Educational environment refers to the diverse physical facilities, the clinical settings where students learn, the design and delivery of the curriculum, and involve the skills, and attitudes of the teachers. Due to various undesirable aspects of the educational environment, students often do not attain the expected professional standard of nursing care. There is limited evidence on students’ perception of their educational environment in Ethiopia, particularly in the study area. Thus, this study aimed to assess nursing students’ perceptions of their educational environment in government Universities of Southwest Ethiopia.An institution-based qualitative case study was employed. Eight participants were interviewed from government Universities of southwest Ethiopia. Face to face in-depth interview was used to generate data. The interviews were conducted for forty-five minutes to one hour using an open-ended semi-structured guiding questionnaire. All interviews were recorded, transcribed, translated, and analyzed using a conventional content analysis approach; finally, themes were derived and presented with narration.The analysis of this study yields four themes categorized as curriculum, instructors’, organizations’, and students. The result of the study revealed that there were poor institutions students support systems, inadequate skills and knowledge in certain instructors, inadequate instructional materials and teaching aids, scarce facilities in students’ practical areas, accommodation, and transportation.Improvement of nursing students’ educational environment was recognized as a strong attention-seeking area. The majority of the key informants stated that the educational environment is not suitable for the teaching-learning process. Thus, to create a conducive educational environment, the Minister of education, Universities, instructors, and other concerned bodies should design and implement strategies targeted at the aforementioned problems. The educational environment (EE) refers to everything that surrounds an educational institution that represents the climate within the classrooms, department, and even the institution in general . It contA qualitative study conducted in Canada showed that confidence and competencies of educators, nursing students’ clinical experiences, subjectively evaluating the students’, poorly qualified instructors who lacked knowledge, skill, and teaching experience, poor relationships among instructors, staff nurses, and students’ were reported as the main challenges in nursing students’ in the clinical setting , 9. A siAnother qualitative study from a Norwegian University showed a shortage of teaching and learning tools, infrastructures, facilities, equipment, and standard procedures. The study also showed that expectations, feedback, and relationships as well as poor resources in the faculty and organization of the curriculum were known as factors that affect the students’ perception of their clinical skill learning environment .In Sub-Saharan Africa, more reforms are needed to increase the capacity of educators and mentors responsiveness of curricula, strong regulatory frameworks, and availability of infrastructures and resources. Universities are responsible for the dissemination and transferring of knowledge, and providing specialized human resources , 13.In Ethiopia, the role of higher education is the backbone for the country’s development efforts towards eradication of poverty and improving the vision of quality and employability of the university graduates. Thus, changing attention to quality, lead to change the schools into honest learning environments like quality-focused school supervision, internal school governance, increased students’ involvement, and school-community partnerships are among the priority focus . There mThe educational climate in nursing schools affects the quality and effectiveness of education . Many quThe goals of nursing education are mainly to equip nursing students with the required knowledge, attitude, skills, and professional ethics that will help them to solve health and health-related problems of the communities. Students’ comments’ are very important for the success of the educational environment . TeacherAn institution-based qualitative case study design was employed for this study seeks to provide a rich understanding of the study phenomenon contextually by researchers work. It is a better approach to understand the deep insight into the phenomenon of interest in the context of the case. In-depth investigation of small number of units at a point in time were done. Accordingly, a total of 8 participants were selected from Southwest Government Universities  were selected purposively. Twelve class representatives from each university were contacted through the representative of students union and selected as key informants assuming that they had adequate information about the educational environment because of their closeness to university and department affairs. Using a convenient sampling technique, the sample size were determined by data saturation. Also we had considered resource constraints. All of the participants were year four students, and age groups between 21 to 33. Data was collected by four experienced interviewers from April 9 to 23/2019 through face-to-face in-depth interviews in the silent and private rooms. A semi-structured interview guide, digital recorder, and field note were used to capture interview data. An initial probe during the first interview was primarily directed to the respondent to expand or explain some of his/ her answers as appropriate to the flow of the interview. The time needed for each interview session was between forty-five minutes and an hour.Interview data were transcribed and translated from local languages to English verbatim on daily basis, to guide the subsequent interviews. Field notes were summarized daily in English to prepare for coding. Data were analyzed using the conventional content analysis approach. Accordingly, to identify the topics, codification of the text, emerge codes, and creation of the categories, each text was read again and again carefully to advance a common understanding of the vital statements. Then, meaning units about participants’ experiences of nursing education, existing problems, and challenges were extracted from the transcriptions. The meaning units were abstracted by summarizing the vital statements’ and labeled as codes. The respondents’ speeches and secret concepts were used for coding, and then the codes were compared for matches and differences. Accordingly, the classification of codes was carried out. Finally, four themes were emerged based on the results. Experts were also asked to review the themes to reach a mutual agreement on related codes and the classifications of the data. Finally, the interview result was written by compiling memos, quotes, and analyzed data, and presented with narrative descriptions.The ethical clearance with reference number GHRPGD/501/2019 was obtained from the Institutional Review Board (IRB) of Jimma University, Institute of Health, and submitted to the concerned bodies. Informed verbal consent was obtained for the digital recording of an interview before beginning any formal interview. The Code of participants was used for all participants in data records . The transcripts were devoid of real names or places thereby ensuring the complete anonymity of the participants. Hard data  were stored in a private room. Electronic versions of these documents were stored on password-protected computers.The perception of the educational environment was explored by the experience of the respondents. The main themes that emerged from the qualitative analysis of nursing students’ perception of their educational environment were related to curriculum, instructors, organizations, and students’ . The resThis theme was directly extracted from curriculum contents and its application strategies. Many respondents were perceived that the working nursing curriculum contents are not sufficient to address the need of the nursing profession and not to the standard. They also perceived that the course delivery system was not convenient for students to acquire the required knowledge and skills. A participant 1 said that: “…the curriculum contents are not comprehensive, redundant and contain courses not related to a nursing profession like civic…; ….the given time for theory is higher than practices” (Participant 4). The other participant reported that: “…in block courses delivery system, we did not remember what we have learned after the exam, but in the semester-based system, we remember the subject matter very well even after a long time” (Participant 5), .The students’ described that even though the curriculum implementation strategies were good; there was a lack of monitoring and evaluation strategies for curriculum implementation. One study participant supports this idea by saying: “…there was no regular supervision by the departments, faculties/colleges or other concerned bodies on curriculum implementation…” (Participant2). Many participants recommended the need for curriculum revision related to the course delivery system, theory-practice balance, and avoid the redundancy of contents. Other participant revealed that: “…the nursing curriculum should be revised… course delivery system for all courses should be semester-based…; the given time for practical attachment should be more than theory class…to create well conducive learning environments” (Participant 6). Further participants recommended that: “…better to take ethics courses at first year, research methodology at the last year; also like health officer and medicine students’, nursing students’ should stay at the campus during the summer season” (Participant 4), .This theme was directly extracted from teaching methods, evaluation methods, skills, and knowledge and behavior of instructors. Most of the students’ opined that some instructors were not adequately prepared for the classroom and clinical teaching. Moreover, they were dependent on single teaching methods and instructional media. Participant 3 said that: “…Some instructors used only one way of teaching methods…. and they depend on a limited type of instructional materials and they did not use other alternative instructional methods, as a result, they omit classes during electric power interruption”. Also, participant 8 said: “…most instructors’ did not follow the adult learning approach and they did not give course outlines on time”. Concerning the evaluation of students’, the participants expressed that the instructors did not prepare the exams in line with the course objectives. Very often the questions for the exams were downloaded from the internet. Few instructors was evaluated their students’ based on social intimacy. Participant 2 said that: “…Some instructors did not evaluate students fairly and they provide grade with intimacy; … the evaluations were without the course objectives, test and exam questions are full of subjectivity and out of the learning objectives and discussion in the classes” (Participant 2). The other respondents reported that: “…a small number of instructors were preparing the exam from the internet which not focuses on the topics of subject matter and there was poor remedial action system for under scorer students” (Participant 7). The participants recommended that the instructors should use multiple teaching aids, follow the pedagogical learning approaches, prepare themselves very well for teaching, should be fair in grading regardless of intimacy and any other conditions, evaluate based on the learning objectives and avoid preparing the test or exams from internet, .Regarding the knowledge and skills of instructors, almost all of the participants reported that very few instructors had poor teaching experiences, lack of proper skills in practice, and most instructors were also not well prepared for class teaching. One participant revealed that: “…there was a gap between educational need with teaching skills and knowledge in very few instructors” (Participant 1). Students’ described the instructor’s behaviors as lacking punctuality, not interested in showing exam results, an unethical approach to students’ and having a dictatorial attitude. Other participant said that: “…many instructors did not respect the time; some of them didn’t want to show test or exam results; few instructors’ were authoritarian or dictators” (Participant 8). Another student’ also reported that: “…Some instructors were unethically intimate with students’, and most instructors are unethically acting during a teaching in the classrooms” (Participant 5), .This theme was directly extracted from teaching and learning facilities, infrastructures, and students’ support systems. Interviewees described a shortage of instructional materials, skill lab equipment, and equipment for practicing in the clinical area from all universities. A Participant 1 reported that: “…there were inadequate instructional materials or teaching aids in the university, for instance, Liquid Crystal Display(LCD), skill development lab equipment’s, shortage of clinical learning equipment like blood pressure apparatus, thermometer, personal protective equipment’s, projectors, photocopy machine, dividers, digital library or computers, reading materials, whiteboard markers, different audiovisuals, flip charts…. and some of the available materials were also not functional”, .Regarding infrastructure, the majority of the participants were described as a lack of a favorable learning environment due to a lack of well-established infrastructures. One respondent explained that: “…there were frequent interruptions of electric power and water supply, poor internet accesses, inadequate number of lecture halls, skill development laboratories, tutorial classes, peer learning classes” (Participant 3). The other respondent also supplemented that: “…lack of electric power in most buildings, lack of dormitory inside the hospitals during practices” (Participant 4). Noise and dust, blocking of routes, traffic, etc… arising from different constructions within the University’s campus contributed to an unfavorable and disturbing educational environment. Participant 7 said: “…there were poor internal roads which were unfavorable to move around to use basic services and road under construction made the environment not conducive for teaching and learning due to noises”.Regarding the students’ support system, the study participants feel that Universities had a poor supporting system for those in need. Respondent eight revealed that: “…there was an inadequate support system for the poor students’, shortage of medications in students’ clinic, inadequate support system during clinical practice like transportation, houses or dormitory, tuition fee payment processes”, .This theme was extracted directly from learning motivation, students’ behavior, academic performance, and students’ satisfaction. Most respondents admitted that many students lacked the motivation to learn. Because of this some of them had no desire to read and prepare themselves. Students’ lacked discipline in the classroom by talking and using cell phones during the lecture. Other Participant stated that: “students’ did not obey in the classroom, they are also not adequately interested to learn new things from their instructors, and they had poor habits for study” (Participant 6). The other respondent also revealed that: “Very few students’ were misbehaving in the class and turn, they disturb teachers during teaching and learning process, few students’ were using substances, improper time utilization , don’t want to study in the library and with their peer learning groups” (Participant 4).Regarding students’ academic performance, the majority of the participants reported that the higher scorer students’ have a positive perception of their educational environment and vice versa. Participant 3 reported that: “students’ perception relies on teachers grading without their input”. Regarding Students’ satisfaction, the majority of the participants described that Students’ satisfaction was highly dependent on high current cumulative grade point average (CCGPA) scores and their support systems. Thus, they recommended that students should respect their profession and read well. They also suggested that the Universities should support stressed students and make teaching and learning processes more conducive, (Participant 3), .The educational environment is the cornerstone for the better productivity of higher educational institutions. A less conducive educational environment reduces the performance of students and a reason for the poor quality of education. Currently, throughout the world, there is limited information about nursing students’ perception of their educational environment , 7. ThusThis study showed that the contents of the current nursing curriculum inadequately addressed the need of the profession and it is not to the standard. Some courses are redundant and unrelated to the nursing profession like civics. The participants believed that hours given for the theory were more than the hours allotted for clinical practice. Besides, the study showed a lack of uniformity with block and semester-based delivery of courses. The curriculum was haphazardly implemented during a block-based system. Thus, the participants recommended shifting all the block courses to the semester-based delivery system and the pressing need for nursing curriculum revision. This study had similar findings with studies conducted at the Kuate University of Saud Arabia, a Private University of Malaysia, and a qualitative study conducted in Iran , 10, 11.The current study also revealed that students felt nursing instructors had inadequate knowledge and skills to teach nursing students, particularly in the clinical area. The majority of respondents reported that some instructors are unethical, biased in students’ evaluation, preparing examinations out of the learning objectives especially from the internet, and had not respected their students’. The result also showed that most instructors were using one-way teaching methods; merely relied on projectors or LCD and they did not use alternative teaching aids in the event of power failure. Moreover, participants also reported that some instructors are authoritarian; they did not follow the course syllabus or give reading materials on time, or show the students’ assessment results. The result of this study was different from a study conducted in three Countries including Aga khan university medical college of Karachi in Sweden, Pakistan in Shifa College of Nursing, and Addis Ababa University, Ethiopia , 12, 17.The result also exposed the lack of teaching and learning facilities/instructional materials like smart classes, desktop computers, LCD, learning videos, manuals, whiteboard markers, and flip charts. Also, the study brought to light poor infrastructure in the study areas like poor internet access, inadequate lecture halls, tutorial classes, and an insufficient support system for needy students’. Lack of support was described as inadequate medications in the clinic, poor transportation, and lack of support system in the hospital practices. These findings are contrary to the study conducted in four Countries namely, University College of Southeast Norway, Students’ perception of the educational environment of medical schools in Korea, Iran, and Addis Ababa University, Ethiopia , 8, 17. The result of the present study showed that lack of motivation to learn from many students’, unethical behaviors in some students, low academic performance, and disinterest in the profession. The participants recommended that students’ should be motivated for learning new things, studying hard to attain high grades and love, and respect their profession. These results are in line with many studies conducted in different countries in the world , 17, 21.The limitations of this study were lacks representativeness for similar populations due to the economic and cultural differences, and differences in Nursing programs that might be affecting the transferability of the result.Even though the participants were optimistic about their educational environment, most of them rated it as not conducive for teaching and learning. The study also revealed that there was poor implementation practice of the curriculum, poor institutions students support system, inadequate skill, and knowledge in some instructors, scarce instructional materials or teaching aids and infrastructures, scarcity of equipment’s for practicing in skill development lab and clinical settings, and lack of motivation from the students’. Thus, Universities should design follow-up and supportive supervision mechanisms for instructors who have knowledge and skill gap and misbehaving towards their students’. In addition monitoring and evaluation of curriculum implementation practices, enhancing the University infrastructures and instructional materials, creating conducive practical areas, improving the motivation of students’ and about adequate students’ support system are important. Also, the Minister of Science and Higher Education of Ethiopia should consider curriculum revision from a block-based to a semester-based approach.S1 Table(PDF)Click here for additional data file.


The coronavirus outbreak (COVID-19) tested health care systems worldwide. This qualitative study aimed to explore and understand the experiences, beliefs and concerns of Primary Care Professionals (PCPs) regarding the preparedness and response of primary care to the first wave of the pandemic in Greece, a country where a public structured primary care system has been developing.We conducted semi-structured telephone interviews with 33 PCPs  recruited from all regions of Greece after the first wave of the pandemic (June 2020). Interviews were transcribed verbatim, data were anonymised and analysed. Thematic analysis was applied developing a conceptual framework.Four main themes were identified: a) Primary care unit adaptation and issues faced during the pandemic; b) Management of suspected COVID-19 cases; c) Management of non-suspected cases; d) Consequences of the pandemic. In the first phase of the pandemic, remote management of suspected cases and their referral to the hospital were preferred as a result of a shortage of personal protective equipment and inaccessibility to coronavirus testing in primary care. Due to the discontinuation of regular medical services and the limited in-person contact between doctors and patients, chronic disease management and prevention programmes were left behind. Social and emotional consequences of the pandemic, such as workplace stigma, isolation and social seclusion, deriving from fear of viral transmission, as well as burnout symptoms and exhaustion were commonly experienced among PCPs. Positive consequences of the pandemic were considered to be the recognition of the importance of an empowered public healthcare system by citizens and the valuable insight, knowledge and experience professionals gained in times of crisis.Primary care has a key role to play during and after the pandemic by using its information infrastructure to identify at-risk groups, detect new cases of COVID-19, provide care according to needs, and carry out vaccination programmes. Central coordination and empowerment of primary care will increase its effectiveness, via public awareness, holistic patient management, and unburdening of hospitals. Primary Care (PC) is the backbone of every health system. Experience from previous epidemics highlights the substantial role of PC and mandates the engagement of Primary Care Professionals (PCPs) in decision-making procedures , 2. The A strong PC system is the foundation of an efficient and effective national health service that eliminates inequalities in healthcare access . In counAccording to a monitoring instrument developed in the PHAMEU , community General Internal Medicine Specialists (GIMS), community Paediatricians and nurses, who were employees of public and private sector PC services in both rural and urban settings of the mainland and islands of Greece.Recruitment was facilitated by the Aristotle University of Thessaloniki Primary Health Care Research Network (AUTH.PHC.RN). Professionals were invited to take part in the study by email, purposively sampled according to the following selection criteria: a) GPs / GIMS / Paediatricians / nurses, working in PC; b) males / females; c) working in public or private sector; c) working experience more / less than 15 years; d) working in rural / urban areas; d) working in health centres / local health units / private practices; e) interested in taking part voluntarily (no remuneration provided); f) given written informed consent to participate. We concluded the interviews when data saturation was reached, i.e. no new themes emerged from the interviews.A topic guide was developed prior to the study and reviewed by the research team. Main topics were: a) preparedness in the management of the pandemic ; b) staff shortages (pre-existing or during the pandemic); c) management of COVID-19 and non-COVID-19 emergencies and chronic diseases; and d) consequences of the pandemic.Interviews were conducted remotely via telephone by PCPs/members of AUTH.PHC.RN, who were not acquainted to study participants, in June 2020 (the end of the delay phase of the first wave of the pandemic in Greece). All interviews were audio-recorded with consent, transcribed verbatim and identifiable data was anonymised.Transcripts were read by all members of the research team. Thematic analysis was used to identify key emergent themes and their meaning . The anaThe study protocol received ethical approval by the Medical School Bioethics Committee of the Aristotle University of Thessaloniki (AUTH). All participants signed informed consent before inclusion in the study.A total of 33 PCPs participated in the study, 24 doctors and 9 nurses, from 28 different health units (17 public and 11 private). A summary of participants’ characteristics is presented in Table Four main themes emerged: a) Primary care unit adaptation and issues faced during the pandemic; b) Management of suspected COVID-19 cases; c) Management of non-suspected cases; d) Consequences of the pandemic.“When someone calls me and asks for an examination, I will ask him what this is about. If there is a fever or any small increase in temperature, I will make sure to examine him at the end of my shift.” Participant 16, Private sector, General PractitionerAll PC units [except for Regional Practices  that ceased operations] followed a system of triage, distinguishing patients without suspected symptoms from those with COVID-19 symptoms.“Regarding the operations in our Health Centre, we have an entrance for the outpatient department, where citizens and personnel are checked and their temperature is taken. Another separate entrance for emergency cases and patients brought in via ambulance is also available. In the outpatient department entrance, health documents are collected, repeat prescription is performed and all documents are handed over to patients. Only if there is a need for examination, patients enter the Health Centre having an appointment, in order to avoid congestion.” Participant 23, Public sector, NurseUnits with multiple entrances used the main entrance for triage and a secondary entrance for emergencies. Triage was mainly performed by nursing staff according to guidelines and protocols of the National Public Health Organisation (NPHO/EODY), Regional Health Authorities (RHA/YPE), and the Ministry of Health.“I think the biggest issue was how patients would visit us. Attendances, in the form of appointment, were taken care of with much greater accuracy. We could then avoid meetings within the practice, and there was time to decontaminate the room from one patient to the other.” Participant 32, Private sector, PaediatricianIn several public units, a separate special examination and isolation area was set up either within or outside the Unit through the deployment of isolation booth structures. In the private sector, where separate examination rooms were not available, suspected COVID-19 cases were triaged by telephone. When these patients were examined face to face, there was a reasonable time difference from the rest of the appointments, taking place either at the beginning or at the end of working day, to prevent congestion in the waiting room and to allow time for disinfection and ventilation of the premises.“They were sending us little, very little equipment. We needed to record the slightest consumption of equipment, whether they were masks, antiseptics or other. We didn’t have uniforms,…, glasses. During the previous SARS [outbreak], a few years ago, they had sent us 4–5 uniforms and we have kept them. We had to manage with them for several months. We were afraid that, if anything came up, we only had this equipment to use.” Participant 19, Public sector, NurseHealth units faced detrimental shortages in PPE, such as surgical and high protection FFP2/FFP3 masks, gloves, face shields, bodysuits, and foot protection.“The municipality gave us a container with two indoor spaces. We could examine patients and, of course, after each suspected case, the municipality was decontaminating the area.” Participant 5, Public sector, General PractitionerIn the public sector, the provision of PPE from RHA/YPE was initially limited and then gradually increased in the majority of units. Many PCPs reported that they became equipped with masks and gloves at their own expenses, whilst important donations from public authorities, private companies, associations, and individuals were welcome.“The truth is that we got charged a lot of money to provide ourselves with disinfectants [for our practices]; because the prices became too high, the products were too expensive, and as a result we paid too much for hygiene products”. Participant 33, Private sector, PaediatricianIn the private sector, the acquisition of PPE was at the expense of PCPs, with Medical Associations across the country providing inadequate quantities, without aid by the government.“We had a big problem in finding face masks, gloves, light uniforms and waterproof uniforms, which are hard to find and of course extremely expensive”. Participant 16, Private sector, General PractitionerMoreover, the global shortage of PPE for citizens made PCPs’ efforts in securing adequate PPE supply a difficult task.“We had mothers who had to stop working. However, we made ends meet. All of them got rotating special purpose leave. They understood that having continuous leave was not an option, one could not leave work for 2 or 3 months while the pandemic is looming. They were taking for example 6 days of special-purpose leave and 2 days of personal leave, which makes a total of 8 days within a month, that mothers took on rotation.” Participant 5, Public sector, General PractitionerNo major problems in personnel capacity were reported in the majority of public units, although in some cases PC staff were temporarily transferred to SC. In the private sector, on-site working hours were reduced. Yet, telephone consultations for patient information and support took over face-to-face patient contact.“The anxiety of that first week, the stress about how I would get organised, which cases I would see was my main worry, that week was the first when we were reading different things from the paediatric association, different from the [regional] association, … different guidance from the government. That week there was a lot of confusion.” Participant 31, Private sector, PaediatricianPrivate doctors felt less supported in terms of education and information, and perceived guidelines as inundating, ever-changing, and confusing.“We were informed by EODY [i.e. National Public Health Organisation] official website and from what was sent to us by Regional Health Authorities. Starting from there, we were browsing through websites, official sites, information sources from abroad searching for things to notice, such as atypical symptoms .” Participant 10, Public sector, General Practitioner“We had to learn how and if we had to use PPE. In this direction, hospitals helped a lot, by 1.5-h seminars for all healthcare workers to participate in. Then these participants were demonstrating [the use of PPE] to others in the health centre and we reached a very good point of understanding at this moment.” Participant 5, Public sector, General PractitionerOn the contrary, the majority of employees in public units reported that they had received guidelines from RHA/YPE and took part in educational activities, such as the proper use of PPE.“In the beginning, we only had respiratory symptoms [that were considered suspicious]. Then they told us that in the elderly, delirium and gastroenteritis could also be present.” Participant 6, Public sector, General PractitionerIn PC settings, fever, cough, and dyspnoea were the main symptoms that raised suspicion of COVID-19. Yet, other non-typical symptoms were reported, including hypothermia, loss of smell, gastrointestinal disturbances, delirium, and falls. In children, diarrhoea was considered a non-typical symptom.“The first thing we did was taking a good history. Then if it was a case of fever, we initiated the isolation process of the patient and his/her close contacts. We informed EODY and we were given guidelines for potential testing. Communication with patients was happening on a daily basis.” Participant 4, Public sector, General PractitionerManagement of suspected cases was mainly performed via telephone, including history taking, confirmation of symptoms, and contact with NPHO/EODY for guidance and testing procedures.“We kept a record sheet in which we reported symptomatology and we gave telephone instructions on what to do. We kept our patients at home and set up a review by phone the next day or the day after. Most of them were mild cases and ended up just with instructions over the phone.” Participant 10, Public sector, General Practitioner”In some units, a registry of telephone follow-ups for at-home patients was in place.“I refer him to the hospital, while simultaneously calling EODY. I either send him by his own [transport] means, wearing a mask and after I have called the hospital to inform them that this patient will arrive by car in 20 min, so that they expect him. We either follow this procedure or we call an ambulance. We usually advise them to use their own transport, as I consider it a luxury for such a case to go by ambulance.” Participant 3, Public sector, General PractitionerIn deterioration of symptoms or general health, patients were referred to SC for further assessment and potential admission.“I could say that, at least personally, I partially disregarded EODY’s guidelines. They were saying at the beginning that in case of fever they should stay at home. That is something I could not do, as sometimes there is not only COVID-related fever but also fever from other causes. We had to examine them. We examined patients and told them to stay at home. If their condition was deteriorating or the fever was too high, then we were re-examining them.” Participant 5, Public sector, General Practitioner“My private practice was practically closed but guidance was given via telephone. I was afraid as I did not know whether I was giving the right advice and if the patient’s situation was deteriorating, I would have kept him in his house without examination, without auscultation.” Participant 16, Private sector, General PractitionerHowever, it appears that PCPs used their own personal judgment in the management of suspected cases. Their decision-making regarding face-to-face assessments was affected by a balance between uncertainty over diagnosis and perceptions about risks, and it often was a stressful and difficult process, as illustrated by the quotes below:“If that is a patient I routinely follow-up or if it is a first-time patient. In the second case, I would ask him/her to visit my private practice immediately, when calling for medical consultation. In the case of patients that I have been following-up for years, if I estimate that the symptoms are mild, very mild, I will not ask them to visit my practice. We will talk again on the phone and decide what to do depending on the progress.” Participant 17, Private sector, General PractitionerAnother important determinant of management of suspected cases included PCPs’ individual knowledge and longitudinal relationship with a patient.“You can estimate patients’ condition remotely. This could be better performed via video call instead of a simple telephone consultation. In no case does this replace immediate medical examination, but it can help in a lot of cases.” Participant 9, Public sector, General PractitionerTelephone management was the case not only for patients with suspected symptoms but also for those with other symptoms not related to COVID-19. Video calls or other remote technologies were not widely endorsed in the public sector, despite professionals’ positive views, mainly due to shortages of equipment and lack of experience. On the contrary, these technologies were broadly used by PCPs working in the private sector, and mainly by Paediatricians, who reported similar use of such means before the pandemic.At the end of the first wave of the pandemic, sufficient supplies of PPE, reinstatement of face-to-face physical examination, and increased familiarity with referral procedures and remote management of patients via telephone were the main changes observed.People with pain were coming, people with urological problems, who were saying ‘I am in pain like this for 10 days’ … or with an orthopaedic issue … many serious problems … and they were telling us that … ‘I was in pain for 10 days and I waited, but I cannot wait any longer’ … or heart problems … arrhythmia patients… with atrial fibrillation telling me ‘I was patient, I knew my pill was not covering me anymore, I was taking Rhythmonorm [propafenone] and I wasn’t feeling covered’; everyone did whatever they could to refrain from using the hospital or any health unit.” Participant 25, Public sector, Nurse.“During the first wave of the pandemic, Emergency Department attendance due to acute symptoms and conditions not related to COVID-19 was lower than expected, and delayed care-seeking was reported.“There was no follow-up, except when major issues arised. Patients were not visiting but were rather contacting us through the phone … some were visiting our practices just for repeat prescriptions … most of patients were contacting us through the phone for repeat prescriptions. Management of chronic illness was left seriously behind … there was no management at all.” Participant 8, Public sector, General PractitionerPoor attendance was also reported for those suffering with chronic illnesses, mainly due to lack of access to premises and fear of potential viral contamination, with potential detrimental effects on chronic disease management.In many public PC units, patients were contacting doctors by telephone, whilst the use of other remote means  was mainly reported by private practitioners. Private and public doctors were in agreement that while telephone management of chronic illnesses was helpful during lockdown, it should be used as a contingency plan and not as regular practice. In nearly all units, attendance in outpatient clinics bounced back in pre-pandemic numbers after the end of the lockdown restrictions.“Electronic prescription was performed through telephone in our Health Centre. Social security number was given over the phone, or pharmacists and relatives were coming, bringing prescriptions. Nobody was entering our Health Centre.” Participant 6, Public sector, General PractitionerThe process for repeat prescriptions was not affected in either the public or private sector. The vast majority of prescription requests were actioned via telephone. Repeat prescriptions were sometimes facilitated by pharmacists, regional authorities, and municipality officers, such as those involved in the “Help at Home” program, providing basic home care support for older people. The newly introduced remote electronic prescription system was reportedly used only by a few public professionals, and was not widely used by private clinicians including Paediatricians. A common barrier was the lack of technology literacy among older patients.“Before the pandemic I did home visits … now, I try to minimise them … as you never know what you may find in a home visit. In the beginning of the pandemic, I was contacted through the phone in the early morning and went on to visit an older lady I knew, who had dizziness and nothing more. She was in fact feverish, had an 80% oxygen saturation and after contacting EODY, she was transferred to the hospital by ambulance…” Participant 13, Private sector, General PractitionerIn units performing home visits before the pandemic, fewer visits were reported during the first wave of COVID-19 and these were restricted to non-suspected cases, although the in-person assessment might in fact reveal signs of COVID-19 where it was not expected.“Home visits increased…, mainly as parents did not want to visit the practice, fearing … even with appointments … that they might contract something more, they wanted to stay at home for most of the time and have the doctor visit them instead. For newborns, infants … I preferred to vaccinate in their homes so as not to expose them to the risks in private practice.” Participant 33, Private sector, PaediatricianPrivate GPs and GIMS avoided them, while some Paediatricians did home visits regularly, mainly for infant vaccination purposes.“What we finally won, is a sense of worthiness in the eyes of the population, as in the last decades the Public Health System was depreciated. It was finally vindicated. Because, let’s face it, in difficult times, we all turn to it […the Greek National Health System]”. Participant 12, Private sector, General PractitionerThe COVID-19 pandemic has had a tremendous impact on the GNHS, PCPs and citizens. Importantly, the need for an empowered public health system was acknowledged.“The need for general practitioners, family doctors, and their role was acknowledged and these doctors are the ones we did not have.” Participant 17, Private sector, General PractitionerMore specifically, the need for an empowered PC system also emerged in view of gaps in care that became evident.“I feel empowered, as I have the knowledge to manage cases and system’s operations in times of crisis. The Public Health System won knowledge in the management of cases and so did the Health Centre.” Participant 28, Public sector, PaediatricianProfessionals gained valuable insight, knowledge, and experience in times of crisis.Nevertheless, a cluster of participants in the study reported that the GNHS failed to be reinforced both in manpower and suitable equipment to support citizens’ needs in the occurrence of an anticipated second wave. Moreover, the pandemic signalled reduced activity or ceased operations in the country’s hospitals, skyrocketing the already long waiting list for routine appointments and procedures. Importantly, the GNHS reinforcement in the first wave was focussed on SC and the role of PC was not considered to be critical.During this pandemic, PCPs gained clarity on infection prevention strategies, familiarised themselves with hygiene and safety protocols in the workplace, while showcased readiness and discipline in applying specific management guidelines. As a result, they gained invaluable experience in practising their profession under special circumstances, such as those of a pandemic.“… I lost interpersonal contact with patients I did not know so well, I was trying to put everyone in order and make sure we are in an acceptable pre-symptomatic control state.” Participant 4, Public sector, General PractitionerOn the other hand, loosening of strong patient-doctor relationships was reported, posing a threat to citizens’ participation in preventive medicine activities.“… Remote electronic prescription is definitely a practical measure for patients and for doctors when it comes to conserving paper. Our concerns are that there was never any plan for reimbursing private doctors for our services.” Participant 27, Private sector, InternistFinancial implications were reported mainly by professionals in the private sector, including loss of productive time due to delays of managing suspected cases in communication with NPHO/EODY and to longer appointment slots in order to avoid congestion and to secure airing and sanitising. Ultimately, the increased cost of securing PPE, the reduced income due to dropped attendance rates, as well as the inability for reimbursement in certain services, such as the newly introduced remote prescription system, posed an economic burden for private PCPs.“….They brought me things… masks, disinfectants and equipment, and that was very moving… ‘take care doctor’… I think that in such cases the world shows solidarity, especially to the person being in the frontline.” Participant 14, Private sector, General PractitionerSocial and emotional consequences of the pandemic were common among PCPs and citizens. A positive aspect was thought to be a sense of solidarity that was born through the crisis.“I get tired of explaining all day to people that they cannot enter without wearing a mask. Some abide. Those who do not, are kind of pressuring me… I do not have the courage to fight with people and … sometimes I do not fight, but I feel like I am putting a burden, as if I have a problem and not others. It feels as if I have an issue in the end.” Participant 18, Public sector, NurseWorkplace stigma, isolation as well as social seclusion, deriving from fear of viral transmission, were mainly reported by nursing staff. Burnout symptoms as a result of stress at work and exhaustion were also reported.“The economic aspect was also posing a detrimental role … the upside downs … a lot of people faced economic insecurities … and now lockdown, panic, personal responsibility, economic insecurity take over… everyone by himself… and some with minor [mental issues], that were not easily recognised … now these issues became evident… and such issues can not only be recognised, but they also have to be treated and heavily treated… with weekly visits to a Psychiatrist. The issue has become complex.” Participant 12, Private sector, General PractitionerA wide spectrum of mental health problems arising in the population amid the pandemic was reported by professionals, including withdrawal and lack of social interaction in children, and anxiety and depression, sometimes combined with suicidal ideation, in adults.The present qualitative study demonstrates the side-lining of PC in practice, as highlighted by the closure of Regional Practices as a result of shortages in personnel and isolated examination areas, the movement of PC medical and nursing staff towards SC reinforcement, the instructions of public health agencies calling for exclusive management of cases, as well as the availability of testing only in hospitals during the first wave.Shortly after the start of the pandemic, the overwhelmed hospitals, the exponentially increased number of cases, and the experience gained from overseas management of the pandemic , 16–18 pIn addition, several units used remote assessment and monitoring, as the literature demonstrates the contribution of telemedicine to the approach and management of both chronic and mild COVID-19 cases –26. AwarA large number of study participants reported concern over reduced prevention and management of chronic illness, due to exclusive engagement of the medical community with CΟVID-19 cases. Several studies confirm this phenomenon, even in countries with more robust PC, where the disruptions of prevention, treatment and rehabilitation of non-communicable diseases were described as an invisible epidemic , 31, 32.Ultimately, the psychological support of both PCPs and the general public is of utmost importance. The unprecedented changes to the commonly utilised patient management practices and to the working environments threaten their mental health and bring forward physical and mental exhaustion , 36. FacRegarding the acclimatisation to the unprecedented conditions in the workplace, significant educational steps were taken after the first wave of the pandemic in Greece. Nevertheless, communication and information distribution between PCPs and national health organisations are often criticised in our interviews. The sense of lack of communication or miscommunication with public health agencies due to the constant modification to the provided guidelines is also reported in other studies , 26, 30.Globally, the prevalence of the COVID-19 pandemic requires coordinated efforts to achieve the goal of “flattening the curve”. Primary care practice is in this crisis very much community-oriented, contributing to limiting the spread of the infection . The conThe strength of this study is that it is, to our knowledge, among the first to explore the perspectives of frontline PCPs involved in the management of the pandemic. A qualitative approach including semi-structured interviews was used to achieve a level of understanding and interpretation of the associated operational conditions, dysfunctional aspects, and areas of improvement, which are rarely described in the currently available literature. Although we employed purposive sampling of participants, there is always a possibility some views and perspectives might not have been fully represented.Another factor for consideration is that, since these interviews were conducted, the dynamic situation of the pandemic in Greece evolved, leading to a second wave, during which primary care was assigned a more central and proactive role in the handling of the pandemic. More specifically, PCPs were given direct access to COVID-19 testing for their patients, and most public PC units became vaccinating centres. Vaccinations against COVID-19 currently constitute a major part of PCPs’ workload. The PC workforce has been instrumental in delivering the vaccine at a mass scale and thus mitigating the pandemic. This transformation of PC during and after the second wave may have significant implications in terms of recognition of its importance in protecting health both at an individual and at a public health level.The COVID-19 pandemic redefined the role of PC, and PC units were quick to realise their potential. Important steps are yet to be taken for the management of the population’s health needs, with special focus on the systematic follow-up of COVID-19 patients at home, as well as the management of chronic conditions at times when social distancing is deemed necessary.


In recent years, a vast body of research has investigated trends of declining alcohol consumption among youths. However, the extent to which restrictive-youth approaches towards drinking are maintained into adulthood is unclear. The aim of this study is to explore how young people’s relation to alcohol changes over time. Our data are based on longitudinal qualitative in-depth interviews with 28 participants aged 15 to 23 conducted over the course of three years (2017–2019). The study draws on assemblage thinking by analysing to what kinds of heterogeneous elements young people’s drinking and abstinence are related and what kinds of transformations they undergo when they get older. Five trajectories were identified as influential. Alcohol was transformed from unsafe to safe assemblages, from illegal to legal drinking assemblages, from performance-orientated to enjoyment-orientated assemblages, and from immature to mature assemblages. These trajectories moved alcohol consumption towards moderate drinking. Moreover, abstinence was transformed from authoritarian assemblages into self-reflexive assemblages. Self-control, responsibility, and performance orientation were important mediators in all five trajectories. As the sober generation grows older, they will likely start to drink at more moderate levels than previous generations. In recent years, a vast body of research has searched for explanations that indicate the trends of declining alcohol consumption among youths. No single explanation is sufficient to understand why such a large share of youths in high-income countries today choose to abstain from alcohol compared to previous generations ,2. EarliThe clear decrease in youth alcohol consumption during the past two decades is a cross-national phenomenon in high-income countries, which confirms the globalisation of youth culture . To undeOther research, however, proposes that decreased risk-taking such as heavy drinking is rather a sign of increased diversity when engaging in adulthood  or in adAlcohol consumption among 15- to 16-year-olds is well-studied, but knowledge on the extent to which modest drinking practices among youths will sustain later in their lives is scarce . HoweverYoung people’s drinking or abstinence is influenced and mediated by multiple interacting causes . When weassemblage refers to heterogeneous sets of relations composed of both human and non-human actors and agencies  is that important as such. It’s more like you have gotten accustomed to that it’s always around you. For example, I tend to go to all the Friday pubs, not that, “Oh, it’s Friday, let’s get drunk” but more like, “Ah, it’s Friday, a week of studies is over”, and I’ll hang out with all the students (…) and just celebrate the weekend. And then I have two or three beers because I’m there; it’s there. And that’s nice .As seen in the section above, turning 18 years old is one central actant in translating unsafe drinking into safe drinking. It is, however, also pivotal in the trajectory where legal aspects of drinking are highlighted in comparison to other elements in drinking. For example, Ella does not even consider drinking as a possibility before she turns 18. She argues that this is not a question of choice but a matter of whether someone has a right to drink or not. Since she and her friends are minors, they simply do not drink.Not that we are “abstainers”, but more like “we don’t drink”. We are minors—why would we? It’s as if there is a totally different perception of what’s allowed compared to earlier. (…) It feels like many people take them [the age limits] more seriously .The legal age of 18 defines the moment a person gains the right to drink; it distinguishes a minor from an adult. As this moment is upheld by legal institutions, it moves the actors who turn 18 towards an adult identity with corresponding rights, such as permission to develop a relation to drinking. Our three interviews with William exemplify the power of this legal age limit. At age 15, William finds drinking “stupid” and prefers to spend his time playing video games and sports. At age 17, he is still an abstainer but plans to start drinking when he turns 18. His action is bolstered by strict parental rules.They [the parents] say I shouldn’t start drinking… [and that I should wait until] I turn 18 .When I’m 18, I can drink, and they will trust me. (…) I want to devote myself to sports, and I can’t do that if I drink a lot. When I’m 18, or at graduation, there will be a champagne breakfast and such. Then I’ll probably drink. (…) First of all, I’ll have turned 18 and [at that point] we can celebrate something .William’s decision to consider drinking only after turning 18 is thus an outcome produced by multiple actants such as legal age, maturation, and trust of parents’ advice and rules.Many of our participants who turn 18 consider the translation of abstinence into drinking—especially into moderate consumption of alcohol—as a natural step in becoming an adult. At 18, you can enter into assemblages where alcohol functions as an actant that increases your capacities in diverse social events. You can go to bars and clubs (Victoria), partake in campus drinking activities , seek after-work drinking occasions (Emily), and partake in adulthood by joining your parents for a glass of wine (Alice). Olivia’s maturing process exemplifies this. When she turned the legal age of 18 and was allowed to buy and consume alcohol, her abstinence was translated into moderate drinking, which she considered a natural process. The translation increased her capacities to engage in adult-like sociability, “like having coffee with a friend at night, but drinking wine instead.”The third type of maturing trajectory concerning drinking deals with the opposition between assemblages of high performance and self-control on the one hand and assemblages of hedonism or pleasure on the other. In the high-performance assemblage, the actors aim to achieve excellent grades in school, aspire to successful careers, or perform at the top level in sports. Their focus on performance is boosted by both their parents’ and their own expectations to succeed. Sana’s quotation below exemplifies this assemblage and shows how it is often linked to responsibility towards one’s own parents.My parents would prefer me to do something they never had the opportunity to do, and that is to study and educate myself. (…) I try to prove myself to my parents; I want them to perceive me as a very responsible person. I want to make my own money, and I want them to trust me (…) because you never know what will happen. One of them could pass away, or we could lose the house and then it’s always good if I have money on the side to provide for us for at least a month or so .As Sana grows older, her performance orientation becomes more stressful as her friends and boyfriend expect her to spend more time with them and not so much time on her studies. Sana solves these conflicting expectations by continuing her sobriety and realising that in the future, she can participate in drinking situations sober while pretending to drink.Alice’s maturing trajectory, in turn, demonstrates a case in which the interaction between different assemblages does not lead to conflict between various expectations. Instead, the diverse assemblages fold into one another to enable new possibilities for her and enhance her capacities for pleasure and enjoyment in life. First, her engagement in elite sports—a high-performance assemblage that builds on relations of regular exercise, rules of abstinence, self-control, lack of time, and uncomfortable feelings in drinking settings—hinders drinking and makes it appear unattractive and unhealthy.I have never had the feeling of wanting to try it out [drinking]. I think it seems scary to lose control, sort of, and I don’t like those settings. (…) It seems uneasy. (…) I can’t see a reason for it. But, well, it has to do with health, too, why I wouldn’t .One year later, her high-performance assemblage (where she now combines elite sports with a job) still keeps her abstinent, but she recognises that drinking might be fun.First, I thought it could be fun, but then I had to work early the morning after, and I had practice. I was considering it, but it didn’t happen. Well, I don’t know, I might be a bit more attracted to it .In the last interview, however, she describes how her high-performing assemblage has undergone chains of translations that have made room for a new relation to drinking. With the influence of her friends and sister, she has started to drink moderately and learnt in the process that alcohol as an actant does not necessarily diminish her body’s capacities for action and well-being but rather—when consumed in the right and controlled way—increases them so that she can better enjoy the encounters with people, food, drinking settings, dancing, and herself.I have a friend, and when I got to know him more, we started to hang out and drink beer together. (…) I have realised that it is a way to meet people in society today (…) I think one beer tastes good, it is a nice beverage with food, sort of. (…) It feels extra luxurious (...) I become a bit more relaxed, and things can be a bit more fun. (…) On occasion, I have felt this feeling of panic in alcohol environments, that I am not comfortable in the situation (…) I just want to leave. (…) I have managed to overcome that a little. My sister knows how I feel, so she tried saying to me, “Come on”, tried to make me dance and eventually she managed to and then I overcame [my fear] … I went from feeling really uncomfortable to actually enjoying myself .The fourth type of trajectory in relation to drinking deals with the opposition between immature and mature intoxication. The assemblage of heavy drinking becomes—as time passes—modified by linkages that increase heavy drinkers’ capacities to drink in a more controlled, responsible, and personal way. Oliver describes this in the following way:It feels more fresh now, sort of. Before [the drinking] could be more frowzy, but now… I have more control over myself. That has changed. But I do the same things. (…) Take more responsibility, am older and hang out with older people. I don’t have to go out partying just because everybody else does it. Now I have other friends to watch a movie with. (…) I have more options of what to do. More money and more diversity. Before, I could go out drinking because I had just turned 18 and everybody wanted to go out. Now I’m 20, and I can sit and knit a sweater if I want to [laughter], and that wouldn’t be a problem .As our heavy drinking participants become older, their assemblages may undergo multiple “chains of translations” that can increase, decrease, or momentarily stabilise their drinking. For example, when Oliver focuses on his studies, this results in momentary decreases in his heavy drinking. When his romantic relationship breaks down, and he becomes single, this culminates in an increase in his drinking, and when he notices that drinking makes him look obese, this, in turn, for a while, decreases his drinking. The next excerpt from Thomas exemplifies how in the maturing process, heavy drinking habits tend to diversify through encounters with alternative drinking styles:I drink a lot less nowadays. (…) I know I have more control now. It’s not that I drank myself under the table every weekend, but it doesn’t happen as often that I get that drunk. And that’s because, I think, I don’t find it as fun anymore. (…) I’ve started to like red wine and beer too. (…) In that sense, I’ve started to drink in other social settings. Not just to get hammered. I drink because I enjoy it. Is it good for me?—That I don’t know .For many of the heavy drinkers, encounters with intoxication have increased their capacities to reflect on their drinking. Thus, previous negative drinking experiences have become actants moving them towards a more moderate drinking assemblage. For example, at the ages of 18 and 19, Lily first drank heavily with her girlfriends at home parties and bars—especially when she had finished upper secondary school and started working while still residing at her parents’ house; she had money to party. She describes how things often got out of hand, how her parents expressed concerns over her drinking and how she found out that her grandfather had previously experienced alcohol problems. These encounters made her reflect on her drinking. Later, she also realised that drinking caused anxiety and disturbed her studies.I have had anxiety [after drinking]. It’s felt unnecessary to drink because I know it will make me feel bad. I’ve had depression and take antidepressants too. Sometimes the anxiety gets worse the day after and the few days after drinking. (…) I don’t want that anymore because I don’t want to feel that way. (…) I’d rather concentrate on my studies .These negative experiences and her concerns over her health translated her heavy drinking trajectory into a moderate drinking trajectory. In our data, heavy drinkers describe similar kinds of translations. As they accumulate intoxication experiences, they not only translate their relationship with drinking into a more mature, responsible, and controlled one but also become more ambivalent and cautious. The learning-by-doing introduces actants to their heavy drinking assemblage, which decreases their desire to drink. They relate concerns linked to health , risks of drinking , and appearance .On the other hand, in our data, there are also participants who—despite developing an awareness concerning the risks of heavy drinking—state that for a few more years, they can continue to drink heavily, unhealthily, and irresponsibly since they are still young. For example, Thomas insists that his heavy drinking eventually will decrease.I don’t think I drink an awful lot, considering that I am 21 years old. I would not regard myself as an alcoholic. (…) You know it’s not good for you to drink, so you will scale down eventually. But I want to have fun now while being young, so I do it anyway .The last trajectory concerning drinking deals with the tensions between authoritative and self-reflexive forces in abstinence. The participants’ abstinence is first conveyed by an authoritative assemblage with actants such as religious beliefs, parental rules, subcultural norms, temperance movements, or political values, but later mediated in conjunction with a more self-reflexive assemblage related to personal reasons, acknowledged feelings, and authentic individual experiences. Through these chains of translations, abstinence becomes modified into more nuanced relational forces. For example, when Adina is 18 years old, one of the driving actants in her abstinence assemblage is religion—she does not drink because she is a Muslim. Two years later, her interview illustrates that the relational agency of her religious beliefs has weakened, and her abstinence is further moved by actants that are associated with personal concerns, experiences, and choices.I still don’t drink (…); my thoughts about it are still the same. (…) And I have maybe developed a broader picture of why. That it’s not the best and you can have fun without drinking. Before, when I was younger, I thought mainly about religion, but when you get older and start thinking… that you are not aware of yourself and such [while drinking], that causes concerns. You get more concerned about yourself somehow. Especially if there are things happening that are not good, that you can’t trust everyone. But I discovered that later, for me, I should actually not drink. (…) I’ve reached this age and made my own decision, and I will continue with it, to not drink .Similarly, in Mateo’s abstinence trajectory, the primary actant is first a figure of authority, his father, who argues abstinence to Mateo by maintaining that drinking would ruin his health, diet, and training schedule in sports.I know what my father would think about parties and such. He doesn’t approve. He would be very disappointed if I wanted to do it, but I respect that he doesn’t want me to. So I won’t. (…) My friends in school, they know me, and they know that my father doesn’t like it. So, they wouldn’t ask. (…) He tells me, “You should not drink” since he knows about my sport and that. He told me, “It would ruin your exercise and condition”. (…) If I were an adult, he wouldn’t be angry .One year later, Mateo interestingly finds himself in his father’s shoes and presents himself, his studies, his exercise, his risk of addiction, and saving money as actants that increase his capacities to stay sober.I don’t drink because my exercise would crash. It ruins your health, (…) diet and the training program that I have set up myself. I don’t find it important to drink and such. You know you get addicted and such. (…) I don’t want to take the risk. (…) It’s sort of a matter of principle that I learned myself. (…) I can focus on studying and exercising instead of partying and drinking and spending money on such things .In the article, we have analysed 28 complete cases of in-depth interviews conducted over the course of three years (2017 to 2019). The study deepens our understanding of how emerging adults approach alcohol over time. As the study results are based on a small purposive sample, one limitation could be the lack of generalisability of the results to Swedish youths in general. Social desirability bias in self-reported data should also be considered. However, by including interviewees from different sociodemographic backgrounds and by interviewing the same interviewees three times, the study is able to both capture the variation in young people’s drinking and abstinence trajectories and show how these trajectories are influenced by diverse kinds of material settings, relationships, health concerns, interests, emotional issues, practices, and habits.Our analysis identifies five trajectories that describe what kinds of chains of translations young people’s relation to alcohol have undergone over time. The first trajectory shows that young people consider underage drinking unsafe. It is related to informal spaces , vulneraThe second trajectory demonstrates how the accepted time to start drinking has moved from early adolescence to the moment of becoming a legal adult. If, for the earlier generations, the subcultural norms, group pressure, and intoxication provided the “social clock”  for the The third trajectory demonstrates the opposite displacement in young adults’ passages to adulthood. While the first and second trajectories exemplify in what way the current teenagers’ childhood lasts longer than that of the earlier generations , the thiThe fourth trajectory also displays how in heavy drinking assemblages, the maturation process means embracing relations that increase heavy drinkers’ capacities to act responsibly, controlled, and reflexive. This trajectory further concretises how young people, through multiple encounters with intoxication, learn to realise that heavy drinking is a risky and unhealthy practice. This learning-by-doing intoxication introduces to their heavy drinking assemblage actants that link their drinking to diverse physical, emotional, and social concerns and modify their relation to drinking to ambivalent and cautious ,33. ThesThe last trajectory expresses how abstinence in emerging adulthood is transformed from authority-related ideological, religious, and parental justifications towards personally experienced reasons, and in these, chains of translations become more mediated by individualised concerns. Although research suggests that abstinence might not be as socially sanctioned among youths in some contexts , youth nOverall, our results point out how young people’s relation to school, family, leisure, and the labour market is influenced early on by expectations in which the individual responsibility to exercise self-control, gain self-knowledge, and implement self-improvement is emphasised as an important element in becoming an authentic and successful person ,38. ThesOur study suggests that when the “sober generation” grows older ,10, it i