Background: The Coronavirus disease 2019 (COVID-19) has emerged as a global health threat. Certain factors like age, an immunocompromised state, and social impoverishment, etc. can add to health vulnerabilities during this pandemic. One such group is older transgender adults, who often bear a combination of these risks. As the world is aging fast, their numbers have also been increasing. With this in mind, this study explores the lived experiences and psychosocial challenges of older transgender adults during the COVID-19 pandemic in India.Methods: A qualitative approach was used. Ten individuals with “transgender” identity above the age of 60 were recruited with consent through purposive sampling. In-depth interviews were conducted on the telephone using a pre-designed interview schedule. They were recorded, translated, and transcribed verbatim. Hasse's adaptation of Colaizzi's phenomenological method was used for analysis. Independent coding and respondent validation were used to ensure the rigor of data.Results: The super-arching categories (with themes) were marginalization , the dual burden of “age” and “gender” , and multi-faceted survival threats  during the pandemic. Social rituals, spirituality, hope, and acceptance of “gender dissonance” emerged as the main coping factors, whereas their unmet needs were social inclusion, awareness related to COVID-19, mental health care, and audience to their distress.Conclusion: The elderly gender minorities are at increased emotional and social risks during the ongoing pandemic, and their voices are mostly unheard. The need for policy implementation and community awareness about their social welfare is vital to improving their health and well-being. The last 8 months have seen the emergence of a new global health threat, the Coronavirus disease 2019 (COVID-19). After being declared a pandemic by the World Health Organization (WHO), it has affected more than 37 million, with nearly a million people succumbing to the infection . Data alThe World Professional Association for Transgender Health (WPATH), in association with the Sappho Good Practice Guide, India, has laid down consensus guidelines for diagnosis, hormone therapy, recommendations for sex reaffirmation surgeries, and subsequent follow-ups. The guidelines stress multi-disciplinary efforts, appropriate knowledge regarding the procedures, and adequate psychological support, both pre and post-treatments . HoweverHijras.” They are often equated with “Kinnars” , as represented in the Kamasutra  and even in the epics like Mahabharata   . For genikhandi) . Over tiikhandi) . Even thikhandi) . LiteratThe study followed a qualitative method, using a social constructivist paradigm. In contrast to the positivist paradigm, this paradigm permits the researcher to be open-minded and flexible in exploration, rather than intervening or analyzing based on pre-fixed notions. Furthermore, we chose the phenomenological approach as we wanted to understand the specific “experiences and challenges” of a particular population in the context of an ongoing crisis. Such paradigms have been used in previous studies for studying phenomena like experiences of motherhood, pain, and post-traumatic stress among women, war veterans, and disaster-survivors, respectively . TelephoThough transgender or “trans” is commonly used as an umbrella term, for this study, we considered “transgender” as any person for whom their gender identity or expression is different from the sex assigned at birth (or that written in their birth certificate) .We obtained appropriate ethical approval from the Institute board. The participants were initially contacted via telephone, informed about the objectives of the study, and we sought informed consent verbally. Interestingly, all 10 participants welcomed the study initiative and were willing to participate without hesitation. A General Health Questionnaire (GHQ)-12 and Hindi Mental Status Examination (HMSE) were used as screeners for any psychiatric and cognitive disorders. The cut-offs were 3 and 19, respectively , 18. We The initial semi-structured interview schedule was designed based on a literature review, which was later modified based on the first two interviews. In that sense, they can be considered to be a pilot for this study. We recorded the socio-demographic details in a separate datasheet. The questions involved in the schedule were open-ended, facilitating rich data regarding their difficulties during the COVID-19 pandemic, their psychosocial needs, access to health care, perceived stigma and discrimination, and the effects of lockdown measures. The salient questions of the interview schedule are summarized in Appendix.can you tell me more about it,” “how did that happen,” “please elaborate on the context,” etc. were used to receive rich data on their lived experiences. The analysis was done simultaneously with data collection by both the researchers independently to add to the rigor.Probing questions like “We used Haase's adaptation of Colaizzi's method for analysis , 21. It Familiarization .Identification of significant statements and restating them in “general” terms.Formulating meanings relevant to the phenomenon of interest.Clustering “identified meanings” into categories, themes, and sub-themes.Rigorous discussion among researchers to develop an exhaustive description of the clustered themes.Developing a conceptual structure of the studied phenomenon.Respondent validation from the participants (seeking verification of the developed structure).As mentioned, the verbatim transcripts were translated into English . The transcripts and memos were read several times through thematic coding until significant recurrent phrases emerged, and they were re-described in general terms to formulate contextual meanings and then organized and structured by discussion among the researchers. We clustered the super-arched topics into relevant categories and themes, along with verbatim data supporting each of them.Trustworthiness and credibility are used to establish rigor in qualitative studies, which are different from the concepts of reliability and validity that underpin quantitative research . The resThe sample consisted of 10 elderly people from the transgender community. Four participants identified as “third gender,” while two preferred “male” gender, one preferred female, and one did not want to disclose gender and orientation. Six participants resided with their families or friends, and four lived alone. Among the latter, one resided at an old-age care home and another in temporary shelters, frequently living on the streets. They belonged to various states of Karnataka, a mix of lower and middle socioeconomic status. Throughout the pandemic, eight of them resided in the same place, whereas two had changed residence. One of these two included the homeless individual who kept changing temporary shelters for support. Only two participants received an old-age pension, as they had previously been employed in Government sector jobs. Six others were not aware of the senior citizen benefits of the country. Two were unemployed, whereas others did menial jobs for a living, apart from the homeless person, who at times begged at street signals. Four of them did not have a valid VOTER or AADHAR card (proof of identity in India). The mean age of the participants was 66.4 years. The mean GHQ-12 and HMSE scores were 1.7 and 25.2, respectively. The mean duration of the interviews was 45.20 min. We conducted the interviews in April and May 2020 when India underwent a four-phased lockdown to curtail the COVID-19 outbreak. The socio-demographic parameters for each of the elderly participants are mentioned in The experiences of participants during the pandemic were broadly categorized into feelings of marginalization , vulnerability due to the “dual burden” of age and gender , as well as multiple physiological, psychosocial, and economic survival threats. Social rituals and festivities within their community, acceptance of their “gender dissonance,” and spirituality provided them hope and helped them cope with the adversities. Knowledge-attitude-practice (KAP) gap regarding the outbreak was a major concern among them, while the predominant “unmet needs” were social inclusion, emotional well-being, social benefits, and receiving an “outlet or audience” for their suffering.The resultant super-arching categories and themes, along with the respective sub-themes, are summarized in Biological disasters like COVID-19 often hit the most vulnerable in the worst ways. Advanced age and belonging to a gender minority group are both crucial susceptibilities during the pandemic. They contribute to the “minority stress” of marginalized populations like the homeless, migrants, socially impoverished, and especially the Black, Asian, and minority ethnic (BAME) communities, as already postulated during the ongoing outbreak. These include social insecurity, unemployment, experiences of racism, prejudice and xenophobia, lack of social welfare benefits, precarious work, increased risk of infection due to lack of precautionary measures and overcrowding, and most importantly, lack of knowledge and awareness related to the pandemic and its related issues , 24.The study participants revealed a sense of increased “ageism” during the ongoing outbreak, which has also been raised as a potential concern in public health guidance measures for the “elderly” during COVID-19.“Throughout our lives, we have been ‘observed’ differently, now it's even more as we are old. We even get called names when we ask for help.”Such age-related prejudice and attitudes that consider the “elderly” as a “justified loss” for the sake of younger lives were also documented during the Severe Acute Respiratory Syndrome (SARS) and Ebola outbreaks , 26. AgeHijras take to baby showering ceremonies (Badhaai), which are an essential source of income, and during the pandemic have become scarce. Furthermore, the “sexual vitality” and “auspiciousness” of the Hijras, for which one welcomes them in ceremonies decreases with age, and hence older transgender adults often run out of income ! This is something we have been doing since we are young. Other people welcome us during these times. It has become our true festival! This disease has taken it away from us!”“In spite of all the ‘hate’ for us, society requires us for these ceremonies. Now, with the fear of infection, they don't even allow us near people's houses. Our livelihood and connections both are at risk!”Most participants mentioned being the “second priority” for health and legal services, including access to medications, medical protective equipment, and testing.“For [the] last three months, I have been so used to hearing: ‘people like you should come later, any way you are old, what's the need… just go and stay with your people…’ It hurts you know, it feels we are ‘aliens’ in this world. This adds to my uncertainty…”The Third Sex and Human Rights discusses the deprivation of human rights, poverty, and violence inflicted upon this community in India. Besides financial constraints and unemployment, many individuals from the Hijra community are forced to pursue a living through extortion, begging, exhibitionism, and sex work . The violence directed against transgender people has been widespread and often brutal, and is documented as taking place in their places of residence, prisons, police stations, and other public spaces “They were supplying free masks and soaps. I couldn't stand in the queue due to the constant ridicule and mockery that I saw in people. At times I feel… getting the infection is better than facing such insult at this age!”The resultant “minority” stress has been explained in terms of the Health, Stigma, and Discrimination model , where fSix participants reported self-stigma, a common finding in the LGBTQ community when they feel guilt about their “sexuality” and social notions that are against them, meaning they are further segregated from the mainstream and adopt their “community customs and rituals” . Social “I have always been seen as ‘seductive’ in personal and professional circles; I have no idea why! Now I have come to believe that probably my gender is responsible for this… age changes a lot in you… and there are certain ‘blames’ you cannot take any more at this age.”“I feel that I am different… I have always felt that way… people passing sexual comments and ridiculing me… that's how we, Hijras live…even in this situation, we need to go out for living…but get threatened by people and police telling we are on ‘business’! I get tired of my ‘appearance’ at times and wish it was different.”In the above excerpts, participants mentioned social stereotypes against their communities and how they have internalized these misrepresentations over time. While P10 started “believing” the blame attributed to her gender, P4 wished she could change her appearance for the “sake of society.” Other transgender individuals in our study also mentioned “reduced self-esteem” and developing a “hatred toward themselves” after constantly battling social injustice and prejudice. The self-stigma generated in an already marginalized community can be further detrimental to their ability to cope during the crisis.Loneliness, social disconnectedness, and depression were reported by 8 out of 10 participants. Major factors that have influenced these feelings include restricted travel, physical distancing, and difficulties in using and accessing technology (in 5 participants). Even though digital connectivity and telemedicine have repeatedly been used during the pandemic, they can be real challenges in lower and middle-income (LAMI) countries like India, where technology still fails to reach the masses, especially in the rural areas and minorities. Furthermore, age, with its sensory and cognitive limitations and frailty, can impair the appropriate use of video-connections with loved ones, which can lead to further loneliness and social segregation. Berger , in his “All throughout I wished I was like the ‘others’! My gender kept bothering me like a curse from birth. Living through so much of difficult times, it mattered little… Everyone was suffering and dying the same way. I don't know when, but I had stopped wanting to be ‘different’!”“Sometimes I feel this was needed… I witnessed the death of my friends, colleagues… there is so much suffering all around…I somehow feel stronger, more ready to face the world…”“Age brings in experiences, wisdom, acceptance, and much more… all my life I have faced hardships, even in daily existence… it's tougher times now, deaths, medicines, hospitalizations all around… with my age anyway I have nothing to lose… so I try to make maximum out of my life now, irrespective of everything… I tell others the same…”Psychotherapy for the elderly often uses such lived experiences, building upon notions of resilience and post-traumatic growth after disasters/crises, based on existential and humanistic approaches . Earlier“They say people who are living on the streets are being targeted for having the infection. I have the additional issue of being a Hijra. They were almost forcibly admitting me to the hospital… even without testing…”There is also a common myth that the elderly do not have sexual needs, and these ideas were challenged by P4 and P7, who mentioned that they “cannot even experience intimacy to soothe us during difficult times as they (their partners) go out for work, and the risk of infection” is present. The pandemic's effect on psychosexual health and deprivation of “social touch” remains largely unspoken but is critically detrimental to well-being. As COVID-19 is a highly contagious infection, this has led to doubts relating to sexual transmission and a definitive fear of intimacy. Sexual relationships and sexual well-being can be affected, irrespective of age or gender specifications .“Our relationship and closeness have literally formed my core strength in the worst of times. He goes out, so we sleep in separate rooms… the infection has created an emotional wall between us…”“Intimacy with my partner is a major comfort. But he goes for work. So, we don't feel comfortable making love… It makes me weak and vulnerable!”It is important to note here that resilience and strength emerging from their relationships and intimacy served as “viable supports” during the pandemic crisis. This is in contrast to models of psychological resilience being conceptualized as “personal internal attributes” based on Western mainstream psychology schools . The autOverall, the above factors together generated physiological, emotional, and financial pressures for participants. Losing priority and stigma kept them at a “backfoot” for health care, their voices unheard, and the uncertainty of the COVID-19 situation was amplified due to the double fear of “aging” and “being deprived.” Many of the participants reported mentioning that “old people are dying fast,” which they encountered in the media, with detailed information about morbidities that added to their fear. Besides, it is essential to understand that frequent comorbidity of Human Immunodeficiency Virus (HIV), diabetes, and other chronic medical conditions, compounded by neglect, often leads to persistent immunocompromised states in transgender people. These, along with age, can form the two most crucial risk factors for morbidity and fatality in COVID-19 . Associa“My neighbors would not want to interact with me. I was old, staying alone, and even basic needs were difficult… people knew that, but I hardly even got anyone asking how I am doing…”“‘Take care’ is the maximum assurance that I have received! Nobody bothered about how I needed to care for myself staying on the streets…Even begging didn't help.”Higashinihon Dai-Shinsai (The Great Japan Disaster) of 2011, which began with a tsunami and earthquake, led to a lack of shelters, mass stigma, bullying, violence, and social exclusion for the Japanese LGBTQ community, effects that have been vastly under-represented in the literature “There was no respect for age or humanity… how can I expect help!”While these were their vulnerabilities, we will now discuss how transgender individuals have navigated the crisis and the barriers they face.Five participants in this study were aware of the Pride movement and ongoing Pride month. Two knew that there was some celebration scheduled for their community at this point of the year, and three were unaware. Pride celebrations emerged after the Stone Wall riots in 1969, and mark the ongoing protest and expression of the social integrity of the LGBTQ community . Around “I know about this place where all of us gather and celebrate. Someone told me it is this time of the year. I wish it could have happened.”“I don't know too much about it and what they call [it]. But in our community, we have small celebrations, cooking, singing, and all… nobody dared to do all these… it will lead to more trouble in society, as such we are always blamed…”Spirituality and hope emerged as essential themes in seven and five participants, respectively. Ross et al. , while s“I used to go to Hanumanji's temple whenever possible, irrespective of all odds. It really helped. There was so much peace there…”“God or not, there is a force I believe in and worship. Can't explain! But that gives me hope…”The need to identify oneself with society for perceived self-worth, irrespective of disabilities, formed an essential aspect of the community health care needs of the elderly in a systematic review done by Holm and Severinsson . A low lAll the participants agreed that they lacked awareness about the necessary measures and ongoing situation about the pandemic. Only two followed social media updates, and apart from the numbers projected in the newspapers, they had questions about safety and testing for COVID-19. Three were increasingly dependent on their families while four others worked in shops as manual laborers and domestic help and lost working days during the lockdown. Salary cuts and unemployment have been widespread during the COVID-19 pandemic. Data from the PSB Research group in the United States showed that 30 percent of the LGBTQ community had their working hours reduced and salary decreased, compared to 22 percent of the general population . This crAll of the study participants agreed that they felt like an “outcast” even when they repeatedly heard people saying “we are in this together.” Eight of them reported lacking an audience for their problems, which was why they welcomed the interview.“Thanks to your research that you are asking… I felt good sharing these issues with someone, very few bother… already old, now more of a burden to the society!”“Media arrives and raises thousands of questions when needed. Nothing changes! Maybe nothing will, but at least you asked…”Social integrity and support are essential components in creating resilience during widespread disasters. These needs were not met in most participants. To summarize, the “dual burden of ageism and third gender” along with marginalizing factors decreased their access to health care and created physically unsafe and emotionally insecure environments, which along with “dependence” and “poor awareness” increased their physical and psychosocial vulnerabilities to the COVID-19 situation.Our study had a small sample size and is subject to the usual limitations of qualitative research, such as subjective interpretation and reduced generalizability. The ongoing pandemic crisis could also have exaggerated participant responses to questions related to their suffering. However, in a marginalized sector of the population, each voice matters, and our study benefits from a rigorous methodology, analysis, and reflecting and providing a platform for these usually “unheard and invisible” voices. As requested by the participants, the researchers present these “narratives” as representations and accounts of social suffering, rather than mere data.Aging with Pride: The National Health, Aging and Sexuality/Gender (NHAS) study has proposed the “Health Equity Promotion” model for older transgender adults, based on a bio-psychosocial understanding of their unique vulnerabilities  in India are comprehensive, but unfortunately fail to mention the already neglected experiences of the transgender community , 55. Wanbilities . The Corbilities . Such mobilities  have disbilities . As the The original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by JSS Academy of Higher Education & Research, JSS University, Mysuru, Karnataka, India. The patients/participants provided their written informed consent to participate in this study.DB was involved in data curation, analysis, and drafting of the manuscript. TSSR was responsible for designing the study, data collection, reviewing, and editing the manuscript. Both authors conceived the study, read and agreed on the final version of the paper.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.


Bundles of cytoskeletal filaments and molecular motors generate motion in living cells, and have internal structures ranging from very organized to apparently disordered. The mechanisms powering the disordered structures are debated, and existing models predominantly predict that they are contractile. We reexamine this prediction through a theoretical treatment of the interplay between three well-characterized internal dynamical processes in cytoskeletal bundles: filament assembly and disassembly, the attachement-detachment dynamics of motors and that of crosslinking proteins. The resulting self-organization is easily understood in terms of motor and crosslink localization, and allows for an extensive control of the active bundle mechanics, including reversals of the filaments’ apparent velocities and the possibility of generating extension instead of contraction. This reversal mirrors some recent experimental observations, and provides a robust criterion to experimentally elucidate the underpinnings of both actomyosin activity and the dynamics of microtubule/motor assemblies in vitro as well as in diverse intracellular structures ranging from contractile bundles to the mitotic spindle. Many cellular functions, from motility to cell division, are driven by molecular motors exerting forces on actin filaments or microtubules held together by crosslinking proteins. This wide variety of processes is powered by an equally wide range of structures, many of which do not display any apparent spatial organization of their components . While amechanical nonlinearities, for example, the buckling of individual filaments under compression could suppress the propagation of extensile forces and thus favor contraction , Focusing on a single right-pointing filament, the combined effect of motor motion and treadmilling implies that motors move with a velocity plus end , this imxtension . Note thThe density  another . As eachSolving To understand how the motor velocity i.e., Rescaling all lengths by -1/y see . As a>0 i.e., is compressed), while We now turn to the contractile/extensile character of a bundle comprised of To analyze the different regimes accessible to our bundle, we illustrate them in To understand this reversal of contractility qualitatively, we first consider a contractile situation at low crosslink detachment time lus ends , and thulus ends , right aructures , left foparallel, not antiparallel filaments, which is at odds with experimental observations that bundle-wide force generation in actomyosin requires antiparallel filaments  . Such ch and τm) . The exp, τm=5s , vt=1000nm⋅s-1 , and τc=  or motor dwelling over broad ranges of parameters, suggesting that the self-organization mechanism could be a substantial contributor to bundle tension in vitro and in vivo.In this section, we show that in addition to being on par with experimentally observed forces, the tensions generated by our self-organization mechanism exceed those resulting from mechanical nonlinearities  filaments. To estimate the associated tension, we use the model of filament , and theosslinks .To compute the tensions of interest, we extrapolate their value to a bundle with one filament per cross-section, keeping in mind that both Complementing these assumptions with the values of Motor dwelling at the filament ends takes place in certain types of microtubule-associated motors , and couThese assumptions imply uniform bulk densities of non-dwelling motors To characterize the resulting bundle steady-states, we apply the velocity selection and stability criteria described in Sec. ‘Velocity selection and bundle tension’ and compute the resulting bundle tension. The case As the dwelling and self-organization mechanisms both rely on a localization of the motors induced by the filament/motor dynamics, they result in quantitatively similar tensions as long as crosslink localization remains limited, that is for small values of τ~c . HoweverIn contrast with the static organization of striated muscle, many non-muscle actomyosin structures as well as motor-microtubules assemblies are very dynamic, and their components continuously assemble and disassemble even as they exert forces on their surroundings. While numerical simulations are useful to investigate these systems , the manWhile some of our simplifying assumptions may affect the accuracy of our quantitative predictions, the simplicity of the underlying mechanisms make our qualitative statements very robust. Indeed, we predict extension whenever the filament plus end polymerizes quickly enough to induce significant crosslink depletion in its vicinity, resulting in a sarcomere-like organization. This depletion is insensitive to whether filament disassembly occurs through depolymerization at the minus end or cofilin-induced severing . It is anot observed, as it implies that the absence of extension in certain parameter regimes argues against self-organization mechanisms in favor of mechanical nonlinearity (in actin) or motor dwelling (in microtubules) models. As an illustration, Our prediction of a robust extensile regime provides a stringent test to validate or invalidate the self-organized force generation model in specific experiments. As such, it constitutes an important statement even for systems in which extension is Drosophila, C. elegans, and Xenopus development .Thank you for submitting your article "Reversal of contractility as a signature of self-organization in cytoskeletal bundles" for consideration by The reviewers have discussed the reviews with one another and the Reviewing Editor has drafted this decision to help you prepare a revised submission.Summary:The author examines the dynamics of a circular bundle of filaments predicting regimes in which the bundle can contract or expand, in the presence of passive crosslinkers and crosslinking motors. The theory is done in 1D, following a mean-field approach. While all the assumptions are fairly standard in the field, their combination is interesting. Particularly filament treadmilling (assembly at the barbed end that is exactly compensated by disassembly at the pointed end) effectively provides a 'motor' quality to the crosslinkers, as they appear to move towards the pointed end, while the true motors move in the opposite direction. As a consequence, the system can be tuned to be contractile or extensile by changing the treadmilling velocity, which affects the speed of motors and crosslinkers move toward the ends. Treadmilling also leads to filament movements, but within the assumed of periodic boundaries, this has little impact on the overall length of the bundle. The buckling of filaments is not considered. The results are not entirely surprising, but the possibility for a network to expand is insufficiently discussed in the literature, although it is certainly an important behavior of cytoskeletal systems. The theory itself is clearly explained and convincing. It is of high quality and in line with that the author and others have done before on contraction, but now including extension, and this is new.Minor points:"Our prediction crucially rests on a simultaneous theoretical treatment of the filament, motor and crosslink dynamics detailed in the subsection “Motor and crosslink dynamics”. Previous studies of contractility mechanisms only involved partial treatments, whereby the time scale associated with one of these dynamics was effectively assumed to be much larger or smaller than the others."We would agree that for most previous work this is true, but in Belmonte, Leptin and Nédélec, 2017, crosslinkers and motors were treated symmetrically, without making an assumption relating to different time scales. Please, note the supplementary material of this work, is not a simulation, but an analytical result.ρm(ξ) would be measured with L=0 at the barbed end, and not the other way around, which seems more natural (0 = minus-end).Figure 2 legend: We were confused at first that ξ and thus "In the opposite limit where crosslinks are absent, motors slide filaments along at their unloaded velocity without producing any stresses, which rules out both contraction and extension "This is only true if one neglects the viscous drag, and this assumption should be repeated here ('without any stress' is an exaggeration)."Indeed, while extension has been observed in numerical simulations reported in Belmonte, Leptin and Nédélec, 2017, this behavior was directly tied to a choice of somewhat exotic motor end-dwelling properties that favor anti-sarcomeric structures."Belmonte, Leptin and Nédélec, 2017, discussed the consequence of a 'depletion zone'  on which is a cornerstone of the current work, and have predicted that they would lead to the extension of the network. We fail to see how this can be reduced to 'anti-sarcomeric structures' unless this would apply similarly to the current work."This system additionally does not manifest a transition from contraction to extension as the parameters of the model are continuously varied.". Please, refer to Figure 3D  and correct (or delete) the statement."Another instance of bundle extension is reported in Kruse and Sekimoto, 2002. In that model, the extensile behavior stems from the interaction between parallel, not antiparallel filaments, which is at odds with experimental observations that tension generation in actomyosin requires antiparallel filaments ." This statement appears inconsistent because it compares extension to contraction, and it seems possible to generate opposite forces, on different configurations . At least that would be the expectation of many readers, and the statement, therefore, does not work. Perhaps the author could find something more positive to say about  which lead the way to the submitted work. We see it as a clear demonstration that the depletion zone can lead to movements between two parallel filaments, and thus break the symmetry that impairs extension/contraction in general.S. pombe to be very different, one having a cell wall that dominates the mechanical behavior. Thus it is invalid to extrapolate from one condition to the other.Subsection “Quantitative Aspects and Alternative Models” seems flawed, as we expect the balance of forces during cytokinesis for echinoderms and A number of formulations: "has been suggested to occur in some actin-myosin systems ", "somewhat exotic", "Finally, the motor properties leading to extension in this model may be relevant for microtubule systems, but are not for actin" suggest that the author does not believe that end-dwelling motors could exist for actin.These statements are surprising especially in a theory paper. Can we really consider our knowledge of the cytoskeleton complete enough today to exclude a possibility that is already accepted for microtubules?Finally, this comment is also relevant to the Discussion, specifically the fact that the absence of certain features can be taken as a proof of some other mechanism: I would argue that we do not know all the mechanisms operating in a cytoskeletal system, and with this in mind, can the author be confident enough to use the absence of a predicted behavior to make a strong conclusion about some other mechanism? Minor points:"Our prediction crucially rests on a simultaneous theoretical treatment of the filament, motor and crosslink dynamics detailed in subsection “Motor and crosslink dynamics”. Previous studies of contractility mechanisms only involved partial treatments, whereby the time scale associated with one of these dynamics was effectively assumed to be much larger or smaller than the others."We would agree that for most previous work this is true, but in Belmonte, Leptin and Nédélec, 2017, crosslinkers and motors were treated symmetrically, without making an assumption relating to different time scales. Please, note the supplementary material of this work, is not a simulation, but an analytical result.I thank the reviewers for critiquing this sentence. What I meant was that this work was to my knowledge the first to consider motor, crosslink as well filament treadmilling dynamics. Belmonte, Leptin and Nédélec, 2017 only describes the first two, and thus effectively assumes that treadmilling is much slower . I have clarified that the reference to filaments in this sentence regards their treadmilling/polymeration through the following modification of the sentence:“Our prediction crucially rests on a simultaneous theoretical treatment of the filament polymerization, motor and crosslink dynamics detailed in subsection “Motor and crosslink dynamics”. […] We show in subsection “Self-organization and force distribution” that the coupled dynamics of these three elements induces a spatial organization of motors and crosslinks along the filaments”.On the issue of numerical vs. analytical results, I have made the following addition to the conclusion highlighting the analytical contents of Belmonte, Leptin and Nédélec, 2017:“[…] our analytical approach allows us to derive a complete phase diagram for self-organized motor-filament bundles. References Lenz et al., 2012b; Lenz,2014; Belmonte, Leptin and Nédélec, 2017 derive similarly useful analytical results applicable to situations dominated by filament nonlinearity or motor dwelling.”m(ξ) would be measured with L=0 at the barbed end, and not the other way around, which seems more natural (0 = minus-end).Figure 2 legend: We were confused at first that ξ and thus ρI added a comment stressing the convention used to minimize the risk of a reader being confused by this:“Note that the coordinate ξ is measured from the filament’s plus end” ."In the opposite limit where crosslinks are absent, motors slide filaments along at their unloaded velocity without producing any stresses, which rules out both contraction and extension "This is only true if one neglects the viscous drag, and this assumption should be repeated here ('without any stress' is an exaggeration).This is correct. One has to keep in mind that viscous drag is negligible compared to the other forces discussed here, as currently discussed in the Discussion section. Following the reviewers’ recommendation I now explicitly state this assumption earlier in the section:“Finally we neglect viscous drag, as further argued in the Discussion”."Indeed, while extension has been observed in numerical simulations reported in Belmonte, Leptin and Nédélec, 2017, this behavior was directly tied to a choice of somewhat exotic motor end-dwelling properties that favor anti-sarcomeric structures."Belmonte, Leptin and Nédélec, 2017 discussed the consequence of a 'depletion zone'  on which is a cornerstone of the current work, and have predicted that they would lead to the extension of the network. We fail to see how this can be reduced to 'anti-sarcomeric structures' unless this would apply similarly to the current work.I take the reviewers’ overall point that my previous discussion of Belmonte on was needlessly critical, and have modified the language to offer a more nuanced discussion.On the specific issue of the antenna effect, I now specifically mention its presence in the work of Belmonte, keeping in mind that it is only qualitatively discussed in the Discussion section rather than quantitatively modeled as I do here. I removed the “anti-sarcomeric” comment:“Extension has indeed been observed in numerical simulations reported in Belmonte, Leptin and Nédélec, 2017, but only in situations where the motors were assumed to dwell at the filament ends. The Discussion section of this reference does however qualitatively predict that extension should result from an “antenna” mechanism similar to the depletion quantitatively modeled here.”"This system additionally does not manifest a transition from contraction to extension as the parameters of the model are continuously varied.". Please, refer to Figure 3D  and correct (or delete) the statement.The original idea behind this comment was to contrast a situation where the transition is induced by a change in the composition of the system vs. its intrinsic parameters. This is however a very inessential point, and I deleted it according to the reviewer’s suggestion."Another instance of bundle extension is reported in Kruse and Sekimoto, 2002. In that model, the extensile behavior stems from the interaction between parallel, not antiparallel filaments, which is at odds with experimental observations that tension generation in actomyosin requires antiparallel filaments ." This statement appears inconsistent because it compares extension to contraction, and it seems possible to generate opposite forces, on different configurations . At least that would be the expectation of many readers, and the statement, therefore, does not work. Perhaps the author could find something more positive to say about Kruse and Sekimoto, 2002, which lead the way to the submitted work. We see it as a clear demonstration that the depletion zone can lead to movements between two parallel filaments, and thus break the symmetry that impairs extension/contraction in general.The reviewers are correct in pointing out that my statement is confusing due to its clumsy use of the word “tension”, which may be taken as a synonym for “contraction”. I modified it slightly to more accurately portray the underlying reasoning:“[…] which is at odds with experimental observations that bundle-wide force generation in actomyosin requires antiparallel filaments .”I do not agree with the characterization of Kruse and Sekimoto, 2002, as a proof that depletion zones  can lead to movements between parallel filaments. Indeed Kruse and Sekimoto, 2002, is not concerned with the depletion/antenna effect, but rather with motor traffic jams, which essentially give rise to an emergent motor end-dwelling.S. pombe to be very different, one having a cell wall that dominates the mechanical behavior. Thus it is invalid to extrapolate from one condition to the other.Subsection “Quantitative Aspects and Alternative Models” seems flawed, as we expect the balance of forces during cytokinesis for echinoderms and I agree with the reviewers that the extrapolation discussed in the first paragraph of the subsection “Quantitative aspects and alternative models” (and only there) is a bit of a stretch. I have thus replaced the numerical force extrapolated from echinoderms by a direct fission yeast measurement, which gives a result consistent with the one produced by the model using fission yeast parameters:“The magnitude of the forces and velocities predicted by our model are on par with those found in vivo, e.g., in the cytokinetic ring of fission yeast. Indeed, setting L = 1.4µm, […] we find a contractile force T ' 120pN comparable with the ring tension of 390pN measured in fission yeast protoplasts .”A number of formulations: "has been suggested to occur in some actin-myosin systems ", "somewhat exotic", "Finally, the motor properties leading to extension in this model may be relevant for microtubule systems, but are not for actin" suggest that the author does not believe that end-dwelling motors could exist for actin.These statements are surprising especially in a theory paper. Can we really consider our knowledge of the cytoskeleton complete enough today to exclude a possibility that is already accepted for microtubules?My position is not to exclude this possibility, but to point out that end dwelling is certainly more speculative in actomyosin than in microtubules, and should thus not be our default assumption. It seems to me that this position is indistinguishable from that expressed in the reviewers’ own work , where the Figure 2 presents non-dwelling motors as “actin-like” whereas Figure 3 presents a mixture of dwelling and non-dwelling as “microtubule-like”. To better reflect this in the text I have modified the formulations that the reviewers objected to.In the order of the citations above: “and could occur in some actin-myosin systems ”“in situations where the motors were assumed to dwell at the filament ends”[sentence deleted] .Finally, this comment is also relevant to the Discussion, specifically the fact that the absence of certain features can be taken as a proof of some other mechanism: I would argue that we do not know all the mechanisms operating in a cytoskeletal system, and with this in mind, can the author be confident enough to use the absence of a predicted behavior to make a strong conclusion about some other mechanism?I agree with the reviewer’s careful take on the issue, and have modified some of the language of the Discussion accordingly, replacing my previous uses of “ruling out” self-assembly mechanisms by “arguing against” and “tending to disqualify”.


This study focused on urban corporate people and applied multinomial logistic regression (MLR) to identify the impact of anthropometric, biochemical, socio-demographic and dietary habit factors on health status. Health status is categorized into four levels: healthy, caution, affected, and emergent. A cross-sectional study, based on convenience sampling method, was conducted to select 271 employees from 18 institutions under the Grameen Bank Complex, Dhaka, Bangladesh. Biochemical measurements such as blood uric acid are highly significant variables in the MLR model. When holding other factors as constants, with a one-unit increase in blood uric acid, a person is 11.02 times more likely to be “emergent” compared to “caution”. The odds are also higher, at 1.82, for the blood uric acid to be “affected” compared “caution”. The results of this study can help to prevent a large proportion of non-communicable diseases (NCDs) by reducing the most significant risk factor: blood uric acid. This study can contribute to the establishment of combined actions to improve disease management. Anthropometric and biochemical measurements are important factors for determining the health status of an individual. These are also used to diagnose chronic illness . Some prLike other developing countries, Bangladesh is changing in the disease and death patterns from communicable diseases to NCDs and due to urbanization and economic growth, these are spreading very fast here ,6. MoreoHow much does each factor contribute to the health status among urban corporate people in Bangladesh?What is the most significant factor for influencing the health status among urban corporate people in Bangladesh?People who usually work in urban areas of Bangladesh lack health insurance and high health awareness, do not get routine mandatory health checkups and are not habituated to using ICT-based healthcare services . It is aThe health status of an individual can be measured by previous and current diagnosed illnesses and by clinical parameters . DiseaseSocio-economic status plays an important role in the determination of health status . StudiesTherefore, we hypothesize that the higher the level of education, the better the health status. We also expect that the health status will worsen with age. Health status may be good or bad for males or females, but we have no prior expectations. Dietary habit is associated with different clinical measurements and has an influence on health status . Due to Therefore, we hypothesize that dietary habits (drinking sugar-containing drinks and eating fast foods) have a bad impact on health status.Anthropometric measurements such as weight, height, body mass index (BMI), body circumference , waist to hip ratio (WHR), elbow amplitude and knee–heel length, etc., are highly related to the health status of an individual . They reTherefore, we want to explore how much of an impact anthropometric measurements have on health status.Biochemical measurements such as blood uric acid are used to assess the health status of an individual. Poorer health status is associated with higher blood uric acid. High uric acid is a biomarker of various chronic diseases and thus reflects one’s health status .Therefore, we want to explore how much of an impact this biochemical measurement has on health status among urban corporate people.The conceptual framework of the multinomial logistic regression (MLR) model is shown in A cross-sectional study was conducted among all employees who agreed to participate in the portable health clinic (PHC) health checkups (described in the next section) and eHealth services in the Grameen Bank Complex in Dhaka, Bangladesh. The Grameen Bank Complex holds 18 different offices, such as Grameen Bank, Grameen Communications, other non-government organizations, and private companies, with more than 500 workers.Grameen Communications, Bangladesh, and Kyushu University, Japan, have jointly developed a human-assisted PHC system . A PHC iIn this study, the test items included  in thisBefore the implementation of PHC services, awareness events and prior notification to each employee were made to provide information on the availability of PHC services. Data was collected from 6 August 2018 to 16 August 2018 through a convenience sampling method from a sample of 271 employees who came to the PHC service center inside the Grameen Bank Complex to receive the PHC service. All participants involved were treated based on the safety procedure described in the “Helsinki Declaration 2013” . The datSocio-demographic and dietary information were collected using a questionnaire. Each individual’s clinical measurements such as height, weight, BMI, waist to hip ratio, body temperature, blood glucose, pulse rate, and blood uric acid were measured by pre-trained healthcare workers. The descriptions of independent variables are presented in Health status is an important outcome or method for assessing the level of health of a person, a group, or a population, as calculated by the individual or by objective measures . Health Multinomial logistic regression (MLR) analysis was applied  to analyze the association of clinical factors, dietary information and socio-demographic factors with the health status. MLR is an extension of the binary (or dichotomous) logistic regression and it is used when the outcome variable has more than two outcomes. For the MLR, one category or level of the dependent variable is specified as the reference category and regression coefficients are estimated for each independent variable . The indThe authors obtained ethical approval from the National Research Ethics Committee (NREC) of the Bangladesh Medical Research Council with approval No. 18325022019. Descriptive statistics were used to describe the baseline characteristics of the participants. The summary statistics of participants are shown in The mean age of participants is 49.61, most of the participants are aged 50 years. About 83% of respondents are male and most of them have completed a college/university degree. Among 271 respondents, 9.6% reported that they drink sugar-containing drinks  three or more times a week and 18.1% reported that they eat fast foods  three or more time a week. Among 271 employees 2 (0.7%) reported as “healthy”, 80 (29%) reported as “caution required”, 122 (45%) reported as “affected” and 67 (25%) reported as “emergent”.According to BMI measurements, the mean value of BMI = 25.37, i.e., most of the participants are overweight. According to the WHO, a BMI ranging from 25 to 29.9 is defined as overweight. The mean amount of uric acid is 6.63 mg/dL. This means that the uric acid of most of the people is close to the borderline of the suggested normal range: <7.0 mg/dL . Multinomial logistic regression (MLR) analysis by using R statistical software was applied to estimate the influence of health checkup test results, including blood pressure, pulse rate, and blood uric acid, on health status. MLR does not assume a linear relationship between the dependent and independent variables , and theThe ratio of the probability of choosing one outcome category over the probability of choosing the baseline category is referred to as the relative risk ratio. The relative risk ratio can be obtained by exponentiations of the logit coefficients. The standard errors of the coefficient estimates (B) are used to check for numerical errors or multicollinearity in the solution of the MLR. A standard error that is greater than 2.0 indicates that multicollinearity exists among the independent variables . The output coefficients are represented in the log of odds. Relative risk ratios allow for an easier interpretation of the logit coefficients. They are the exponentiated values of the logit coefficients. Gender is a significant non-policy variable that increased the likelihood of one being “emergent”. The estimated coefficient is negative, which indicates that females are more likely to be “emergent” than males. Blood uric acid is a highly significant variable in the MLR model. The estimated coefficient is positive, which indicates that employees with high uric acid are more likely to become “affected” and “emergent”. Education, drinking sugar-containing drinks, eating fast foods, body temperature, and pulse rate fail to be significant explanatory variables; the results do not provide evidence about a link between health status and these variables.Looking at the blood uric acid, it can be concluded that, when holding other factors constant, for a one-unit increase in blood uric acid, the person is 11.02 times more likely to be “emergent” compared to being “caution”. The odds are also higher, at 1.82, for the blood uric acid to be “affected” compared to being “caution”. Respondents are significantly more unlikely to being “emergent” in terms of height, waist and BMI. This is because the odds ratios of the category “emergent”, when compared to “caution”, are close to zero for these factors. Therefore, there is a huge difference between the category “emergent” and the “caution” for these three factors. The estimated coefficient of BMI is negative (−2.77), which indicates weight is higher compared to height. Those who have a higher weight compared to height tend to be “emergent” compared to “caution”. The negative estimated coefficient of height (−0.91) means shorter people tend to be “emergent” compared to “caution”. On the other hand, respondents are significantly more likely to be “emergent” compared to “caution” on weight, hip, WHR, and systolic blood pressure (systolic BP). The positive estimated coefficient for hip (0.42) means those who have a high hip circumference tend to be “emergent”. The positive estimated coefficient of WHR means those who have a high waist to hip ratio tend to be “emergent”. The positive estimated coefficient of weight means people who have more weight tend to be “emergent”. Respondents are significantly more likely to be “affected” compared to “caution” in terms of their waist, and diastolic BP.This is the first study in the context of a developing country like Bangladesh that reports the predicting factors of levels of health status among urban corporate people. This study has found that, in an urban corporate setting, females are more likely to be vulnerable than males. Therefore, this finding will help us to warn female corporate workers to be more concerned about their health status. By our analysis of the multinomial logistic regression model, we have shown that blood uric acid appeared to be the best predictor of health status compared with other parameters, while BMI was the weakest predictor. A purine-enriched diet, obesity, and alcohol intake are reported as the predictors of hyperuricemia (high blood uric acid) ,39,40. ACountries like Bangladesh need to make proper policies for each risk factor separately to prevent the harmful prospects of them . PrioritThis study worked with a human-assisted portable health clinic system, with the aim being to provide primary healthcare services, including blood uric acid measurement, regularly. Regional and corporate officials who have a high risk of developing NCDs must be investigated in terms of the effects of socio-demographic characteristics, dietary habits, anthropometric, and biochemical measurements on health status. One of the strengths of our study is the identification of the most significant risk factor of corporate people in Bangladesh who have a high risk of developing NCDs and do not have national health insurance. Another strength is that all clinical measurements were done using cost-effective PHC instruments by pre-trained healthcare professionals rather than being self- reported by the participant. The results of this study can help to prevent a large proportion of NCDs by reducing the most significant risk factor: blood uric acid. This study can contribute to the establishment of combined actions to improve NCD management..This study is limited by geographical scaling; the survey has been conducted in one country and focused on 18 institutions only. Thus, the results may raise a concern about the generalizability of the findings. Therefore, there is a scope to make its findings more generalized by examining more institutions and countries. A future study could include additional factors such as physical activity, information about eating purine-enriched foods such as red meat, lentils and sodium-containing foods, mental health factors, and environmental factors (duration of living in a city)This work assessed the importance of risk factors to predict the health status of urban corporate people in Bangladesh. Anthropometric variables, socio-demographic characteristics, dietary habits, and biochemical measurements were used in the multinomial logistic regression model. Data were collected from 271 employees  aged between 34 and 77 years. Among urban corporate people, blood uric acid was found to be the factor that was most significantly (high impact variables) associated with health status. Interventions to reduce these factors are needed and should target older employees, who have a high waist to hip ratio  and a large hip size, large waist size and high levels of blood uric acid. Screening and health promotion initiatives should be launched by targeting the high-impact risk factors for health status. However, to prevent the seriousness of NCDs, all of these risk factors should be measured and monitored regularly. This study can contribute to the establishment of combined actions to improve NCD management. Creating employees’ clubs or employees’ associations can help to improve the health status, wellbeing of employees and engage them in physical activities.


Worry about COVID-19 is a central topic of research into the social and economic consequences of the COVID-19 pandemic. In this paper, we present a new way of measuring worry about catching COVID-19 that distinguishes between worry as a negative experience that damages people’s quality of life  and worry as an adaptive experience that directs people’s attention to potential problems . Drawing on work into fear of crime, our classification divides people into three groups: (1) the unworried, (2) the functionally worried (where worry motivates proactive behaviours that help people to manage their sense of risk) and (3) the dysfunctionally worried . Analysing data from two waves of a longitudinal panel study of over 1000 individuals living in ten cities in England, Scotland and Wales, we find differing levels of negative anxiety, anger, loneliness, unhappiness and life satisfaction for each of the three groups, with the dysfunctionally worried experiencing the most negative outcomes and the functionally worried experiencing less negative outcomes than unworried. We find no difference between groups in compliance and willingness to re-engage in social life. Finally, we show a difference between the dysfunctionally worried compared with functional and unworried groups in perceptions of risk . This finding informs what sort of content-targeted messaging aimed at reducing dysfunctional worry might wish to promote. We conclude with some thoughts on the applicability of our measurement scheme for future research. The 2019 novel coronavirus (COVID-19) has affected many aspects of life globally. One consequence has been the surge of public anxieties and worries in some parts of the world Lin , with siIn and of itself, worry  can damage people’s mental health and quality of life. Yet, worry can also stimulate care and precaution. The type of worry that helps people to develop coping strategies has been described in the fear of crime literature as “functional fear”; people use adaptive emotions and precautionary activities to help guard themselves against the cause of their worry  and positive . Finally, we consider a possible intervention to address those experiencing dysfunctional fear, exploring who messaging should target, but also what content that messaging might consider. To achieve this, we look at differences in risk perception between the three groups, and speculate on the type of information that might target people’s perceived likelihood, perceived consequences, and sense of control. We argue that the dysfunctional group would be best served by targeted messaging and time and effort from governments and other organisations in order to reduce their worry, or, to shift them to the “functionally worried” group  there have been 84 million confirmed cases and 1,160,650 confirmed deaths across 226 countries and territories  stimulate adherence with public health measures , (b) have negative consequences on mental and physical health, and (c) prevent people from re-engaging with social and economic life once government restrictions of such activities are eased. This concern has spurred various initiatives. For example, the World Health Organisation has supported a range of projects aimed to reduce COVID-19 related stress, including, a telephone counselling service in Turkey , we consider what sort of perceptions might mean someone is in one group over the other. Much fear of crime literature focuses on people’s demographic characteristics , and this is also the case in fear of COVID-19 literature. But fear of crime is transitory and situational, meaning that people move between states of worry. Studies following people over time have found that their worry levels change as they experience various different situations which might make them worry  and 1–5 June (wave 3) 2020 (The first wave did not ask questions about worry). The second wave was fielded the day after UK prime minister Boris Johnson’s address to the nation that announced an easing of the initial lockdown restrictions. These changes involved revised messaging from ‘stay at home’ to ‘stay alert’ as well as some rule changes , and came into force on 13 May. The data collection of the third wave took place 10 days after the nation learnt about the lockdown breach by Dominic Cummings, the prime minister’s chief advisor, which was followed by a national outcry. The data collection for wave 3 also coincided with further easing of the restrictions, including permitting up to six people to meet outside, the reopening of some childcare facilities, and so on. According to the data by the Office of National Statistics, on the week of survey wave 2, 3810 people died with COVID in the UK; this dropped to 1588 COVID deaths by the week of wave 3. A total of 1100 people participated in wave 2 of the study, and 1019 in wave 3. Respondents lived in ten metropolitan areas across the UK . Quota weights were calculatedThis section details how we operationalise the key concepts discussed above. The specific questionnaire items are in In order to classify worry about COVID-19, we use answers to questions adapted from fear of crime questions  caused by COVID-19.To assess the extent to which mental and emotional wellbeing is associated with worry we asked people about how strongly they had felt anxiety, anger, loneliness, and happiness in the previous day. We also asked people overall how satisfied they are with their life and to what extent they feel that the things they do in life are worthwhile. Those who answered they felt anxiety/anger/loneliness “Not at all” were coded as “No”, everyone else as “Yes” to experiencing these outcomes. For happiness, those who answered “Not at all” were coded as “Yes” to never having felt happy, and for Worthwhile and Satisfied we coded “Not at all…” feeling that the things they do in their lives were worthwhile or “Not at all…” satisfied with their lives as “Yes” to feeling not satisfied and not worthwhile. As a result, a positive (“Yes”) outcome for each respective emotions indicator represents a bad emotional experience. We also created a summative emotion score, where answers were re-coded to run from 1 to 5, with higher scores representing a worse emotional outcome. A Cronbach’s alpha of 0.88 indicates good internal consistency among these indicators.We also asked people the extent to which they engaged in the following behaviours: socialised in person with friends or relatives they do not live with; went for a walk or run or cycle and spent time sitting somewhere to relax; and travelled for leisure. In wave 2 these behaviours were in breach of the lockdown restrictions put in place by government, so participating in these events reflected a lack of compliance. However, in wave 3, these behaviours were once again allowed. As a result, people in the UK were being encouraged to re-engage in some semblance of normal life–they were allowed to stop and rest during or after walking, running and cycling, they were allowed to travel for leisure, and they were allowed to socialise in groups of 6 in England or 8 in Scotland. Thus, changes in self-reported behaviour betweens waves 2 and 3 represented the extent to which research participants were re-engaging with the social world. We calculated a re-engagement score by taking the score for the compliance item in wave 2 and subtracting it from the sum of the compliance items in wave 3. This means higher scores indicate more re-engagement: A score of 0 represents no change in engagement, a negative score represents more engagement in wave 2 than wave 3 (less engagement after easing of lockdown), and a positive score signals more participation in the activity in wave 3 than wave 2 (re-engagement). Similar to impact of COVID-19 score, this is not a construct as such, rather a mock-count using a formative approach to measurement adding up people’s answers to create an index.Of course, other factors besides worry might affect compliance and reengagement, so we included measures of the following in our modelling: knowledge of the virus (self-rated knowledge level of the virus), their perceived risk of sanctions for breaching lockdown restrictions (how likely they think it is to be caught and sanctioned for each activity), expressive function of the law , social norms , feelings of duty to obey the police and follow the law, and their normative alignment with the police and the law.We also asked for demographics, such as age, gender, ethnicity, and whether they held employment that considered them to be ‘key workers’.Finally, to measure perception of risk, we used three risk related questionnaire items adapted from perceived victimization risk questions Jackson  to measuIn wave 2 just over one-third (34%) of people said that “No”, they had not worried about getting COVID-19 in the past 3 weeks. From those who said “Yes”, there was variation in self-reported frequency and intensity of worry. 35% of people who were worried experienced this “Once or twice” in the last 3 weeks, while 21% worried more than 10 times in this timeframe. On the last occasion, 58% said they “felt fairly worried” or “very worried”.First, individuals were classified as unworried if they reported being unworried about catching COVID-19: it did not matter if they took precautions that made them feel safer, or if their quality of life was reduced by their precautions; if they reported being unworried they were simply classified as unworried.To be classified in the functional worry group, respondents must have met three conditions: (a) they must have reported being worried about catching COVID-19; (b) they must have taken precautions that made them feel safer; and (c) they must have judged their quality of life to be unaffected by either their worries or their precautions. Importantly, we assume that the worry process partly motivates these beneficial precautions; as Tallis and Eysenck To generate the three groups, Tables Table By cross-tabulating precautionary activity with levels of impact on quality of life, we can identify the functionally worried and the dysfunctionally worried. The cell to highlight is top-left Table . This reBringing this classification process to a close, we found that just over one-third ) of the sample were unworried, about one-in-five ) were functionally worried, and just over two-in-five ) were dysfunctionally worried  had themselves lost their job or were unable to work, 10% (118) had a member of their household lose their job or be unable to work, 6% (67) reported being unable to pay bills, 0.4% (5) couldn’t access sufficient food, 5% (59) couldn’t access required medication, 2% (28) had been evicted or otherise lost their accommodation, 3% (36) saw someone they are close to go in hospital and 3% (35) saw someone close die as a result of COVID-19. Some 171 people reported suspecting themselves having COVID-19.2We see that those who have had (or thought themselves to have had) contracted COVID-19 already are more likely to be in the functionally worried group (vs unworried). On the other hand, those scoring higher in the COVID-19 effect measures are those in the ‘dysfunctional worry’ group Table .Table 4PWe find that separating out the types of worry, and comparing to the unworried, shows that for all our measures of emotional wellbeing those in the ‘dysfunctionally worried’ group report more negative emotions than those who are not worried, while those in the ‘functional’ worry group do not. In fact, on all outcomes, those in the functionally worried group report fewer negative emotional outcomes than the unworried, while dysfunctional worry group report more Fig. .Fig. 1EmSeparating out the functional and dysfunctional worry here highlights that it is those who are experiencing ‘dysfunctional worry’ that are more affected by these negative outcomes, and not the ‘functional worry’ group.Modelling the outcome variable to the summative score on negative emotional outcomes shows that those in the functional worry group score lower on this negative emotion score than unworried people, while those in the dysfunctional group score higher, i.e. have worse wellbeing outcomes Table .Table 5NWe next consider whether worry is a factor in shaping people’s compliance with lockdown regulations, and whether worry discourages people from re-engaging with social and economic activities once these restrictions are eased. We asked people a series of questions related to compliance as well as questions about other factors which may influence such behaviours see “”. When wWe now turn to whether it is possible for people to move between worry groups, and what might motivate them to do so. Previously we found that some factors such as previous experience with COVID-19 and the extent to which it has negatively affected people’s lives are related to which group they belong to (see ‘Previous experience’ section). Yet, this is not something that lends itself readily to practical interventions aimed to nudge people from one group to the other.Instead, here we explore how perceived risk might differ between the worry groups as this might be something that targeted messaging might better be able to influence. First, we need to see whether people move between worry groups, or whether this is a static attribute. The longitudinal nature of this survey allows us to assess this. While most people stayed in the same group between the two waves (71%), almost a third 29%) moved between categories  was associated with negative emotional outcomes which may affect people’s mental health. On the other hand, people who experienced functional worry, which is worry that encourages them to take precautions, did not have the same association with these negative outcomes. This suggests that, for some people, worry can be beneficial, and does not damage wellbeing. Similar to the relationship between previous victimisation and fear of crime, we found that having previous negative experiences as a result of COVID-19 such as loss of income or housing was associated with dysfunctional worry, but unlike crime victimisation, having had COVID-19 was associated with functional worry instead.We also found, however, that none of the groups of worry were associated with either levels of compliance with lockdown measures, nor with subsequent re-engagement in these activities once the restrictions are lifted. It is instead likely that other factors are at play, such as the sense of a common fate, a shared identity, or acting for the common or the social good, centred around national sentiment towards the NHS for example.Finally, one key difference between the worry groups was perceived risk, made up of the perceived likelihood of getting COVID-19, perceived severity of the consequences, and their perceived control over it. Future work could explore any causal relationship in order to inform targeted interventions that may help move people out of the dysfunctional worry group into the functional one and thus, it might be hoped, improving their quality of life and other outcomes. Interventions aimed at reducing worry should target those experiencing dysfunctional worry, possibly by exploring the effect that targeted messaging/communications campaigns might have on reducing perceived likelihood and severity of consequences, or increasing people’s perceived ability to control whether or not they contract the virus.Of course, such targeted messaging should take into account all possible consequences, and specifically that the aim is to move people from dysfunctional to functional worry. We would want to eliminate the negative outcomes on wellbeing, but maintain the prosocial precautionary behaviour of functionally worried people. For example, it might be an intervention to trial whether identifying and messaging dysfunctionally worried people about ways in which they can gain some control over their risk of catching COVID-19, for example by talking about wearing masks (something they can control) in places where they do not perceive other people to be following social distancing guidelines (something they cannot control) to increase perceived control. A follow-up evaluation of such messaging might measure to what extent such messaging influences perceived control, and whether if it increases people’s sense of control this is associated with moving out of dysfunctional and into functional worry. We note that risk perception has to be understood in a systems context, as people belonging in one worry group or the other is likely influenced by a myriad of complex reasons  and so on, but targeted (e.g. warning) messages can influence these perceptions within said contexts (Laughery and Wogalter In light of the above findings, we suggest that future studies exploring worry about COVID-19 take into account this difference between functional and dysfunctional worry. Of course, we realise that asking many follow-up questions is not always possible due to resource and other constraints, so asking about worry and precautions might not always be feasible. In our data, we also explored a simplified classification, in which we do not take into account precautions, but instead divide people into functional or dysfunctional worry based on whether their worry reduces their quality of life or not. Using this simpler classification, we find the same relationships between dysfunctional worry and worse negative emotional outcomes, and the same differences in risk perception, alongside there still being no relationship between worry and compliance or re-engagement see . While s


In Ontario, Canada, Indigenous communities experience some of the province’s worst drinking water, with issues ranging from deteriorating water quality to regulatory problems and lack of support. When water is known, or suspected, to be unsafe for human consumption, communities are placed under a Drinking Water Advisory. Between 2004 and 2013, approximately 70% of all on-reserve communities in Ontario were under at least one Drinking Water Advisory. Despite the widespread impact of Drinking Water Advisories on health and wellbeing, little is known about First Nation individuals’ perceptions and experiences living with a Drinking Water Advisory. This study presents information shared by members of a community who have lived with Boil Water Advisories on and off for many years, and a long-term Boil Water Advisory since 2017. The goal of this paper is to unpack and explore the Boil Water Advisories from the perspective of community members and provide considerations for current and future Boil Water Advisory management.Methodological choices were driven by the principles of community-based participatory research. Two data collection methodologies were employed: hard copy surveys and interviews.Forty-four individuals (19.5%) completed a survey. Eight Elders and 16 key informants participated in 20 interviews. Respondents expressed varying degrees of uncertainty regarding protective actions to take while under a Boil Water Advisory. Further, 79% of men but only 46% of women indicated they always adhere to the Boil Water Advisory. Knowledge gaps that could lead to risky behaviours were also identified. Finally, Boil Water Advisories were demonstrated to have physical, financial, and time impacts on the majority of respondents.A direct outcome was the identification of a critical need to reinforce best practices for health protection through community education and outreach. More broadly, Chief and Council were able to use the findings to successfully advocate for improved drinking water for the community. Additionally, benefits of participatory research and community ownership include enhanced local research capacity, and increased awareness of, and desire for, research to inform decisions.The online version contains supplementary material available at 10.1186/s12889-020-09825-9. In Ontario, Canada, Indigenous (on-reserve) communities face drinking water insecurity . Issues When water is known, suspected to be, or could become, unsafe for human consumption, communities are placed under a Drinking Water Advisory (DWA). The type of DWA depends on the nature of the problem, with advisories ranging from boiling tap water before consuming  to not consuming or using tap water under any circumstances (Do Not Consume Advisory). DWAs can be issued for any community in Canada but are more complicated in the Indigenous context in Ontario. This is because water systems in Ontario must meet provincial standards rather than federal guidelines. However, despite being located in Ontario, reserves are under federal jurisdiction because they are on Crown Land. Thus, the onus for water treatment and management falls on Indigenous communities and the Government of Canada, specifically Indigenous Services Canada (ISC) and Health Canada (HC) . ISC supThe Indigenous framing of human health and wellness differs from the Western biomedical model, which sees health as the absence of disease . In manyis life and water has life or a spirit  running properly” (KI15); a lack of “regulatory infrastructure” on reserve (KI15); the use of reserve land to haul oil or other harmful substances (E10); and, larger populations  having more expensive water treatment plants (KI5).n = 8, 18%) and community fliers, posters, or bulletins . A significant number of respondents indicated that they always consider themselves under a BWA  because they are never sure if there is one in place or not - “[I] never drink uh, water from the tap because [I] don’t know whether it’s uh, it’s on or not” (E9). It should be noted that a lack of access to the Internet was perceived to be a barrier to receiving BWA notifications.Not everyone demonstrated the same level of awareness of the current BWA Table , despiten = 12, 27% did not know), or if a Brita filter is effective in decontaminating tap water . Some respondents identified knowledge gaps that could lead to risky behaviours, believing that they could continue to drink their tap water as long as it is clear , use their tap water to make ice , or use their tap water to clean their teeth , all of which are potential transmission routes for disease, and advised against while under a BWA. An additional 39% (n = 17) believed that a Brita filter would purify their tap water, when in fact it does not remove microbiological contaminants. When looking at knowledge of practices by gender, men were more likely to correctly identify recommended practices than women. For example, 84% (n = 16) of men but only 67% (n = 16) of women correctly identified that they could not drink their tap water even if it was clear, and, proportionally, twice as many men than women correctly identified they could not use their tap water to brush their teeth  indicated that respondents use tap water for cleaning their teeth, aligning with the knowledge gap identified previously, and demonstrating that lack of knowledge leads to risky behaviours. Approximately one-quarter of responses indicated that participants use tap water for food preparation and cooking , with 6% (n = 3) using lake water, and one respondent using boiled water. Three KIs identified that they could boil their tap water to make food, soup, and coffee, which makes it difficult to ascertain whether survey respondents were referring to using tap water for all food preparation and cooking, which could pose a health risk, or just for foods that could be boiled.When asked about their water sources and uses Table , responsn = 27, 61%) indicated that they always adhere to the BWA, while 36% (n = 16) occasionally adhere  and one indicated that they never adhere. When stratified by gender, there was a clear difference in reported adherence between men and women. While 79% (n = 15) of men indicated they always adhere to the BWA, less than half of women  said the same. However, age also played a role in reported adherence  or cooking  under a BWA although, as previously indicated, some ambiguity may exist around whether this extended to all food types. The largest disconnect between knowledge and practice was around teeth cleaning; 39% (n = 18) of respondents indicated that they always adhere to the BWA, but also indicated that they used tap water for cleaning their teeth. Some people clearly expose themselves to risk unnecessarily while believing that they are adhering to the BWA. A risky practice that has not caused illness in the past is still a pathway for disease in the future.Clear disconnects emerged between knowledge and practice. For example, 4% (n = 2) of respondents indicated that they always adhere to the BWA, while also indicating that they use tap water for drinking during a BWA. Other respondents indicated that they always adhere to the BWA, but use tap water for food preparation (n = 39) of respondents indicated at least some impact and 59% (n = 26) reported significant or high impact in one or more categories , finances, and time as a result of living under a BWA. Eighty-nine percent (n = 4) of respondents did not report any adverse impacts. It is important to note that responses differed according to gender and age  and time  impacts. The greatest disparity across age categories was with respect to social impacts, where 42% (n = 10) of younger respondents indicated significant or high impacts, while only 16% (n = 3) of older respondents said the same. More men than women reported significant or high spiritual impacts . Finally, women were more likely to report little or no impact financially compared to men , but impacts did not differ across younger and older respondents.Only 9%  and KIs (n = 2). Other health concerns identified as resulting from community water problems included hair loss (E8) and itchy skin (E1) or eczema . One KI linked health effects to “whatever they put in the in the water” (K12). Four Elders and KIs extended water-related health to wildlife, referring to “fish with lumps on bodies” (E8) and fish “full of mercury” (E9). As expanded in the discussion section, this speaks to the community’s worldview of interconnectivity. When water quality impacts animals it also impacts their human counterparts: “They drink the water, they get sick and then we eat the meat, we get sick” (KI12). In this context, the relationship goes beyond physical health and encompasses environmental stewardship:“You respect all life right from the tiniest insect to the biggest animal and they’re here too for a reason. And we all depend on water to survive. We all drink water. And that’s what we have to protect … all creation comes from water. And without the without the water we all die. Without the bugs we all die. Everything has a balance.” (KI12)Many stories were shared about experiences with waterborne diseases, especially those causing diarrhoea. While one KI indicated that there were no recent occurrences of reportable waterborne diseases (KI18), another reported hearing of people contracting giardiasis and cryptosporidiosis and needing antibiotics (KI11). e issues , was refn = 26, 23%), unhappy , and angry . Other negative emotions identified included fear, stress, and confusion. Safety and happiness, which were also identified, may be seen as counterintuitive. However, the declaration of a BWA was seen by some to have inadvertent benefits. These included government awareness and facilitation, clean bottled water to drink, health protection, communication, and strengthened relationships:“I think the project as a whole has actually brought everybody together uh, more closely because uhm, there’s a lot of, there’s a lot of action … I think it’s just sort of brought everybody together to, to work on the solution, so it’s, it’s been a positive experience.” (KI17)Most respondents described their emotional responses as worried .Several solutions to the ongoing water issues were identified by survey respondents, Elders, and KIs. This is unsurprising, as it indicates a variety of valid avenues through which remediation can occur and through which individuals want to see action taken.“we talk to the to the entities, the spirits, entities whatever you want to call them, and they uh they set things right for us. And uh it’s something that science can’t explain. Sometimes I can’t explain it. But it happens.” (KI12)One solution was to resolve the BWA in traditional ways, such as turning to Mother Earth (E6), Elders (E8), or spirits:Installation of point-of-use water filtration systems was another solution identified, particularly for homes that could not be connected to the community water distribution system (KI17). Other, less-cited, solutions included an unidentified “filter” (KI12) and finding a water source other than the lake (E6).“Hooking up with the city of {name} is like bang, they’re there. They’re trained, they’ve got their qualifications they don’t go into a water plant unless they are qualified” (KI3)Cleaning the lake or stopping pollution was another solution  that included upgrading septic systems on the reserve (KI5). A role was identified for government in terms of involvement in finding, funding, and implementing a solution, partly because the reserve did not contaminate the water in the first place (E4). However, others saw this as requiring not only money, but also trust between the community and the government (KI5) and the nearby town (KI18), as well as a continued commitment to address BWAs on reserves . The solution articulated most frequently was to pipe water to the community from the closest town:n = 9). Though it would require less time and financial resources, piped water from the city was not always seen as the preferred solution over a community water treatment plant. One survey respondent illustrated this in a free-text comment:“I hope that the water is drinkable someday … With the agreement to be connected to the {name} water system, I hope the work starts as soon as possible. I do however, think that we should have gotten our own water plant instead of connecting to {name}.” (S007)It should be noted that this reflects an ongoing planning process that started after this study began. Many KIs noted that this solution was faster and less expensive to implement than other options such as upgrading the existing water treatment plant to meet provincial standards . However, risks were also identified - one KI was scared that their water would be shut off if they did not pay their bill (KI5). At a higher level, this partnership was seen to create a reliance on the town as well as an undermining of autonomy. Other potential risks were identified, but seen to be mitigated already. For example, ISC was expected to bear the costs , and the current water treatment operators were expected to retain their employment (KI19).“at the end of the day [to] have clean, safe drinking water for our membership so they could actually have that luxury of going to their tap, opening it up, and having a drink of water.” (KI19)Regardless of the final solution, there is an overwhelming desire:Research findings were reported back to the community in the form of an oral presentation and discussion, a written report, and a photo report, as requested. The community used the written report during negotiations with the closest town and ISC, which ultimately resulted in an agreement between the town and the community regarding the terms and conditions to connect the community to the municipal water treatment plant, and a commitment from ISC to cover the full cost of water usage by the First Nation, in addition to the original capital and maintenance cost of the infrastructure. Well drilling, for those who were unable to be connected to the piped water, will be started ahead of schedule. Originally the timeline for these connections was uncertain. Members of the community have postulated that this was ushered along faster than anticipated because of the unfairness between those who have and have not that emerged as a result of this research. In addition, the report helped the community health department identify the need for more bottled water for distribution and influenced the structure of bottled water delivery.Census data from 2016 indicated that 300 people 15 years of age or older lived on the reserve. Of those, 80 27%) were between 15 and 24 years old and 155 (52%) were 35 years of age or older [% were beGiven that, in general, women are more aware of the health implications of poor water quality, the differences in reported adherence to a BWA between men and women appear, on the surface, to be counterintuitive. There are several possible explanations for this finding. For example, a body of literature indicates that women have more ethical intentions than men, meaning they would be less likely to lie in their survey responses (reporting bias), although this is debated . It may Disconnects between reported adherence and practices may indicate a lack of understanding about the best practices to protect health under a BWA. Based on this lack of understanding, educational programs about practices that pose a risk to human health, and what one should do instead, are encouraged. Though this has the potential to benefit everyone, education aimed at women may have a larger impact given the gendered differences identified in this study.With respect to differences in BWA impacts between younger and older respondents, younger people spend more time interacting socially . If the While self-reporting of illness is not always reliable , under-rThe consideration for animal life points towards the equal importance of all living things , the strThe differences between those who have and those who have not is starker when it comes to a basic necessity such as water, even within a community. This may make it more difficult, but all the more important, to close the drinking water access gap between on- and off-reserve communities, especially given that Indigenous people in Canada make up the majority of the 1% of Canadians currently without access to improved drinking water  requiredSome general methodological limitations were identified through this research process. First, the survey response rate  was lower than anticipated. Though surveys were disseminated to every adult, in an effort to give everyone a voice, many homes appeared to return one survey that was intended to be representative of the knowledge, actions, and beliefs of all adults in the residence. While response rates were incentivised through a draw for a tablet and potential respondents were reminded of the deadline, the desire to provide a household-level response was clearly stronger for some people. Additionally, as previously mentioned, discussions regarding a pipeline from the town were already under way during the data collection; this may have dis-incentivized people from participating as a potential solution had already been articulated. Secondly, while it was anticipated that some potential KIs may have felt uncomfortable participating or sharing sensitive stories because of the otherness of non-Indigenous members of the study team, some KIs may have been uncomfortable participating or sharing with the community research associate because this individual was also a community member. Allowing interviewees to choose which of the facilitators were or were not present during their interviews mitigated this limitation.The low response rate as a sub-set of an already small population would suggest that the findings have limited generalizability within the community. However, during the co-analysis process with Chief and Council, many findings resonated with community challenges and experiences. Finally, although these findings represent the health, social, cultural, and economic costs and consequences to this particular First Nation, First Nations’ traditions and Traditional Knowledge varies. Thus, the results are not generalizable to all First Nations, but some elements are likely to resonate with other communities navigating life under a DWA.A key finding that emerged from this research is that DWAs negatively impact multiple facets of every-day life. These impacts vary according to age and gender and may affect an individual’s ability to consistently adhere to the advisory. This finding has implications for education and interventions. For example, women, and particularly mothers of young children, require tailored information to keep themselves and their families safe, as well as additional support to reduce the physical and time burdens placed upon them by DWAs. However, not all impacts were considered negative. Indeed, the existence of long-term DWAs drew attention from outside the community, which ultimately led to dialogues, resource allocation, and change. Some of this change was in response to this research project. Specifically, the findings were used to successfully advocate for improved drinking water for the community.Additionally, benefits of participatory research and community ownership include enhanced local research capacity, and increased awareness of, and desire for, research to inform decisions. The elimination of DWAs on reserves remains a priority for the Government of Canada but needs to be expanded to include those who are not currently served by a community drinking water system. Communities will need to continue to advocate for their basic human rights to clean water and their rights as First Peoples to govern and guard their water and, by extension, the environment. The messaging that comes from research conducted in this way reminds leaders, funders, and partners that there are actual people with voices and stake in these issues – it is their health and culture on the line. There is power in the narrative that emerges because it humanizes decisions about local drinking water security.Additional File 1. Survey Instrument. This document provides a copy of the survey instrument distributed to eligible community members. The survey consisted of four short sections that focused on: 1. basic information about the respondent; 2. knowledge of the BWA; 3. water sources and uses before and during the BWA; and, 4. impacts of the BWA upon the respondent’s life.Additional File 2. Interview Instrument. This document provides a copy of the interview instrument used to elicit contextual information from key informants and Elders. The interview instrument contains twelve interview questions or prompts.