De conceptione, considering for the first time its interest in non-generative conception. Further, it considers the way that Harvey entangles observations about erotic and maternal love in his discussions of the conceiving body. Love provides a context which Harvey reads for information about conception. But, for Harvey, conception and generation are not synonymous. Conceptions can be without as well as with a foetus, and Harvey is at least as interested in non-generation as he is in generation, and false pregnancy as pregnancy. Harvey’s notion of an immaterial or ‘mere’ conception, on which he builds an intricate analogy about the relation of uterus and brain, is designed to accommodate un-reproductive as well as reproductive experience. Reading signs of love – desires, devotions, intimacies – gives Harvey a way of distinguishing between different kinds of reproductive non-events, health and pathology. He offers an extended consideration of wind eggs and uses fictions of the wind to credit the loves of those that produce no offspring as nonetheless creatively conceiving and biologically demonstrative.This essay offers a new reading of William Harvey’s  De conceptione, which is appended to Harvey’s larger work Exercitationes de generatione animalium, he describes an intimate relationship between brain and uterus, an idea of conception which is thoroughly embedded in the ‘psychophysiology’ of his age, which read biology and the passions together.De conceptione, discussing it alongside the larger work De generatione to which it is appended, as an articulate account of non-reproductive experience, using the work of feminist Elizabeth A. Wilson on the psychosomatic to listen to Harvey’s ideas anew.William Harvey’s writing on conception is necessarily caught up with the question of love: both the erotic love which precedes conception and the maternal love emergent in its aftermath. This essay considers how these kinds of love are implicated in Harvey’s understanding of conception. As well as considering forms of human love, my discussion also takes in the cross-species love of a pet – a parrot – for its owner – Harvey’s wife Elizabeth – and the evidence it gave Harvey for understanding the place of sexual love in un-reproductive health and illness. The relationships between love and conception are, in Harvey’s view, very close. In particular, in an odd little treatise, De conceptione before later setting this analogy within a picture of erotic and maternal affections. In De conceptione, Harvey speculates on the relationship between the physiological and psychological effects of the sexual act:Male, doth so largely fructifie the whole Female, that it produceth a thorough change and alteration, as well as the frame of their minds, as in the constitution of their bodies. (541)the vertue proceeding from the The effect of sex, he concludes, is not local to, and does not isolate the sexual or reproductive organs, such as the uterus. Instead, masculine ‘vertue’ (virtus), or power, transforms the entire woman, body and mind together. Harvey arrives at this position, on the unity of mind and the female reproductive body, through one of his central observations about animal generation, which he returns to regularly in his work: the absence of any appreciable continuous mass linking sperm and embryo:Uterus after coition, whereunto I might ascribe the principle of generation; no more then remaines in the braine after sensation, and experience, whereunto the principle of Art may be reduced. (546)since I plainly see that nothing at all doth remaine in the This material absence or gap was observed through dissection of animals at different temporal points between coitus and the time when an embryo could be seen with the naked eye. These two quotations offer differing, though related propositions. In the second, brain and uterus share only the habit of making copies without direct material connection with their originals; they are thus only rhetorically related. On the other hand, in the first quotation, Harvey suggests a much more integrated account of the female mind and reproductive body. Here, the changes that take place in the uterus after sex are not just similar to the changes that take place in the brain after sensation and experience; instead, sex is sensation and experience and it alters the mind at the same time as it effects change in the uterus.First, I lay out the analogy between conceptions in the brain and uterus which principally concerns Uterus, now ready for Conception, doth so neerly resemble the Constitution of the Braine: why may we not imagine, that both their functions are also alike; and that something like, if not the self same thing that the phantasme, or appetite is to the brain is excited in the Uterus: from which the generation or procreation of the Egge doth succeed? For both their functions are equally called conceptions, and both are Immaterial. (542–3)and seeing the substance of the Here, Harvey considers the exact relation between conceptions in the brain and the uterus to be uncertain, offering alternatives – ‘something like, if not the self same thing’  (295). Whilst Harvey’s figure is usually understood in modern critical scholarship as an analogy, in fact he never rules out the prospect of these two kinds of conception being not just rhetorical substitutes but being identical, naturally and irrevocably inseparable. In that respect, Harvey prevaricates over what Charis Charalampous has termed ‘the intelligent body’; how far does the body itself think?conceptiones, he does not spell out exactly how the two senses of the word relate and what a shared etymology precisely means in this case. Again, he leaves the nature of the relation undecided.Thus Harvey develops an ambiguous notion of how alike the uterus and brain are; so that at times he brings together the different propositions represented in these two quotations, and at others he holds them further apart. That vacillation about their exact relation can be seen in this passage, in which Harvey lays out his analogy again, but with variation:uterus appears thicker and more fleshy: and afterwards  it groweth more tender, answering in lubricity and softness to the internal ventricles of the Braine, as we have even now affirmed concerning Hindes, and other creatures which cleave the hoofe. (542)First of all the Observing the visual and textural similarity between the increasing fleshiness of the endometrium in the later, luteal phase of the mammalian menstrual cycle, and the sponginess of brain tissue, Harvey notes that the uterus becomes more or less brain-like depending on its receptivity to and readiness for conception. Harvey cannot come to a definitive conclusion on the exact proximity between brain and womb because they constantly move together and apart, in rhythmic relation to cyclical change. Time and seasonality are critical factors in Harvey’s understanding of this rhetorical proximity between womb and mind.One aspect of this question about the degree of similarity between the two organs is the rapport between look and function:Georgics, which attributes this ripening in the natural world to the influence of Zephyrus:Whenever Harvey thinks about seasonal change, springtime coupling and the birds’ broodiness, he turns to Book II of Virgil’s Zephyrique terpentibus aurisLaxant arva sinus, superat tener omnibus humor,De generatione, Latin 38)Parturit omnis ager, etc’. . The personification of Zephyrus anthropomorphises springtime proliferation, writing it as erotic verse. Harvey recognises that Zephyrus’s authorship is a poetic or folkloric conceit; nonetheless he finds this amatory fiction useful to think through reproductive and sexual maturation, demonstrating what Gail Kern Paster has described as the ‘oscillation of metaphorical and literal comparisons between the wind and the passions’ in early modern culture.After this quotation Harvey offers this analysis: ‘[a]nd therefore the people of old, seeing their Hens in the Spring-time lay, this wind then blowing, did conceive Zephyrus to be the Author of the generation of those eggs’ , and Harvey speculates that an analogous process operates in the uterus, which he dubs ‘natural conception’ [conceptus naturalis], which forms the child in the image of its father. Of ‘natural conception’, Harvey writes: ‘[a]nd from this Appetite or Conception it cometh to pass, that the female doth produce an offspring like the male Genitor’ (543). In these terms, ‘animal conception’ differs from ‘natural conception’ in that it proceeds from cognitive agency, happening in the brain rather than the uterus. Incidentally, elsewhere, Harvey considers how it is that children resemble both parents and ‘must needs be mixt’ , but here he is interested in how, without material transmission, the idea or form of the father is realised in the offspring. Because there is no appreciable connector, Harvey transfers the authority for ‘natural conception’ to a uterine ‘appetite’ as much as to the masculine virtus to which it responds.When Harvey thinks about the brain and its making of copies, reproduction in the broadest sense, he thinks about it in two ways. On the one hand, in some parts of his treatise, he makes a particular example of the artistic brain: ‘how the brain of the Artist, or the Artist himself, by virtue of his brain, doth form things which are not present with him, but such as he only hath formerly seen, so much to the life’ (545). On the other hand, at the same time, Harvey makes a special case of the female brain, understanding heterosexual female desire to be instigated by a sensory perception of the external male body, the ‘appetible or desirable object’ (543), which enters the brain through the eye. This cognitive process – in an artist’s or a woman’s brain – is ‘artificial’ or ‘animal conception’ ather than dismiss his predecessors, Harvey looked anew, and found that the past could be used’.De conceptione, and particularly to consider false pregnancy?The accusation from Goldberg, Giglioni, and Lennox here is that Harvey falls into the trap that, from his own time, Aristotelian teleology had always been understood to be: that it was animistic or anthropomorphising.De conceptione begins and is motivated by non-generation and, in particular, the perplexing issue of false pregnancy:female sometimes  doth not produce a Foetus: yet we know that those Symptomes did ensue, which gave a cleare testimony [claram fidem] of a conception set on foot [peractae], (though it came to nothing.) For though the The first parenthesis makes the case unequivocally: it is possible to have conceived even in the absence of a foetus. The next clause reiterates: Harvey’s knowledge comes from the appearance of symptoms which produce a clear promise or guarantee (fidem) of a conception achieved (peractae). In his view, false pregnancies are conceptions. Because he cannot see continuous matter, Harvey concludes that: ‘[w]e have no refuge left us, but to fly to meere Conception [merum conceptum], and reception of Species without any matter [speciumque sine materia receptionem]’ . Latin merum carries a sense of purity and is not perfectly translated by modern English ‘mere’, insignificant or feeble. Of course this is what Harvey proposes for all conceptions, fruitful or not, yet the idea of the ‘mere conception’ enables him to include non-generative conceptions in his understanding of what happens inside the body after sex. To read it in the terms of Harvey’s own analogy, an artist might conceive an idea, suffering the pangs attendant on artistic process, but, then, not generate the work. Sex generates expectations which may not always deliver.What goes unnoticed in modern historians’ rejections of Harvey’s brain-uterus analogy is that Harvey is not only and principally interested in generation. Rather, he is concerned with conception and, for Harvey, generation and conception are different things. Indeed, False pregnancy was a significant concern in Harvey’s time, being fully discussed in a number of culturally apparent places. This is shown, for example, by Jonathan Gil Harris in his discussion of pregnancy and dropsy, both on the Renaissance stage and in the political debates concerning the childlessness of queens Mary and Elizabeth.sola phantasia] . Harvey’s point is, again, about the immaterial connection, the gap between copies and originals, arranging his examples as more or less ‘strange’ according to how far they are mediated by a discernible or material pattern. Harvey’s view of fiction here is that facticity emerges from immaterial reproduction: that ‘meere phansie’ can bring into being a nest, a web, a song.The psychophysiology or intelligence of early modern bodies and, more specifically, Harvey’s thinking about a brain-like uterus, offer a way in to thinking about the confounding case of the somatoform kind of false pregnancy. To begin this task, I return to Harvey’s concern with the artistic brain and ‘animal conception’. Harvey considers a spectrum of ‘animal conceptions’ and not just the one I’ve already discussed – the case of the artist producing life-like depictions or sculptural forms. First, he notes, birds ‘which immure themselves all winter, do exactly chant, and recall to minde those Ditties, the next Spring, which they had learned the Summer before, though they did never practise them all the while’; secondly, he marvels at birds that can build nests, and spiders that can spin webs exactly similar to others that they have never seen, ‘and that not from her memory, or any habit implanted in her, but onely by meere phansie’ , unthinkingly code-switching just at the point when he meets the human/animal species barrier.conceive egges, but lay them also’  . So, at one end of the spectrum, cyclical signs of fertility and particularly menstruation are understood by comparison to wind eggs. Wind eggs are produced even without intercourse, part of the regular round of the reproductive cycle. Although Harvey uses the verb concipere here, he makes a clear distinction between eggs and conceptions (between the nouns conceptus and conceptio), throughout his work. De conceptione earns its title by being concerned with conceptions proper; because De conceptione is principally presented as a solution to the puzzle of the missing spermatic mass, it is necessarily only concerned with post-coital events. At the other end of the spectrum from menstruation and other cyclical signs of fertility, Harvey likens wind eggs to non-generative conceptions after intercourse:Conception (like an addle Egge) is fruitles, and without a Foetus, do suffer abortion the third moneth. I have often dissected an abortion of that age (being of the bigness of a Goose-egg) wherein was a foetus, distinct in all its parts; though their form was rough and unshapen’. (335–6)Divers Women, whose Here Harvey is concerned with first-trimester pregnancy loss, where the miscarried conceptus might possibly be with or without foetus. From menstruation and early miscarriage, to false pregnancy and conditions like dropsy which resemble pregnancy, the wind egg is analogous to the multiple ways in which generative potential is not realised.Using the ideas he inherited, Harvey draws specific conclusions about human non-generation from his observation of birds’ wind eggs. He notes in De generatione Harvey discusses the way that birds which are not mated try to incubate unfertilised eggs, in De conceptione when he discusses birds inclined to sit on wind eggs, and also false pregnancy in dogs, he is careful to add a clause about coitus. Bitches, he says, that ‘admit coition’ can ‘have milk, or beestings  in their teats; and are obnoxious to the distempers of those that have really puppied’ (540). Similarly birds, as dogs, present as if they have reproduced although they haven’t, building and sitting on their nests:birds (as namely Pigeons) if they admit coitione at the wonted time, though they lay no eggs at all, or subventaneous ones onely, yet are possessed with their usual sedulity & providence of building nests. (541)Some kinde of This emphasis upon intercourse enables Harvey to disambiguate the animals he considers here from the unmated ones he discusses in De generatione: in their case, after sex, maternal habitus marks out a conception achieved. Harvey’s observation of maternal behaviours in birds makes little distinction between those whose eggs hatch, and those whose eggs do not. Because good eggs cannot be told from bad except in time, Harvey uses affective contexts – desire; sex, both practised and inhibited; and maternal devotion or attention – to distinguish them. Whilst Thomas Laqueur cites the objection that, if Harvey’s account ‘were true, women should be able to conceive by just thinking about it’, Harvey might reply that women may well be able to conceive, first by having sexual intercourse and then afterwards by ‘thinking’ about it.Despite this wide range of ways of understanding the human wind egg, for Harvey, sex or lack of it makes the difference, separating out conceptions – whether with or without a foetus – from eggs. Blocked or satisfied erotic desire acts on the body and changes it, even though it may not result in offspring. Although in De generatione Harvey says he discovers this by observing his wife Elizabeth’s parrot. This is an animal that he assumed was male, because it was so vocal and tuneful, an aspect of the amorousness it displays in its relationship with Elizabeth (24–5). However, during the autopsy Harvey performs on the parrot after its death, he discovers it to be female and to have a corrupted egg retained in its uterus. He imagines that something similar can happen to girls:virgins to have their wombs grow warm; their termes flow, their breasts increase, and (in a word) to become marriageable [viro maturam esse]; which if they be too long detained from, they are assaulted with dangerous symptoms;  or else fall into the green sickness, and severall other distempers. For all Creatures [animalium], when they are love-struck [cupidinis oestro percita], grow extravagant, and debarred of enjoyment [nisi se invicem fruantur], do at length recede much from their usual temper. Hence some women grow frantick for love; and this extravagancy is so outragious in some, that they seem bewitched [venesicio afflatae], planet-struck or possessed. As if it were the same thing for those creatures [ie some insects and hens] to be with egge, as for In his discussion of hysterical affections and related conditions here, Harvey is not concerned with conception. Instead he charts what we might call sexual repression as a cause of female sickness. In that sense, Harvey recognises non-generative conception to be distinct from hysteria and associated conditions, not a pathology but a relatively ordinary consequence of a sexual life. Harvey’s narrow understanding of hysteria and related conditions, then, does not fit the picture of ‘Hysteria […] before 1750’, described by Heather Meek as suffered by ‘all women’ ‘to some degree’.Unsurprisingly, whether or not love and desire are expressed through the sexual act is important in relation to reproduction; what is less obvious is that sexual expression is also biologically momentous in the case of non-generation. Harvey takes the contemporary view that love-sick females who are held back from a desired sexual life become ill. In Anatomy of Melancholy, where the oestrum, or bite of the gadfly, is evoked to retell the story of Sappho and Phaon.De motu locali animalium as causing movement within animals.Anatomy that were particularly concerned with uterine and menstrual health, Harvey instead cites and engages with Burton’s definitions and understanding of love sickness.phantasm: the perceived, spiritual image that is impressed upon his or her mind’.Harvey borrows the phrase ‘cupidinis oestro percita’ [literally: stirred by the gadfly of desire], in the quotation above, from Robert Burton’s De generatione, 4–5). Rather, Elizabeth’s queer parrot, gendered masculine but anatomically female, is love sick, green sick, or a hysteric, its putrefying egg like retained menses. The story shortly precedes Harvey’s concerns about marriageable girls suffering ‘hysterical affections’ that I discussed above. Harvey’s autopsy of the parrot is an investigation not into pregnancy but rather female love-sickness, and enables him to sort health from disease in the case of non-generation.In the story of Elizabeth’s parrot, Harvey brings the question of the difference between un-generative conception and uterine pathologies home. Elizabeth Spiller has also discussed this parrot in her satisfying account of Harvey’s writing on generation.gremium – which he also uses earlier to denote the place the parrot liked to lay its head to be stroked when it was alive. He complains that in life the animal ‘was now grown so familiar, that he was permitted to walk at liberty through the whole house’ (24), taking up an illegitimately intimate place in his marital home, even in his wife’s lap. Keller has considered Harvey’s descriptions of himself throughout his writing on generation and conception as a ‘torchbearer’ and ‘hero-adventurer’.Harvey’s description of the parrot’s attempts to court his wife are full and excessive, charting its ‘mutterings’ and ‘shaking of his wings’, its ‘familiarity’ and ‘obsequiousness’, its ‘singing and talking’ (24). The parrot dies, Harvey says, in Elizabeth’s lap or bosom – his Latin word is Georgics, on birds and windy reproduction. Harvey says he reads in Aristotle that male birdsong can be carried on the wind and fecundate a hen bird:Aristotle saith, If partridge-hennes stand over against the cocks, and the winde blow from whence the cocks are, they conceive and grow big, and for the most part, they teem [ingravescunt] even by the voice of the cock, if they be at that time wanton and lustfull (24)Spiller sees in the discussion of birdsong the figure of the potent male artist and, indeed, of Harvey himself.ingravescunt [grow heavy] does not populate the abdomen in the same way that English ‘teem’ does. Abdomens may swell and gain weight, but not gestate or deliver young. Tellingly the lengthy quotation from the Georgics which follows describes the fructifying descent of the god Aether into the joyful womb, lap, or bosom of his consort: the earth. The Latin phrase is ‘gremium laetae’, ; and, as I noted, Harvey uses the same word, gremium, twice elsewhere in his description of Elizabeth’s intimate interactions with her pet. Whilst Harvey’s anecdote about the parrot at first appears to be about the parrot’s un-generative pathology, in the repetition of gremium, it also elliptically points out Elizabeth’s un-generativeness, and a womb, which Harvey’s biography reminds us, did not bear children.The narrative of the parrot’s love is interrupted by a digression, derived from Aristotle and, again, Virgil’s Georgics; fiction offers the best, because most immaterial, grounds for approaching non-generation. However, Harvey’s use of Virgil’s poem is characterised by resistance to its compulsory reproductive logic. In particular, Harvey is careful not to exclude un-generative wombs, and particularly not Elizabeth’s, from his version of the erotic descent of Aether. If Virgil had used the spring winds to link eros and reproduction, Harvey instead finds this erotic moment in Virgil’s text useful to consider not infertility exactly but rather an in-between diagnostic state which may be generative, but equally may not. Harvey understands that conceptūs without foetuses have seasons, just in the way that fruitful ones do, that there are particular times when expectations rise. Harvey replaces Virgil’s emphasis on reproduction with another, on conception, and additionally offers maternal affection, which is not a concern in Virgil’s poem, as a sign of a conception achieved after intercourse. In this way, he dignifies the un-generative body by including it in ancient erotic dramas which placed human sexuality in cosmological and natural perspective. Furthermore he reorients his readers to consider birds that sit on wind eggs – and perhaps the falsely pregnant women they resemble – and to acknowledge their loves, desires and maternal ministrations, as much as those whose sitting is rewarded with ‘chickens to discipline […] assemble, nurture, feed and protect’ (71).Elizabeth’s frustrated parrot also stands in contradistinction to those broody birds that Harvey returns to throughout his writing on generation, who incubate subventaneous or addled eggs. Pathological love-sickness, like the parrot’s, is not conception, unlike the wind eggs of mated birds. In this way, Harvey credits false pregnancy and recognises that it provokes or is accompanied by maternal behaviours in animals, which he observes with some tenderness. For all that Keller is right on Harvey’s ‘sex stories’, and Spiller, too, on his generative fictions, we should also acknowledge Harvey’s insight into non-generation. This is particularly evident at the moments when Harvey self-interrupts with literary quotation particularly from the De conceptione as itself un-generative and limited by its place in history, to his credit, Harvey recognises and is reflective about his partial perspective. Unable to see the sperm ‘remaining behinde in the female’ (548), he draws this blank:What remains, since I can imagine nothing else, nor no man hath hitherto dreamed of any other thing, but freely to profess my self to be at a stand? (548)As Spiller has argued, Harvey’s work on generation and particularly De conceptione is concerned with his own act of creation; this passage is no exception.mera figmenta & imaginationes] .merum here apparently empties fiction of its value except that he deploys the same word in his awed account of the body’s powerful creative capacities. In De conceptione Harvey finds that conceptions are ‘mere’ works of the imagination, yet they can be credited, even in the absence of a foetus, not only because they are accompanied by biological symptoms of pregnancy, but also because those symptoms are generated by erotic and romantic expectations and signed by maternal love. Love is crucial to Harvey’s symptomology of the intelligent un-reproductive female body, and of a womb that can envisage, although perhaps not always deliver, the children often looked for in a sexual life.Whilst many critics have dismissed


Like most women, female nurses in the workforce experience life events such as marriage, childbirth, and child-rearing, and carry out numerous personal roles. This may result in an increase in various demands for nurses, and coping with these roles may promote work engagement. However, few studies have focused on work engagement or spillover effects, including those in the family domain, in female nurses with multiple roles. In the present study, we aimed to examine work engagement in female nurses and investigate its relationship with factors such as the presence or absence of multiple personal roles.The subjects of this study were 1225 female nurses working at three general hospitals, each with at least 200 hospital beds in Fukuoka Prefecture, Japan. The cross-sectional design of the study used anonymous self-administered questionnaires. Responses were received from 650 nurses (response rate 53.1%), of which 612 were valid . Multiple regression analysis was performed on the 612 responses regarding associations between work engagement and the presence or absence of multiple roles (role as a wife or mother), spillover effects, coping characteristics, job demands, and job resources.In general, the work engagement of female nurses was low, as is the case with other female workers in Japan, but work engagement was higher among female nurses with multiple roles than among those without. The regression analysis showed that factors associated with better work engagement in female nurses were family-to-work positive spillover, job resources, coping strategies including “changing a point of view,” “active solution for problems,” “avoidance and suppression,” and the presence of multiple roles.The results indicate that in addition to resources in the work domain, a family-to-work positive spillover effect, which is a variable in the non-work domain, may also promote energetic work among female nurses. Therefore, it is necessary for nurses to receive support at work and use effective coping strategies. In recent years, various initiatives have been undertaken to improve workers’ mental health. Moreover, the conventional concept of salutogenesis has been developed to complement pathogenesis  and mentAccording to the National Institute for Occupational Safety and Health occupational stress model that explains the mental and physical health of workers, adding “non-work factors” such as domestic and family demands to “job stressors” impairs mental and physical health . In partOn the other hand, studies on work engagement and burnout have shown that nurses with multiple roles, who are married, have a higher level of work engagement than those who are not married  and thatBased on the studies above, we can predict that, for female nurses, carrying out numerous roles may result in an increase in various demands, and coping with all those roles may be a strength in work life. However, few studies have focused on work engagement or spillover effects after including the family domain in female nurses with multiple roles. By identifying factors that promote working energetically, including having multiple roles, female nurses will be able to perceive life events such as marriage, childbirth, and child-rearing positively that earlier inhibited them to work and work energetically maintaining good mental and physical health.Therefore, the study hypothesizes thatH1: The work engagement of female nurses is higher among those with multiple roles than among those without multiple roles.H2: The factors associated with work engagement in female nurses are job resources, high WFPS and FWPS, low WFNS and FWNS, and the presence of multiple roles.We aimed to clarify the current state of work engagement in female nurses and its relationship with factors, such as the presence of multiple roles.Subjects were 1225 female nurses working at three general hospitals, each with at least 200 hospital beds in Fukuoka Prefecture, Japan. The study was a cross-sectional design using anonymous self-administered questionnaires. A total of 1225 questionnaires were distributed and 650 responses were received (response rate 53.1%). Of those, 612 were valid . The 612 subjects who provided valid responses were divided into two groups based on the presence or absence of multiple roles. Multiple roles in this study were defined as work roles and roles played as a result of life events such as marriage, childbirth, and child-rearing. The main roles refer to worker roles and wife or mother roles, as life events such as marriage, childbirth, and child-rearing in Japan can lead to women discontinuing their nursing profession. As a result, 262 nurses had multiple roles and 350 did not. We calculated the power based on previous studies and confirmed that the minimum sample size needs to be at least 100. In this study, the number of female nurses with multiple roles was 262, indicating an appropriate sample size.While distributing and collecting the questionnaires, subjects were provided with a written explanation about the purpose and methods of the study and were assured that participation was voluntary. Submission of a completed questionnaire was considered to indicate consent. Questionnaires were returned via post.The entire procedure followed in the study was reviewed and approved by the Ethics Committee of the University of Occupational Environmental and Health Japan .Work engagement was assessed using the short-form Japanese version of the Utrecht Work Engagement Scale (UWES-J) created by Shimazu et al. based on the simplified version of the original UWES created by Schaufeli and Bakker , 34. TheJob demands and job resources were assessed with items from the new Brief Job Stress Questionnaire . The jobSpillover effects were measured using the Japanese version of the Survey Work–Home Interaction-NijmeGen (SWING) created by Geurts et al.  and tranCharacteristics of coping, which is a personal resource, were assessed with the Brief Scales for Coping Profile (BSCP) for workers created by Kageyama et al. –44 The BAttributes investigated were age, years of experience, frequency of night shifts per month, position, type of employment, department, shift format, marital status, presence or absence of a spouse, cohabitation status with spouse, employment of spouse, presence or absence of children, number of children, presence or absence of children under school age, and the number of children under school age.U tests on the scores of each scale. For all subjects, simple correlation tests were performed with work engagement as the dependent variable and each measure as an independent variable. Next, hierarchical multiple regression analysis was performed on variables found to be significantly associated with work engagement in simple correlation tests (p < 0.05) and variables found to differ between groups (p < 0.05) with years of experience and presence or absence of multiple roles as independent variables. The Kolmogorov–Smirnov test was used to assess the normality of work engagement as a dependent variable. If the data were not normally distributed, the distribution was corrected with Blom’s normal score transformation. Variables were included by forced entry for each category, and a dummy variable was included for the presence or absence of multiple roles . Multicollinearity between variables was verified with a criterion of variance inflation factor < 2. The analysis was performed using SPSS Statistics version 24 statistical software (IBM).Descriptive statistics were calculated for attributes and scores for each scale. To compare the two groups (presence and absence of multiple roles), Fisher’s exact tests and chi-square tests were performed on the subjects with each attribute, and Mann–Whitney In this study, participants were recruited from three general hospitals in Fukuoka Prefecture, Japan between January and March 2017. Since nursing services can differ with the number of beds and functions of a hospital, we included hospitals with 200 beds or more to eliminate any bias.Responses were obtained from 650 nurses (response rate 53.1%), of which responses from 38 participants were discarded due to missing data. Of the 612 valid responses , 262 nurses had multiple roles , and 350 nurses did not have multiple roles .Table p < 0.001). Meanwhile, scores for the strategy of “changing mood” were lower among those with multiple roles than those without (p = 0.002) and scores for “avoidance and suppression” were also lower among those with multiple roles than those without (p < 0.001). For the variables of “job demands” and “job resources” that assess the work domain, there was only a significant difference between groups in the former, with higher scores observed among nurses without multiple roles than nurses with multiple roles (p = 0.001). For spillover effects, which assessed the work-life domain, significant differences were observed between groups in three of the four subscales and scores for WFNS, a type of negative spillover, were higher among nurses with multiple roles than nurses without (p = 0.003). In addition, scores for WFPS and FWPS, both of which are types of positive spillover, were also higher among nurses with multiple roles than nurses without (p < 0.001 for both). For UWES-J that assesses work engagement, total and individual scores of the three subscales were higher among nurses with multiple roles (p < 0.001 for each).Table r = 0.194, p < 0.01; r is Spearman’s rank correlation coefficient), years of experience , BSCP “active solution for problems” , “seeking help for solution” , “changing a point of view” , job resources , WFPS , and FWPS . Negative correlations were obtained with frequency of night shifts per month , BSCP “avoidance and suppression” , job demands , and FWNS .Simple correlation analysis on the factors associated with work engagement revealed significant positive correlations between the total UWES-J score and age (R2 coefficient increased significantly with the addition of variables in each category. The adjusted R2 coefficient was largest in model 5 (0.324) and factors that were significantly associated with work engagement were FWPS , job demands , BSCP “changing a point of view” , “active solutions for problem” , presence or absence of multiple roles , years of experience , and BSCP “avoidance and suppression” .Table The aim of this study was to examine work engagement in female nurses and investigate its relationship with factors such as the presence or absence of multiple personal roles. Results indicated that work engagement of female nurses was low, as is the case with other female workers in Japan. However, the hypothesis that work engagement is higher among female nurses with multiple roles than among those without was supported (H1). In addition, the factors associated with work engagement in female nurses were positive family-to-work spillover, job resources, coping strategies including “changing a point of view,” “active solution for problems,” “avoidance and suppression,” and the presence of multiple roles. Therefore, H2 was also supported partially.The mean age of subjects in the present study was 35 years, which is roughly the same as the mean age of nurses in Japan . In factBased on a previous study, the reference score for the UWES short form was 3.7 points , and theThe present study showed higher work engagement among female nurses with multiple roles than those without. The female nurses with multiple roles in this study had experienced life events such as marriage, childbirth, and child-rearing, and held roles such as a wife and mother. Previous studies have also found that work engagement is higher among (a) female nurses who are married than those who are not married  (b) marrIn the hierarchical multiple regression analyses, work engagement of female nurses, which was the dependent variable, was predicted by high FWPS, more job resources, greater use of “changing a point of view” and “active solution for problems” as coping strategies, the presence of multiple roles, and less use of “avoidance and suppression” as a coping strategy, even after controlling for years of experience.In the present study, based on the JD-R model, we postulated that spillover effects that include variables in both the work and family domains would be associated with higher work engagement, which is an outcome in terms of high WFPS and FWPS, and low WFNS and FWNS. However, for positive spillover, only FWPS, namely, the positive effects of family on work, was associated with work engagement, and there were no associations with any type of negative spillover. A comparison of the spillover effects between the two groups revealed that FWPS was higher among those with multiple roles than those without. This suggests that female nurses with multiple roles may be more influenced by the effects of FWPS, which is a resource that increases work engagement, than by the presence of multiple roles. The circumstances within the family domain that positively affect the work domain may be an important contributing factor. A study on the determinants of work engagement in nurses working in hospitals found that the presence of someone who is pleased by their work contributes to higher work engagement . Female Coping strategies that were associated with an increase in work engagement included the greater use of “changing a point of view” and “active solution for problems” strategies, and reduced use of “avoidance and suppression.” These results are consistent with earlier work studying factors related to work engagement of nurses working at hospitals examined by years of experience; this research suggested a greater use of “changing a point of view” and less use of “avoidance and suppression” strategies among nurses with between 4 and 9 years’ experience and 10 or more years’ experience . AnotherCompared to the scores of the standard population calculated in the BSCP development process  , the preBased on the difference in the presence or absence of multiple roles, nurses with multiple roles had lower scores than the standard population in “changing a point of view” and “avoidance and suppression” and roughly the same scores in “active solution for problems” and “changing mood.” In contrast, scores for “active solution for problems,” “changing a point of view,” and “avoidance and suppression” were lower among nurses without multiple roles compared to the standard population. This indicates that the greater use of “active solution for problems” and “changing a point of view” as coping strategies may increase work engagement in female nurses. In addition, while it has been suggested that the use of both “active solution for problems” and “changing mood” are effective in improving mental health associated with work engagement , nurses In a similar vein, having greater “job resources” was detected as a determinant of work engagement in the work domain, and this is consistent with the JD-R model , 4. LikeThis study has some limitations. First, the participants in this study were limited to those from a single prefecture in Japan, and the response rate was about 50%. Thus, the sample may not be representative of all female nurses in Japan. Although age, years of experience, and employment conditions of the participants in this study are very similar to the average in Japan, further studies with a higher response rate are needed, and collecting more comprehensive data could provide insights into how female nurses can lead a more balanced and active work life.R2 value, it was still only 0.324; therefore, we were able to explain work engagement with predicted variables by only about 30%. The determinants of work engagement used in the present study were presence or absence of multiple roles, coping strategies as a variable related to personal resources, job resources and job demands as variables in the work domain, and spillover effects as a variable in the work and family domain. However, other relevant variables may also influence the level of work engagement [Second, although we used the results of model 5 that had the largest adjusted gagement . FurtherThird, the presence or absence of multiple roles was significantly associated with work engagement, but the standardized regression coefficient β was as low as 0.097. This is because multiple roles in this study only include employee, wife, and mother, and caregiver role was not included. Therefore, studies that include caregiver role as part of multiple roles should be conducted in the future.Lastly, the survey was conducted only with women. Most nurses in Japan are women; however, expanding the scope of research to include men would further elucidate nurses’ work engagement and could help determine the measures that are necessary to improve the quality of nursing care.Work engagement of female nurses was low, similar to other female workers in Japan in general; however, work engagement was higher among female nurses with multiple roles than those without. In addition, greater work engagement of female nurses was associated with high FWPS, more job resources, greater use of “changing a point of view” and “active solution for problems” as coping strategies, the presence of multiple roles, and less use of “avoidance and suppression” as a coping strategy. These results indicate that having multiple roles as a result of life events such as marriage, birth, and child-rearing may be one of the positive factors for improving work engagement. Therefore, it is necessary for nurses to receive support at work and use effective coping strategies. This can help reduce female nurses’ perception of difficulties in the balance between work and family.


Background: Humanitarian migrants from Myanmar represent a significant refugee group in Australia; however, knowledge of their health needs and priorities is limited. This study aims to explore the meaning and influencers of health from the perspectives of refugees from Myanmar. Method: Using a community-based participatory research (CBPR) design, a partnership was formed between the researchers, Myanmar community leaders and other service providers to inform study design. A total of 27 participants were recruited from a government-funded English language program. Data were collected using a short demographic survey and four focus groups, and were analysed using descriptive statistics and thematic analysis methods. Results: Key themes identified included: (1) health according to the perspectives of Australian settled refugees from Myanmar, (2) social connections and what it means to be part of community, (3) work as a key influence on health, and (4) education and its links with work and health. Conclusions: This study outlined the inter-relationships between health, social connections, work and education from the perspectives of refugees from Myanmar. It also outlined how people from Myanmar who are of a refugee background possess strengths that can be used to manage the various health challenges they face in their new environment. A significant number of refugees settle into new home countries every year. In 2018, Australia accepted 16,250 people from refugee backgrounds (refugee status as defined by the United Nations High Commissioner for Refugees) through the Humanitarian Program ,4,5, andPeople from refugee backgrounds have poorer health outcomes than those from non-refugee backgrounds ,11,12,13One framework used to understand the health of refugees is the socio-ecological model (SEM), as it recognises that the health of individuals is influenced by complex interactions between social, cultural, and environmental factors ,31,32,33Knowledge of the health needs and priorities of refugees from Myanmar who reside in Australia is currently limited. Indeed, community members report health promotion programs may be ineffective due to lack of community engagement and consultation. In this paper, we describe how community-based participatory research (CBPR) methods were used to engage and build a relationship with the Myanmar refugee community as the foundation for future community-led health promotion efforts. The aim of this study was to investigate the meaning of and influences on health from the perspectives of refugees from Myanmar.Acknowledging trauma and the potential for participants to be re-traumatised through their engagement in research is a key consideration when conducting ethical research with refugee participants . Due to A CBPR design and qualitative methods were chosen to investigate experiences of health and its determinants among refugees from Myanmar. Although qualitative research methods aim to amplify the voice of participants , CBPR haThe research team was approached by a community leader who recognised the need for a health promotion program for refugees from Myanmar. A research partnership between community leaders, the local primary health care service and Swinburne University of Technology was formalised and a steering committee was established to guide the study. The steering committee met every three months and included key stakeholders including the researchers , two clinicians from the local community health service , a nurse from the campus health service, two student members of the refugee community (referred to as ‘community members’), the campus Adult Migration English Program (AMEP) convenor and a representative from student engagement and the Migrant Information Centre. Four members of the steering committee were from Myanmar.The purpose of the steering committee was to: (i) gain an overview of the issues of concern to the community; (ii) develop the research questions, recruitment material and data collection tools; (iii) engage the relevant refugee community and (iv) interpret and disseminate the findings from the study. Minutes were taken at each steering committee to document discussions and decisions and provide an audit trail for the project. At the beginning of the project, a member of the steering committee who was from Myanmar and had refugee experience (BT) provided cultural awareness training. This gave the researchers a contextual overview of life in Myanmar, common refugee experiences and insights into relevant cultural beliefs and practices.Swinburne University of Technology (SUT) is a dual sector education provider that delivers English classes to refugees across three campuses in Melbourne, Australia. The AMEP at the Croydon campus was selected as the setting for this study because (i) 2.3% of the total population of this suburb is from Myanmar and (ii) more than 50% of the student cohort were humanitarian migrants from Myanmar. Purposive sampling was used to recruit students from intermediate (level 2) and higher level (level 3) AMEP classes, as these students had some English language proficiency. These students were also more likely to provide in-depth information as they had spent more time living in Australia and could reflect on their settlement. Inclusion criteria were (i) from Myanmar; (ii) enrolled in AMEP at SUT, Croydon campus and (iii) aged between 18 and 65 years. Students were excluded if (i) they were born in Australia or a country other than Myanmar, (ii) they were unable to give informed consent due to mental or cognitive impairment or (iii) they were aged under 18 years or over 65 years.Prior to recruitment, rapport with the students was built over time via a person trusted by the community. The campus nurse introduced the researchers (A.L. or C.W.) to students. Over the next month, the researchers attended classes to build relationships and trust with students in a familiar and safe environment. During this time period, a local healthcare provider (EACH) delivered one health education session as part of their comprehensive refugee primary healthcare service model, which was developed to align the research with the AMEP curriculum. One week prior to data collection, the researchers (A.L. and C.W.) and the campus nurse attended level 2 and 3 AMEP classes to explain the research project, with assistance from one of the steering committee members as an interpreter. All students from Myanmar were invited to participate.A short demographic survey and a focus group topic guide were co-designed by the steering committee. Information regarding refugee status was not collected, as all students enrolled in the AMEP were holders of a humanitarian migrant visa, and therefore their refugee status was assumed. On the morning of the focus group, students were collected from their class. The participant information and consent statement was read out and translated into the relevant community language by a qualified interpreter, who had been briefed on the purpose of the study and focus group topics. Three students declined to participate and returned to their classroom. After giving consent, participating students were given a $20 gift voucher to reimburse them for any expenses associated with their involvement in the study.A total of 27 students gave verbal consent to participate, and completed a short written demographic questionnaire, independently or with assistance from an interpreter. Four focus groups, of 60 min duration, were conducted with between six to eight participants. The focus groups were conducted in English and moderated by the lead researcher (C.W.), according to a semi-structured topic guide. Students could respond in English or in their preferred language via an interpreter. The focus groups were audio-recorded using a digital audio recorder, and a note-taker (A.L.) recorded written observations of participants, seating arrangements and body language to provide context and help interpret the verbal information. After the focus groups, the moderator and note-taker offered the interpreters an opportunity to debrief. During this time, some interpreters provided contextual information, which gave the researchers a deeper understanding of the participants’ responses and the issues that arose during the focus groups. Once the interpreters had gone, the researchers wrote field notes separately, before discussing their observations and insights together.Quantitative data from the demographic questionnaire were analysed using descriptive statistics using Microsoft Excel. Audio-recordings from the focus groups were transcribed verbatim by two researchers (A.L. and C.W.). The focus group transcripts were analysed using thematic analysis techniques ,39. For Strategies to enhance trustworthiness were incorporated into the study design . MinutesA total of 27 participants were recruited, including 12 men and 15 women from the SUT AMEP classes. Of the participants, 23 were recruited from intermediate English level classes (level 2), whilst four were recruited from higher level English level classes (level 3). Participants spoke a variety of Myanmar languages including Zomi, Haka Chin, Burmese, and Karen. More than half (66.7%) of participants had lived in Australia for more than 2 years. Participant characteristics are presented in Participants identified good health as being relevant to every person regardless of where they lived, and related health to different domains such as physical, social and mental health. One participant described health holistically as “your mind, your spirit and your body”. Physical health related to feelings of wellness, such as energy levels and absence of pain, whilst mental health was associated with “not overthinking” and having “a peaceful heart”.Participants discussed practical health behaviours that were conducive to the attainment of health including eating, physical activities and strategies for managing mental health. As one participant described, “health means to me eating regularly, sleeping regularly and also peaceful mindful heart not to overthink”. Eating behaviours, which included consuming fruits and vegetables, drinking less alcohol, and reducing fat and salt intake, were identified by participants as supporting their health.The physical health of participants was influenced by their migration journey, and participants made comparisons in the differences in healthcare access before and after arrival in Australia. For instance, participants compared healthcare access in Myanmar and places of transit with the healthcare that was available in Australia. In Myanmar, accessing healthcare services was difficult, especially for participants who lived in villages, where the government provided infrastructure but not services, including staff and equipment. Limited finances were an additional barrier to seeking healthcare. One participant commented, “[We] cannot easily go to the doctors since we do not have enough money”.Once participants arrived in Australia, they received free comprehensive health screenings and follow-up as part of the settlement process. Overall, participants appreciated the level of healthcare available to them in Australia, with one participant saying, “the care in Australia in health departments is really good”, and another stating, “we’ve got full assistance by [government funded healthcare scheme], and we’ve got full support for everything that we need”. The significance of accessing more comprehensive healthcare in Australia was highlighted by one participant who said, “the health system’s changing. When [participants] were in the camp, they didn’t have enough access to healthcare, so they got sick and they don’t have enough access to medications, and when they came here they prescribed with the right medication”.However, participants experienced challenges understanding and using the Australian health system when compared with other countries they had lived in before. This was illustrated by one participant who described, “in our country you can buy medicine without prescription so that is different because [in Australia] they always investigate it first and never prescribe medication easily… so that is really hard to understand.”Another participant raised concerns about the need to make a healthcare appointment in Australia, “sometimes when we get sick and then make an appointment and we can’t get the same date so wait another two or three days”. Managing multiple health appointments created additional challenges. For instance, one participant described, “Sometimes getting around is a problem for me for example a doctor refer me to a certain hospital or clinical service but I don’t know the location and sometimes I fail to attend for example once I need to check my stomach and get a gastroscopy but they give me a certain place and I do not know where to get there.” For newer members of the community, lack of familiarity with geographical locations, limited access to transport and language barriers resulted in missed healthcare appointments.Participants perceived social connection as a key part of health within their culture, “we tend to live together in a group, very closely”. These social networks included family, community members from their ethnic group, church and the broader Australian community. Social connections therefore played an important role in achieving good social and mental health, as one participant explained, “I think it is good to be a part of community surely it is better than living alone or having no one to talk to. And it’s good if you can go to church every week with a set of people and if you participate so I think that it is good for your mental health and social”.Upon arrival in Australia, people from Myanmar sought to live where other community members of the same ethnicity resided, and this was outlined by one participant who said, “most community members tend to move where their community members already there so it is very important for community.” Being able to connect with people from the same ethnicity and language group through activities such as going to church, celebrating personal and community events and playing sports was therefore viewed as important. After arriving in Australia, participants also connected with the broader Myanmar community, as illustrated by one participant, “only Chin is big enough, Chin community but we have other connections as well as the other ethnicities from Burma”. Connections between people from different ethnic groups were generally made through organised multi-ethnic Myanmar events, which afforded smaller ethnic groups the opportunities to connect with others.Social connection was a key resource used by participants to overcome challenges, and to adapt to life in Australia. For instance, participants supported each other to engage in health-promoting behaviours and worked together to address challenges within their communities, “Others do , if it’s possible for us to come together even if it’s to reduce the amount of intake”. Social connection was also a source of emotional support, as one participant explained, “sometimes everyone like feel sad and have problems so if they think about themselves the problem gets worse so it’s good to share with friends and um if you get with others we can listen to them, support them and encourage them so that’s how they relieve their problems.”Participants shared information with new arrivals about local resources such as where to get food from “both from supermarket, from the garden, from Burmese grocery shop” and opportunities for physical activity. Focus group participants reported engaging in a variety of activities such as riding a bike, going to the gym, group sports such as soccer and volleyball, gardening, and casual dancing. These activities were done in a social context, that is, with family members, friends or other members of the Myanmar community. However, their choice of physical activity was influenced by their gender and associated roles. As one participant explained, “[no time for exercise] because my husband is always at work so I am the one that has to look after the children”, whereas another participant added, “because I have a young kid, it’s hard for me to go out and exercise”. Therefore, while men engaged in social sports, such as playing soccer, which required planning, women engaged in spontaneous physical activities such as going to the local park to play volleyball and casual dancing at home.Community members also shared information about navigating the health system with new arrivals. One participant explained, “I tell [new arrivals] the health system in Australia because in our country we just go to see a doctor, just pop in, [I] just tell them that we need to make an appointment first and see a doctor”. Community members who have been settled for longer periods in Australia therefore provided practical assistance to new arrivals such as taking them to medical appointments.The ability to work was a key influence on the participants’ health. The participants described a strong work ethic, as one man commented, “we are born to work and eat”. Another participant explained, “back in Myanmar, I work and walk a lot”. Working directly benefited the participants’ physical health, for instance earning money enabled participants to afford a wider variety of foods, and also provided incidental exercise when travelling to and from work or when performing physically demanding jobs. Many participants experienced barriers to paid employment since their arrival in Australia.Participants described the frustration of being “willing to work, but we can’t get a job”. Whilst many participants had skills and work experience, participants felt that these were not recognised or relevant in Australia, “we don’t have any skills. Um, even if we [have] work experience, it’s not related in this country, we can’t really use them”. Some participants had received support from a job network provider to gain local experience, “we got a lot of support so even though they provide volunteering, um I have done volunteering for a week, I still can’t get a job…” The distance required to travel to available job opportunities was also reported to be a hindrance to employment, with one participant saying, “there may be some [employment] but it is too far and [Myanmar community members] can’t go”.Most participants relied on financial support from Centrelink (government welfare support), which gave participants some means to support their health through buying food or going to the doctor. Despite this financial support, some participants reported financial hardship, which affected both their physical and mental health. To overcome this hardship, some participants had established a garden at their home so they could pick fresh vegetables to eat. In addition to ensuring a healthy diet, gardening and doing other household work had additional benefits by “mak[ing] yourself as busy as you can so you can sleep better.” One participant commented, “we are working unpaid job, full-time job at home… looking after children, and gardening.”English proficiency was perceived as necessary to secure employment in Australia, and all participants were enrolled in English language classes. As one participant said, “To get a job, we need experience and speak English in certain case”. One participant explained this further, “I think that language could be a bigger barrier than qualifications because in some fields, such as working in a factory, you don’t necessarily need any qualifications…but you do need the language so if you speak English getting to that employment then you’ll be able to pick up on that trade.”Participants expressed concern that the time commitment of full-time study meant that they were unable to work, “we worry sometime because we are studying full-time and not working yet”. Worrying about their livelihoods made it difficult for students to learn “[because we are] overthinking, we can’t concentrate on the things that we are going to do”. Another participant said, “here we feel like [attending English language classes] is compulsory even if we don’t have enough money”. In addition to worry, staying up late because of study affected some participants’ sleep, and therefore their health.Nevertheless, participants valued the opportunity to learn to support future employment and their health. One participant said, “we need education… and information, what to eat, what not to eat, we need more information about healthy food.” Another added, “we don’t really know what is healthy eating… some information would be very helpful”. Participants also wanted information about topics such as exercise and sexual and reproductive health. One participant said it would be good to learn about “de facto or just boyfriend, and safe sex, those things can be included as well. You can get transmitted disease. Some people have HIV and don’t know.”Health remained a constant value for participants throughout their migration journey. This study highlights some of the changes refugees experienced upon migration to Australia and the positive and negative impact that these changes had on their health. Improved access to healthy food, settlement and livelihood support from the Australian government, access to healthcare, and strong social networks were amongst the strong influences on health for participants after arrival. These influences supported health-promoting behaviours that participants associated with the attainment of wellbeing. For instance, connections and linkages to their own ethnic communities played important roles in sharing information and knowledge, enacting health promoting behaviours such as physical activity and taking collective community action to address health issues.Our findings are similar to studies of other refugee communities. For instance, in a study of a Bhutanese refugee community, Im and Rosenberg  discusseParticipants in our study described the numerous difficulties and challenges during the settlement process, such as low literacy in the host language, challenges accessing services  and low income and unemployment. The challenges identified in this research echo that of other studies relating to refugee settlement ,23,24,43Through sharing information and providing social and emotional support, our study highlights how members of the Myanmar community worked together to overcome health challenges. Our research builds on existing evidence that social support was a common strength and trait of refugee communities hailing from Asia ,44. ThisOur study looked at the inter-relationships between health, social connections, work and education. The complex nature of health and relationship with non-biomedical factors as highlighted in previous literature ,23,24,25Whilst service provision is usually driven by service providers and their respective funding bodies, as well as policies behind them, our study gave examples of how refugees from Myanmar demonstrated understanding of service needs and gaps, and the roles that they played to problem solve when these gaps were present. For instance, some information and support needs were met by members of the Australian Myanmar community, by which community members took initiative to orientate new arrivals to living life in Australia, thus acting as a key resource for information. It is important for service providers to recognise community strengths as a resource and to consult closely with the community to ensure that service needs are appropriate and meet service needs and gaps. Service providers and policies should support refugee communities in driving and taking community-initiated action for their wellbeing.Community members were integral in designing this research through their active involvement in the steering committee. Another significant strength was the trust that developed between the participants and the researchers, resulting in high participation rates in the focus groups (only three students declined). This trust was attributed to the rapport-building strategies, which were designed with community leaders, and involved a trusted individual introducing researchers to the students over a sustained period. Trauma-informed and strengths-based approaches also contributed to establishing trust while also affording the past and present health experiences of the participants to be explored without re-traumatization. Focus group participants represented a good cross section of ages (18 to 65 years), and the gender split was almost equal. A possible explanation of this is the nature of the setting where participants were recruited from (English language classes at Croydon SUT), highlighting that education is important across both genders as well as age groups.We recognise that our study has some limitations. The main limitation is that focus groups were conducted in English and translated into several community languages through interpreters. To maximise data quality, qualified interpreters were employed and a researcher with experience conducting focus groups and working with interpreters was chosen as a moderator. In addition, the interpreters were briefed before each focus group to provide context, describe the purpose of the study and outline related focus group questions. In addition, data may have been influenced by differences in vocabulary between the two languages. For instance, there is no expression in Myanmar languages for ‘mental health’. We therefore tried to avoid such terms wherever possible, and used plain English throughout the focus groups. Due to the close-knit nature of the Myanmar community in Melbourne, participants may have withheld or modified information shared, if they had an existing relationship with the interpreters. Nonetheless, we believe that this was a minor limitation as participants discussed sensitive topics, such as betel nut chewing, in depth. The ethnic groups and religions recruited in the study reflected the Myanmar refugee student population living in the local catchment area. We recommend that other ethnic groups who have settled in other catchment areas such as the Kachin, Shan and Rohingya communities be included in future research. Although we consider high rates of participation a strength, it is possible that participants felt obliged to participate due to the power differential, despite our efforts to minimize this through the participatory nature of this study.Our current study only examined the perspectives of health and wellbeing from Myanmar refugees. However, there are numerous service providers who presently provide health and wellbeing-related services to refugees in Melbourne, and the health needs of Myanmar refugees from the perspective of service providers remains unexplored in the literature. Further research exploring the latter is therefore warranted, offering opportunities to compare both perspectives in view of further improving healthcare services for all refugees.This study outlined the inter-relationships between health, social connections, work and education from perspectives of refugees from Myanmar. The complex relationships between health and social, economic and environmental factors was in line with other existing literature. The study also outlines how people from Myanmar who are of a refugee background possess strengths that can be used to manage the various health challenges they face in their new environment. This approach is supported by assets-based or strengths-based community development literature and person-centred care approaches, while also being in line with trauma-informed care. Service providers in different sectors should work collaboratively to address the multitude of factors impacting health of refugees. Furthermore, service providers should recognise the strengths that people from refugee backgrounds possess and work closely with individuals and/or the community to support them in developing strategies and interventions tailored to their needs.


The exact times that count as “night” are somewhat arbitrary, if only because nightfall varies by season and latitude, and bedtimes vary between individuals. However, we did present the results for <7 and 7+hours worked per night (Table 2) and found no raised risk with working 7+hours per night. Working 7+hours between 10pm and 7am could not be considered primarily evening work.That our question on night work mixes evening and night-shift work, and this would result in the “exposed” group including non-exposed evening workers. This, of course, depends on one’s definition of “exposure”. Interest in night-shift work and breast cancer springs from the hypothesis that exposure to light at night may increase cancer risk.ii.3 cited by Kogevinas as evidence for an association, and much younger than the mean ages in the recent pooling of prospective studies .4 To limit the burden on respondents, we did not collect the lifetime history of night shifts but only night work that occurred, or at least ended, during the 10 years before recruitment. Some have suggested that any increased risk associated with night-shift work may diminish soon after exposure ceases,6 and recent, rather than historic, night shifts may be the more appropriate exposure measure. Thus, we analysed night work in the last 10 years, for which period earlier night work would not be the exposure of interest.That our study includes mostly middle-aged participants and may have misclassified some women who worked night shifts in an earlier period. At recruitment, women in our study had a mean age of 40.2 years, which was considerably younger than the mean ages (between 54 and 59 years) in the five case–control studies in the pooled analysisiii.That we only included long-duration workers if they had survived and entered the period 10 years before recruitment, and this could bias towards the null analysis by duration. We found no association with duration in our study, and as we acknowledged in our paper, our data for durations beyond 10 years of night work were limited (see response to (ii)).iv.4 our finding of a statistically significant trend with average hours per week on its own did not provide strong support for a real causal association. However, as we noted, unlike traditional carcinogens where cumulative duration and dose response are critical exposures as evidence for the cause–effect association, it is still unclear which exposure “domains” may be important in relation to night-shift work. Therefore, we neither “discarded” the results on intensity, nor selectively focussed on them, but presented them and commented on their material significance in the context of other results and the existing literature.That the least biased results in our study are certain ones cited by Kogevinas that approached statistical significance. Interpretation of the results, however, needs to consider the whole breadth of the variables analysed, and of the existing literature. We concluded that in the absence of an association between breast cancer and night-shift work overall, or by other measures of dose, duration or intensity in our study, and no evidence for association from the most recent meta-analysis of prospective studies,We thank Kogevinas for his interest in our paper on night-shift work and breast cancer risk in women.Finally, with regard to Kogevinas’ advocacy that we should not have published these results, we would note that all epidemiological studies have limitations and are vulnerable to bias. If authors should self-censor information for publication when a study includes potential limitations or biases, as Kogevinas advocates, there would be no literature on shift work. The point of peer review and journal editing is for journals to judge whether papers are of sufficient quality, and for readers to make judgements from the literature overall, including both the significant findings and those that are null, to come to a conclusion about the state of the evidence.


Primary care patients with prediabetes is a priority group in the clinical, organisational and policy contexts. Engaging in regular physical activity is crucial to prevent diabetes for this group. The objectives of the study were to assess factors associated with meeting the recommendation of at least 150 min of moderate/vigorous physical activity weekly, and to explore facilitators and barriers related to the behaviour among primary care patients with prediabetes in Singapore.This was a mixed methods study, consisting of a cross-sectional survey involving 433 participants from 8 polyclinics, and in-depth interviews with 48 of them. Adjusted prevalence ratios (aPR) were obtained by mixed effects Poisson regression model. The socio-ecological model (SEM) was applied, and thematic analysis performed.The prevalence of meeting the recommendation was 65.8%. This was positively associated with being male , living in 4–5 room public housing , living in executive flat/private housing , having family members/friends to exercise with ; and negatively associated with a personal history of osteoarthritis , as well as time spent sitting or reclining daily . The recurrent themes for not meeting the recommendation included lacking companionship from family members/friends, medical conditions hindering physical activity (particularly osteoarthritis), lacking knowledge/skills to exercise properly, “no time” to exercise and barriers pertaining to exercise facilities in the neighbourhood. The recurrent themes for meeting the recommendation included family/peer influence, health/well-being concerns and education by healthcare professionals.Much more remains to be done to promote physical activity among primary care patients with prediabetes in Singapore. Participants reported facilitators and barriers to physical activity at different levels of the SEM. Apart from the individual and interpersonal levels, practitioners and policy makers need to work together to address the organisational, community and policy barriers to physical activity. Prediabetes is a health condition where the blood sugar level is higher than normal but still below the threshold for diabetes . The annLifestyle modification is the main means to prevent cardiovascular diseases and diabetes in individuals with prediabetes . Other tThere were at least 3 gaps among studies which had been conducted to investigate the prevalence and correlates of physical inactivity in individuals with prediabetes –14. FirsSimilar to other Asian countries such as India and China, prediabetes and diabetes are also common in Singapore. By 2030, 1 in 4 Singapore residents will have prediabetes . LikewisThe mixed methods approach was adopted, consisting of a cross-sectional survey (quantitative phase) and then in-depth interviews (IDIs) . The explanatory sequential design was applied . The firThis occurred in 8 out of 20 polyclinics in Singapore between July 2017 and January 2018. Polyclinics are public healthcare institutions where primary care doctors and other healthcare professionals such as dietitians and nurses deliver medical care. Approximately half of the patient population with chronic illnesses in Singapore are treated in this setting . During For the cross-sectional survey, the inclusion criteria were (i) community-dwelling patients with existing prediabetes who were Singapore citizens or Singapore Permanent Residents, aged 21 to 79 years, (ii) diagnosis verified by oral glucose tolerance test (OGTT) and diagnosis code, and (iii) currently following up at any one of the 8 polyclinics. Individuals who had converted back to normoglycemia or progressed to diabetes based on the last diagnosis code and laboratory test were excluded. The polyclinic headquarter database formed the sampling frame, where patients with a diagnosis code of “impaired fasting glycaemia (IFG)” or “impaired glucose tolerance (IGT)” without “diabetes mellitus” were identified. We adopted the definitions of IFG and IGT from the World Health Organisation (WHO) . Time loWith precision of 5% and confidence interval (CI) of 95%, assuming a prevalence of 60% who reported physical inactivity, the estimated minimum sample size would be 283 .The questionnaire was self-administered, and the recruiter was nearby to provide clarification if required. Depending on the participant’s language preference, the questionnaire was available in English, Mandarin or Malay. We took actions to minimise social desirability biases, such as the use of non-judgemental questions, use of frequency-based rather than leading questions, and stressing the anonymity of their responses.Physical activity was assessed using the global physical activity questionnaire (GPAQ) which has been validated in the local population . MeetingBefore the study, we reviewed the literature to select the possible factors that could contribute to differences in meeting the physical activity recommendation. These could be broadly categorised into 3 main groups, (i) sociodemographic factors such as sex, ethnicity, marital status, education level, housing type, current work status and age, (ii) medical history, as well as (iii) sedentary behaviour and the availability of family members/friends for companionship during exercise. Sedentary behaviour was assessed by using a self-reported question from the National Health Survey Singapore , “How muP < 0.10 were selected for multivariable analysis to identify the independent factors. A backward stepwise approach was then performed to obtain the adjusted PR (aPR) and 95% CI, where only variables with P ≤ 0.05 were included in the final model. The study sample was also compared with the polyclinic headquarter database consisting of all the patients in NHG polyclinics with prediabetes pertaining to sex, marital status and age. We performed all statistical analyses using STATA version 15.0 [The prevalence of participants meeting the physical activity recommendation was obtained. Bivariate analysis between each independent variable and meeting the recommendation was conducted. The association between each variable and meeting the recommendation was evaluated employing mixed effects Poisson regression model accounting for clustering by polyclinic venue. The crude prevalence ratio (PR) and 95% CI was obtained. Poisson was preferred here, rather than logistic regression, as more than 10% of the study population met the recommendation . Thereafion 15.0 .Forty-eight out of 433 who participated in the first phase underwent IDIs from September 2017 to April 2018 at the National University of Singapore. Prior to the interviews, we asked for their willingness to participate in the IDIs in the survey questionnaire. We used the maximum variation sampling strategy to select a purposive sample from diverse backgrounds, based on sex and whether they reported meeting the recommendation. We created 4 matrices based on these criteria . We contacted participants who had indicated their interest earlier and also fulfilled the criteria for each of these matrices. Using the SEM as a framework, we conducted the interviews employing a topic guide based on whether they reported meeting the recommendation  in accordance with the Declaration of Helsinki. Informed written consent was obtained from all the participants.Out of 948 whom we approached, a total of 648 responded. The participation rate was 66.8% where 433 out of the 648 agreed to take part. Non-participants did not differ significantly from participants in terms of sex, age and ethnicity. “Busy” and “not interested” were the main reasons cited for non-participation. Participants mirrored the total NHG Polyclinic patient pool with prediabetes in sex, marital status and age (results not shown) , 36. Tabp value for the trend was 0.02. The prevalence of meeting the recommendation was lower in those with osteoarthritis than those who did not . Compared with participants who did not have companionship of family members/friends during exercise, the prevalence of meeting the recommendation was higher among those who did . The prevalence of meeting the recommendation also decreased with the number of hours spent sitting or reclining daily .Table On multivariable analysis, the prevalence of meeting the recommendation was positively associated with being male , living in 4–5 room public housing , living in executive flat/private housing , having the companionship of family members/friends during exercise . In contrast, the prevalence was negatively associated with having a history of osteoarthritis  and time spent sitting or reclining daily .Table “So, when you go outside to exercise, you feel the sunshine, you breathe in the fresh air, your body will then be good. It is for our well-being.” . Participants also wanted to prevent disease complications, particularly diabetes, “Oh because of this prediabetes problem. That’s why I thought better to do some exercise and increase my activity level. I don’t want to get diabetes.” .Figure “Once exercise becomes a habit, I don’t think you want to give it up. It becomes a part of you. One day if I miss out on the cycling, I will feel uncomfortable.” . For others, it was to fulfil their personal priorities and concerns, including being self-reliant, “Yes, the aim is to rely on yourself. I keep thinking to myself if I don’t be active and take charge of my own health, nobody can.” .Other participants engaged in physical activity as a hobby or for recreation. For some, it had become a habit, “My son encourages me by asking me like every other day, did you exercise today? Oh, you didn’t, you must exercise!” . It could also be through motivation from exercising with peers, “I do exercise with my friends, one or two days a week, play badminton, play games or jog.” .The main recurrent themes were observed at the interpersonal level where family/peer influence played an important role in facilitating the recommendation. This could be in the form of receiving reminder cues from family to exercise, “So, my whole family all very active. Even my mother until today, ninety-two already, still physically active. Until now, all my brothers and sisters, they are all five years younger than me, but they also have their form of exercise, it’s in our family culture.” . For others, they were doing it for the family, “I also feel that I need to keep a healthy body because I want to depend on myself. I don’t want to burden my family, that is why I exercise regularly to keep healthy for my family.” .For some, it was the family norm to be active, “Yes, the polyclinic doctor advises me to do some exercise like brisk walk, so I have to do it. I mean what the doctor says is good for me right? So, I follow …” . For others, a conducive work environment facilitated meeting the recommendation. These participants were able to access exercise programmes or facilities near or in their workplace. Yet others felt that their flexible work hours were useful, “Yes, my workplace allows me to work flexible that’s why it is more convenient for me to arrange my schedule such that I can fit in my exercise regimen.” .At the institutional/organisational level, participants met the recommendation because of influence from healthcare professionals in polyclinics and hospitals, “I do have an exercise group in the neighbourhood that I live in, we exercise together, motivate each other, and remind each other to do exercise.” . In addition, some participants would utilise the exercise facilities in their neighbourhood, particularly for mature housing estates, “Yes, at the neighbourhood where I stay which is considered a mature area, there is the gym and the swimming pool, so it is convenient for me to use these facilities.” .At the community level, participants took part in community group exercises, “...nowadays they have a lot those parks being connected to one other, including the one at my place too, so it is convenient to exercise there.” . Park connectors are walking/running/cycling paths that connect various parks and other green spaces in Singapore.At the societal/policy level, the availability of parks and park connectors nationwide facilitated meeting the recommendation for some participants, “The TV, especially those programmes talking about health, they will show you how to take care of your health, how to be active.” . Some attributed it to the national physical activity promotion programmes, “… the government is also encouraging, they give the Active SG credit for a year for all citizens which we can use to book table tennis, entrance to swimming pool, so I make use of it.” . The Active SG is a national programme where Singapore residents are provided with SGD$100 credit online to sign up for physical activities or to pay for usage of public physical activity facilities.For others, it was due to the influence of mass media, “from Monday to Friday I’m working .... then Saturday and weekend I need to run errands for my children, my husband, and on top of that there is the housework. I also need to spend some time to visit my parents. Time is very important to me, I have so many duties and roles to fulfil, my first priority is always my family.” . This contrasted with male non-doers, who mostly cited work as the reason for “no time”.Figure “I don’t know much about exercises, like how to exercise properly, how to protect my knees when exercising, which exercises are suitable for me and my medical condition.” . There were others who erroneously perceived that light-intensity activity was exercise, “So, doing housework is enough physical activity for me, walking in the house is exercise.” .For others, they either felt too lazy to engage in physical activity or too tired to do so. Some non-doers lacked the knowledge and skills to exercise, … at one time my knee gives the cricking sound when I do the Zumba dance. And at another time it was inflamed, in fact a few times. And doctor say it’s wear and tear, so I decide to cut down on exercise.” . Participants also feared sustaining injury during exercise, “Once an elderly falls down...it is very bad...becomes a burden to the family … that’s why I rather don’t do exercise, don’t move about so much … I don’t want to injure myself.” .For others, their medical conditions hindered physical activity engagement, particularly if they had osteoarthritis, ““I find that indoor gym work is a bit boring, unless there is someone to accompany me like my family or my friends. Then it is ok, we can talk and exercise at the same time. If not, one person alone I won’t go.” .The main recurrent themes were observed at the interpersonal level where family/peer influence played an important role in not meeting the recommendation. Participants perceived the lack of companionship from their family and friends, during exercise, as a barrier, “I have no one to motivate me. No one in the family or my friend encourages me to exercise.” . For others, it was the family norm to be inactive, “No, my family also never do exercise. It is not our family culture to do any exercise, has been like that since the children are young.” .For some, the lack of encouragement from their family or friends was an important barrier, “There is no gym for us to use at the workplace.” .At the institutional/organisational level, some participants cited non-conducive work environments, such as lack of exercise facilities, as a barrier, “For example, my neighbourhood there, they got this yoga class in a mall, but the monthly subscription is SGD$110, that is costly for me, since most of us are semi-retired at this age. The Active SG credit cannot be used to pay for this as the class is not part of their recognised list.” . The lack of such classes in certain neighbourhoods, particularly for young housing estates, was cited as another barrier. In addition, participants faced barriers relating to exercise facilities in the neighbourhood, such as overcrowding, “My neighbourhood has outdoor fitness equipment, but I don’t really like because it is crowded. The equipment there is always occupied, and you have to wait, so forget about it.” .At the community level, participants experienced barriers pertaining to community exercise classes, such as high cost, “The on-going government campaigns do encourage us to exercise. But these are targeted at people who can exercise. They don’t have the knee pain or arthritis, they are okay. For people like us who have the knee pain or some other medical conditions, I don’t see any specific campaigns for us.” . The lack of public indoor exercise facilities that could be used during bad weather also emerged as a barrier.At the societal/policy level, there was the perception that national policies on physical activity programmes was only applicable to healthy people, Two in 3 primary care patients with prediabetes met the WHO’s physical activity recommendation. This was more prevalent among those who were male, those who stayed in 4 to 5-room public housing, those who stayed in executive flat/private property and those with family members/friends to exercise with. In contrast, fulfilling the recommendation was less prevalent among those with osteoarthritis and those who spent more hours sitting or reclining daily. Reasons existed at different levels for facilitators and barriers related to physical activity. The recurrent themes for not meeting the recommendation included lacking companionship from family members/friends, medical conditions hindering physical activity (particularly osteoarthritis), lacking knowledge/skills to exercise properly, “no time” to exercise and barriers pertaining to exercise facilities in the neighbourhood. The recurrent themes for meeting the recommendation included family/peer influence, health/well-being concerns and education by healthcare professionals.The correlates from the quantitative phase were generally supported by barriers and facilitators from the qualitative phase, hence there was data triangulation. For example, pertaining to facilitators of physical activity, the correlate of having family members/friends to exercise with from the quantitative component concurred with the recurrent theme of family/peer influence from the qualitative component. Similarly, for barriers to physical activity, the correlate of having a history of osteoarthritis from the quantitative phase concurred with the recurrent theme of medical conditions hindering physical activity (particularly osteoarthritis) from the qualitative phase.The proportion of those who met the recommendation (65.8%) in our study population was slightly higher compared to other studies where the prevalence ranged from 27.3 to 57.3% among those with prediabetes , 37, 38.Meeting the recommendation was negatively associated with sedentary time spent reclining or sitting. Sedentary behaviour is associated with an increased risk of diabetes, independent of physical inactivity . AccordiMeeting the recommendation was positively associated with companionship of family members/friends during exercise. This was also a major recurrent theme in our IDIs. Consistent with other studies, “needing family or friends to exercise with” was associated with physical activity engagement among older adults at risk of diabetes  . Family/Meeting the recommendation was negatively associated with having osteoarthritis. This was also highlighted in our IDIs. Another study reported this association in the United States where arthritis was associated with insufficient physical activity among adults  . During Research into physical activity has always focused on intrapersonal and interpersonal factors, partly due to the difficulties in examining structural and social influences . Our resThere were some limitations. Firstly, we could not exclude social desirability bias since there was sole dependence on self-reported data. Nevertheless, we have described in the Methods section the steps which have been taken to reduce this bias. Secondly, we cannot infer causal relationships from a cross-sectional study (first phase). Thirdly, we did not show the transcript to the participants during the qualitative phase to confirm whether their responses had been accurately documented. This was however mitigated by constantly paraphrasing and “checking back” with the participants to ascertain the accuracy of their responses. There were notable strengths despite the limitations. The GPAQ component of the survey has been validated in the local population. This was one of the very few studies to utilise a mixed methods approach in understanding the correlates, barriers and facilitators pertaining to meeting the physical activity recommendation among primary care patients with prediabetes. This approach facilitated triangulation since not only were some of the correlates in the quantitative analysis recurrent themes in the qualitative analysis, the IDIs also enabled better understanding of these correlates. We reached data saturation for the qualitative analysis. Although our study sample was not generalisable to all individuals with prediabetes in Singapore, it largely reflected the total NHG Polyclinic patient pool with prediabetes.Much more remains to be done to promote physical activity among primary care patients with prediabetes in Singapore. Participants reported facilitators and barriers to physical activity at different levels of the SEM. Apart from the individual and interpersonal levels, practitioners and policy makers need to work together to address the organisational, community and policy barriers to physical activity.Additional file 1. Topic guide used for in-depth interviews.