Nature-deficit disorder, a journalistic term proposed to describe the ill effects of people’s alienation from nature, is not yet formally recognized as a medical diagnosis. However, over the past decade, the phrase has been enthusiastically taken up by some segments of the lay public. Social media, such as Twitter, with its opportunities to gather “big data” related to public opinions, offers a medium for exploring the discourse and dissemination around nature-deficit disorder and other nature–health concepts. In this paper, we report our experience of collecting more than 175,000 tweets, applying sentiment analysis to measure positive, neutral or negative feelings, and preliminarily mapping the impact on dissemination. Sentiment analysis is currently used to investigate the repercussions of events in social networks, scrutinize opinions about products and services, and understand various aspects of the communication in Web-based communities. Based on a comparison of nature-deficit-disorder “hashtags” and more generic nature hashtags, we make recommendations for the better dissemination of public health messages through changes to the framing of messages. We show the potential of Twitter to aid in better understanding the impact of the natural environment on human health and wellbeing.Evidence continues to grow supporting the idea that restorative environments, green exercise, and nature-based activities positively impact human health.  Research in public health , environNature-deficit disorder (NDD) is a term proposed by journalist Richard Louv in 2005 to describe these ill effects of people’s separation from nature. Louv argues that the human cost of “alienation from nature” is measured in “diminished use of the senses, attention difficulties and higher rates of physical and emotional illnesses” [NDD has resonance with lay audiences, especially parents, educators, and environmental non-profit organizations. In the UK, for instance, concern over NDD motivated the National Trust, whose mission is to preserve places of historic interest and natural beauty, to propose programs to ensure that every child has the chance to develop a personal connection with the natural world [NDD [lnesses” . NDD hasal world . A recenrld [NDD .NDD is not generally recognized as a medical diagnosis or a public health issue. To demonstrate the differential between public discourse about NDD and the health-related discourse, a Google search of the World Wide Web produces more than 800,000 hits for NDD, while a search of PubMed produces only one [Twitter and Facebook have provided opportunities for people to express their opinions publicly more often than ever before.In contrast, only one . Howeveronly one  so an exsentiment analysis, the objective of which is to translate opinions and expressions of human emotion into data that can be quantified and categorized to determine the attitude towards particular topics, services or products [The use of Twitter for both research purposes and as part of specific interventions is growing in the field of public health, especially in the last few years . Twitterproducts . Sentimeproducts , includiproducts . Commercproducts .social awareness streams (SAS) [In terms of this study, it has been shown that general attitude and commentary about the human relationship with nature and interests in outdoor activities have lately become a popular topic of debate and conversation within social media platforms ; especiams (SAS)  like thoNDD and other nature–health related concepts. Our work aims to build a dataset that will enable in-depth qualitative analysis of tweets linked to NDD published by the general public. Mining the “big data” of Twitter to study the social construction of nature and health, NDD, or other important public health messages requires new tools and techniques, which we intend to both explicate and critique. To the best of our knowledge, no previous study of this kind on this subject has been carried out, though this has potential to help to understand the relevance of NDD and related nature–health concepts in the community—and their online dissemination—and in turn suggest recommendations for policy makers.The goal of this article, then, is to utilize Twitter to explore the online dissemination and sentiment associated with the concept of Twitter [To carry out our work, we began by choosing Twitter , as the tweets [Twitter is a service that helps people create and share ideas and information instantly. It offers an easy way to follow trends, stories, and breaking news making headlines around the world, and it also provides a mechanism to stay in touch with other people, businesses and social causes. Precisely, Twitter is an information network made up of 140-character messages called tweets . Tweets trending topics [In the context of Twitter, a “hashtag” is any word or phrase immediately preceded by a hash sign (#) . Hashtagg topics .RT). Retweets are often used to pass along news or other valuable discoveries on Twitter. It should be observed that retweets always retain original attribution.A tweet that a user forwards to all of her “followers”, or designated contacts within Twitter, is known as a “retweet”, (The method that we pursued to retrieve relevant tweets is described below.Children & Nature Network (childrenandnature.org)—we did not focus our investigation on specific communities where NDD advocates are likely to gather up. Rather than monitoring particular websites, we aimed to capture the overall sentiment expressed in Twitter by anyone referring to NDD. Since the number of tweets published on a daily basis is too high  and vetted among scholars with knowledge and involvement in the field of nature and human health. Such hashtags were selected to include phrases directly associated with NDD—e.g., #naturedeficitdisorder—phrases that were conceptually related to NDD—e.g., #playoutside—phrases about general nature and health—e.g., #natureheals—and also generic nature terms—e.g., #outdoors. NDD section of NDD explicitly, but to concepts and phrases connected to NDD. For instance, “Last Child in the Woods” is the title of the book where Louv introduced the term NDD; “Park Prescriptions” is a movement to create a healthier population by strengthening the links between the healthcare system and public lands across the US; and “The Nature Principle” is the title of another book by Louv—yet, no tweets including the hashtag #thenatureprinciple were posted while our research took place. Indeed, only one tweet including the #thenatureprinciple was posted in 2014 and this was on 7 September 2014—a week after our retrieval of tweets had ended.Although a number of online communities and portals to encourage and support people and organizations working nationally and internationally to connect children with nature have been created lately—for example, the r second ), and moapplication programming interface (API) library Twitter4J [Twitter Search API [We retrieved the tweets for our study using the open source, Twitter witter4J . At the arch API —in otherThe Twitter Search API  behaves To accumulate as many tweets as possible—ideally all the tweets published for each of the hashtags chosen—we issued our queries twice a day: at 9:00 a.m. and 5:00 p.m. Certain tweets corresponding to particular hashtags were captured in the morning and once again in the evening—when the number of tweets published for those hashtags on a single day was smaller than the number of tweets that we were allowed to retrieve. For the same reason, some of the tweets captured in the evening were recaptured the following morning too.https://t.co/GEavvJ1ZFn.Nature Deficit Disorder and climate change widen the debate for a future worth having #naturedeficitdisorder After retrieving tweets, we removed duplicates to ensure that every tweet in our study was considered only once. The only case in which a tweet was considered more than once was when the tweet referred to two or more hashtags or phrases involved in the study. For example, the following tweet contains the hashtag #naturedeficitdisorder and the phrase “Nature Deficit Disorder”. Therefore, we processed it twice: first for the hashtag #naturedeficitdisorder and then for the phrase “Nature Deficit Disorder”.opinion mining—is concerned with the use of natural language processing and computational linguistics to identify and extract subjective information in text materials, such as tweets. A wide range of human moods can be discovered through sentiment analysis, but a major focus has been identifying the polarity of a given text [i.e., to automatically recognize if a text is positive, negative or neutral.Sentiment analysis—or ven text —i.e., toet al. [emoticons—for instance, “:)” and “: is a text mining platform providing semantic analysis capabilities. It is piece of software used over 3 billion times globally per month, on average, enabling academics and commercial firms to perform social media monitoring and sentiment analysis . In Marcet al. showed that AlchemyAPI’s sentiment analysis achieved an 86% accuracy after manual testing carried out on a corpus of 5370 tweets employed by an intelligent recommendation system for tourism [et al. [Zemanta [OpenCalais [Extractiv [DBpedia Spotlight [et al. favored AlchemyAPI over OpenCalais and Zemanta for the task of concept extraction, due to its better coverage [As independent research has demonstrated, AlchemyAPI’s sentiment analysis is uniquely positioned. Meehan  tourism . Rizzo a tourism  and Saif [et al.  have als [et al. —such as,[Zemanta , OpenCalenCalais , Extractxtractiv  and DBpepotlight . Similarcoverage .Based on the evaluations stated in previous research, we believe that AlchemyAPI is a suitable choice to support our work.Every time the AlchemyAPI’s sentiment analysis API is invoked for a tweet, it returns the following information:polarity, which can be positive—“this car is great”—negative—“this car is overpriced”—or neutral—“this car is red”.(1) The sentiment strength, which is a real number value between −1 and 1 that expresses how negative or positive the sentiment is—zero means that the sentiment is neutral, negative values refer to negative sentiment and positive values refer to positive sentiment.(2) The sentiment mixed—i.e., both positive and negative. Note that the same tweet or statement in general can be negative about a person or product and positive about something else.(3) A Boolean value to indicate whether the sentiment is For illustration purposes, i.e., nearly 6 months—to determine the polarity of the entire collection of tweets in our experiment . We could have completed the processing earlier, by exclusively requesting the polarity of original tweets and assigning the same polarity to all the retweets—this would have saved us 80 days of processing, approximately. However, retweets frequently remove the last few characters of an original tweet, because there is not enough space to keep the whole content posted initially—recall that tweets cannot be longer than 140 characters . Since the polarity scores supplied by AlchemyAPI are based on the whole content, and this may change slightly between a tweet and a retweet, we decided to process the retweets separately.It took 178 consecutive days—NDD advocates, but are also used, extensively, by adult-content communities to share references to nudity and sexuality that are not relevant to NDD. Thus, we removed 11,244 tweets from the #outdoors collection that contained hashtags such as #nudist and #adult. It should be observed that the total number of tweets retrieved belonging to #outdoors was 31,830; yet, the number shown in Certain hashtags considered in our study, such as #outdoors, are not only of interest to Even though we aimed to capture tweets written in English, exclusively, a number of tweets in non-English languages were retrieved too. This is largely because some users typed their tweets in other languages, but “labeled” them with the hashtags chosen for our study.NDD, we opted to discard them from our evaluation, because we did not have enough resources to translate them into English or process them in their respective languages.Another reason why we discarded some tweets from our evaluation is that AlchemyAPI was unable to identify any intelligible text within them. This might be caused by tweets originally written in languages whose alphabets are not Latin—for example, languages using the Cyrillic or Japanese alphabet. As a result, Twitter4J misses the original encoding and we end up collecting a series of punctuation marks accompanied by some hashtags and links to other resources.net sentiment rate (NSR) [Both commercial and academic researchers have proposed a number of metrics to estimate the overall sentiment expressed towards particular topics on social networks. A common metric for this purpose is the te (NSR) ,51.The (NSR) is defined as the subtraction of the number of negative conversations—negative tweets in our case—from the number of positive conversations—positive tweets—divided by the total number of conversations—total number of tweets. In other words,NDD, rather than opinions about NDD itself. Consider the following tweets:http://t.co/eivBfx1gmY@Sam10k Too many parents glued to #Electronic devices setting bad example! #NatureDeficitDisorder http://t.co/zdtdKTYlTeLink to childhood #depression #ADHD and #obesity “Nature Deficit Disorder”. Less screen time & more green time We propose that the negative quality of the NSR for the hashtag #naturedeficitdisorder and the phrase “nature deficit disorder” is caused by the presence of comments in tweets that refer to negative behaviors and afflictions commonly associated with the causes and consequences of NDD with conditions such as depression, attention deficit hyperactivity disorder (ADHD) and obesity. NDD is not negatively qualified within this tweet, but its associations are.The first tweet and its attached link are intended to critically evaluate families who seem to be getting worse at communicating—presumably, due to parents failing to set a good example to their children. The author of this tweet highlights a behavior that she strongly disapproves. As a result, AlchemyAPI classifies the text as negative—indeed, the score is −0.687712. Similarly, the second tweet—whose score is −0.74948—associates In contrast to sentiments for the hashtag #naturedeficitdisorder and the phrase “nature deficit disorder”, the hashtag #nochildleftindoors comprises only three tweets, but all of them are associated with positive behaviors—in the view of their authors—and in some cases a cheerful, almost celebratory, phrasing style. http://t.co/2LJyaUwB5e#ParkPrescriptions: New Treatment for #Obesity #GLV Similar kinds of tweets can be found under the hashtags #natureheals and #outdoors, which have the most positive NSRs. The case of the hashtag #parkprescriptions is slightly different though: #parkprescriptions is made up of a small number of tweets published during the length of our study—37 in total. However, 36 of these tweets refer to the following post, which AlchemyAPI classifies as negative with a score of −0.208067.We contend that the post above, and consequently the 36 tweets that included it, could have been considered neutral, as the post is simply reporting on a new treatment, rather than criticizing or disqualifying it. The automatic assessment of polarity made by AlchemyAPI is not flawless and, in this case, it does have an adverse impact on the computation of the NSR. Had the post in question been marked as neutral, the NSR for #parkprescriptions would have been 0.03, rather than −0.95.It is worth noting that we captured a particularly large number of tweets on 9 July 2014—specifically, we captured 5373 tweets in total on 9 July 2014, and 3023 of them were positive. A semi-final match of the 2014 FIFA World Cup took place exactly on that day, and this might be the reason why a high Twitter traffic was observed on 9 July 2014  whose content republished original material posted within the length of our experiment.There were 78,531 retweets in the collection—force-directed graph representing the tweets and retweets that we retrieved. The blue sections in Robert Gordon University to draw Neo4j datastore—Neo4j is a popular open-source graph database . The adNDD-related hashtags are also widespread—i.e., #goplay is quite separate from the bulk of the graph. However, #getoutdoors and the NDD hashtag, #vitaminN, are relatively closely aligned with the more general concept #outdoors. Thus, our choice of hashtags actually allowed us to cover a large, heterogeneous range of tweets.To further analyze the distribution of tweets, retweets and hashtags, and to explore possible linkages between hashtags, we created The polarity of retweets is rather similar to the polarity of the collection as a whole. As a step in finalizing our dataset for an in-depth qualitative analysis that looks at themes, we quantified the other hashtags included in our identified set of tweets. We expected in advance that certain hashtags such as #wildlife, #green, #outdoors and #getoutside would be in this list of most frequent hashtags, because we retrieved a large number of tweets using them. Perhaps not surprisingly, the only hashtag to appear in the top ten in all four of our subgroups was #nature.NDD hashtags include several about #physicalactivity, which is consistent with the outdoors as a preferred setting for physical activity. An alarming group of hashtags include #beheadingchristians, #isis, #nukeisis. On further investigation, we found that all these hashtags were used in a tweet along with #vitaminN that had a very different meaning than we would expect of “N” for “Nature”. Such a tweet appears below,http://t.co/KjuFhqxWU2#ISIS needs some #VitaminN #NukeISIS #StopISIS #BeheadingChristians #Iraq #Yazidis #Sinjar #StandWithIsrael #tcot In the case of the tweet shown above, “N” stands for “Nuke” or “Nuclear”. The 17 instances of the hashtags #beheadingchristians, #isis, #nukeisis include the original tweet and its retweets. This finding suggests that looking at the most frequent hashtags in a group of tweets can surface content that needs to be excluded as non-relevant to the desired inquiry.NDD-related hashtags are topped by our preselected hashtags: #getoutside, #goplay, #outdoorfamilies, #playoutside. Other hashtags, #nature, #hiking, #summer, #outdoors—one of our generic nature hashtags—also make a strong appearance. Taken together, these suggest active outdoor play, which is a strong concept in Louv’s work [rummy game from India that runs on an app that can be taken anywhere, including the great outdoors. Again, looking at the hashtags allows us to quickly target content that might be appropriate to exclude from the analysis.The v’s work . The anoGreater London Volunteering  which sFinally, in the Generic-nature hashtags, we find classic nature content, such as #animals, #birds, commonly related activities like #photography, #art, and place-based sentiment like #love and #beautiful.stop-words—i.e., extremely common words that are of little value in helping identify characteristic themes—from the tweets, prior to counting word occurrences. The stop-word list that we used was built by Salton and Buckley for the SMART information retrieval system [Our next level of content overview included determining the most frequently used words within the tweets. In accordance with information retrieval practices, we removed the l system , and it NDD hashtags could be interpreted as negative words: disorder and deficit. These words likely contribute to the negative sentiment analysis for this category. The other categories are largely made up of positive words, descriptive of the positive experiences in nature.Further mapping of these common words as well as thematic analysis of complete tweets is beyond the scope of this paper, but has been fruitful in other public health contexts including dental pain surveillance , surveilNDD relevant tweets—we refer to NDD relevant tweets as those that contain at least one hashtag or phrase included in our study—and the total number of tweets published at the time of writing, regardless of their connection to NDD, and the corresponding number of followers listed on their profile at the time of writing, as an indicator of how influential they might be.The 176,494 tweets considered in the study were published by 74,485 different users, for an average of 2–3 tweets per user; however, some users post much more frequently. Sub Saharan African Concise News Service. These services are largely produced by automatic aggregation. The most prolific user in our collection is @pinkbigmac—a service that allows the virtual exploration of travel destinations around the world. However, @pinkbigmac is not particularly influential, since it is not followed by a large number of users. It is notable that two names of top publishers indicate a link with the hashtag #photography: @photosinthewild and @FredHolmesPhoto—“photography” is also a common word found in our identified set of tweets. In this context, Sipo Liimatainen (@SipoArt), a surrealist and abstract Scandinavian artist, is the most influential user—followed by more than 23,000 users.Some of the most frequent publishers in the collection appear to be news syndication services—like, @PhuketDailyNews and @environsecnews, which publish material gathered from the nature-deficit disorder. In doing so we have described our methods of data gathering, applied an emerging methodology, sentiment analysis, and mapped the hashtag, tweets and retweets related to content about nature and health. Sentiment analysis has previously been used to track opinion about health care reforms over time [We set out to discover if a social media channel like Twitter could provide useful data about the public viewpoint and the social dissemination of the concept ver time . Anotherver time . We emplNDD, such as going outside for play or other activities that afford a greater connection with nature, is important for the uptake of healthier behavior and improvement of health and wellbeing. Previous studies have shown that the negative framing of messages has a lower effect on attitudes, intentions and behavior than messages framed positively [The dissemination of messages relating to sitively . Our ressitively . There isitively ,65. By eNDD is framed in a negative way. Tweets including the words “deficit” or “disorder” could be considered by automatic systems as being more negative in sentiment. However, this does suggest that public health officials and organizations interested in promoting outdoor exposure to reduce the potential negative health impacts might consider using more positive language in communications. For example, the wider use of the hashtags #getoutside or #outdoorfamilies in tweets from such groups may influence the response of Twitter users to the concept and aid in the wider dissemination of the ideas.The results may in part be affected by the fact that in its name We have documented how the general Twitter traffic and sentiment in our dataset swells and ebbs over time; yet, it is consistently relatively positive about nature and health-related concepts. This is compatible with other research demonstrating positive emotions elicited in nature ,67,68. FNDD and related nature–health ideas. Ironically, the very technology that might lead to NDD may be part of the way to understand and communicate deeply held feelings towards nature and how nature experiences affect human health and wellbeing.We have demonstrated the process of preparing a Twitter dataset that can expand our understanding of In conducting this study using the new methods of Twitter information-mining, sentiment analysis, and mapping of retweets, we encountered a number of important limitations. First, we were limited in the number of tweets that could be collected with each query, meaning that some very prominently used hashtags—e.g., #wildlife, #green—contained truncated data. This could bias our results. However, we collected over 175,000 tweets and as such have a relatively robust sample. Second, we used a limited set of hashtags based on expert opinion. Had we used an iterative process whereby little-used hashtags were dropped and commonly identified hashtags were added, we might have obtained a richer dataset.AlchemyAPI does not publish its dictionary and assignment, so while we can deduce the categorization of some words, in general this is opaque. Recent work also shows little agreement in sentiment analysis conducted with different software applications that may rest on this lack of consensus in assigning emotional valence [While quantifying sentiment, we recognized that the results are based on the assigned emotional polarity of words in the software’s dictionary.  valence .NDD, so the available data was, in fact, sparse, merely quantifying the persistent background discourse. We also saw how world events, such as the FIFA World Cup and the Ferguson killing in the US, may influence the day-to-day volume of available tweets, even on an unrelated topic [Another caveat to successful use of social media data has to do with the timing of data collection. We did not link our two-month data collection to a specific event or public campaign about ed topic . Seasonaed topic .We also found that while mapping tweets, retweets and hashtags is possible, detailed qualitative analysis of the statements in tweets will be challenging, given the brevity of the content and the extraordinary high volume of tweets available for analysis. Analyzing selected tweet subsets and using mind mapping tools along with qualitative methods software may assist in illuminating diverse themes and their relationships ,72. Irvivs. commercial or non-profit organizations, in order to better understand their divergent opinions.Finally, we also encountered the challenge of identifying the originators of tweets. It is appealing to think of them as individuals, tweeting from their cell phones in pristine environments, or sending photos of exquisite natural beauty to the public at large, but our look at influential users revealed automated news syndication services, professional artists and photographers, and travel facilitators, among others. An important future step in the analysis of this dataset would be to parse the sample into individual users Nature-deficit disorder is not yet regarded as a medical condition—it is not recognized by any medical coding schemes, such as ICD-10 [With the growing interest in how online sedentary activity might hinder the contact of both children and adults with the outdoors and offline healthy practices, we have presented an exploration of social media activity related to human health and the environment. s ICD-10 , or the s ICD-10 , the Ames ICD-10 , while ps ICD-10  and sedes ICD-10 . Numerous ICD-10 .Social Awareness Streams, like those found in Twitter, have implications for public health promotion efforts ,78. UniqNDD suggests there are significant differences in the way that messages associated to certain hashtags are framed. This may influence the uptake and wider dissemination of these messages via retweeting. It is important that public health officials and those seeking to disseminate knowledge regarding NDD consider carefully both the hashtags used and the sentiment of the message.Analysis of Twitter data using hashtags relevant to the concept of The results presented here are based on a limited sample of Twitter data. Further use of sentiment analysis in the assessment of Twitter data regarding emerging environmental health concepts may aid in better understanding the way such concepts are being used by the public and organizations. This in turn may lead to improvements in the use of Twitter for the communication of public health messages.


The United States wields disproportionate global influence in terms of carbon dioxide emissions and international climate policy. This makes it an especially important context in which to examine the interplay among social, psychological, and political factors in shaping attitudes and behaviors related to climate change. In this article, we review the emerging literature addressing the liberal-conservative divide in the U.S. with respect to thought, communication, and action concerning climate change. Because of its theoretical and practical significance, we focus on the motivational basis for skepticism and inaction on the part of some, including “top-down” institutional forces, such as corporate strategy, and “bottom-up” psychological factors, such as ego, group, and system justification. Although more research is needed to elucidate fully the social, cognitive, and motivational bases of environmental attitudes and behavior, a great deal has been learned in just a few years by focusing on specific ideological factors in addition to general psychological principles. The scientific community exhibits widespread agreement about anthropogenic climate change and the need to reduce greenhouse gas emissions . For a nDue to its disproportionate global influence in terms of carbon dioxide emissions (second only to China) as well as its role in affecting international climate policy, the U.S. stands out as an especially important context in which to examine social, psychological, and political dynamics. In 2009, a task force of the American Psychological Association (APA) identified numerous reasons for the public’s lack of urgency on the issue, including old habits, feelings of personal insignificance, uncertainty about the severity of climate changes, mistrust of information, the belief that the costs of climate change will occur later in the future than scientists expect, and high rates of denial and skepticism . Indeed,In the APA report, Since the 1980s, U.S. political leaders have been resistant—symbolically and operationally—to domestic action and international cooperation on climate change . PolarizWhile some surveys suggest broad support for certain climate change-related policies  and Spanish newspapers (El Mundo and El Pais) and found that U.S. newspapers used twice as much “hedging” language—words that suggest uncertainty . An analysis of 2,064 print media articles spanning six countries  from November 2009 to February 2010 revealed that the U.S. had the highest proportion of articles—one-third—expressing skeptical positions about climate change  interact with “bottom-up” factors such as the ideological inclinations of the audience. This work suggests that exposure to the same information can produce divergent effects—as a function of the message recipient’s political orientation—when it comes to attitudes about climate change. For example, an ideological divide was readily apparent in response to the 2007 report of the Intergovernmental Panel on Climate Change (IPCC). Why would exposure to the same information elicit divergent responses from liberals and conservatives? Recent work at the intersection of sociology, psychology, and political science has emphasized the role of “motivated reasoning” e.g., . It may For over 30 years, researchers have understood that individuals engage in “biased assimilation,” so that they readily absorb new information that upholds the validity of their pre-existing beliefs and opinions while resisting new information that might challenge them e.g., . With reIn many cases, it may be difficult to disentangle ego and group justification motives for processing information in a selective or distortive manner. This is because many cherished beliefs are linked to membership in a social group  or politAccording to system justification theory, people are not only motivated to defend and bolster the interests and esteem of their personal self-concept and the social groups to which they belong; they are also motivated to defend and bolster aspects of the social, economic, and political systems on which they depend . This moStudies show that conservatives are indeed more strongly motivated by system justification concerns e.g.,  and thatLikewise, nationally representative surveys conducted in Australia demonstrated that system justification in the economic domain was negatively associated with support for carbon pricing and other pro-environmental initiatives. Economic system justification was also associated with decreased moral engagement concerning environmental issues and—consistent with the “palliative function” of system justification—decreased negative affect concerning climate change .A study of university students in Finland revealed that perceptions of climate change as a threat to the national system and right-wing orientation predicted system justification in general as well as justification of the food distribution system in Finland. System justification, in turn, was associated with denial of anthropogenic climate change, decreased knowledge about climate-friendly food choices, and a decreased willingness to make climate-friendly food choices .We have reviewed recent work in sociology, psychology, and political science that illuminates both “top-down” and “bottom-up” factors contributing to the ideological divide concerning climate change (see Figure At the same time, it is clear that certain ways of framing messages are more effective than others when it comes to encouraging support for climate change policies e.g., . JohnsonNevertheless, focusing exclusively on message framing is likely to address proximate rather than ultimate causes of the ideological divide, which presumably include top-down, discursive structures as well as bottom-up, psychological functions. Few studies to date have isolated precise causal mechanisms linking political ideology to environmental attitudes and behaviors (but see The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


There are significant gender differences in injection drug practices and relative risks involved for women who inject drug compared with men. This qualitative study aims to explore the social, contextual, and behavioral dimensions of injecting practices among women who inject drugs.Participants were selected by purposive venue-based sampling from a syringe exchange program in 2012–2013. In-depth interviews were conducted with 26 women to elicit detailed perspectives regarding injection drug use practices and women-focused decision-making. All interviews were transcribed verbatim and analyzed with Atlas.ti.Participant’s mean age was 43.2 years, 48% Caucasian, 36% African American, and 16% Latina, poorly educated, mostly single, and heroin self-injectors. Three themes emerged; a) transitioning from non-injection to injection drug use; b) patterns and variations of initiation to injecting; and c) shifting toward autonomy or reliance on others. Women were predominantly influenced to transition to injection drug use by other women with their claims that injecting was a way to curtail their daily drug expenditure. More than half the women received their first injection from another woman in their social network rather than a male sexual partner. Self-injecting women exhibited agency around the circumstances of injection safety and potential risks. Other women revealed that their inability to inject themselves could and did make them dependent on others for unsafe injection practices.The finding that many women were influenced to transition to injection drug use and receive the first injection from a woman is contrary to literature claims that male sexual partners introduce and initiate women to injection drug use. Self-injecting women possessed capacity to act in a way that produced the results they wanted, not sharing prepared drugs or injecting equipment. In stark contrast, women assisted with injections could and did make them vulnerable to unsafe injecting. Findings support early prevention strategies that discourage women’s transition from non-injection to injection and development of female peer-driven experiential interventions to dispel myths for non-injection women and to increase personal capability to self-inject for women who require assistance with injecting, to reduce injection-related harm. Unsafe injecting drug use (IDU) is a significant factor in the HIV transmission dynamics of women who inject drugs (WIDUs). Different understandings of risk behavior or harm exist among them, and such differences are likely to depend on the social, contextual, and behavioral domains in which IDU occurs. A recent review on IDU and HIV found that, compared to men, WIDUs experience faster progression from first drug use to dependence, increased likelihood of injection-related problems, and higher levels of risky injection, sexual risk behaviors, rates of HIV, and significantly higher mortality rates -4.IDU when compared with non-injection drug use comes with a myriad of additional risk factors for women, including risks associated with injecting partners and the use of unsterile syringes -9. OtherResearch has identified several personal and environmental characteristics which act as predictors for initiation to IDU for women. Factors include engagement in sex work, non-injection drug use history, lifetime history of sexual abuse (particularly at a younger age), exposure to trauma and violence, social networks that include IDUs, family history of drug use, social disadvantage , lifetime history of incarceration, delinquent behavior (truancy or running away), young age of first illicit drug use, early sexual experiences, and mental illness or suicide attempts .The context of the first injection also affects the potential risks faced by WIDUs for the duration of their injection career. Variables such as where the injection takes place, who is present, where the drugs and equipment come from, and types of drugs used are all important risk factors. Women are more likely to inject in a social setting, less likely to inject alone, more likely to have their spouse or partner present, and more likely to have been in a group of mostly WIDUs -14.Scarce research illustrates that women with injection partners differ from women who self-inject. Self-injecting women relish the independence of being able to choose when and where to have their drugs, which vein to inject into, and freedom from reliance on an injecting partner. Women injected by others experience lack of agency, fearful of causing harm to themselves, and injected in areas of their body they would not ordinarily choose out of an urgent need to alleviate withdrawal. As such, partners sometimes had a pervasive influence on women’s drug use and injection practices . The praData consistently show that IDU is a highly gendered activity. WIDUs have substantially different needs and face higher risks of disease than do men who inject drugs. Given this difference, it is surprising that much of the literature on IDUs does not distinguish between men and women when discussing prevalence, needs, risks, and outcomes of IDU. This has led to a possible underrepresentation of the WIDUs perceptions of their injection practices and significant factors in their HIV transmission dynamics. There is a clear need for more systematic collection of data specifically with WIDUS.Qualitative research of WIDUs is scant in the literature and was chosen for this study because it allowed in-depth exploration and elucidation of the unique contextual factors of WIDUs, specifically around the shift from non-injection to IDU and the factors coupled with “self” versus “assisted” IDU implications for HIV transmission. This study addresses this gap by exploring the social, contextual, and behavioral dimensions of injecting practices of WIDUs in a syringe exchange program (SEP).Purposive venue-based sampling was used to select WIDUs from the Lower Eastside Harm Reduction Center’s SEP in New York City, between October 2012 and August 2013. The HRC mission is to reduce the spread of HIV/AIDS, HCV, and other drug-related harm among IDUs and the community by incorporating a spectrum of strategies such as syringe exchange. The SEP provide free sterile syringes and collect used syringes to reduce transmission of blood-borne pathogens.A screening form was administered at the time of initial contact to determine study eligibility. Study inclusion included women, >18 years, IDU in the past month, and the ability to speak English. Interviewers observed visible injecting marks confirming injector status.Twenty-six WIDUs were interviewed for the study. Participants were interviewed in-depth by two trained interviewers using a topic guide encouraging the participants’ discussion of injecting drug practices and decision-making. The interview guide emphasized the following topics: substance use, IDU practices, and injecting decision-making. The one-time, in-depth interviews lasted between 60 and 90 min, digitally recorded, transcribed verbatim, and entered into Atlas.ti for data analysis.The study received ethical approval from the New York University Human Subjects Committee. All participants were consented, provided with a project summary sheet, and received $15 for their participation.The research used a grounded theory approach to understand the concerns, actions, and behaviors of participants and to explain those patterns of behavior . ProceduSelective coding and constant comparative analyses were conducted to yield core categories or themes . Themes The sample consisted of 26 women, ranging from 22 to 63 years, with an average age of 43.2 years. The racial-ethnic composition was 48% Caucasian, 36% African American, and 16% Latina. The sample was poorly educated, less than half graduated high school, and the entire sample were unemployed. Sixty-four percent were single/never married. Six women reported childhood sexual or physical abuse by male family members.r = 9–29). First injection mean age was 23.8 years (r = 12–58). Most injected heroin, with a few cocaine and speedball injectors. Average duration of injecting drug use was 18.2 years. Sixty percent were identified as self-injectors, 20% as assisted injectors, and remaining women were reported self and assisted injections.Four WIDUs were not participants in the SEP but receiving services in the HRC. All participants reported a period of illicit non-injecting drug use prior to injecting. The mean age of initial drug use was 16.2 years  transitioning from non-injection to IDU, (b) patterns and variations of initiation to injecting, (c) shifting toward autonomy or reliance on others. These themes, along with illustrative quotes from participants, will be discussed below.Reasons why women transitioned from non-injection to IDU at any given point in time were complex. The expense of sniffing or smoking drugs was the primary reason many decided to begin injecting. For many women, drug use was often a social network experience shared with friends, partners, and spouses. Most women expressed the importance and safety of using drugs around people they knew and trusted. In many cases, the decision to transition to IDU was influenced by a combination of factors.It was gettin’ expensive by sniffin’ and so my friend said it holds you longer and you don’t have to be doin’ as much bags … by sniffin as injecting like they say, which is what’s true (23).Women non-injectors were advised by their peers about the benefits of transitioning from non-injection to IDU. Examples included the following: they would use less drugs, spend less money, and get a better, quicker high compared to sniffing. Prior to their first injection, it was a common belief among participants that injecting would be a way to get their expensive habit under control.I sniffed heroin at 21 years old. I was 23 and basically wasn’t feeling it at all anymore, and I was now with a crowd of shooters that looked at me like I had four eyes because I sniffed (21).For some women, the shift from intranasal to IDU to their first injection was based on her need to increase the high and desire to go along with others or fit in with IDU social network.Me and her was together one day and she was like “Why don’t you shoot it? It’ll hit you better and you’ll feel it much better”, and I was real scared and she was like “I’ll hit you, I’ll hit you, I’ll hit you.” That was the first time, she hit me, and I started shooting drugs (1).It was common for experienced WIDUs to encourage their non-injecting friend to change the route of their administration to injection by explaining the benefits of IDU such as the better quicker high than the intranasal route of administration:I got curious…one night I was like I want to try it, and he’s like, absolutely not happening, and I’m like, listen let me tell you something. I’m the one that’s bringing it [heroin] back up here and you ain’t going to find anybody else who’s gonna do it who’s as young as I am, so either you turn me onto it or I go…He actually hit me before he hit himself the first time (18).The transition to IDU was often motivated by curiosity and self-gratification. Women were not always passive in the transition process. Often, they had an active role in their shift to injecting. Some women stated that injecting for the first time was their own idea, curious about injection but unable to inject themselves. This woman wanted to inject heroin so badly that she “blackmailed” someone to inject her.Most often, the first injection was prepared and administered by someone they knew, usually through a well-established social network of IDUs. An important finding was that again, a WIDU who was a friend or relative injected more than half the women their first time. Most of the initiates had only one other person present at initiation and in a private indoor venue; home, apartment, or bathroom. None of the women were alone the first time they injected.Experienced WIDUS very often served as instructors by explaining the injection process and in almost most cases, the injector prepared the drugs and injected themselves before injecting the other women. The skill of the injector was important to women receiving their first injection. A skillful injector was thought to be anyone that could inject them without any complication or marking. Some initiators would take their time and be gentle, careful and patient and others already high may miss or go through the vein.So she explained to me how it works… she told me not to be scared. I wasn’t. I really was feeling sick. I needed to get straight. I saw how she did it, she tied me up with her belt and she told me to relax and then she put the needle and got the vein real fast and she told me that as soon as you…pushed the syringe back and you see the blood floating, that’s how you get the vein. That’s all it took, just one time. The experience was amazing. I instantly felt ok (10).This woman was already in withdrawal, experiencing symptoms and not fearful of being injected the first time. She expressed how good she felt after the injection and no longer in withdrawal and continued IDU following their first injection.Well, I injected myself. I watched somebody inject themself and since I had good veins, at the time, I had no problem injecting myself…they showed me how to do it and that was it (24).Only two women in the study self injected their first time but after they observed another injector who served as their instructor, usually a female friend, acquaintance, or relative. They both thought they had good veins.At first I snorted for a couple of years. Then after that I was seeing how…I’m snorting five bags to their equal to two and they’re like stoned…I said to myself, you know what? I never stuck a needle in my arm.’ I didn’t like needles. My sexual partner did everything for me…injected me. The first time it was, ‘I’m home! This is it!’ And I never stopped from then (26).Conversely, a quarter of the women reported a male sexual partner, spouse, or friend initiated their transition to their first injection.In most urban areas where rates of IDU are high (NYC), there are common neighborhood locales for purchasing and using drugs. Among the highest risk locales are “shooting galleries” or “safe houses” places where people go and inject and usually pay in order to be able to inject. Hit doctors are frequently male and known within the IDU community for their skill as injectors. Some women who required assistance with their first injection went to safe houses belonging to IDU friends who lived alone and would serve as a place for a group of close friends to inject together.I was young, 13 and down the block was what you’d consider a crack house and it was really dirty in there and they had 10 cats. I sat on the couch…he had a ponytail and he was really cool, he kissed my arm, before he did it and, I looked away and he did it for me and it was quick (15).For this woman, being reassured by an experienced, knowledgeable hit doctor who blew on her skin as the needle was pushed in to reduce stinging when being injected. Often, these decent experiences of assisted injecting ensured dependency on the hitter and injecting at the same time.Most women in this study identified as self-injectors. For these women, the shift to becoming a self-injector is related to many protective strategies; independence from other injectors, self-sufficiency, choice of body injection site, and control over the time, place, and relative safety of injecting practices.I learned how to hit myself. A lot of people say, ‘oh well I need somebody to hit me,’ not me. I close, I drew it, and I put it back in. I didn’t need nobody to help me draw up. I didn’t need nobody to help me do that no more because I do everything myself. Everything (11).After learning how to self-inject, this woman expressed a strong sense of independence and autonomy of her ability to learn how to self-inject.First time I self-injected was in my hand, and I fucked it up, like twice. But you know, then I got the hang of it. I didn’t push it in. I knew it wasn’t in because the blood wasn’t registering…I have no track marks. I felt a hell of lot more independent and more in control. …. Now I can do it everyday (18).This woman described the process of teaching herself to self-inject. Her ability to self-inject also instilled feelings of competence, independence, control of oneself, and prevention of harmful, noticeable scars on her body.I watched somebody inject herself. I had good veins, at the time. I had no problem injecting myself. They showed me how to do it and that was it. I think it’s safer. I don’t want someone else injecting me. I can tell when I register. I shoot up in my own way. That’s when I made the choice. I chose to be a self-injector because I do it my way (24).Another woman strongly described her choice to self-inject as a competent and safer practice.I always use clean syringes from here, I shared one time in my life, and I was very nervous, I got an HIV test after that. I was very scared to get that test, cause, this person was a junkie, and dirty. I always carry cleans. If my friends didn’t have cleans, I gave them cleans. If I use the same one more than once, I made sure I knew it was mine, I had a little makeup case that I carried all my needles (26).These experiences of self-injectors described above sometimes triggered women to contemplate the intrinsic worth of self-injecting. Many of the women who were self-injectors expressed a sense of autonomy and control in utilizing the SEP as a protective and safer measure.However, several women did describe requiring assistance with injecting because they lacked knowledge, uncomfortable self-injecting, or small veins making self-injection complex. Women who were injected by others experienced a lack of autonomy, reliance on others, and fear of causing harm to themselves. People sometimes injected women in areas of their body, or, they were people they would not ordinarily choose out of an urgent need to alleviate withdrawal. These risks of being injected by others; transmission of blood-borne viruses, bacterial infections, damage to the circulatory system, and overdose were rampant among this group.I didn’t know how to hit myself. Then after a while she would do it for me, I would have to call her. I started having to go to the shooting gallery…I learned when they would hit you…That’s how I think that I contacted the hep C, you only get it blood to blood. Then, I really did wanted to learn how to hit myself, but I never did learn how to do that (1).This woman appeared to be unaware regarding the potential risks associated with being injected by another, until after she realized she was infected with hepatitis C.He was injecting me. At first, because very, very hard for me to hit myself. I had these little girly veins. They roll. It’s really hard, so I used to let him hit me in my neck because I had bad veins. It’s really hard (21).An implicit understanding existed for some women that they should not question the injector’s skill or knowledge when being injected, for example, about which vein to inject into. Women injected by others were clearly much less in control of their injecting situation. Skillful and experienced injectors however did not always successfully inject others. Women had experienced harm from injectors and often compared the abilities of different injectors.Women requiring injecting assistance often spoke about being second on the needle. It was common for the women to receive their injection after the injector had self injected. The injector’s condition often affected the injection technique particularly if they had already self injected. Injectors being heavily intoxicated when injecting women placed them at an increased risk of physical harm.I was asking do I need my own set? She would say no. She always went first and she was mainlining and did me second and it was actually hell because I always had to wait for her and then sometimes she didn’t clean the needle. [She] done die of AIDS (8).Some women thought people who self injected before injecting them were selfish and impatient for drugs.I didn’t think about safety…I didn’t think about nothin’. All I wanted was to feel the heroin run through my veins. There was a needle that was shared and at the moment I don’t even think about it. I didn’t think about this person, how well do you know him or did somebody else use it and if he just cleaned it (7).For others, experiencing withdrawal affected their ability to assess risks or take precautions. This woman describes how she just wanted to get high.He would have to hit me cause I couldn’t hit myself. Sometimes we would get I into arguments over who would go first. We had this thing between us that we used to call it I say I’m first on the case. But if I call I’m first on the case first, he would get angry cause he had to hit me first. He would do it in a rough way (13).Women’s experience of physical harm and damage to their veins as a result of being injected by others was common. Women spoke about the injector “missing” as a result of the needle not going into the vein or being pushed through the vein were frequent which often resulted from the injector rushing when injecting them due to their own withdrawal. The injector’s condition often affected the injection as they took less time and care when injecting the women if they had already self injected. Several participants described harmful and risky syringe-sharing behaviors with IDU partners who provided injection assistance:This qualitative study contributes to the knowledge concerning social, contextual, and behavioral domains affecting WIDUs injecting practices through three key themes; transitioning from non-injection drug use to injection, initiation to IDU, and shifting towards autonomy or reliance on others.First, the transition process, from non-injection drug use to IDU, was greatly influenced by women’s social network. Myths and half-truths about IDU was spurred most often by WIDUs beliefs; IDU is a more efficient route of drug administration, a way to curtail daily drug expenditures, and a promise made more alluring by witnessing the amplified high female friends experienced after IDU. This finding is often ignored in both the prevention and treatment literature. But substance abuse treatment is a prospect for early intervention for women who do not inject drugs. An example may be a women’s group aimed to hinder transition to injection through heightening their awareness of the risks, outlining ways that women make the transition into injecting, and by encouraging the development of anti-injecting rationales and resistance skills.Other women expressed the pressure of their network, which created an aspiration to be similar and fit in with their network, a network comprised mostly of WIDUs. This finding supports existing literature on the influence of peer pressure and the supposition that injectors are related to, not isolated from, the larger social group of injectors . A gendeSecond, a main finding of this study is that many women received their first injection from a female rather than a male sexual partner, running counter to literature claims that male partners initiate women to IDU -14,22-24Another novel finding is that many of the women were self-injectors. These women exhibited decision-making and agency around the circumstances of injection safety and potential risks. They chose safer injection practices; carrying sterile syringes, preparing their own drugs, and not sharing prepared drugs or injecting equipment. Self-injectors avoided withdrawal and harm through self-reliance, injecting in private and safe venues, and participating in syringe exchange. This sense of autonomy and control highlights their lack of dependence on an injection partner. These findings are contrary to literature signifying that women’s drug initiation, continued access to drugs, and injecting occur mainly through male sexual partners. It is surprising that no prospective study has fully examined the protective factor of self-injection and it’s relation to HIV infection and transmission.Fourth, in stark contrast, several women required assisted injection throughout their injecting career because of their lack of knowledge or deference to an injector due to anxiety or withdrawal. The presence of an established SEP did little to mitigate this risky behavior. This is concerning, as non-self injection is an independent predictor for HIV infection . Women wOne limitation to the research was the sampling method. Although this sample size was consistent with the qualitative research goal of gathering extensive information from a small group of individuals, the 26 women interviewed may not generalize to WIDUs who were not receiving services in a HRC or SEP. A second limitation was that respondent-driven sampling to recruit subjects was not used, and therefore the sample is not necessarily generalizable to the WIDU populations in SEPs in NYC. Nevertheless, saturation was observed on a number of themes, which provides confidence that the findings are meaningful. Additionally, the data was collected through the women’s self-report in a face-to-face interview format and the women may have been subject to providing socially desirable responses.Findings suggest that interventions that dissuade women who inject drugs from transitioning to IDU are to a great extent are needed and enhance self-efficacy and independence among women WIDUs. Development of peer-driven experiential interventions with strong female representation to dispel myths with the aim to dissuade women from transitioning to IDU and increase their personal capability to self-injection is needed. Interventions could provide information, enhance risk-reduction skills, and motivate injection practice change. WIDUs should always be involved in the design and implementation of these programs, to ensure that programs are effective, appropriate, and respectful of human rights . Governm


Background: A recent review of interaction (or conversation)-focused therapy highlighted the potential of programmes targeting the person with aphasia (PWA) directly. However, it noted the key limitations of current work in this field to be a reliance on single case analyses and qualitative evidence of change, a situation that is not unusual when a complex behavioural intervention is in the early stages of development and evaluation.Aims: This article aims to evaluate an intervention that targeted a PWA and their conversation partner (CP), a dyad, as equals in a novel conversation therapy for agrammatic aphasia, using both quantitative and qualitative evidence of change. The intervention aimed to increase the insight of a dyad into facilitator and barrier conversation behaviours, to increase the understanding of the effect of agrammatism on communication, and to support each speaker to choose three strategies to work on in therapy to increase mutual understanding and enhance conversation.Methods & Procedures: Quantitative and qualitative methods are used to analyse multiple pre-therapy and follow up assessments of conversation for two dyads.Outcomes & Results: Results show that one person with severe and chronic agrammatic aphasia was able to select and practise strategies that led to qualitative and quantitative changes in his post-therapy conversations. The other PWA showed a numerical increase in one of his three strategies post therapy, but no significant quantitative change. Although both CPs significantly reduced barrier behaviours in their post-therapy conversations, neither showed a significant increase in the strategies they chose to work on. For one CP, there was qualitative evidence of the use of different turn types.Conclusions: Individually tailored input from a speech and language therapist can assist some people with chronic agrammatism to develop conversational strategies that enhance communication. Outcomes are influenced by the severity and extent of language deficits affecting, for example, single word writing. In terms of behaviour change for CPs, it appears that it may be easier to reduce barrier behaviours rather than to increase the use of facilitatory strategies. The results have implications for collaborative goal setting with clients undergoing conversation therapy. Conversation partner (CP) training programmes have become increasingly popular over the last decade . We present two illustrative case studies from a larger study, chosen for the similarity of the barrier conversation behaviour used by both CPs  and the extent to which it dominated pre-therapy conversations. An analysis of all eight dyads is in preparation.Each case study involved a PWA and their chosen CP in 6 months of intervention, subdivided into three phases of 8 weeks each: (a) pre-therapy baseline assessment; (b) therapy; and (c) post-therapy follow up assessment. A dyad participated in 8 weeks of pre-therapy and 8 weeks of post-therapy assessment, which took place at home, once a week for around 1.5 hr. Assessment of conversation involved video recording eight pre- and eight post-therapy samples, labelled C1–8 and C11–18, respectively, and two conversations during therapy , each of approximately 20 min in length, totalling around 6 hr of recordings per dyad. To do this, a dyad was trained in how to operate a digital video camera. The research speech and language therapist (SLT) was not present when the recordings were made. Dyads were advised to record at a time when they would normally sit down for a chat, to catch up on events and news, for example; there were no suggested topics. Assessment of language impairment, activity, and participation was split into three pre-therapy and two post-therapy assessment baselines see  and conshttps://extend.ucl.ac.uk).Therapy sessions took place at the participants’ home once a week for 8 weeks, each lasting around 1.5 hr. The therapy, designed specifically for people with agrammatic aphasia, was adapted from SPPARC , and applying a statistical test to look for significant change. Sample selection was motivated by the wish to minimise participant awareness of being part of the study, and particularly of being video recorded. Thus, we discarded C1, the very first conversation that participants recorded before therapy, and C18, the final post-therapy sample. The remaining seven pre- and seven post-therapy samples were felt to be more ecologically valid. Of these 14 samples, to date we have counts for 12 , and this analysis is reported here. Where a conversation sample was 10 min in length or longer, the first 5 min was discarded, with the second 5 min selected for analysis to maximise ecological validity. If a sample was less than 10 min in length, the final 5 min was selected for analysis.The counts of facilitators and barriers reported here are the work of six Masters students of speech and language therapy at University College London, who completed their theses with the project team between 2010 and 2012. Prior to rating, students  received 6.5 hr of group training split across four workshops, covering the aims and design of the project, how to produce a transcript of a sample (one turn to a line) prior to rating , and how to rate a sample for barriers and facilitators. Student raters were given written guidelines that defined each barrier and facilitator and gave real-data examples, and workshops included a discussion of these definitions followed by group rating practice, with conversation samples taken from two people with agrammatic aphasia who were not part of the project. During the rating process, students attended a further two group meetings at which they could discuss any difficulties with rating and categorising aspects of conversation. They also had access to a group e-mail via which they could post queries to their fellow students and the project team. Each student was allocated between two and eight samples to rate , depending on the scope of their project. All were blind at the time of rating as to the point of collection for all samples. In some cases, it was possible to ask two students to independently rate the same sample and to agree counts for individual facilitators and barriers. Agreement was defined as both students applying the same rating to a specific turn; consensus agreement techniques were not used. Where available, we report counts of facilitators/barriers agreed by two students, even if this is zero. Otherwise, counts by an individual student are reported.z score approximation may not be very accurate. Because of the directional hypotheses for change, we employed one-tailed tests.The counts constitute non-parametric frequency data across occasions. The Poisson distribution can be applied where there are a large number of possible events which are rare. A weighted Poisson trend test for frequencies, derived from a Jonckheere Trend Test, was applied to identify whether there was a significant change in these counts after therapy . This enabled us to test the hypothesis that the post-therapy counts differed significantly from the pre-therapy counts. To test this, all pre-therapy conversations were weighted the same and all post-therapy conversations were weighted the same. We did not explore other possible hypotheses, such as gradual change over the course of the study. It should be noted that, if the number of observations in any condition is less than 5, the In addition, the methods and published findings of CA were applied to conversational extracts to illustrate the impact on conversation of a reduction in CP barrier behaviours and an increase in PWA strategy use and the interconnected nature of such changes. Three of the four extracts analysed here  were originally identified, transcribed using CA conventions and analysed by three of the six Masters students. This formed part of the qualitative data presented in their theses alongside the conversation ratings. They performed this work after producing the ratings, when they had been unblinded as to sample collection date. Their transcripts and analyses have been refined and extended by the first author.Two dyads are reported here. The first is Graham, a right-handed male British-English speaker with severe non-fluent aphasia, and his partner, Alex . Graham was 63 years old when recruited to the project, having had a left middle cerebral artery infarct 5 years before, affecting the fronto-temporal cortex and parts of the parietal lobe. After the stroke, Graham was in intensive care for 4 weeks. He then received 12 weeks of National Health Service (NHS) inpatient rehabilitation followed by a further 6 sessions of community speech and language therapy. After this he had private SLT for 3 years, twice a week for the first 6 months, weekly thereafter. Graham left school at 16 years, trained and worked as a nurse, and latterly worked as a nurse manager in several hospitals. Alex is a retired accident and emergency nurse and was in his early 60s when recruited to the project.“a cat (2) and (2 sylls) and the (2 sylls) (1) and a then a another one and (8) a (1 syll) and (SLT: that’s it?) yes” His test profile is suggestive of severe agrammatic aphasia.As During therapy, after viewing video footage of their conversations and discussing facilitators and barriers with the SLT, Graham chose to work on the following strategies: writing and drawing; mime; keyword. Alex chose to work on: “let the conversation continue (for further clues/so Graham can use strategies)”; “carry on if you have understood (it does not need to be perfect)”; “comment” on Graham’s turn. A key conversational barrier discussed with the dyad was Alex’s use of test questions. A test (or “known answer”) question is defined as one to which the questioner already knows the answer and was first outlined in the context of formal talk in the classroom McHoul, .The second dyad is Stuart, a right-handed male British-English speaker with severe non-fluent aphasia, and his wife, Pamela. Stuart was 57 years old when recruited to the project, having had a left cerebrovascular accident 10 months before (no scan results were available). After the stroke, Stuart received NHS inpatient rehabilitation for an unknown length of time before having 12 weeks of community SLT. Stuart left school at 16 years, and, prior to his stroke, he worked as a self employed van driver. Pamela is a school dinner lady and was in her mid-50s when she and Stuart joined the study. They live with their son, Graham, who was 12 years old at the time of their involvement in the project. Some of the conversations recorded by Pamela and Stuart include Graham (though he is not visible on camera).“yeah yeah picture and (1) book (1) book umm tree (1) tree uh uh uh and ((taps with fingers)) (3) (1 syll) (10) picture (4) and book and (3) book and  (9) book and right (2) know what I mean, d’you know what I mean, ooh oh (SLT: anything else) book and (2) book, yes (6) book (3 sylls) look look no one two three four five (1) book book book and woman woman woman (3 sylls) and run run run run (3 sylls) (10) (SLT: yes) ((PWA writes)) (4) miaow miaow miaow miaow” His test profile is suggestive of severe agrammatic aphasia.As During therapy, after viewing video footage of their conversations and discussing facilitators and barriers with the SLT, Stuart chose to work on the following strategies: writing and drawing; gesture; keyword. Pamela chose to work on: “let the conversation continue (for further for clues/so Stuart can use strategies)”; “carry on if you have understood (it does not need to be perfect)”; “paraphrase” what you think Stuart said/meant. In common with Graham and Alex, a key conversational barrier discussed with this dyad was Pamela’s use of test questions.We predicted that there would be an increase in behaviours targeted as helpful in conversation (facilitators) and a decrease in behaviours deemed unhelpful (barriers). Here we present results of statistical analysis of strategies chosen by the PWA and by the CP (deemed facilitatory behaviours), and CP barriers, for six pre- and six post-therapy conversation samples, to identify whether therapy had a significant effect on conversation. This section is followed by a qualitative analysis of conversation extracts that explores how the turns taken by the PWA and CP changed after therapy.z = 2.83, p < .01); mime ; keyword . . As pre-therapy samples, thus the result for writing appears to reflect adoption of a new strategy. However, the counts for mime and keywords reveal that Graham was making some use of both before therapy, so the results reflect increased use of these behaviours, rather than adoption of new strategies. For Alex, the CP, there was no significant effect of therapy on strategies that he chose to work on: Poisson trend for frequencies (1-tailed), “let the conversation continue” , “carry on if you have understood” , “comment” . For each strategy, the numerical data for pre-therapy and post-therapy total counts are stable, as are the means. However, there was a significant result for test questions, a barrier behaviour in Alex’s conversations that was targeted for reduction: Poisson trend for frequencies (1-tailed) test questions . Thus, for Alex, behaviour change as a result of therapy constituted the reduction  of a barrier conversation behaviour (asking test questions), but there was no corresponding increase in his three chosen strategies, which remained at pre-therapy levels.For Graham, the PWA, strategies that he chose to work on in therapy all increased significantly in post-therapy samples: Poisson trend for frequencies (1-tailed), writing , gesture , keyword ; Pamela: “let the conversation continue” , “carry on if you have understood” , “paraphrase” . Note that there were no counts of drawing in pre- or post-therapy samples. However, therapy did have a significant effect on Pamela’s use of test questions: Poisson trend for frequencies (1-tailed), test questions . Thus, for Pamela (as for Alex), behaviour change as a result of therapy constituted the reduction of a barrier conversation behaviour , but there was no corresponding increase in her three chosen strategies; these remained relatively stable as the means per sample before and after therapy illustrate. In the case of Stuart, therapy had no statistically significant effect on his chosen strategies; however, numerically, keywords showed a slight increase, from a pre-therapy mean of 2.5 per sample to a post-therapy mean of 3.8 per sample. In contrast, gesture showed a numerical decrease  and writing remained relatively stable . All Stuart’s chosen strategies were in use before the therapy began.For both Stuart (the PWA) and Pamela (the CP), there was no significant effect of therapy on strategies that they chose to work on: Poisson trend for frequencies (1-tailed), Stuart: writing,  almost eradicated test questions from their talk; however, use of chosen strategies remained at pre-therapy levels. Whilst Graham used significantly more of his chosen strategies , Stuart’s use of strategies  showed no significant change compared with pre-therapy levels .To shed some light on these results, it is helpful to perform a qualitative exploration of the data using CA. The analysis that follows is divided into two sections, the first explores the form and impact of test question sequences in pre-therapy conversations, the second explores the opportunity for PWA strategy use when such questioning by the CP is reduced.Test questions are typically a feature of pedagogic interactions, and they set up a context in which the addressee is expected to provide a very specific known answer, commonly a noun or a noun phrase. This clearly sets up a difficult interactional task for any PWA, given the persistent word finding difficulties associated with all types of aphasia. The literature reveals the social and emotional impact of test questions in aphasic conversation to be variable. Sometimes they can be a positive method of promoting language use ; since Alex and Graham both participated in the event involving Anne, we surmise that Alex knows the answer to his question. Graham’s response is highly constrained by the test question formulation—it must consist of a noun to stand in the place of the word “what” in Alex’s question. Graham produces “birthday”, and Alex’s evaluation of this as an acceptable answer  provides further evidence that this is a “test” sequence. Then Alex makes a genuine request for Graham’s opinion about the birthday party , but as the talk progresses, Alex’s subsequent turns suggest that he already knows that Graham did not enjoy it, and he may also know why. Although it is difficult to know if “what didn’t you like” (line 07) is a genuine question, “what was difficult about the night” (line 15) appears to be designed to prompt mention of a specific negative issue already known to them both. This is suggested by Alex’s verbal and gestural cueing behaviour in line 17; he says “the nuh” while touching his ear. At this point in the sequence, his turn could be designed to offer a guess, marked with rising intonation, for Grahame to accept or reject, in order to help move the conversation along. However, this is not what Alex does; he provides a cue to elicit a specific word, “noise”, in answer to his question. Graham encounters severe difficulty when attempting to answer these questions. His responses consist of fillers and long pauses (lines 08 and 16), and his turns remain incomplete. He does appear to have some success responding to Alex’s prompt in line 11, a gestural cue to name a drink, producing syllables unintelligible to the analyst (line 12) but apparently understood by Alex, who responds “yeah” (line 13). Having ignored Alex’s cue for the word “noise” in line 17, Graham goes on to mention other things, some of them unintelligible (line 20) before describing the noise in his own way, by gesturing “chatter” and mimicking the sound of talking (“(but) eh = and bay ay ay ay ay- oh god!”, line 22). Alex appears to attempt one further elicitation of the reason why the night out was difficult, saying “because…” (line 25) and repeating the gesture of touching his ear that was seen in line 17, but Graham is unable to respond. In the end, it is Alex who voices the reason, saying “to hear people was hard” (line 27), to which Graham responds “yeah…yeah” (lines 28 and 30). This sequence is representative of Alex and Graham’s pre-therapy exchanges. It is notable that Graham has severe difficulty in producing answers constrained by test questions, yet does appear to be able to talk more freely when not required to produce such specific turns; compare direct attempts to answer test questions in lines 08 and 16 with turns in lines 18, 20, and 22. Although the impact of test questions on Graham’s turns appears problematic, such sequences are often collaborative, and there is little sign of negative emotion. Interestingly, when asked in therapy session 5 how he feels about Alex asking test questions, Graham rolls his eyes and shows quite plainly that it annoys him.However, some people with aphasia, like Stuart, appear in their conversations to be frustrated and upset by being asked test questions. Extract 2 has been chosen to illustrate the common pattern of test questions in Stuart’s and Pamela’s conversations before therapy. In this extract, their 12-year-old son, Graham, is present.This extract opens with Pamela asking a question, “where did you go this morning?”. As the sequence progresses, it becomes clear that this something she already knows and that Stuart is required to say the “correct” word rather than talk about his day. The son’s comment “don’t panic” (line 03) reinforces the sense that Stuart is being tested and leads to a humorous aside between mother and son, centred on a catchphrase from a television programme (“don’t panic Mr Mainwaring”), while they wait for Stuart to respond (lines 03–08). Stuart recognises that an answer is required; lines 09 and 10 show signs of word search behaviour including pausing, mouth movements, gazing to the middle distance and fillers. Pamela then repeats her question, this time stressing the word “go”, marked by underlining in the transcript (line 11). Stuart writes the letter W in the air (line 12), but this strategy goes unnoticed, and Graham comments about being able to hear the fair outside their house. Stuart’s body language suggests a negative reaction to this interruption (line 14). In the next turn, Stuart manages to give a spoken but only partially intelligible response (“(sedskai) gardens”, line 15). However, Pamela’s response , delivered after a 0.7 s pause, appears to indicate that it is not the answer she is looking for. Stuart looks down, drops his arm onto the table top and sighs heavily. Pamela asks again, and Stuart continues to have severe difficulty formulating an answer (lines 19–20). There is a 9.2 s pause, at the end of which he holds his head in his hand. It is unclear whether he will make any further attempt to respond. Recognising this, Pamela gives him the option to stop, asking “do you know?” (line 21), and Stuart resumes eating. She then encourages him to think while he eats. Next, she attempts to cue him by starting a turn for him to complete with a noun, “you went over thu-” (line 25). A 3.1 s pause follows during which Stuart gazes to the middle distance and then at Pamela. In response, Graham produces the determiner in full, saying “the” (line 27). Pamela’s reaction is to tell her son not to “give any more clues because it’s cheating then” (line 28), making explicit the interactional “rules” that are in play during this test question sequence. In overlap, Stuart tentatively offers the word “park?” (line 29). Pamela’s turn in line 30, “you didn’t get that because we gave you a clue”, suggests that Stuart has now produced the required response however, and this is not acknowledged directly; she voices a view that the “test” was not valid because they gave him a clue.As Extracts 1 and 2 show, test question sequences constrain Graham’s and Stuart’s turn constructions; they are required to answer questions typically by producing nouns, and as a result, their turns display severe word search behaviours and often remain incomplete. After therapy, the quantitative findings reveal a significant decrease in both CPs’ test questions. This change leads to less constraint on what type of turn the PWA has an opportunity to produce, and the next section explores what effect this opening up of the turn space has on Graham’s and Stuart’s turns.Extracts 3 and 4 have been chosen as representative examples of post-therapy sequences of talk, where Graham and Stuart can be seen to construct turns that reach completion and are much less problematic to produce than those seen in Extracts 1 and 2. These turns are produced in the context of Alex and Pamela taking types of turns other than test questions.In this extract, Graham and Alex are discussing an item on their “to do” list, which possibly relates to legal issues ; although it is not entirely clear what is being talked about (in part because Graham’s identification of a key referent is distorted by dyspraxia), the speakers appear to understand each other fully. When asked by Alex about an item on the list, Graham verbalises a name that sounds like “susums” (line 02). Alex’s response is quick and makes apparent his understanding not only of the referent but also of what has to be done “…we have to give them identification…for you” (line 03). Graham agrees and then begins a word search, saying “erm” and looking down at his list for 3.5 s. Subsequently, he picks up a pen and begins writing for 14.5 s (line 05), during which time Alex watches. When Graham puts the pen down, Alex asks for clarification of what he has written, saying “is that London” (line 06). In response, Graham offers what appears to be a correction (“(lunuh)”, line 07); his production of the word is distorted by dyspraxia but Alex understands it to be “Lauren” (line 08), which Graham accepts. Alex then shows his understanding of how this referent links to the topic of talk, saying “for the will as well” (line 10). They then go on to have a discussion about how best to change the will, and when. By using his chosen strategy of writing, Graham is able to circumvent his severe word finding difficulties to take a turn that extends the current topic and launches discussion about an issue of importance to him. It is notable that before therapy, Graham did not write to circumvent his word finding problems—there were no examples of writing in pre-therapy samples see . In addiIn this extract Pamela asks Stuart about his trip out with Sonny earlier that day. Although Pamela still asks Stuart questions, there is a marked contrast with pre-therapy talk as exemplified in Extract 2. Rather than prompting Stuart to name referents that are already shared knowledge (where he went and with whom), Pamela instead asks about details that she does not appear to know, such as what car they went in and where Stuart sat. Importantly, she also takes different kinds of turns to those seen pre-therapy, creating humour with “ohh you poser you!” (line 05) and “I don’t know” (line 16), said with mock despair. By constructing turns that express her opinions, rather than asking test questions, she succeeds in collaborating with Stuart to create a light-hearted exchange, which both of them appear to enjoy. Thus, although the quantitative findings reveal no significant change in Pamela’s use of her chosen strategies, there appear to be qualitative changes in her post-therapy turn types. In line 20, she asks Stuart to tell her what colour the car is, a question that bears a resemblance to those seen in their pre-therapy conversations. Interestingly, she begins a direct question, saying “what”, but immediately reformulates it into a statement that focuses on her own failings, “I’ve forgotten what colour it is”. The fact that we cannot tell from the sequence of turns if she knows the colour of the car, and thus whether this is a test question, is testament to the subtlety of her interactional behaviour here. Her question casts Stuart in the role of knowing the answer, rather than being “tested”. One final turn of interest is line 31 where Pamela asks their son to stop interrupting Stuart. This suggests a shift from pre-therapy conversation dynamics in which Pamela and Graham collaboratively prompted Stuart to talk. For his part, Stuart succeeds in providing the answer over lines 21–36, in collaboration with Pamela and Graham. Some of Stuart’s turns appear to be constructed using similar strategies as those used before therapy, namely keywords and writing letters in the air. However, in this post-therapy extract, Stuart makes more effective use of these strategies, in part because Pamela appears to treat his sky writing as part of his turn (compare this with Extract 2 line 12 where sky writing is ignored). Thus, he perseveres with a self repair to successfully identify the car as “white and… black” (lines 27 and 33). In addition, Stuart takes very different kinds of turns to those seen in Extract 2. He deploys stereotyped phrases such as “yes indeed” (line 06), “d’you know what I’m saying” (line 08), “I don’t know” (line 17) and “I know” (line 19) to great conversational effect, allowing him to collaborate with Pamela to create a humorous story about his day out.This article reports the quantitative and qualitative therapy outcomes of conversation training for two dyads where one speaker has agrammatic aphasia. The quantitative results reveal that therapy had a significant effect on both speakers of one dyad, Alex (CP) and Graham (PWA), but only on the CP of the other dyad, Pamela, and not on Stuart (PWA). Thus, Alex almost eradicated test questions from his talk after therapy, having identified this as a barrier behaviour that he wished to change. Qualitative analysis showed that Alex was taking facilitative turn types (such as commenting and asking genuine questions) after therapy; however, the quantitative analysis revealed no significant increase in the specific strategies that he chose to target ; commenting was present in pre-therapy samples. Graham, his CP with aphasia, used significantly more of the strategies he chose to practise during therapy .While Pamela too almost eradicated test questions from her talk after therapy, she did not significantly increase her use of chosen strategies , though qualitative changes were noted. Post-therapy turns expressed her opinions, and questions appeared to arise from a genuine lack of knowledge. There was no significant change in strategy use  for her CP with aphasia, Stuart, although a numerical increase in keywords was noted. These findings strengthen the evidence base for the success of conversation therapy in changing the behaviours of CPs and also add quantitative evidence to the growing case for the effectiveness of direct conversation training for some people with aphasia.With both CPs asking significantly fewer test questions, the post-therapy conversational context for both PWAs changed. They were presented with an opportunity to take turns that were less constrained; they were no longer frequently being selected by the CP to produce a specific (and often known) answer. In this relatively open post-therapy turn space, both increased their use of keywords, but this only reached statistical significance for Graham. Graham also increased his use of writing and mime, yet Stuart showed no change in his use of writing and, indeed numerically, gestures reduced. So we might ask why Stuart was less able to take advantage of the changed interactional context in his conversations with Pamela and was less able to deploy the strategies he practised during therapy. One reason appears to be his pattern of language impairments. As If, as it appears, the extent and pattern of language deficit has an impact on a PWA’s ability to learn to deploy conversational strategies successfully, we may need to reconsider the conversation therapy goal setting process. When working with a CP on conversation training, it is common for the SLT to facilitate the CP to choose his or her own strategies, as it is felt that this has a beneficial effect on motivation to change behaviour. However, transferring this goal setting technique to direct work with a PWA appears to raise additional challenges, in that he or she may choose a strategy that has limited use, given his or her aphasic deficits.It is interesting to note that, although both CPs reduced their use of test questions, neither significantly increased the use of their strategies chosen to enhance conversation. For Pamela, qualitative analysis revealed the use of different types of turns after therapy , whereas Alex continued to comment, as he had been doing before therapy. Therapy aimed to reduce barrier behaviours such as test questions indirectly: it was hypothesised that such barriers would fall away as other positive conversational behaviours came online. However, this does not appear to be the mechanism for behaviour change that operated for Alex or for Pamela. Intuitively, it seems possible that stopping oneself from engaging in negative behaviours might be easier than learning to systematically use positive ones . Perhaps a single, very distinctive, conversational barrier can be avoided with relative ease once one has insight into its negative effects, yet more complex behaviour change is required to deploy a facilitative strategy in an appropriate interactional context. This idea clearly has important implications for how SLTs might guide the goal setting process and deliver conversation therapy. Research into behaviour change mechanisms in conversation therapy is currently under way by the authors, led by Johnson.Finally, it is recognised that stability of interactional behaviours may vary naturally, both within a conversational sample and over time  captured by video were highlighted by the SLT for discussion, then the dyads selected and practised strategies to enhance their communication. A quantitative analysis of barriers and strategies across pre- and post-therapy conversation samples, combined with a qualitative analysis of interaction, revealed that the same change in conversational behaviour of two CPs (significant reduction in test questions) went hand in hand with a different outcome for each CP’s respective PWA; the combination of strategies that work for one dyad may not work for another. Questions have been raised about what types of behaviour may be more amenable to change and the effect of a PWA’s language deficit. Once the data from all eight dyads have been analysed, conclusions about the effectiveness of this intervention will be reconsidered in the light of variation of language profiles and other variables recorded in this study.In this article, quantitative and qualitative analyses of pre- and post-therapy conversations between two dyads have been presented and discussed to illustrate not only whether but www.ucl.ac.uk/ls/cava/). We are very grateful to Graham and Alex, and Stuart and Pamela (pseudonyms) for their enthusiastic participation and commitment to the project and to their respective SLTs for referring them to us. Better Conversations with Aphasia, a free e-learning resource available at UCLeXtend, was funded by the Economic and Social Research Council [grant number RES-189-25-0292]. The data analysis presented in this article builds on and extends the work of six Masters students of speech and language therapy at the University College London, who undertook their final year dissertations with the authors: Selina Buenaventura, Fran Children, Fiona Jorrisch, Sarah Lambert, Kate Middleton, and Amie Wilson. We thank them for their work on the ratings reported here. The first author has refined the CA transcriptions produced by Sarah Lambert (Extract 2), Selina Buenaventura (Extract 3), and Kate Middleton (Extract 4) and has extended their analyses of these data for use in this article. The transcript and analysis of Extract 1 is the first author’s own work.This work was funded by a Stroke Association project grant  and data are lodged in the human Communication Audio Visual Archive (CAVA) at UCL (