Student stereotyping of non-native English-speaking teachers is a common focus of research and there is a paucity of studies targeting trilingual students of multicultural backgrounds. The present study aims to investigate the dimensions of trilingual Chinese heritage undergraduates’ perceptions of English teachers from Kachru’s stratification of native-English-speaking (Inner-circle), ESL (Outer-circle) and EFL (Expanding-circle) regions. A mixed study design was used to collect data including online questionnaires and an offline semi-structured interview. Quantitative findings indicate the subjects’ preference for native speaking teachers, together with a hierarchical ranking in teacher assessments according to race/ethnicity. Qualitative findings demonstrate that students are also less biased on racial grounds, considering all teachers are “qualified and good enough”, hence the “Inner > Outer > Expanding = Qualified > Unqualified” result. Multilingual and multicultural factors have been used to account for the mitigated linguistic stereotypes from sociocultural and political perspectives. Findings of this study challenge but nevertheless also confirm to some extent the traditional native/non-native dichotomy that manifests raciolinguistic traits and support Kachru’s stratification with statistical evidence. Educational implications are discussed to benefit future practice to further eliminate student prejudice and to better prepare native Chinese teachers of the English language. With the continued advance of globalization, despite headwinds such as the recent pandemic, tertiary education has become more diverse. This is not only the case in developed Anglophone countries like the US, UK, Canada or Australia, which have long been major destinations for “study abroad” for students worldwide, but also in some developing countries such as China. Some challenges have emerged inherent in international study in multicultural settings which have become new and pressing topics for research. This includes perceptions of teacher qualifications in regard to the teaching of English as a foreign language (EFL).There is near consensus that native-English-speaking students (NS) in Northern America harbor prejudice against non-native English-speaking teachers (NNS), rating them less favorably and less effective than their NS counterparts, no matter how effectively these teachers are prepared ,3,4,5,6.Teacher–student relationships, especially in a multicultural context, have been under-researched . As ChinScience has reported on the significant effect of homophily on a group’s acquisition of novice health habits [The teacher–student relationship is considered a dyadic social process that involves ongoing interactions of the two parties in classroom settings ; interpeh habits . In the h habits , showingh habits ,13,16,24Homophily scales have been utilized to investigate the teacher–student relationship; the correlation between homophily and the student–teacher assessments are often examined. Scholars have found that the teacher–student background and attitude homophily and interpersonal attraction positively relate to instructor’ immediacy , an attrA second generation of homophily scales has been proposed and tested with reasonable validity and reliability. This model consists of two dimensions of homophily, attitude and background, and has been proven to work better in line with the homophily principle. Further empirical studies are now anticipated using this second generation of such scales .When undergraduates are asked to rate their teachers, their assessments are every so often influenced by the teachers’ demographic attributes, such as race, language background, or gender ,9. InfluOn hearing samples of merely accented speech, negative attributions are associated with the NNS speaker who is then regarded as having low prestige and rated inferior in many ways, with this being termed a linguistic stereotype. Another pattern has been detected by Kang and Rubin that is termed Reverse linguistics stereotype (RLS) , meaningMeanwhile, NNS prejudice and (reverse) linguistic stereotyping has also been detected in students and the education discipline and industry outside the Anglosphere. In China’s mainland, the matched guise method revealed the RSL pattern with the Cantonese learner of English: after listening to the same recordings by an NS speaker, those who were told that they were listening to an NS speaker outperformed those who were told that they were listening to a Cantonese speaker in almost all listening comprehension tasks . Also, wIn South Korea, case studies and content analysis show that the English teaching workforce remains subject to the NS fallacy. Seo (2023) implemented a case study of the racialized experiences of a female Ugandan teacher of English who has an MA degree in TESOL and is an experienced English teacher, identifying herself as an almost native speaker. However, she reported being rejected by the formal accreditation process in Korea and having her qualification as an English teacher scrutinized and challenged . By examAlthough some scholars have recently detected that multiculturalism has a mitigating effect on NNS stereotypes , sAs the extant literature makes manifest, NNS prejudice creates at least two substantial negative consequences for students: first, an unfair psychosocial bias detrimental to the mental health and the whole-person education of these students, and second, impediment of both teacher–student relationships and students’ academic performance.Although the NS/NNS dichotomy has been well established and closely examined, some studies have challenged its dominance in related research designs. A conclusion is easily drawn from a closer examination of the matched guise design that the underlying bias is based upon not only the NNS stereotype, but also a racial/ethnic ideology, as when the raters prioritize the so-called NS speaker, it is usually a Caucasian face—a “White” identity—that triggers a higher evaluation. For example, in the Alsace region of France, African-American English was associated with positive human characteristics, but also a lack of education . As GhanAs previously mentioned, when plotting an NS/NNS-dichotomy-based language attitude or interpersonal relationship investigation, especially in the matched guise scheme, it is more often the racial/ethnic identity that is featured, covered, or guised by its linguistic surface. NS preference itself might be a guise of racial discrimination. As pointed out by Lee and Canagarajah (2019), the binary NS/NNS dichotomy only reifies monolingual ideologies, in spite of all the efforts to empower NNSs . Cheng eKachru (1992)  innovatiThis theory has ignited much debate, criticism and challenges, for example, for its implied “correctness” of the English used by the Inner circle , the ambThe Outer-circle SOCs are appropriate subjects to fill the gap of WE studies. Theoretically, research on these students will contribute to the WE literature because they usually have real encounters with teachers of all three Circles, and such research will be trusted to produce real instead of imaginative assessment to teachers; meanwhile, many of EFL students of the mainland only have had local (Expanding) EFL teachers throughout their studies, making them less qualified to comment on the Outer- and Inner-circle teachers. Also, practically, although trilingual speakers might not be difficult to find, it is still always easier for researchers to collect data from a group of students who study and live together. Furthermore, raciolinguistics suggest that race and language should be observed together on a much more “macro context” level, involving political and economic systems, among others ,11. UndeA number of empirical studies have been implemented to inspect the influences and extents of WE in education. For example, it is revealed that features of Indian and Chinese English, representing the Outer and Expanding circle, respectively, affect the student interpreters’ performance of consecutive interpreting , and thato investigate students’ linguistic and professional assessment of English teachers of the three Circles;to examine students’ background and attitude homophily perception of their teachers and their correlation with the assessment; andto observe the effects of gender homophily on student perceptions on the teachers.This present study aims to observe the assessment made by trilingual Chinese heritage students from the Outer-circle regions of their English teachers of the Three Circles, with a triangulation design of the use of homophily scales, teacher assessment scales, and a third-party interview. Given the previous discussion regarding the potential mitigating effect of multiculturalism on NNS stereotypes . These students were in their last English class of their first academic year in university. A convenience sample of 48 females and 48 males agreed to be part of the study.The sample consisted of students who came from Singapore, Malaysia, India, Hong Kong the Philippines, South Africa, etc., and “returned” to China’s mainland to “seek their roots”. These particular ESL countries and regions consist of citizens representing multiple languages and races within their communities. The participants were verified as trilingual speakers who use English as their second language and have had NS as well as NNS teachers previously, and had before been required to acquire a relatively higher command of Mandarin Chinese (HSK level 5 and above) for tertiary education. They also reported speaking fluent Malay, Filipino, Hindi, Hakka or Cantonese, and having had NS teachers for English courses in primary or secondary education. They were all between the ages of 18 and 20, and only expressed binary gender identity, with no one choosing a third gender preference. They majored in 11 different disciplines, including science, engineering and humanities, and were instructed by Chinese EFL teachers for their English courses.NS teachers (in your former experience), teachers from your own nationality/race (in your former experience), and Chinese teachers (in your freshman year experience). For the gender effect tests, each group of both teachers and students is further divided into sub-groups of male and female. The questionnaire is distributed using questionnaire app Wenjuan-Xing, which can be further connected with the app Wechat for distribution and data collection.A mixed study method is used, with a 3-section online questionnaire for quantitative data and a face-to-face interview for qualitative results. The questionnaire is prefaced with an introduction and begins with a first section that collects the students’ demographic data in terms of age, gender, and university details. Both sub-questionnaires, i.e., the second and third sections, feature homophily scales and teacher assessment scales, respectively, both having passed the Cronbach test (Cronbach’s α = 0.824 and 0.853). For each of the items in the 2 and 3 sections, a five-point Likert scale  is used to elicit students’ answers. Teachers are classified into 3 groups for student evaluation: The first section of the questionnaire is homophily scales. This study copies and modifies the homophily scales of McCroskey et al. (2006) , which haffinity, teaching competence, English competence, accent standardness, and an overall evaluation.The second section of the questionnaire is teacher assessment scales. Following and modifying Kang et al. (2015) , the teacan you give us examples”, or “do you have anything else to add” and “why do you think that…”:1.Do you fully comprehend the content of the questionnaires, including background, attitude, gender, race, and regional homophily?2.From these five perspectives, do you have any specific thoughts or other supplements on the teachers you had (from these three different regions)?To further explore perceived homophily, 8 students  who volunteered to be interviewed participated in semi-structured interviews. They are between the ages of 18 to 20 and are from Hong Kong, India, Malaysia, Singapore, and the Philippines. Six of them major in social sciences and two are engineering majors. To decrease any undue influence by having the faculty interview the students, a peer is recruited to interview each of the students in their residence halls in Chinese. This occurred a week after the questionnaires were completed. All interviews are semi-structured and follow a common interview protocol, carried out personally and individually and recorded with a digital audio recorder. Two questions are asked with follow-up prompts to gain further insights into their initial responses, such as “The first question addresses the concept of homophily and raciolinguistics, while the second allows deeper conversation regarding the topics in the first question. The interviews are conducted in Chinese, recorded and then later transcribed. They take place in a safe and relaxed location at the participants’ residence hall.Following the approval of our study by the institutional review board of the first and third author’s college, students participated in the survey at the end of their last English class of the freshman year. Before the online questionnaire was distributed from the questionnaire app Wenjuan-Xing to the social media app Wechat, they were given the opportunity to choose whether or not they were willing to continue with the questionnaires. They were also asked if they would like to participate in an interview. Those 8 who were interested participated.Data analysis occurred in two steps. The first involved analyzing of the quantitative data from the instruments, while the second involved a content analysis of the 8 interviews. Quantitative data: Questionnaire results were analyzed using one-way ANOVA, correlation analysis, and paired-sample tests in the SPSS Statistics 26.0 software package. First, one-way ANOVA tested to what extent the SOCs rated teachers of the three Circles differently. Second, correlation analysis was adopted to see the correlation between the SOCs’ homophily perception and their teacher assessment results. Finally, the paired-sample tests were implemented to address the gender differences between male and female SOCs on their ratings of the teachers.background, attitude, gender, race and regional homophily, according to the concepts within the scales that included affinity, accent standardedness, teaching competence, and overall evaluation. These categories were applied to the students’ responses to note if these particular categories were found, and, if not, what other patterns were noted.Qualitative data: Semi-structured interviews were conducted in the study to triangulate the quantitative results and to obtain a fuller and deeper understanding of the perceptions and feelings of the participants. The recorded interviews were transcribed, read through, and double checked by the first and the third authors. The transcripts were analyzed for patterns and then themes. A constant comparative method, etic approach, was used to note similarities and differences within each of the 3 categories of teachers and of the 2 genders of SOCs across all interviewees. An etic approach was used to examine the data initially in regard to the two questions on gender homophily and racial discrimination. Then, the data were analyzed using an etic approach that applied the factors of affinity  = 13.396, p = 0.000), teaching competence  = 29.121, p = 0.000), accent standardness  = 96.449, p = 0.000), English competence  = 74.343, p = 0.000), and overall evaluation  = 12.749, p = 0.000).The results of One-way ANOVA tests and repeated contrast measures are reported in affinity across the three groups of teachers.These results show that the SOC assessment of teachers of the three Circles is in line with the linear order of the concentric Circles. The students still regard Inner-circle teachers superior to their peers of the Outer-circle and the Outer-circle superior to those of the Expanding-circle. An NS preference or a racial/geographic difference prevails as a hierarchy in SOCs’ perception of teachers. attitude homophily has extremely low and positive correlation with the overall evaluation and teaching competence . However, background homophily has a medium level or a slightly negative correlation with the dimensions of accent standardness, English competence, and overall evaluation .The Pearson’s two-tailed tests as in  indicateThese results show that the homophily factor has weak albeit some correlation with teacher assessment. This is especially the case with attitude homophily, in which there is no distinctive difference across teachers from the three Circles, as can be seen in teaching competence , accent standardness , and overall evaluation ; they assign much lower scores to male teachers than female teachers. On the dimensions of affinity and English competence, the differences are not obvious .The paired-sample tests  revealedteaching competence , affinity , accent standardness , and overall evaluation , they actually even assign the same scores for English competence .Female students do not rate male and female teachers noticeably differently. Despite minute differences regarding The results derived from questionnaires show that male students favor female teachers while female students do not show gender preferences; these findings are also supported by qualitative data collected from the interviews.In the next section, the results from the qualitative interviews are presented. These interviews were analyzed using the concepts from the instruments, as well as the two research questions.Two themes can be concluded from the qualitative data. The first is the support of the male SOC gender heterophily, as discussed in the previous section. Gender homophily was also noted in the qualitative interviews with male students favoring female teachers, and the female students expressing no gender distinction. For example, two male students stated the following:Chinese male teachers usually have accent problems, but the lady teachers are usually speaking beautiful English.” “We all know the lady teachers are more careful.”“they are just good anyway.Male teachers may not explain the details of English as well as the lady teachers do, but ”Meanwhile, a female student expressed lack of preference: “These findings support the quantitative findings as well regarding gender homophily.Hong Kong’s education is more or less related to the UK’s so our (HK) English teacher is also good.” “Not all, but most teachers in Singapore are excellent English speakers, close to native.” “The second key pattern is the support for the NS preference, i.e., racial/geographical heterophily and for the Three Circle theory in many aspects. This brings an addition to the NS preference. In the perceptions of Chinese heritage SOCs, native English is still considered “best”, ESL areas are considered secondary, and English spoken by Chinese people in the EFL region of China is considered the lowest among the three. This recognition of NS preference can be seen in the following quotes:These findings support the research regarding the NS preference in the Inner-circle while expanding our understanding that the third circle of Chinese EFL teachers face more prejudice than others. The next section speaks to the particular factors examined in the instruments.affinity, participants stated that stronger criticism is imposed on both Inner-circle and Chinese teachers. This is reflective of the racial and geographical heterophilia discussed earlier. Comments focused on the quality of the relationship between teacher and students as represented by the two comments below.In regard to the first factor, The western countries are more open… the teachers are like friends to the students. It’s so not the case in Asia, coz we value ‘zun shi zhong dao ’, so the teacher–student relationship is always rigid. It’s in our history.” “Most teachers are good already. But the mainland has a huge number of students so the teachers only pet those who are good with study… the poor students feel ‘abandoned’.” “These comments can also reveal the participants’ perspective as foreign-born Chinese students returning to the homeland. But they still reveal a prejudice against their Chinese faculty.accent standardness and English competence, were the two qualities that also reflect the preference for native speakers, but increase allowance for Chinese teachers who have advanced education in an English-speaking country. The two quotes below illustrate this point. The first quote emanates from outside of China, but does show a bias against the Chinese English faculty.The next factors, I won’t say my teacher in Singapore is as good as the Canadian. She received her MA in Canada and she said she was afraid that her English is not as good as the Canadian. But she’s still better than Chinese teacher. Lady teachers usually don’t have any problems.” “No problem with that.European and American teachers are of course the best, for they are native. Our teachers back in the Philippines are also having standard accent; we use American education system in my hometown; it can’t be as good as the American or British for sure. I can understand the Chinese teachers’ accents. ” “Though not a direct bias in this second quote, she still points to the preference for an “American accent”. In both quotes, home experiences have shaped a preference, but also slight bias against the Chinese English teacher.teaching competence, was a theme that addressed a preference for a more “Western-speaking approach” over rote-learning assignments. For example, the first quote is reflective of a preference for the American style of classroom teaching, while the second quote notes the increased emergence of this approach in some of the Chinese-teacher-taught courses, and the third is a rather positive comment on the special expertise of Chinese EFL teachers.The next factor, Chinese teachers always ask us to memorize English words or even paragraphs. That’s silly and annoying. I am sometimes under pressure. Back home , we always study English so we are more natural with the language. And English is like Malay in many ways. We use English every day. I think the native teachers will have some easier ways to teach. Americans are known for their flexible classes, right?” “ different than before now. They are not bad. They must have gone through the language study as a foreign language themselves, so they know what’s difficult for us, and they how to teach others.Mainland teachers are” “The English teachers will mark at places where you made a grammatical mistake, but they didn’t make me understand why. Now the Chinese teachers are very good at giving a lot of examples to make grammar understandable. It’s their strength.” “Again, these comments could also reflect the participants’ role as international students who have experienced different instructional strategies back home. All international students must make the same adjustments, but some of the participant above have points of reference due to previous experiences with Chinese teachers.overall evaluation of the teachers. Again, this reflects that the students are accepting of the Chinese teachers, but there is still a preference for native-speaking English teachers. The comments below reflect this qualified acceptance of the Chinese teachers.The last factor concerns the  they are good enough.I think all teachers are just good and most of them are just kind. Our Chinese teachers may not speak as well as the native teachers, but they can make it to teach in the university, so it already tells us that” “There is no high or low about the teachers. Everyone has his or her strengths and weaknesses. Of course, native will be best. It’s English anyway. Actually, It’s not the teachers that matter, it’s that I don’t love studying that much. Haha.” “they are qualified for us. My friends told me that because our tuition is higher than that of local students, the school gave us the best teachers.Real difference lies in the diploma the teachers have. In India I went to an international school so most of my teachers had high diplomas. Here in China, since we are talking about university teachers, who should have PhD degrees and won’t be too poor, it’s easy to come to this conclusion—” “good enough”, “just good”, “best teachers” and “qualified”, as can be seen from the above underlined statements. These comments though are coached in the multiple experiences of the participants with NNS and NS English teachers while back home. Despite their multicultural experiences and apparent acceptance of their Chinese English teachers, as discussed earlier, they still carry similar biases to their Chinese native colleagues, as evidenced in previously discussed research.So far, the formation of a three-layered hierarchical opinion is very evident, supporting the native speaker fallacy in many measures. However, a third and also most important theme is the discovery that, despite all the differences, Chinese teachers are seen as “Inner > Outer > Expanding”, supporting Kachru’s WE theory while stressing the differences among the three groups; Second, the Expanding-circle teachers, especially mentioned as university teachers, are also acknowledged as “qualified and good enough”, despite the inferiority in ratings compared to those in the other two circles. As shown in Inner > Outer > Expanding = Qualified > Unqualified”  for competence, warmth, and perceived positive attitude of the speaker, revealing a clear background homophily [Outer > Expanding > Inner” from almost all the other assessment factors.The teacher assessments of the Outer-circle region participants of our study portray a homophily-mitigated NS preference, and the negative correlation between background homophily and scorings on omophily . More inomophily . When inmost of them are just kind” . Gender heterophily is detected with male students. Binary gender is one of the key variables in teacher–student interactions [While background homophily might have some effects on teacher preference, attitude homophily has only a slight correlation with ratings. This is further confirmed by the qualitative data that “ractions  (p. 6); ractions  (p. 202)ractions  (p. 59).ractions  (p. 20),She does have an accent, but…” [When probing into students’ language attitudes in educational contexts, especially in recent years, Lee and Du 2021)  detectedt, but…” , a mitig  detectet, but…” ,41,62,63Multicultural experiences have shaped student perceptions. In this current study, the participants are invited to rate the teachers based not on their imagination, such as in the matched guise studies ,15, but A recent online survey in Australia collected university students’ perceptions of speeches made by either a Chinese guise or a Caucasian guise, and there appear no statistically significant differences between student responses. Because this survey was implemented in Australia, the scholars decided that this difference from Rubin’s findings , though teaching competence and overall evaluation. Researchers have proven that multicultural and linguistic interventions work efficiently to moderate the NS preference for both NS and NNS learners. Kang et al. [Active classroom teacher–student interactions throughout the academic year might also contribute to the positive feedback from students, especially on the scales of g et al.  reportedteaching competence and overall evaluation—is the result of a one-year exposure to multicultural and multilingual environments. In addition, an important factor that should not be underestimated is the Chinese culture identification policies designed and implemented by the Chinese government and universities. In year 2021 alone, there were approximately 100 National Social Science grants disbursed  targeting both the improvement of Chinese cultural integration and also the relevant research of the overseas Chinese and Chinese people of Hong Kong, Taiwan and Macao. In university classrooms, there are both English and Chinese medium courses that introduce Chinese wisdom, culture, traditions and history. Students share both content courses and language courses with local students in a hope to “merge” them better, thus providing a considerable amount of cross-cultural interaction. Outside the classroom, universities have organized “root-seeking” cultural journeys all around China for Chinese heritage students. There are also a variety of culture- or language-oriented competitions in which students are encouraged to join free training courses and compete in demonstrating Chinese knowledge acquisition, such as in Chinese calligraphy, painting, and opera competitions. For all these extra-curricular activities, the Chinese government allots special funds, recognizing that China values the experience of these students. In daily lives, different from US universities where students are encouraged to live off campus, Chinese international students are offered on-campus dormitories where they actually share a living experience with the local students. All this friendliness in Chinese policy helps to successfully achieve a more friendly and less biased attitude within SOC students towards China in general, and thus an improved teacher–student relationship more specifically.In the case of young SOCs in this study, it is convincing enough that their less negative and more objective and sometimes even positive attitude towards the Chinese EFL teachers—which is manifest especially in their interview comments on the Inner > Outer > Expanding”. This result, which supports the WE theory and brakes the NS/NNS preference, is still exhibiting raciolinguistic features: if both Outer and Expanding circles are bracketed together and termed “non-native”, the NS preference becomes obvious. This is especially obvious in accent standardness and English competence that “(his teacher in Singapore who) received her MA in Canada…said she was afraid that her English is not as good as the Canadian”  and that “European and American teachers are of course the best” . The quoted Singapore teacher’s self-evaluation is exactly in line with the psychological inferior complex that Fanon [Despite all the above discussions and the emphasis on the working mechanisms behind the modest mitigation of stereotyping of the SOCs—compared with many other surveys on student–teacher assessment in extant literature (as mentioned in the previous review of the literature)—what cannot be ignored by the researchers and what both the quantitative and qualitative result are revealing is still the hierarchical descending assessment of “at Fanon  concludeat Fanon , and thiat Fanon .A closer look at the backgrounds of the eight SOC interviewees displays that they are all from previously colonized places: Hong Kong, Singapore, the Philippines, Malaysia and India. The ESL regions are the regions that “have passed through extended periods of colonization”  and thisAs the SOCs in this study actually assess their teachers based not on their imagination but on actual experiences, there arises from these results the fact that both the educators’ and the students’ professional/academic development call for more attention from Chinese EFL teachers.teaching competence and overall evaluation, they themselves have made great strides with increasing the number of higher education degrees from overseas and improving English levels. Perhaps, however, based on student feedback (consider “rote-taking skill” and “(not) open” up enough to the students, etc.), expanding and diversifying the instructional style would help this particular group of students, as well as all students with NNS perceptions, and thus improve the student–teacher relationships, and also advance the levels of learning. Activities like participation and communication in training sessions, self-assessment and peer assessment might be effective to help [First, though Chinese teachers were rated lower on most dimensions measured in this study, on top of the fact that they also receive positive feedback especially on  to help  (p. 600)Second, collecting and examining feedback from the students is crucial . While tThird, the native speaker fallacy and racial heterophily discrimination can be dangerous to both students and teachers. Not only does it contribute much to the NNS movement in the TESOL discipline , but it Fourth, as mentioned earlier, well-designed interventions should be included throughout language courses as they are proven to work efficiently to mitigate NS preference. In fact, even a small amount of intervention can serve well. For example, before presenting the two groups of listeners with the same audio speech made by a single French speaker to rate, Reid et al. (2019)  told then = 96), so future studies might employ participants from more diverse origins. Internet and mobile apps might work as a far-reaching tool for data collection. Second, only the Outer circle has been chosen for the convenience of study: future research might be able to compare student perceptions across the Three Circles. Third, as most matched guise studies yield results demonstrating Reverse linguistic stereotype which may be covert to some learners, future studies might follow the common matched guise design and include listening comprehension tests in the survey so as to examine the potential impact of teacher assessment and homophily on language acquisition performance.As a tentative study of SOC students, our investigation features several limitations that future research should address. First, the scale of the study is limited: through simple sampling, we only collected students from four Outer-circle countries and Hong Kong (The Chinese heritage undergraduates’ English acquisition processes, especially the ways in which it is affected by their perceptions of English teachers of the Three Circles, is under-researched. As this diaspora of students spread globally, it is hard for scholars to target and design a study. In fact, Chinese heritage undergraduates are actually very typical language learners possessing trilingual abilities and multicultural experiences, and they are under special care of the Chinese government. These features help them achieve an attitude more flexible and tolerant than a simple NS/NNS dichotomy might suggest, thus signaling a reasonable student–teacher relationship. This study is one of the first steps to investigate the students’ assessment of English teachers according to the Kachruvian stratification of Three Circles, and its results mitigate the NS/NNS stereotype and support the WE theory with statistical evidence. With the increasing trend of globalization and cross-cultural exchanges and with the unremitting efforts of educators and researchers, it is promising that more students and teachers will be less subject to the native speaker fallacy and raciolinguistic stereotypes and will adopt a more objective and positive attitude towards qualified English teachers of all races and regions.


Preliminary research based on everyday observations suggests that there are people, who experience severe fear when addressing others with their personal names. The aim of this study was to explore the extent to which this hitherto little-known psychological phenomenon really exists and to investigate its characteristic features, considering the everyday experience of not being able to use names and its impact on affected individuals and their social interactions and relationships.In this mixed-methods study based on semi-structured interviews and psychometric testing, 13 affected female participants were interviewed and evaluated using self-report measures of social anxiety, attachment-related vulnerability, and general personality traits. An inductive content analysis and inferential statistical methods were used to analyze qualitative and quantitative data, respectively.Our findings show that affected individuals experience psychological distress and a variety of negative emotions in situations in which addressing others with their name is intended, resulting in avoidance behavior, impaired social interactions, and a reduced quality of affected relationships.Alexinomia, meaning “no words for names”.The behavior can affect all relationships and all forms of communication and is strongly linked to social anxiety and insecure attachment. We propose calling this phenomenon  I couldn’t address others with their names, and it took extreme efforts to try. I became really conscious of it, when I met my husband. I wanted to address him by name, but I could not do it. That’s when I realized that it’s a problem, that I can’t say other people’s names.”knowing a name but being unable to use it in personal communication. For affected individuals, it is impossible to say, for example, “Good morning, Maria.” or “Armin! Great to see you.” They experience acute anxietiy and a variety of other negative emotions in social situations in which using a personal name is intended. We refer to this undocumented psychological phenomenon as Alexinomia. Alexinomia is a compound of the Greek loanwords á  + λέξεις  + óνoμα  and literally means “no words for names.”In this article, we present an unknown psychological phenomenon characterized by Personal names—in the context of this article defined as first names, given names, and forenames, rather than last names, family names—are of substantial social importance . We use The significance of using names in personal conversations has been highlighted in research in various fields. In education it has been claimed that teachers knowing and using the students’ names creates an atmosphere of trust and community in the classroom that facilitates learning . It has From a psychological perspective, the subjective experience of fear related to addressing others by name was preliminarily described by To address the most fundamental open questions related to alexinomia, an explorative mixed-methods study was employed that expanded qualitative  with quantitative  data. To identify the experiential grounds and constituting factors of alexinomia, we employed a descriptive approach to inquiry using qualitative semi-structured interviews and inductive content analysis.In addition, a psychometric test battery, including a set of standardized psychological self-report questionnaires, was administered to test for links of alexinomia with already known psychological constructs. Given the social importance of names and the social nature of the situations in which alexinomia seems to occur most frequently, social anxiety was considered a likely candidate to underly the problem. The role of names in identity formation  and the By expanding qualitative data with already known psychological attributes using quantitative parameters, our intention was to provide an as comprehensive a picture of the phenomenon as possible. The method and results sections are therefore divided into qualitative and quantitative procedures and results. In the discussion, we draw links between the different levels of data and give a summarizing interpretation that allows a first systematic conceptualisation of alexinomia.via the author’s personal website1 over the past few years. At the time of data collection, the database included about 80 entries of affected individuals from all genders and many countries. Most contacts belonged to the group of young, female, German-speaking adults. Hence, for the purpose of this study, we recruited participants from this largest group of available contacts. The sample size was determined after iteratively analysing the contents of the first interviews. Once the central conceptual categories had emerged and started reappearing throughout most of the interviews, we stopped the sampling process.Thirteen German-speaking women with a mean age of 28.1 years (range: 18–40 years) participated in the study. Participants were recruited from a patient database created by one of the authors (L.W.) in response to letters from affected individuals that were received Out of these 13 participants, 11 indicated noticing the problem of not being able to use names daily or multiple times per day. Nine participants reported noticing it for the first time as a child or teenager. The degree of psychological strain caused by the problem was rated as 5.7 on average . A summary of participants’ socio-demographic data and descriptive data with regards to the symptoms of alexinomia are shown in Semi-structured interviews were conducted with all participants to explore in depth their everyday lived experience in relation to using names. An interview guide including a set of open-ended questions was prepared before data collection that was flexible as to the sequence of questions and adapted according to the responses of the interviewees. The interview guide was structured into three main topics: (1) General experiences with the phenomenon of having difficulty addressing someone by their name, (2) coping strategies and (3) self-theories on alexinomia-related symptoms. This interview structure ensured that participants could develop their narratives openly to maximize our understanding of the phenomenon by allowing participants’ own frame of reference and concepts to unfold naturally . Where nHow often do you experience these difficulties?), history (When did it first occur?), personal psychological strain (0 to 10), and interest in a therapy to treat the problem.At the end of the interview, the interviewers asked for the relevant socio-demographic data that would allow for a sufficient contextualization of the interview data. The following factors were addressed: age, gender, partnership, the highest level of education, occupation, frequency of experiencing difficulties with using names  Big Five Inventory BFI-2; : The BFIAll instruments are listed in The study was designed following a mixed-methods approach by which qualitative data as the primary source of data were expanded with quantitative data. This design allowed us to fully exploit the breadth of content and scope by using different methods for different parts of the study . TherefoThe two parts of the study were conducted in the following order: (i) interview and (ii) psychometric testing. Interviews were conducted for each participant individually with two interviewers (T.D. and L.W.). Due to the security measures in place at the time of the data collection caused by the Covid-19 pandemic, the interviews were conducted online using the video meeting software Microsoft Teams . Video and audio channels were used for the entire meeting by all parties. Audios were recorded using an external digital voice recorder  placed next to the interviewers’ computers. The video was not recorded. Participants were informed about the audio recordings prior to the start of the interviews. Participants were also informed about the general aim of the study and the interview procedure, stating that the interview will address how people with alexinomia feel and how it affects everyday life. Additionally, participants were informed about the GDPR-conform processing of personal data. Raw data audio files were kept on secure storage media at the university and stored locally and separately from any identifying personal data. Participants gave written consent to all described procedures.https://onlinebefragungen.sfu.ac.at/. It included five standardized psychological instruments  were applied. Personal data  were replaced with pseudonyms.The interview data were coded according to Mayring’s procedure of an inductive, summarizing content analysis , 2015. MThe inductive, summarizing coding process was structured into the following seven steps : (1) DefFurther, the category scheme was summarized by revising the list of categories and generalized again by combining categories with similar meanings, thus identifying main- and subcategories. This step was repeated multiple times to carve out the main factors of the phenomenon.The category definition focused on the identification of all relevant intra- and inter-personal factors characterizing the phenomenon of having difficulty with saying names in everyday practice including interactions where it occurs and their subjective experience, coping strategies when it happens, and self-theories on the development of the difficulty throughout the lifespan. To ensure reliability, two researchers coded the first interview. From this first interview, the initial main categories as well as the subcategories were created and on this practice the coding guidelines for the analysis of further interviews were developed. According to these guidelines, all other interviews were coded independently by two researchers.t-tests, one for each subscale of each instrument for which norm data  were available. These instruments were the BFI-2, DSI, and ECR-RD12. Questionnaires using cutoff-scores to indicate the presence or absence of a psychological trait  were analyzed separately for each subscale using one-sample t-tests tested against these respective cutoff values. The alpha-level was set to 0.05 for all analyses. All p-values were corrected for multiple comparisons (Holm-Bonferroni) across the entire data set. Hedges’ g is reported for all analyses as a measure of effect size.To analyze the questionnaire data, participants’ test scores were subjected to a series of summary independent-samples We identified the following four main categories that, based on our data, constitute alexinomia: (1) Factors of subjective experience when trying to address others by their personal names such as emotional states and physical reactions, (2) general characteristics of alexinomia such as first occurrences, affected relationships, and affected forms of communication, (3) effects on relationships and on communication in relationships and strategies to cope, (4) vulnerability factors based on biographical information and current relationship patterns. All participants in the study reported having problems with addressing persons by their names. When, for instance, asked to describe the problem in their own words, they said:It has always been like that, as long as I can remember, in kindergarten, in school. I couldn’t address classmates with their names, and it took extreme efforts to try. I used to think twice about whether I really needed to say the name, whether my question was important enough or not. (…) I then became really conscious of it, when I met my husband about one and a half years ago. I wanted to address him by name, but I could not do it. I wanted to, but I couldn’t. That’s when I realized that it’s a problem, that I can’t say other people’s names. (…) I tried to practice his name alone, because I thought maybe it’s because I’m afraid that I pronounce it wrong or something like that, and I still couldn’t do it. And yes, even to this day it’s still difficult for me to address him by name, I always say “you” or “hey,” things like that (Participant 3).It’s very difficult for me to call someone by name, but also when I talk about someone, to say the name. (…) I always say “I was walking with my neighbor” or “I meet with my fellow student.” I wouldn’t say their first names. That’s when I really notice how difficult it is for me, no matter whether it’s a good friend or not such a good friend, to say the name. (…) To give an example, I was helping in the field to dig up potatoes. We were up at the back of the harvester and my ex-boyfriend was driving the tractor. And then the ladies who were also helping asked me to please tell him to slow down, otherwise it’s going too fast. I was completely overwhelmed, and I shouted “Hey, hey, hey!”, because I just could not call the first name. He didn’t hear me and finally one of the other ladies then said his first name and he then heard that and stopped. So that was a situation where they actually hoped for me to tell him to please slow down. But I just couldn’t do it, I just didn’t call his name, I said “Hey, hey!”, I was like, I failed (Participant 8).in situations in which saying a name is intended, participants frequently reported experiencing negative emotions such as anxiety/panic, shame/embarrassment, regret/frustration, and feelings of inadequacy/failure. These feelings are often accompanied by unpleasant physical reactions that, for example, were described as “a tight feeling in the chest” (Participant 10) and were compared to how it feels to “touch someone” (Participant 11) and “to look someone into the eyes” (participant 11). In the words of participant 2:It feels almost a bit like the beginning of a panic attack. Like loss of control and nervousness, agitation (…) a feeling of discomfort, an “I’m about to be the center of attention” feeling or like when you have to give a lecture, like stage fright, really extremely uncomfortable and scary. It’s insecurity. Insecurity (Participant 2).Participants further highlighted what seems to be a complex relationship of the inability to say a name and the control of closeness and distance in a (often romantic) relationship. While about half of our participants reported experiencing forms of alexinomia in all their social relationships (7 participants), several participants reported that the problem became more severe the closer the relationship (4 participants) and many claimed that it is strongest in romantic relationships (10 participants). Saying the name of a loved one was frequently described as too close, too personal, too intimate, and thus overwhelming and emotionally exposing. Therefore, some affected individuals speculated that not saying a name could have the function of keeping the other person at a certain distance. This distance, however, puts strain on the relationship and affected individuals expressed a strong desire to be able to overcome it. Almost contrary to the above situations, for some participants using names was also described as distancing and impersonal, as if using a partner’s personal name would take away “the magic” (participant 4) between them and thus create an unwanted distance. Along these lines, some participants indicated the use of names deliberately to control the distance in a relationship. Participant 10 described the dilemma of a deep longing for closeness and worries about the vulnerability that would come with it as follows: “I’m not sure if I would be able to cope with this, this closeness that would then be there. The vulnerability that would then be there, although this is what I want so badly.” (Participant 10).Participant 12 addressed the complexity of the impact of naming on the experienced closeness or distance in social relationships:It’s strange, at first I thought that somehow it had something to do with closeness, but then I realized that on the other hand you can use it very well to maintain distance. It’s somehow this autonomy, closeness, distance, where that plays a big role, especially with hierarchies, like bosses or superiors, or in love relationships, where you’re kind of afraid of showing yourself vulnerable, where you think “oh, there is suddenly someone above yourself.” (…) There is also a bit of fear that it sounds funny for him because I might pronounce it somehow special or that he could hear my emotions because of me pronouncing it somehow differently. (…) To me, saying his name would feel closer, but when he says my name, I feel more of a distance. Because everybody calls me that. It’s nothing special (Participant 12).Affected relationships included mainly romantic relationships, close friends, and family. However, several participants reported experiencing alexinomia in all relationships, regardless of the level of closeness. Hierarchy seems to play a role in a way that the symptoms are more severe in interactions with persons of authority such as bosses, superiors, and teachers. For example:At school it was sometimes unpleasant to address teachers by name, especially those who were very authoritarian. (…) I couldn’t say the names of people who were hierarchically superior. (…) In relationships with a power dynamic it is more pronounced (Participant 7).Some participants indicated that the severity of the problem also depends on the name in question. Unusual names, names that are difficult to pronounce, and names that are considered particularly beautiful or unattractive can make the symptoms more severe.Other factors that contribute to the name saying difficulties of our participants included the relationship to one’s own name, whether one likes to be addressed by name or not, and the general attitude toward naming others and being named by others. Most participants said that they liked to be addressed by name and that they considered it a sign of respect. Some participants, however, associated being called by the name with a certain seriousness that feels strict, cold, and generally unpleasant. Interestingly, even in very severe cases of alexinomia, there were usually certain individuals whose names could be said .Frequently, the symptoms of alexinomia extend to conversations with others about the person with the problematic name. For some participants however, the symptoms were limited to only direct personal conversations. Participant 1 described the situation of saying her partner’s name when talking to someone else about her partner while him being present: “With very great restraint and with a low tone, it works. But so that he almost doesn’t hear it. It’s unpleasant, but I somehow manage.” (Participant 1) In conversations with others, names are often avoided even if the respective person is absent by refering to their social role such as “my friend,” “my cousin,” etc. Symptoms can be less severe in written compared to verbal direct communication. About half of our particpants have no difficulty writing someone’s name in Emails and texts. For participant 1 it “just feels safer in writing.” Other participants on the other hand indicated avoiding names also in writing, for example participant 13 who prefers to use nick names, such as “sweetheart” to greet a female friend in a written conversation.Characteristically the signs of alexinomia were there from the very beginning of the affected relationships and, if untreated, were present throughout the entire duration of the relationship. Most of our participants reported that they recall having the problem since they were children or teenagers or that it “has always been there” (participant 11). In several cases, participants first noticed having the problem in their first romantic relationship.via eye contact, physical touch  or using “telepathy” (Participant 10). If none of these worked, several participants reported that they would rather stay silent and forget about the intended conversation than using the name. To give an example:Alexinomia affects communication in relationships in a multitude of ways. Instead of using names, most affected individuals reported starting a conversation without using a personal address or by using an impersonal address such as “Hey” or “Hi.” Often, they would wait for some time before saying something until they got the addressees’ attention I wait for eye contact. When sitting at a large table with many people talking, it’s sometimes a bit difficult. I really have to wait until he looks directly at me and then say, “Can you please pass me something?”. So stupid. Or just “You” or “Hey,” so rude actually. Or I touch him, tap him and just start talking. (…) Anyway, apparently I have done really well, no one has noticed until now (Participant 2).According to some participants, it sometimes helps to use nicknames or to say the name in a playful way (4 participants). Most participants, however, said that using nicknames was also not an option for them (9 participants).While these compensatory strategies can help avoiding names and hiding the problem successfully, alexinomia can put a serious strain on a relationship due to the distance and insecurities that it facilitates in both partners:With my husband, I notice that it burdens him. (…) He spoke to me directly about it and said that he thinks it’s a shame that I never address him by his name. He said that it annoys him and that he finds it impersonal and kind of disrespectful, like when you’re not looking at each other in a conversation. That’s how it feels, like I’m looking away. I then tried to explain to him, it’s just the opposite. (…) It is very hard for me to realize that he feels offended and put down. We have very, very different views on what it means that I am not saying his name (Participant 1).When my partner confronted me, that was actually the most unpleasant thing, it was like getting caught, “Oh my God, now someone has caught me, after all these years someone has now really caught me.” Yes, that was the most unpleasant thing. (…) It was very, very, very embarrassing, I felt ashamed that I had to admit having a problem with this. It was a feeling of extreme shame (Participant 2).It burdens me, because I see that it burdens him. Because he says that he is also a normal person, like me, and that he also needs love and to hear his name from my mouth and that he never gets that from me. I get it from him, but he does not get it (Participant 6).The main purpose of this study was to describe alexinomia with regards to its main characteristics and attributes, thus the underlying causes of the problem will be the subject of future research. However, there were details that were mentioned multiple times in the interviews that could constitute factors of vulnerability which might contribute to the development and maintenance of alexinomia. From the category of biographical details participants mentioned early signs of social anxieties as a child , childhood trauma, violence, and neglect, and the presence of psychological disorders such as depression, addiction, and personality disorders in the family. From the category of current relationship patterns participants displayed a tendency to avoid conflicts and to enter symbiotic relationships and to have low levels of self-esteem and self-confidence in relationships and social interactions. Another category was formed from reports of having difficulty in expressing emotions. Participants reported having problems with expressing emotions in general and especially with verbally expressing love, affection, and gratefulness (3 participants).All participants completed all questionnaires. There were no missing data and no outliers. Therefore, all available data was included in the analysis.t-tests were calculated for each of the five subscales of the BFI-2. The mean test score of the test group was significantly lower in the scale Extraversion  compared with norms , t(781) = -3.302, p = 0.014, g = 0.92. Comparisons of the other subscales were not significant (Summary independent-samples nificant .M = 60.92 (SD = 10.94). A one-sample t-test against the test value of 35 confirmed a significant group effect for social anxiety, t(12) = 8.547, p < 0.001, g = 2.22  = 2.859, p = 0.035, g = 0.82), Emotional Cutoff  = 4.600, p = 0.010, g = 1.31), and Fusion with Others  = 3.525, p = 0.011, g = 1.07). Comparisons of the subscale I-Position were not significant  = 3.306, p = 0.013, g = 0.94) and Attachment-related Avoidance  = 4.060, p = 0.012, g = 1.16) as revealed by summary independent-samples t-tests  = 3.619, p = 0.032, g = 0.94. Differences in the other scales were not significant (ps > 0.05).The VASQ includes three scales, and it offers cutoff values for each of these. In our sample, 10 out of 13 participants scored above the cutoff of 57 which indicates the presence of general  Seeking . One-samTo summarize, results from psychometric testing show that our sample of individuals affected by alexinomia fulfilled the criteria for the presence of social anxiety both on individual and group levels. In addition, participants scored significantly higher on several attachment- and relationship-related anxiety and vulnerability scales compared with the respective norms. The ability to regulate emotions was reduced and participants showed decreased levels of extraversion. This pattern of results is well in line with previous research showing that social anxiety is related to insecure attachment , impaireTaken together, and as a very first attempt to conceptualize alexinomia from a clinical diagnostics point of view, data from both qualitative and quantitative analyses suggest the following key symptoms of alexinomia: (i) The individual experiences fear or anxiety in situations, in which using personal names is intended; (ii) Intending to use a name almost always provokes fear or anxiety in the individual in at least one relationship; (iii) the feared situations are avoided or dealt with using compensatory strategies, (iv) the fear, anxiety, or avoidance is persistant; (v) the fear, anxiety, or avoidance causes significant distress or impairment in social, occupational, or other important areas of functioning.Diagnostic and Statistical Manual of Mental Disorders (DSM-5), is not exhaustive and should be seen as a first proposal to the scientific community to inspire the generation of new hypotheses to testify the construct in a more rigorous statistical fashion.This preliminary symptom list is based on the diagnosis of Social Anxiety Disorder according to the The aim of the study was to explore and describe the distinctive features of alexinomia—a previously unknown and scientifically undocumented psychological phenomenon characterized by an inability to use personal names in communication. Using a mixed-methods approach combining qualitative data from personal interviews with participants who are personally affected by alexinomia, and quantitative data gained from psychometric testing of the same sample, our findings allowed us to describe alexinomia on a phenomenological level and to get an understanding of its key attributes and potential links to other psychological constructs including social anxiety and attachment.Results indicated that all participants had the desire to use personal names in everyday social interactions, especially in their closest relationships. The phenomenological experience of alexinomia, however, is that of an inability to do so. This inability is accompanied by feelings of anxiety, panic and physical as well as psychological discomfort. The affected individuals’ experience is further characterized by feelings of regret, embarrassment, and shame, especially when confronted with their behavior by others.Our data suggest that alexinomia usually occurs for the first time in childhood or adolescence and is then ongoing. It affects all forms of relationships and communication and is strongest in romantic relationships and in direct verbal communication. Interestingly, the problem becomes increasingly severe the closer the relationship, which often puts a heavy strain on also the romantic relationships of the people affected. There operates a painful ambiguity in individuals affected by alexinomia in the form of a longing for closeness and intimacy in a relationship on the one hand and feelings of vulnerability and being emotionally overwhelmed, that come with saying a loved ones’ name on the other hand. Such feelings of emotional exposure and fear of unbearable closeness seem to constitute the core features of the name saying avoidance behaviors described here.Results based on the analysis of psychometric tests suggest a strong link between alexinomia-related behaviors and social anxiety . All parTaken together our findings based on both qualitative and quantitative data suggest alexinomia lies at the center of where social anxiety, fear of attachment, and impaired emotional processing with regards to social interactions meet.Several additional factors that relate to and/or potentially interact with alexinomia were observed but not elaborated in depth in the present study. These included participants’ attitudes toward their own names, whether they liked their name and being called by it or not and its co-existence with related phenomena of impaired communication, including an inability to call one’s parents “Mom” and “Dad” and to say “I love you.” So far, we do not have any data on whether or not affected individuals are able to say and write their own names. Another potentially directly related concept is name idealization in in-love couples, which, together with name avoidance, has been suggested to be a sign of the partners’ name being a taboo .Alexinomia should be differentiated from physical and cognitive impairments that affect the ability to produce language, known as aphasia. Also, alexinomia is not caused by impaired memory for names. Further, deliberately refusing to say someone’s name to humiliate a person or to show dominance or disrespect, in our opinion, is also fundamentally different from the type of name avoidance described here.Our sample consisted of German-speaking women aged between 18 and 40 years, therefore all conclusions drawn from this study are limited to this sociocultural group, which was selected based on the availability of contacts of affected individuals. With these limitations in generalizability of our findings in mind, findings from ongoing online research suggest alexinomia to be prevalent also in other sociocultural groups (unpublished data). Hence, future research will explore whether alexinomia also occurs in other genders, age groups, cultural regions and how it is affected by language and cultural aspects of naming and name usage in everyday language. A scale to measure the precence and severity of alexinomia-related symptoms is warranted for statistically validating the construct further and for the development of a clinical diagnostic. Future quantitative research on larger samples might further address the prevalence of alexinomia in the general population, its neurobiological foundations, and psychosocial origins and causes. Not at least, the research presented here was mainly focused on the impact of alexinomia on primarily affected individuals. However, our findings also suggest a significant impact on family and other affiliates; therefore, looking at these secondarily affected individuals will be another important next step in this line of research to further understand alexinomia and to work toward a potential treatment of it.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Sigmund Freud University (SFU) Ethics Committee. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.TD and LW collected the data. TD and NR analyzed the data. TD wrote the first draft of the manuscript. NR wrote sections of the manuscript. All authors contributed to the conception and design of the study, manuscript revision, read, and approved the submitted version.


Unfavorable psychosocial work factors are associated with poorer worker health, such as depression and cardiovascular disease (1). Most evidence is based on studies linking the exposure level at baseline to worker outcomes at follow-up (1). A next step to better understand the impact of psychosocial work factors on worker health is to investigate changes in exposure levels (2).There is no consensus on how to operationalize changes in psychosocial work factors. This is not surprising for three reasons. Firstly, psychosocial work factors are most often measured by self-report . This makes interpretation and generalization more difficult compared to other, more objectively measured exposure–response relationships such as, eg, exposure to chemicals. Due to these self-reports, measured differences in psychosocial factors may be biased and thus not always reflect a change in the work environment. Several attempts have been made to counteract this challenge in the field by using indicators from registers (5), cluster unit analyses (6), and job exposure matrices (7). Secondly, there is no consensus on which psychosocial work factors in what combinations are unfavorable for workers. For example, the Danish Psychosocial Work Environment Questionnaire (DPQ) covers as much as 38 psychosocial constructs (4). Knowledge is still limited: which ones are most important for worker health and which ones are of less importance. Because of this knowledge gap, we still do not know what the exposure–response relationship looks like. What is clear, though, is that exposure to high job strain  is detrimental for worker health . Thirdly, there is no consensus on cut-off scores for unhealthy psychosocial work factors, which makes it difficult to interpret changes in these factors and, thus, to compare results across studies.Scandinavian Journal of Work, Environment and Health (SJWEH) published 82 papers including these search terms. Of these 82 published papers, 11 studies analyzed changes in psychosocial work factors (9–19). In these SJWEH publications, we found two different approaches to investigate change in psychosocial work factors. Most studies focused on membership of a high risk group (9–14). First, they defined cut-offs based on the distribution of data points, and subsequently divided respondents into four groups based on their scores over time: stable unfavorable, worsening, improving, and stable favorable psychosocial work factors , in which the ‘stable unfavorable’ and ‘worsening’ groups can be considered as high-risk groups. Moreover, many studies combined job demands and resources into one measure for job strain and analyzed changes in this composite score , which was subsequently related to worker outcomes.To examine to what extent and in what manner changes in psychosocial work factors are being studied, we conducted a search in Pubmed on 25 January 2023 using the search terms ‘change’, ‘employees or workers’ and ‘work factors’ in the title or abstract, which yielded 7461 hits . The ScaAs no golden route exists to analyze change in psychosocial work factors, in the following, we present some options, and describe pros and cons of these options. This editorial is a call not only to carefully think through how to define change in a study but also to share arguments for the choice of definition in the methods section and to be transparent about the underlying assumptions. The key issue to consider is the approach to study change in exposure. There are two different ways to study change. Firstly, studying changes in exposure levels  that will lead to an increase of the risk at individual level. Secondly, studying transitions in membership of high-risk groups. Below we will explain both options that we illustrate with examples.Option 1: Changes in exposure levelsWhen a linear exposure–response relationship is assumed, every increase in exposure is associated with an increase in risk . For example, Milner and colleagues analyzed how the psychosocial quality of a job was associated with mental health outcomes using longitudinal fixed effects regression models (16). The disadvantage of this method is that every change is considered equally relevant. This means that every unit of change  in score has a similar effect on the outcome, independent of the baseline value. However, since psychosocial factors are often measured as ordinal variables, we know that the differences between the answering categories are not equal. For example, answering options in dimensions of the Copenhagen Psychosocial Questionnaire (3) are on a scale from 1 ‘always’ to 5 ‘never/hardly ever’, and a change in exposure from 1 ‘always’ to 2 ‘often’ versus from 2 ‘often’ to 3 ‘sometimes’ may have a different effect on the outcome (3). Most studies on changes focused on within-person changes, in our search we found only one study applying a population approach to study trends in psychosocial work factors over time (17).Option 2: Changes in high-risk group membershipThe second approach involves membership of a high-risk group by crossing a threshold or cut-off score. A worker can enter a high-risk group when crossing the threshold, even with a minor change in score. Yet, another person can remain in the low risk group with a larger change in score. When the threshold for high risk is for example 3.5, a worker with an increase of 2 points from 1.0 to 3.0 will not become at risk, whereas a worker with a score increase of 0.5 points from 3.1 to 3.6 will become at risk. The increase itself, 2 points versus 0.5 points is not informative here; what matters is whether the threshold from the low risk to the risk group is crossed. In this case, it is important to consider that not all workers crossing the threshold will have a relevant change in score, as the group of workers very close to the threshold will only need a little change to cross it.When taking the high-risk approach, it is important to define what we consider a high risk. Ideally, the relevant cut-off scores are known. Alternatively, the high-risk group can be defined based on the distribution of scores within the population, based on eg, the median , (upper) tertile (13) or any exposure (versus no exposure) (10). This method using the median as a cut-off is most often used in studies on change published in SJWEH. For example, Saastimoinen and colleagues performed a median split for job demands and control variables separately, which enabled them to construct a variable for job strain based on high/low demands/control (9). Too and colleagues analyzed data from four waves of the Whitehall study based on a tertile split and showed how job control could vary between low, medium, and high levels over time (13). With the cut-off, one takes into account the distribution of scores within a population, and the researchers define which percentage of the population is at high risk. However, depending on the population, the cut-off score for being at high risk may differ largely between populations. This makes it difficult to compare exposure–response associations between studies. When demand and control variables are combined into a job strain measure , the comparison becomes even more challenging. Moreover, how sure can we be that a specific percentage of our research population is at risk? By assuming that by definition 50% (median split), 33% (tertile split), or 25% (quartile split) of the sample is at risk, the exposure prevalence is defined by the researcher and a similar exposure prevalence across studies may hide completely different exposure patterns.Both the changes in exposure levels and the changes in high-risk group membership approaches have their pros and cons . In bothAnalyzing changes in psychosocial work factors requires clarity on the approach. When taking the changes in exposure levels approach, an interpretation of the meaning of a certain change  is needed. When taking the high-risk approach, transparent choices have to be made to define the high risk group(s). This is important because these choices can heavily influence the conclusions. Hence, we strongly recommend to explain the choices and the underlying assumptions made to enhance the interpretation of the results. In that way, the evidence becomes more comparable which will improve our understanding of exposure–response associations in studies on psychosocial factors at work and worker health.


Sexual and gender minorities (SGM) experience higher rates of discrimination and violence when compared to cis, heterosexual peers. However, violent crimes and other hate incidents against SGM persons are consistently not reported and prosecuted because of chronic distrust between the SGM community and police. Brazil is one of the most dangerous countries for SGM persons in the world. Herein we describe the development of a mobile health intervention to address the rampant violence against this population, the Rainbow Resistance - Dandarah app.We conducted community-based participatory research (CBPR) between 2019–2020. The study started with in-depth interviews (IDIs) and focus group discussions (FGDs) with representatives of the SGM community from Brazil. Descriptive qualitative data analysis included the plotting of a ‘word cloud’, to visually represent word frequency, data coding and analysis of more frequent themes related to app acceptability, usability, and feasibility. A sub-sample of SGM tested the app and suggested improvements, and the final version was launched in December 2019.Since the app was launched in December 2019, the app recorded 4,114 active SGM users. Most participants are cisgender men (50.9%), self-identified as gay (43.5%), White (47.3%), and aged 29 or less (60.9%). FGDs and IDIs participants discussed the importance of the app in the context of widespread violence toward SGM persons. Study participants perceived this mHealth strategy as an important, effective, and accessible strategy for SGM surviving violence. The CBPR design was highlighted as a key strategy that allowed SGM persons to collaborate in the design of this intervention actively. Some users reported how the panic button saved their lives during violent attacks.Rainbow Resistance - Dandarah app was endorsed as a powerful tool for enhancing reporting episodes of violence/discrimination against SGM persons and a key strategy to connect users with a safe network of supportive services. Results indicate that the app is an engaging, acceptable, and potentially effective mHealth intervention. Participants reported many advantages of using it, such as being able to report harassment and violence, connect with a safe network and receive immediate support. Over the past decade, Latin America has stood out for recognizing sexual and gender minority (SGM) rights. Outside of the Caribbean, most countries in the region have decriminalized same-sex sexual acts between consenting adults. In most countries, SGM individuals are constitutionally protected from discrimination based on their gender and/or sexual orientation. Latin America has also made impressive progress on marriage equality. In 2010, Argentina became the first country in the region to approve same-sex marriage, followed by Brazil and Uruguay in 2013, Colombia in 2016, Ecuador in 2019, Costa Rica in 2020, and Chile in 2021 .However, several obstacles stand in the way of further progress. SGM activists face backlash from social and religious conservatives, and some leaders, including Presidents Nayib Bukele of El Salvador and former Brazilian president, Jair Bolsonaro, are openly hostile to LGBTQIA+ rights. With hundreds of unprosecuted hate crimes, endemic violence and discrimination, Latin America continues to lag in SGM rights among rampant violence against the community. The average life expectancy of trans women in Latin America is only 35 years, according to a report by the Inter-American Commission on Human Rights - compared to 80 years among the general population .The Trans Murder Monitoring project registered a total of 4369 murders of trans and gender-diverse people in 77 countries and territories between 1 January 2008 and 30 September 2022. 68% of all the murders registered happened in Central and South America, and 29% in Brazil. . Brazil Experiences of discrimination, bullying and violence against SGM persons are widespread in schools, workplaces, healthcare settings, restaurants, streets, etc. . SGM perHerein we describe a mobile health intervention developed to address the rampant violence against SGM persons from Brazil and structural problems that influence underreporting of crimes.To develop the Rainbow Resistance - Dandarah app and address the specific needs of SGM persons from Brazil, a community-based participatory research (CBPR) was conducted between 2019–2020. The study started with in-depth interviews (IDIs) and focus group discussions (FGDs) with representatives of the SGM community from Brazil. Our major aim was to identify feasible strategies to increase the reporting of discrimination and violence episodes against SGM persons from Brazil and to connect those in need with a broad range of supportive services.CBPR involved collective, reflective, and systematic inquiry in which researchers and SGM community members worked together in all research process steps. CBPR is a key methodology for bringing about social change and is particularly useful when working with highly marginalized populations such as SGM in Brazil . Twenty-Following this first phase, the app was developed and pilot tested by ten members of the SGM community in Brazil. Those participants pilot-tested the app to determine users’ comprehension of the educational content, understanding and use of intervention features, and overall impressions of app relevance and appeal. Participants were asked to share their thoughts and impressions as they moved through the different components and features of the app. After this pilot test, a new review and features tailoring round were conducted before the app was launched in December 2019. The final app included the following features: violence registration, report, mapping, a panic button, and features offering 24/7 support to violence victims.Community Advisory Board: Eleven participants from the Brazilian SGM community participated in the study Community Advisory Board (CAB). Members of the CAB represented the broad diversity of the SGM community. They met once a month, collaborating with the research team to develop culturally sensitive and adequate recruitment strategies, adapt study protocols and tools, and contribute to interpreting and disseminating research findings.Analysis of IDIs and FGDs: The IDIs and FGDs were audio-recorded and transcribed. Descriptive analysis included the plotting of a world cloud with more frequent words utilizing an extension of the statistical software R version 4.1.1 (rquery.wordcloud). All transcripts were reviewed and independently analyzed by two investigators (MM & ABS), and themes/coding discrepancies were discussed to reach an agreement. During this process, the domain structure was continually reassessed and underwent subsequent revisions. The app features were based on results of this qualitative analysis and major themes identified. The Rainbow Resistance - Dandarah App was then developed to allow users to register, denounce? and map acts of violence, discrimination and hate crimes towards SGM persons from Brazil.Results from IDIs and FGDs were categorized into the following domains: acceptability, anticipated usability, and feasibility. Acceptability was defined as the willingness of SGM persons to use the Rainbow Resistance- Dandarah app. Anticipated usability was defined as the extent to which SGM persons found the program useful to report violent episodes and access support. Feasibility was defined as the extent to which the program could be made readily available and implemented among the SGM from Brazil. In addition, feedback on the app’s look, feel, and content was also gathered to enhance acceptability.This was a pilot study, and our major goal was to establish Rainbow Resistance - Dandarah app acceptability and feasibility, utilizing a mixed-methods strategy that compared and combined qualitative  and qualitative results . Below we describe the major results of the study.Since the app launch, in December 2019, until August 2022, 4,114 active SGM users have been recorded. Most participants are cisgender men (50.9%), self-identified as gay (43.5%), White (47.3%), and aged 29 or less (60.9%) .We go out with a client, but we don’t know if we will come back alive”. Participants also expressed their gratitude for having their voices and concerns heard and being included in developing and improving the Rainbow Resistance - Dandarah app.The descriptive analysis of qualitative data included plotting a ‘word cloud’ to represent word frequency visually. The more commonly the term appeared within FGDs under analysis, the larger the word appears in Acceptability was defined as the willingness of SGM persons to use the Rainbow Resistance- Dandarah app. Participants said the community was willing and interested in utilizing the app. Many FGDs participants mentioned the importance of the collaborative strategy utilized in the study, where the SGM community was consulted to identify their specific needs, was invited to compose a highly active Community Advisory Board, tested the app prototype, and had the opportunity to criticize and contribute to improving the app.“We know the way the LGBT community is extremely technological, like these things, will use it here, it’s a lot, and it stays at the national level, it [will be] a lot of denunciation, a lot of denunciation… We need this”“Yesterday, the test was with trans people. And then, we did different things because the needs and worries of the trans population are completely different from the LGB population. And this participation of the ENTIRE LGBT community is just… Amazing. I mean, this makes all the difference. That’s not a study that some white, rich researcher planned and decided to do. Do you know what I mean? That’s something built for and by our community. And OMG, I’m so proud to be here! We’re making history!”Anticipated usability was defined as the extent to which SGM persons found the program useful to report violent episodes and access support. Many participants identified problems to be further addressed, mostly related to the mapping feature. Standardized maps like Google Maps and Waze frequently miss out on specific locations, such as informal settlements. Favelas (slums or shantytowns) are located within or on the outskirts of the country’s large cities, such as Rio de Janeiro. Many of Favela’s streets are not included in formal maps of those cities. Therefore, when utilizing the ‘panic button’, several participants reported that their location was unavailable in the app.“The first and most important mistake is the location. Like, when I needed to use the panic button, the app didn’t find the street where I was. And we live in favelas, right? So, you guys gotta update this. There gotta be some sort of check or maybe another feature where we could enter our correct location…”Now, do you see here? I’ll try to press the panic button… Now gals, let’s pretend this guy here is attacking me…Okay [laughs]And check it out, I gotta fill all that stuff before pressing the panic button… I mean, it’s impossible right?Yeap, it’s like ‘Hey yow, I know you wanna attack me, but chill man… Wait just a sec until I fill all that stuff and then you attack me, okay?She is dead already… [laughs]I mean, this gotta be quickly, right?”Another usability problem was related to the questionnaire that needed to be filled out before pressing the panic button:Feasibility was defined as the extent to which the program could be made readily available and implemented among the SGM from Brazil. The vast majority of participants perceived the app as a huge success and understood that it would be available soon after the pilot tests, and features review was finished.“ Y’all, this app is like… It’s fierce! Like, they got together Fiocruz, ANTRA [Brazilian National Transgender Association], and ABGLT [Brazilian National LGBTQ+ Association]. That’s dope!So, we want to thank you for the opportunity for us… I speak on behalf of everyone here so that we can speak out, understand?I’m emotional here…” [cries]The revised app was launched in December 2019 and became a formal strategy from the Brazilian Ministry of Health through an active partnership with the Oswaldo Cruz Foundation, its research branch.Feedback on the app’s look, feel, and content was also gathered to enhance acceptability. Participants requested the inclusion of additional information such as legislation, addresses of local services, non-governmental organizations, shelters etc. A few participants also suggested additional features highlighting success stories of well-known SGM activists and not-so-well-known members of the community as well. Those features are under development.Following the pilot testing, our team reviewed all suggestions and improved/revised a few app features. Between December 2019 and August 2022, over 4,000 SGM persons have been using the app to report violence, crowdsource information about safe places for SGM persons, and connect with other users to offer support for violence survivors in need.“Doc, let me tell you… It was late at night, and I was waiting at the bus stop. Then a car approached me super slowly, and when it was in front of me, it stopped. I got the chills, you know? Four white men got out of the car, and I knew they wanted to beat me just by the look in their eyes… They started laughing and teasing me. One of them opened his pants and asked the others to hold me… I knew I was gonna be raped, and just like many Black trans women before me, I might end up dead in an alley… I quickly opened the app and touched the panic button as my last breath of hope. No more than 5 minutes later, three trans women showed up, screaming and telling them the cops would be there any minute. They are sex workers and happened to be on the other street, less than five minutes from me!! You know that when you press the panic button, it shares your location with friends, right? So, they knew I was in trouble. Those guys, I could see they were freaking out! They ran to the car and left me alone with my friends, no harm done. I was shaking and scared but safe. My friends took me home. I reported the incident on the app but didn’t go to the police… Like, they would laugh in my face, like always… I never used that bus stop again… [get emotional] Honestly, your app saved my life that night…”“Like, I was living with my partner when the pandemic got really bad… He was a truck driver, and I was used to staying all by myself at home. He was always on the road, you know? But when COVID came, he was laid off… So, I was supporting him and the house… Like, I’m a sex worker, and he could only eat if I got laid with other guys, some of whom he knew… And changed… Like, he started drinking every day and got really violent with me. I don’t make a lot of money, so I had to save for the bills and groceries, right? But he wanted money every day to get drunk. One day I stood tall and said, “No! That’s enough! We will starve to death like this.” Girl, he got possessed! I never saw such a scary face in my life… And he punched me in the face, took my purse with all the money I got from the night before, and started kicking me really hard… I thought I was gonna die that day… But I had my cell phone in my pocket, and I don’t know how, but I managed to press the panic button when he was not looking. Guess what? A few minutes after, a client of mine, who is in the army, showed up at my door!!! He was arrested, and the social worker took me to a safe shelter. I mean, if it was not for your app and this panic button, I could be dead!”“When things got bad, with COVID, you know? My life became a mess! I had no school, and all my classes were online… And my dad hates me. He really does. Like, he doesn’t accept a lesbian daughter, you know? And he was also working from home, so I was like… Trapped. He looked at me with hate in his eyes. I could tell… And my mom works cleaning homes all day long… I used to lock my door ‘cause I was really afraid… But one day, I forgot to lock my bedroom door and napped after my morning class… When I woke up, my dad was staring at me, and he said: ‘Now you will learn to like a man!’ I knew exactly what he meant… And he started taking off my clothes and put my hand inside his pants… It was sooo gross, OMG…, but I had my phone under my pillow, you know? And I pressed the RISE panic button, hoping my mom or someone else would see it… He beat me badly, and I don’t remember much after that… But when I woke up, my mom was home with a woman police officer, and they were taking my dad to jail… Then they told me that my dad raped me… [gets emotional] I’m still shaking just by telling you this… When they arrived, my dad had a gun and almost killed me, but I was unconscious… Thankfully the police arrived quickly and got him before that… My dad is still in jail and won’t leave any time soon, I’m seeing a psychologist that mom found on your app for free, and she is helping me… I’m still really depressed, you know? But I’m glad to be alive and free to be who I am. And my mom is also free from him… Thanks to this app, I’m still alive, and my dad is in jail…”Unfortunately, during the COVID-19 pandemic, the levels of violence against SGM persons from Brazil were even higher: around 1 SGM person was murdered in the country every day between 2020–2021. Levels of physical and sexual violence were also rampant but continued to be under-reported to local authorities. The Rainbow Resistance - Dandarah App helped to connect survivors with a broad range of services, including shelters, post-rape care, and pro bono legal, psychological, and social support. App users reported a deep sense of gratitude for having the app downloaded. Many even mentioned that it might have saved their lives, as we can see from the quotes below:SGM persons frequently experience hate crimes, violence, attempts to change their sexual orientation forcibly and/or gender identity, and discrimination in education and employment settings, healthcare facilities and public spaces . This poThe current study presented the development and first feedback about the impact of a mHealth intervention for SGM persons from Brazil: The Rainbow Resistance - Dandarah. The strategy was developed to increase reports of discrimination and violent episodes and to provide support for SGM surviving those experiences in one of the most dangerous countries in the world for SGM persons: Brazil.According to participants, this mHealth strategy was perceived as an important, effective, and accessible strategy for SGM surviving violence. Other studies have implemented mHealth interventions to improve SGM’s mental health and quality of life . HoweverAccording to initial results, the Panic Button is a highly important feature for SGM persons who are experiencing an assault. By pushing the red Panic Button, the app sends their current position and address (in the form of a Google Maps link) to five numbers registered in their panic contact list. Such a list can be a true lifesaver, as mentioned by users’ feedback. There are many apps specifically developed for personal safety and violence prevention. However, the vast majority was not developed to address the specific needs of SGM persons SGM persons usually have higher rates of mental health issues than people in the general population . SGM surThrough crowdsourcing, app users now have access to an updated feature that allows them to identify SGM-welcoming and safe services. This additional feature is key to improving SGM persons’ access to healthcare services. Several studies have identified that SGM persons experience additional barriers to accessing healthcare when compared to the general population . By idenBrazil is a country where at least one SGM person is murdered every day, and discrimination/violent episodes are highly underreported. In this context, the Rainbow Resistance: Dandarah App is not only collecting pivotal and inexistent data about violence and discrimination of SGM persons but also connecting those in need with a broad range of supportive services.Rainbow Resistance: Dandarah App. Future work is needed to evaluate the impact of app use over time, for instance, improving crime reporting to the police and/or improving access to healthcare.The current study included a large but convenient sample of SGM persons actively utilizing the Within the broad SGM community, transgender and gender non-conforming persons and radicalized SGM persons experience a higher prevalence of discrimination and violence. Therefore, it is pivotal to consider the unique needs of this population and perhaps include additional features that might help to address barriers to receiving healthcare among these underserved populations.The SGM community experiences additional barriers to reporting experiences of discrimination and violence and accessing a broad range of services needed after an assault . Therefore, innovative approaches to improve the reporting of discrimination/violence, like the Rainbow Resistance: Dandarah App, are urgently needed for the SGM community. The presented results are descriptive and preliminary. Ongoing and longitudinal analyses are still needed and will be conducted over time.The usability evaluation was conducted during FGD, with a moderator always present. The group setting and the presence of researchers may have inhibited participants’ responses. Therefore, assessing Rainbow Resistance: Dandarah App usability may be useful when there is no researcher present through self-report as well. Additional evaluations should also include previously validated scales and a more robust design to identify the App efficacy.Despite those limitations, it is important to highlight that the intervention was conducted in one of the most dangerous countries for SGM to live in. Brazil records at least one murder of an SGM person every day, interventions are scarce, and violence/discrimination reporting is almost absent due to police SGM phobia and victim blaming. To the best of our knowledge, this is the first nationwide intervention implemented in Brazil that allows SGM persons to report violence/discrimination and access a broad range of supportive services. Additionally, the Dandarah: Rainbow Resistance App includes crowdsourcing and mapping strategies, allowing users to identify services that are more welcoming and accessible for SGM persons. Those additional features might be highly important to decrease barriers to accessing services among this highly vulnerable population.The Rainbow Resistance: Dandarah App is the result of a broad and collaborative work that included the Brazilian SGM community, healthcare professionals, researchers, and government representatives. The results of this pilot study indicate that Rainbow Resistance: Dandarah App is an engaging, acceptable, and potentially effective intervention. Participants reported many advantages of using the app, such as reporting violence, connecting with peers, and accessing help in real-time. This study provides initial support for the acceptability and usability of Rainbow Resistance as a mHealth intervention designed by and for the SGM community from Brazil. The next steps involve further app refinement, including mental health screening, referrals, and more substantial feasibility testing. It is also essential to evaluate if app users can connect with healthcare services, stratifying by type of discrimination/violence experienced and by sub-population.