The experience of Covid-19 has taught us many things, not least the consequence of what John Milton termed ‘gibberish law’. Law drafted amidst the ‘throng and noises of irrational men’. The closer purpose of this article is the attempt to regulate ‘gatherings’ during the coronavirus pandemic, including the re-invention of a bespoke crime of ‘mingling’. A jurisprudential curiosity which, it will be suggested, is symptomatic of a broader malaise. An assault on the integrity of the rule of law which is only too familiar; much, it might be said, like the arrival of a pandemic. The first part of the article will revisit three particular gatherings, in part to debunk the myth of the unprecedented. But also to introduce some themes, literal and figurative, of masking and muddle. The conjuring of what Shakespeare called ‘rough magic’. The second part of the article will then take a closer look at the jurisprudential consequence of this conjuration. The final part will venture some larger concerns, about the crisis of parliamentary democracy in the ‘age of Covid’. The experience of Covid-19 has taught us many things, not least the consequence of what John Milton termed ‘gibberish law’. Law drafted amidst the ‘throng and noises of irrational men’.As advertised, we will revisit three gatherings, stretching across two centuries, and taking us from Manchester, via northern Italy, to south London, and then Bristol. Our purpose, again, is to spot some resonances, and introduce some themes, prosaic and poetic, each of which speaks to the consequence of ‘gibberish law’.Starting then in summer 1819, on the Ligurian coast, at the Villa Volsovano. The home, in that moment, of the poet Percy Shelley. Shrouded in ‘melancholy’, having just buried his youngest child, his wife Mary enduring another bout of manic depression, his consolation was a large glass tower, to which he could escape, to stare over the bay, and read the newspapers, when he had the energy.Around 60,000 had turned up to listen to the famed Henry ‘Orator’ Hunt; arguing the case for franchise reform. Many from miles around, marching in organized groups, with bands and banners, carrying mottoes such as ‘Liberty and Fraternity’ and ‘Unity and Strength’.The Mask of Anarchy. Ninety-one stanzas, in three sections. The first thirty-four tore into the government of Lord Liverpool. A series of caricatures, as would be written into a Court masque. Murder, Fraud, Hypocrisy; attaching to particular political figures. Here, respectively, Castlereagh, Eldon and Sidmouth. Others too of course. But these were the three who Shelley held especially responsible. Eldon was the Lord Chancellor, with whom Shelley anyway held a grudge.The day after reading the report, Shelley wrote to his friend, Thomas Love Peacock, attesting to the ‘torrent of indignation… not yet done boiling in my veins’. He waited ‘anxiously to hear how the Country will express its sense of this bloody murderous oppression of its destroyers’. The ‘dread lighting’ of vengeance.Last came Anarchy: he rodeOn a white horse, splashed with blood;He was pale even to the lips,Like Death in the Apocalypse.…And he wore a kingly crown;And in his grasp a sceptre shone;On his brow this mark I saw –I AM GOD AND KING AND LAW! (30-7)11The poem reaches its brilliant crescendo in the ninth stanza, with the arrival of Anarchy; the figure before which all the ministerial sycophants cower:Over the English land he passed,Trampling to a mire of bloodThe adoring multitude. (39-41)Plain enough. But there are twists. Not least in the stanza which immediately follows:We will return to this ‘adoring’ later. It insinuates something about how anarchy is sustained. But also by how it might, ultimately, be defeated. The subject, indeed, of the second set of stanzas. Anarchy overcome by Hope. In the figure of the ‘maniac maid’ who stands up to the onslaught; an image which Shelley took from the account of a young woman trampled to death by the Hussars.The old laws of England – theyWhose reverend heads with age are gray,Children of a wiser day;And whose solemn voice must beThine own echo – Liberty! (333-5)The third set of stanzas paints a brighter picture, of democracy and liberty, in a distinctly English hue:The Revolt of Islam, and plenty more sonnets and verses.Enquiry Concerning Political Justice, at the heart of which was a simple thesis.Mask. Anarchy is not found in the crowds that protest, but is rooted in the terror of those who fear the protest. Which in August 1819 was the Manchester magistrates, and their masters in London. It was the ‘tyrants’ sat around Liverpool’s Cabinet table who had ‘first shed blood’.15At the title supposes, Shelley wants us to think about anarchy and masks, and how the latter covers the former. We will start with the anarchy, which meant something different then. Shelley knew all about the politics, and the theatre, of tyranny. He had written about it in his epic poem on the French Revolution, There are two reasons why Shelley’s poem has a particular prescience. The first is prosaic, the familiar truth, that governments, trapped and themselves terrified, tend to react violently. And they think nothing of cutting down liberty as they go. The second is to spot the more poetic resonances. Two again. First, that Shelley wrote a protest poem; about a protest. And second, the central metaphorical conceit; the mask and the masque. The wearing of a mask in order to prevent viral transmission during a pandemic may have a prosaic purpose. But it also has a semiotic resonance. In its original, tightly-conceived, design, the Renaissance ‘masque’ was all about the restoration of order. A first part depicting the ‘state of nature’, and its consequence, and a second during which calm is restored by a wise magistrate; albeit with the turn of a neatly placed heel, rather than the flash of a sabre-blade.Shake your chains to earth like dewWhich in sleep had fallen on you –Ye are many – they are few.Shelley knew all of this. It is why he selected the metaphor. The spectacle of government, purposed to awe. A masque of terror. With, in the end, a simple enough message: strip away the mask, and beneath lies the familiar face of tyranny. He closed optimistically:Mask to his friend Leigh Hunt, editor of the Examiner, at the end of the month. The news, when it finally filtered back, was disappointing. Threatened with prosecution for sedition, Hunt could not publish.18An excited, and exhausted, Shelley despatched a finalised draft of the At which point we will move forward two centuries, to 13th March 2021. Three days earlier the body of a missing woman named Sarah Everard had been discovered. Murdered, it transpired, by an off-duty police officer. The last sighting of Sarah had been near Clapham Common. An organisation named ‘Reclaim These Streets’ (RTS) approached the Metropolitan Police in order to facilitate a peaceful vigil, in accordance with existing Covid ‘regulations’. Which should have been possible, but proved not to be. The vigil was duly cancelled, but people continued to turn up during the day to pay their respects, many laying wreaths near a band-stand. As the evening drew on, numbers increased. Until, at some point, a fateful decision was made by senior police officers. Informed that the gathering was ‘static’ and ‘growing’, and might conceivably ‘present a health risk’, it was decided that the ‘vigil’ had transmuted into a ‘protest’, and should be dispersed. A dispersal order was read out. A handful might have heard it, not many. No-one moved. Absent any hussars, police snatch-squads were sent in; in the process radically increasing the risk of viral transmission, and setting in train what would prove to be a marketing disaster.19Leigh et al. v Commissioner for Metropolitan Police.The Home Secretary asked the Inspectorate of Constabulary to provide a ‘bespoke thematic’ report. Which returned a largely exculpatory verdict a few weeks later, albeit with a couple of caveats. Both reinforcing concerns expressed by the Metropolitan Police. The first bemoaned the marketing disaster, the second the state of the ‘frequently changing’ law. The matter did not, however, rest. Two months later, an All-Party Parliamentary Group (APPG) on ‘Democracy and the Constitution’ reviewed the events at Clapham Common. It concluded that the Metropolitan Police had failed on various accounts. First to engage ‘constructively’ with RTS. Second to ‘give transparency and clarity’ as to how it intended to police the regulations. Third, in failing to ‘conduct a proper assessment of the proportionality’ of its subsequent response to the ‘verbal resistance’. Such were the operational failures. Perhaps more serious were a set of broader intimations. First that the Met had applied a ‘presumption of illegality’ that was wrong in law. Something that was emphasised by Holgate J in his ruling, the day before the planned vigil, in The Everard vigil will continue to stimulate debate for some time. As it should. We will shortly contemplate the extent to which the events which unfolded on 13th March might be ascribed to the hazards of ‘gibberish’ law. In the meantime, though, we will contemplate the related issue, the adverse impact of the imagery. It matters every bit as much. Mary Shelley later recalled her husband roused to ‘indignation and compassion’ by what he had read of the events at St Peter’s Field.23Dismayed perhaps, but there was certainly no reason to be surprised. At least not, if the Home Secretary had read her Shelley. Or indeed her Bagehot. A journalist by training, Walter Bagehot knew all about the darker arts of public perception. How to spot a ‘political cheapjack’, how to play the part, how, most importantly, to keep the ‘bovine’ masses in a state of ‘mystic reverence’.27Later in the essay, we will contemplate John Austin’s suggestion, that the facility of law depends, ultimately, on a ‘habit of obedience’.31in extremis; though the subsequent jaunt to the bluebell fields of Barnard Castle was less easy to reconcile. And then, a year on, the Health Secretary, Matt Hancock, discovered groping an ‘aide’ in his office. Moral depravity is hardly a bar to a life of sorcery, as any devotee of the classic fairy-tale knows. But the context can vary, and the regulations in place required all sorcerers to remain at least two meters apart from any fair maiden they were trying to bewitch. A couple of days later, the lovelorn Secretary found that his magical powers had been ‘all o’erthrown’.34Which brings us to a couple more marketing disasters. Cautionary tales, to reinvest Bagehot’s metaphor, of sorcerers trapped in their own ‘rough magic’.The charm dissolves apace;And as the morning steals upon the night,Melting the darkness, so their rising sensesBegin to chase the ignorant fumes thatMantle their clearer reason.35As, of course, always happens. For no magic lasts for ever:Time to move on, to our third ‘gathering’. Which, to retain Prospero’s parlance, ‘transports’ us to Bristol.Police, Crime, Sentencing and Courts Act. The passing irony is patent; a series of protests against attempts to inhibit protest. The events on the 21st followed a customary course. An initial request to hold a march turned down by the police, who asked people not to attend for reasons of ‘public health’. Some heeded, some did not. A peaceful gathering which became more agitated, an order read out, which no-one appears to have heard, and a decision to break it up by force, followed by a predictably frantic attempt to exculpate. An evening of ‘thuggery’, pure and simple, the Home Secretary declared the following day. Violent, certainly, but the situation was hardly simple. The fact situation was contested, the law far from clear, and plenty of other ‘kill the bill’ marches in other cities had passed off peacefully enough.36A couple of gatherings in fact. The first just a week after the Sarah Everard vigil, on 21st March. A series of ‘kill the bill’ events had taken place over the preceding days, held to protest against the government’s prospective Public Order Act, to vest increased powers in the police to prohibit any ‘procession’ which might ‘result in serious disruption to the activities of an organisation which are carried out in the vicinity’ or may ‘have a significant and relevant impact on persons in the vicinity’. Section 55.4, notably, gives the Home Secretary power to determine, in secondary legislation, the meaning of ‘serious disruption’. Section 56 replicates the same for ‘static’ gatherings. Section 57 provides increased penalties for those convicted of holding, or joining protests, which have not been permitted by the police.In order to better understand what happened in Bristol on the 21st we need to think about causation, both in the immediate and the slightly longer-term. The immediate reason is found in the ‘bill’ that the marchers were hoping to ‘kill’, more particularly a number of provisions in Part 3, which amend the law in regard to ‘protests’. In effect, criminalising the existing law of public nuisance. Most obviously in Sections 55–57. Section 55 amends section 12 of the 1986 There is, of course, the customary declaration of compatibility with Convention rights, purposed to ward off potential legal challenges. The Convention right most obviously relevant being Article 11, the Freedom of Assembly and Association. The sub-clause of which permits ‘restrictions’ where ‘prescribed by law’ and ‘necessary’ in the ‘interests of national security or public safety, for the prevention of disorder or crime, or ‘for the protection of health or morals’. Whether this extends to merely annoying the neighbours, as section 55 might, is questionable. The reason why the government feels the need to place further restrictions on the right to protest, outwith present Covid regulations, can be found in the sentiment which underpins section 55. It is here that we need to conjure the slightly longer perspective.More precisely the consequence of an earlier march in Bristol, on 7th June 2020. This march, which took place during a brief lull between lockdowns, was organised in support of the Black Lives Matter movement. And culminated in a series of indignities inflicted on the statue of an eighteenth-century slave-trader named Edward Colston, which had stood on the dock-side since 1895. The idea that something might be done about the statue had been ventured before; hardly a man, it was supposed, deserving of commemoration.39A series of protests followed against more statues scattered about the country, to include not just slave-traders, but others who might be variously termed imperialist.42Rights worth having are unruly things. Demonstrations and protests are liable to be a nuisance. They are likely to be inconvenient or tiresome, at least perceived as such by others who are out of sympathy with them.43The concerns are evident. Some are principled, of the kind which underpinned Lord Justice Laws’s renowned observation, on being asked to prohibit another annoying gathering a decade ago:Ozymandias, published in early 1818:Half sunk, a shattered visage lies, whose frown,And wrinkled lip, and sneer of cold command,Tell that its sculptor well those passions readWhich yet survive, stamped on those lifeless things,The hand that mocked them, and the heart that fed…45Others assume, once again, the sillier aspect. A statute designed to protect statues. Milton would certainly have found it ridiculous. Better still to pass legislation requiring the ‘casting down’ of ‘idols’, the purpose of which was to keep the gullible ‘fatally stupifi’d and bewitch’d’.Ozymandias: time passes, and statues fall down. And a subtler. Statues are representative, and in the falling the representation mutates. We still comprehend them, but we do so differently. The statue of Edward Colston can still be seen on display in a city museum, replete with its new paint-work. Not left out of laziness, but because the colouring adds something to our appreciation of the statue, and its history. We might, or more likely not, be much offended by the dunking of Edward Colston. But we are certainly wiser for it.Ozymandias is the cannibalised version of the Greek name for the Pharaoh Rameses II, a serious slaver.Act, which duly secured Parliamentary approval the following July, will inhibit protest. They could, though for reasons we will shortly consider, the inscription of so many ‘dodgy definitions’ will militate against effectiveness.Act.Time will tell the extent to which the provisions in the new It should be beyond argument that clarity in the law is a virtue, for reason of both utility and justice. Especially, it might be supposed, where the law touches on what we might imagine to be ‘fundamental’ rights. Of the kind Lord Hoffmann had in mind, when he affirmed, in the plainest of terms, that such rights should never ‘be overridden by general or ambiguous words’.Province of Jurisprudence Determined, published in 1832. In Austin’s opinion, clarity of exposition was critical in the writing of good law.56There was not much that Milton had in common with his near-contemporary Sir Francis Bacon. This though; the surmise that laws badly drafted may not be properly termed law at all. ‘So if the law give an uncertain sound, who shall prepare to obey it’, Bacon wondered, before surmising that ‘certainty is so essential to law, that law cannot even be just without it’.Public Health Act and the 2004 Civil Contingencies Act. Neither were purposed for a viral pandemic. The latter was intended to deal with terrorists, but included useful clauses which facilitated the detention of anyone who seeks to disrupt ‘services relating to health’, or otherwise threaten ‘damage to human welfare’.A good point at which to turn our closer attention to ‘lockdown-law’. The framework for which is found in three statutes. Two are pre-existing, the 1984 Coronavirus Act is a vast document, in its original form comprising 102 sections and 29 schedules, many of which were purposed to bolster public health services. The greater controversy moves around the legality of Schedule 21, which permits the detention of ‘potentially infections persons’, Schedule 22 which can be used to prohibit ‘mass gatherings’, and Schedule 23 which permits a wide range of surveillance powers. Here again, there is no definition of ‘mass gatherings’. Given that the purpose of the Coronavirus Act was to provide a bit of cover, the masque of parliamentary process, the absence of much by way of definition is hardly surprising. Where there might be a meaningful distinction, between the ‘gatherings’ written into Schedule 22 and those alluded to in subsection C(4)(d) of the 1984 Act, is the possible application of the former to non-infected persons. Though we can only surmise; as we can the countervailing assumption that the meaning of the latter is for the ‘restriction’ on the movement of the infected only.The Health Protection  Regulations, under the aegis of section 45. Two concerning presumptions to note, in passing; subsection C, the predictable self-certification of Convention compatibility, and subsection R, which, ‘by reason of urgency’, justifies the limited presentation of successively amended regulations for Parliamentary scrutiny. We will revisit the issue of legislative scrutiny in due course. Our immediate concern is with the consequential mess. Evident, perhaps most obviously, in the confusion regarding the generic difference between legally-enforceable rules and statements of mere ‘guidance’. So evident, indeed, that the conspiratorially-inclined have surmised that the confusion might be ascribed to what Shakespeare termed the raising of ‘wild waters’.The substance of ‘lockdown-law’ is, of course, discovered in the hundreds of provisions published in successive Various social distancing ‘rules’ fall into the category of ‘guidance’, as does the instruction, in certain circumstances, to self-isolate after coming ‘in contact’ with an infected person.HealthProtection  (No2) (England) (Amendment) (no 4) Regulations.Our closer concern is, though, with the attempt to constrain smaller gatherings during the pandemic. Something which has its own, predictably confusing, history. For the present we only need to note the first part of this history, from March 2020 to September. By way of a timeline; all gatherings, of more than two, were prohibited during the first national lockdown, announced in 23 March; on 1st June this was adjusted to the so-called ‘rule of six’, at which point a first definition of ‘gathering’ was written into the regulations. A ‘gathering’, it was suggested, comprised ‘two more persons… present together in the same place’, for the purposes of ‘social interaction’.The re-imposition of the ‘rule of six’ was announced at 1140 on the evening of the 14th September, to come into force twenty minutes later. Here again some might detect a darker sorcery, the raising of ‘wild waters’. Conversely, it might just be a consequence of gibberish thinking leading to gibberish law. The scattergun nature with which so many regulations were announced during the pandemic intimates the latter. As did the rather frenetic appearance of the Home Secretary the following day, venturing onto the airwaves to try to explain what was going on. Before we see what she had to say, we should acquaint ourselves with the relevant piece of secondary legislation.Sub-sub-sub-sub section 2(3)(2B)(b)(ii) of amended Regulation 5 reads that no-one should ‘otherwise mingle with any person who is participating in the gathering but is not a member of the same qualifying group as them’. Founded on the broader proscription of ‘gatherings’ discovered in 5(5G), which was re-defined as occurring where ‘two or more people are present together in the same place in order to engage in any form of social interaction with each other, or to undertake any activity with each other’. All of which leaves the interested reader to wonder what a ‘social interaction’ might be, and indeed an ‘activity’. It is here that the ‘exceptions’ could help; or not. Amongst the explicit was a ‘gathering’ in a household of more than six, certain work and education exceptions, weddings, funerals and other ‘significant events’, along with various sporting and ‘licensed’ activities, to include grouse-shooting and paint-balling.It was evident, though, that ‘mingling’ was meant to be rather different. Sadly, though that difference was not itself evident. No-one knew what it meant. It was wondered if the placing of the ‘mingling’ provision imputed application only where there might be a nearby sanctioned ‘gathering’ to which the prospective mingler had not been invited. Maybe, maybe not. Otherwise, there was simply the discretion of passing police officers, and a bottomless pit of prospective anomalies, commonly of the ridiculous variety. A casual chat over a garden-fence perhaps, three on one side, four on the other. Did it make a difference if they were stood or moving up and down the fence? We might recall that it was the ‘static’ nature of the ‘gathering’ at Clapham Common which led to the band-stand assault. We do not need to conjure more examples to appreciate that the law of mingling was a classic piece of ‘gibberish’. One incredulous MP was led to wonder, tongue at least partly in cheek, whether there was now a difference in law between mingling, ambling and merely pottering around.And all despite the best efforts of the Home Secretary, who was invited to lend some clarity the following day in a BBC studio. She might as well have taken a seat at the Mad Hatter’s picnic-table. Mingling, she ventured, should be understood as ‘people coming together’; which came close to the idea of being ‘present together’, though perhaps not quite as close as she thought, one rather obviously more ‘static’ than the other. She was, though, unable to extrapolate further, at least on the semantics. And so, instead, sought sanctuary in numbers, taking the opportunity to explain what six meant. Which was somewhere between five and seven, and certainly less than eight; the latter of which could be comprised of two groups of four, and which was ‘absolutely mingling’. At which point, having shed as much light as she could, the retired, back down the rabbit-hole. With the parting shot that the situation would be helped if everyone could keep a close eye on their neighbours, to see that they were compliant. She certainly intended to.Oddly, the police were nothing like so convinced that the ‘war on the virus’ might be best defeated by an army of ‘curtain-twitchers’. There was not the resource to send officers chasing around the streets on the behest of twitchers. Neither, more importantly perhaps, could they make much sense of the new provision. Or most of the older. They were still asking for further clarification in regard the still relatively recent amendment which granted them discretionary powers to break-up larger ‘gatherings’ of thirty or more. How did that stand in light of the new provisions introduced on 15th September? The situation was not, in the context much helped, by the Home Secretary’s collateral advice, that the new law against mingling should understood in the ‘context’ of ‘keeping our distance, wearing masks’. The latter had some legal force, in certain circumstances, the former none. It was simply ‘guidance’. Whether the Home Secretary herself knew the difference is matter for conjecture.67A prophesy that would find a tragic prescience six months on. By which time, the aligned histories of ‘gathering’ and ‘mingling’ had mutated further, generally in response to a bewildering array of different metaphorical strategies designed to persuade everyone to ‘stay at home’; tierings, traffic-light systems, mole-whacking. On 5th November, a second national lockdown reduced the number allowed to gather back to two. On 2nd December it was back up to six. On 20th December it was back down to two, for anyone living in a Tier 4 area. On 5th January, everyone found themselves in Tier 4; which is when snowball-fighting was criminalised. It was also the regime in place when Sarah Everard was murdered. There might be a reasonable excuse as to why the law kept changing so frequently, and so suddenly. The inability to provide either the police or the public with sufficient notice or ‘clarity’ is less excusable. As the Parliamentary Joint Committee on Human Rights concluded. It was, in their considered opinion, the lack of ‘clarity’ which led directly to the shameful scenes witnessed at Clapham Common on 13th March.68The Crisis of Parliamentary Democracy.70It remains to conjure some conclusions, past and prospective. We will start in the past, with the publication in 1921 of a provocative essay entitled Something to ponder as we reflect back on the passing ‘age of Covid’. We can acknowledge the presence of parliamentary scrutiny, and occasional legal challenges against various aspects of ‘lockdown-law’, without accepting that they either suffice or convince.Areopagitica, published in 1644. There is no clearer evidence of tyranny than the attempt to suppress common ‘grievances’, and no more futile an endeavour. He famously likened it to the ‘gallant man who thought to pound up the crows by shutting his park-gate’.76It is this latter ‘right’, to protest, which is our closer concern. A right which is often assumed to be a litmus-test of a credible parliamentary democracy.On Liberty. At the heart of which can be found the critical difference, between mechanisms of ‘legal coercion’ and those of mere ‘persuasion’. The former being reserved only for actions ‘calculated to produce evil to someone else’.Ode to Liberty.And then forward again, to 1859, and another defining texts in the history of liberal philosophy, John Stuart Mill’s London Times, wondering, not least, if those gathered really had represented an ‘unlawful assembly’, that warranted the reading of the Riot Act. Or whether it was just an excuse to disperse a ‘gathering’ that was bothering some business ‘carried out in the vicinity’. Another journalist present was John Edward Taylor, who immediately began a subscription to found another newspaper. The first edition of the Manchester Guardian appeared in spring 1821, advertising in its prospectus that it would ‘zealously enforce the principles of civil and religious Liberty’.We might, as we move to a conclusion, return to autumn 1819. Shelley was certainly not alone in his condemnation of the events which had taken place at St Peter’s Field. A young journalist named John Tyas, who had journeyed to Manchester, filed a damning report in the Seditious Meetings Act.Not that Sidmouth seemed inclined to compromise. Cavilling journalists and activist poets were not going to deter him from doing his duty. Noting Tyas’s comments, he immediately set about strengthening the statutory regime. A couple of months later, Parliament passed a There will, in summer 2022, be a public inquiry into governmental responses to the coronavirus pandemic. It might invite along a few historians, and indeed poets, to contemplate the resonances. But probably not. More likely preoccupied by the prosaic question of why, despite an array of natural advantages, the UK ended up with the highest aggregate death rate in Europe, at the greatest economic cost.Law in a Time of Crisis:We will not recognise the end of democracy when it comes. Advanced democracies are not overthrown… Instead, their institutions are imperceptibly drained of everything that once made them democratic. The labels will still be there, but will no longer describe the contents. The façade will still stand, but there will be nothing left behind. The rhetoric of democracy will be unchanged, but it will be meaningless. And the fault will be ours.84Whether that leads us to share Lord Sumption’s misgivings is a matter for individual contemplation. The most ‘coercive’ regulatory regime ever ‘imposed’ by the ‘state, a ‘monument of collective hysteria and government folly’. A ‘remarkable… departure from our liberal traditions’, effected with a ‘cavalier disregard’ for the principle of the rule of law.Mask in this register:Stand ye calm and resolute…With folded arms and steady eyes,And little fear, and less surprise,Look upon them as they did slayTill their rage has died away. It is tempting to end here. But Shelley would have us hope, if cautiously, and he closed his The Triumph of Life. A metaphysical sequel to the Mask. No less hopeful, that ‘surging humanity’ will sweep aside the ‘hoary anarchs, demagogues, and sage’, but reconciled also to the ‘rhyme’ of history, which intimates that struggle between Anarchy and Liberty is protracted and painful (237). Shelley knew that the ‘Peterloo massacre’ would not be the last. Nothing that happened at Clapham Common on 13th March, or in Bristol a week later, or indeed six months earlier, would have surprised him. Nor should it us.Three years later, Shelley was dead, leaving behind an unfinished poem entitled


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Understanding stressors is an effective measure to decrease employee stress and improve employee mental health. The extant literature mainly focuses on a singular stressor among various aspects of their work or life. In addition, the extant literature generally uses questionnaires or interviews to obtain data. Data obtained in such ways are often subjective and lack authenticity. We propose a novel machine–human hybrid approach to conduct qualitative content analysis of user-generated online content to explore the stressors of young employees in contemporary society. The user-generated online contents were collected from a famous Q&A platform in China and we adopted natural language processing and deep learning technology to discover knowledge. Our results identified three kinds of new stressors, that is, affection from leaders, affection from the social circle, and the gap between dream and reality. These new identified stressors were due to the lack of social security and regulation, frequent occurrences of social media fearmongering, and subjective cognitive bias, respectively. In light of our findings, we offer valuable practical insights and policy recommendations to relieve stress and improve mental health of young employees. The primary contributions of our work are two-fold, as follows. First, we propose a novel approach to explore the stressors of young employees in contemporary society, which is applicable not only in China, but also in other countries and regions. Second, we expand the scope of job demands-resources (JD-R) theory, which is an important framework for the classification of employee stressors. Stress is an integral part of employees’ lives and occurs in a wide variety of work environments . EmployeA good understanding of employee stressors is an effective measure to decrease employee stress. Therefore, a significant number of research on employee stressors across various occupations have been developed over the last forty years. According to , there aWork-related stressors can be divided into direct stressors and indirect stressors. In terms of direct stressors, performance stress is the top stressor for employees . PerformBesides the direct stressors of work, there are another three indirect stressors. First, the negative effects of technology-related stressors  can cause stress by reducing employee productivity ,22,23. SIn addition to work-related stressors, studies have also identified family life as an important employee stressor. These studies focus on the following aspects: family financial stress, educational stress, and housing stress. First, employee stress is higher when they experience higher levels of family financial stress. Researchers suggest high rates of mental health issues among low-income families and their children ,29,30,31The above studies mainly focus on a singular stressor among various aspects of work and life such as performance stress, technology stress, commuting stress, etc. To our best knowledge, however, the literature has not presented a clear picture of all the comprehensive stressors from work and life that young employees are experiencing in contemporary society. In addition, there is research summarizing the previous research results on the stressors for young employees, but it does not verify these stressors using the real data . FurtherAnother research gap is that the extant literature generally uses questionnaires or interviews to obtain data. These research methods are conventional and have the following two advantages: (1) they save time, money and manpower; and (2) the results are easier to quantify. However, the problem with such measures is that the same test object provides all the information and therefore the statistical relationship between the structures may be inflated due to common source bias . In addiIn this paper, we introduced a machine–human hybrid approach to conduct qualitative content analysis of UGC to obtain comprehensive stressors. We divided the obtained stressors into mainly four categories: working process, family life, social media, and subjective cognitive bias. Finally, we give feasible suggestions to alleviate stressors.There are two contributions in this paper. First, we systematically studied the stressors for young employees in contemporary society and identified some new stressors. Second, to obtain comprehensive and objective data, we developed a machine–human hybrid approach to gain insights into stressors for Chinese young employees.The rest of this paper is organized as follows. We developed a machine–human hybrid approach to conduct qualitative content analysis for the identification of stressors for Chinese young employees from UGC. The proposed approach can be divided into five stages see . First, We collected the raw UGC from “Zhihu”, the largest Chinese social question and answering platform. Zhihu, which started their business in December 2010, provides long-term detailed answers and discussions raised by the users. As of December 2020, the total number of questions and answers on Zhihu had exceeded 44 million and 240 million, respectively. Users of Zhihu can openly and freely express their opinions on various topics. In addition, Zhihu’s data are available to the public and can be used for opinion mining .According to the literature, we choose several keywords that could directly point out that young employees were under stress. We searched the questions containing these keywords on Zhihu, and crawled responses to the three questions: “What makes young people feel tired?”, “Why do so many employees work overtime in China? and what are they doing?”, and “Why do young people in China have no desires?”. Here, “burn out”, “work overtime”, and “desirelessness” can all infer people are under stress ,37,42. TUGC contains a substantial amount of sentences that do not relate to the stressors. To improve the accuracy of subsequent machine-learning, we identified the informative sentences that can directly express stressors for employees. We treated the identification process as a classification task: the classifier will identify the informative and noninformative sentences, and label them as 1 and 0, respectively. The Convolutional Neural Network (CNN) model was chosen to train the classifier. As an important basic model in deep learning, CNN can automatically extract key features and has a short training time to avoid the tedious process of manual feature extraction ,44. In aAs mentioned earlier, texts cannot be directly calculated, so we needed to preprocess the informative sentences and map the words onto word embeddings. The process of preprocessing can be divided into two steps. In step 1, we segmented the Chinese sentences. Since the sentences were written in Chinese, it was necessary to split the sentences into words. We used “Jieba”, a Python software for Chinese text segmentation, to segment the Chinese sentences into a corpus. It is worth noting that, as mentioned earlier, we collected responses from three questions. We segmented the responses to the same question into one corpus. In this way, we constructed three corpora. In step 2, we removed the stop words. In the corpus, there were many stop words  that would significantly affect the efficiency of NLP and need to be deleted. We mapped the preprocessed words onto numerical word embeddings using the skip-gram model. The skip-gram model is a kind of language model, which is based on the artificial neural network. It can process large-scale textual data and capture the contextual information of the text . We implTo efficiently review the informative sentences, we clustered the words in the corpus into several groups based on word embeddings. We applied the “k-means” algorithm to cluster the keywords. This algorithm was implemented with the following steps. First, several words were randomly designated as the cluster centers of each group. Second, the distance between words and each cluster center were measured. Third, the words were classified into the nearest cluster. Fourth, each cluster center was recalculated. The iterations of the second and fourth steps continued until there was no further change in each cluster center. We clustered the words into 30 groups for each question, with a total of 90 groups. The words in the same group usually had similar semantics. The clustering results were saved for use in the next stage.Since the existing NLP technology is not able to really understand the semantics of the text, we have to manually analyze the meaning of the sentence. We randomly selected four sample words from each group, and extracted the sentences that contained the sample words from the UGC. We manually reviewed the extracted sentences and identified the details of stressors for young employees. Two professors and two graduate students participated in this operation. They conducted an evaluation based on the four eyes principle, which can effectively reduce serious error in judgment . InitialAfter reviewing the chosen sentences, we identified four main categories of stressors for Chinese young employees mentioned frequently by users of “Zhihu”: working process, family life, social media, and subjective cognitive bias. The dark blue central node represents employee stress. The light blue nodes linked with the central dark node represent four categories. The keywords included in the four categories are listed nearby. The number in parentheses express the counts of responses that mention the keywords. The first was working long hours. There were four main keywords related to working long hours: “working overtime”, which can stress the body as well as the mind; “health” and “rest”, where there is talk that working long hours will cause health problems and reduce the amount of rest time; and “stay up late”, where people mentioned that they felt a lack of entertainment due to their working long hours, so had fun at night, sacrificing their rest time. The second subcategory was dead-end job. There were four main identified keywords related to dead-end jobs: “hope”, which is at the top of the keywords mined from the answers, where many people mentioned that even if they worked very hard, there was little hope in their jobs; “graduation”, where new employees complained that they were always confronted with job stress; “COVID-19 epidemic” and “competition”, where due to the outbreak of COVID-19, many people felt higher competition pressure. The third subcategory was a rough time during work. There were mainly four keywords related to this subcategory: “supervisor” and “push”, where many people complained that they were often pushed to work overtime by their supervisors; “reward“, where many people complained that they were not rewarded enough for what they produced; and “resign”, where many people said that they dare not resign even if the job was painful. The fourth subcategory was the social life at the workplace. There were two main keywords related to this subcategory: “colleagues” and “boss”, where many people said that they did not get along with their colleagues and bosses. The fifth subcategory was a dislike of their jobs. There were two main keywords related to this subcategory: “dream” and “love”, where many people said that they did not love their jobs and they chose to suppress their inner desires and dream. The sixth subcategory was the commute to work. There were three main keywords related to this subcategory: “stop”, ”bus”, and “commute”, where many people complained that they struggle through the long commutes. The seventh subcategory was a lack of social security. There were two main keywords related to this subcategory: “squeeze” and “exploit”, where some people said that they faced exploitation and pressure caused by their jobs due to the lack of social security. Keywords emerged for family life were categorized under nine subcategories, see The first was low salary. There were two main keywords related to this subcategory: “salary” and “income”, where many people complained about the low salary. The second subcategory was high cost of family life. There were three main keywords related to this subcategory: “feed”, “marriage”, and “brother”, where many people said that they had to spend a considerable sum of money supporting their families. The third subcategory was high housing costs. There were three main keywords related to this subcategory: “buying houses”, “can’t afford”, and “house prices”, where a great number of people complained that the house prices were too high. Housing price was mentioned repeatedly in 5357 responses. The fourth subcategory was the high cost of getting married. There were two main keywords related to this subcategory: “get married” and “betrothal gifts”, where many people complained that getting married in China will cost too much. The fifth subcategory was daily consumption. There were two main keywords relating to this subcategory: “car loans” and “consumption”, where many people complained that daily consumption was too high to afford. The sixth subcategory was educational cost. There were three main keywords related to this subcategory: “kindergarten”, “kids”, and “tuition fees”, where many people complained that the educational cost was also too high to afford. The seventh subcategory was supporting aging parents. There were two main keywords related to this subcategory: “supporting aging parents” and “the elderly”, where many people mentioned that they had to spend a lot of money to support their aging parents. The eighth subcategory was health care expenses. There were two main keywords related to this subcategory: “health care” and” doctors”, where many people said that drugs, treatments, and seeing a doctor were very expensive, and they even dreaded being ill. The ninth subcategory was social pressure. There were two main keywords related to this subcategory: “parents”, where many people complained that they were under parental pressure to get married to anyone and “social situation”, where some people said that they had significant anxiety and depression due to poor ability to communicate in social situations.Keywords that emerged for social media can be categorized under three subcategories, see The first is the consumption of time and energy caused by social media. There were three main keywords related to this subcategory: “mobile phone”, where many people said that they spent a lot of time every day with their mobile phones unconsciously; and “video” and “Tik Tok”, where many people said that they watched videos on social media every night before bedtime, even when they came home late. The second subcategory was desire for materials aroused by social media. There were two main keywords related to this subcategory: “actual life”, where many people said that they dreamt of the high-end lifestyle spreading on social media, but were unable to make it happen in actual life, which would drag them into a deep depression; and “friend circle”, where many people said that they envied the lives of friends seen on social media. The third subcategory was lives occupied by busy working. There were three main keywords related to this subcategory: “punch a time clock”, “WeChat”, and “message”, where many people complained that since social media made it easier to contact them after work hours, their lives were further occupied by busy work.Keywords emerged for subjective cognitive bias were categorized under three subcategories, see The first subcategory was insatiable desire. There were three main keywords related to this subcategory: “desire”, “satisfy”, and “consumerism”, where many people said that they were passionate about the products out of their affordability. If their desires are not satisfied, they will feel frustrated. The second subcategory was the gap between the rich and poor. There were two main keywords related to this subcategory: “the gap between the rich and poor” and “the poor”, where many people said that through the information spreading on social media, they realize that there exists a growing gap that separates them from the richest people, and they are increasingly dissatisfied with their current situation. The third subcategory was the gap between dream and reality. There were two main keywords related to this subcategory: “gap” and “frustration”, where many people said that there exists a huge gap between their dreams and real life, which will lead to a sense of failure.Based on the above results, we found that working process was usually at the top of the list of stressors for young Chinese employees. These have centered on fears that their jobs have no future: the chance of being promoted is low, and it is even possible to get fired. Long working hours and heavy tasks also make them feel tired and under great strain. On the other hand, high living expenses such as buying houses, supporting aging parents, and so on, weigh heavily on their minds. In addition, it is worth noting that besides external pressures, many young employees are also constantly under the stresses resulting from the gap between their dreams and real lives. People have an easy access to luxurious lifestyles through social media, which can produce the illusion that they are inferior and lead to people’s discontentment with their current situations.The above results also provide further support for the JD-R theory. The identified stressors for young Chinese employees correspond precisely to the job demands, job resources, and personal resources. Job demands refer to those physical, social, or organizational aspects of the job that require sustained physical or mental effort and are therefore associated with certain physiological and psychological costs  . The ideThrough qualitative content analysis conducted by a machine–human hybrid approach, we developed a comprehensive understanding of stressors for young Chinese employees. Our results matched the JD-R model exactly. In particular, we systematically integrated employee stressors and identified three kinds of new stressors that have not been mentioned in the previous literature.First, we found that being squeezed by supervisors, as mentioned in Second, we found that affection from others see  could alFinally, we found that subjective cognitive bias see  plays anIn light of our findings, several strategic directions have emerged to reduce employee stress and improve the employees’ physical and mental health.First, we need to focus on the two kinds of stressors of being squeezed by supervisors and a dead-end job  as they Second, the negative impact of pressure from others and subjective cognitive bias are serious concerns. Strategies for limiting such negative impacts are therefore necessary. Employees should be guided to establish clear self-cognition, correct values and beliefs, and judgement ability for Internet information. Besides, websites should also be able to automatically identify, filter, and remove misinformation. Such methods are an effective means of alleviating employee psychological stress and promoting their psychological health. Third, efforts should be made to reduce the mental stress, mental fatigue, and exhaustion experienced by employees with a family life. Suggested policy recommendations include improving social welfare protections for wage-earners. The provision of practical support for raising children, supporting the elderly, and buying houses could help employees to focus on their work more easily. In general, interactive mechanisms between employment and social security help to vigorously ensure and improve people’s well-being, maintain social stability, and promote social harmony and progress.In conclusion, through the technology of natural language processing and machine learning to mine UGC on Zhihu, we proposed a novel approach to investigate the details on stressors for young Chinese employees. The proposed approach for stressor identification is applicable not only in China, but also in other countries and regions. We also contribute to JD-R theory by expanding the scope of resources . In light of our findings, we offer valuable practical insights and policy recommendations to relieve stresses and improve the physical and mental health of employees. Our study can be extended in several directions. First, this research lies in the fact that our conclusions are based on the answers to the three questions from one social question and answer platform. The UGC data are from a single source, and do not contain socio-demographic and socio-economic characteristics of the users or the specific professions. In the future, we can utilize UGC data from various sources and conduct research together with other traditional social science methods. Second, our approach can be further improved, since it still needs human reading sentences for categorization. In the future, we can utilize automatic text classification techniques and text generation techniques for categorization and interpretation. Third, this research only discussed the stressors from the lack of resources and the increase in job demand. We encourage future research to further explore the factors in the context of the entire JD-R model and examine the direct and indirect effects on and of resources on the stressors. Finally, all of our samples were collected from China. We encourage future research to further explore the employee stressors in different countries and compare the differences.


The Health Action for Psychiatric Problems In Nigeria including Epilepsy and SubstanceS (HAPPINESS) project trains non-specialist and primary health care workers in Imo State, Nigeria. This project adapted the World Health Organization’s Mental Health Gap Action Programme-Intervention Guide (mhGAP-IG), emphasizing stigma reduction among trainees. This convergent mixed-methods proof-of-concept study evaluates the HAPPINESS pilot project mhGAP-IG training’s impact on mental illness stigma among trainees and barriers, facilitators, and opportunities to consider for project improvement.n = 13) completed a 43-item questionnaire before and after their 5-day training to assess perceptions of mental disorders and attitudes towards people with mental illness. These responses were analyzed using paired-sample t-tests for four subscales of the questionnaire: acceptance of socializing with people with mental illness, normalizing activities and relationships with people with mental illness, supernatural causation of mental illness, and endorsement of a biopsychosocial approach to mental illness. Semi-structured key informant interviews (n = 11) with trainees, trainers, and local health officials who participated in or supported the HAPPINESS project were thematically analyzed to understand their experiences and perspectives of the project’s barriers, facilitators, and opportunities.Trainees . No significant effect was seen on the biopsychosocial subscale; however, evidence of biopsychosocial beliefs was found in interview responses. Key informant interviews revealed that the HAPPINESS project enhanced trainees’ diagnostic and treatment abilities, mental health awareness, and empathy towards patients. Misinformation, stigma, inadequate funding, and lack of road access to clinics were identified as barriers to mental health care integration into general care in Imo State. Respondents also suggested ways that the HAPPINESS project could be improved and expanded in the future.Trainees showed significant improvements on This study adds to the limited evidence on the implementation of mhGAP-IG in Nigeria. Using mixed methods, it evaluates how mhGAP-IG can impact perceptions and knowledge of stigma among primary care trainees. It also highlights barriers, facilitators, and opportunities to consider for project growth. Future efforts should focus on clinical support, supervision, health outcomes, as well as scaling up and assessing the cost-effectiveness of the HAPPINESS project intervention.The online version contains supplementary material available at 10.1186/s12913-022-07703-1. The prevalence of mental, neurological, and substance use (MNS) disorders is on the rise globally . These rDespite these dire numbers, only about 10% of Nigerians with mental disorders receive any formal specialist mental health care irrespective of severity . Poor anIn accordance with emerging evidence and WHO recommendations, Nigeria’s Mental Health Policy (adopted in 1991 and reviewed since) established that mental health care was to be integrated into primary healthcare, with responsibility for implementation delegated to local governments . This poFinding innovative approaches to increase access to effective treatments for MNS disorders in LMICs like Nigeria is in line with WHO Sustainable Development Goals ; howeverHealth Action for Psychiatric Problems In Nigeria including Epilepsy and SubstanceS (HAPPINESS) project. In particular, this study identifies implementation barriers, facilitators, and opportunities, with a focus on the impact of its training component on mental illness stigma among trainees.The mhGAP-IG has been implemented and evaluated in many countries. In a review of 162 studies, Keynejad et al. concluded that more research is needed to look at mhGAP implementation especially focused on contextual adaptations . In otheTraining, Refresher Training, Clinical Practice, Support Supervision, Community Engagement, and the Drug Revolving Fund (DRF).In 2018, the Yale Global Mental Health Program and CBM International, in collaboration with Imo State University Teaching Hospital (IMSUTH) and Imo State Primary Healthcare Development Agency, initiated the HAPPINESS pilot project . During Essential Care and Practice, Depression, Psychoses/Mania, Epilepsy, and Substance Use Disorders and made relevant adaptations based on local needs. We also created a module that focused on stigma reduction. Adaptations, module selection, and the idea to embed a stigma module into the mhGAP were decided during the needs assessment meetings.The training aimed to improve knowledge of MNS disorders, attitudes towards persons with mental illness, and skills in assessing and managing MNS disorders. Of the nine modules in the mhGAP-IG, we chose depression teaches symptoms/signs, differential diagnoses, assessment, including risk assessment, and biopsychosocial treatment planning over time. The module on psychoses/mania teaches both psychosis versus mania in bipolar disorder symptoms and signs, diseases’ natural history and course over time, assessment, and treatment planning including managing adverse reactions and side effects of medications. The module on epilepsy teaches convulsive versus nonconvulsive seizures, contextual symptoms and signs, causes, and assessment . The module on substance use disorder (SUDs) introduces the misuse of substances , khat, tobacco, stimulants), their signs and symptoms, biopsychosocial impact, assessment of SUDs, and the biopsychosocial treatment and management over time. It also includes motivational interviewing and management of medical and psychiatric emergencies related to SUDs such as intoxication, overdose, and withdrawal. The module on stigma reduction discussed common, local stigmatizing language, myths, beliefs, and ways to decrease associated stigma, discrimination, and human rights violations.The module on observed practice sessions to evaluate trainees on MNS screening, assessment, treatment, and follow-up planning. Post-training certification was based on the following: 100% attendance to all training activities, a score of at least 90% on the post knowledge test, and a “pass” grade on the observed practice session as scored by trainers according to pre-set competency rubrics . A one-day in-person refresher training was scheduled for every six months for all trainees and topic-based discussions using a group WhatsApp forum was planned for every two weeks. Refresher training topics included depression and substance use as these were deemed high priority by clinicians. WhatsApp forums were led by primary care nurse trainees on a rotating basis (nurses from different participating PHCs took turns every two weeks) and topics varied depending on need .The training was delivered in person, facilitated by five trainers experienced in mhGAP-IG training. It was a 9-hour per day, 5-day training (with scheduled breaks) that contained sessions composed of didactics, group workshops, and role-plays. Didactics were based on mhGAP-IG modules with adaptations made, following initial needs assessment meetings with community stake holders and clinicians, to include local content, examples, and narratives  for all the trainees depending on their roles in the primary health center  also engaged with local groups, individuals, and organizations to create mental health awareness and disseminate information about the project.The project utilizes a DRF to ensure consistent availability, affordability, and accessibility of high-quality psychotropic and anticonvulsant medications for those who need it . MedicatImo state has a population of about 4 million people, with 527 PHCs staffed by 453 nurses, 76 community health officers, and 864 community health extension workers spread across the State’s urban and rural areas (as of 2017). Each center has a part-time or full-time covering physician. During initial planning meetings, 10 PHCs from five local government areas of the State were selected for the pilot study based on the availability of staff (to take over while some attended training), proximity to the state capital , and geopolitical representation.This is a convergent mixed-methods  proof-ofAs a part of the HAPPINESS project’s SOP, all trainees completed a paper-based pre-and post-initial training stigma questionnaire that captured the local stigmatizing beliefs and negative attitudes about mental disorders. The questionnaire took 15–20 min to complete. Trainees were not additionally compensated for responding to the questionnaire but were given meals during the training and reimbursed for transportation costs. Trainees’ perceptions of mental disorders and attitudes towards people with mental illness were assessed using a 43-item questionnaire , profession , where they were born, and where they currently live.“innovation characteristics”, “outer setting” , “inner setting” , and “characteristics of individuals”   with psychosis. After treating them, they become better and go back to their families, they gained back their responsibilities.“ – Primary Care worker.“Many noted a drastic improvement in their ability to detect, diagnose, and treat mental illness. For instance, the workshop taught them how to record and use Patient Health Questionnaire-9 (PHQ-9) and Brief Psychiatric Rating Scale (BPRS) scores to screen for and assess the severity of common mental disorders. Trainees also reported increased belief in the importance of counseling:“I think the most important thing is counseling. Every patient needs counseling. Because one out of every 10 patients have an MNS condition, even silently […] so we counsel them […] they tend to open up things that you may not have really known. Or they have an issue that they never wanted to say. We need to create that good relationship with the patient and try to let them know that everything I discuss with you is private, is between you and (inaudible), except when they give you consent to discuss these things [with others]” – Primary Care Worker.A psychiatric nurse also noted marked improvements in her ability to diagnose and treat patients with a mental illness (including providing the correct drug dosage), despite being a psychiatric nurse who was already formally trained in psychiatry:“We [found] it difficult before, to give diagnosis but after the training, most of us, even those who are not psychiatric nurses can now identify the mentally ill…we now make the right diagnosis. Even when I can’t do it myself, I’ll call  and [they’ll] give the right diagnosis. We give the right diagnosis, we give the right drug […] with this project, it’s actually really improved my knowledge and gave me [a] wider knowledge of psychiatry, so I’m impressed and happy”.“Some of them [used to] react to the dosage but nowadays, since this training, none of my patients have reacted to dosage, because I give them the right drug dosage now”.Lastly, many respondents indicated feeling confident to apply what they learned in the training workshop to practice. Notably, there was one occasion where the psychiatric nurse advocated for their patient, who would have been arrested by the police if they did not step in:he had a problem with somebody and they started beating him, the police arrested and they locked him up, so I went to the police station and I told the cops in charge, I said, please don’t beat this person, he is a mentally ill patient, he doesn’t know what he’s doing… he’s not mentally sound, this and that, and I said he’s my patient [… ] I stood my ground because I know what I am saying…”.“The training equipped the nurse with the confidence to advocate for their patient, which was rooted in their new and more expansive knowledge of mental illnesses.The training also led to a changed attitude regarding mental illness. Many developed a sense of empathy and respect for patients. This went on to change the way they interacted with patients, as well as how they provided treatment to patients:most of them need privacy [for the] patient doctor-relationship, [we need] to create that perfect environment for them … so I ask, are you okay? Do you need somebody to stay with us? […] I’ll keep the patient’s relative outside … just to make the patient feel comforted. And first off, I need to let them know that whatever we’re going to discuss, [will] be confidential, [will] be between me and the patient” – Primary Care Worker.“… “I’ll go ahead to ask them if they permit me to bring in a colleague or a nurse […] and if they say no, I don’t go ahead, I respect their decision” – Primary Care Worker.These primary care workers described how they altered the environment and treatment approach to make patients feel more comfortable and that their autonomy was being respected. They also noted pre-workshop versus post-workshop ideas about people with MNS disorders in the following quote:“[I] felt that [before], [we were] not really tending to MNS […] because of, probably because of their environment and how violent they can be. You know? But after that training, I was able to […] show love to these patients. They can be understanding to you, can listen to you or […] instructions […], the training made me realize that we are all one […] they have the same problem […] it’s just a sickness that needs to be treated” – Primary Care Worker.This mentality of “they are just like us” and that the patient has an illness that needs to be treated is evidence that some respondents may have developed a biopsychosocial view of mental illness. Related to this mindset, some participants also mentioned the importance of helping patients integrate back into society and regular life  after treatment.In general, respondents had positive views of the DRF. They noted that although it involved a lot of “paperwork”, it led to drastic improvements in the ability of patients to pay for and adhere to treatment. The following quotes show, from multiple perspectives, that the DRF is beneficial for patients and affordable:“[…] financial constraint is another problem because you have a family that doesn’t have money to afford medications […] so if you have no money, you can’t be treated. So, I think the program can help to either reduce the funding from bill of these patients or trying to subsidize so everyone can access treatment irrespective of your income”- Primary Care Worker.“They don’t complain even though financially, things are not suitable for most people even though it is very, very affordable for them, but some of them take it with ease, some come and pay half and half. But in my clinic […] I told them don’t ever stay at home because you don’t have money to take your drugs. Please take your drugs, please be stable. By the time your patient is stable and improving, the patients’ relatives will not hesitate to pay for the drugs […] they pay for it” – Psychiatric Nurse.intramuscular injection as opposed to oral administration; for example, when health workers encounter severely agitated patients:The main limitation of the DRF is that it only covers oral medications that are found on the country’s Essential Drug List . This reusing the drug revolving fund. But the problem with that, [we don’t] get access to injectables, we only have oral drugs. And like…Yes, most psychotic patients find it hard to take oral drugs initially. If you can inject them, they will calm down and then start taking oral drugs” – Primary Care Worker.“I’m All the providers we interviewed noted many existing barriers to mental health care in Imo State that could influence the success of the HAPPINESS project. The following quote by a mental health specialist highlights the main barriers that are experienced by people who are seeking care:“There is no insurance to cover mental health in the country, so treatment is basically out of pocket. The barriers to care [include] the distance [and] accessibility to care. Most of the patients live in the rural areas, [but] the facilities are located in the urban areas. So, there is a very large distance for them to [travel] to access care, which is very expensive. [Other barriers include] […] lack of knowledge and lack of awareness about mental health. A lot of people still believe that they are caused by spiritual power, and the severe lack of… nurses, doctors, social welfare workers, therapists, I don’t think there’s any in the state now, clinical psychologists are very few…”.An inadequate physical environment, lack of funding, and poor availability of mental health professionals were noted as barriers to mental health care that have persisted in Imo State.Many respondents noted a lack of basic health care tools in many clinics . Moreover, project supervisors claimed that routes leading to PHCs were difficult to physically access.Lack of funding was commonly mentioned as a barrier to seeing a mental health worker or to acquiring medications that are prescribed for treatment. There are very few mental health specialists in Imo State; thus, people living in more rural areas have difficulty accessing treatment. Moreover, people must be screened and referred before they can access care from a mental health specialist (they may not self-refer).Regarding the supply of mental health workers, there are relatively few programs in Nigeria that train and produce psychiatrists:“We have two colleges, the [National Postgraduate Medical College of Nigeria] and the [West African College of Physicians] for training of a specialist. And then when you graduate, the training averages 4–6 year for you to become a fellow of the college and when you graduate you become a psychiatrist, a general psychiatrist […] because of brain drain, most of the personnel (these trained psychiatrists) are outside of the country”- Mental Health Specialist.Aside from the limited availability of mental health specialists, there are a limited number of health workers  that are already overburdened. Many trainees noted working full days, 7 days a week, and frequently working overtime:“[I work] from 8 o’clock. The official time is [to] 4 o’clock, but I go beyond that if I have a patient or if [anyone] calls me on the phone that they’re coming, I have to wait for them. So specifically, I don’t have times when I don’t see anybody and leave. – Psychiatric Nurse.A severe lack of mental health awareness was frequently noted by all the interviewees as a common upstream challenge to receiving adequate care and early diagnosis. In particular, they noted high levels of misinformation and stigma among the general population and local community leaders. The following quote by a primary care worker details the severity of stigma that people are facing:“Most of them are scared. They don’t want to tell their neighbors, or [their] son or [their] daughter or [their] friend […] that they are having this problem, so that they don’t stigmatize them. So, they tend to hide this problem, and this problem is killing the patients. So, it’s a very big problem, so I think that has been a stumbling block”.Another theme related to a lack of awareness is that underlying mental illnesses are often ignored and go undetected because mental health is the last priority. At the health system level, resources and attention tend to go towards acute and chronic physical illnesses and conditions, rather than mental health. This lack of awareness leads to a delay in receiving the correct and suitable care. One state health official demonstrates this in the following quote:“The person that comes with the thing that is malaria, that’s the reason why they came to the health center. Or they may have typhoid fever, meanwhile the issue [that remains] is depression”.The majority of respondents talked about the urgency of taking measures to ensure that people with MNS disorders are diagnosed and treated as early as possible. Many were concerned that those affected by mental illness get exposed to alternative treatments , which are viewed as improper treatment. These treatments reportedly often involve violence and are perceived as very harmful to individuals:“I also experienced a case where this patient had this condition and the parents took the patient to somewhere where they were flogged […] in general in rural [settings], creating awareness that once someone, your child or your daughter, or your son is having this problem, or someone you’re familiar with is having this problem, please don’t do this. You can’t […] look at [the] difference, there are fully steps you can take to ensure that this patient gets treated.“ – Primary Care Worker.Many respondents viewed increasing awareness as a key element to early detection and proper treatment. They also believe that raising awareness and educating the public is essential to combating stigma as a barrier to treatment. They suggested raising awareness through paper advertising , media advertising , and directly engaging with churches. The content of awareness initiatives should include basic information about mental illness and advocate for bringing those  to clinics rather than churches. Additionally, they emphasized partnering with local government leaders on awareness-raising initiatives.The target for awareness-raising should be the entire community, people with a mental illness, and their families. Specifically, these should focus on educating people on what mental illness is, its treatability and what are safe treatment settings:“it also made me to realize that whenever I see families, [I tell these] families – don’t chain [your] loved ones because of these conditions […] I need to intervene as quickly as possible, you know, let them know that this is not the right way to do it” – Primary Care Worker.“probably tell the villagers […] you should accept them, be friendly with them … give them a chance to say something, contribute […] And probably to teach them the signs [to] notice earlier. Because a mentally ill patient may not know because some of them lack insight. Even when you tell them, they say no. So, when they see such people…they bring them to the clinic and they better. They shouldn’t be hiding them because of stigma or what people will say, they should help the patients” – Psychiatric Nurse.The person who has a mental illness may not realize they have a mental illness; thus, it is up to the community and people around them to not impose and exacerbate stigma, to recognize that someone may have a mental illness, and should consider seeking professional help. Moreover, a reduction of stigma in the communities will be conducive to helping individuals recover.In-person supervision post-training was also key to project implementation:[After the HAPPINESS project] I have someone around that always visits [the] office. I feel happy when [the project supervisor] around, if I have patients I will say, talk to them, take care of them. And [the project supervisor] does” – Psychiatric Nurse.“However, supervisors noted that they are strained and have difficulty accessing the primary care centers:“We do supervision, the circuits. Because we need to supervise them. Not just training them and leaving them, they need to be supervised […] I’m the only clinician at the training part of the training now. Though we have a project coordinator who goes twice a month to collect data.“ – Mental Health Specialist.“We need to supervise them. Not just training them and leaving them, they need to be supervised. So, it’s been difficult doing the supervision because of the state of the routes, the routes are very bad. We don’t have a project vehicle, which is a very urgent need. The roads and centers cannot be accessed using a normal [vehicle]” – Mental Health Specialist.Respondents commented favorably about the training materials  and found them to be a helpful resource when they are unsure about a patient or unable to reach a mental health specialist. Moreover, the WhatsApp forum was transformative, especially when there were no mental health specialists physically or virtually available. It provided a quick way for trainees to ask for help and seek advice from specialists and fellow trainees.Participants also suggested several improvements to the training itself, including additional training materials and topics, and amending the training structure and length. For additional materials, one respondent suggested making a website to collect information from the training:this program has been so helpful, but I still want to know more. You should create a platform, we already have one (the WhatsApp forum), but I don’t know if we have everyone. We should have access to a website where we can see materials to improve our knowledge about MNS conditions that would be great” – Primary Care Worker.“…Some respondents also desired new topics such as child mental disorders, cognitive behavioral therapy, and other neurological disorders. Some respondents also reported that more in-depth training would help them differentiate between different disorders and improve identification and diagnosis .“MNS conditions can be confusing. So, it can really be confusing, and we need to understand every aspect of these conditions. I think they need to go deeper. So, we can be able to differentiate. Um, these conditions, everybody sees it, then most of the times it can look like the symptoms” – Primary Care Worker.“I want to know the difference between depression and anxiety, and manic depression. I want to know the differences. Manic depression and depression and anxiety” – Psychiatric Nurse.Most respondents believed that the training was “rushed” and that there was “too much information”, but they liked the way materials were taught . For this reason, many suggested a 7-day training, with a refresher every 3 months (compared to current 5-day training with a refresher every 6 months). Respondents also indicated that the project should continue to provide travel stipends and lodging for the duration of the training:“…residential training is good, and you know the cost. They have to take care of the logistics and also pay for the transports and all the other out of pocket expenses” – State Health Official.“…if you increase it to 7 days, of course, it would be better, but it needs to be an in-house training so that some of the rural health centers [can attend]” – State Health Official.Some respondents also expressed that some trainees felt “rushed” because they were coming in with different expertise. Thus, many suggested training different professions separately:“So I think the training can be increased, you can have a separate training for doctors and nurses, then you have for the CHEWs, you also have a separate training for them because for those you need to be slow […] some of the CHEWs, they’re going to start from the basics, so they need time” – State Health Official.“I think that doctors should be trained differently, separate from nurses and also CHEWs because this one uses SOP’s (standard operating procedures) that doctors that use to treat. So, the content really shouldn’t be the same” – State Health Official.Professionals from different backgrounds may learn at different speeds, and these differences could be better addressed by training them separately. Additionally, each profession has a different SOP, meaning they have different skills and scope of practice for treating patients. Conversely, however, one primary care worker expressed their desire to share information between different types of professions.Respondents were favorable towards the current HAPPINESS project retention strategy of only recruiting trainees who will be staying in their location for at least two years. Respondents suggested multiple retention strategies including that the HAPPINESS project should provide travel and lodging for trainees and have adequate resources within clinics. Many respondents also thought it was important that training should only be for those who are motivated and passionate about mental health. Respondents believe that people without motivation will be passive learners and not gain a lot from the training. There was also concern that people will misrepresent their roles after being trained as being a mental health specialist:“Somebody can just try this training and put on his or her bag and walk into the village and say, you know, now I am a psychiatric doctor, if anybody, please come to this address. Those are the things you people have to avoid and you use those within the health system. That’s my own advice, it’s an opinion. If you use people that are not into health, they can’t do what I’m doing, in the villages […] with formal training, yes, doctors, nurses, community health workers, yes” – Psychiatric Nurse.When asked about how the HAPPINESS project could expand, respondents suggested recruiting more trainees and partners.All respondents agreed that there should be more trainees in the future. This could involve an expansion beyond the 5 local government areas (LGAs), to the rest of the total 27 LGAs, or the inclusion of trainees from a wider range of backgrounds :“I still see those 5 local governments, meanwhile we have 27 local governments. So, the training can [be increased] so that all 27 local governments can benefit” – Mental Health Specialist.traditional rulers, and the local governments. They believed that with more links to these community stakeholders, the chances of helping people with MNS disorders increases. Traditional rulers  were commonly noted as they are the stable, sustainable interface between LGA’s and the communities. Thus, they would be useful in getting community buy-in and long-term support for the project.Respondents also suggested forming more partnerships with potential local funders, the local community, schools, churches, ideological changes and promoting early detection and raising awareness sub-themes. The questionnaire found that trainees were significantly improved on the socializing, normalizing, and supernatural causation subscales, which complements respondents’ reports that they developed a better understanding of mental illness and had more empathetic and respectful interactions with patients. These findings were also bolstered by participants’ expressing that the HAPPINESS project should raise more awareness about mental health to prevent alternative treatments . The quantitative result for the biopsychosocial subscale  was the only subscale with an improved but non-significant change pre-and post-training. However, evidence of improvement in this biopsychosocial view of mental illness was also seen in the ideological changes sub-theme from the qualitative data, especially where participants acknowledged that people with a mental illness are “just like us.”We merged data from the stigma questionnaire with qualitative sub-themes that demonstrated a change in participants’ perceptions post-training . Significant findings from the stigma questionnaire related to findings under the This study evaluates the impact of the HAPPINESS pilot project mhGAP-IG training on trainees’ mental illness stigma perceptions and knowledge as well as barriers, facilitators, and opportunities related to project implementation. Findings from the stigma questionnaire were congruent with the qualitative data that showed a favorable change in attitudes regarding mental illness following the HAPPINESS project training. As indicated by the questionnaire, trainees reported significantly more acceptance of socializing with people with mental illness and more favorable attitudes towards normalized activities and relationships with people with mental illness; further, they were less likely to endorse supernatural causes of mental illness. These preliminary quantitative results were supported by emergent themes from the interviews, which showed that trainees gained a better understanding of mental illness, learned new skills in providing diagnosis and treatment, and developed (and acted with) more empathy and respect towards patients. A demonstrated increase in empathy and respect from the interviews also demonstrated biopsychosocial perceptions of mental illness . Moreover, participants emphasized the importance of integrating patients back into society and regular life  after treatment. This is a key component of the “recovery approach”, which has long been used to guide the creation and delivery of mental health services . The implack of awareness and promoting early detection and raising awareness sub-themes). These discussions provide interesting insight into and demonstrate trainees’ understanding of the mental health context of the HAPPINESS project, especially regarding public stigma. Informants often described how lack of awareness among people, their families, and the community-led to delayed care-seeking and detection of a mental illness, which leads to poor management of mental illness. Specifically, they reported that misinformation and stigmatization often alienated people with a mental illness (which may exacerbate their illness) and led them to be brought to churches for treatment . This supports the need for the HAPPINESS project and other mental health programs to organize awareness programs in the community to improve treatment receptiveness. Eaton and Agomoh show that such a program can help increase help seeking for mental disorders in Nigeria, especially if it ties in the availability of mental health services [A notable concept that emerged from the qualitative component of this study is the negative downstream impact of the lack of public awareness regarding mental illness on people receiving timely and suitable care  and tailoring training for different health professions . Additionally, respondents still desired extra training on how to differentiate between illnesses and additional topics they wanted to be covered. Thus, a challenge will be to slow down the training’s pace while adding additional topics. The HAPPINESS project’s refresher trainings can address this need for continuous training; however, longer trainings with new topics may not be financially feasible long-term or accessible to all trainees. Thus, it is crucial to bolster and continue offering alternative learning avenues, such as the HAPPINESS project’s WhatsApp forum and specialist supervision. Ongoing specialist supervision and collaborative and multi-disciplinary peer-to-peer learning (the “Community of Practice” approach) was noted by Fargeh et al. as a solution to similar learning gaps found in initial mhGAP training in Chad, Ethiopia, Nigeria, Guinea, and Haiti .Beyond the training, respondents suggested working closely with community leaders and creating promotional material to improve awareness of mental illness to promote primary care center visits for people who may have a mental illness. The HAPPINESS project had already taken steps to address these avenues via raising awareness on social media and on local radio shows (whose effects may not have been captured at the time of this study). Additionally, some project sites have made outreach visits to traditional rulers, village committees, and councils . This also aligns with recommended best practices for community engagement in global health implementation research and projects . AnotherThis study adds to the limited literature on the impact of mhGAP-based training on stigma, specifically, how embedding anti-stigma components into mhGAP training can improve mental illness stigma among primary care trainees. The barriers that were identified in the implementation of this project are also consistent with other cultural and contextual challenges to the mhGAP-IG implementation identified by Fargeh et al., including the local perception of mental disorders, the healthcare system, available support for trainees, prior knowledge of trainees, trainee recruitment, and the larger socio-political context .The present study complements previous Nigerian mhGAP-IG projects’ studies that focus mainly on trainee skill retention and clinical outcomes by detailing challenges that arise in initiating a mhGAP-IG implementation project, as well as how external factors  contribute to the success of the project , 30, 59.Although one of the main strengths of the HAPPINESS project is its use of the widely available primary healthcare system in Imo State, it should be acknowledged that there are challenges to access that go beyond an easily accessible PHC. Most of these factors are connected to the community and system-level stigma and negative attitudes toward mental health, leading to low interest and minimal investment in mental health services. Firstly, this study revealed that a lack of human resources limits aspects of project implementation and day-to-day primary healthcare center functions. Respondents expressed that the lack of psychiatry training programs within Imo State means that local people will unlikely become psychiatrists. With brain drain being very common, Imo State natives that are trained elsewhere may also choose not to return home to practice . Having Beyond challenges within PHCs, there are also severe disparities with regard to individuals’ abilities to pay for care in Nigeria. Even with the establishment of the federal National Health Insurance Scheme (NHIS) in 2005, more than 90% of the national population (and 5 million people in Imo State) remain uninsured , 64. NHIInstead of being fully reliant on federal health insurance programs, the Imo State Health Insurance Agency, in 2019, started to collaborate with the WHO and different unions and health organizations in the community to improve health insurance for people in Imo State . LookingThere were methodological limitations to this study worth noting. Firstly, due to financial constraints, this was a small pilot, proof-of-concept study that focused on integrating mental health into primary healthcare using the mhGAP-IG in select LGAs in one state in Nigeria. Because of these constraints, it was not possible to train a large cohort of staff (which would have increased survey participants) nor was it feasible to incentivize interview participation, leading to a low sample number. Thus, the findings may not be generalizable to larger portions of the state or the country. Optimistically, the project team has received funding to use the data and lessons learned from this pilot study to conduct a larger, prospective study to evaluate the feasibility, acceptability, and effectiveness of the HAPPINESS intervention across the entire state (Imo State).community engagement components of the HAPPINESS project as these effects are more challenging to capture within our time frame and with a small sample size of informants that were already actively involved with the project. Future evaluations of the HAPPINESS intervention will aim to capture community perspectives to evaluate this component.Secondly, this study was not designed to evaluate the Thirdly, less than half of the questionnaires were complete and included in the analysis, limiting the robustness of the findings. However, the results align with existing literature and provide useful insight into approaches for integrating anti-stigma components into mental health capacity-building interventions in primary care settings. Additionally, the use of convergent data was helpful. For example, our qualitative data found positive ideological changes in trainees’ perceptions of mental illness, which bolstered findings from the quantitative questionnaire. We will incorporate lessons learned in this pilot project to ensure a higher survey completion rate in future studies.Lastly, this study only examined the perspectives of healthcare workers (doctors and nurses) and health systems leaders. It did not include any community health workers (CHWs), community health extension workers (CHEWs), or the patients’ perspectives. In the next, planned larger implementation study of the HAPPINESS intervention, the study team intends to include perspectives from CHWs, CHEWs, patients, families, and other relevant community stakeholders.This study adds to the available evidence on the implementation of mhGAP-IG, a model of care that uses task sharing to integrate mental health treatment into primary care, in Nigeria. It quantitatively and qualitatively evaluates how this model of mental health care can impact perceptions and knowledge of stigma among trainees. It also highlights the barriers, facilitators, and opportunities necessary to consider for this project to improve and grow in the Nigerian context. Future efforts should focus on clinical support, supervision, and health outcomes as well as scaling up and assessing the cost-effectiveness of the HAPPINESS project intervention.Additional file 1. The HAPPINESS Project Standard Operating Procedure (SOP). SOP for clinical record-keeping and reporting for primary care nurses and community health workers.Additional file 2. The HAPPINESS Project Drug Revolving Fund (DRF). Outlines the project’s DRF scheme.