyone works together, [rather] than have discrimination, or just like, splitting people apart, it would be a communion. Many participants shared visions of alternative futures that involved replacing or enhancing systems of governance to address inequalities in power. Improved systems were associated with cooperation, transparency and devolution.L3_P4: […] the community would run the community. So it would just be normal people […] And you can go to, like, the big town hall, or something, have a discussion, get to know each other's points, have a bit of an argument and debate […]. Because there's nothing saying that we can't do the job that they're [current UK government] doing, […] if we managed to get our idea out there, into our own communities, we could be the change that we need. This participant shared concerns surrounding historic examples of Communism and infringement of freedoms, alongside a desire for a shift from the current system to one centred around community and cooperation. Similarly, more community‐based governance was proposed by another participant:Artwork Figure  from GlaThe artist explained: ‘I really wanted to have a pattern in it, so using little hands would be a good idea to symbolise that communities, that are being brought together, make decisions’ . Across groups, discussions often focused on moving towards systems of governance in which communities play a greater role in decision‐making. These suggestions appeared to emerge from concerns that key institutions  and existing democratic arrangements perpetuated inequalities in power, in ways that some participants thought predicated health inequalities. This echoes population health experts emphasis on the importance of considering power as the essential element in generating or reducing health inequalities.L3_P5: I don't think it's the right approach to take down the government because I think we need stability, I think the way it's run isn't the right way and that's where we need to change, so we shouldn't be like altering the system, we should be working with it to change it. Despite a general sense, across groups, that changes to the political system were needed (primarily ceding power to citizens and communities), these views were not universal. One participant conveyed her alternative perspective in an interview:G3_P4: And for rules and stuff like that I wrote, the rules of the people […] I hope that in a utopia like far, far, far, far, far, far, far future, it's less of governments in localised places, like countries and things like that. […] But I feel like human beings will progress to the point where we're just like; countries are a bit stupid; we're going to planets now. This participant was cautious about the revolutionary rhetoric some participants in Leeds 3 were adopting, though remained committed to change. Another perspective from Glasgow 3 shifted focus from local notions of community to thinking in more global, planetary terms:democratic rejuvenation to address health inequalities in the United Kingdom, which would involve embracing democratic innovations and participatory decision‐making to reduce those power imbalances which predicate health inequalities.Visions of alternative systems of democracy, therefore, were not unified. Despite this, consensus was built around a concern to disentangle control over policy change from current systems reflecting changing patterns of political engagement amongst young people, with a preference for alternative over formal modes of political participation.3.2.2L2_P3: I can hear the rustling of the wind. I can hear nature. I can hear live music. I can't hear violence or shouting. I cannot hear cars or trains. Young people's utopian conceptualisations and policy proposals regarding the environment illustrate the wide‐reaching positive impacts they conceived improving places could have on health. When asked to envision a utopian society, initially many of the young people focused on physical aspects of the environment with a connection to nature prioritised. One participant described ‘blue skies’, ‘palm trees’ and ‘seagulls’  while another listed, ‘fruit trees, plants, greenery, flowers, land, clean’ . A sensory spoken word performance about Utopia also suggested this preference for living close to nature:Links made by young people between access to nature and mental and physical health broadly reflect evidence on the positive effects of exposure to green space on levels of health inequality within populations.Several participants extended their discussions of natural environments beyond benefits to individuals or communities to focus on sustainability and planetary health. One participant made this a central theme in her final artwork Figure .She described the aim of the work: ‘I decided to make my poster about environmental alternatives and the importance of coming together to make the world a greener place’ . Links to cooperation and community are evident but in combination with considering sustainability. Several young people tied together concerns for human, animal and environmental health, as interconnected and interdependent goals, in line with wider concerns for the converging crises of health and climate change.G3_P3: I think there is a lot of unused space that could be used to make it greener, like putting gardens on top of it, namely roofs, so I think there could be many benefits to this. I think it would be more space for people to hang about, it would be a fun thing to get into gardening and take care of it. L3_P1: Like, they could have, like a lot of, like, flowers and plants, and things, so like, people can go, and like, take plants if they need it, like, grow food there. Addressing inequalities in access to green space was also discussed. While some suggested bigger individual gardens were desirable, or ‘green spaces for all flats’ , many focused more on common areas, owned and enjoyed by all:Many participants envisioned a social or community element to the green spaces they described, whether places to ‘hang about’ or grow food to share. These remarks suggest intuitive understandings of theoretical pathways through which contact with nature is expected to increase social cohesion, through fostering relationships with neighbours and increasing a sense of community, which in turn is seen as likely to improve health and wellbeing.L1_P4: There're a lot of buildings that are like really important but they're not being used just because they're just like really important buildings. They're completely empty. Those could come in use and people could benefit from them. But how is it they've just kept them there just for people to admire instead of actually…Facilitator: Do you mean like buildings that don't have anybody in that are like abandoned, or…?L1_P4: Yeah.Facilitator: Is that what you mean?L1_P4: Those ones are like buildings that maybe the Royal family used to live in and no one uses anymore, it's like a tourist site, or…Facilitator: Brilliant, yeah, get people in them.L1_P1: Like the Queen has how many castles? She's got…Facilitator: Oh gosh, so many.L1_P1: Well she doesn't live in them all, does she?Participants also discussed the built environment and housing. Concern to ensure a high quality of housing for all and to prevent or mitigate homelessness was discussed across several groups, reflecting well the importance of housing for healthAlthough participants across groups did not always draw distinctions between income and wealth, interest in addressing vast inequalities in housing and property suggests some young people's concerns to address inequalities in wealth, at least in terms of property. This notion is partly aligned with wider calls for mechanisms such as land reform and inheritance tax, to reduce wealth inequalities, as potentially important ways of addressing health inequalities.3.2.3L2_P2: I also put acceptance. I also felt free, that no one was judging me, because usually, when I'm in town, I'm, you know, all gothed up and everything, I get stares, slurs, all that good old stuff. I also felt less alert when I was there.Facilitator: Yes, because there's no need to be alert?L2_P2: No need to be alert. The values of a well‐functioning society were central to young people's discussions of alternative futures, reflecting the core position of ‘cultural and societal norms and values’ in some prominent conceptual frameworks of health.This participant juxtaposed acceptance in utopia to a current reality in which identities and practices are constrained by concern, even fear, about people's reactions. This aligns with existing qualitative accounts of social determinants which identify fear and stigmatisation as important factors constraining health (by restricting people's access to spaces and activities) and which suggest that such experiences are not equally distributed but concentrated in already disadvantaged communities.G3_P4: When I think of utopia, I don't think of like everything's perfect […] which is technically what a utopia should be, […] when I think of like what I would like the planet to be, I think of more of like all people together, it's like all people against the problems instead of separating each other […]. So like there's still like sadness in family and people getting caught in the rain, but it's everyone kind of together against the problems. The artist reflected on how unity is featured in his artwork:Population health experts consider discrimination an important and under‐researched influence on health, with various individual and structural pathways through which discrimination impacts health.G3_P2: Well one thing that they need to put in schools earlier is more on the LGBT stuff […], when kids start to understand it because kids are just coming out and they don't really know anything about it. And then you're getting people making fun of them, ‘cause they don't understand anything about it.[…]G3_P1: Yeah. I included that in my social stuff as well. Like, LGBT acceptance and BLM acceptance because those are important things. When asked about how these visions might be achieved, some participants described schools as a venue for cultural change. For example, young people across groups supported improving curricula through consideration of the UK's role in the slave trade, racism, bullying and lesbian, gay, bisexual, transgender and questioning+ issues:Across groups, efforts to address injustices related to ethnicity, gender, sexual orientation and identity were well supported, reflecting a concern for considering multiple axes of inequality, as well as the institutions in which these are produced. Here, young people's assertions align with calls for intersectionality‐informed approaches to health inequalities, paying attention to the imbalance of power that underlies intersecting axes of inequality, shapes social position and influences health.L3_P4: […] Say you're really rich and you're not fully aware to the extent of someone who's of a lower class, you're not understanding how much less money that they'd earn or get compared to you. […] I think you've either got to give them some statistics or you've got to show them […] to make them feel real sympathy and see if that will hopefully get to the heart. Articulations of injustice related to class or differences in income and wealth were more varied. For some, discussion of class/material inequalities was less concerned with injustice and discrimination (as above) and more with sympathy and pity, and proposed solutions reflected this:G1_P6: Jeff Bezos worked really hard to get to where he is. I'm not saying the person who's paid £120 hasn't worked really hard but they've not created something which is world widely used.G1_P2: Revolutionary.G1_P6: Revolutionary, yes.G1_P7: But what if they didn't have the opportunity to or the qualifications?G1_P6: You don't need qualifications to make something revolutionary.G1_P7: Not a lot of people pay attention to you if you don't.G1_P6: Well, I'm assuming that Jeff Bezos, people didn't listen to him at first. I don't think it's unfair.G1_P7: I think a lot of people that have money are just, like, putting it down the drain and just burning it basically with how they're using it. And, like, if…the common phrase keeps coming up, like, ‘eat the rich’ that's coming back into popularity in 2020. Like, the rich get richer and the poor get poorer. It's, like, they're cutting funds from needed services… In contrast to this call for sympathy from the most advantaged, another participant's utopian vision comprised: ‘Unemployment not being stigmatised, but everybody would be supported rather than ostracised. Erasing the concept of the powerful and powerless’ . This latter framing echoes critiques of the shortcomings of dominant models of charitable social support in reinforcing power imbalances  and calls for a more rights‐based approach.Figure 3.2.4Young people's visions of economic futures broadly focused on three main areas: employment and the labour market, pay and welfare/universal basic income (UBI), with concerns around addressing injustices and protecting people's mental health evident across each. In general, the visions young people shared of employment focused on wellbeing. One participant wrote of her ideal model of employment: ‘People work half the week and rest the other half’ . Similarly, in Leeds 3, one participant contributed: ‘There would also be paid hobbies with hourly rates. Choose how much you work. […] Encourage work to benefit the community, i.e. picking up rubbish’ . For many of the young people, work was reconceptualised as protecting the health of individuals and communities in terms of what it entailed (enjoyable activity), what it contributed to  and how much was required . These suggestions echo calls for the kind of substantial policy shift that some researchers and advocacy organisations promote in which wellbeing  is placed at the heart of policymaking.Facilitator 1: …[L2_P1] said that everyone should be paid the same – what do people feel about that?L2_P2: I'm pretty sure she means by everyone as in it doesn't matter what your race, gender is, I'm pretty sure that's what she means. Not by, oh yeah, doesn't matter what job you do, you still get paid the same. I'm pretty sure she doesn't mean it like the latter. But yeah, it sounds pretty cool.Facilitator 2: You're shaking your head. What did you mean by that, do you want to explain?L2_P1: I did mean everyone get paid equally, like no matter what gender and stuff, but also for work and things. Like depending on the job, maybe some people should get paid a bit higher, depending on what it is. But I feel like everyone should get equal pay, but not like a low amount, like a higher amount personally. Because then everyone could just afford the same things. You wouldn't have people looking down on others and stuff like that, and it would just be more equal. And less people would be struggling with money […] when really everyone needs the same amount of money to have a really good life. Discussions across all groups included proposals to address levels of pay, with an emphasis on fairness. Some interpreted fairness as equal pay for equal work, including addressing the disparity in UK minimum wage by age , echoing claims about the pernicious effects of inequality.L3_P4: Yeah, I think because you've got to have basic necessity, but what you've got to have, it's heating, food, and water, I believe, or electricity, or something.Facilitator: Yeah.L3_P4: And I feel, saying to people, look, you've got to have that as basic necessity, you've got to have it, but yet, they're not providing for it. So, I feel like, if they have a basic income to provide for at least that, I feel like it would be more beneficial to everyone. Because, they can't say, oh well you've got to have it, but not provide it, because it's just wrong. Participants also discussed overhauling the UK welfare system to better address poverty, a goal that was universally supported. Interest was expressed by most groups in UBI, an unconditional income for all, which some experts argue has the potential to address health inequalities globally.Despite the emphasis on the importance of community‐level governance, widespread support for improving safety nets, aligned with recent calls from researchers,4Taken together, these visions demonstrate diversity in participants' views about improving governance, environments, society/culture and the economy, but also a high degree of consensus around a need for systemic changes to achieve reductions in social inequalities . This broadly aligns with recent research in deprived areas of England which found that young people have a good understanding of the ‘upstream’ drivers of health inequalities.Throughout the project, the extent to which young people were focused explicitly on health varied. At times, links to health were clear, particularly with reference to how some determinants and solutions might impact mental health. Framings of environmental solutions (contact with greenspace) or social/cultural solutions (addressing discrimination) included pathways to health impacts. When discussing proposals for more participatory governance and community decision‐making, however, the specific pathways via which health might be influenced were often not articulated explicitly, though the perceived need to address unequal power relations was consistent across discussions. This aligns with existing research; while inequalities in power have been identified as a fundamental cause of health inequalities,Other studies employing the concept of utopia to explore inequalities have consciously focused on envisaging futures with young people that are not explicitly linked to health, to free up discussions and enable participants to prioritise those issues most important to their current experiences.As previously noted, variations in existing research suggest that the specific questions and approaches taken to exploring public perspectives on addressing health inequalities influence the accounts generated. Politically innovative proposals suggested by our young participants, including increasing participatory governance, are notably absent from existing studies,In terms of limitations, our study engaged groups of young people in discussions and creative activities focused on addressing health inequalities; however, some perspectives were likely not well‐represented. Limited information was collected on participant sociodemographics. More detail may have allowed us to explore how individual and social identities influenced perspectives. The study was also limited in terms of content covered. A longer‐term project, conducted over several weeks (meeting less frequently), would have allowed for engagement with evidence and discussion of the range of social determinants and axes of inequality that characterise understandings of population health inequalities and for the responsive pursuit of evidence most relevant to emerging priorities. However, the young people were variously committed to other activities and may have been unable to commit to a longer‐term project. Further, while art‐making and creative engagement were prioritised within the project, detailed exploration of artworks and performance pieces during the process of data analysis was limited. The inclusion of visual and performance artworks was generally limited to triangulation with textual data rather than standalone analysis.Despite these limitations, our research with young people suggests that calls for wider public conversations around the social determinants of healthGillian Fergie conceived and designed the research project with expert input from Katherine Smith, Mhairi Mackenzie and Shona Hilton. Gillian Fergie and Thu Thuy Phan jointly designed (with creative organisations) participant workshops and coordinated these, including all data collection. Caroline Vaczy and Gillian Fergie coded and analysed the data with input from Katherine Smith, Mhairi Mackenzie and Shona Hilton. Gillian Fergie, Caroline Vaczy and Katherine Smith conceived the paper and co‐authored the first draft. All authors contributed to drafting and revising the paper and approved the final version.The authors declare no conflict of interest.


All were new developments in surgery that failed to reach their potential to benefit patients and surgeons, and instead caused harm. There is now urgent interest in how surgical innovation should be regulated.There have been numerous recent high-profile cases of ‘surgical innovation’ gone wrong, including vaginal mesh4, who develop more efficient and more effective procedures and devices that improve patient outcomes.Surgical innovation has the potential to bring significant benefit to patients, and innovator surgeons are historically heralded as inspirational leaders, and courageous risk-takers5. Research itself is heavily regulated, and many UK hospitals have New Procedure Committees or Clinical Effectiveness Committees (or such like), providing an alternative ‘research approval’ process. They, in theory, monitor and authorize new procedures and new uses of devices7. Yet, if surgeons do not identify their practice as ‘research’, or do not self-identify as doing something ‘new’, these mechanisms fail, and practice goes unregulated and unmonitored.Currently, in the UK, surgeons are able to modify procedures, introduce procedures and devices, or use existing devices for new purposes with very little, if any, oversight. Guidance from the National Institute for Health and Care Excellence (NICE) is not followed7. Consequently, innovations associated with harms/risks go unreported  and future innovators cannot learn from them, meaning mistakes may be repeated. Mandated (cardiac surgery)8 and optional (e.g. arthroplasty) registries are designed to monitor standard (not innovative) procedures, and data capture is not routine. Although changes are occurring for the introduction of new devices, these are yet to be implemented. One challenge is defining what constitutes a new procedure, the associated risk, and what magnitude of modification/risk requires registration and/or regulation.Compounding this, there are limited reporting mechanisms for failed innovations, and existing ones are underusedinnovation10 to improve patient safety. We agree but, perhaps controversially, contend that the term ‘innovation’ should be eliminated.There is currently much focus on regulating surgical 11. ‘Innovation’ is a rich and value-laden concept, simultaneously conveying newness and benefit, and, as such, functions to characterize the ‘innovative’ as positive. ‘Innovation’ is supported and celebrated, and, if it is good to innovate, then, ceteris paribus, innovation is good. This rhetorical spin and ambiguity makes ‘innovation’ ill-suited for regulation or governance, not least because labelling a practice ‘innovation’ can hide a multitude of sins, both allowing the unconscientious surgeon to avoid regulatory scrutiny and misleading patients during informed consent processes, while staying just on the right side of truthfulness. Here, we outline our reasons for eliminating ‘innovation’ from our regulatory and informed consent lexicon, with renewed focus instead on newness and risk.Based on our research exploring the nature and meaning of surgical innovation, we argue the term ‘innovation’ is problematic11. Our own purpose is to improve the safe and transparent translation  of surgical innovation into practice. Key to determining safety and transparency is the stage of newness of the invasive procedure/use of device, which—we argue—in turn must be defined by what is known about its safety, efficacy, and effectiveness. If we are interested in regulation for safety and transparency, then the conceptual baggage that accompanies ‘innovation’ is irrelevant. Consequently, whether a procedure or device is ‘innovative’ has no bearing on how it should be regulated.Any definition of ‘surgical innovation’ has to be specific and purposive, rather than generic10; but we diverge from that work in defining ‘newness’ not in terms of whether the surgeon recognizes a practice as new (which acts as a proxy for ‘innovative’), but in terms of how much is objectively known about the practice in terms of safety, efficacy, and effectiveness.This association of ‘innovation’ with ‘newness’ is not itself new, and our work to this point follows colleagues at Macquarienewness in relation to the context in which it is occurring.This moves away from conceptualizing newness as ‘ontological newness’ —which leads to difficulties determining when a practice is new. Rather, ‘newness’ is conceptualized as ‘indexical newness’; that is, This effectively defines ‘newness’ as a spectrum, the position on which a practice lands being based on what is known about the safety, efficacy, and effectiveness of a procedure/device in the context in which it is being used.Fig. 1).Accordingly, ‘newness’ occurs whenever change is introduced to a surgeon’s practice. Any change introduces some level of uncertainty about safety, efficacy, and effectiveness, and the magnitude of newness is determined by the magnitude of uncertainty. ‘Newness’, therefore, manifests in various ways , each carrying different magnitudes of risk.‘Newness’ spans a continuum from ‘completely new’ to ‘not at all new’, with varying degrees of ‘somewhat new’ between the two (An invasive procedure may be introduced at any point along this spectrum and, regardless of its entry point, a risk assessment must be undertaken to ascertain how much risk is introduced. The ‘newer’ an intervention, the less evidence we will have about its risks and benefits. The less ‘new’ the intervention, the more evidence of its risks and benefits will be accessible.A very new, high-risk procedure will require a different regulatory response to a somewhat new procedure introducing no/little risk, and each is likely to require a different kind of evaluation. Broadly, an intervention assessed to be completely new and high-risk may require registering, formal approval, and formal evaluation, similar to research. A partially new, low-risk intervention might require registering and reporting only. The most appropriate regulatory system will need developing, but what is clear is that whether or not the intervention in question is an ‘innovation’ is immaterial. Shifting the focus from ‘innovation’ towards what is known about safety, efficacy, and effectiveness will also help keep informed consent discussions clear, and focused on what is most important.Improvements in surgery would be impossible without individuals who respond to surgical challenges creatively, pushing the boundaries and finding more cost-effective and efficient ways to help patients. However, the risks must be acknowledged and minimized.The term ‘innovation’ carries an inherently positive rhetoric and ambiguity, making it unsuited for use in informed consent processes, and too unclear to be useful for regulation and governance.We support experimentation and development, and encourage surgeons to embrace new and untrodden paths. To facilitate the safe and transparent translation of new invasive procedures/devices into practice we propose the elimination of ‘innovation’ from our informed consent and governance lexicon, in favour of the much clearer language of newness and risk.


Cervical cancer is preventable with vaccination and early detection and treatment programs. However, for these programs to work as intended, stigma related to HPV and cervical cancer must be understood and addressed. We explored pre-existing stigma associated with HPV and cervical cancer in the public healthcare system and community of a low-resource setting prior to implementation of an HPV screen-and-treat program.This study conducted thematic analysis of data collected during implementation of a novel HPV screen-and-treat system for cervical cancer early detection and treatment in Iquitos, Peru. We included 35 semi-structured interviews , eight focus groups (70 community women), one workshop , 210 counseling observations (with 20 nurse-midwives), and a document review. We used the Socio-Ecological Model to organize the analysis.We identified three main themes: 1. the implication that women are to blame for their HPV infection through characterizations of being easy or promiscuous, 2. the implication that men are to blame for women’s HPV infections through being considered careless or unfaithful, 3. HPV is shameful, embarrassing, and something that should be hidden from others. Consequently, in some cases, women refrained from getting screened for HPV. These themes were seen at the individual level among women, relationship level among women, men, and family members, community level among healthcare staff, and societal level within components of cervical cancer guidelines and male chauvinism.Cervical cancer early detection and treatment programs in limited resource settings must address stigma entrenched throughout the entire healthcare system and community in order to sustainably and successfully implement and scale-up new programs. Interventions to tackle this stigma can incorporate messages about HPV infections and latency to lessen the focus on the influence of sexual behavior on HPV acquisition, and instead, promote screening and treatment as paramount preventative measures. The large-scale elimination of cervical cancer is feasible through the implementation of human papillomavirus (HPV) vaccination for girls, screening eligible women, and providing treatment for those who need it , 2. CervStigmatization of women with HPV is a barrier to cervical cancer screening uptake , 4 and aIn LMICs, rates of cervical cancer exceed those of high-income countries (HICs)  . In the We did not originally intend to explore stigma related to HPV and cervical cancer, but the theme emerged so often among women, healthcare staff, and governmental institutions during Proyecto Precancer’s work and challenged programmatic success that we decided to explore this topic retrospectively. This qualitative study explores the perspectives of various stakeholders within the EDT system, including women, nurse-midwives, doctors, and cancer coordinators on HPV and cervical cancer stigma. The data were collected during Proyecto Precancer's involvement in Iquitos, prior to implementation of the novel screen-and-treat program and include interviews, focus groups, a workshop, counseling observations, and document reviews. Our objective is to understand the existing stigma before introducing the screen-and-treat program by identifying the influence of community members, health professionals, the healthcare system, and healthcare policies in perpetuating HPV and cervical cancer stigma. This research will provide an understanding of stigma in low-resource settings that must be addressed prior to implementation of novel EDT programs to ensure appropriate and sustainable implementation.This study was based in the largest public health network – the Micro Red Iquitos-Sur (MRIS) – in Iquitos, the capital city of the state of Loreto, located in the Peruvian rainforest (population 1.1 million). Iquitos is the largest city in the world that can only be accessed by boat or plane; there are no roads to Iquitos. The MRIS extends over urban, peri-urban, and rural areas, with much heterogeneity with regards to access to tertiary care. Specifically, for those in urban areas, access to a hospital could take 15 minutes on paved roads. However, for those living in peri-urban and rural areas, the main forms of transport are motorcycle taxis and boats for the river communities. The boats and motorcycle taxis frequently traveling on unpaved roads are often slow, meaning that accessing healthcare facilities, specifically tertiary care, can take hours for much of the population. Though the Amazon basin region of Peru is geographically unique from the mountain and coastal regions, this region accounts for the highest cervical cancer mortality and covers two-thirds of Peru’s territory ” (community women's focus group #8). In some cases, having HPV was associated with prostitution. In a focus group, when the interviewer asked what participants thought of women with HPV, one woman responded: “that they are prostitutes” (community women's focus group #2).On the individual and relationship levels, women associated HPV infection with behaviors such as having multiple sexual partners and engaging in what was perceived as irresponsible sexual conduct, particularly among younger or single women. One participant spoke about how younger, sexually active women could get HPV stating, “"You have to know the person you're with, I mean, what kind of person you're messing with" (community women's focus group #3). Other women stated that it is women’s responsibility to not have unprotected sex, even with a steady partner. During a discussion of a scenario where a woman with a partner finds out she has HPV, a participant responded: “We are not going to be trusting because we have a partner; it is better to be safe” (community women's focus group #5).Some women emphasized that it is a woman’s responsibility to know the type of person she has sex with in order to avoid HPV. One woman described this as, Sometimes, we don't know what kind of people we are dealing with" (woman with precancer/cancer's interview #11). In a separate counseling session, another nurse-midwife addressed what they perceived as risky behavior and advised the patient to question her partner’s sexual history asking, “How many partners has your partner had? Who is he?” (nurse-midwife observation #7).On the community level, these messages were similarly conveyed by health professionals. One woman reported she was told by a nurse-midwife during counseling that it is important to know the type of people she has sex with because, as the nurse-midwife told her, “The more sexual partners we have, the more likely we are to have HPV” (nurse-midwife observation #1). Another nurse-midwife listed risk factors for HPV during counseling as: “promiscuity, fewer children, early initiation of sexual activity” (nurse-midwife observation #7). In an interview, a nurse spoke about a patient with precancer as having poor sexual behavior: “We know that she is a young woman, that she is not very well behaved” (nurse interview #1).Health professionals also described women who have had multiple sexual partners as more likely to get HPV. During counseling about HPV, one nurse-midwife referred emphatically to having multiple sexual partners as an important risk factor: “Here, sexual activity starts at the age of 12, 13, 14 and even more [earlier] if we talk about the communities that are [on the] rivers” (nurse-midwife interview #6) and another stating:My concern is the beginning of sexual relations at an earlier age. Here we know that at 13, 14 years old they already have their first child or maybe their first partner. They arrive at 19 with more partners, even with more children. Those women are getting lost, they are going to arrive at 40 already with cancer (workshop #1).A number of health professionals expressed concern that women in Iquitos are more likely to develop cervical cancer at an early age due to early initiation of sexual activity with one nurse-midwife stating, “The discussion of women’s actions leading to their acquisition of HPV was also visible at the societal level in materials published by the Peruvian Ministry of Health. The 2017 National Clinical Practice Guidelines for Cervical Cancer Prevention and Control was created for health personnel to provide evidence-based recommendations for cervical cancer prevention. It specifies the following risk factors associated with HPV progression to cervical cancer: HPV type, genetic susceptibility , immunocompetency , tobacco use, and vitamin deficiency. Notably, a lack of screening is not mentioned as a risk factor for developing cervical cancer. Although not directly related to the development of cervical cancer, the list also mentions risk factors that significantly increase risk of HPV infection such as early initiation of sexual activity, having multiple sexual partners, and being with a partner who has multiple sexual partners .idiosincrasia de la poblacion”), low screening coverage, delay in returning results, high loss to follow-up, low number of treatment centers, and concentration of specialized care in urban settings. Notably, the National Plan does not identify the same risk factors specified in the Clinical Guidelines though it was published only six months later; instead, it only lists one vague risk factor for cervical cancer related to individual sexual behavior   has been promiscuous … I am paying the price" (community women's focus group #4). Another woman described how women can develop cervical cancer due to men’s infidelity: "Sometimes men are not faithful to you. You may think they are, but, in the end, you don't know. You can be healthy, and some time goes by, and you find out that you are sick" (community woman's interview #11). In some cases, these women had experienced infidelity or knew women with unfaithful partners: "My brother had sex with another woman. The woman infected him. And he went to his wife, and he infected her" (community women's focus group #4). Only a couple of women mentioned the possibility of infection through previous relationships: “Perhaps her partner has had other encounters before her” (community women's focus group #8).HPV infection was also commonly viewed as a sign of male infidelity. Women spoke about what their reactions would be if they were told that they had HPV, with one woman stating, “the partners, right?” but after thinking about it a bit more stated, “well, but in the end, she will get it anyway” and emphasized the importance of screening (field notes). During counseling for HPV, a nurse-midwife stated, “Your partner infected you during sexual relations” (nurse-midwife observation #3), and another spoke about when she used a megaphone to announce that “faithfulness” is one of the ways to avoid HPV (nurse-midwife interview #6). A doctor also discussed seeing a book titled Human Papillomavirus: The Virus of Infidelity displayed on a nurse-midwife's desk. The book was written by a nurse-midwife from Iquitos, and the doctor told this nurse-midwife, “You can't put that [book there] because it is not entirely true. You’re going to get in trouble” (doctor interview #2).The implication that men are to blame for HPV infection was also observed at the community level. When asked about the risks and main ways to prevent cervical cancer, one of the cancer authorities quickly answered: “The implication that men are to blame for HPV infection was also observed at the societal level in the 2017 National Clinical Practice Guidelines and 2019 Health Directive for the Prevention of Cervical Cancer which suggested a heightened importance of men’s sexual activity to explain women’s positive screening results. The Clinical Practice Guidelines and Health Directive included being with a partner who has multiple sexual partners and having a partner who has had or has many sexual partners, respectively, as risk factors for progression to cervical cancer. However, the 2017–2021 National Plan does not explicitly include this risk factor related to men’s sexual behavior, and the National Plan and Health Directive both include the absence of screening or inadequate screening first on the list of factors contributing to cervical cancer .Women often experienced the consequences of stigma related to abnormal cervical cancer screening results and HPV. This was observed across the individual and relationship level among community women who discussed how women are told to consider and considered abnormal cervical cancer screening results to be embarrassing, in some cases disgusting, and something that should be hidden from others. This was also seen at the community level among nurse-midwives who described abnormal cervical cancer screening results as embarrassing, and the societal level where male chauvinism resulted in secrecy around HPV. As a consequence of the stigma, women sometimes refrained from getting screened for cervical cancer.ugly” and felt “disgust” (community women's focus group #6). Similarly, women referred to stigma around gynecological symptoms they associated with abnormal cervical cancer screening results: “Sometimes they have discharge and do not want to go to the post [because] of shame,” (community women's focus group #6). Another woman described this as, “Sometimes they feel the symptom and are ashamed to talk, to go to a health center” (woman with precancer/cancer's interview #8).On the individual and relationship levels, women referred to HPV as ““Maybe she doesn´t want someone to find out, so she gets information through the internet” (community women's focus group #5) while another stated, “I think she prefers the internet because… she could suddenly feel shame, I don’t know, to go and to ask about this virus, no?” (community women's focus group #3).Women also expressed perceived feelings of embarrassment to seek information regarding HPV or HPV screening and fears of being perceived as having HPV. During discussions of scenarios about how women with HPV might seek more information, one woman described, that we have cancer” (community women's focus group #6). One of these women stated that she wanted to do this “to keep others from seeing [her drop off the HPV test]” (community women's focus group #6).Women were often reluctant to be seen dropping off HPV samples for fear of being judged. During a focus group, a few women discussed how if they were to do an HPV test, they would prefer to drop off the HPV samples at a secure location outside of the health center so that their neighbors would not think ““Because when they hear the name HPV, they would think that she is having a very liberal sex life, wouldn't they? … because the mother does not know how her daughter behaves in the street” (community women's focus group #3).Women also described perceptions that their families would think differently of them if they found out they were HPV positive. During a discussion of a scenario where a young woman with HPV tells her family about her HPV infection, participants described how the family would react: the first thing she said was that she did not want to be registered in the system because she was a little ashamed” (field notes).This was also seen at the community level among nurse-midwives who support the need for secrecy; according to a nurse-midwife, some colleagues who had positive cervical cancer screening results asked not to be logged on the registry system as they preferred discreet management. Our research team also observed this, with one researcher noting that when a nurse-midwife found out about her positive result, “Maybe your husband sees you are sick. He is not going to want a sick woman who is suffering. Instead of supporting you, what he will do is, “You know you are sick, and I have another one out there.” He will go to the other one. He will abandon you. (community women's focus group #4).Women's desire for secrecy regarding HPV was reinforced at the societal level, largely due to widespread male chauvinism. Women expressed concerns about men's ability to accept information about HPV and provide support if they became ill. During a discussion of scenarios where women with HPV tell their husbands about their HPV infections, one woman described:Maybe because they are afraid of being left,” and another adding, “The fear of feeling rejected” (community women's focus group #3). Another woman described how she felt a husband would react to finding out his wife has HPV: “Suddenly, he would leave you” (community women's focus group #1).During a focus group, other woman discussed why women would be afraid to tell their husbands that they have HPV with one stating, “In order to eliminate cancer, in order to protect so many women who sometimes die because of their negligence, I say, because of their negligence, because they do not take care of themselves… sometimes they feel the symptom and are ashamed to talk, to go to a health center. (woman with precancer/cancer's interview #8).The stigma around HPV was described by some women as a barrier to screening:She said that my father always told her that, why would she go for a check-up, why would she go for a check-up if she has nothing… he was always a little bit macho in that aspect, and my mother never went for a check-up. She says that she was afraid of having a Pap smear done… I asked her, “Why are you scared?” …"I don't know, but your dad never wanted me to do that." (woman with precancer/cancer's interview #11).Male chauvinism was also mentioned as a barrier to getting screened for cervical cancer by women and health professionals. One woman spoke about why her mother had never done a Pap test before she was diagnosed with cervical cancer and died from cervical cancer a few years later:Even in our region there is a lot of male chauvinism. How many times have I visited the homes of families where the husband came out and said, “My wife is not a prostitute, she cannot have a Pap test,” even another one told me - the patient - “Look, I do not do the Pap test because I only have one husband, because they [women with HPV] have a lot of men (workshop #1).A nurse-midwife also discussed stigma related to HPV as a barrier to screening in the workshop:We found pervasive stigma throughout the healthcare system and community that, in some cases, led women to avoid HPV screening. This stigma may, ultimately, facilitate women dying from a preventable cancer, and subtly or overtly, it is shaped by policymakers, experts, healthcare providers and community members who have formed perceptions about who is at risk for and who might develop cervical cancer due to women’s or their partners’ sexual behaviors. Throughout this study, we found that stigma emerged unprompted in approximately half of interviews, in all focus groups, the design workshop, and among a fifth of the nurse-midwives’ providing counseling.Stigma was associated with HPV through the implication that women are to blame for their HPV infection. This implied blame was attributed as either a direct consequence of their actions  or an indirect consequence . On the individual, relationship, and community levels, women, nurses, and nurse-midwives characterized women with HPV as promiscuous or irresponsible while on the societal level healthcare guidelines emphasized the influence of women’s sexual activity on HPV acquisition. Previous literature focusing on women’s perspectives has similarly found the implication that women are to blame for HPV infections due to having multiple sexual partners, promiscuity, prostitution, or a lack of cleanliness , 24, 25.We also found that women attributed HPV infections to men’s actions, through infidelity or carelessness. On the individual, relationship, and community levels, women, nurse-midwives, and cancer authorities characterized men as unfaithful, and on the societal level healthcare guidelines emphasized the influence of men’s sexual activity on women’s HPV acquisition. Previous studies in LMICs have found perceptions that HPV is caused by infidelity, though many of these studies discuss women being perceived as unfaithful , 12, 28;Additionally, we found attitudes of shame toward HPV. This was seen on the individual, relationship, and community levels expressed by women and nurse-midwives. The shame towards HPV, in addition to the fear of being stigmatized as being promiscuous or easy, lead both women and healthcare workers to keep their cervical cancer screening results secret. In previous research, women have described similar attitudes of perceiving HPV as shameful , 26 and Stigma pervades each level of the healthcare system and community, potentially intensifying as it moves through different levels. For instance, the presence of stigma among women may be exacerbated by healthcare professionals who, in turn, may have internalized stigmatized information from policies. It is important to recognize that the information flow is predominantly unidirectional; policymakers wield influence over healthcare workers and, subsequently, women, whereas women may exert limited impact on policymakers. While addressing stigma across all levels is essential, we must prioritize instigating change where it can have the greatest influence, starting with healthcare policies.We have seen that misinterpretation and over-emphasis of less-significant risk factors related to sexual behavior stigmatizes women (regardless of whether they even have any of these risk factors). While early sexual initiation and number of sexual partners have been identified in epidemiological studies as increasing the likelihood of testing positive for HPV or developing cervical cancer , 32, theFor HPV related stigma, this process must begin with developing national plans, directives, and clinical guidelines that consistently provide the same key messages about HPV infection and its latency and promote access to screening and treatment. Messaging on the importance of sexual activity on HPV acquisition in these documents is fallacious. The changes must include developing communication messages and cervical cancer screening forms that do not focus on or collect data on age of sexual initiation and number of male sexual partners. These materials can be developed in a participatory manner with key stakeholders, allowing them to internalize these key messages and feel ownership over new policies , 39. AwaThis process must also directly target healthcare providers who play a critical role in transmitting information about and attitudes toward HPV to women. Training can aim to improve knowledge among healthcare professionals about HPV infections and promoting access to screening, while specific guidelines and tools can be developed for health professionals that help reduce misinterpretation and allow consistency in messaging. A number of interventions using these methods have been shown to reduce HIV stigma among healthcare providers –43 and mReducing stigma among women and community members may also include providing counseling or developing an intervention that focuses on open discussion and improving knowledge at the community and individual level. In places with high male chauvinism or that are very conservative, it might be appropriate to include men in such interventions. In fact, addressing stigma through the lens of also addressing gender equality presents an opportunity for regional authorities in low-income settings to work toward the fifth Sustainable Development Goal while providing women with further autonomy and empowerment in screening and treatment of cervical cancer . Only a During implementation of the HPV screen-and-treat program, Proyecto Precancer provided counseling and training to nurse-midwives that aimed to address stigma and improve the overall care process for women. Future research will need to evaluate the impact of this work and any further interventions implemented to address stigma.This study utilizes a variety of data that were not specifically collected to examine stigma in the MRIS. As a result, it is not possible to determine the prevalence of stigma, and there is a possibility that additional stigma-related themes could emerge with further stigma-focused data collection. However, the themes and data in this paper are reflected in extensive observations made throughout years of Proyecto Precancer's fieldwork in a public health network of a low-income area in Peru and include the perspectives of multiple stakeholders, from community women to hospital-level doctors, that consistently highlight these themes. While the findings may not be generalizable to all countries or the whole country, they provide valuable information on the stigma faced by women in resource-limited settings and provide context for the scale-up and implementation of new EDT programs in these settings.Stigma is prevalent throughout this resource-limited healthcare system and community, with women, healthcare workers, and policy makers contributing to implied blame of women for their HPV infections and implied blame of men through accusations of infidelity. This stigma created feelings of shame and secrecy surrounding HPV that were present among women and nurse-midwives, and, in some cases, led women to avoid HPV screening, and ultimately, can facilitate women dying from this preventable cancer. Cervical cancer EDT programs in resource-limited settings must take into consideration and address the stigma experienced by women at the policy, health system, healthcare provider, community, and individual levels when implementing and scaling-up new EDT programs. Stigma reduction interventions should emphasize information on HPV infection and its latency over and beyond emphasis on the impact of sexual behavior on HPV acquisition to promote screening and treatment as the most important preventative measures.