We examined event organizers’ understandings and management of alcohol-related risk and accommodation of people in recovery from substance use disorders and other non-drinkers, when organizing alcohol-permitted events that primarily involved faculty, staff, and graduate students. We interviewed 31 event organizers at a large, public university in California. Organizers were most concerned about avoiding legal liabilities, were less concerned about promoting responsible drinking among drinkers, and often failed to consider the needs of non-drinkers. Their actions were informed by problematic beliefs about alcohol , drinkers , and people in recovery . Organizers over-relied on informal control to shape attendees’ behavior, failing to acknowledge contextual factors. They need education on how they can shape the event context to better promote healthy behaviors, avoid exclusively focusing on informal control and prevention of unhealthy behaviors, and promote better inclusion of people who do not drink alcohol. There is fertile ground for infusing a culture of health into events in higher education.The online version contains supplementary material available at 10.1007/s10935-022-00686-z. Higher education institutions in the United States aim to promote the health of students and employees through separate measures  . This literature documents the value of environmental prevention: population-based strategies that change the context in which people make decisions and have the capacity to affect large numbers of people . Accordingly, the university has an interest in preventing liability. One way that institutions manage alcohol-related risk is by issuing permits for events with alcohol. Permits aim to ensure that event organizers implement safety precautions, such as checking identification to enforce the drinking age minimum and training beverage servers to recognize, and refuse service to, intoxicated persons and mix drinks in accepted proportions. These precautions aim to prevent adverse events and protect the institution from liability  describe event organizers’ understandings and management of alcohol-related risk and accommodation of people in recovery from substance use disorders and other non-drinkers, when organizing alcohol-permitted events that primarily involved faculty, staff, and graduate students, and (2) identify opportunities for deploying culture-of-health approaches to organizing events with alcohol.The study makes several important contributions. First, the study adds to the literature on community health and Healthy Campus by examining whether and how event organizers employ a culture-of-health approach when planning alcohol-permitted events. Second, it addresses gaps in the literatures on environmental prevention and alcohol in higher education by examining events involving faculty, staff, and students, the inclusion of people in recovery from substance use disorders, the public sphere , and institutional practices, specifically event planning. Third, the study fills gaps in research on alcohol-permitted events by examining event organizers’ understandings of how permits relate to alcohol-related risk reduction and health promotion. It explores the extent to which university event organizers aim to provide an event space that is supportive of, or at least not hostile toward, people in recovery. Finally, since university events may also include people who are abstinent for other reasons , this study explores how event organizers consider abstainers when planning events.The study was conducted at a large, public university in California and approved by its Institutional Review Board. We obtained a copy of the university Risk Management Office’s database of alcohol-permitted events from 7/1/2018 to 6/30/2019. No-cost permits are required for university events with alcohol. They cannot be requested for undergraduate events. To get a permit, organizers provide information on the alcohol to be served, who will serve it (a licensed server or other), whether it will be free or for purchase, whether attendance is open or by invitation, the number and nature of participants, the availability of food, the event purpose, and the event location.An analysis of the database informed our purposive selection of event organizers to interview. We employed a maximum variability sampling strategy, selecting “cases with maximum variation for the purpose of documenting unique or diverse variations that have emerged in adapting to different conditions, and to identify important common patterns that cut across variations” . Thus, the criteria for capturing variability in the event characteristics were as follows: we included recurring events (which tended to be work-related such as seminar series) and one-time events , events planned by different campus units, and events planned by different organizers: faculty, staff, or graduate students. We initially identified 55 different events organized by 42 people.Once we selected the events, we contacted, by phone or email, the people listed as the event organizer in the permit database, using the contact information in the database. Seven organizers refused an interview (indicating lack of time) or were unreachable (did not reply to our inquiries). In 2019, we conducted in-person interviews with 31 people who organized 31 focal events . We reached data saturation with these interviews, meaning new data were redundant and participant responses were similar for our research questions  for which they had requested a permit(s). We clarified that their work performance was not being evaluated. The audio-recorded, one-time interviews were conducted by student research assistants who received training in interviewing technique. They occurred in the participants’ work setting  and ranged in duration from 20–45 min, lasting on average 25 min.Supplementary Table 1 contains the interview protocol.Our analysis centered on identifying opportunities for intervention to better promote a culture of health at campus events, not on evaluating the permitting process. We conducted a descriptive analysis of the permit data to summarize the alcohol-permitted events that occurred in the review period. We coded for whether the event was one-time or part of a series, the type of alcohol served, whether the event was public or private, who was invited, the number of attendees, the timing of the event (part of the work day or after hours), the location of the event (on or off campus), and the type of event.In addition to the descriptive analysis of permit data, we conducted a thematic analysis of the interview data. The first two authors read all transcripts and developed thematic codes to answer the following questions: What were the reasons alcohol was provided at the events?, How were alcohol-related risks managed and responsible drinking promoted?, and What accommodations were made for non-drinkers? These thematic questions were derived from the research aims. This coding strategy is in line with what Constas  terms thResults are presented using pseudonyms. Although the results were not shared with participants, they were shared with the campus permitting office and members of the campus’s Healthy Campus organization, both of which provided input on the results’ implications for practice.There were 213 alcohol-permitted events. Their characteristics are summarized in Table “Because it was supposed to be an informal event for them to network with each other and get some practice presenting in front of a non-combative, non-stressful audience. They wanted to provide…a little bit of extra motivation to show up….”Participants (n = 21) also revealed a belief that people need alcohol to socialize, celebrate, or have fun. Greg  stated, “I think they wanted [the event] to be a little more social, and alcohol gets a little more liquid courage”—that is, it reduces social inhibitions. Jeremy  described alcohol as a “social lubricant,” particularly needed by academics.“I’m sure you know working with scientists as well, we’re not always the most social bunch. One thing that I’ve always found that would break down some of those socially awkward barriers has been providing something that makes people feel comfortable. For some people, that is alcohol.”John  explained, “…to have alcohol kind of [makes it] more of a fun event, rather than all business.” Kayla  stated, “networking is definitely facilitated by alcohol.”Organizers endorsed the belief that alcohol is needed for a successful event. Fourteen organizers reported that people need alcohol as an incentive to attend events. Christine  explained that having alcohol at the event “helps people—we found that people will attend knowing there’s going to be alcohol.” Jack  said that alcohol encourages graduate student attendance:“There are gonna be adults there. To a certain degree, some people like alcohol. They’re gonna want it at their party…. For those people that do prefer it, it’s there for them.”Others described providing alcohol as a way to be inclusive. Isaac  explained, “having it as an option for those that would like a drink is typically a little more inclusive than not offering it at all.”Participants expressed the idea that people want and request alcohol at events. They reported a belief that these requests should be accommodated. Jim  said, “Historically, if there is an event that is going to be a social event in our department, faculty likes to bring in wine and beer.” Penelope stated that they offered alcohol at the event because people were, “asking to have alcohol, beer, wine, a nice little selection. A lot of people in our department want it to be there.” In Jeremy’s  words, “If this is what you guys want, then we want to be accommodating in that respect.” Another idea expressed was that not only do people want alcohol included at events, but also because the attendees are adults, they expect it to be present. Jeremy  explained:“We haven’t really encouraged anything like that. We probably would have a talk with anybody who we could see was becoming inebriated, or maybe a one-on-one. That would be expected. But again, we haven’t seen any sign or need of that. So, we’ve kind of left it to the discretion of the individual to figure out how to manage their inebriation levels.”Organizers’ considerations of alcohol risk were narrow and liability focused. Some participants emphasized that obtaining the event permit was enough to ensure safety. Peter  said: “…since we were able to get permits to make it a closed event for us, then it was okay.” Other participants emphasized aspects of the event that they believed made the provision of alcohol less risky. Taylor  explained that not allowing hard liquor at the holiday party allowed her to “control the environment.” Other organizers (n = 10) were concerned with event privacy. Morgan  explained: “It’s people that we know. We have a list. People check in; so we know who they are. Yeah, it’s usually just a private event. It’s not open; so we’re not giving alcohol to people we don’t know.”Participants’ narratives revealed limited understandings of alcohol risk. The events were characterized by (1) little promotion of responsible drinking, (2) narrow and liability-focused considerations of risk, and (3) an overreliance on informal controls. While the events did not appear to promote irresponsible drinking, most participants (n = 28) indicated that their event included no formal promotion of responsible drinking, such as print flyers or signs encouraging guests to take a ride service in the event of intoxication. When asked about promoting ride service use to prevent post-event drunk driving, Daniel  said:Many participants (n = 25) were primarily concerned with the presence of undergraduate students or people under 21 attending events. Jim  said, “The main thing is to make sure that underage students don’t get alcohol.” Madison  said, “…we might have an undergrad intern, but I know who they are and we can follow…but if it was a mass number of folks that I don’t know, that are undergraduates, underage, then no, we are not going to [serve alcohol].”Organizers relied on informal controls in monitoring their events. Some (n = 8) explained that there was always a person tasked with checking guests’ identification to verify that everyone who consumed alcohol was of legal drinking age. However, this person is often someone just “filling in,” not paid to formally perform this job. There was also a reliance on informal monitoring, often by the organizers themselves, of guests’ alcohol consumption. Anna  said, “In the beginning of an event, I’m watching what’s happening at the bar. I’m watching to see who’s lining up, who’s bellying up, who’s ordering what.” She added, “It is constantly something…that I am watching and monitoring and taking care of.” Daniel  explained, “Especially when you distribute the alcohol, you have to have ideally more than one individual who can be trusted to watch over the distribution of it. And ideally somebody who is assertive enough, that if somebody is taking too much, or if we have reason to think that somebody is underage, that they will actually speak out and talk to them.”Other organizers (n = 13) relied on the guests themselves to monitor and control their behavior. They tended to believe that the formal promotion of responsible drinking was unnecessary because guests could and should be responsible for monitoring their alcohol consumption and ensuring their own safety. Jack  described graduate-student self-regulation: “Responsibility was encouraged by the fact that there was heavy faculty in attendance at the event, and students quite rightfully don’t want to get intoxicated in front of their faculty mentors.”“We don’t hype up the alcohol consumption. We don’t promote it in any way. People can just go up and select what they want. So I don’t think there’s any kind of pressure at our events for anyone to drink alcohol. Or I don’t believe that anyone would feel weird or different if they didn’t drink it.”Evident in their discussion of accommodations for non-drinkers and their reliance on informal controls, participants had a limited understanding of addiction and recovery. They identified several accommodations for non-drinkers: offering non-alcoholic drink options, keeping alcoholic and non-alcoholic beverages in separate locations, offering food at the event, not over-emphasizing alcohol at the event, and letting participants know ahead of time that there would be alcohol at the event. Most reported that they always served some non-alcoholic beverage. While many (n = 20) reported serving spa water, soft drinks, mocktails or lemonade, others (n = 5) reported that they offered only water, black coffee, or tea as non-alcoholic alternatives. Still others (n = 3) indicated that guests had to provide their own non-alcoholic alternative. Some organizers (n = 13) indicated that their event accommodated non-drinkers by not focusing on or over-emphasizing alcohol or expecting guests to drink alcohol. Jim  explained, “It’s not like we’re forcing people to drink. It’s just there to take if you want it.” Shelby  said:To better understand how higher education institutions can incorporate a culture-of-health approach into existing institutional practices and structures, this study examined alcohol-permitted event organizers’ understandings and management of alcohol risk and accommodation of non-drinking event guests. The organizers endorsed problematic beliefs about alcohol, had limited understandings of alcohol-related risk, addiction, and recovery, and employed a narrow set of strategies and efforts. Thus, there is fertile ground for incorporating a culture-of-health approach into event organization to address alcohol risk and promote inclusion at events with alcohol.Our results showed that event permits insufficiently address alcohol-related risks and non-drinkers. We identified various types of alcohol-related risk that are overlooked at events. For example, a reliance on self-control misses the fact that people with substance use disorders are substantially less able to control their behavior White, . FurtherWe also identified little effort by event organizers to promote health—for example, by promoting responsible alcohol consumption or consumption of healthy alternatives to alcohol. Event permits are, by design, focused on protecting the institution from liability; they are not intended to promote health among individuals. For example, participants’ narratives indicated the false belief that safety is achieved by excluding from events members of the community who are less than 21 years old, excluding from alcohol consumption guests who lack identification at the event, or excluding guests who become drunk or disorderly. Permits, thus, do only partial work. Additional work is needed not only to promote greater safety but also to promote health.Our results revealed ways that a culture-of-health approach may help to address health and safety at events with alcohol. First, because this approach emphasizes structure over individual agency, it can guide organizers in shaping the event context to influence guest behavior. Rather than relying on individuals to control their behavior, organizers can influence the behavioral choices available to guests. Organizers in the study reported that they monitor closely for the development of problems, such as if a guest becomes drunk and disorderly, but they give little attention to the conditions that could prevent such a development. Unlike the risk management focus of event permits, a culture-of-health approach aims to promote health by creating conditions conducive to healthy behavior. In the case of alcohol, those conditions include what beverage choices are available, how the beverages are displayed, and the extent of emphasis given to alcoholic beverages relative to other beverages.Second, because a culture-of-health approach emphasizes the collective over individuals, it can guide event organizers in attending to the inclusion of diverse guests—in this case, guests who consume alcohol as well as those who do not. Organizers could be educated about the potential diversity of event guests , conditions that make an event “sober friendly,” and common myths about substance use , substance users and abusers , and substance use recovery . This education could be required as part of event permitting or offered to the university community at large.Third, the culture-of-health approach emphasizes prevention over intervention. This distinction is evident in cutting-edge approaches to other health and safety issues, such as sexual assault. Research on college sexual assault has highlighted the need to reduce the emphasis on criminal behavior and punishment and instead, promote healthy sexual behavior and community values, such as respect for people’s sexual citizenship  in event advertising. This suggestion is consistent with research recommending attention to the ways that events with alcohol are marketed  or to a separate, controlled area . If providing assigned seating, organizers could ask guests to express their seating preferences . These suggestions are consistent with prior research recommending changes to the physical environment to reduce alcohol risk , prior research has documented the role of the alcohol industry in either supporting or interfering with environmental prevention efforts Below is the link to the electronic supplementary material.


In light of the fact that increasing consumer emphasis is being placed on the concepts of safety, health, and environmental protection, and that consumer groups are now attentive to the issues of “greenism” and sustainable development, the certification label has become an important tool. This study explores individual needs from the perspective of food “clean label” certification, highlighting that the importance of general food certification to consumers is different from the previous literature that only focused on the impact of organic labeling, nutrition labeling, and food safety certification on consumer behavior. In this study, the consumer purchase intention for the use of the “clean label” and its influencing factors are discussed, using product knowledge and involvement as the independent variables. The target is the consumer who has experience with “clean label” products. This study employs snowball sampling. A formal questionnaire was sent to 292 participants. After eliminating the invalid samples, we retained 265 valid questionnaires for the analysis . Structural equation modeling (SEM) was applied to test the research hypotheses. The results indicated that: (1) consumers’ involvement with “clean label products significantly influences their purchase intention; and (2) consumers’ product knowledge of “clean label” products significantly influences their purchase intention and involvement. Based on these results, enhancing consumers’ knowledge of food security is suggested. Furthermore, the findings provide crucial insights for marketing channels, suggesting that the food industry can target consumer confidence over certification labeling and “clean label” products as keys to purchase intention, and to attract business by developing practical marketing strategies. In recent years, food contamination accidents have been frequently reported. For example, in 2016, an illegal factory in Tainan, Taiwan mixed edible pigments and industrial dyes to make tangyuan. In 2017, the chicken eggs at 44 farms in Taiwan were found with excessive Fipronil levels. Food contamination accidents have affected Europe in recent decades, such as those related to BSE and dioxin , and theAs the business opportunities for healthy food continue to expand, the phenomenon of mislabeling in the market has seriously affected the health and rights of consumers. It has also made many consumers doubtful about the claims made by the industry, and they require clear and reliable product information ,8. ConsuMany food consumers appear concerned about these impacts of the food system, as is evident from the increasing demand for environmentally friendly food products . As a reIngredion  recommen“Clean label” products are characterized by the presence of ingredients that are considered natural, harmless, and simple, and that consumers know and use as their own ingredients ,28,29. TIn fact, many consumers think more about the “clean label” when buying food , rather Most of the literature in the past focused on the impact of organic labeling, nutrition labeling, and food safety certification on consumer behavior ,40,41,42Consumers are more health-conscious about functional or 100% natural foods  ,46,47. HSchiffman and Kanuk  defined As implied by the existing studies, there seems to be a lack of sufficient research identifying factors influencing consumers’ awareness of the “clean label” system, which leaves several knowledge gaps that should be filled through further in-depth research. Therefore, the novel approach of this study is to use the three consumer aspects of product knowledge, involvement, and purchase intention to investigate consumers’ attitudes toward and opinion of the “clean label”, which was mentioned in—but was not tested by—previous studies, thereby filling this gap in the literature. Based on the results, recommendations are made for the food industry, product evaluation units, marketing strategies, or business management that are expected to bring a safer and healthier dietary environment to consumers.In the rest of the paper, In this study, consumers’ purchase intention for the use of the “clean label” and its influencing factors are discussed, using product knowledge and involvement as independent variables. A conceptual model of this research is shown in Schiffman and Kanuk  providedAccording to Lee et al. , productAccording to scholars, this study considers that purchase intention is affected by many factors, particularly for products that consumers are not familiar with or new products. Consumers’ purchase intention is more influenced by received knowledge messages and high or low levels of involvement, indicating that consumers’ purchase intention is related to product knowledge and involvement. Consumer product involvement is defined as: “consumers’ level of concern and attention for a product” . AlternaBeharrell and Denison  noted thIn summary, this study finds that the degree of involvement has an impact on purchase intention, and Hypothesis H2 is proposed.Hypothesis (H1).Product involvement positively affects consumer purchase intentions.Such knowledge, according to Lin and Zhen , directlThe consumers who have high product knowledge rely on intrinsic product characteristics to judge product quality and function. In contrast, the consumers with low product knowledge tend to evaluate a product based on its extrinsic cues, such as the price and brand . Ghali-ZWhen engaged in the process of purchasing a given product, the knowledge that consumers have about the product affects their search behavior, their processing of relevant information, their decision-making, and, finally, their purchase intention ,78. HencAs a result, this study argues that, if customers have more product knowledge, they have greater capabilities to distinguish the product’s quality. Additionally, these capabilities can reduce uncertainty to improve the feedback and purchase intention of products.Therefore, we propose the following hypotheses.Hypothesis (H2).Product knowledge positively affects consumers’ involvement.Hypothesis (H3).Product knowledge positively affects consumers’ purchase intention.The questionnaire is divided into four parts, with parts 1, 2, and 3 addressing product knowledge, involvement, and purchase intention. First, the questions related to product knowledge refer to the study by Hunjra et al.  and ChenThis study is based on the three dimensions of product knowledge, involvement, and purchase intention to discuss the cognitions and opinions of “clean label” products of respondents who purchased these products and the impact on their purchase intention. The research method of this study is a web survey, and the formal questionnaire was sent to 292 participants. After eliminating the invalid samples, we retained 265 valid questionnaires for the analysis. The valid response rate is 90.75%.After the data screening, the sample size was 265, of whom 61.10% are females and 38.90% are males. The ages in the sample were 21–30 years (24.15%), followed by 51–60 years (21.50%), and 41–50 years (20.75%). Regarding education level, university was the majority (60%), followed by high school (26.04%). The monthly income of the sample was 20,001–30,000 TWD (29.80%), followed by 30,001–50,000 (26.80%).This study adopted structural equation modeling (SEM) to measure the causal relationships between the latent variables. SEM is an effective model, test, and improvement method that enables theoretical models to be tested. SEM can explain the causal relationships among the variables for hypotheses related to models based on statistical dependence. Consumer behavior is often affected by psychological variables that cannot be directly estimated (latent variables), requiring observation variables to be measured indirectly. SEM is divided into two parts: the measurement model and the structural model. The measurement model is the part that relates the measured variables to the latent variables, and factor analysis is used for the evaluation. The structural model is the part that relates the latent variables to one another, and a path analysis is used for the evaluation. The empirical results are shown in the next section.The results of the reliability and validity analysis of each variable are shown in p < 0.001). These results show that, after a consumer carefully assesses the difference between “clean label” and non-”clean label” products, the consumer’s purchase intention of “clean label” products increases. In response to this statement, Lee et al. [The proposed model was evaluated by running the SEM with the maximum likelihood estimation method. The findings indicate that our proposed model has a satisfactory predictive ability in the outcome variables. H1, which states that product involvement positively affects consumers’ purchase intention, is established  support this hypothesis. According to the literature review, the degree of consumers’ product knowledge plays a very important role when they receive and process information. A study on dietary supplements showed that higher consumer involvement results in more intensive use of information about these products [The results show that H2, which states that product knowledge positively affects consumers’ involvement, was first evaluated, and the results  indicate that H3 is established. Coulter et al. [Last, Hypothesis H3 is examined, which states that product knowledge positively affects consumers’ purchase intention. The results  = 0.907, Tucker–Lewis Index (TLI) = 0.913, Incremental Fit Index (IFI) = 0.943, and the Root Mean Square Error of Approximation (RMSEA) = 0.052. All the other fit indices were above the recommended criteria. As a result, all the indices provided evidence of an acceptable measurement model.  using AMOS 21.0. The measurement model contains five latent constructs . After at model. .Based on the results of the empirical analysis, this study suggests four main conclusions that can solve the problems and dilemmas that food industry and appraisal units may encounter.Adapt to changes in dietary preferences and provide products that meet public expectations.Food safety issues have continued for the last five years, and the public was no longer able to purchase delicate and delicious food. Instead, consumers began to choose natural and organic food. From the product and R&D perspective, the mainstream products in the market now emphasize health and nature. If food companies can change from these two aspects, they can not only meet the public’s needs but also increase customers’ confidence in products and their purchase intention by applying for the “clean label”.2.Indicator selection for “clean label”Even if products on the market have product labels, for customers to identify whether a product is natural and safe is still difficult and can only be determined by the brand or word-of-mouth. Therefore, the “clean label” is not only the recognition of natural products but also becomes one of the new bases for consumers to choose products. It can also be regarded as a way to transform food in a future direction. According to the references and the results of this study, an increase in customers’ product knowledge will enhance their involvement and improve purchase intention. Hence, we suggest making customers understand the significance of the “clean label” to strengthen marketing strategies. Therefore, spreading the concept of the “clean label” will help the public not only easily identify products but also reduce the uncertainty of new products. These results can increase the market of the food companies and enhance consumers’ purchase intentions.3.Improve faith in the “clean label”Since the food industries in Taiwan have experienced many food safety problems, the public has maintained a doubtful attitude toward labels, such as TQF. Thus, the “clean label” belongs to emerging food labeling. The data show that, although the public does not understand the “clean label”, they are willing to buy products with this mark after realizing its meaning. In 2015, the Institute of Food Technologists stated that the “clean label” would be a trend and was the only method to adopt. Currently, approximately 6–10% of foods throughout the world are being replaced by “clean label” products, and this percentage is estimated to continue to increase in the future. Compared with the data from this survey related to achieving the goal of promoting the “clean label”, if the appraisal unit could take the following actions, such as giving this mark greater conformability, improving relevant norms and standards, and strengthening people’s awareness and education, the influence and credibility of this mark will be significantly improved.4.Popularization of “clean label”Cooperating with Family Mart and increasing the cooperation with other marketing channels, such as Carrefour Mart, or other convenience stores that have developed their own brands actively in recent years, is suggested. Given the public’s sense of trust of well-known brands, a series of “clean label” products can be created to increase publicity and purchase intention. On top of that, people clearly need to recognize the idea of the “clean label” concept.After the data is collected and organized, there are still deficiencies in the research process. The data analysis and assumptions should be rigorous in order to obtain more accurate research results. Therefore, for the areas that should be strengthened in this research, the regulations are supplemented here for future research direction.An important limitation of this study is the perception of the label information. Although the definition of “clean label” products was been clearly explained and illustrated with pictures at the beginning of the questionnaire of this study, this topic is new, and not every respondent shares the same understanding, which may make some respondents have biases when answering the questions.To improve the accuracy of the research results and obtain complete information, subsequent researchers can use this study as a basis and collect data from various other market segments  to increase the coverage of the sample. The extrapolation and reference value of the research results can be enhanced, which will be helpful for food industry managers to formulate marketing strategies for target markets and improve the research on the factors influencing the behavioral intention regarding “clean label” products. In addition, future studies could perform random sampling collection and use larger sample sizes. Moreover, as past studies have noted that peer communication through social media can significantly influence purchase intention , social Consumers’ environmental concern is an inevitable trend in the pursuit of Earth’s sustainable development. In contrast, producers can also be research subjects to discuss the effects of food safety, health, and environmental friendliness on business development, and whether they will integrate the concept of “clean label” products into practices when developing a production plan, as they want to shoulder social responsibility to gain consumers’ attention, thereby improving their company’s image.This study incorporates variables, such as product knowledge and involvement, to discuss Taiwanese people’s thoughts on purchasing “clean label” products and the factors influencing their purchase decisions. Future studies can incorporate variables, such as product trust, perceived risk, and perceived benefits, to make the overall research more complete.


In this cross-sectional, semi-longitudinal and quasi-experimental study, our goal was to determine the effect of data storage conditions on willingness to take a genetic test. We compared individuals’ preferences regarding how they want to store health data collected from genetic tests through two survey experiments fielded in Switzerland in March 2020 and January 2022. We tested for differences whether genetic data are presented as private goods or public goods. Results confirm our initial research expectation: more control over storage increases willingness, so does framing genetic data as private good. However, they also show that the willingness to take a genetic test has noticeably increased between 2020 and 2022. Our results point toward a “pandemic effect” which would have increased willingness take a genetic test, nevertheless, more data are needed to understand this putative effect. Willingness to share personal health data has been an increasingly relevant topic since the development of personal health records –3. BeyonGenetic data is a particularly sensitive form of health data, and individuals’ willingness to even elect to take a test may be mitigated by their attitude toward genetic information and its use –14. In tIn this quasi-experimental, cross-sectional, and semi-longitudinal study, we analyze Swiss residents’ willingness to take a genetic test as the dependent variable. We test the expectation that privacy concerns are crucial to explain why individuals report that they are willing to take a genetic test. Specifically, we conducted two surveys on the willingness to take a genetic test, one in March 2020 and one in January 2022. We test storage conditions as independent variables. To generate a quasi-experimental approach, we randomly framed individuals into two equal-sized groups while controlling for the gender, age and language region distributions and framed genetic data as public good for one group and private good for the other . Our research builds on prior studies which emphasize that individuals cherish the protection of their personal health data [In March 2020, we tested individuals’ willingness to take a genetic test in a field survey in Switzerland sample  in which we applied the same framing and asked the same questions. Both samples were representative of the Swiss population: men and women are distributed equally, the participants, aged between 25 and 65 years, are evenly distributed into four age groups, and the same quotas for the German and French language regions are used  received the following framing: “Some consider that personal health data is a common good and should be used to improve public health.” Then we asked them how likely it would be that they take a genetic test, if their data were stored by public authorities, such as a biobank. The other group (private good framing—PG) was provided with a different framing: “Some consider that personal data are private and should be used exclusively to improve the health of the individuals to whom they belong.” After that, we asked respondents if they were willing to conduct a genetic test, if they were to store their health data themselves, for example in a”datasafe” or secure server. In January 2022, we conducted a follow-up survey in Switzerland . Table t-test and the difference between 2020 and 2022 is statistically significant although not as much as for the full sample (p = 0.0289 for CG framing and p = 0.0011 for PG framing). Finally, we also compare those who received the same framing in 2020 and 2022 and we observe an increase in willingness to conduct genetic testing of 12.4 p.p. Nevertheless, amongst those who changed from a CG to a PG framing, the willingness to test increased even more (15.5 p.p.), whereas the respondents that changed from a PG to a CG framing augmented their willingness only by 7.5. p.p.Among the 1046 respondents to the 2022 survey, 426 of them were also respondents in the 2020 survey, but did not necessarily receive the same framing: we thus were able to establish a panel sample  might have increased trust in testing for other diseases early on or incited individuals to conduct check-ups. Finally, another possible motivation could be increased health-consciousness. Put differently, the pandemic might have put maintaining good health higher on the agenda of individuals.This study has limitations. More data is needed to establish the causal relation of this claim: our study did not aim to identify the cause of such changes and our explanation of those results remains speculative. The representativeness of the panel-elements in our sample is limited, as females, older people and French speaking cantons are overrepresented compared to the overall sample. Further studies could rule out sample limitations, chance, and other explanatory variables, such as trust, which were not included in this analysis. In addition, future research could dig deeper into the difference between where data is stored (private or public place) and access (control or limited control) by individuals.Nevertheless, this study can inform policies which aim at developing prevention through genetic testing, for instance related to cancer screening. The Covid-19 pandemic might have opened a window of opportunity to advance the use of genetic data, whereas for individual care or to contribute to research. Our study shows that, this will depend on how the very concept of health data is framed to the public.Supplementary material


Despite the high prevalence of ocular complications in patients admitted to the intensive care unit (ICU), eye care, as an important component of the care plan, has not received much attention from nurses. To improve the quality of eye care, the challenges and concerns of ICU nurses should be studied deeply. Thus, the present study aimed at exploring the challenges faced by ICU nurses in taking care of patients admitted to the ICU.The present conventional qualitative content analysis study was carried out on 11 nurses and 3 head nurses selected purposefully by observing the maximum variation. The data were collected through face-to-face, in-depth, and semi-structured interviews. All data were recorded, transcribed, and analyzed using the conventional content analysis method proposed by Graneheim and Lundman . The Max Q Data software 2020 was run to record the interviews and extract codes from the transcriptions.The participants’ mean age was 37.14 ± 6.41 years and their average work experience in ICU was 10.29 ± 7.63 years. The core category that emerged from data analysis was “the lack of an evidence-based approach”, which was subdivided into five categories: “education, the missing link”, “nurses’ inadequate professional competence”, “unsafe nursing care”, “organizational requirements”, and “difficulty in eye care evaluation”.Evidence-based practice plays a minor role in the field of eye care in Iran, despite its critical importance. Thus, the Ministry of Health and Medical Education of Iran is recommended to adapt the clinical guidelines so that more attention is paid to this field. Human beings receive most of their knowledge and information through their vision power as one of the vital senses . Eye heaOcular complications occur in a large number of patients due to the healthcare team’s inattention, neglect, and ineffective care , 3, 11. Since the qualitative approach, such as conventional content analysis, is a comprehensive, complete, and in-depth way to obtain a clear and accurate picture of a given phenomenon , the preNursing staff in hospitals in Iran include nurse managers, clinical supervisors, educational supervisors, head nurses, and clinical nurses with an MSc or BSc degree. Operating room nurses and nurse anesthetists with a BSc degree also work in operating rooms. Unlike some western countries, licensed nurses are not ranked in Iran and the registered nurse (RN) is the single professionally accepted rank. The Iranian nursing education program lasts for 4 years and graduates receive a bachelor’s degree. Graduates of nursing schools are considered RN, which is the minimum requirement for nursing practice. Besides, graduated nurses have to work in governmental hospitals for 24 months, after which they are permitted to apply for employment. Enrolment in a master of science program in nursing requires the applicant to hold a bachelor’s degree in nursing and to successfully pass the university entrance exam. The master of science in nursing is a 2–3-year program including about 32 compulsory and optional credits in total .Two other types of health staff are also employed to assist RNs . NursingHaghdoost et al. 2018) reported that the number of active beds in the country was 117,580 in 2016. They also estimated that to meet the community’s need for healthcare services, this number should reach 194,471 beds by 2026. There were 1.47 beds for 1,000 people in 2016, which will increase to 2.9 in 2026 [18 reportThis study employed a conventional content analysis approach to examine the problems faced by nurses in taking care of the patient’s eyes in the ICU. The purpose of content analysis is to obtain a brief and comprehensive description of the phenomena . The curThis study was conducted in three hospitals  affiliated with the Kerman University of Medical Sciences. Each hospital has five ICUs , and neurology department) with a total number of 192 staff . This stIn this study, nurses working at hospitals affiliated with the Kerman University of Medical Sciences were interviewed. The participants were selected using the purposeful sampling method . The resThe current study used MAXQDA-20 to manage data, as well as Graneheim and Lundman’s conventional content analysis method to guide analysis . Thus, tTo perform initial coding, the participants’ statements were examined carefully by the researchers to extract meaning units and concepts from the transcriptions in the form of initial codes. These codes were reviewed several times and those with similar contents were merged into more solid sub-categories reflecting the nurses’ experiences and challenges in caring for the patient’s eyes. Next, separate subcategories were studied and merged into broader categories, which were merged to form the final theme. The codes and meaning units were examined and revised from data analysis up to the final stages of the research project by all authors to ensure the accuracy of the findings. Although the analysis process was systematic, a back-and-forth movement was available between the whole and the components of the text. Table In 1994, Guba and Lincoln determined credibility, dependability, transferability, and confirmability as practical techniques to gain the robustness of data . ResearcThe participants’ mean age was 37.14 ± 6.41 years and their average work experience in ICU was 10.29 ± 7.63 years. Most participants were women (85.7%) and 14.3% had postgraduate education.From a total of 16 interviews, 410 primary codes were found. Given the semantic approximation, many codes were merged. Finally, the “lack of an evidence-based approach” was identified as the core theme. It covered five categories including “education, the missing link”, “nurses’ inadequate professional competence”, “unsafe nursing care”, “organizational requirements”, and “difficulty in eye care evaluation”.According to the nurses, inadequate eye care was among the main challenges in taking care of the ICU patients’ eyes. They believed that although education is required to empower nurses in eye care, nursing managers do not care about its significance due to their lack of awareness about implementing eye care. Other reasons for inadequate attention to nurses’ education were “the lower importance of eye care in the patient’s life-threatening conditions, ineffective needs assessment of ICU nurses’ educational needs, and authorities’ unawareness of educational methods or educational content”. According to the findings, nurses need to obtain information about assessing the patient’s eye health, the frequency, and site of using eye ointments and drops, and perform preventive care for ocular complications caused by patients’ admission to the ICU. However, the nurses stated that they did not receive any education in the field of eye care through the formal educational system. They also complained that eye care was not emphasized by the relevant managers and authorities in their working units.I have been officially hired for 20 years. We never had a training course about eye care. This topic was not addressed in any educational programs” (P7).Accordingly, a participant mentioned, “Most nurses do not know about the exact site of the eye that should receive medication, the interval between medications, and the symptoms that should be reported to the physician. Although providing these instructions and eye infection prevention methods to nurses is important, usually more vital training should be incorporated into educational needs assessment, and eye care has been neglected” (P4).Another nurse stated, “When we were students, we never received any education about eye care. Most educational contents were about suctioning, oxygen levels, and the Glasgow Coma Scale (GCS). We did not receive any training about eye care in the college” (P3).Despite the existence of several theoretical and practical courses on intensive care in nursing education programs, unfortunately, eye care education has been marginalized and downplayed in academic nursing education. In other words, more attention was paid to the management of the patient’s life-threatening conditions: “Analysis of the participants’ experiences showed that nurses did not have adequate professional competencies in eye care. Professional competency is defined as a set of characteristics in nurses that improve the quality of nursing care and care outcomes. Some reported some competency-related problems such as inadequate knowledge, inefficiency in performing duties, negligence in eye care, inadequate communication skills, low self-esteem, and lack of teamwork.A nurse must have a professional conscience and clinical reasoning skills to provide effective care to patients” (P5).A participant with 27 years of work experience in the ICU said, “If a nurse has enough knowledge of eye care, she can effectively assess the patient’s needs and conduct principled care because the initial assessment determines the routine care performed for the eye” (P8).Another participant with eight years of experience in the ICU stated, “We only control the patients’ pupils by flashlight. More thorough examinations should be performed by physicians and they would obtain ophthalmologists’ advice if necessary. Generally speaking, assistant nurses are responsible for using drops and ointments for the patient’s eye or closing the patient’s eyes with adhesive tapes” (P5)According to the participants’ statements, nurses underestimated their knowledge, skills, and abilities and believed that eye checks should be performed by ophthalmologists. As they stated, nurses should only perform pupil checks. This confirms their low self-esteem, inadequate interdisciplinary communication skills, and passive performance in patient care. In addition, nurses considered eye care, the use of drops or ointments, and closing the patient’s eyelids as duties of nurse assistants, not nurses. The participants commonly stated, “Unfortunately, the nurse-to-nurse and nurse-to-physician relationships are not good. That is to say, nurses are ashamed to ask more experienced nurses or doctors about the patient’s eye care. For example, they are afraid to seek help and advice for the patient’s problems. In such cases, the nurse leaves the patient believing that in the next shift, others will do something for him/her. We have seen such cases” (P1)In the same vein, another participant stated, “Eye care in our ward is performed by a normal saline wash. For example, every morning before the shifts change, we clean the patient’s eyes with normal saline and sterile gas. Only in the case of patients with low GCS, we close the patient’s eye with anti-allergic adhesive tapes” (P1).The participants’ experiences indicated that the lack of an evidence-based approach leads to unsafe care. Nurses stated that patient eye care in the ICU is performed based on the personnel’s ideas and experiences, nursing interventions not consistent with scientific principles, as well as the different procedures in eye care. A participant with 10 years of experience stated, “For eye care, we don’t usually pay too much attention to the patient’s eyes at the time of admission to the hospital. We had a patient with completely swollen conjunctivitis. I knew from experience that these patients usually get worse and die. To take care of these patients’ eyes, we just tape their eyes closed” (P2).A nurse with 17 years of job experience in the ICU indicated, “Since nurses are faced with a huge workload in the ICU, they cannot do pupil checks every two hours. So, we only check the patients’ pupils twice a day; at the beginning and the end of each shift” (P11).Based on the nurses’ experiences, factors, such as high workload, the shortage of nurses, and crowded wards result in unsafe and unprincipled care in ICU. A male participant with two years of experience in the ICU said “Many participants were more attentive to the scope of their occupational duties in addition to performing the routine care plans and physician orders. Although some nurses acknowledged their abilities to go beyond their job descriptions, they only made decisions within the scope of their duties because they would be questioned by doctors and prosecuted by the law if they did something not included in their job descriptions.The nurses stated that they examined the patient, determined the problem, and reacted to it if the treatment was part of their job description; otherwise, they would refuse to take any treatment measures and inform the doctor.Sometimes the patient’s eyes may have developmental secretion and pus despite the application of ointment. In this case, we should inform the doctor and act upon the ophthalmologist’s order. We cannot give a drop of water to the patients without the physician’s permission” (P4).One of the head nurses of the ICU suggested, ““Simple ophthalmic care is one of the orders that should be performed perfectly. The only thing that matters for us is the doctor’s order” (P13).Although the participants emphasized paying attention to the patient’s needs in nursing care, it seems that physicians are mainly considered a reference for diagnosing the client’s needs without taking into account the patient’s values, preferences, and concerns. This indicates the gap between modern and traditional nursing. In other terms, while modern nursing necessitates conducting evidence-based care, performing patient-centered care, paying special attention to the patient’s needs, and involving them in the treatment process, nursing in our national hospital system emphasizes the traditional care and implementation of medical instructions. In this way, the doctor’s instructions and routine tasks establish the basis of care.When writing a nursing report for eye care, we just tick the options. If we see a particular point and if special treatment is required, we write a note like ‘eye drops are shed, the eye doesn’t have an infectious discharge, etc.’ Otherwise, as usual, we just tick the options and that’s all” (P10).Evaluation of nurses’ performance in terms of eye care is faced with challenges by officials and head nurses. Head nurses stated three main reasons for difficulties in evaluating eye care: (1) Instead of writing a nursing report, nurses tick on the patient’s sheet and consider it a suitable alternative to documentation of eye care in the ICU. Consequently, they do not mention the eye care measures taken in their nursing report. (2) Given that ophthalmic drugs are often used in the form of drops and ointments, assessing their quantity and quality is hard for the supervisors because it is difficult to measure and estimate the volume of drugs used or unused by nurses for ICU patients. (3) Since patients admitted to ICU are not often able to report the quality of nursing care, especially their eye care, evaluation of nursing interventions in the field of eye care has been accompanied by problems. A participant referred to the quality of nursing care for the ICU patients’ eyes, ““The nurse would often come, pick up the ICU sheet, tick on it, and leave the shift. That is to say, there will be no follow-up procedure, evaluation, and care for the patient. So, it’s really very difficult for me as a head nurse to understand why the patient, who received eye care based on the documentation, hasn’t recovered yet”. (P14)Participants’ statements regarding eye care assessment indicated concerns about the adequacy of nurses’ attention to the patient’s eye in the initial evaluation in the ICU or deficiencies in the quality of ophthalmological nursing reports. Excerpts from the participants’ statements are as follows:When the patient is hospitalized, we can do our initial assessment up to the end of our working shift. The initial evaluation involves assessing the patient’s physical and mental status, factors threatening their safety status, etc. But everything depends on whether the evaluating nurse cares if the patient’s eye is healthy. Sometimes, the patient has been in the ward for two days and no one has noticed the patient’s eye problem; everything  depends on the knowledge and information of that nurse” (P4).“The participants also acknowledged that the initial assessment and consequently the eye care procedures in the ICU were not desirable. They urged further consideration and training in this area.We need some education about the importance of using the nursing process in eye care and most importantly, the significance of the patient’s initial assessment by nurses during patient care”. (P12)A nurse stated, “Thus, the participants’ statements confirmed the significance of ‘patient’s eye care’ amid the complex and numerous problems of the patient and highlighted the necessity of employing holistic and multidimensional nursing care for ICU patients.An exploration of the nurses’ experiences highlighted the absence of an evidence-based approach” to ICU patients’ eye care. The findings revealed the importance of nurses’ experiences and the challenges faced by them in taking care of the patient’s eyes.Unfortunately, eye care has been neglected not only in Iran but also around the world. The ICU nurses believed that ICU staff mostly take care of the patients’ life-threatening signs and symptoms . This viSince the ultimate goal of nursing services is to provide quality care to improve the outcome of services to the patients and the community, many medical and care measures are taken based solely on traditional trends, guesses, occupational assumptions, individual skills, and non-organized clinical observations. As a result, health system services are expected to be based on evidence, scientific methods, and scientific decision-making . EvidencThe results of this study indicated that nursing care programs for eye care are not developed and implemented based on scientific evidence in Iran because nursing eye care starts after the eye damage has occurred and only medications prescribed by the physicians should be applied to the patient. According to Momeni Mehrjardi (2021), in some countries, nursing care for the ICU patients’ eyes is not based on an evidence-based approach”. In IranIn this study, we found that “education is a missing link” and one of the challenges faced by nurses in taking care of patients’ eyes, highlighting the absence of an evidence-based approach.The nurses’ did not possess adequate knowledge of eye care, which can be associated with inadequate nursing education in the field of eye care, ineffective assessment of nurses’ educational needs, unawareness of the importance of eye care for ICU patients in academic education, and the failure to pay attention of the necessity of implementing holistic and humanitarian care in nursing faculties, as indicated in the literature , 38, 39.The “nurses’ inadequate professional competence” was associated with nurses’ inadequate knowledge, nurses’ inefficiency in performing the assigned duties, and nurses’ negligence in eye care. The holism theory considers competency as a set of factors, including knowledge, skills, attitudes, thinking ability, and values needed in specific fields . KrokmyrOne of the challenges reported by the nurses in this study was unsafe nursing care. Accordingly, scholars believe that the first requirement for safe care in ICU is to meet the standards, and if these requirements are not met, optimal and quality care cannot be provided, resulting in unsafe care . AnotherDifficulty in evaluating eye care was another challenge reported by the participants. According to Asgari, “the first and most important factor in improving the quality of care is the evaluation of nurses’ performance in providing nursing care to patients”. EvaluatAccording to the nurses’ experiences, “organizational requirements” were associated with physician-centeredness, inadequate support from managers, and unfavorable working conditions that were caused by the absence of an evidence-based approach. Organizational requirements play a clear and significant role in the care process. Other studies indicated that organizational requirements are of great importance in providing quality care. According to Bucknall, although nurses consult doctors in cases where they cannot make decisions legally and independently, it is the doctors who make the final decisions .Nursing is one of the challenging jobs because nurses have daily interactions with patients, colleagues, and other health professionals but most nurses do not have many opportunities to express their opinions since they have to render care services for long hours in a tense atmosphere and enforce strict regulations. Nursing, as a critical, ambiguous, and transient occupation, has largely been downgraded in comparison with other medical professions .Coombs (2003) argues that the key structure and content of relationships between physicians and nurses to make decisions in intensive care are strongly influenced by basic knowledge and medical authority . It seemOne of the limitations of this study was that we only focused on nurses’ perspectives; however, the views of ICU doctors or the patient’s family could also provide richer information. Therefore, future studies can explore ICU physicians’ or family patients’ perspectives on eye care. As another limitation, this study was conducted on ICU nurses in hospitals affiliated with KUMS. It is recommended to conduct similar studies on nurses working in private hospitals and other wards and compare the results with the findings of the present study.Following the findings of this study, caring for ICU patients’ eyes has been neglected due to the lack of evidence-based practice. Thus, the Ministry of Health and Medical Education of Iran is required to prepare localized clinical guidelines and make appropriate fundamental decisions. If necessary, a directive can be issued to require hospitals to engage healthcare providers, especially nurses in the decision-making process. A clear guideline can improve the quality of nurses’ eye care and subsequently increase patient safety. Moreover, nursing education planners and educational managers are needed to revise the nursing education programs and academic syllabi to provide the necessary ground for the education of principled and correct eye care in academic and in-service training programs. Nursing managers can enhance evidence-based practice in clinical settings by creating a suitable organizational environment, adopting practical policies, enacting laws and regulations to facilitate evidence-based practice, and improving nurses’ competencies by creating a suitable platform for evidence-based practice.


A Land of Permanent Goodbyes by Atia Abawi. War fiction, such as Abawi's novel, highlights the concept of psychological trauma as a double wound (known as “outsiders” and unknown as “insiders”) through the textual analysis and characterization of characters by presenting their haunting pasts, present lives, and losses concerning traumatic events. The present study also recounts what the trauma of the unknown means to war-torn survivors by focusing on “trauma as double wounds” from three aspects: cause, effects, and recuperation. Finally, the study concludes with a new paradigm in which trauma is portrayed as a healer rather than a wound.The present study explores the concept of reenactment of known and unknown war trauma that may be unfamiliar to the readers while also opening up new discourses of understanding and empathy through the lens of Cathy Caruth's trauma theory by focusing on the novel  War and its catastrophic repercussions on the human psyche, which Sigmund Freud termed “traumatic neurosis,” create a “breach” in the “protective barrier” According to Caruth, the traumatized victim recovers from trauma by repeatedly recalling or going through past events. D. Laub pointed out that “the survivors [of the war] did not only need to survive so that they could tell their story but also needed to tell their story to survive” . Thus, aFurthermore, the latency of experience is also responsible for redundancy, the second significant idea attached to Cathy Caruth's concept of trauma injury. This insight hypothesis is the emergence of hope in the stories of destruction. Trauma not only destroys lives but also serves as a healer to restore the victim to a normal existence .Besides psychiatrists, writers like “Wilfred Owen” focused on psychological trauma to find a cultural definition of trauma that is as useful as the implications of trauma theory for determining the problems. Similarly, Sarah Cole also pointed out that the writers “emblematized the war not in death or in physical injure [sic] but in the psychological wound” . Likewise, Galsworthy argues the following:Stress has a more powerful and deep influence over literature as compared to war itself. In literary fiction, a common man or protagonist becomes a symbol and sign of psychological crisis who undergoes traumatic problems .The Reluctant Fundamentalist experiences. However, Arcimaviciene and Baglama  as a current portrayal of the forced movement of people around the globe from places experiencing anarchy. Amanda Lagji's  perspective did not get the attention it deserved. However, this study focuses on how relocation during a war leads to war trauma, causing identity crises and affecting victims' lives. The novel A Land of Permanent Goodbyes (2018) by Atia Abawi deals with loss, rape syndrome, the “othering” of migrants, and their struggle with identity, alienation, and survival. To the best of my knowledge, no researcher has yet analyzed the selected novel to highlight war trauma by applying the psychoanalytical approach of Cathy Caruth's trauma theory.Moreover, this paper on the fiction The study drew its methodology from Cathy Caruth's trauma theory, retained the memory of “unwitting” traumatic events, and focused on the notion of “the unknown” and “not locatable” trauma A Land of Permanent Goodbyes, which was written after Syrian and before the Russian attack on Ukraine. By doing so, the researcher used the “text and context of an event” In relation to the experience of a traumatic event and witnessing it, Caruth focused on the traumatic effect on a traumatized person by calling it a “threat [that] is recognized by a mind one moment too late” A Land of Permanent Goodbyes traces the life of a young refugee, Tareq, from a war-torn country, who loses most of his family members to the war and is forced to flee but suffers from what ard Said , commentard Said , (p. 11)Beyond the Pleasure Principle also suggests that repetitive behavior, flashbacks, and intrusive thoughts are imprinted in the subconscious as a reality or truth and are unavailable that Cathy Caruth  in his seminal work y Caruth  in her by known”  to the cy known” , p. 31)Beyond th Caruth,  pluralis Caruth,  explainsIn addition to losing a home, the war severely affects a victim's identity. Caruth calls it a “horrendous experience,” which is possible to access in normal consciousness later. In this study, “normal consciousness” refers to the trauma that resides in the unconscious in a timeless, speechless state that causes continuous pain and damage to the psyche Awabi's work also depicts neurosis effects on females concerning sexual exploitation and bodily injury during wartime, which works as a rule for “the development of a neurosis” [, (p. 12)Rape Trauma Syndrome” of war-torn migrants, a study showed that “the terrifying flashbacks and nightmares” cause traumatic “neuroses of war” among victims . In such situations, dreamers, like Muzhgan and Tareq, encounter a person who is struggling for life, and in the dream state, that person exists as if in reality, whether still living or deceased.Caruth commented on Sigmund Freud's On Dream Theory, saying that Freud compared unknown trauma to a recurring nightmare during sleep that produced a fear-based physical response, even after waking up: dreams that involve memories of traumatic experiences return patients to the psychological state induced by accident, a circumstance from which they awaken in distress (61). Moreover, on “Cathy's model's definition shows that once the “unknown” trauma is “spoken” and comes to consciousness, it becomes less “traumatic,” which, for Freud, was a “perplexing experience of survival”; otherwise, the victim remains in the “black hole” of trauma [, p. 9–1 stated, Writing History, Writing Trauma (2001), talks about two states with reference to trauma, i.e., acting out and working through. Acting out suggests the state in which the person is traumatized, engulfed in his fears of the past, and unable to escape that situation. He relives the same traumatic experience again and again and is unable to come out of that fear, while in the case of working through, the victim can differentiate between moments of trauma that he experienced in the past and moments of everyday life.Similarly, LaCarpa, in his work Involving trauma survivors in a dialectical process of listening and answering to the right to vote, empowering them within the context of a sympathetic denomination, is essential to normalizing their state or helping them recover from trauma. The first step to achieving this goal is trauma rehabilitation. The rehabilitation of trauma exposure supports the victim in working through the damaging force of the shock, which is repeatedly implicated in reviving their suffering, which exacerbates over time. Narrating a traumatic event through talk helps traumatized people work through the destructive force of trauma. This process enables them to remove traumatic highlights of the event repeatedly.In addition to a dialectical procedure, the enactment of trauma may also help the victim recover from trauma as the reenactment process is based on the quality, purpose, condition, and nature of reenactment within the social context in which it occurs. The social context covers the social position of the traumatized person and creates empathy for the witness or audience for the victim. The deliberate recovery of the trauma of an ongoing sympathetic social environment helps to alleviate unbearable stress or at least completely separate the victims from it. It not only harmonizes the survivors' trauma and traumatic events (such as war), which shock and embarrass their victims, but also establishes an emphatic link between society and the victim.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.


General medicine, as the Japanese version of primary care or family medicine, is critical for healthcare in aging societies. Medical students’ perceptions of general medicine and education might be associated with changes in the number of general physicians. This study aimed to clarify the association between these perceptions and students’ preferences for general medicine. A cross-sectional survey was conducted among Japanese medical students using a questionnaire on their perceptions regarding general medicine, background, and preferences for general medicine . The response rate was 70.3% (490/697). There was a large percentage gap between interest and motivation; therefore, a logistic regression analysis was performed to investigate the cause of this difference. The perceptions that general medicine meets the needs of society and the lack of general medicine educators were positively associated with motivation to become a general physician. In contrast, perceptions of lack of exposure to general medicine beyond the curriculum and inaccessibility were negatively associated with motivation. Medical students’ motivation to pursue general medicine may increase with improvements in flexible general medicine education and accessibility. Future research should investigate the relationship between students’ perceptions of general medicine and their motivation to become general physicians through longitudinal studies. Physicians engaged in primary care, called general physicians in Japan, are increasingly needed in aging societies . GeneralCurrent medical students’ perceptions of general medicine should be understood to improve general medicine education and the quality of practice. A previous study showed that a relatively high percentage of medical students are interested in general medicine. However, the number of general physicians is low, indicating high interest and low preference for acquiring specialties in general medicine . Our preFor effective general medicine education, in addition to medical students’ perceptions, their preferences for general medicine and related factors should be considered. Education in line with their preference for competency in general medicine may drive their motivation to become general physicians. In Japan, some studies have identified factors associated with a career choice in general medicine ,9; howevIn Japan, there is a regional quota called “Chiikiwaku”, which aims to train doctors to work in community medicine, alleviate the shortage of doctors, and require students to work in a designated region after graduation. The availability of scholarships and the length of mandatory post-graduation years differ among universities. In 2020, 18.2% of all admissions to medical schools were Chiikiwaku . In addiA cross-sectional study was conducted using a questionnaire to investigate the association between medical students’ perceptions of general medicine and their preferences for general medicine.This study was conducted among medical students at the Faculty of Medicine, Shimane University, Japan. Shimane is one of the most aged prefectures, with 34.3% of the total population of 674,000 aged 65 and over (as of 1 October 2019) . ShimaneIn 2021, there were 697 medical students at Shimane University, comprising 108 first-grade, 120 s-grade, 110 third-grade, 99 fourth-grade, 130 fifth-grade, and 130 sixth-grade students. They learned general medicine based on the Shimane University Faculty of Medicine curriculum in 2021  8,14]..14].Data were collected online from 14 September to 9 November 2021, using a closed-ended questionnaire. For students in the first to fourth grades and the sixth grade, we presented the online questionnaire with a QR code at the end of a face-to-face class and asked them to complete it. Fifth-grade students were asked to complete the form through social networking sites and personal negotiations because they were in clinical practice and did not attend offline classes.To measure the participants’ preference for general medicine, we used a logic model of human behavior change. According to the model, people change their behavior in four steps: knowledge, interest, motivation, and intention. The more knowledge people have about a particular behavior, the more interested and motivated they are to engage in it, leading to intention and the actual behavior itself. We asked about knowledge, interest, motivation, and intention regarding general medicine  using the following questions: (a) Do you know about general medicine? (b) Are you interested in general medicine? (c) Are you motivated to become a general physician? (d) Do you intend to become a general physician? Participants completed these questions on a five-point Likert scale .To measure medical students’ perceptions, we used a questionnaire established based on our previous study . The queWe collected the background data of the participants based on previous studies: sex , grade (grades 1 to 6), hometown (home prefecture), and Chiikiwaku (yes or no) ,9. Chiikp-value < 0.05. Questions with missing data were excluded from the analysis. All statistical analyses were performed using the Easy R software  [Fisher’s exact test was used to compare the proportions of categorical variables between groups. Variables using a five-point Likert scale were divided into two groups: . The grades were dichotomized as follows: pre-clinical years (grades one to four) and clinical years (grades five and six). Hometown was binomial based on whether it was local (Shimane) or not. Univariate analyses were performed between preference for general medicine  and other variables. In addition, we illustrate the proportion of each grade in the four preferences in graphs. The results showed a large gap between the proportions of interest and motivation in all the grades. Therefore, a multivariate logistic regression analysis of motivation was performed to identify the factors contributing to this gap. We used all 24 questions regarding perceptions of general medicine as variables, with statistically significant variables in the univariate analysis including “Hometown (Shimane or other)” and “Chiikiwaku”. Statistical significance was defined as a , Japan) .Anonymity and confidentiality of the participants’ information were ensured throughout the study. All participants provided informed consent before answering the questionnaire. The research information was posted on the hospital website without any participant information. Likewise, the contact information of the hospital representative was listed on the website so that questions about the research could be answered at any time. All procedures in this study were performed in compliance with the Declaration of Helsinki and its subsequent amendments. The Unnan City Hospital Clinical Ethics Committee approved the study protocol .p = 0.001, 0.029, and 0.019, respectively). All preferences  were significantly associated with Chiikiwaku . In addition, motivation for general medicine was significantly associated with the Shimane group (p = 0.005). There were three missing data for the hometown question, which were excluded from the analysis.The total response rate for the questionnaires was 70.3% (490 of 697), and the grade-wise rates for grades 1 to 6 was 86.1% (93 of 108), 63.3% (76 of 120), 81.8% (90 of 110), 92.9% (92 of 99), 48.5% (63 of 130), and 58.5% (76 of 130), respectively. The characteristics of clinical-grade, being from Shimane, male sex, and Chiikiwaku, were significantly associated with knowledge of general medicine. Regarding the perceptions of general medicine among the students, “Community-based medicine”, “Preventive care and public health”, “Homecare”, “Broad scope of practice”, “Balance between practice, education, and research”, “Meeting the needs of society”, “Diversity and development”, “Criticism from other specialists”, “Lack of educators”, and “Large Regional Disparity” were significantly related to knowledge of general medicine.Chiikiwaku was significantly associated with an interest in general medicine. Perceptions that were significantly related to interest were “Community-based medicine”, “Preventive care and public health”, “Broad scope of practice”, “Balance between practice, education, and research”, “Meeting the needs of society”, “Diversity and development”, “Difficulty”, “Lack of classes in the curriculum”, “Lack of educators”, and “Large Regional Disparity”.Motivation to become general physicians was significantly associated with the factors being from Shimane and Chiikiwaku. The motivation was also significantly associated with the perceptions of “Community-based medicine”, “Preventive care and public health”, “Broad scope of practice”, “Meeting the needs of society”, “Diversity and development”, “Lack of educators”, and “Large Regional Disparity”.Chiikiwaku was significantly associated with the intention to become general physicians. Among perceptions, “Ambiguity in career path”, “Lack of clinical practice in the curriculum”, and “Criticism from other specialists” had significant correlations with intention.We performed a multivariate logistic regression analysis, focusing on motivation. Among the positive perceptions, “Meeting the needs of society” was significantly associated with medical students’ motivation to become general physicians , and among the negative perceptions, “Inaccessible” was significantly associated with motivation . Regarding the factors affecting students’ perceptions, “Lack of exposure beyond the curriculum” was negatively associated , and “Lack of educators” was positively associated with their motivation  .This study found factors associated with medical students’ preferences  for general medicine, including their background and perceptions of general medicine. Our findings show a gap between the percentage of students interested in general medicine and those motivated to be general physicians. Furthermore, medical students’ perceptions of general medicine associated with this gap were identified as follows: “Meeting the needs of society”, “Lack of educators”, “Inaccessible”, and “Lack of exposure beyond the curriculum”. These findings are expected to play a crucial role in general medical education.The background factors of the participants that were associated with knowledge of general medicine were clinical grade, hometown, sex, and Chiikiwaku. Medical students’ perceptions of general medicine associated with knowledge were community-based medicine; preventive care and public health; home care; a broad scope of practice; a balance between practice, education, and research; meeting the needs of society; diversity and development; criticism from other specialists; lack of educators; and a large regional disparity. To the best of our knowledge, this is the first cross-sectional study to examine factors associated with medical students’ knowledge of general medicine in Japan. The students in the clinical years were significantly more likely to know about general medicine than those in the pre-clinical years. This result suggests that exposure to general medicine at community hospitals is highly effective in understanding general medicine ,17,18. KThe background factor associated with participants’ interest was Chiikiwaku. Medical students’ perceptions of general medicine associated with interest were community-based medicine; preventive care and public health; a broad scope of practice; a balance between practice, education, and research; meeting the needs of society; diversity and development; difficulty; lack of classes in the curriculum; lack of educators; and a large regional disparity. More students (66.3%) were interested in general medicine than in previous studies ,9. Our fCompared with the number of interested students, fewer students were motivated to be general physicians. We identified five factors associated with this gap. First, students’ perception of a lack of exposure to general medicine beyond the curriculum was negatively related to this gap. No study has clearly shown that a lack of exposure to general medicine is negatively related to medical students’ motivation to become general physicians in Japan. These data suggest that collaboration between universities and community hospitals and providing opportunities for students to be exposed to general medicine is critical to motivating them ,17,18. SThe percentage of students who intended to become general physicians was even lower than for motivation. The background factor of the participants associated with intention was Chiikiwaku. Students’ perceptions of general medicine associated with intention were ambiguity in career path; lack of clinical practice in the curriculum; and criticism from other specialists. The intention was significantly associated with the perception that the career path of general physicians was unclear. This result suggests that ambiguity in the career path makes medical students anxious about becoming general physicians. A previous study conducted on residents also showed that anxiety about the future was a barrier to choosing a department of general medicine . This maThe causal relationship between general medicine and regional quotas must be investigated. We could not determine whether Chiikiwaku as a regional quota of medical resources motivated people toward general medicine or whether those who opted for Chiikiwaku were more motivated toward general medicine in the first place. Previous studies have shown that students motivated to practice family medicine or in medically underserved areas during admission are associated with a greater willingness to practice primary care in rural areas upon graduation and after graduation ,27. On tThe association between a lack of exposure to general medicine beyond the curriculum and motivation toward general medicine needs to be elucidated. We cannot determine whether motivated students believe there is sufficient exposure or whether the lack of exposure has reduced students’ motivation. Previous studies have revealed that community-based medical education improves students’ motivation toward general medicine ,28,29,30The association between students’ perceptions of general medicine as inaccessible and challenging and their motivation toward general medicine needs to be investigated. We cannot determine whether inaccessibility is decreases motivation or highly motivated people are likely to have better accessibility. To the best of our knowledge, no research has been conducted on inaccessibility. Therefore, further research is needed to determine the causes of this perception and whether interventions to resolve it  will affect motivation toward general medicine. The relationship between students’ perception of general medicine as having a broad scope of practice and their motivation toward general medicine needs to be clarified. Whether the broad scope of practice is attractive and motivating or whether motivated people like to diagnose and treat multiple diseases is unknown. Recently in Japan, problem-based learning (PBL) has been conducted as a part of education in general medicine at universities. There have been several study meetings about clinical reasoning by general physicians, and many books have been published on the topic. One study found that general medicine rotations are associated with improved resident ability in clinical reasoning . In contIn rural contexts, community-based medical education accommodates general medicine education, which can be applied by various professionals. For effective education, general medicine education should include various stakeholders, such as nurses and citizens, to improve the quality of education ,38. RuraThis study had some limitations. First, students initially interested in general medicine may have answered the questionnaire, leading to self-selection bias. However, since the response rate was approximately 70%, the results could be considered acceptable. The response rate of the fifth- and sixth-grade students was low. This could be caused by the lack of clinical training because of COVID-19 and the lack of the timing of the explanation of this research face to face. Second, regarding the generalizability of results, it is unclear whether the results can be applied to urban areas since this study was conducted in a rural community in Japan. Third, we used a logic model of human behavior change comprising four stages ; however, further research is needed to determine whether other models may have been more suitable. Fourth, this study’s applicability to other settings must be further investigated. This study was performed in a rural Japanese prefecture; hence, the following study can be performed in other contexts to confirm the difference in the perception of general medicine and family medicine. Finally, since this was a cross-sectional study, causal relationships remain unclear. Further research is required to determine the causal relationships between the relevant variables.This study clarified the factors associated with medical students’ preference for general medicine. There was a large gap between the percentage of students interested in and those motivated toward general medicine. This gap was associated with factors such as “Meeting the needs of society”, “Lack of educators”, “Lack of exposure beyond the curriculum”, “Inaccessible”, and “Broad scope of practice”. These findings may provide clues for future interventions in general medical education. General medicine education should accommodate more medical educators in clinical settings and give concrete experience to medical students regarding meeting the needs of society and the broad scope of practice. Further research is needed to investigate the relationship between medical students’ perceptions of general medicine and factors such as general medicine education at universities, their impressions of general medicine, and regional quotas.


This principle constitutes an ethical “spine” of the practice. Other ethical principles of research ethics  make up an ethical “skeleton” of morally sound payment schemes by providing additional moral reasons for offering participants (1) recompense for reasonable expenses; and (2a) remuneration conceptualized as a reward for their valuable contribution, provided (i) it meets standards of equality, adequacy and non-exploitation, and (ii) it is not overly attractive ; or (2b) remuneration conceptualized as a market-driven price, provided (i) it is necessary and designed to help the study achieve its social and scientific goals, (ii) it does not reinforce wider social injustices and inequalities; (iii) it meets the requirement of non-exploitation; and (iv) it is not overly attractive. The principle of justice provides a strong ethical reason for not offering recompenses for lost wages (or loss of other reasonably expected profits).In contrast to most publications on the ethics of paying research subjects, which start by identifying and analyzing major ethical concerns raised by the practice  and end with a set of—more or less well-justified—ethical recommendations for using payment schemes immune to these problems, this paper offers a systematic, principle-based ethical analysis of the practice. It argues that researchers have a  Recompense amends to research participants for financial and non-financial losses or injuries resulting from their participation in research. Thus, this type of payment does not constitute a gain or profit, but merely covers—understood in broad terms—costs of the participation. Recompense may include three sub-categories of payments: (i) reimbursement of direct financial expenses incurred as a result of participation in research ; (ii) compensation for indirect financial expenses, i.e., losses, that arise from participation in research (e.g. loss of wage in result of taking unpaid leave from work); and (iii) compensation for financial and non-financial losses resulting from injuries suffered as a direct consequence of participation in research.“Remuneration” refers to any payment provided to individuals for their service as research participants, which exceeds expenses, losses or injuries experienced by participants as a result of their participation, and brings net benefit  for recipients. The remuneration for research participation (same as for “regular work”) may be understood either as a reward given in recognition of and as an appreciation for participants’ valuable contribution; or as a price—money given in direct, market-driven exchange for a service provided by participants  that have minimal market value, serve only as token of appreciation, and have likely zero impact on recruitment Grady .Having clarified basic terminological and conceptual issues, we can move on and explore the ethical anatomy of payment for research participants. It would be useful, however, to indicate briefly—from the outset—the scope of the forthcoming analyses.service without determining whether the service should be treated as an unskilled labor, “regular” work, body renting, or a unique sui generis endeavor  as a paradigmatic case of payment, leaving aside all forms of in-kind support. This paper also leaves aside payments to participants unable to give consent, because those raise additional, substantive issues, as well as recompenses for research-related injuries as they would require in-depth legal analysis. The presented analysis applies to research which RECs/IRBs would consider scientifically and ethically sound thus presenting arguments that payment is offered to overshadow or mask some ethical deficiencies of a study project, especially those regarding its risk–benefit profile or criteria of subjects selection. In other words, it considers “research which ethics committee would allow to proceed, were the subject not paid”  and obligations of all societies to protect other important interests of their members, especially interests of research participants and/or involved communities. These latter obligations may be viewed as constituting a general “imperative of non-exploitation” that sets boundaries for the practice of human biomedical research, in general, and for the practice of paying participant, in specific.Offering payment for research participants is an incentive One of the core values behind the imperative of non-exploitation in research is the value of human autonomy. The principle of respect for autonomy is a cornerstone of modern research ethics , thus compromising the validity of informed consent  exploitation.Another ethical principle that has a direct relevance for the practice of paying research subjects is the principle of justice, both in its distributive and commutative dimensions. Many scholars worry that payment may be more attractive to individuals of lower SES, and thus offering payment for participation may result in unfair distribution of research benefits and burdens across the general population , which should be mitigated, and ideally eliminated by broad social reforms. Research enterprise should not entrench or exacerbate these background social injustices. However, it is neither designed for nor capable of actively fighting them, especially against participants’ poverty, unemployment or lack of access to high-quality healthcare Fisher . JusticeMoreover, contrary to views of some commentators, the commutative justice per se does not require offering payments to research subjects. Largent, Emanuel and Lynch claim that “when goods and services are not indented as gifts, failure to pay for them is a problem: we call it theft” , p. 1, tprima facie required by social beneficence, not by justice or fairness. However, when it is to be offered, the offer should satisfy the requirement of distributive and commutative justice.Payment is a recruitment incentive justified and It is commonly accepted that the principle of justice requires distributing burdens and benefits of study participation in such a way that no segment of the population is unduly burdened by research or denied its potential or actual benefits. Recruitment criteria should reflect the scientific purpose of the study, not target populations which are considered “easy to recruit” “simply because of their easy availability, their compromised position, or their manipulability”  offered for a similarly time- and effort-consuming, burdensome and risky activity, outside research context in the same setting . Offering disproportionally high and/or differential remuneration does not violate requirements of justice insofar as the payment is designed to help the study to meet its social and scientific goals by enhancing recruitment and retention of the necessary category of subjects, and it does not reproduce or reinforce wider social inequities and injustices, e.g., racial biases or class differences ;remuneration conceptualized as a reward for their valuable contribution, provided (i) the remuneration meets standards of equality, adequacy and non-exploitation, and (ii) it is not overly attractive, i.e., it does not constitute undue inducement for participation or retention, and does not encourage deceptive behaviors;remuneration conceptualized as a market-driven price, provided (i) the remuneration is necessary and designed to help the study achieve its social and scientific goals, (ii) it does not reinforce wider social injustices and inequalities; (iii) it meets the requirement of non-exploitation; (iv) it is not overly attractive (as defined above).The paper argues that the ethical anatomy of paying research participants is built upon four basic principles of research ethics . The ethical “spine” of the practice is the principle of social beneficence, which requires the maximization of the common good—in the case of research practice—socially valuable scientific knowledge. This principle grounds a general Obviously, a proper application of this ethical “skeleton” into research practice requires investigators and RECs/IRBs to take into account “the nature of the study, the nature of participants contributions and vulnerabilities, institutional and organizational guidelines, and local and cultural norms” Grady , p. 1686


Insight is a complex and multidimensional phenomenon. Metacognition, awareness of illness or anosognosia are some of the terms used to designate this feature of the mental state exam.To attempt to explore the evolution of the concept of insight as a psychiatric symptom over the years and to bring up some up-to-date features on this theme.Literature review, using the most relevant papers, with the keywords “psychiatric insight”, “awareness of illness”, “metacognition” and “phenomenology”.The term ‘insight’ has been described since 1896 when Kraepelin had noticed that patients with dementia praecox were unaware of their condition. Nowadays, it is recognized in several psychiatric disorders, with different meanings in each one. Overall, insight in psychiatry involves an attempt to see one’s thinking and behaviour ‘objectively’ and comparing it to some representation of mental health. Impaired insight has been linked to poor treatment compliance and outcomes, overall symptom severity, higher relapse, lower self-esteem, and impaired psychosocial functioning. White matter and connectivity problems may be related to poorer insight, as well as impaired frontal lobe functioning. In psychotic disorders, lack of insight is a primary symptom with poorer outcomes. Regarding affective disorders, the lower the mood the better the insight. Neuroimaging has been correlating insight with the inferior frontal gyrus, anterior insula, inferior parietal lobule, and ventromedial prefrontal cortex. In everyday practice, there are scales used to assess insight.Inferences about patients’ insight are important to evaluate severity of illness, suicidal risk, compliance, and response to treatment.