Changing lifestyle patterns over the last decades have seen growing numbers of people in Asia affected by non-communicable diseases and common mental health disorders, including diabetes, cancer, and/or depression. Interventions targeting healthy lifestyle behaviours through mobile technologies, including new approaches such as chatbots, may be an effective, low-cost approach to prevent these conditions. To ensure uptake and engagement with mobile health interventions, however, it is essential to understand the end-users’ perspectives on using such interventions. The aim of this study was to explore perceptions, barriers, and facilitators to the use of mobile health interventions for lifestyle behaviour change in Singapore.Six virtual focus group discussions were conducted with a total of 34 participants . Focus group recordings were transcribed verbatim and analysed using an inductive thematic analysis approach, followed by deductive mapping according to perceptions, barriers, facilitators, mixed factors, or strategies.holistic wellbeing is central to healthy living ; (ii) encouraging uptake of a mobile health intervention is influenced by factors such as incentives and government backing; (iii) trying out a mobile health intervention is one thing, sticking to it long term is another and there are key factors, such as personalisation and ease of use that influence sustained engagement with mobile health interventions; (iv) perceptions of chatbots as a tool to support healthy lifestyle behaviour are influenced by previous negative experiences with chatbots, which might hamper uptake; and (v) sharing health-related data is OK, but with conditions such as clarity on who will have access to the data, how it will be stored, and for what purpose it will be used.Five themes were identified: (i) Findings highlight several factors that are relevant for the development and implementation of mobile health interventions in Singapore and other Asian countries. Recommendations include: (i) targeting holistic wellbeing, (ii) tailoring content to address environment-specific barriers, (iii) partnering with government and/or local (non-profit) institutions in the development and/or promotion of mobile health interventions, (iv) managing expectations regarding the use of incentives, and (iv) identifying potential alternatives or complementary approaches to the use of chatbots, particularly for mental health.The online version contains supplementary material available at 10.1186/s12889-023-15598-8. Non-communicable diseases (NCDs) are non-infectious, chronic conditions that often require long-term treatment and care, impacting on patients’ functional capacities and quality of life . NCDs, sThe Southeast Asia region has experienced a rapid increase in NCD-related deaths . For exaMobile health interventions may be an effective, low-cost, and scalable solution to support individuals in adopting and maintaining a healthy lifestyle –18. SmarDespite their potential however, the effectiveness of many mobile health interventions has been hampered by low engagement and high user drop-out –28. To dConsidering the aforementioned gaps in the literature, the present study aimed to: (i) explore perceptions of healthy lifestyle behaviours and mobile health interventions; and (ii) identify barriers and facilitators to using mobile interventions for health behaviour change, in Singapore.Focus groups were conducted during July and August 2021 as part of a wider research project aimed at developing and evaluating a new smartphone-delivered lifestyle intervention for the prevention of NCDs and CMDs in Singapore . EthicalIn line with recommendations , 32, thiParticipants were recruited via mailing lists from the Singapore-ETH Centre (the institution where the research was carried out) and the Facilitators Network Singapore , as well as online advertisements on the Singapore-ETH Centre website and social media. Those who were interested in participating were invited to access a link or scan a QR code that directed them to a participant information sheet. It provided details of the research team, explained the study purpose and procedure, and included a recruitment survey which collected sociodemographic information, contact details, self-rated confidence using apps and the internet, and previous experience using lifestyle apps. Recruitment surveys were reviewed for eligibility and a purposive sampling procedure was used to recruit participants, whereby those with indicators of lower socioeconomic status (SES) and those with prior experience using lifestyle apps were invited to participate first. Reasons for this sampling procedure were threefold: (i) people with lower SES are at greatest risk of developing NCDs but are among the least likely to engage with health interventions ; (ii) thThe questioning routes for all groups centred on perceptions, barriers, and facilitators to (i) healthy living and (ii) digital health interventions, including mobile lifestyle applications (apps) and chatbots. The content of the topic guide was developed by one researcher (JM) based upon the research team’s experience and the Theoretical Domains Framework, an integrative framework of behaviour change constructs that can be used to systematically understand behaviour and its determinants , as usedFocus groups were conducted online using a videoconferencing platform . Discussions were facilitated by two professional local moderators from the Facilitators Network Singapore, one male (lead) and one female (supporting), who were independent from the research team and had no personal interest in the research topic. The lead moderator explained the guidelines, set ground rules, and introduced the topics for discussion. Two scribes (AA and RK) summarised participants’ comments using the chat function and took field notes during the discussions. One lead researcher (JM) attended all focus group discussions to assist the moderator if needed but made no contribution to the discussion. The questioning was semi-structured and open-ended to encourage discussion, with probes used to solicit additional information when required. Focus groups were 90 min in duration, with 15 min allocated to introductions, guidelines, ground rules, and an ice breaker, 70 min allocated to the main discussion, and 5 min to close the session. Participants received a S$30 e-voucher as reimbursement for their time. Focus group discussions were discontinued when data saturation was achieved (no new themes were identified) based on an iterative review of the field notes following each discussion and agreement among the researchers.Focus group data were analysed using a two-step approach. First, relevant themes were identified through inductive thematic analysis , 44, folIn stage 1 of thematic analysis (data familiarisation), focus groups interviews were initially transcribed automatically by the Zoom platform. Two members of the research team (BF and JN) reviewed the transcripts, together with the recordings, and corrected errors. Any difficulties in transcribing certain phrases were reviewed by two other researchers (SZ and JM). Comments from participants that had been written in the meeting chat were incorporated into the transcript. Transcripts were then uploaded to Atlas.ti V.9 to facilitate the analysis. BF and JN engaged with the focus group transcripts by reading and noting down initial thoughts and observations.During stage 2 (code generation), BF and JN generated initial codes independently for the entire sample of focus groups transcripts. In thematic analysis, codes are short labels that represent important features of the data relevant to answering the research questions . For exaIn stage 3 (theme development), the final list of codes generated by BF and JN were reviewed by AS, JM, and OC, who made suggestions on whether some codes could be merged or separated and developed an initial grouping of codes independently. BF used the team inputs to implement further changes to the list of codes and grouped the codes together into a tentative set of overarching themes and sub-themes. For the purposes of this study, themes and sub-themes were understood as a collection of similar codes that provides detail about the participants’ views on healthy lifestyle and mobile health interventions.Stage 4 (review of candidate themes) involved a critical analysis of BF’s final list of themes and sub-themes by AS, JM, and OC, to examine whether they told a convincing story of the data (one that answer the research questions) as well as revisiting the raw data under each theme and sub-theme to ensure coherence and consistency. The whole team discussed and agreed on any revisions to the final list of themes .In stage 5 (theme refinement), names and descriptions for each theme / sub-theme were written up by BF and JM and discussed with the rest of the team. Where relevant, sub-themes within each of the themes were then deductively mapped according to perceptions, barriers, facilitators, mixed factors, or strategies, in order to provide further structure and meaning to the data. Finally, all authors were involved in writing up the analysis and findings.Six focus groups, each with between 4 and 7 participants, were held virtually over a two-week period during July and August 2021. Initially we recruited 36 participants but one participant did not attend the scheduled focus group and another decided to withdraw from the discussion, therefore a total of 34 participants  were included  holistic wellbeing is central to healthy living, (ii) encouraging uptake of a mobile health intervention, (iii) trying out a mobile health intervention is one thing, sticking to it long term is another, (iv) perceptions of chatbots as a tool to support healthy lifestyle behaviour and (v) sharing health-related data is OK, but with conditions.Quote: “Healthy lifestyle has two aspects, one is a physical health, which is, of course, your diet and your exercise and the other one is your emotional health, which means to be spending time with your loved one, having some ‘me time’. So, to me that is healthy lifestyle, so everything has to be in balance.” .Holistic wellbeing was the key overarching theme when discussing the topic of healthy lifestyle. Participants felt strongly that healthy living requires a balance between both physical and mental health, as well as activities of daily life. They viewed exercise, nutrition, and sleep as core pillars, or the foundations, of a healthy lifestyle but they also identified several other aspects of life that are important. For example, having social connections and a good support network, paying attention to emotional and mental wellbeing, being surrounded by positivity, spending time on spiritual practice, or having security and certainty in life were discussed.Quote: “I would think that it is more than the physical and the food and the sleeping, for example, to me, also making meaningful connections to people around me.” .Quote: “for the mental health challenges right, if they are not open for professional help, I’ll encourage them to join mental health support groups, you know there’s those available where diagnosis is not required, because of the stigma.” .Participants identified three support mechanisms that they felt would help them to live a healthy lifestyle. These were trained professionals, peers or family members, and the internet. Although professionals were perceived to be the best support for mental health, there was the view that mental health stigma prevents people from seeking their support due to concerns that a diagnosis could lead to negative consequences, for example on future employment. Instead, for mental health support, people may rely more on the internet, family and friends, or a support group.The identified barriers, facilitators, and strategies to healthy living are summarized in Table Environmental factors were viewed as both barriers and facilitators to healthy lifestyle in Singapore. For example, residents generally have good access to parks and outdoor activity spaces, such as outdoor gyms, and fitness centres are generally low cost. However, the weather conditions limit outdoor activity to the early morning or evening, when temperatures are cooler. Participants also explained that the food environment in Singapore does not promote healthy eating, as unhealthy food is cheaper and highly available, compared to healthy food.Social influences were also perceived as creating both barriers and facilitators to healthy eating and participation in exercise and physical activity. Participants talked about how food choices are influenced by what others are eating or the food preferences of others, both when dining out and preparing food at home. They also talked about how involving family and friends in physical activity can motivate them to be more active.Participants also described the actions they were already taking or could take, to lead a healthy lifestyle. Dietary strategies included making conscious diet choices, for example eating more balanced meals, ordering less ‘take away’ food, and cooking at home. Exercise strategies focused on integrating movement into daily activities, for example walking after meals and taking activity breaks during the workday. Different psychological strategies included setting goals, following a routine, journaling, and spiritual rituals like meditation and praying. Finally, time management strategies, including a focus on work-life balance and planning ahead for healthy eating and physical activity, were named by the participants.“I honestly feel that HPB’s model (free tracker coupled with incentives) is pretty effective and has seen a very good adoption rate.” Quote: Theme 2 discusses the factors influencing the initial uptake of mobile health interventions. Participants’ comments were largely in relation to digital health promotion programmes offered by the Singaporean Government’s Health Promotion Board (HPB), although opinions on other commercially available apps were also discussed. In general, participants were open to using digital health interventions and apps. They acknowledged that the Singapore Government has made significant effort to promote health through digital programmes and that the incentives offered with these programmes  are effective in getting people to sign up initially. Some also commented that programmes or apps that are popular, and that many people are talking about, encourage wider uptake. Apps with essential features linked to lifestyle behaviours, for example, booking systems for fitness classes, or tracking body weight with a linked digital scale, also have higher uptake.“For me, I feel probably you need to make the app more popular first, maybe some incentive to initially just jump start, like everyone now notices the [online retailer] app. You need to make the app popular so that word of mouth or that you get more and more people use it then. Quote: “I was introduced to it [Healthy 365 app] because there’s a dance class that goes on right underneath my window, and that was like so attractive, so I just appeared then they told me, oh yeah you can dance here, and you can download this app.” Quote: The identified barriers, facilitators, and strategies for the uptake of mobile health interventions are summarized in Table The marketing strategies and outreach efforts used to encourage uptake of mobile health interventions were seen as both a barrier and a facilitator. On the one hand, roadshows and the use of radio jingles were mentioned as memorable tools that convinced people to join. On the other hand, one participant said that it was often difficult to find further information about ongoing programmes and it was too effortful to sign-up to participate. Similarly, there were mixed views regarding the cost of commercial apps. While participants felt cost was a limiting factor in the uptake and long-term use of commercial apps which ultimately led the abandonment of the app, they were also dissatisfied with the limited features available with free apps. Still, if apps were able to offer the same service as comparable offline services, such as receiving support from a health professional, participants saw cost benefits for the app.Strategies for the uptake of mobile health interventions were centred around ways to reach people. Participants viewed places visited frequently by people, such as supermarkets, schools, or workplaces, to be the best places to reach and engage people with mobile health initiatives. In addition, participants felt certain individuals, such as doctors, friends, or community support groups, would be best placed to convince people to use mobile health interventions. Consistent and persistent messaging about a mobile health intervention over a long period of time was also mentioned as a way to encourage uptake.““Lose to Win” is also organized by the Health Promotion Board…I took part in a few seasons, and I think it was really, really helpful. The first time when I take part in it they organize you into groups and then you meet regularly to exercise together, and also on nutrition workshops and yeah talks and workshops, which is very helpful. I got to know a few friends from that programme.” Quote: Theme 3 explores user experience and factors influencing long-term engagement with mobile health interventions. Overall, participant’s perceived mobile health interventions as useful and effective, highlighting the benefits of certain features like providing free apps and activity trackers, being able to collect rewards, and using the technology to connect with group activities and workshops.Quote: “that’s quite exciting for the first two seasons of this ‘National Steps Challenge’, then after that, even though I sign up on the latest ‘National Steps Challenge’ but because I’m not clocking much [steps], I kind of also semi give up, yeah [laughs]. So yeah, the initial excitement has gone.” Participants mentioned that the novelty and excitement of a new app encouraged them to use it more in the beginning, but after some time, the novelty effect would wear off and they would either stop using the app as frequently or give up using it altogether.Quote: “I think the initial stage, because of the novelty people will get a tracker try to clock 10,000 steps, every day, but after a number of days, it wears off, so once the novelty wears off, we are back to our usual: people who are active remain active, people who are not active will still be not active because it’s like there’s no more incentive anymore really.” The identified barriers, facilitators, and strategies linked to long-term engagement with mobile health interventions are summarized in Table Rewards and incentives via mobile health interventions were seen as both facilitators and barriers to engagement with healthy lifestyle behaviours. On the one side, participants said incentives, such as receiving vouchers for performing healthy activities, can be effective in engaging people with a mobile health intervention and help to motivate them to change their behaviours. On the other side, they acknowledged that this form of extrinsic motivation is unlikely to work long-term and can lead to users abusing the system. For example, when rewards and incentives are no longer available users become disengaged, suggesting they will only perform the desired behaviours when an incentive is involved.There were also mixed views on tailoring and personalisation of app content and features. Although tailoring was perceived as a very desirable feature, participants commented that existing apps often take a ‘one-size-fits-all’ approach and, while that approach might work for some people, it is unlikely to work for the majority. In general, if a mobile health intervention is not tailored, personalized, or bespoke to the individual, people will eventually abandon it.Participants identified several strategies that they felt would improve engagement with mobile health interventions. Social strategies included collaborating as a group with family and friends to achieve prizes or using peer pressure to help drive behaviour change. In relation to incentives, while they were identified as creating both barriers and facilitators to longer-term engagement, participants still felt that they could be used to further facilitate long-term engagement. For example, they suggested different models of incentivisation such as delayed rewards or only allowing users to redeem points against healthier choice products. Regarding desirable features, participants highlighted the importance of personalization, whereby an app can cater directly to a user’s specific needs and tailor support or content as needed. They also discussed a desire to be able to track and visualize their progress and achievements easily. In addition, apps should be extremely easy to use, offer multiple health and wellbeing services, and integrate different data sources in one place to reduce burden on participants.“I think it’s just based on past or present experiences that we had on chatbots, they’re usually not answering your question directly, I think a lifestyle, digital coach, whether health exercises or even mental health, I guess, I wouldn’t want to use it.” Quote: Participants’ views on chatbots were largely based on their experiences using customer service-related support. They had a negative perception of chatbots, perceiving them as useless, and described the process of interacting with them as frustrating. Specifically, chatbot interactions are time-consuming and the chatbot itself is often unable to understand questions or provide helpful answers. These issues were perceived to have a demotivating effect on users and made them sceptical about how useful a chatbot would be in the health context.Well, if it is still not a real person, then after all it is programming, so I wouldn’t say that I have much confidence in it, because, after all, for everyone the problem is unique.” Quote: ““…might people lose their job or get replaced? If you can understand yourself, why would we need a doctor, why would we need a psychologist, physically?” Quote: Participants were also concerned that chatbots, or digital interventions more generally, might be used to replace face-to-face services and could lead to job losses for certain professionals, like psychologists.One of the bad things about digital health coaching is that it can come across as slightly impersonal and the other thing is that it may try to be motivational but it might end up having a really opposite effect” Quote: “While participants were open to the idea of a chatbot supporting them with certain health issues or behaviours, there was concern that, for mental health support, a chatbot might not only be demotivating but also problematic and that AI might never be able to replace a human being.Quote: “For me, I think, I would like to know whether it is a chatbot or real person. I mean if it’s for food, okay lah, just a chatbot will do. But if it’s a mental health coach, I would prefer a human being. I mean a real-life human behind the chat. I mean, that’s why I feel that robotic or AI can never replace a human being, I’ll need the touch, yeah, so I think for mental health, I prefer a human being behind it.” Quote: You can have the Doctor Google or Alexa, you know, answering your queries anytime of the day, but if you’re talking about psychological well-being it’s pretty hard to trust just a robot, you know, answers which are like generic anyway.” Quote: “So I mean of course there are like some established chatbots where people use it so much that the AI is good enough to be able to give good answers, but it always takes – yeah I mean it’s a good time to start – but it always takes a while before the data collected is good enough for it to give reasonably good answers.” However, they also acknowledged that the technology is still in its infancy and apps using digital health coaches could have potential due to their availability, accessibility, and cost-effectiveness when compared to offline options.Quote: “compared to like a physical coach, right, I think I would be more receptive to having a digital coach. Simply because of the availability, the accessibility and then I think working with a digital coach would also be more cost effective. In a sense, I think, probably for a digital coach, at most, the cost involved probably would be from your monthly subscription if it’s chargeable in that sense. But then, whereas you know if you have a physical coach, I think in the terms of costs here will be higher. So in that sense, I think I would be more receptive towards the app.” “…the interactive element there, so if a digital health assistant wants to maybe be a little bit more effective, it should be your friend. It shouldn’t be something that is very much like your doctor sitting there and then looking at vitals. It should be the friend who says ‘hey, wanna come with me today and let’s go for just a short walk?’ and then after that before you know it, that app has brought you on a slightly longer walk, than the short walk that you originally wanted. And then the app says ‘hey I had lots of fun with you’ and all that kind of thing, so it has to have a very human side to it in order to be effective.”Quote: Potential strategies to improve chatbots for the purpose of digital health coaching were largely focused on the qualities of the chatbot and the type of support that the chatbot could provide. For example, the chatbot should be empathetic, interactive, encouraging, and helpful, like a virtual friend who can provide motivational support and makes personalized health suggestions based on current progress. Participants also suggested giving users different ways of interacting with the chatbot, for example through speech or text, offering free trial periods to test out the chatbot, and providing an option to link users to real-life coaches.Quote: “I know I’m sharing my personal data for the better of the community.” .Participants were largely unconcerned about health-related data sharing, especially if they could see a benefit for them or the wider community. However, this sentiment was conditional on three aspects: (i) who will have access to the data, (ii) how it will be stored, and (iii) for what purpose it will be used. Participants needed to be able to trust the entity accessing and using their data. In this regard, government agencies were viewed as more trustworthy than private companies, as the latter were perceived to benefit from the data themselves by monetizing it. Participants were generally happy to share their data if it was aggregated, anonymized, and securely stored. Participants highlighted the importance of being informed about the proposed use of their data and being explicitly asked to provide their consent for this use.Quote: “I think what’s important is to generate more trust or like you know, for us to want to be more willing to share data, we’d like to know, what actually is being done with the data, like, why do you need this information and what’re you going to do with it and what do I get back in return for sharing that bit of data and how it can help me? .The aim of this qualitative study was to explore perceptions, barriers, and facilitators to mobile health interventions targeting healthy lifestyle behaviours in Singapore. We identified one broad theme relating to healthy living and holistic wellbeing, two themes relating to the uptake and continued use of mobile health intervention, and two narrower themes discussing the potential of chatbots in supporting health behaviour change and in what circumstances health-related data might be shared. These themes and relevant sub-themes are discussed below, with a particular focus on the practical implications for developing and implementing mobile health interventions in Singapore and, potentially, other Southeast Asian countries.Participants showed a generally positive attitude towards digital health interventions in general and highlighted the importance of targeting holistic wellbeing, including body, mind, connectedness, and spirituality. Current health-related interventions, however, rarely address these elements together but rather focus on a single domain such as doing more exercise . Even wiMost of the identified barrier and facilitators to leading a healthy lifestyle were in line with previous literature in Singapore and beyond. For example, several studies have highlighted lack of time  and cost  as key barriers to healthy living –56. SimiThe food environment in Singapore was also widely discussed during the focus groups, with participants agreeing it is not conducive to healthy eating as energy-dense, nutrient-poor foods are widely available, affordable, and heavily promoted. This is in line with recent studies analysing the health of the Singapore food environment , and it A key challenge for any mobile health intervention lies in how to motivate users to start using the app and/or wearable device and adhere to it long enough , 30. ParThe use of rewards and incentives was generally viewed by participants as a useful strategy for both initial uptake and sustained engagement with a mobile health intervention. Financial incentives in the form of redeemable points or coins are common in the Singaporean app landscape, both for health- and non-health-related apps. However, the effectiveness of financial incentives is debated in the behaviour change field , 67, witChatbots are rapidly becoming important gateways to delivering digital services in multiple areas, including health, customer service, or work assistance . HoweverLastly, it is worth mentioning that participants were particularly concerned about the use of chatbots for mental health support, compared to physical activity and/or healthy diet promotion, and felt strongly that chatbots should not replace humans in this regard. These views have also been reported elsewhere , 76 and Strengths of this study include the use of the COREQ reporting guidelines  and the Our study also has some limitations that need to be considered. Results are based on a predominantly Chinese sample with a majority of women. Therefore, findings may not be applicable to all middle-aged adults in Singapore. Despite our purposive sampling procedure prioritising individuals with low SES, nearly 80% of our participants had a university degree, which is a strong indicator of middle-to-high SES. There is a steep socioeconomic gradient for both the incidence of NCDs  and engaThis study adds to the limited body of literature exploring public perceptions of mobile health interventions in Asian populations. Findings highlighted several factors that are relevant for promoting a healthy lifestyle and for the effectiveness of existing and emerging mobile health interventions in Singapore and other southeast Asian countries. Future work in this area should consider: (i) targeting holistic wellbeing, (ii) tailoring content to address environment-specific barriers, (iii) partnering with government and/or local (non-profit) institutions in the development and/or promotion of mobile health interventions, (iv) managing expectations regarding the use of incentives, and (iv) identifying potential alternatives or complementary approaches to the use of chatbots, particularly for mental health.Below is the link to the electronic supplementary material.Supplementary Material 1: Consolidated criteria for reporting qualitative studies (COREQ)Supplementary Material 2: Topic guideSupplementary Material 3: Thematic analysis checklist


One of the most brutal dictators in humanity’s history, Joseph Stalin forged the Soviet Union into a massive superpower, crushing the lives of millions of his own citizens along the way. His sudden death in March 1953 from a stroke took the world by surprise and led to a frantic power struggle within the ranks of the Soviet government. In recent years, researchers have proposed that Stalin’s stroke was not natural and was potentially caused by one of his lieutenants poisoning him with warfarin or a similar anticoagulant. After examining the evidence, this article concludes that both Stalin’s disease course and the properties of warfarin make it highly unlikely that he was deliberately assassinated. In the early days of March 1953, as the rest of the world waited with bated breath for news out of the Soviet Union, an American ambassador sarcastically wrote: “Uncle Joe is sick in bed - Rush in blood up in his head - If he can’t walk and he can’t talk - By whom now are the Communists led?” , was dyiStalin’s healthBefore a thorough discussion of Stalin’s death can occur, his life must also be addressed. The man that the world would know as Joseph Stalin, the “organizer and director of one of the most powerful and merciless terror machines known to history”  was bornThe following decades of his life were even harder on his health. The now-revolutionary, exiled to the harsh and austere environment of Siberia, experienced a bout of typhus in 1909, followed by pulmonary tuberculosis in 1917. During the Russian Civil War, he underwent an urgent appendectomy in 1921, with complications so significant that his surgeon thought his death was almost certain , along wBy nearly all accounts, Stalin entered World War II - dubbed “The Great Patriotic War” by the USSR  at the hBy 1952, Stalin’s health, worsened by advancing atherosclerosis [Before discussing the Doctor’s Plot, it is necessary to establish Stalin’s history with healthcare professionals. In one of the most important moments of the 20th century, the “Big Three” leaders of the Allies met at the 1945 Yalta Conference to lay out the course of postwar Europe. Interestingly, all three of the major leaders - Winston Churchill, Franklin Delano Roosevelt, and Joseph Stalin - suffered from hypertension, and all three would die of strokes . Of the In his later years, the only physician that Stalin ever showed a measure of respect for was the famous Dr. Lina Shtern, even going so far as to reduce a death sentence for her for being in the Jewish Anti-Fascist Committee (JAC) to a prison sentence. Rumors abounded that he spared the famous biochemist and winner of the 1943 Stalin Prize because of her research regarding longevity [Pravda officially announced the discovery of a “terrorist group of doctors who had made it their aim to cut short the lives of active public figures of the Soviet Union” [Pravda article even admitted that it had been fabricated. The MGB soon released seven of the arrested doctors - the remaining two had already died in captivity [The government crackdown on the JAC and Vinogradov’s 1952 arrest were direct precursors to the infamous Doctor’s Plot. Less than two months after his arrest, the January 13th, 1953 edition of t Union” . Includet Union” , and Dr.t Union” . Though t Union” , the majt Union” . From JaAs some of the most talented physicians in the USSR were being tortured to confess their collusion with “foreign intelligence services” , Stalin There is no archival evidence that Stalin was under the care of any physician since January 1952, aside from the brief visit to an ENT specialist in April that has already been discussed . Even hiThe death of Stalin Piaterka - the “Five,” four of his most powerful underlings and himself, known to the others simply as “the Boss”. Included in the Five that night were Lavrentiy Beria, the ambitious and sadistic chief of Stalin’s secret police, Georgy Malenkov, Deputy General Secretary of the USSR, Nikita Khrushchev, future Premier of the Soviet Union, and Nikolai Bulganin, the Minister of Defense [It is in this environment of malaise, paranoia, and ill health that Joseph Stalin, Premier of the Soviet Union, found himself on the night of February 28th, 1953. At his private dacha in the suburbs of Moscow, he had a private gathering of the Defense .Khrushchev would later claim in his memoirs that Stalin was otherwise in a good mood that night, “tipsy” from consuming more wine than usual , althougAs some of the guards moved Stalin to a large sofa in the guest room, one of the others frantically called the head of the MGB, Semyon Ignatiev. Frightened, he ordered them to call Malenkov and Beria instead . Beria iRegardless, the growing terror of the dacha came to the attention of Khrushchev, who arrived at the facility at approximately 7:30 AM that same day. Shocked by what he saw, he quickly summoned the ruling group and a group of doctors that arrived an hour later . After 9While Stalin’s own personal physician was being tortured in the depths of a prison cell, a hastily-assembled team of doctors examined the dictator . They weOver the next several days, the physicians would attempt a number of treatments, including “absolute quiet; the application of leeches to his ears; a cold compress on his head; an enema of milk of magnesia, and the removal of his false teeth” . Mid-intAs the dacha became crowded with a “swirl of anxious chaos,” the upper echelons of the Party gathered to witness the death of their leader - and to plan for the subsequent power vacuum that followed. Beria in particular seemed to be overjoyed, although Khrushchev noted that on the few instances where Stalin briefly seemed to regain some semblance of consciousness, Beria “threw himself on his knees, seized Stalin’s hand, and started kissing it” . Most daBy 3 March, the doctors announced that “Death is inevitable” . The SovOn 5 March, Stalin’s condition worsened. He vomited blood on two occasions , signifiBy then, there was nothing that could be done. Svetlana described her father’s “death agony” as “horrible,” stating “he literally choked to death as we watched.” With his last breath, Stalin “suddenly opened his eyes” and cast a “terrible glance, insane or perhaps angry and full of the fear of death” over the entire room, raising his left hand in a strange gesture as if “bringing down a curse… the gesture was incomprehensible and full of menace, and no one could say to whom or at what it might be directed” . SecondsBut it was not quite the end. To Khrushchev’s horror, one of the aids rushed to the bed and started giving Stalin artificial respiration, “massaging him to get him breathing again” . This coPravda and revealed a large hemorrhage in the subcortical areas of the left cerebral hemisphere, as well as significant hypertrophy of Stalin’s left ventricle, numerous hemorrhages in the myocardium, stomach, and intestines, and significant atherosclerotic changes throughout his blood vessels. Pravda concluded that “all treatment attempts could not have led to a favorable outcome and prevent a fatal end” [Pravda was brief, and did not describe the neuropathology of Stalin’s brain in significant detail [The subsequent autopsy was published in the 7 March edition of tal end” . The destal end” . Much lital end” . The autt detail . Nor doet detail .Warfarin hypothesisFor decades, the USSR’s official determination that Stalin’s death was due to natural causes went unquestioned. However, Radzinsky’s 1997 biography of Stalin, as well as Brent and Naumov’s 2003 book detailing the Doctors’ Plot, both raised the intriguing possibility that Stalin’s stroke was instead due to being poisoned by one of his inner circle sometime during the late hours of 28 February or the early morning of 1 March ,5. Out oBeria’s behavior was also inordinately suspicious during Stalin’s illness. As previously established, he and Malenkov - unwittingly or not - delayed any medical treatment for Stalin for at least an additional five hours . He was Also suspicious, as Faria pointed out in his 2011 article examining Stalin’s death, are the episodes of hematemesis that Stalin experienced in the latter half of his disease course . As discFaria, as well as Brent and Naumov, suggest that Stalin was poisoned by warfarin , or a similar anti-coagulant agent, that was slipped into his wine the night of 28 February to 1 March, possibly in a plot by both Beria and Khrushchev ,6. The pIn a 2019 rebuttal to this theory, researchers stated that Beria would likely not have had access to warfarin in the early months of 1953, claiming that warfarin, initially synthesized at the University of Wisconsin, was first marketed in the United States as a rodenticide in 1952, and not approved for human use until 1954, limiting its availability at the time . ObtainiFurther supporting the theory of a warfarin poisoning, a supratherapeutic International Normalized Ratio (INR) due to warfarin overdoses does have the potential of causing an acute GI bleed. One study found that 12% of cases of warfarin overdose may manifest with clinical hematemesis, melena, or hematochezia, and noted that “in the pre-endoscopy era, the etiology of bleeding (secondary to warfarin overdose) was often attributed to trivial mucosal lesions”  - remarkBeria also had a history of poisoning his enemies. In 1936, he invited one of his rivals, Nestor Lakoba, to dinner and poisoned him with an unknown substance. Lakoba died “convulsing” in agony . It woulRejecting the poison hypothesisWhile Beria likely could have secured access to warfarin and had a history of using poisons to eliminate enemies , it appeThe first rebuttal to this theory can be observed in Stalin himself. As his paranoia grew, he became “obsessive about the possibility of being poisoned” . He madeThe second rebuttal is that warfarin is not a particularly effective poison, at least in terms of assassination. By 1951, it was already established that vitamin K could be used to counteract the effects of an acute warfarin overdose. In the case of the US Army inductee mentioned above, his attempted suicide via warfarin overdose was reversed by large doses of vitamin K . With suWarfarin also has a delayed impact on coagulation and INR, due to the half-life of factors II, VII, and IX in particular. Typically this means that the patient’s INR will not change within 24-48 hours after the administration of warfarin . While tIt also appears that even if Stalin had been poisoned with warfarin, it would have taken even longer than 24-48 hours for any symptoms to manifest. In the 1954 case of warfarin overdose discussed above, the family continually ate the warfarin-laced bait for several days before manifesting any symptoms, with one of the children consuming the bait for 15 days before she died of a severe “nasal hemorrhage” on the 17th day . SimilarEven in the 1951 case, the first recorded poisoning of a human with warfarin, the US Army inductee reported that he consumed warfarin for six consecutive days, consuming approximately a 113-gram carton of warfarin-derived rodenticide during that time. He had no symptoms until two days after his final dose, when he began to experience constipation, epistaxis, back pain, abdominal pain, vomiting, and a petechial rash . InteresThe source of the hematemesisIf Stalin’s hematemesis and reported GI hemorrhages were not due to poisoning via warfarin or a similar anticoagulant, then what caused them? A 2011 review article raised the interesting possibility that Stalin may have suffered from stress ulcers or a Mallory-Weiss tear . While SThe most likely possibility for Stalin’s hematemesis is that it was stress-related, “secondary to the prolonged time interval between the onset of his stroke and his death” . While tGiven the evidence currently available to us, it is almost certain that Stalin - a paranoid, inactive, generally unhealthy man in his mid-70s who routinely imprisoned and executed his own physicians, with a longstanding history of chronic untreated hypertension - died exactly the way that the Soviet government declared: from a left MCA hemorrhagic stroke secondary to his hypertension.It appears highly unlikely that Stalin was poisoned by warfarin or a similar class of anti-coagulant. Although Beria certainly had the motive to assassinate Stalin, the dictator’s death ultimately led to his own several months later. His strange behavior at Stalin’s bedside can either be attributed to Khrushchev deliberately altering the facts for his own political advantage, or due to genuine relief that Stalin was dying. In addition to this, the description we have of Stalin’s illness does not match the appearance or timeline of patients that experience severe warfarin or warfarin-related overdoses. His hematemesis does not appear to be associated with any other generalized coagulopathy, and was likely stress-related. While Beria and Malenkov may have deliberately stalled Stalin’s care during the morning of 2 March, it appears highly unlikely that either of them played a role in deliberately poisoning the dictator. Ultimately, it appears that Joseph Broz Tito, the dictator of the communist regime of Yugoslavia, was correct when he pronounced upon Stalin’s death: “Nature is the ally of justice.”


We analyzed the transcripts of 36 individual interviews with a diverse group of sex workers using thematic analysis. Five general themes emerged regarding the detrimental impact of COVID-19 on sex workers: (1) the impact of COVID-19 on physical health; (2) the economic impact of COVID-19; (3) the impact of COVID-19 on safety; (4) the impact of COVID-19 on mental health; and (5) adaptive strategies for working during COVID-19. Participants reported that their physical and mental health, economic stability, and safety worsened due to COVID-19 and that adaptive strategies did not serve to improve working conditions. Findings highlight the ways in which sex workers are particularly vulnerable during a public health crisis, such as COVID-19. In response to these findings, targeted resources, an increased access to funding, community-empowered interventions and policy changes are needed to protect the health and safety of sex workers in Chicago.COVID-19 exacerbated health disparities, financial insecurity, and occupational safety for many within marginalized populations. This study, which took place between 2019 and 2022, aimed to explore the way in which sex workers ( Sex work can be described in a number of ways; however, for the purpose of this study, sex work is defined as the exchange of oral, anal, or vaginal sex for something of material value . Prior tResearch points to a negative cascade in relation to sex work and the potential for harm. For sex workers, an increased exposure to trauma and structural violence likely increases the prevalence of physical or emotional harm and the potential for the acquisition of sexually transmitted infections (STIs), including HIV . ResearcWith the exception of 10  counties in Nevada housing legalized brothels , sex worStructural vulnerabilities such as unstable housing, gender inequality, and lesbian, gay, bisexual, transgender, and queer (LGBTQ+) identities increased incidents of physical and sexual violence perpetuated by clients, partners, and by law enforcement related to selling sex and may have increased the risk of exposure to STIs and HIV . ConsistWhen COVID-19 government relief became available for the millions unemployed in the US, sex workers were not prioritized as a vulnerable community as their work was unreportable due to criminalization and thus were not financially protected through the program ,19. In tIn addition to increased incidents of violence, the US additionally saw an amplified mental health decline among the general population, such as a rise in depression, anxiety, substance abuse, and suicidal ideation . Prior tOur interview guide used an intersectional lens to highlight the structural inequities experienced by sex workers. Intersectionality has been pivotal in understanding the experiences of marginalized individuals, as the intersections of gender, race, sexuality, and socioeconomic inequality are closely related to the health of sex workers . The comThis qualitative study was guided by a community empowerment framework . Communin = 36) analysis aimed at the development of community empowerment interventions by understanding the self-management, health promotion, and harm reduction needs of sex workers in Chicago  actually really grateful for having had the time to feel grief again, because then how else would you like finally move on and like evolve it into a different thing.Some participants expressed that the social isolation caused by the pandemic was particularly harmful to their community’s mental health and stressed the importance of peer support networks in this community. Billy  stated as follows:Well, we deal with a lot of people who deal with mental health in this community, so it’s been a struggle. It’s definitely been a struggle to not have that interpersonal connection with people to be able to talk some things through and process some things.Finally, some participants discussed the secondary impacts they experienced due to the mental health challenges faced by others around them, both fellow workers and clients alike. Some expressed positive feelings about the role they could play in helping others process and manage their stress, anxiety, and depression, whereas others found this role to be overwhelming and burdensome. Rosa  acknowledged the ways in which sex work has impacted her mental health:I have to take very good care to understand like obviously sex work is very can be traumatic. It can be uncertain and it can be very unstable and that can contribute to a lot of things anxiety, depression, a whole list of mental health issues. And so that’s, you know, really important for me to check in with those.n = 28) or dropped to 0 (n = 5) during the pandemic, mostly due to a decreased demand for services. Demand was impacted not just by clients’ COVID-19 exposure concerns, however additionally because clients were experiencing financial hardship themselves and thus were unable to afford sex work services. Johnson  described this ripple effect as follows:This theme describes sex workers’ experiences navigating financial issues during COVID-19. The participants were no exception to the financial hardships the COVID-19 pandemic created for most people. Nearly all participants reported that their income either decreased , spoke about this dilemma, additionally noting that the government stimulus did not prioritize her financial burdens:In particular, this last month, I had to choose between my cell phone bill and buying groceries, and so…for the first time since I was like 19, my cell service ended up getting suspended because I just couldn’t give them money that I don’t have. And for the last two months it’s been overdue, you know, even savings being depleted […]. When the pandemic started, I was paying for health insurance out of pocket, and it was about $170 a month. So, when it started, I decided I’m going to have to unsubscribe from so many things. And I weighed the options and I decided that I couldn’t really at this point afford to pay $170 something dollars a month for health insurance.Another participant, Anna , additionally described the loss of income security when she said the following:I have no income security. I have not been able to work, and I went from making, like $2000 a month to $3000 a month to like nothing.We address the safety theme by illustrating the unique impact of the pandemic on the participants’ legal and physical safety. This theme includes a persistent fear of financial exploitation, sexual safety, and legal danger.Participants were fearful of clients attempting to exploit them by requesting sexual activities beyond what was initially agreed upon. Participants navigated these fears in a variety of ways, balancing their financial realities with their sense of personal safety. Joy  shared her perspective as follows:A lot of these men… They think that we’re desperate right now. And so, they’re trying to take control [of] the situation and that’s what scares me a lot too. A lot of these [people] that have never done sex work before that are getting into it at the worst, most dangerous time because they’re so vulnerable. These men will take advantage of them because they know that people are desperate right now.Angie  described how important it was for her to maintain her sense of choice and agency, despite a client attempting to exploit her financial vulnerability, even if it meant losing an opportunity for income:I remember this one guy, he keeps messaging me and he’s like, ‘well, I know it’s hard for providers now. So, let’s do a webcam thing.’ And I’m like, ‘no, I don’t do.’ I try to be nice about it. I’m like, ‘I’m sorry, but I don’t do webcam stuff or online things but if you want to see me…’ And he’s like, ‘well, no’ and then like every week, ‘Hey, let’s do a webcam thing.’ Like he said in a way where it’s like, ‘you don’t have a choice.’ I’m like, ‘excuse me, I do have a choice and you’re not telling me that I don’t have a choice.’ And then I’m like, I’m never going to see this guy again because he’s just making me uncomfortable.The nature of sex work places sex workers at a high risk of HIV/STI compared to people in other occupations, given the high coital frequency with different sexual partners. Yet, many participants expressed that their sexual safety was compromised during the pandemic, largely because local clinics either decreased in-person appointments or diverted resources toward COVID-19, limiting the availability of HIV/STI testing and PrEP for workers and their clients. For example, Britney  described her challenges with PrEP as follows:In terms of testing, I was on PrEP and then kind of fell off of it, during COVID. So I haven’t gotten tested in maybe six months. Which doesn’t feel great but I just… When I was on PrEP, I had to get tested every three months and so that was a good routine. So I think COVID has really gotten in the way.Some participants reported an increased risk of legal danger. Due to the scarcity of trusted regular clients, the fear of encountering undercover police officers posing as clients was a looming concern. Chris  described it as follows:I have been forced to see a lot of new people, potentially exposing me to more cops.This theme describes the resilient coping and adaption strategies utilized by sex workers to adjust to new working conditions, and it includes the following: the shift to online platforms, the employment of COVID-19 risk reduction measures, and the adjustment of prices to meet the new market needs.n = 23) shifted toward some form of online services during the pandemic, such as OnlyFans. Physically, this was a safer alternative to maintain or supplement their income while eliminating physical contact with their clients. Less than a quarter (22%) of participants reported engaging exclusively in online work during the pandemic. Britney  said the following:Most participants  shared the following:“[Online work is] so difficult, and for, like, so much less pay, but it’s like… but you’re like, like working 40, 50 h a week and like for a while you’re not making anything.”On the other hand, a few participants expressed that working online was enjoyable and lucrative, and that they would consider maintaining this avenue of work well into the future. Arden  shared the following:Actually, COVID really exposed me to the beauty of online sex work.While working online did reduce the COVID-19 exposure risk, it additionally presented other safety challenges that participants had to learn to navigate. For example, some participants expressed a reluctance to work online because they felt it decreased their anonymity and subjected them to increased stigma. Joy  shared her concerns as follows:I know a lot of people are moving to online work. But as somebody who’s not fully out as a sex worker and I like to be more discreet about my status, I don’t really have that option.Others expressed uncertainty about how to navigate the internet legally and securely, specifically mentioning the impact of the Stop Enabling Sex Traffickers Act (SESTA) and the Fight Online Sex Trafficking Act (FOSTA). These laws, which enable digital platforms to be held liable for third-party content depicting underage or nonconsensual sexual activity, have made risk-reduction, safety, and economic stability far less obtainable for online and in-person sex workers . Pamela SESTA/FOSTA and the new laws that came about, make it harder for people like me to protect ourselves… That’s what gets in my damn way.Participants who chose to continue in-person services utilized several COVID-19 risk-reduction measures. These included requiring testing prior to a session, checking clients’ temperatures, utilizing disinfectant spray, requiring masks and other personal protective equipment, and using hand sanitizer before, during, and after a session. Some participants were strict about their requirements, whereas others were concerned that they would have to negotiate with clients around these measures. Hope  described the measures she employed as follows:So, every time I get in a car with someone, or even someone comes to mine, I always go through the COVID procedure. This person got their mask, you keep your mask on while I’m giving you service. We’re using hand sanitizer wipes, we using hand sanitizer. I frequently take two bottle of hand sanitizer with me.Finally, location was additionally a significant part of the participants’ risk calculations. Some chose to meet their clients in hotel rooms, believing hotels have higher sanitation standards than other spaces without sanitation requirements. Kit  described the following:“Yeah, we’ve been meeting at like in a hotel rooms, which feels like pretty clean. Just because they are cleaned every day, so that feels like safe.”Participants adapted to the pandemic by adjusting their prices. Some participants implemented more flexible pricing for their regulars, in part out of sensitivity to the economic insecurity clients were facing. Most participants reported the need to decrease prices in order to maintain their clientele. For example, Angie  described the following:When some clients are like, “I’m trying to save up for the future because I don’t know what’s going on. Can I give you how much I can afford?”… Especially if it’s a recurring client, I always say yes. I’m like, “Whatever you can donate is definitely fine.” So, when it comes to the monetary, I definitely have compromised.A few participants reported increasing prices due to decreased demand, or due to the greater health risks they were incurring with in-person services, as described by Jane :“However, the business is slow but with supply and demand, prices can go up because now you’re like, I’m charging pandemic rates and I’m taking a risk myself”.Our findings revealed five themes related to the impact of COVD-19 on sex workers in Chicago on their physical health, mental health, economic impact, safety, and the adaptive strategies used to work during COVID-19.The physical health of sex workers, many of whom identify as LGBTQ+ were impacted by COVID-19. Despite higher incidence of STIs and HIV, previous experiences of healthcare discrimination and microaggressions prevent sex workers from consistently accessing needed and preventative care ,38,39. AMental health in the LGBTQ+ communities was impacted by the isolation experienced within the pandemic . Our stuAccess to healthcare for sex workers was impacted by COVID-19. Participants discussed interruptions in the PrEP care cascade/continuum. Similarly, previous research has reported that financial barriers limited access to dependable care ,7,42. OuThe participants in this study described multiple forms of safety issues, including a persistent fear of financial exploitation, sexual safety, and legal danger. Sex workers are victims of more violence than the general community at large . Police,Our findings need to be interpreted in the light of some limitations. Although recruitment was conducted in-person during outreach as well as online, interviews were conducted only online, using the Zoom platform. Consequently, those without access to smartphones or computers were unable to participate. By limiting participation to those with access to dependable technology, results may have been skewed to those with greater education, housing stability, food security, and health insurance. Additionally, participants were concentrated in a single geographic location. Sex workers in other parts of the country may have had different experiences.The participants expressed significant hardship. An increased attention to structural factors impacting the livelihood and well-being of sex workers is needed, especially as it relates to access to mental and physical health services. These findings are useful for designing prevention and protection guidelines for sex workers in the face of the continued health threats associated with COVID-19, recently emerged risks such as mpox, and the increased likelihood of future threats. Improving access to care through community-empowered and culturally safe care modalities such as group care, telemedicine, and mobile clinics is needed. Because community-empowered interventions are designed, implemented, and evaluated by the community served, partnering with current and former sex workers to develop and implement healthcare options responsive to their needs is likely to improve regular engagement with the health system and reduce incidence of HIV ,25,47,48In addition, the decriminalization of sex work has been shown to successfully prevent HIV among sex workers and their partners . The redWhile stay at home orders related to the COVID-19 pandemic have subsided in the US, our findings support previous evidence that the impact of social and structural factors on the health of marginalized populations such as sex workers has persisted ,50. Our


Intimate Partner Violence (IPV) is a global social problem that includes using coercive control strategies, including financial abuse, to manage and entrap an intimate partner. Financial abuse restricts or removes another person’s access to financial resources and their participation in financial decisions, forcing their financial dependence, or alternatively exploits their money and economic resources for the abuser’s gain. Banks have some stake in the prevention of and response to IPV, given their unique role in household finances and growing recognition an equitable society is one inclusive of consumers with vulnerabilities. Institutional practices may unwittingly enable abusive partners’ financial control as seemingly benign regulatory policy and tools of household money management exacerbate unequal power dynamics. To date, business ethicists have tended to take a broader view of banker professional responsibility, especially post-Global Financial Crisis. Little scholarship examines if, when and how a bank should respond to societal issues, such as IPV, traditionally outside their ‘remit’ of banking services. I extend existing understandings of ‘systemic harm’ to conceptualise the bank’s role in addressing economic harm in the context of IPV, viewing IPV and financial abuse through a consumer vulnerability lens to translate theory into practice. Two in-depth stories of financial abuse further illustrate the active role banks can and should take in combating financial abuse. Violence against women is a global scourge, a complex social problem with wide-ranging and expensive harms for communities, economies, and society. Intimate partner violence (IPV), often referred to as family violence, domestic violence, or domestic abuse, is predominantly violence against women  in Australia and Surviving Economic Abuse (SEA) in the U.K. working toward banking solutions. Similarly, in Aotearoa New Zealand (N.Z.), the social sector  is aiding victims-survivors facing the realities of this oppressive form of violence and working with motivated banks.Banks hold a unique and powerful position in an intimate relationship, power yet to be fully tapped into by the bank to both avoid harm and do good. Notable exceptions exist, both at an individual banking level  and industry level, including the Australian Bankers’ Association  IndustryBusiness ethicists have tended to take a broader view of banker professional responsibility. The focus on banking stability and systemic importance is constrained for the most part to the “too big to fail” setting, especially post-Global Financial Crisis (GFC), see for example Moggia , Linsleywhy and illustrate how the financial institution, specifically the retail bank, plays a vital role in society’s response to financial abuse as IPV. The first is systemic harm  article to theorise the argument for retail banks taking an active role in combating economic harm in intimate partnerships. Further, framing victim-survivors of financial abuse and IPV as vulnerable provides a framework for putting theory into practice. I present two juxtaposing examples, one positive and one negative, to illustrate the real consequences of bank and financial institution inaction in this space. The stories are drawn from a collection of twenty-three women’s stories of violence gathered over two related qualitative studies, both under institutional ethics committee approval (AUT Ethics Committee AUTEC Reference Numbers 18/85 and 18/214). The article is conceptual rather than empirical and is not a complete retelling of their complex stories nor a presentation of the findings from those projects. Rather, the examples underscore the importance of considering victim-survivors as vulnerable and the financial institution as systemically important in preventing further harm and actively responding to financial abuse as part of a collective societal response.Financial abuse is defined as behaviour that restricts, controls, exploits, or removes another person’s access to money, economic resources, or participation in financial decisions. While the literature tends to use the terms ‘economic abuse’ and ‘financial abuse’ interchangeably, recent work by Sharp-Jeffs  clearly Consequences of financial abuse include trauma-related health issues, poverty, debt, lost income, and unemployment  Royal Commission into Misconduct in the Banking, Superannuation and Financial Services Industry has led to significant legislative and regulatory change across the sector. In the N.Z. context, third-tier lenders (including consumer finance companies and ‘truck shops’) have come under scrutiny for predatory lending practices. They are now subject to stricter lending rules under the amended Credit Contracts and Consumer Finance Act . Protecting individuals facing not disadvantage but life circumstances leaving them vulnerable has been highlighted as essential to ensure an equitable and inclusive society. Such ethical discussions are not new, with marketing practices that may be considered exploitative (‘target marketing’) and their ethical implications considered for decades  provides a unique setting for exploring the role of retail banks in responding to financial abuse in the wider context of IPV. Intimate partner violence (IPV) rates are among the highest globally  and one positive (Eloise). Both stories highlight the tangible impact banks can have on the experience of women facing violence, their financial security both during their ‘relationship’ and post-separation, and the challenges financial institutions face in providing support for victim-survivors. In writing this article, I have opted to outline where improvements are crucial to avoid furthering economic harm of vulnerable victim-survivors post-separation financial abuse looks like from women’s experience (in N.Z.). Both larger projects were designed and developed in alignment with a Constructivist Grounded Theory romantic partner  are described to provide context for Anna and Eloise’s interviews, followed by my self-reflexive positioning . Preliminary analysis follows, providing a foundation for selecting Anna and Eloise’s stories.Women were invited to participate in the 2018 and 2019/2020 studies through two advocacy organisations, which acted as crucial conduits between participant women and the researchers. For the 2019/2020 project, some women contacted the author directly following media interest in the earlier study. For eligibility, we required women to be permanently separated from their former partners. The ‘snow-ball’ purposive sampling approach ensured recruitment could be carefully managed in terms of the number of potential participants so that no eligible woman was refused a place in the study due to time or funding resource constraints. The inclusive nature of the approach was ethically important to the researchers, given traditional silencing of women’s stories of violence. While the recruitment strategy sought to avoid further silencing participant women and their voices, I acknowledge we primarily spoke to those women selected by the advocacy organisations.Twenty-three women were interviewed: fifteen over four months in 2018 and a further eight in late 2019 and early 2020. Qualitative methods are appropriate to capture the complexities of lived experiences of IPV and, specifically, financial abuse. Interviews were semi-structured and lasted between 90 and 120 minutes, with each woman provided the opportunity to recall her experience of violence both during and after the ‘relationship’ ended. Interviews were audio-recorded and later transcribed by one of three research assistants (except one transcribed by me), then collated with any additional documentation provided by participants. Transcripts were read for accuracy and each interview summarised in preparation for further analysis. Anna and Eloise, the cases presented in this article, were two of the twenty-three participant women interviewed.Each successive interview challenged my prior understandings of the role banking institutions have in the private lives of individuals and couples. Charmaz , p. 165 Trained in finance, both academically and professionally, I am fascinated with how money and financial resources influence behaviour and shape individuals’ lives. Societal-level factors, including the money taboo, gender pay and investment gaps, and the ownership we may place as individuals on ‘our money’, prevent open and constructive money conversations and can contradict the equality we look for in our intimate relationships. When paired with the emotional complexity of intimate partnerships, it seems logical that unequal power dynamics are exacerbated by inequity in financial resources. By extension, in the context of IPV, money and financial resources can be used as weapons of entrapment against an intimate partner .A white New Zealander (Pākehā), raised in Australia, I am a university-educated working mother of young children, who assumed the role of ‘stay at home’ mother initially and now, am primary breadwinner while my husband is the primary carer of our children. Overlaid by studying and working in a male-dominated profession, each of these roles influenced my collection and interpretation of all stories collected during the study. My analytical and emotional response to the research project has evolved and matured over time, as my professional background has strengthened to include wider understandings of how money is used to exert control over another  redirected the conversation at this point, or stated the bank was not a factor and/or indicated they had not disclosed nor thought to disclose their situation to their bank. Such redirection was not unusual over the course of the twenty-three interviews, as women sought to tell the researchers their story, their way and interwove their narratives of financial harm with other forms of violence. Somewhat jarringly  the financial lives participant women lead could not be easily disentangled from the wider environment of violence they face, either during their ‘relationship’ or afterward  with a relative minority responding in detail/at length. Anna and Eloise’s narratives were selected from this smaller group of eighteen.n = 17) related negative banking experiences during our talk. Of these, three alluded to (either directly or indirectly) the arguably nefarious intent of individual actors at the bank. While perhaps indicative of poor organisational practices and processes, this article remains focussed on industry and institutional level systems and policies, seeking not to focus on any one bank or financial institution or actor within that organisation. These three stories were thus excluded from case selection in this article. Of the fourteen remaining ‘negative’ stories, Anna’s interview explicitly documented the unintentional harms financial and banking institutions cause via their pre-existing policies, practices, and systems. She highlights many of the elements contained within the interviews of other participant women, bringing together the tentative codes and preliminary understandings built over previous interviews and illustrates the cumulative impact of successive institutional actions. Anna’s articulate recount draws direct links between the abuse, bank actions and how the real consequences played out, clearly demonstrating the urgent need for action by organisations to respond to financial abuse and IPV, more generally.Participant women we spoke to overwhelmingly  banking experience. However, of the eighteen who discussed banks as relevant to their experience of abuse, only To illustrate the complex lived reality of both women, Anna and Eloise’s experiences of violence and their subsequent banking interactions, I present each as a vignette: a short summary of their experience. Doing so allows focus on the elements of their narratives most relevant to the topic of this article  whilst retaining the wider context of their lives, as relayed to the researchers. While contrasting markedly, when Anna and Eloise’s stories are taken together, an understanding of why and how  institutions must respond to financial abuse in the context of IPV can be built.Anna, a mother of four, spoke of two relationships during our talk. The first, her 21-year relationship with her former partner, is the focus of this case. I will use minimal commentary, preferring to use Anna’s words where possible, although the potential points of bank intervention are emphasised.Anna had been with her partner for 14 years before they had children. She says the relationship had always had “moments” of violence, but that “she didn’t really know because a lot of the times you don’t know it’s a controlling, abusive relationship”. Their finances were completely joint, including bank accounts and two rental properties—everything in both names. They were never married. Anna pointed to a change when she had children, as “when it started to get quite dark”. She stopped working and says “there’s a sense of entitlement” to him becoming the sole breadwinner. Money became tight, and she did not have enough.As her pre-children career in hospitality was no longer practical, Anna opted to find other sources of income, including study. She said, “Okay, I can study, but that is when he started getting violent…I went to sit my first exam management 101. I think it was five essays, and … he broke my hand.” Then, he opened a separate bank account and got wages put into that—Anna does not know when he did this; she guesses when she started having children. Anna had been seeing a counsellor and recognised the abusive nature of her relationship—she says, “You plan, to get out of abuse you have to plan.” For Anna, that involved staying in the relationship until her broken ribs had healed, as she knew she would struggle with four young kids at home (the youngest were twins). For brevity, by 2006, Anna had a protection order, although she distrusted organisations she’d had contact with, including the police, lawyers and other government institutions.“So, I start to feel really scared. Scared of her [the lawyer], scared of the police, scared of him, scared for my kids.”—Anna.For example, the lawyer suggested she take the joint credit card to pay the legal fee incurred in obtaining the protection order, NZD3000, and Anna refused: “I can see that being used against me, for clearing out the credit cards like that.” On another occasion, the police asked what she had done to make him so angry that he would breach the order. Her abuser went on to breach the protection order “probably every couple of months for seven years.”In terms of banking, Anna was on the Domestic Purposes Benefit for those seven years and “never missed a mortgage repayment”. Her former partner was not contributing to the mortgage or maintenance on the family home, nor paying child support. At one point, when she estimated they had about 50% equity in the family home, she requested an NZD10,000 loan to replace leaking windows. Her abuser refused to sign the documentation from the bank to extend the loan.Later, she applied for a mortgage holiday as she wanted to work now her twins were at school. The mortgage holiday would enable her to repay her credit card debt of approximately NZD3000, and she could start work without the debt burden. Anna explained her situation to the bank employee; he provided assent. She filled out the paperwork and, 2 weeks later, was declined. Upon querying why Anna was informed she was on welfare. When Anna challenged their reasoning, given she had never missed a repayment, the bank advised she required her former partner’s signature. Anna explained she would try but that she did not think he would sign. He did not. In her words, “I had tried on three occasions to separate from him financially”.The bank then advised Anna to “stop paying the mortgage, and we’ll go for him, that might make him start the proceedings.” When I asked Anna how she felt about that advice, she told me she was sceptical at first, but in the end “trusted the bank manager” and stopped paying. When her former partner arrived home to N.Z. from a stint working overseas, his bank accounts were frozen. Anna says the bank didn’t tell her they would freeze his accounts, and had she known, she would never have asked for the mortgage holiday nor stopped paying. I asked why. In Anna’s words, “He would do something…I mean this guy had the potential to kill, he was that type of person.” Out of fear, Anna then went home to pay the mortgage up to date. She had no money in her account to do this .The bank’s advice had consequences. Not paying her mortgage allowed Anna’s former partner to tell the court she was forcing a mortgagee sale on the family home and was therefore playing games. The judge ordered the protection order lifted and the children to remain with their father. The house was ordered to be sold via an agent. Despite claiming to the court he had no money and therefore needed the house sold, her former partner bid on the house at auction. Anna eventually settled in the Family Court for much less than her lawyer thought she should have, to have it over and done.Anna says, “I needed counselling…none of that was available. I had no money. I needed to understand the dynamics of abuse. I was hugely vulnerable.”Unfortunately, Anna then met a man online, and the vignette related here is not the end of her story.Eloise, a mother of two adopted daughters, was mid legal battle at the time of our talk—her story, as written here, illustrates the severity of harm faced by victim-survivors and its ongoing and long-term nature. She met her former partner, Edward, overseas and married him one year later, returning to N.Z. while he stayed in his home country. When he later joined her in N.Z., Edward was “really upset” she did not own a house. Eloise is unsure why he thought she did, as she had not indicated she owned property.“I remember when he had his hands around my neck, I stopped struggling. And it was a conscious decision, you know. And immediately fear left me, the panic or the fight for life just left me. That survival instinct just left. … And he stopped squeezing. When I gave up, I think he must have thought that he’d already done the job. … I think in that moment, if I hadn’t believed, all that rubbish [I deserve to die. And everything he says is right] and not relaxed, I’d be dead. And still, I kept throwing money at him so he could see his mummy.”—EloiseTo appease Edward, Eloise bought a house, originally under the impression it would be under both of their names. Edward refused, insisting they have a contracting out agreement , as was custom in his culture. Doing so meant his assets overseas were partitioned from Eloise’s in N.Z. (she purchased a second property in addition to her home). Before the agreement was signed, Edward decided he would return to his home country to visit his mother. When Eloise advised she did not have the money to send him, he “smashed [her] head into a wall”. Unable to work or complete her study, Eloise separated from Edward and moved into her property, getting a flatmate to help cover the mortgage as she could no longer work full-time. Following their first separation, the marriage became somewhat on-and-off, with Eloise funding Edward’s lifestyle, trips to his home country and sending money to his mother and friends. However, Edward became increasingly violent. Eloise explained various situations where Edward would become enraged, including if she walked past him as he prayed or prepared food he did not like, and physically assault her.Eloise detailed several specific events in addition to her quote above, including one where she asked him to look at her camera as it was not working, and he smashed it on the floor in front of onlookers. She was so embarrassed she separated from him immediately, although he remained in the house and paid her a nominal amount in rent. Despite her re-applying for divorce, he wanted to reconcile—Edward’s visa needed renewal, and he asked Eloise to halt divorce proceedings. She did.“He had his own account. I had my own accounts. So, he had his accounts, which his money went into. He spent his money. And I had my accounts, but I could only spend my money the way that he told me to spend my money. So, I couldn’t go out and buy new clothes or take the girls to a coffee shop or go out for a meal unless, well I couldn’t. He just wouldn’t give me permission for that. So, his money was his. My money was his. Even though we had separate accounts.”Regarding their financial arrangements, Eloise says,“You might have account in your name. That doesn’t mean, you have control over your finances. Doesn’t mean you are not going to get beaten within an inch of your life if you dare buy a cup of coffee or a fluffy for the children. You know, ten dollars compared to the tens of thousands of dollars that he takes out.”Explaining her experience of entrapment, she elaborated,Eloise remembers the time Edward was overseas fondly, despite him using her money to travel, explaining during these periods she felt she was independent, able to use the phone freely and go for walks. However, when he returned, it would be 3 weeks of hell as Edward re-adjusted to N.Z. life. Eventually, following the adoptions of their two daughters, Edward agreed to separate from Eloise. Less than a year later, he approached her for NZD7000 to go overseas. Eloise gave him the money. They had commenced separation proceedings, and Edward placed a caveat on Eloise’s house, claiming it was relationship property and that due to his poor English, he had not understood the contracting out agreement  he had signed. The caveat meant that she could not sell the property, and despite Edward promising to remove the caveat several times over the 2 years that followed, he has not.Three years after their final separation, Edward almost succeeded in killing Eloise. Police were called; however, Eloise was advised not to go to court as “they’re going to crucify you” because “you could say, anyone’s done this”. Instead, they suggested she seek the help of support services (their commanding officer later apologised for the officers’ inappropriate response to the assault). While Eloise said attending a family violence service and meeting other women facing similar circumstances has helped immensely, she is angered any of them have experienced what they have.Post-separation, Edward refused to pay child support. Despite the Family Court acknowledging the abuse Eloise and their daughters have suffered, at the time of her interview, Eloise was concerned his claim of fifty per cent of the value of the property plus legal fees would be awarded. To fund her own legal expenses, she took a mortgage out on one of her two properties, which ended up going to a mortgagee sale.Over the separation proceedings, Eloise credits her bank as getting her through: “I’ve never dealt with such a terrible situation with such lovely people.” She appreciated the credit controller kept her updated on what she could expect, such as a bailiff arriving, and reassured her throughout the process. However, Edward’s lawyer halted the proceeds of the mortgagee sale being released and eventually, her bank settled with her former husband to release the funds. The money from the sale (less the settlement) was used to purchase a new property, and her loan was restructured. The bank allowed Eloise to pay interest only on the mortgage. When the interest-only payments come to an end, Eloise will need to pay the mortgage in full (which she will be unable to do), and the house will go to a mortgagee sale.“It doesn’t mean that you’ve got your own name on your bank account, that you have financial freedom. Or you have control over your own life or what you spend. And that has been the hardest lesson.”—EloiseAt the time of our conversation, Eloise advised Edward had had her accounts frozen—she believes with the intent to ensure she cannot provide for herself or the girls. She lived off the generosity of friends and was working 80-hour weeks. She had formulated a plan for the care of the girls once she lost her home, knowing her credit rating was too poor to rent a property and was facing homelessness herself.Eloise has stayed in sporadic touch with me since her interview. She and Edward are still in the Family Court, and proceedings to financially separate from him remain ongoing.To unpack what is going on for Anna, Eloise, and other victim-survivors of financial abuse, I will first revisit the concepts of entrapment and vulnerability expounded on above. Second, I relate the experience of financial abuse as consumer vulnerability to our bank and financial institution setting . Finally, referring to Herzog’s  ‘narrow’Economic abuse  is the use of financial resources, including employment or education, to control an intimate partner. Coercive and controlling relationships rarely appear obvious to outsiders, and victim-survivors may not immediately realise they are being abused. Victim-survivors, by definition, may not have the level of independence and agency to make decisions benefitting themselves and their families—they may not act in ways outsiders think they can or should. Using a lens of consumer vulnerability, an organisation may recognise a consumer’s circumstances render them vulnerable to harm. However, the victim-survivor may not perceive they are vulnerable until the interaction with the organisation leads them to feel this way or know their vulnerability.In Anna’s case, she simply wanted to be kept safe from her abuser. The systems in place were inappropriate for doing so. In Eloise’s case, her bankers responded to her situation with empathy. They made her feel as though they were doing everything they could, within the parameters of their organisation, to support her. Through these two examples, a clearer picture of both what it means to be vulnerable and how a financial institution can respond emerges.There have been instances of privacy and system failure in a banking setting, including disclosing a victim-survivor’s new address to her abuser Austin, . Such exUnlike in Eloise’s case, where each step of the process was outlined to her, for Anna, the implications of accepting a banker’s actions were not spelt out. Victim-survivors are the experts when it comes to keeping themselves safe. When weighing the advice of professionals or outsiders, it is crucial for a victim-survivor to know exactly what will happen should they assent to a specific action or procedure, so they can effectively assess the risk the action may pose to their safety. While being financially capable may help, it cannot prevent financial abuse alone. Financial literacy programs aimed at IPV victim-survivors see significant increases in confidence (self-efficacy) rather than money management skills  are important to victim-survivor’s mental health and general wellbeing . Outside the banking context, immediate pandemic-induced need for government, industry, and business-led crisis responses have also led to innovative ways for IPV victim-survivors to report violence. Examples include the use of code words in essential retailers .To appropriately address financial abuse, banking staff require clear tools and financial institutions—indeed, any consumer-facing organisation dealing in economic resources . Economic and financial abuse is experienced by almost all victim-survivors of other forms of coercive control and violence, as one of a range of control tactics used by perpetrators of IPV  is an undeniably complex social problem, requiring a coordinated and collective response from various fields, including legal and justice, health, government agencies Perhaps the biggest hurdle for financial institutions in unintentionally causing further harm to a victim-survivor of financial abuse is that the perpetrator is likely also to be a customer. This joint relationship means several conflicts may arise for banks and financial institutions around regulatory constraints, including privacy and transparency. Transparency in all relationships is key, as demonstrated in Anna and Eloise’s cases above, where their respective bankers offered varying levels of transparency around their actions, systems, and processes. For victim-survivors of abuse, transparency of their financial obligations and money arrangements within their intimate ‘relationship’ often does not exist. However, they are held liable for financial decisions made without their consent or under coercion. For bankers, awareness of the dynamics at play when presented with a case of financial abuse is critical to forming a response that satisfies best practices and reduces the potential for further harm. This hurdle is not insurmountable; however, it requires careful thought and informed policy to ensure procedures are clear for customer-facing staff.When banks are acting on behalf of a victim-survivor, privacy and information-sharing limitations restrict the protective actions the bank can take to limit perpetrator abuse, such as transaction abuse Brook, . When thBankers are not immune to having the same implicit and explicit biases present in the general population, and misconceptions of what a victim-survivor of IPV looks like or the forms violence can take remain an issue globally (see, e.g., Karlsson et al., The importance of awareness, education and training cannot be over-emphasised, as individual bankers and those in the finance industry are likely to have the same misconceptions of IPV as broader society. Specific training on what financial abuse looks like, how it factors into a wider domestic environment of coercive control, and IPV more generally, can help staff identify and respond to explicit disclosures of abuse, and trigger statements that are potential red flags requiring further information. For example, a customer’s throwaway comment about not having access to an account when they should, seeming surprised when presented with an account or debt, or not knowing one’s own private details like a PIN. It is these red flags that customer-facing staff are likely to hear and see, and having clear guidance as to what to do next allows them to respond empathetically and work in the best interests of their customer.Despite not necessarily having an explicit policy or guidelines governing their approach, bankers can and do support their customers outside the ‘usual’ provision of the banking service. Similarly, other financial services, including debt advice services, can help victim-survivors rebuild their lives. Empathy goes a long way, as is evident in Eloise’s story above. However, without trauma-informed guidelines to fall back on, bankers may be asked to make decisions beyond their experience and training. In this case, the consumer experience is likely to be ad hoc, inconsistent and detrimental to a wider agenda of financial inclusion and quality provision of services to those consumers who may be experiencing circumstances rendering them vulnerable to harm.The very question of whether financial institutions have any place beyond the direct services they offer—their core businesses of financial transactions and lending—is an inherently ethical one. Financial institutions increasingly recognise they have an active role in addressing the economic and financial harm inflicted on victim-survivors of IPV, with examples in N.Z., the U.K. and Australia. By the time you read this, further momentum will have built as international information sharing between scholars, NGOs, and industry expands via formal and informal networks. However, the place for financial institutions in responding to economic harm in the IPV context remains under-explored, both in theory and practice. This article has sought to provide a preliminary step toward filling this gap.consumer vulnerability at the micro-level while accepting a macro-level risk of systemic harm, to consider what an operational framework of new and improved policy might look like. Victim-survivors are rendered vulnerable by the circumstances they face—entrapped by their abuser. However, it is not until they have their financial autonomy and agency restricted or controlled in the financial marketplace by the banking systems they must interact with that the financial institution’s relevance in their vulnerability comes to the forefront. By framing victim-survivors as customers experiencing vulnerability, banks and financial institutions can begin revising their policies and practices to prevent the unintentional harm existing policies may cause. Such work is already underway for other consumer vulnerabilities but requires specialised knowledge, training, and understanding.Here, I present an ethical argument for banks and financial institutions, and consumer-facing organisations more generally, in taking a greater role in an area not traditionally thought relevant to their business: economic harm in the context of IPV. I build on work of business ethicists before me, namely The strength shown by victims-survivors, illustrated by Anna and Eloise’s stories, emphasises that it is possible to provide support within the context of their complex stories without presuming to be the entire solution. It is appropriate to provide support to a victim-survivor in a way that is practical, with immediate impact right now, within the confines of existing policy and regulation. Simultaneously, the institution may lead internal and external conversations on best practices moving forward to enact lasting change to those same problematic policies and procedures. By considering more deeply what works in addition to what causes harm, future research may expand on the suggestions and rudimentary roadmap outlined in this article to further illuminate the issue for those working in the banking industry. This article is the beginning of what I hope will be a rigorous scholarship examining financial abuse and IPV more widely, beyond the obvious systems and institutions traditionally associated as having some role to play in addressing this evasive, invasive, and significant global social problem.