Despite advances in surgical techniques and peri-operative care, pain is a significant symptom post-operatively. The purpose of this study was to examine the attitudes, social norms, and behaviors of a cohort of nurses of various ethnic and cultural backgrounds regarding pain and pain assessment and management. The design was a descriptive qualitative study guided by Theory of Planned Behavior and the Theory of Transcultural Nursing. The sample included six registered nurses (RNs) , along with patients of the same and different cultural and ethnic backgrounds in the post-operative unit within 48 h of surgery. The nurses’ results indicated that nurses assess pain severity and patient treatment preferences yet do not conduct a comprehensive pain assessment and have limited knowledge of non-pharmacologic and complementary pain therapies. Despite knowledge of the patient’s pain history, tolerance, and cultural background, the nurses believed that “all patients should be treated the same” and were concerned about the use of opioids beyond the first 24–48 h post-operatively due to the risk of addiction and professional ramifications related to opioid administration. The conclusions are that ongoing education is needed regarding comprehensive pain assessment and pharmacologic, non-pharmacologic, and complementary pain therapies during the post-operative period. Discussion is needed regarding the importance of diversity and equity as it relates to cultural competence within the context of pain assessment and management to provide patient-centered individualized care. Pain, which is one of the oldest and most complex health problems, is an unpleasant sensory and personal experience with physical, emotional, social, and cultural characteristics that adversely affect the patient’s functioning and quality of life ,2. DespiAs pain management is a fundamental right of the patient , patientSince pain is a subjective experience, if a person says that he or she has pain, it should be accepted as true . Yet, itIn qualitative research, a research question states the phenomenon of interest and the population of interest. In this study, the research question was posed not as a declarative statement but as an interrogative question, specifically “What are the attitudes, social norms, and behaviors of culturally diverse nurses related to pain and pain management who are caring for patients during the post-operative period?”.This study was guided by the Theory of Planned Behaviors , which iGiven that there were no instruments with published reliability and validity to measure the concepts of this study, it was decided that the study design would be a descriptive qualitative study. This design may be guided by a conceptual framework which informs the development of structured interview questions. In this study, the interview guide asked about attitudes, social norms, and behaviors related to pain and pain management. As a qualitative study, the Standards for Reporting Qualitative Research (SRQR) informed the research process and critical appraisal criteria .The principal investigator (PI), as an international doctoral student, was funded by the Republic of Turkey Ministry of National Education. The Republic of Turkey Ministry of National Education stipulated that the study was to involve surgical patients, with the recommendation to study some aspect of pain and pain management. Both the PI and second author had surgical nursing experience, which informed the development of the research question and the study proposal. Their clinical expertise on post-operative units also informed the development of the interview questions and interpretation of the data.The nursing manager of the post-operative unit introduced the PI to the nursing staff to discuss the study. A flyer with the contact name of the researcher was distributed and posted to the unit to promote study recruitment. The purposive sample consisted of a cohort of 6 registered nurses (RNs)  who cared for patients within 48 h of surgery in the post-operative observation unit of a large tertiary medical system. Although the inclusion of Asian nurses was sought, there were no Asian nurses employed in the post-operative unit. The nurses’ inclusion criteria were the following: registered nurses (RNs) of identified ethnic or cultural backgrounds who worked in a post-operative unit, spoke English, and worked 12-h day shifts. The exclusion criteria included RNs who did not provide direct post-operative care. The ethnic groups identified in this study aligned with the ethnic groups identified by the National Institutes of Health in the US. Ethnicity refers to groups of people depending on their ancestry, social and cultural identity, race, language, country of birth, or other special characteristics of the society in which they were born, while culture is a social phenomenon that is generally based on the morals, values, beliefs, and characteristics of a particular group [This study was conducted in accordance with the Declaration of Helsinki. Study approval was obtained from the Institutional Review Board (IRB) of Florida International University  and the IRB of Baptist Hospital .Informed consent was obtained from all subjects involved in the study. Upon signing the informed consent, the participants completed a Demographic and Professional Data Form. Digitally recorded interviews were conducted in a private office in the unit, lasting approximately 45 min. To ensure confidentiality, the participants were assigned a code number to all study materials. The study data were kept in the PI’s locked file cabinet and a password-protected computer.A structured interview guide was developed based on the conceptual framework of the study and was informed by the surgical experiences of the authors. The interview guide was reviewed and revised based on the feedback of six master’s-prepared nursing students enrolled in a research project course taught by the second author.The sample of six nurses completed the Demographic and Professional Data Form, which was analyzed using descriptive statistics, and six interviews were digitally recorded and sent electronically via secure measures to a transcription company for transcription. The transcripts, as well as the researcher logs and analytic memos, were analyzed and coded according to Carini’s principles , specifiThe nurses’ ages ranged between 20 and 39 years, with 5 out of 6 reporting being female and single. Three of the nurses were born in the US, while the others were from Haiti, Cuba, and Guyana. They were of varying religious backgrounds. All of the nurses had a bachelor’s degree, worked as an RN for between 1 to 7 years, and worked from 2 months to 5 years in the post-operative observation unit. All the nurses stated that they did not receive formal training in pain assessment and management in their BSN programs. However, post-degree, half completed continuing education courses on pain assessment and management and received ongoing training in culture competence. In reporting the findings, pseudonyms were given to the nurse participants rather than the use of their initials.“Post-operative pain is expected. I explain that they are not going to be completely absent from pain, but I will help reduce it.”All the nurses stated that they expect pain in the post-operative period and that the pain would gradually decrease. However, they emphasized the importance of assessing pain intensity and cited their responsibility to act on the patient’s behalf by giving pain medications, advocating for acceptable pain control, and educating patients about what to expect following surgery. Nurse Clara said “It’s very subjective. Some people have more tolerance for pain, while others are less tolerant. People experience pain differently, and you should not judge anyone.”The nurses emphasized that pain is a subjective feeling which indicates that something is physically or psychologically wrong and necessitates a prioritization of patients in pain. Each believed that if a patient says he or she has pain, he or she should not be judged, and individualized care should be given. The nurses knew that patients reacted differently to pain due to differences in pain thresholds and tolerance levels. The nurses recognized that some people express pain verbally or through non-verbal gestures, such as facial grimacing. Nurse Alexandra said that “It’s when patients are yelling, screaming, cursing, that kind of behavior needs to be immediately addressed.” The nurses said that patients who report frequent pain are trying to attract attention, but they do not judge them. The nurses believed that if a patient asks frequently for pain medication, they need to learn about other pain medications or ways of reducing their anxiety. Nurse Amanda said that “I try not to judge them, like if they’re in pain and they require more pain medication, but it is important to follow the orders and hospital rules.” Nurse Clara emphasized that ‘’I just try to educate them, but it’s not our job to say you’re asking for it too much, if they have it ordered.”The nurses emphasized that they are concerned if a patient screams, yells, curses, or is demanding and aggressive, as it is “rude” to the healthcare team and shows “inappropriate behavior”. Nurse Clara stated that “When patients pressure nurses to move quickly, we are at greater risk of making mistakes.”All of the nurses recognized that developing a caring relationship with a patient is important in providing post-operative care, but that time is limited when patients only remain in the observation unit for 48 h. During this time, the nurses emphasized that supportive interactions included “trying to calm the patient by giving them attention and even changing the environment by decreasing noise and increasing privacy.” In return, the nurses felt that they “gained the patient’s cooperation” and that the patients were “more likely to follow the nurse’s instruction or advice.” The nurses spoke of the “demands that were made by some patients who were not understanding of their workloads and work stress” and that some patients were “constantly on the call bell”, while others “saw how busy the nurses were with other patients who were in severe pain”. Nurse Clara was concerned that The nurses were concerned that “patients may exaggerate their pain because they have a substance abuse history and are drug seeking”. Another nurse realized that “if a patient has had an opioid addiction, they may need more pain medications because they have a higher level of tolerance”. The majority of the nurses took a “neutral” and “nonjudgmental” approach, realizing patients also have “different personalities” and nurses are “responsible for minimizing pain”.“I notice some patients are better without the family interaction, as they follow instructions better when family is not present.”All the nurses recognized that pain restricts patient functions and movements, including activities of daily living, and with limited mobility due to pain, patients are at “greater risk for post-op complications, such as pneumonia, DVT, muscle atrophy, and alterations in the overall nervous system. Such restrictions and problems can also delay the healing process and recovery.” On a psychological level, the nurses cited that “patients in pain may be agitated, anxious, withdrawn, and at times, even ‘crazy’.” Pain affects “patients’ ideals and moral function” and may lead to a “decreased mood, increased stress, depression, hopelessness, as well as less willingness to cooperate”. The nurses also recognized the various relationships between pain and interactions with family. Depending on the patient and family, their communication may differ. “Some families worry too much about the patient and this may increase the anxiety of the patient.” Nurse Alexandra stated that “I ask them to describe their pain and rate the pain severity so I get a better understanding of what they’re feeling.”All of the nurses agreed that the patients’ verbal pain reporting is an important factor in pain management, stating “When the patient reports the pain before it is too bad, it is easier to manage.” The nurses believed that “patients verbal communication may not always be consistent with the actual intensity of pain.” Nurse Bibi stated that The nurses generally felt that adequate pain management is difficult if their patient workload is beyond two patients. Additionally, if another patient’s condition is life-threatening, such as with bleeding, then the patient in pain must wait for medication. Furthermore, patients with drug addictions or drug allergies have individual needs beyond the usual treatment plan, which complicates care. Pain assessment is also difficult if there is a language barrier or the patient is unable to communicate or is disoriented, “so, you cannot use the pain scale to determine pain severity”.“If the patient never had pain medicines I am okay with giving them a strong medication, but those with a drug dependency, I am concerned.” Nurse Charlotte emphasized that “Even with a substance abuse history, patients need their pain controlled. Short-term use is not a concern, but long-term use is a worry.”Five of the six nurses were concerned about the side effects of opioids after surgery. They believed that adverse effects could be life-threatening, such as impaired breathing, impaired renal function, electrolyte imbalances, GI bleeding, falling, or coma. They were also concerned about minor side effects, such as drowsiness, constipation, dizziness, nausea, and vomiting. They emphasized the importance of “educating patients about side effects, particularly of opioids”. In general, the nurses agreed that opioids are needed in the first 2 days following surgery, but after 2 days, the emphasis should be on the use of non-steroidal anti-inflammatory medications and non-pharmacologic treatments. Some nurses try not to give patients with substance abuse histories opioids and make an effort to try all other alternatives for pain management. Nurse Bibi explained that “I could dig into their previous problems to know if they are pain related.”The nurses wished they “knew in more detail the medical history and diagnosis” of the patients. They also wished to “learn more about different cultures about how to manage pain, so that they could try to put themselves in the patient’s shoes”. One nurse felt that “at times they were only second guessing”. Nurse Alexandra wished “I’m more understanding of someone from my culture because I understand why they feel that way.” Nurse Brandon, in contrast, stated “I’m Haitian and just because I don’t feel the need to express my pain does not mean that another Haitian person reacts the same way. So, I would treat the pain as it is presented to me.” The nurses recognized that the expression and reaction to pain may be different based on a patient’s cultural background and that a patient’s age may make a difference. It was emphasized that nurses should “talk to their patients to understand their culture and their preference for pain treatment.”Each of the nurses stated that regardless of the culture they were from, they gave the “same treatment and the same approach to the patients” and “treated them without discrimination based on their culture”. Yet, several of the nurses were more comfortable with patients who shared their culture or ethnicity because they had “a greater understanding of a patient from their own culture”. However, one nurse also emphasized that “despite coming from the same culture as the patient, it does not mean that all patients from a particular culture express pain or behave in the same way or feel pain the same way.” Nurse Bibi stated that “I won’t let them go with pain for a long time, but I have to prioritize patients.”The nurses reported that they “act quickly when the patient has severe pain”, “communicate with the doctor”, and “give the patient the medicine as soon as possible”. However, the nurses “have to prioritize the care of other patients if there is a crisis situation”. Nurse Clara said, All the nurses preferred pharmacological pain management for the first post-op day, but by day 2, they preferred not to administer opioids but give “a lower level of medication”. All the nurses asked the patients about their pain management preferences. The nurses reported that when a patient is in moderate to severe pain, they “take vital signs”, “check the patient’s position”, “evaluate the patient visually”, “ask about the cause of the pain”, “evaluate pain intensity using the pain scale”, and “check to see what is ordered to relieve pain”, as they do not want the patient to “suffer”. The nurses reported that depending on the severity of the pain, commonly used drugs are Toradol, Tramadol, Dilaudid, Morphine, and NSAIDS.“Patients should participate 100%. They should be taught how to manage the pain when they go home and, of course; whenever we give the pain medication, we tell them exactly what we’ve given them and how long it may start working.”The nurses felt that patients should actively participate in their care. They emphasized that patients “should know how to recognize pain” as well as “what has worked for them in the past” and “tell nurses their preferences for pain management”. The nurses believed that patients need to be educated about “when they can expect pain relief after receiving pain medication”, as well as other “non-pharmacologic treatments, such as a warm shower, repositioning or lowering lights to reduce pain”. Nurse Brandon said that “Sometimes, I may believe that certain treatments and complementary therapies are not effective. However, if patients believe that the treatment helps them, they should be allowed.”The nurses preferred to use non-pharmacological methods, such as heat or ice and repositioning, with pharmacologic methods, as “non-pharmacologic methods have no side effects and risk of addiction”. The nurses mentioned the value of a calm environment with decreased noise and light. Although one nurse mentioned the use of distraction, there was no discussion on the use of music, prayer, meditation, or other complementary therapies. Nurse Clara shared that “All MDs and NPs need to be better educated about pain assessment and management and work closely with nurses to ensure holistic pain management.”The nurses expressed several challenges, including “lack of orders for pain medications”, “physicians not seeing patients themselves after surgery”, “not being able to reach a doctor in a short time particularly on the night shift”, “lack of coordination between nurse practitioners who cover surgical practices”, and “the workload of the nurse which limits response time to patients”. The nurses also expressed challenges when they felt the “patient is being undertreated”. Sometimes, “patients’ medications may be insufficient”, while “some providers may not accept the nurses’ assessment and expressed concerns as they advocate for the patient”. The nurses indicated the importance of “developing pain protocols so that they could administer appropriate medications based on the pain assessments”. Nurse Amanda’s recommendation is that All the nurses in this study agreed that pain is a subjective experience, and a patient’s report of pain should be believed, as purported by Özveren et al. (2018) . The nurThe nurses believed that establishing a personal relationship with the patient was also important and wished there was more time to get to know the patient. They realized that the way a patient reacts is also different depending on the family involvement. The nurses did express distress when patients reacted to pain by screaming or being demanding or aggressive. Yet, the nurses often felt that the patients were not understanding of their workload. The nurses wished for potentially lower nurse-to-patient ratios to decrease their own work burden and respond more quickly to patients. Patients with substance abuse histories were also of concern, as they realized that the patient may have a different level of pain tolerance and require a higher dose of medication. Yet, addiction was of serious concern, with worry about negative work outcomes if the patient was overmedicated. The nurses in the post-operative setting did wish they had a greater understanding of the disease process and patients’ pain histories to guide their assessments and treatment of pain. They understood that a patient’s level of pain was also related to the extensiveness of the surgery. However, the nurses reported that their assessments focused on visually assessing a patient, and they depended on a patient’s rating of pain on the assessment scale. The nurses did not speak about conducting a comprehensive pain assessment, which includes documentation of the location of pain, quality of pain, duration, relieving and exacerbating factors, associated factors, or the meaning of the pain as per the patient . They diThe nurses did ask the patients about their preference for pain medications. However, they expressed significant concern if a patient had a strong preference, given the possibility of addiction. The nurses realized that in the first post-operative day, most patients experience moderate-to-severe pain and need IV pain medication. However, on post-op day 2, the nurses preferred to administer weaker medications by mouth, such as NSAIDS, to prepare patients for discharge home. The nurses expressed a preference for relieving pain using non-pharmacologic methods, such as positioning, walking to relieve gas, and creating an environment with minimal stimulation. However, they had limited knowledge of other non-pharmacologic pain treatments and the use of complementary therapies, such as music or distraction. Although these complementary therapies may be used in their personal or family context, this knowledge did not transfer to informing complementary therapies they could offer to their surgical patients. Midilli et al. (2019)  stated tConsistent with the nurses’ concerns, Şenyüz and Kocaşlı (2017) discussed the side effects of opioids used for moderate and severe pain, specifically the effects on respiration and bowel function . The nurWith regard to social norms, such as culture, the nurses expressed greater comfort in caring for patients of their same cultural or ethnic backgrounds, as they were more “familiar” with their expectations and behaviors. These results suggest that culture does play a role in nurses’ experiences when caring for patients of the same and different cultural backgrounds, which will be addressed more fully in another manuscript. Narayan (2010)  believedThe nurses expressed concern regarding overprescribing opioids, which could “get us into trouble” if the patient experienced negative outcomes related to opioid use. In contrast, the nurses indicated that physicians and nurse practitioners needed more education on prescribing appropriate doses of pain medication. An additional challenge expressed was the medical coverage of the unit, as there was often difficulty reaching practitioners post-operatively. The nurses were upset themselves when the pain medications ordered did not sufficiently relieve pain, and the provider did not come to see the patient but questioned the nurses’ judgement. Similar to Costello (2015) , who empThe nurses spoke of the importance of individualized care, recognizing differences in patients’ pain experiences and levels of pain tolerance, the extent of the surgical procedure, and differences in pain perceptions and preferences based on a patient’s cultural background. Yet, juxtaposed to this perspective, each of the nurses mentioned that they were taught to “treat all patients the same”. This potentially reflects a cognitive dissonance between patient-centered individualized care verses diversity and equity. “Treating all patients the same” may lead to a “one size fits all approach”. Access to adequate pain medications is important for all ethnic and cultural groups, but in the process of “standardizing” care, there may be a risk of jeopardizing patient-centered, individualized care. In addition, given that the nurses expressed greater comfort in caring for a patient of the same cultural background, it is unclear how this may negatively impact care offered to patients of differing cultural backgrounds from the nurse. For example, if vocalization of pain is culturally accepted, a nurse from a culture that has a stoic approach to pain may interpret “screaming” as an inappropriate pain response. Therefore, further understanding of cultural differences related to pain and pain responses needs to be discussed in educational offerings related to pain assessment and management.In reviewing the information shared by this cohort of nurses in a post-operative observational unit, several important issues have been raised: (1) the need for nurses to conduct a comprehensive pain assessment, (2) identifying the personal attitudes and preferences of nurses related to pain and pain management in comparison to patients, (3) exploring the impact of patients’ and nurses’ cultural backgrounds on pain management, (4) offering appropriate pain management in accordance with the level of pain severity, (5) using pharmacologic treatments, including opioids, non-opioids, and adjuvant therapies, and reassessment of pain following the administration of pain medications and other treatments, (6) increasing nurses’ and patients’ knowledge regarding the use of non-pharmacologic and complementary pain therapies, and (7) lastly, in consultation with pain management experts and unit management, determining the availability of non-pharmacologic and complementary therapies available during the post-operative hospitalization period.This study was approved by the institutional review boards during the first 3 months of the COVID-19 pandemic, a time when all hospitals were closed to visitors and on-site research could not be conducted. Data collection was therefore delayed until a COVID Mitigation Plan could be submitted, indicating measures to limit transmission of the virus. The time frame for data collection was also shortened, as only emergency surgeries were being performed in the first few months of the pandemic. As a further limitation, the researcher was working within a specified time frame to complete her research as stipulated by the Republic of Turkey Ministry of National Education, which funded the study. The nurses were also working under the stress of the pandemic, and the recruitment of nurses was challenging as they had time constraints related to time availability for interviews. Although the sample for this study included a cohort of six nurses of varying cultural backgrounds , no Asian nurses were working on the unit at the time of data collection, which was an identified limitation. Furthermore, the study consisted of nurse–patient dyads, with 6 nurses and 12 patients, 1 of the latter representing the same cultural background as the nurse and 1 patient being of a different cultural background from the nurse. Although a sample size of 18 participants was satisfactory for a qualitative study, the sample size of nurses was limited. Given the usual small sample sizes of 10–30 participants in qualitative studies, the results are not generalizable. However, the results provide a contextualized understanding of the human experience through intensive study of a few cases. Rather than the term generalizability often associated with quantitative studies, qualitative research speaks of transferability, which is known as case-to-case translation [Based on the results of this study, it is suggested that nurses on the post-operative unit have a greater understanding of the medical history and prior pain history of patients. In addition, nurses should receive education regarding conducting a comprehensive pain assessment, including visualization of the pain site. In continuing education seminars, perhaps in “unit huddles”, a nursing staff could discuss the challenges to pain assessment and management and discuss “case studies” representing patients who had significant pain management issues.Further consideration should be given to the nurses’ concerns about the use of opioids and opioid addiction. Nurses should be instructed regarding the use of the World Health Organization pain model, which indicates the importance of using non-steroidal medications, as well as adjuvant medications for mild pain (0–3 intensity), then adding opioids to this regimen in the face of moderate-to-severe pain . Given tGiven the nurse-to-patient ratios and consideration of emergencies other than pain management, the nurses expressed distress about workloads and feeling pressured when patients were extremely demanding, which may lead to an increased risk of medication error. This suggests the need for consideration of the nurse-to-patient ratios during a 12-h shift, given the types of surgeries scheduled. Written pain protocols may also be important in treating patients during the post-operative period, particularly if the prescription providers are not immediately available to write pain orders. NP coverage of the unit may ensure the availability of providers to write pain orders.Based on the results of this study, there remains concern that differences in the cultural backgrounds of the nurse and patient may influence the quality of care offered, specifically pain management. “Treating all patients the same” may result in stereotyping, in which the attitudes, norms, and behaviors of a person are contextualized primarily by culture. Nurses should be educated about assessing a person’s degree of assimilation in American culture and their individual perspectives regarding pain and pain management. In this study, the nurses expressed the importance of being non-judgmental, non-discriminatory, and accepting of diversity, yet juxtaposed to these ideas were the comments from the nurses to “treat everyone alike”. This negates the importance of diversity of needs, attitudes, preferences, involvement in deciding care options, and providing individualized care to meet the unique needs of patients. The implications and recommendations are for an emphasis on the importance of discussions between nurses and their patients in understanding health concerns, preparing patients for the surgical and post-operative experience, and offering guidance in a range of treatment options for pain.What does this paper contribute to the wider global clinical community? (1) It identifies the concerns of culturally diverse nurses in providing pain management for post-operative patients; (2) it indicates nurses’ challenges and recommendations regarding pain assessment and management; and (3) it highlights the issue of culture and cultural competence as it relates to standardization of pain management of patients verses individualized, patient-centered care.


Future of Home Care, how to provide this care. They primarily learned their techniques through their caring for patients as unique, highly valued persons and their ability to form warm caring relationships with their patients. Together they painted a portrait of the attitudes, knowledge, and skills needed for PCC and CSC. PCC and CSC are mutually reinforcing concepts essential to the high-quality, equitable care needed to mitigate healthcare disparities prevalent in home healthcare. A teaching resource for incorporating PCC/CSC into home health clinician practice was derived from the data.In their seminal paper outlining the proposed  The Future of Home Health Care states that one of the “pillars” of home healthcare should be “patient/person-centered care.” They define patient-centered care using the definition in Crossing the Quality Chasm: “Patient-centered care (PCC) is providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions” . Indeed, previous research indicates that, at the clinical level, PCC and CSC use the same principles and strategies to help patients achieve optimal health outcomes . PCC mushow do they do this?Patient assessment and care planning are crucial for home healthcare. PCC requires an assessment of the factors that affect the patient's health and well-being; and requires nurses to collaborate with patients to develop a mutually agreeable care plan that promotes patient health and well-being.  Because patient assessment and care planning are the basis for home health practice, home health clinicians should provide patient-centered assessments and care planning, but N < 10), and generally found nurses had not mastered the communication and partnership skills nor the ability to balance their nursing responsibilities with a patient-centered approach to care.A medical librarian-assisted search, using various other terms for PCC and CSC, found no published research reports in the nursing or home health literature describing how home health nurses (HHNs) incorporate PCC into their assessment and care planning processes. Broadening the search, we found that even though the term “patient-centered care” is ubiquitous in the nursing literature, there were no studies in the home health literature that used this term. However, by expanding the term to “person” and “client,” and using the British spelling “centred,” six home health studies were found , 2006. AA search for studies addressing CSC in home health nursing resulted in four studies . These fThe Future of Home Health Care report, the authors posed the question: “What constitutes person-centered home health care and how [is it] defined and measured in home healthcare?” . For example, participant 7 (P7) revealed, “When my cultural beliefs butt up against a patient's cultural beliefs, it reminds me that I'm thinking through my own cultural lens and not theirs.” Several HHNs discussed the importance of “meeting patients where they are” physically, cognitively, and emotionally. Some HHNs stressed the importance of being present to the patient through careful attentive listening, until the nurse understood what the patient was experiencing, thinking, and feeling, and then “being non-judgmental, open and receptive” (P10).Caring was described as empathy, compassion, nonjudgment, and kindness, which depended on “getting inside the patient's perspective” (P5) about their health issues. As P20 said, “The diversity of my patients keeps me looking things up and makes me continue to do research into different things.” Other attitudes included optimism (conveying optimism to the patient about their ability to achieve good outcomes), commitment to the patient (willingness to work extra time to provide patient-centered/culture-sensitive care), and resilience .A few participants discussed the need to be flexible and adaptable so they could tailor their assessments and care planning to each patient. Others discussed the need to have an ongoing commitment to learning (a willingness to give time to learning about best practices and cultures), so each patient received quality care. For instance, P9 stated, “what the participants felt they needed to know to deliver patient-centered/culture-sensitive care and how they learned what they learned. In the what-to-know category, several HHNs commented on the value of self-knowledge, knowing themselves as “cultural beings” with their own positive and negative biases and their own preferences for certain beliefs, values, aspirations, behaviors, and practices. They felt that self-knowledge helped them to manage their biases and helped them to be more accepting of patients' differences.The themes for knowledge fell into two categories: The way they talk in certain cultures came across as aggressive or angry. It almost sounds like they are yelling at you. But if you know that's just the way they communicate – very loudly – then you're no longer threatened.” Several HHNs commented on needing to know each patient as a unique person, instead of a stereotype of any of the groups they may be part of. P5 said, “Everybody is different. Everybody is diverse. I just try to think of each person as an individual. What is this person's story? What are this person's beliefs, ways of doing things?”Another crucial area was general knowledge about the ways cultural groups could differ from expected American and western medicine norms Figure . Severalhow they learned their patient-centered/culture-sensitive knowledge, there were three types of responses. First, they learned by consulting websites, books, journals, or cultural experts. For instance, P14 described how nurses at her agency learned about cultural norms. “Some of the nurses took it upon themselves to really study and learn and became knowledgeable about the norms of a population we were serving, and then they shared their knowledge with the other nurses at case conferences.” Participants said it was important to learn how to ask cultural and lifestyle questions in a sensitive way. P5 suggested asking, “Is there anything I should or shouldn't do to honor your culture [or lifestyle]?” P10 said he realized that it is culture-sensitive to ask culture-sensitive questions, saying, “I think for the most part, patients appreciate those kinds of questions. It lets them know you're thinking about them as an individual.”When asked At first, I went in to fix things, and then after a few times I thought, I don't know anything about this culture. Why am I trying to fix what I don't understand? And it's at that point I started asking questions. If you don't know why the patient is doing something, or how it is related to their culture or lifestyle, the right thing to do is to ask people questions.”Many nurses reported they learned their patient-centered/culture-sensitive skills through a trial-and-error process of thinking reflectively on patient experiences with their critical and creative thinking skills to figure out effective ways to be more patient-centered and culture-sensitive. For example, P9 reported how she used this process to enhance her skills. “I don't really rush into anything with them. I sit there and I do small talk with them for a while whether it be about the picture of their grandchild or their collection of the dolls. I establish a relationship with them before I start getting forms signed and doing the assessment.”Almost all the participants felt the most important step for conducting a good assessment and creating an effective Plan of Care was to build a warm, trusting relationship with the patient and family/caregivers. They spoke about making a good impression from the first phone call and visit, being courteous, cheerful, positive, and relaxed—a pleasant person who “has time” for the patient as a person. They also felt nurses should project a knowledgeable professional demeanor that inspires confidence. Several HHNs talked about the importance of social small talk before getting to the business of the visit. For instance, P7 said, “You have to build that trust between you and the patient. That, of course, takes time. People don't trust someone right away. It's just listening, making the patient feel they're very important to you.” Thus, continuity of care (one primary nurse for each patient) and listening carefully to the patient help show patients the nurse truly cares about them, which builds the relationship. P20 said, “Listen carefully, so the patient feels heard and respected. When they feel heard and respected it gives them more comfort in sharing their needs and desires than they otherwise would. And I think it gives them more power to be involved in planning their care.” Sharing power with the patient not only builds the relationship, but it also is the only way to develop a truly effective care plan. As P15 explained, “If you don't respect the patient's concerns and preferences, it affects how much you are going to be able to accomplish because they are going to put up a wall between you and them. If you are not willing to work with them, nine times out of ten they're not going to work with you.”The participants had several recommendations for deepening the warm trusting relationship. P2 reported, “Share a little information about yourself to let them see you are a person, and not just the nurse. I think that it helps build the rapport and makes them more comfortable with you. If you want to have a good therapeutic relationship, they've got to like you. So, you open up. You show them that you're human.”A few nurses mentioned the need to assure good communication with the patient, which requires the nurse to meet patients within their language  and their health literacy . Another strategy for building the relationship that several nurses mentioned was sharing a little bit of who they are as persons, which humanizes themselves, demonstrating the nurse is like the patient. P5 explained, “Your assessment should include a lot of factors because lots of factors affect their ability to reach healthcare goals.” P12 stated, “Patients live and get better holistically, so they need holistic assessments so we can provide holistic care.”Participants felt that assessments should be holistic, individualized (patient-centered), and/or culture-sensitive. They described holistic assessment as assessing factors that affect the patient's ability to heal and recover, like psychosocial, cultural, spiritual, and financial factors. For example, P7 said, “You have to meet them where they're at. So, I tailor my assessment to how the person presents. It just depends on what they say and what they tell me and then I tailor what I do and say to them, from the type of language I use, to the way I phrase questions, to the order in which I assess things.” To make their assessments culture-sensitive, a few participants described how they questioned patients about their cultural norms. P8 explained, “If there is something I don't understand, I say, ‘This is something I'm not familiar with, but I want to make sure that we understand what you'd like us to do. Can you explain to me a little bit about how your culture influences your healthcare? I want to make sure we're respecting your wishes.”A few HHNs discussed how they individualized their assessments to their patients' unique circumstances, which is a hallmark of PCC. P5 said, “Even though it's something that may not relate to the physical health of the patient, their mental health is just as important and the things going on around the patient affect them. There are social issues in the home that are a bigger need at the moment. So, we need to take care of all those things.” Other nurses focused on the learning needs assessment, such as health literacy level and what the patient already knew about their condition and its management. For instance, P10 reported, “If their problem is diabetes, I say, ‘Tell me what you know about diabetes. What has your doctor told you your blood sugar range should be? Tell me how you control your blood sugar.’ So, I ask questions, almost like doing a Teach-Back thing.” P13 described how she used motivational interviewing and the Importance/Confidence ruler to determine the patient's ability to manage their health problems.Participants tended to discuss two assessment areas in particular: psychosocial assessment and assessment of learning needs, which are more important to home healthcare outcomes than in many other nursing settings. P8 discussed the importance of the psychosocial assessment. “I know the OASIS well enough to get the answers to those questions in a conversation. There are very few things I actually point-blank ask; it's all in conversation.” Another technique was to pay attention to patient cues. P16 commented on how easy it is for nurses to not hear when patients cue us to their needs and concerns, even though hearing those cues is a patient-centered requirement. “I think nurses get so task-oriented, and we've got our computers in front of us doing the OASIS, that when patients drop cues about other needs, we don't' even hear them, so we don't follow up.” P10 emphasized the importance of hearing those cues. “I would say an effective assessment tool is being an active listener, hearing and responding to patient cues. Just follow-up on cues, diving deeper into wherever the patient leads you.”Finally, a few participants discussed techniques to assure a patient-centered assessment. P7 described how she made her Outcome and Assessment Information Set (OASIS) assessment a conversation. “A good care plan starts with asking the patient, ‘What are your goals? Where would you like to see your health in the next two months? What do you want to be able to do?’ Then you figure out how we are going to get them there.” P12 described how she combined the patient's goals with the medical goals for a particular problem, explaining, “Although the patient's goals seem to differ from typical medical goals, usually their goals and your goals overlap. They say it in a personal way, so you can incorporate your goals into their framework.” P17 described how she helps the patient come up with their goals and then how she follows up with the patients' progress toward their goals each visit.Several participants outlined a PCC planning process. First step is to identify the patients' health/well-being goals (expected outcomes). As P5 said, “You've got to include the patient in planning the care plan. Make sure the patient helps develop the plan. If they feel engaged, then they're more likely to follow the plan.”After identifying the patients' goals, a few participants described how they engaged patients in care planning, telling them that they are a crucial member in the care team and seeking their opinions on how to achieve their goals. They suggested that if patients are part of the care planning process, they will be more motivated and adherent to the plan. For instance, P6 explained, “This patient is an individual. They have individual needs. I cannot put them in a mold. I cannot use a cookie cutter on them.” P14 advised, “You've got to build the Plan of Care around what's going to work for the patient, or you end up with a non-compliant patient.”The final step in the care planning process is to assure the Plan of Care is tailored to the patient's lifestyle and preferences, instead of telling the patient to adhere to the computer-generated, diagnosis-based care plan. As P5 remarked, “Future of Home Care authors' (2016) question about what PCC is in home care. Together, these HHNs painted a portrait of what PCC can be in home health nursing care. The results provide an initial outline of how to incorporate PCC into the nursing assessment and care planning. Our knowledge about how to incorporate PCC into home healthcare can be developed and refined, however, a resource for beginning to integrate PCC into home health assessment and care planning activities was derived from the data  a lack of knowledge of the principles and strategies of PCC or CSC, 2) biases and stereotypes about some patient populations, 3) authoritarian versus collaborative attitudes about care planning, 4) cutting corners  to promote efficient visits and accommodate productivity requirements, and 5) a task-oriented (care focused on the minimum tasks needed to complete a visit) versus a patient-centered approach to care, among others. Although some nurses were successful at achieving PCC, some were less successful, leaving patients, especially minority patients, at risk for poorer outcomes.ractices , none ofImportance of PCC. Patients have a right to high-quality and equitable outcomes. One way to promote high-quality care is through PCC . I use the term “culture-sensitive care” instead of “culturally competent care,” which has some unfortunate connotations: 1) It is perceived by many as knowing a lot about other cultures instead of the ability to respect and adapt to patients' cultures; 2) It is about clinicians' abilities instead of patients' needs, so it is not patient-centered; 3) It lacks the concept of humility needed to deliver care across cultures.Patient-centered care (PCC). Although many nurses prefer the term “person- or client-centered care,” I use the term “patient-centered” because it connotes the ethical relationship nurses have with patients. Patient-centered care always includes care that is sensitive to the patient's cultural beliefs, values, needs, and preferences.Patient-centered/culturally sensitive care. I use this term to reinforce that patient-centered care is always culture-sensitive and culture-sensitive care is always patient-centered.


To assess the knowledge of students from public high schools in poor communities about HPV and Sexually Transmitted Infections and their attitude towards and prevention of such diseases.Cross-sectional study with adolescents from public schools of São Paulo – Brazil. Participants were selected for an interview by a randomization program. A questionnaire about knowledge, attitudes, and preventive practices regarding STIs, including HPV, according to sex was administered and answers were analyzed by the Poisson regression model with robust variance.Median age of the 269 participants was 16 years. The majority was of African descent , most  were religious and the vast majority  lived with their parents. The Poisson regression revealed statistically significant sex-related differences regarding the following questions: “Do you know how it is prevented?” ; “Have you ever been concerned with HPV?” ; “Have you ever sought health care due to concerns about HPV?” ; “Do you know what a Pap Smear is?” ; “Do you know what the cervix is?” ; “Do you know what cervical cancer is?” .The present results show that adolescents from public schools in poor communities in São Paulo City know little about HPV and cervical cancer. Male adolescents know less than female adolescents and are less concerned with health care. Adolescence is the period when sexual life might initiate. Currently, most adolescents engage in sexual intercourse at an increasingly early age.The prevalence of HPV in Brazil is 40% to 60%, and in the state of São Paulo, it is over 56%.,Distribution of male condoms and HPV vaccination are strategies to reduce transmission of HPV and other STIs and prevent precursor lesions of cervical cancer among teenagers. Adherence to condom use and to vaccination are behaviors dependent on one's knowledge of these infections, and they may be influenced by sex, socioeconomic level, and educational, cultural, and religious backgrounds.,A school is a place of learning for adolescents. It not only plays an important role in education, but it is also a setting for the promotion of reproductive and sexual health among youth.,HPV infection is associated with age, for it is young people who are most prone to taking risks. In Brazil, the quadrivalent HPV vaccine is freely distributed to girls from 9 to 14 years old, boys from 11 to 14 years old, and immunosuppressed men and women, aged 9 to 45 years, living with HIV/AIDS, transplanted solid organs or bone marrow, and cancer patients.,However, the authors don't know if public high schools in underprivileged areas are being able to transmit necessary information about HPV and STIs and to develop the interest of adolescents from low-income families in their sexual health.This cross-sectional study assessing students from three public high schools was conducted by the Discipline of Gynecology of the Universidade de São Paulo (USP) between 2018 and 2019. The project was approved by the Ethics Committee of the “Faculdade de Medicina da Universidade de São Paulo” (FMUSP). The protocol number is 38719314.2.00000068.Of the 2588 students from three state high schools located in the city of São Paulo, 375 were selected for an interview according to the following inclusion criteria: proper enrollment in a public school and 19 years of age or less. The sample size was estimated at 253 students, given a confidence level of 85% and power test of 80% in line with the Kops et al. (2019)The students were selected for an interview by a computer-generated randomization list. If a student on the list was unwilling to participate, no substitution was made . Prior to data collection, all interviewers were trained and certified.The questionnaire was designed by the authors in accordance with the scientific literature. It addresses the student's knowledge of the prevention, transmission, and consequences of STIs, including HPV, as well as their attitude toward the diseases and their preventive practices. The questionnaire contains 13 items grouped into four categories: knowledge, attitudes, health practices, and HPV vaccination.Programa Institucional de Bolsas de Iniciação Científica (PIBIC) , which is a program of prescientific initiation and technology innovation at USP. Before the questionnaires were handed out, the participants were informed about the research objectives, and they signed an informed consent form. No student identification was required on the questionnaire. After the students completed the questionnaires, any questions they had were answered for further clarification.The questionnaires were administered by students from the A pilot study was conducted in 2018 (n = 50) to evaluate and improve the questions and ensure comprehension. Validation of the questionnaire was based on experts’ analyses , semantic analyses, and pretesting. After completion, each questionnaire was analyzed and then tabulated. Thirty pilot interviews were recorded, and three interviewers listened to each interview. The questionnaire was then improved further, and the interviewers received instructions for administering an interview and training as well as shown in Supplementary Material.Bolsa Família), sexual intercourse, and family nucleus.In addition to the questionnaire above, a sociodemographic questionnaire was drawn up with questions about birthplace, age, ethnicity, sex, religion, family income, the social welfare program  software. Answers to questions 1, 2, 3, 6, 7, 8, 9 10, 11, 12, and 13 were dichotomized into “presence of knowledge” when the answer was “I know a little” or “I know”, and “lack of knowledge”, when the answer was “I don't know”, “I heard of” or “I know partially”.On the other hand, answers to questions 4 and 5 were dichotomized into “I was worried/I sought health care”, “when the answer was “frequently”, “I'm aware”, or “I worried a lot”, and into ‘I wasn't worried/I didn't seek health care’ when the answer was “never” or “sometimes”.https://doi.org/10.7910/DVN/OCNLUF.The datasetParticipants were divided into 2 groups according to their sex: male or female. Qualitative variables were reported as absolute and relative frequencies, and the quantitative variable ‘age’ was expressed by the median and confidence interval. The Chi-Square and the Mann-Whitney tests were used to analyze homogeneity between the two groups in relation to socioeconomic variables.The Poisson regression model with robust variance was used to analyze the answers to questions about students’ knowledge, attitudes, and preventive practices with respect to STIs, including HPV, according to sex. The level of statistical significance for the sample was set at 5%. The model was adjusted according to income, age, ethnicity, grade repetition, cohabitation with parents, and religion.The internal consistency of the questionnaire, expressed by Cronbach's alpha coefficient, 0.78 in this case, was substantial.The total study population consisted of 269 high school students in which themedian age was 16 years . The majority  lived in the city of São Paulo, and most of these  resided in neighborhoods near their schools. A considerable number of the students  were of African descent.Bolsa Família  declared they had already engaged in sexual intercourse; most  had religious beliefs; a vast majority  lived with their parents; and over two-thirds  had never failed a grade in school. Despite the fact that most  received less than the minimum salary, a very large number  were not enrolled in the country's social welfare program, the so-called  Família .Table 1SThe comparison of sociodemographic characteristics between the female and the male students yielded a significant statistical difference only in terms of the variable “has religious beliefs” (p = 0.037).A sex-based analysis of the student's responses to questions about their knowledge, attitudes, and preventive practices with respect to HPV and STIs, along with the 95% CI, prevalence ratio, and p results, is shown in The use of the adjusted Poisson regression model with robust variance revealed a difference in the answers of boys and girls. The following questions had statistically different answers when comparing the female and the male adolescents: “Do you know what HPV is?” ; “Do you know how it is prevented?” ; “Have you ever been concerned with HPV?” ; “Have you ever sought health care due to concerns about HPV?” ; “Do you know what a Pap Smear is?” ; “Do you know what the cervix is?” ; “Do you know what cervical cancer is?” . A statistical difference was also found in the crude model, which also exhibited a difference in relation to the question “Do you know how it is transmitted?”  .In adolescence, the desire for sexual experience frequently predisposes young people to risky sexual habits due to their immaturity and inexperience. Access to information and health professionals can assist with guidance and the acquisition of healthy habits.The present study indicates that adolescents know little about STIs, that less than 40% show some concern about HPV, and that only 12.6% have sought health care due to worries about HPV. The male sex was less knowledgeable and concerned than the female sex.,Studies of knowledge about HPV/STI are important guidelines in public health, as they show that gaps in understanding can be barriers to the self-care process and to adherence to vaccination programs. The consequences of HPV are not immediate since cancer precursor lesions and HPV-induced lesions take a while to be detected and treated, with repercussions that include high mortality from these cancers, mainly in developing countries.The sample was characterized by a majority population of Afro-descendants. This epidemiological profile is similar to that of other studies with parallel topics. The predominance of students of African descent in public schools should be highlighted. Racial inequality among low-income adolescents in Brazil is a factor that may have a negative psychological influence, especially when one feels discriminated against by their ethnicity.The assessment of homogeneity between characteristics of male and female adolescents shows that the variable ‘has religious beliefs’ is answered positively more often by the female population. The studied country is predominantly Catholic, and the Church provides information on reproductive and sexual health,An important point in the present study is the difference in knowledge about STIs, including HPV, between the male and the female sexes: the latter know more about the subject than the former. Many factors may be associated with the discrepancy between the sexes. The study by Genz et al. (2017)Besides, in Brazil, the implementation of the government's HPV vaccine program in schools, initially was limited to girls and their parents, which may have contributed to the differences in knowledge between the sexes.In the study by Sousa et al. (2018),The results of this study reinforce the need for health promotion actions with adolescents – especially male students ‒ in order to improve their knowledge about HPV and/or STIs beyond the dissemination of such knowledge in schools,This shows a clear need to address the male population; even if male adolescents have not been strongly affected by HPV, they may have transmitted the virus and spread it among the female population.Cervical cancer has HPV as its main etiological viral factor and other STIs as associated factors, being highly prevalent in Brazil.Thus, there is a need to intensify campaigns, which should aim mostly at public school male teenagers. Not only chemical and biological processes, but also intense and unstructured emotions occur in this phase, possibly triggering affective relationships that become the gateway to erroneous, premature, and unprotected sex predisposing adolescents to contract STIs.One of the limitations of this cross-sectional study is that the present study's sample consisted of adolescents from public schools. This narrow selection of subjects may have biased the variable ‘knowledge and perception’ because it does not necessarily express the reality of other teenagers with the same socioeconomic level or access to education.Another limiting factor is the use of quantitatively analyzed objective questionnaires, where students were asked whether or not they had knowledge about the subjects in question, but these answers were not confirmed. In this way, the knowledge investigated is referred/perceived. In addition, the questionnaires do not allow the exploration of socioeconomic aspects, such as religious beliefs. nor the prevalence of STI/HPV and vaccination. Another shortcoming is the fact that this study was not designed to assess the real causes of male disinterest in their health. Therefore, other studies are needed.The highlights of this study conducted in a poor community include an elucidation of the divergences of sexual health knowledge among adolescents and a comparison of boys’ and girls’ knowledge. Such information can be used to underpin sex education, reproductive health programs, and specific health promotion actions. Public health education should be the focus of pediatric and adolescent gynecologists.The presentresults show that about half of the adolescents from public schools in the city of São Paulo do not know what HPV is, nor do they know what cervical cancer is. Indeed, a large part never worried about HPV and the vast majority did not seek a health service due to HPV-related issues. In addition, male adolescents not only know less than female adolescents but are also less concerned about health care.The project was approved by the Ethics Committee of the Faculdade de Medicina da USP. The protocol number is 38719314.2.00000068.The participants were informed about the research objectives, and they signed an informed consent form.J.M.S.J.: He made substantial contributions to the concept, study design, and definition of intellectual content; he was involved in literature search, data analysis, statistical analysis, manuscript preparation, and manuscript writing; he drafted the article or revised it critically for important intellectual content, and he approved the final version to be published.H.M.C.O.: She made substantial contributions to the concept, study design, and definition of intellectual content; she was involved in literature search, data analysis, statistical analysis, manuscript preparation, and manuscript writing; she drafted the article or revised it critically for important intellectual content; and she approved the final version to be published.C.M.L.: She was involved in literature search, data analysis, statistical analysis, manuscript preparation, and manuscript writing; she drafted the article or revised it critically for important intellectual content.L.T.S.Z.: She was involved in literature search, data analysis, and statistical analysis; and she approved the final version to be published.E.C.A.V: He was involved in literature search, data analysis, and statistical analysis; and he approved the final version to be published.J.Z.R.: She was involved in literature search, data analysis, statistical analysis; and she approved the final version to be published.F.W.S.F.: He was involved in literature search, data analysis, and statistical analysis; and he approved the final version to be published.M.S.A.: She was involved in literature search, manuscript preparation, and manuscript writing; and she approved the final version to be published.I.C.E.S.: She made substantial contributions to the concept, study design, and definition of intellectual content; she was involved in literature search, data analysis, statistical analysis, manuscript preparation, and manuscript writing; she drafted the article or revised it critically for important intellectual content; and she approved the final version to be published.E.C.B: He was involved in literature search, data analysis, and statistical analysis; and he approved the final version to be published.FAPESP (#2016/16847-0 and #2017/07276-2), CNPq (#301725/2017-9), and CAPES .This study was supported by The authors declare no conflicts of interest.


Nearly 50 million people globally have been internally displaced due to conflict, persecution and human rights violations. However, the study of internally displaced persons—and the design of policies to assist them—is complicated by the fact that these people are often underrepresented in surveys and official statistics. We develop an approach to measure the impact of violence on internal displacement using anonymized high-frequency mobile phone data. We use this approach to quantify the short- and long-term impacts of violence on internal displacement in Afghanistan, a country that has experienced decades of conflict. Our results highlight how displacement depends on the nature of violence. High-casualty events, and violence involving the Islamic State, cause the most displacement. Provincial capitals act as magnets for people fleeing violence in outlying areas. Our work illustrates the potential for non-traditional data sources to facilitate research and policymaking in conflict settings. Blumenstock et al. find that high-frequency mobile phone data can be used to precisely measure the impact of violence on internal displacement. Using data from Afghanistan, they show how patterns of displacement depend on the nature of violence. Recent estimates indicate that the number of people living in proximity to conflict has doubled since 20073. Despite the global scale and importance of this crisis, empirical analysis of the link between violence and displacement is complicated by the inherent difficulty of observing displaced populations—a difficulty that is compounded in developing countries and in insecure environments4.Every year, tens of millions of individuals and families are forcibly displaced by armed conflict, creating enormous humanitarian, social and economic costs6, survey-based9 and observational studies12 on conflict and displacement in the developing world. It also builds on recent work using non-traditional sources of digital data to study the movement of human populations24.This paper develops and tests an approach to studying the impact of violence on internal displacement. Our first contribution is methodological and illustrates how high-frequency ‘digital trace’ data can enable different approaches to identifying and estimating the causal effect of violent events on internal displacement. We use a panel event study framework that is feasible only because we observe the locations of millions of individuals near-continuously over time: the high-frequency data allow us to draw causal inferences from discontinuities in spatio-temporal trajectories that coincide with specific violent events. Such an estimation strategy would not be feasible with traditional survey-based data, which track a relatively small number of individuals at infrequent intervals. This complements recent qualitative1. We contribute a quantitative perspective on the nature of this displacement, complementing more traditional approaches based on surveys and administrative reporting27.Our second contribution is to provide rich evidence on the impact of violence on internal displacement in Afghanistan—a country that has experienced decades of conflict and that contains over two million internally displaced people28. We use 3,354 events in our analysis, corresponding to the subset of all events that are recorded with sufficient spatial and temporal precision  and which overlap with our phone data; the limitations of the UCDP data are discussed in the ‘Our analysis is based on the universe of mobile phone activity from Afghanistan’s largest mobile phone operator for a four-year period from April 2013 to March 2017. This dataset contains the anonymized mobile phone metadata of approximately ten million mobile subscribers . We separately obtain geo-coded information on fatal violent events in Afghanistan, which is collected by the Uppsala Conflict Data Program (UCDP) from public media reports29 to identify days on which the subscriber’s home district changes—we refer to this as a ‘migration’.  defines migration as “the movement of persons away from their place of usual residence, either across an international border or within a State”30. Our main analysis focuses on migrations that involve a person leaving their origin district for at least a week; we validate our empirical measures of migration with IOM statistics in the The empirical approach we develop uses the mobile phone data to observe the movement of subscribers between regions, and a statistical model to estimate the causal effect of violence on this movement . Violence-induced displacement is persistent: even 120 days after the violent event, subscribers who were present for the event are roughly 2% ; P = 0.007) more likely to still be outside of the district. We show that these results are robust to several potential data and modelling issues in the Violence in Afghanistan causes internal displacement Fig. . Among sWe also find evidence that displacement often anticipates violence. This is apparent in Fig. P < 0.001); Taliban, 1.9% ; P = 0.111); Taliban–IS difference in coefficient estimate, 0.10 ; P = 0.002)). Such evidence is consistent with the fact that IS attacks are particularly brutal and frequently target civilians; the Taliban have condemned IS attacks as ‘heinous’36.The aggregate effects shown in Fig. P < 0.001 for a paired t-test of the 120 values shown in the figure; mean difference, 0.034; 95% CI, ). Figure P < 0.001 for a paired t-test; mean difference, 0.030; 95% CI, ). This result is perhaps surprising given prior work suggesting that people in chronically violent areas may acclimate to conflict39. However, in the context of the prolonged and pervasive Afghan conflict, we take this as evidence that people are more likely to flee their homes after recent and sustained violence but may be willing to withstand ‘idiosyncratic’ violence.High-casualty and high-frequency violence also have larger effects on displacement. Figure P < 0.001 for a paired t-test; mean difference, 0.026; 95% CI, ). Afghanistan’s 34 provincial capitals are regional seats of government and are where the Afghan National Security Forces are typically concentrated40. As a result, they may be seen to offer relative safety compared with outlying districts. We also find suggestive evidence that displacement effects are the highest in areas that are under insurgent control or contested by the Taliban  or a more rural non-capital district Fig. . AlthougP = 0.019).)The heterogeneous displacement responses shown in Fig. The analysis of anonymized mobile phone metadata can also provide granular insight into the destinations of the displaced. To build intuition, Fig. More revealing is how the equilibrium pattern of displacement shifts in response to violence. These results are summarized in Fig. 12. In Afghanistan , IOM survey data from 2019 suggest that conflict had caused roughly two thirds of all current displacement25.The preceding results illustrate a granular and dynamic empirical approach to studying conflict-induced displacement. The aggregate finding that violence causes displacement is consistent with prior work on internal displacement in fragile and conflict-affected countries41. The attraction of provincial capitals is probably due to several factors. First, capitals have a higher concentration of government security forces, and in the wake of violence, physical security is probably a crucial consideration. Relatedly, humanitarian aid—whose effectiveness depends on the security of the location42—is often most easily accessed in provincial capitals. Furthermore, provincial capitals are often the most urbanized area in the region, potentially offering greater economic opportunities43. Finally, movement to provincial capitals may create a feedback loop, where families are likely to have connections in provincial capitals, thus encouraging further movement to these capitals45.The main innovation of this approach is that it permits a fine-grained, quantitative analysis of violence-induced displacement that would be difficult to accomplish using household surveys and qualitative interviews. For instance, our analysis documents the important role of provincial capitals in influencing both the impact of violence and the destinations of displaced people. One specific finding is that when violence occurs in non-capitals, subscribers tend to flee to their home provincial capital. Such evidence corroborates qualitative findings that “people displaced by conflict and violence tended to try to stay as close as possible to their homes, moving from rural areas to the provincial capital or a neighbouring province”8. Apart from indiscriminate attacks, IS has orchestrated vivid displays of violence, such as filmed executions, advertising its brutality and intimidating opponents46. The Taliban, by contrast, has support among some segments of society and is seen by some as a legitimate governing force47. Separately, it is plausible that high-casualty and chronic violence similarly create an atmosphere of fear that leads to higher displacement. Casualties have been found to be associated with insurgent recruitment and violence48; their link to displacement is perhaps unsurprising.We also find that the types of violence associated with more displacement include violence related to IS, high-casualty violence and chronic violence. These results can be explained by the level of risk perceived by individuals and households influencing their decision to flee52, including recent work using mobile phone data53. This anticipatory effect is most pronounced with recently experienced violence  For example, there might be skirmishes between armed forces that do not lead to fatalities or are not reported in the media. This is consistent with survey-based evidence, which finds that the perceived threat of violence or presence of armed forces is sufficient to cause displacement, independent of the actual exposure to violence9. Rumours and word-of-mouth may also play a role: prior work suggests that information about violence spreads quickly57—including unverified rumours58—and that rumours may prompt people to take action to protect themselves59.Our analysis also indicates that people appear to anticipate the occurrence of violence, leaving before it occurs—a finding that relates to prior work on the predictability of violence and conflict34). As noted, our measures of migration and displacement only cover interdistrict movement of phones within the country of Afghanistan, and thus probably underestimate the overall effect of violence on displacement, which includes international and within-district movements.While passively collected mobile phone data create new possibilities for understanding forced displacement, there are important limitations and considerations regarding the use of such data  may be interested in making mobility data available to researchers and humanitarian organizations67. Finally, the analysis of phone data must respect the privacy of individual subscribers, particularly when dealing with displaced and otherwise vulnerable populations69. Our analysis involves only anonymized data that are aggregated geographically (by district) and temporally (by day). More generally, de Montjoye et al.70, Mayer et al.71 and others provide broader frameworks for the privacy-conscientious use of mobile phone data.Another obstacle to the widespread use of these methods of studying internal displacement is that mobile phone data are not always easily accessible and may require partnerships with data owners. However, there are encouraging signs that private companies 73 and data on Significant Activities (SIGACTS)74. However, these alternative data sources either do not have full data available during our period of study (ACLED and SIGACTS) or focus on specific types of violence . Thus, the UCDP data are the most suitable for our purposes, but they have their own limitations, in part because they are collected from media sources . In particular, not all events are included in media reports; inclusion is affected by a large number of factors76. For example, more populous regions and economic centres have a larger media presence and are thus better covered than peripheral areas, while contested areas and places with less infrastructure tend to have poorer coverage. Media coverage is also influenced by how ‘newsworthy’ the event is likely to be77. Our analysis is further restricted to those events for which the date and location  are known. Since the spatial and temporal precision of event reporting is not random78, and that non-randomness may even differ across regions of Afghanistan, this could introduce bias into our analysis. For instance, if the threshold for reporting violence in rural areas is higher than the threshold in urban areas77, that could bias our analysis to finding larger effects of violence in rural areas. We perform robustness tests in the 80, and researchers are increasingly exploring how social media and other non-traditional data can be used to source conflict data81.We also note limitations of the data we use to measure violence and conflict. We rely on data collected by the UCDP, which has known limitations that we discuss below. We also considered several alternative sources of data on violence, including the Armed Conflict Location and Event Data Project (ACLED)82. However, we consider such results preliminary, because they are based on a cross-sectional assessment of territorial control conducted in October 2017. Since territorial control changed rapidly during the period we study, a more robust analysis requires panel data on territorial control over time.Our analysis is further constrained by the general scarcity of publicly available quantitative data covering Afghanistan during this period. For instance, Supplementary Fig. 83), if that reduction is offset by other types of violence that dramatically increase out-migration. Relatedly, in discussing the anticipatory response, we noted that recorded  events may be preceded by a broader context of non-fatal violence, and individuals may in fact be responding to broader changes in the local environment that we cannot directly observe in our data.A broader limitation of our quantitative approach is that we cannot say much about what specific aspects of violence people are reacting to and whether observed displacement is voluntary or not. In aggregating effects over all violent events, we find that, on average, violence causes displacement—but this may hide the fact that certain types of violence lead to a reduction in mobility  may be specific to Afghanistan. For example, Afghanistan has a decades-long history of conflict; our results will probably translate better to settings with endemic conflict than ones where violence is new. Afghanistan also has strong clan-based, ethnic and sectarian divisions; a strong patriarchal society; and a relatively poor and young population. These contextual factors probably impact migration decisions in complex ways; our results will naturally be most relevant to environments with similar characteristics.Finally, while we have taken several steps to improve the internal validity of our analysis, we acknowledge that we can only speculate about the extent to which our findings will generalize to other countries. The general result that displacement is affected by violence has been documented in other contexts, including ColombiaDespite these important caveats, we remain optimistic that mobile phone and other digital trace data offer great potential for the study of internal displacement. Our empirical analysis provides insight into the nature of violence-induced displacement in Afghanistan and helps quantify some of the human costs of violence that would be difficult to measure using traditional methods. While there are definite limitations to what can be observed through mobile phone data, conflict-prone regions are often also the places where traditional survey-based data are the least reliable and most difficult to obtain. Our hope is that this approach can complement traditional perspectives on displacement and eventually contribute to the design of effective policies for prevention and mitigation.72. Specifically, we use UCDP Georeferenced Event Dataset Global version 19.1, available at https://ucdp.uu.se/downloads/. This open-source collection of metadata on armed conflict and organized violence is collected from media reports, so it is likely to be biased towards salient events in more populous regions77. The criteria for inclusion of an event are “the incidence of the use of armed force by an organized actor against another organized actor, or against civilians, resulting in at least one direct death in either the best, low or high estimate categories at a specific location and for a specific temporal duration”75. In Afghanistan from 2013 to 2017, 5,984 events were recorded where the event location is known to a district level and the event time is known to a specific day; 4,740 of these events occur during the period April 2013–March 2017, for which we have call detail records (CDR), and 3,354 of those occur in districts on days with mobile phone activity. We discard events that are not recorded with this level of precision , the date and time of the event, and the identifier of the physical mobile phone tower through which the transaction was routed. We also know the exact location of each tower, which allows us to approximately identify each subscriber’s location at the time of the event, to within roughly 500 m in urban areas and roughly 10 km in rural areas.There are 13,315 active towers during this period, many of which are very close together; we group these towers into 1,439 tower groups by combining towers less than 100 m apart. These cell tower groups are plotted in Fig. 30, and we focus on internal migration (“within a State”), where the place of usual residence is measured to a district-level precision. We capture trips that last approximately a week or more (at least five full days and two travel days). The migration that we measure is therefore an interdistrict movement. Complete details on this process are in the From the original CDR, we follow a sequence of steps to determine whether and when a migration event occurs. We adopt the IOM’s definition of migration, which is “The movement of persons away from their place of usual residence, either across an international border or within a State”87. While several prior studies use night-time hours to infer daily locations, we instead use all hours, which allows us to include more individuals in our analysis. For example, in April 2013, data are available for approximately 31 million individual-days using night-time hours (18:00 to 06:00), while 61 million individual-days are defined when using all hours (06:00 to 06:00). The two approaches are highly correlated: of the 31 million observations available using night-time hours, 89% record the same daily modal districts when computed using all hours. Another common approach in the literature divides the physical terrain into approximate catchment areas of each cell tower, using a Voronoi tessellation . Our analysis focuses on slightly larger administrative districts, since many of our violent events are identified at only the district level.Our first step is to derive a ‘daily modal location’ for each subscriber for each day, which is intended to capture the district in which the subscriber spends the majority of their time on that day. For each individual, we first compute their most commonly used cell tower in each hour. Then, for each 24-hour period from 06:00 to 06:00 the next day, we compute the mode of the hourly modal towers. The towers are then mapped to districts using point-in-polygon assignment. Similar methods have been used and validated in other workP < 0.001). ; P < 0.001).)In Afghanistan, we find that the geographic distribution of daily modal locations of mobile phone subscribers broadly reflects the geographic distribution of the population. In particular, when comparing the number of mobile phone users in each district to the district population as estimated by Afghanistan’s Central Statistical Office, the Pearson’s correlation coefficient is 0.94 ; 29 to identify contiguous segments in which a subscriber is, with high probability, resident in a single district. This algorithm helps smooth the influence of noise  and missing data  and has the advantage of not arbitrarily grouping days into calendar weeks or calendar months.These daily modal locations tend to be sparse and noisy—for instance, many people do not use their phones on every single day, people may take short trips to nearby  locations and so forth. Our second step thus employs an unsupervised scanning algorithmhttps://github.com/g-chi/migration_detector), which is specifically designed to infer migration events in transaction log data. The accompanying paper29 validates the use of these methods to measure migration. Tuning parameters are set to identify changes in locations resulting from stays of at least five full days in origin and destination districts. See the The third step is to identify migration events using discontinuous breaks in these contiguous segments. The second and third steps use the open-source Python package migration_detector . To our knowledge, there are no official or other published data measuring interdistrict migration as we do; while we try as far as possible to produce analogous measures, the IOM data measure fundamentally different quantities, and we do not expect comparisons to be identical. Generally speaking, we might expect province shares of migration and displacement to be similar if the fraction of displaced people among those who move for any reason is similar across provinces. This might not always be the case—for example, we might expect the capital, Kabul, to have a much smaller share of displaced people. Nevertheless, we make the comparison, as the IOM data are the closest published dataset on internal migration or displacement in Afghanistan.To validate the measures of migration derived from the mobile phone CDR, we compare our derived migration metrics to displacement measures published by the IOM  in assessed settlements over fixed periods. IDPs are categorized into ‘returnee IDPs’, ‘arrival IDPs’ and ‘fled IDPs’. We use the data collected in the year 2016; to our knowledge, this means that these individuals were recorded as being IDPs anytime during the year. We group ‘returnee’ and ‘arrival’ IDPs together as incoming IDPs, treat ‘fled IDPs’ as outgoing IDPs and sum the total numbers of incoming and outgoing IDPs for each province. We then compute each province’s share of the total incoming and outgoing IDPs.The IOM collects data at the settlement (village) level through key informant interviews, focus group discussions and direct observationhttps://data.humdata.org/dataset/estimated-population-of-afghanistan-2015-2016). We then aggregate these to the province level for 2016 and compute province shares in a similar manner. Supplementary Fig. ρ = 0.49 ; P = 0.004). Supplementary Fig. ρ = 0.56 ; P < 0.001).Next, to construct an analogous metric from the CDR, we compare the district locations of each subscriber at the beginning and end of three four-month periods in 2016 . Since each district could have different cell-phone penetration rates, for each period and each district, we estimate the total number of people who moved in and out of the district by scaling the number of recorded subscribers who moved by 89).In Supplementary Fig. 92), which allows us to estimate the total migration caused by violence while controlling for unobserved district- and time-related factors that might influence the occurrence of both violence and migration. We first present the technical details of this model and later discuss the identifying assumptions and possible concerns with this approach.We combine the violent events data and migrations observed in the CDR into a district-day panel dataset, which we use to estimate the ‘average’ impact of violence on out-migration from the district in which violence occurs. We estimate this effect by adapting widely used panel regression models to our context  and covariates Xdt are given by district fixed effects, γd, and time fixed effects, λt. Td,t+τ are the ‘treatment’ variables (whether or not violence occurs) in district d at time t, at a lag of τ days. Lags of τ ∈  are used, representing violence in the district 30 days in the future to 180 days in the past. This range was chosen because all effects were observed to lie within this window; the results are insensitive to a longer window, while shorter windows are unable to capture all effects of interest. The outcome variable, Ydt,k, is the proportion of those in district d at time t − k that are in a different district at time t. Subscribers present k days ago in district d but with a missing location on day t are included in the denominator but not in the numerator in this computation. The parameter k is introduced to capture the fact that displacement has to be measured relative to some time in the past. g is the logit link function. Since the outcome variable is a proportion, we model it using a beta distribution, a family of continuous distributions in the interval from 0 to 1, taking a variety of possible shapes depending on the values of its parameters. We fit a beta regression using maximum likelihood estimation93. Standard errors are clustered at the district level.For each value of τ, t), for Tτ = 1 (when violence occurs) relative to Tτ = 0 (days without violence), holding the other variables constant. To interpret βτ as the causal effect of violence on displacement, the target parameter is the causal conditional odds ratio, and the set of necessary identification assumptions are positivity, consistency, conditional exchangeability and correct model specification94. In our context, this specification assumes that there are no spatial spillovers, meaning that violence in one district does not have an effect on displacement in other districts. Carryover effects of the violence are limited to 180 days after the violence, and effects from up to 30 days prior are allowed. These daily effects are estimated independently and do not modify one another. The effects are assumed to be identical for all districts and to not vary over the measurement period (2013–2017). The confounders are limited to district, time and treatment in the surrounding window of time, and these enter additively. This implies that there are no unobserved time-varying confounders and that past outcomes do not affect current treatment (this is plausible since in most cases the number of displaced people is not large enough to affect military strategy). We relax several of these assumptions in subsequent analyses—for instance, by allowing for heterogeneous effects of different types of violence in different types of locations.These coefficients can be interpreted as with a logistic regression: for each t on the control variables in equation )). Finally, as an additional robustness check, we find that adding more restrictive region × month time-varying fixed effects to equation . Qualitequation —that is,mentclass2pt{minimmentclass2pt{minimIn estimating these regressions, we exclude district-days in which the outcome variable is 0, 1 or missing. The rationale is that these zeros and ones are probably due to data sparsity. On one hand, if no subscribers were recorded as being in a different district, it could be that their locations were simply missing . On the other hand, it is unlikely that all subscribers would have left a district on any day; a recorded 1 could indicate cell tower outages in the origin district, for example. Several other points are of note. First, this estimation of displacement as an increase in migration due to violence also partially addresses the concern that the place of usual residence might be incorrectly measured using CDR. If violence does not impact the measurement error , then the misallocation will not bias the estimated displacement. Second, although the treatments (violent events) occur relatively infrequently, the statistical model we employ is robust to sparsity; if all of the events are recorded accurately, estimates will not be biased because of sparsity. Non-random missingness of recorded events could bias estimates and are discussed in ‘additional movement that co-occurs with violence.To more plainly summarize our statistical approach to measuring the effect of violence on displacement, we regress out-migration in each district-day on indicators for occurrences of violence up to 180 days prior and up to 30 days in the future, while controlling for geographic and temporal factors. This approach is designed to capture out-migration in excess of the out-migration that normally occurs in that district  and on that day . Thus, the model does not assume that people do not move when violence is not occurring; instead, it uses movement in non-violent times and places as a baseline, to better isolate the We include 180 lag terms and 30 lead terms to measure excess out-migration  that occurs in the 180 days after violence and in the 30 days leading up to violence, as well as excess out-migration on the day of violence. Since violent events may be spatially and temporally correlated, a single observation (district-day) in the regression could have multiple violence indicators that are turned on; the migration dependent variable for that observation would thus contribute to the estimation of violence effects on all of the affected leads and lags.0.03 ≈ 1.03), holding all other variables constant.’ This approach helps limit the extent to which any one specific event, which might have unusual characteristics or correlates, can influence our final results. For instance, if one violent event happened to occur on a day in which a certain district would have seen unusual out-migration even in the absence of violence, that single event would have a limited impact on our final estimates. The main concern is if violent events were systematically correlated with other unobserved factors—above and beyond the flexible spatial and temporal fixed effects that we control for in the regression.Using this regression framework allows us to estimate the ‘average displacement effect’ of violence, averaged over the 3,354 violent events in our dataset that occur in districts on days with recorded mobile phone activity. For example, a coefficient of 0.03 on the indicator for violence at a lag of ten days can be interpreted as ‘On average, violence occurring ten days prior increases the odds of migration out of a district by 3%  violence and Ld,t+τ denote the occurrence of low-casualty violence, we estimate:To allow for the possibility that the displacement response may differ for different types of violence or for types of locations, the results of heterogeneous effects models are shown in Fig. Td,t+τ indicates a single event at a time . Only events in which all βτ coefficients can be estimated are included, meaning that if the outcome variable is unavailable in any day that is 30 days preceding the event to 180 days after the event, it is not included in the analysis. This results in a total of 2,359 events being studied. For each included event, we take the mean of the estimated coefficients for βτ, for τ = 1–15, 16–30, 31–45, 46–60, 61–75 and 76–90. We treat these as outcome variables and model each of these derived outcomes Oi asi is the event, provCapi is a binary variable denoting whether the event occurs in a provincial capital, log(population)i is the log of the population of the district in which the event occurs (added as a control), ISi is a binary variable denoting whether the event involved IS, casualties11i is a binary variable denoting whether the event was associated with 11 or more casualties and peace60i is a binary variable denoting whether the event was preceded by 60 or more days of peace. Figure To account for multiple dimensions of heterogeneity varying jointly, we analyse 30-day displacement by first fitting equation  on day k observed to be at specific types of destination districts, as described above. We use outcomes for k = 7, 30, 90 and fit separate regressions for provincial capitals, for non-capitals and for each outcome. As before, district-days in which the outcome variable is 0, 1 or missing are excluded from the analysis.To estimate the effect of violence on the destination of displacement, we use a similar setup as equation . InsteadAs discussed in ‘Ad,t+τ ; (2) events that occurred within a 25 km radius around a known point, Bd,t+τ (N = 789); and (3) events for which only the district is known, Cd,t+τ (N = 969). These replace the treatment indicators in equation The results, shown in Supplementary Fig. Further information on research design is available in the Supplementary InformationSupplementary Figs. 1–8, Tables 1–9 and information on data processing.Reporting Summary.Peer Review File.