To gain new insight into support for older people with low mood, the perceptions, strategies, and needs of older people with depressive symptoms were explored.Two in-depth interviews were held with 38 participants (aged ≥77 years) who screened positive for depressive symptoms in general practice. To investigate the influence of the presence of complex health problems, 19 persons with and 19 without complex problems were included. Complex problems were defined as a combination of functional, somatic, psychological or social problems.All participants used several cognitive, social or practical coping strategies. Four patterns emerged: mastery, acceptance, ambivalence, and need for support. Most participants felt they could deal with their feelings sufficiently, whereas a few participants with complex problems expressed a need for professional support. Some participants, especially those with complex problems, were ambivalent about possible interventions mainly because they feared putting their fragile balance at risk due to changes instigated by an intervention.Most older participants with depressive symptoms perceived their coping strategies to be sufficient. The general practitioners (GPs) can support self-management by talking about the (effectiveness of) personal coping strategies, elaborating on perceptions of risks, providing information, and discussing alternative options with older persons. In line with the Dutch College of GPs that defined “complex problems” as having several  problems that often interact in old age, complex problems are operationalized as a combination of functional, somatic , psychological and/or social problems  study. The ISCOPE study aims to assess the effectiveness and cost-effectiveness of proactive, goal-oriented, integrated care in general practice with regard to the functioning of older people. It operationalizes care by developing an integrative plan for older persons with complex problems  and their physical condition . Eligible participants were sent an invitation letter and a summary of the study, followed by a telephone call from a member of the research team.Participants in the ISCOPE study were eligible for EPISODE if they gave a positive answer to the screening question: “We conducted two interviews, in a period of approximately six months, in order to provide participants with sufficient time to elaborate on the causes, solutions, and experience of their low mood or depressive feelings, as well as their perceptions about support and available interventions. Participants were informed about the explorative aim of the study.You indicated that you have experienced a low mood [felt downhearted and blue] lately. Can you tell us why? Can you elaborate on this?” These and additional questions enabled the participants to talk freely about their feelings and perceptions.Since all participants had indicated on the screening list that they (sometimes) had depressive feelings, the starting point of the first interview was to ask: “Are you satisfied with the way you feel? Can you think of certain aspects you would like to improve?.”In the second interview, the findings from the first interview were summarized and participants were asked to reflect on these. We asked whether low mood was still experienced in the same way, or had changed. Then, individual needs and perceptions on support were assessed with questions such as: “Interviews were conducted by a medical anthropologist with experience in qualitative research among older people (MF); an anthropologist with experience in qualitative research (GG); and a GP with experience in qualitative research on depressive symptoms in older people (GW). As a team, the researchers received training in the use of Atlas ti, a qualitative data analysis program.The interviews lasted about 1.5 h each and were conducted in the participant's home. Interviews were recorded and transcribed verbatim.Analysis of the data was based on an inductive approach according to the principles of grounded theory . For this, we contacted 55 persons from the former ISCOPE study before reaching a total of 40 persons who agreed to participate. Despite a MMSE score of 24, two participants were excluded after the first interview because of severe memory problems and Alzheimer's disease. The remaining 38 older persons (aged 77–90 years) with low mood (with and without complex problems) were further interviewed about their perceptions.Of the 15 persons that chose not to participate, 9 had complex problems. The reasons to refuse participation in EPISODE were (i) participation in the ISCOPE study was considered to be enough, (ii) recent loss of a spouse, (iii) concerns about opening up old wounds, (iv) not wanting to talk about grief/sadness or private matters like marriage, or (v) hearing loss that would hinder the interviews.The participants lived in seven different urban/rural communities in the western part of the Netherlands, and were registered in 16 different general practices. somberheid” which is best translated as “low mood” or “gloominess.” The way participants described this low mood ranged from experiencing a low mood incidentally (e.g. when reading a sad newspaper article) to experiencing depressive feelings every day and to the extent that they negatively influenced their overall well-being. Depressive feelings were sometimes perceived as an unavoidable and “appropriate” consequence of disruptive life events, such as the loss of a spouse or serious illness of a child. Six participants had been diagnosed with depression earlier in their life.Although all participants indicated depressive symptoms in the screening, they did not always perceive this as a sign of depression. Most participants expressed feelings of ““I think a depression means you can only think about negative things - but I don't have a negative attitude; there are lots of positive things, like the social contacts and visits from the family.” Participants defined a depression as a state of mind that was “out of their control” and could even be dangerous, e.g. leading to suicide, something the respondents did not identify with. Despite a low mood, most participants portrayed themselves as having positive characteristics and had a positive self-image.To their surprise, two participants had recently been diagnosed with a mild depression after they consulted their GP for memory complaints.Most participants gave a multi-dimensional explanation for their low mood or depressive feelings.“I do not understand my wife, and she doesn't understand me. It's reciprocal. We live without any real contact.” “I try to make contact with my grandchildren. However, every time I ring them up, they [daughters] put the phone down.” Social factors contributed for a major part to depressive feelings, e.g. loss of a spouse, feelings of loneliness, unhappiness in marriage, terminal illness of a child, conflict between their children, or loss of contact with children and/or grandchildren due to conflicts:It's difficult because I always suffer from pain. When I want to go out but can't because of the pain, I get depressed.” Pain, or the use of diuretics, was also often a major factor in sleep disturbance.Physical and mental problems  were perceived as influencing factors for a low mood. One woman (with complex problems) explained: “Life is not as much fun as it used to be.” Several participants were disappointed with this phase of their lives. They had expected a pleasant and quiet old age with an opportunity to enjoy life but, instead, had to deal with various problems and limitations. Some men were disappointed about their lives as a whole, or regretted decisions made earlier in life, e.g. their marriage.Old age itself was another explanation given for the depressive feelings. A woman (without complex problems) said, ““When you get older, your resilience decreases. Two years ago, when my son had his heart operation, I could walk and visit him in the hospital. But at the moment I can't - and putting up with problems is getting more difficult. Mother isn't able to provide support any more. I’m afraid that I’ll lose control, that I’ll slip away.”Some participants mentioned anxiety and uncertainty about the future. They feared that their physical condition might decrease to such an extent that it might hamper solving conflicts and restoring lost social relationships before their death, or might interfere with their care-giving role as partner or parent. One woman (with complex problems) who still provided a lot of informal care said:Individual character traits were sometimes mentioned as a cause for low mood. Some participants portrayed themselves as being different from others, being pessimistic or too perfectionistic with regard to their own social and cognitive functioning. Others referred to a life history of depressive feelings or a major depression in the past. One person had earlier been diagnosed with posttraumatic stress syndrome.A few participants could not explain their low mood, mentioning that there was no specific reason.“In case of a low mood you have to seek the solutions yourself, or you have to learn to live with it - but for a major depression there are [professional] resources.” A positive screening score on depressive symptoms did not necessarily mean that participants also expressed a need for professional support. Participants perceived dealing with low feelings as their individual responsibility. With respect to coping, they referred to their capability to solve the cause(s) or to accept the fact that low feelings would be part of their current lives. As one participant stated:Individual coping strategies were directed at maintaining a balance and preserving a feeling of mastery and sense of continuity. These strategies could be divided into cognitive, social and practical strategies.“I think ‘Okay. I can still walk, I see things, I’m able to use my hands and my mind is still good. I’m going to do things.’ I’m considering buying a new Apple computer, although the old one is still okay.” The cognitive strategies encompassed activities directed at fighting, accepting, or giving in to depressive feelings. Examples are: keeping up appearances for outsiders; a selective comparison with peers who are worse off; putting problems into perspective and a positive re-appraisal of the situation; making plans for the future and making a new start:“When I feel down, I sit near the birdcage and talk to them [parakeets] - and then I make a cup of tea and have some chocolate.” Another strategy used was interrupting negative thoughts by, e.g. listening to music, reading, or walking the dog, or to give in to a low mood at certain moments, e.g. by consoling oneself with chocolate, a visit to the hairdresser, or buying something nice:“In the evening I turn off this mobile phone. I do have another one and that one is on, but she [alcoholic daughter] doesn't know the number. So my family and sons are able to contact me in the evening, but she is not.” Avoidance of stress was also a deliberate choice in trying to preserve a balance and trying to master difficult situations, as one participant said:“Well, it wasn't easy, I had to fight for it [the final decision not to move to a home for the elderly]. They didn't get it. They said: ‘But you can meet nice people and you can get together for a cup of coffee. There are so many advantages.’ I said: ‘I know, but that is outweighed by my feelings - I want to stay here and die here.’ So I had to fight for it.” Social strategies included increasing pleasant activities or hobby's with others, traveling, talking with someone, writing a letter, caring for others, doing voluntary work or problem-solving by discussing sensitive topics with children, as illustrated by a woman who decided to stay in her home against the will of her children:“If an outsider would try to help I am sure it would make matters even worse. They would say: ‘Mind your own business.’ [. . .] because some friends and family contacted them earlier on - but this turned out negatively. That's why I’m afraid.” Inherent in the strategies was the assessment of possible risks, as participants were aware that it was sometimes better/necessary to refrain from certain activities, e.g. not talking with certain persons or about certain topics, in order to avoid conflict, as illustrated by one participant who for several years tried to restore the relationship between his three children, without interference of a third person:Practical strategies included self-medication, physical exercises, relaxation exercises, or consulting a GP for chronic pain or memory complaints. Other examples were seeking practical solutions for feelings of fear or anxiety, e.g. installing extra door locks in case of fear of burglary.Mastery. “I’ll seek a solution myself - when I think it's necessary.”In dealing with their low mood or depressive feelings, participants held a clear view about their own role in coping. Several patterns emerged from the data:I’ve been through a lot. I’m 77 years old now [. .] I’ll manage.”Of the 38 participants, 19 felt they were sufficiently capable of coping. They stated that in their current situation they did not need professional support and trusted their self-efficacy or the available social support. This was mainly the case for women without complex problems, but also for some participants with complex problems, as one man said: “With regard to mastery, participants referred to their knowledge about the possibilities for support and former experiences, and sometimes to their goals/plans for the future.not to comply with the medical advice from the GP or specialist. In conclusion, participants with a feeling of mastery experienced a satisfactory feeling of “being in control.”Statements about mastery also showed self-management with regard to medication  and decisions Acceptance. “I accept it the way it is - but there is something that no longer fits.”Participants with a strong sense of mastery were convinced they would receive sufficient professional help should they ask for it. Risks played no important role in their perception of the future.“I had the feeling that everyone was angry with me - eventually it became an obsession. Then one night I got up and I sat at this table. Then I thought: No, I won't let it influence my life any more. I’ll put them [worries] in a box and throw away the key.” Eight participants indicated that their problem could not be solved, e.g. in case of an unsatisfactory relationship with the partner or children. They tried to accept their current situation, to distract their negative thoughts, and to focus on positive aspects. Some even remembered a specific moment or event that made them switch their perception, as stated by this woman:Ambivalence. “Maybe you’ll meet someone. On the other hand, you might not meet someone you can get along with - I won't run that risk!”This attitude resulted in an acceptance of the situation, instead of continuing to worry and seek solutions.“I have my own schedule [. . .]. If someone disturbs this programme, I’m upset for days.”Seven participants mentioned that they were not content with their current situation. They wanted things to change and mentioned possible solutions; however, they were unable to bring about these changes themselves. With regard to the solutions, they weighed the “pros and cons,” like fear for discontinuity, as one man (no complex problems) explained:“It could be a relief, but then again it might bring new annoyances.” Moreover, they feared several “risks” such as: not being in control and unable to foresee the consequences of support and/or interventions ; getting feelings of false hope; a further decrease of self-esteem ; and being worse off and unable to reverse certain decisions once made. The statements of one woman illustrate this topic. She had always been proud of being a “proper housewife” but due to physical limitations she was no longer able to fulfill this role. In addition, she worried about the strain this puts on her husband who had to perform the household activities and, at the same time, was unable to adhere to her norms about the way the tasks should be carried out. She doubted whether professional support would be a good solution:“Should I take medication? I don't want to take pills, at least not for this problem. She [GP] won't be able to solve the problem [conflict with daughters].” The GP was mainly associated with somatic problems and the prescription of medication. With regard to depressive feelings, participants referred to the expected (in)ability of their GP to solve the cause.Some participants stated that they did not want to run the risk that discussing low feelings or other problems would result in a change of medication or receiving professional advice that they could not or would not follow. Most participants were also afraid to be perceived by the GP as “whining” about aspects that one should accept. These fears made several participants hesitant towards changes that might improve their situation.Need for support. “I would like things to change, but what can I do? What can be done? I really don't know.”Some problems needed interventions on multiple domains of social, physical and cognitive functioning at the same time. For some participants the balance was already so fragile that they feared each change; they indicated that they felt tired and had little energy left.Four participants mentioned that they needed specific professional care. Although they invested much time and effort in coping, this was no longer sufficient; a feeling of depression, lack of hope, and inability to control the problems dominated their conversations.“All I want is that he [GP] takes a closer look at the medication [for pain] But he said: ‘Older people should not have too much medication because they have an increased risk of falling.’ Although they were already consulting the GP for physical problems, not all of them reported their psychological distress to the GP. Participants expected GPs to be well informed about the state of affairs of their patients and take the initiative in discussing depressive symptoms when considered necessary. Participants expressed needs about adequate pain medication, assistance in finding a new home, re-examination of anti-depressants, referral to a psychologist, and a supportive attitude in case of a degenerative disease:It was unclear for some participants who could improve their situation and in what way, e.g. in case of declining health combined with a lack of financial and/or social resources. For three of the participants with complex problems, financial problems limited their coping abilities (e.g. moving to another house).“The GP also said that talking to welfare workers would be a solution. But I’ve had that before. They were nice to talk to, but what can they do? You can tell your story in detail and then that's the end. It is like when I was in . . .[name institution].” Participants with a history of depressive feelings and complex problems feared false hopes, and some had lost confidence in professional solutions. One woman with persistent depressive feelings, sleeping problems, and feelings of loneliness, who had received psychotherapy in the past and participated in two courses directed at dealing with these problems, said:Furthermore, whether or not to discuss a low mood with the GP was influenced by the communicative skills of their physician or the doctor-patient relationship.“These low feelings are much less. I’m distancing myself from the illness trajectory; the prospects to live have increased. Last time, the diagnosis in the hospital was that the cancer was completely gone. The radiologist told me: ‘Just continue with your life. [. . .]’ That brightens you up completely. I feel a lot better. I have started to paint again - which is very nice. We’ve also bought new things, like a television and an iPad for playing games.” Coping with regard to low mood and depressive feelings appeared to be dynamic, i.e. to change over time. In the present study, the first interview sometimes led to decisions and practical solutions, or cognitive re-appraisal by the participants. In the second interview, participants mentioned the recent changes in their situation and how these had influenced their mood. Positive changes could be, for example, an improved physical condition, new medication, or a positive conversation with children about a difficult topic. The following example shows how a favorable outcome on a follow-up visit for cancer had a positive effect on low mood and coping:Negative changes included increasing pain, fatigue, a fall, a disappointing outcome of a discussion, or a worsening condition of a child. These developments led to new problems, specific needs for support, or an intensified effort to distract negative thoughts. A few participants discussed their mood with the GP and accepted the prescription for antidepressants.In general, participants with a sense of mastery and positive experiences with support were more positive about taking the initiative to bring up the subject.In the present study, participants with depressive feelings (identified via screening), with and without complex problems, were engaged in coping and solution-seeking behavior. This almost invisible “work”  accepted.et al., Men with complex problems often referred to problems in their social relationships and were trying to accept this, or find means to resolve these problems themselves. Social roles related to parenthood proved to be important for both men and women. The negative influence of the loss of social roles on depressive feelings is also documented among patients with multi-morbidity , we propose that the coping techniques applied by patients to control their depressive feelings could be used as a basis for the GP to monitor patients’ self-efficacy and needs over time. Talking about low mood enables the physician to explore patients’ perceptions of (treatment) risks, to provide information and to discuss alternative options. The burden is on physicians to receive further training, or to refer to other health professionals or welfare workers who can address the patients’ problems and depressive feelings in an appropriate way. In addition, there is a need for older patients to be made aware of the legitimacy to consult their GP about low mood  being sufficient. This may be equally important for participants with only minor mood problems as they will receive useful information, as for patients with more serious depressive symptoms or a diagnosis of depression; also, discussing their needs and perception of treatment risks may increase trust in professionals and the acceptability of therapy. This approach can be tailored to the needs of older people and may improve the dialogue between patient and GP.None.Margaret von Faber: study concept and design, obtaining funding, acquisition of data, analysis and interpretation of data, preparation of the manuscript, final approval. Geertje van der Geest: acquisition of data, preparation of the manuscript, final approval. Gerda van der Weele: study concept and design, acquisition of data, preparation of the manuscript, final approval. Jeanet Blom: study concept and design, analysis and interpretation of data, preparation of the manuscript, final approval. Roos van der Mast: study concept and design, preparation of the manuscript, final approval. Ria Reis: study concept and design, preparation of the manuscript, final approval. Jacobijn Gussekloo: study concept and design, obtaining funding, acquisition of data, analysis and interpretation of data, preparation of the manuscript, final approval.The study was approved in 2011 by the Medical Ethical committee of Leiden University Medical Center (Study no. P09.096). All participants gave written informed consent.


The current research topic inquires: “Should we treat aging as a disease?” Yet, in this inquiry, the question “Can aging be considered a disease?” is secondary, while the more primary question really must be “Is aging treatable?” Paradoxically, the answer given to the second question largely determines the answer to the first. The perceived unchangeable, and hence untreatable, nature of aging is the root cause for many subsequent rationalizations, even to the point of claiming the desirability of aging-derived suffering and death. This is a well recognized psychological phenomenon sometimes referred to as “apologism” Gruman,  or even De Senectute) by Cicero (106-43 BCE). It was written at a time when average life-expectancy reached about 30 years, when even survival to old age was a rare occasion. Consistently with the “apologetic” tradition, De Senectute presents a picture of old age that not only endeavors to “wipe away all the disagreeables of old age” but even to present it as “luxurious and delightful too” , from the Classical through the Medieval well into the Modern times, from the writings of Galen (c. 129-217 AD), through Gabriele Zerbi (1445-1505) and Luigi Cornaro (1467-1566) to Leonardus Lessius (1554-1623), Johann Heinrich Cohausen (1665-1750) and other hygienists , the renowned German hygienist, who coined the term “macrobiotics”—the science of life prolongation. According to him, reaching a lifespan of 200 years may be feasible and “natural” for humans. He perceived “the old age” as “the grand enemy of life,” and as a diagnosable condition, like a disease, not so much dependent on the actual passage of years, as on the internal disarray of the organism: “and one may see very old people of 30 or 40, who have every symptom of extreme age, such as stiffness and aridity, weakness, gray hair, ossified cartilages, &c.” Even though, according to Hufeland, aging can be generally seen as a morbid condition, his objective is actually more complex than a simplistic attempt to eradicate aging (or rejuvenate the body) at once. Though Hufeland saw the degeneration brought on by aging, his ultimate goal was not rejuvenation for the sake of rejuvenation, but “macrobiotics”—the prolongation of life. And paradoxically, “rejuvenation,” an immediate improvement of function, can become an enemy of life prolongation:In other (perhaps more modern) terms, any treatment of old age should consider the aging organism and the aging process as a whole. Any attempt to artificially strengthen some faculty, at the disregard of the general adaptation and available resources of the entire aging system, can further advance the disarray and bring about death sooner. This is a lesson by Hufeland that may be well heeded by some contemporary reductionist “anti-aging” attempts. Still, despite the caution and recognition of complexity, the necessity and possibility of “treatment” of old age as a disease-like, deteriorative condition is recognized. Caution and thoughtfulness just need to become parts of its “proper treatment” [Hufeland, “They show great ignorance who maintain that it is impossible in old men to reverse their organic state so that they resemble that of an earlier age, especially since the organic changes resulting from better nutrition are possible at all ages…Critics of my ideas have said that it is well known that senile degeneration and wasting present insurmountable obstacles, especially return of neural center function both in the sensory and the motor apparatus. A study of the excellent work of Charcot on Aging  and a number of other works show that nothing about senility is constant nor absolutely characterized. …If the degenerations, if the senile alterations are diseases, a day will come when it will be possible to cure them.”Later on, the fact that aging can be treated was further recognized by pioneers of modern medicine. The pliability of aging was stated, among others, by Charles-Édouard Brown-Séquard (1817-1894), one of the founders of modern endocrinology, president of the French Biological Society and Claude Bernard's pupil and successor at Collège de France. In the widely publicized presentation to the French Biological Society of June 1, 1889, entitled “Effects in man of subcutaneous injections of freshly prepared liquid from guinea pig and dog testes”  Metchnikoff . Metchnikoff is of course known as a groundbreaking immunologist, a vice director of the Pasteur Institute in Paris, and the Nobel Laureate in Physiology or Medicine of 1908 for the discovery of phagocytosis (a major contribution to the cellular theory of immunity). Yet, he may also be well credited as “the father” of gerontology—the disciplinary term he coined in 1903 in his book Though, Metchnikoff hypothesized that there might be a point in human life when death will occur naturally, as it is programmed (at about 150 years), we are yet very far from that limit. For the present stage of human condition, the imperative to combat aging and prolong life were posited by Metchnikoff unequivocally. This seems to be a stance befitting a groundbreaking medical scientist. And indeed, during the fight with aging, novel therapies were born, applicable not just to general degeneration but also to specific diseases, including hormone replacement therapies introduced by Brown-Séquard during the study of rejuvenation, or systemic adjuvant immunotherapy and probiotic diets pioneered by Metchnikoff during his study and combat of aging (Stambler, Thus, I argue, acknowledging the possibility of successful intervention into the aging process, in other words treating aging as a curable disease, has been a long and highly respected tradition of biomedical thought. A comprehensive historical overview of the debates regarding the possibility to intervene into or treat aging, from the earlier date until our times, would go far beyond the scope of the present work. An attempt at such a comprehensive history is presented elsewhere (Stambler, The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Patient-provider communication, in particular physicians’ ability to listen to their patients, and support them in making difficult lifestyle changes, is an essential component of effective diabetes care. Clinical communication around diabetes can be especially challenging when language barriers are present, and may contribute to poor diabetes management and outcomes. Clinicians need to be aware of and address potential communication difficulties associated with interpreter-mediated consultations. The purpose of our study was to explore how physicians communicate in interpreter-mediated consultations with diabetic patients, and how their communication behaviors may impact diabetes communication and care.We analyzed transcripts from 8 audio recorded, outpatient consultations at the Basel University Hospital general medicine outpatient clinic involving Turkish-speaking patients, German-speaking physicians, and Turkish-German interpreters (both community interpreters and family members).Clinicians used closed questions when asking about symptoms and glucose control. When providing information and explanation, they spoke in long and complex speech turns. They often directed their speech to interpreters or became sidetracked by family members’ questions or requests for information. Patients’ participation in the consultation was minimal, and limited to brief answers to clinicians’ questions.Clinicians need to be aware of common pitfalls that diminish patient-centeredness during interpreter-mediated consultations, and learn strategies to avoid them. Attention to established guidelines on triadic communication is recommended, as is hands-on training with interpreters. Diabetes is an enormous public health challenge and a major cause of morbidity, mortality and health care costs. In SwitAlthough there is strong evidence that good diabetes control leads to improved clinical outcomes, many people with diabetes continue to have inadequate glycemic and blood pressure control and elevated low-density lipoprotein levels. Poor adPhysicians face a significant challenge in helping patients manage their diabetes and improve their health and quality of life. PatientClinical communication around diabetes is especially challenging in contexts of cultural and linguistic diversity. In multWhen patients and physicians do not speak a common language, interpreters are often perceived as the solution for bridging patient-provider linguistic and cultural differences. A numbeMany studies have examined the effect of interpreter skills and practices on the quality of communication and care,24,26-34Clinicians frequently rely on untrained interpreters  despite the fact that such interpreters have been associated with clinically relevant interpretation errors, non-neutrality and confidentiality problems,43. UntrThe interpreter-mediated medical encounter is a complex interaction between providers, interpreters and patients, but only a few studies have specifically explored how provider communication patterns affect patients’ participation in interpreter-mediated consultations , which is part of the University Hospital Basel (UHBS). The UHBS is a teaching hospital that provides primary, secondary, and tertiary care for a population of approximately 200,000 people. The general medicine outpatient clinic  provides about 17,000 internal medicine consultations each year. The medical staff consists of 11 residents in internal medicine, most of whom have completed more than four years of postgraduate clinical training, and 5 attending physicians who supervise them. PatientCommunity interpreting has been active in Switzerland since the 1990s, and there are currently 21 community interpreting agencies in the country. Formal training of community interpreters and training of clinicians to work with community interpreters is a relatively recent development. Community interpreting training standards were developed in 2002, a certificate in Community Interpreting was first offered in 2004, and a nationally recognized certification exam was created in 2009. HoweverDuring August-September 2005, scheduled consultations at the MUP involving a Turkish-speaking diabetic patient in need of an interpreter were noted. We focused on Turkish-speaking patients because they are an important immigrant population in Basel and amonThe research assistant was informed by the head physician when there was to be a consultation involving a Turkish-speaking diabetic patient and an interpreter . At the beginning of the consultation, the research assistant explained the study objectives, invited all 3 parties to participate  and provided informed consent forms (in Turkish for patients). If all three parties accepted to participate, the research assistant remained in the consultation room and recorded the interview. Ethical clearance for the study was obtained from the EKBB (Ethikkomission Beider Basel).All consultations were fully transcribed at the time of data collection. The research assistant transcribed all German utterances, and a Turkish-speaking university student transcribed the Turkish utterances. The Turkish utterances were then translated to German by a bilingual research assistant.The analysis team consisted of one bilingual German/English researcher (AB) and 3 bilingual English/French researchers. To allow for analysis by non-Germanophone researchers, and to facilitate subsequent publication of results in English, we had the German transcripts translated into English by a professional translator, and double checked by AB. During analysis, AB referred to the German transcripts, while the other researchers worked from the English transcripts.Because we were concerned about potential distortions of the Turkish portions due to double translation (Turkish to German to English), we had one full transcript analysed by an independent, trilingual (Turkish-German-English) professional translator. This translator found no errors and considered the translation to be very accurate. During analysis, on the rare occasions where doubts or questions arose about the Turkish utterances, a local Turkish community interpreter (not involved in the study) was consulted.Researchers initially read each transcript independently with the aim of identifying key passages and themes that illustrated physician speech patterns, interpreter roles and patient participation. Researchers then met to compare and discuss their general impressions of the transcripts and develop a list of codes that were then applied to all transcripts by PH using the qualitative data analysis software MAXQDA2007®. Coding and analysis were then cross-checked by the other members of the research team. When presenting quotes from the consultations, we have used italics to indicate where Turkish was spoken and normal text when German was spoken.Eight interpreter-mediated general medicine consultations were audio recorded at the MUP. There were no refusals to participate. Consultations involved 8 clinicians , 2 professional interpreters and 7 patients, and reflected three configurations: 4 consultations involved a family member as interpreter, 2 consultations involved both a family member and professional interpreter, and 4 consultations involved only a professional interpreter. Table Several communication patterns of clinicians were identified that can act to limit patient participation. While some are specific to working with interpreters, others are potentially problematic even where there is no language barrier. The examples provided point to the importance of general patient-provider communication techniques as well as specific attention to the challenges of interpreter-mediated communication.The use of patient-centered communication techniques such as open-ended questions, empathy, and engagement of patients in discussion is thought to be an important aspect of chronic disease management,54-57.Clinicians in our study used mainly closed questions (98/103 questions), made directive utterances (“Test your blood glucose on an empty stomach”) and made statements about objective reality (“your glucose is too high”). They rarely elicited patients’ feelings, opinions or difficulties, and there was little collaborative problem-solving discussion.Not surprisingly, patients tended to provide mainly short (often just one or two word) answers to clinicians’ questions, and rarely asked questions of their own or spontaneously offered information. Only 4 patients  made a total of 8 spontaneous requests for advice, information or clarification regarding their health . Of these, only 4 were translated back to and answered by the clinician. The other 4 questions were either ignored or answered directly by the interpreter.To facilitate the work of interpreters and increase the likelihood of an accurate and complete translation, clinicians should speak in relatively short turns (one or two sentences or ideas at a time), and ask only one question at a time.In our study, clinicians spoke in short turns when asking questions about patients’ symptoms (“Where does it hurt?” “When did it start?”), but spoke in long turns when providing explanations or instructions to patients (we defined lengthy as 4 or more statements or questions at a time). This practice was especially frequent in consultations D and E, where patients understood a little German, despite the fact that their German was not good enough to forego interpretation. This may indicate that clinicians overestimated the patient’s language skills, or that they were simply unaware of the difficulty of the interpreter’s task. At one point in Consultation E, the doctor spoke 25 sentences before pausing. Interpreters in our study never asked clinicians to pause, but rather summarized the speaker’s words as best they could, often omitting or modifying the content, as in the example below:Dr: So that in the morning/ because exactly, if you have twenty-seven, and you inject ten, then/then it, ten would correct twenty, wouldn’t it? Then ((2s)) yes… Exactly/ that’s it, seven. But in the evening sometimes people are more sensitive to insulin. Then/ especially when their glucose drops quickly, then exactly, it also causes the feeling of hunger. And when you then eat, your levels start to swing, hm? Okay. We’ll make it like that in the evening from now on..[P: Mm] And you go to the Aeschengraben [Mm] and try and get your personal life a bit more under control again. That will surely require time. When your personal life is a bit more peaceful, the eating will also calm down, and then we can start working, hm? And you’ve got the idea, so it’s no great disaster, hm?P: Mm.Well, your glucose is not bad, she says. Only you should do what we’ve talked about, she says. Apart from that, she says go to um the Aeschengraben. Try to get certain things in your personal life in order. She says if these get better, things will… [P:Mm] She says you should sort out all the things that need sorting out. She says when you do it in that way, then I think, she says, that the glucose will sort itself out.I: It has generally been recommended that physicians’ check for patients’ understanding of medical information by asking them to repeat back what they have understood, rather than simply asking “Do you understand?”,59 In ouWhen working with interpreters, clinicians should direct their speech to the patient. This is intended to simplify the interpreter’s task by eliminating the extra mental task of reformulation, such as when the doctor says “Ask him if he has a headache” and the interpreter must reformulate this to “Do you have a headache” or even “He wants to know if you have a headache”. Speaking directly to the patient can also facilitate the patient/provider relationship through eye contact and non verbal interaction.In our study, only the dietary counsellor in consultation C consistently addressed her patient despite the fact that the patient did not speak any German. Clinicians in the other consultations spoke directly to patients who understood a little German , but to interpreters when patients spoke no German at all .Consultation B:Dr: Mm. Um would she like to have a look what such a pen looks like already, or would she rather simply tackle that issue when it’s necessary?By addressing their questions to interpreters, clinicians essentially put them in the role of “expert”, which sometimes led to the interpreter to either answer for the patient or take initiative to reformulate questions or dig for more details. By allowing the interpreter to have a side conversation with the patient, the clinician is excluded from the interaction.Consultation A:Dr: Does he feel it’s got stronger or worse or more frequent in the last while?Have the pains got worse with time?I: Well, in the last while…the pains/since night, I’m in pain all the time) [I:Mm] I don’t know why, was it after eating or why…P: Where does it hurt then?I: Here, here it hurts [I:Mm] In bed, [I:MmMm] I couldn’t sleep, got up and had a shower ((1s)) I went back to sleep very slowly ((2s)) And then while I was asleep I had bladder pressure and wake up again.P: Mm. Mm. So you were in more pain in the last while? Has the pain got worse in the last?I: I went to this swimming pool. At the swimming pool it didn’t hurt [I:Mm Mm] Um, I went home, at home it started again.P: I: Okay. So he couldn’t give a direct answer to my question. I’ve tried several times [Dr: Mm]…Family members can be a source of support and encouragement for patients and can sometimes provide additional information or help patients to remember details. HoweverIn consultations G and H, the patients’ adult child acted as interpreter. In both these consultations the clinicians were sidetracked by family members’ questions and comments, which led to the exclusion of patients from the interaction.In consultation G, despite the clinician’s repeated attempts to speak directly to the patient, the conversation is sidetracked several times by the son’s requests for explanation. In the excerpt below, the doctor is trying to explain to the patient that he will send her again for a Diabetic Education session, but rather than translating, the son asks his mother what diabetes is, and when he doesn’t get an answer from his mother he asks the same question to the doctor.Consultation GDr: Well Mrs Yılmaz. Then we will have to start all over again. Then I will send you to Diabetic Education again.Patient: )What is diabetes?Son: ou haven’t understood anything.Patient: YDr: Exactly, please translate this for (her) now.Son: What is diabetes? I don’t know myself.The son draws the doctor into conversation numerous times during the consultation, and the frustrated doctor reminds him five times to interpret for his parents, to no avail.In Consultation H, the doctor is quite persistent in speaking directly to the patient, but the daughter repeatedly answers for her mother and often fails to translate, as in the example below. Although the doctor receives an answer to his question, the patient is excluded from the interaction.Dr: Then uum you must go to Diabetic Education again. That’s important, hm? I’ll register you again with Diabetic Education. You’ll just have to go there again so that they can discuss it with you. And I’ll look ).I: She did it for a year…she doesn’t do exactly the same at home… I translate it for her and everything but she doesn’t do the same at home…that’s the problem.There was less sidetracking in consultations B and C, where both the patient’s daughter and a professional interpreter were present. In consultation C, the dietary counsellor speaks directly to the patient at all times, and the interpreter translates. The daughter only speaks when the clinician asks her a direct question at the end of the consultation about a next appointment for her mother. In consultation B, however, the daughter speaks much more. The clinician asks her a question near the beginning of the consultation . The daughter answers the question, and from this point on the clinician shifts her attention to the daughter, never speaking directly to the patient again. At first the interpreter attempts to translate the exchange for the patient, but as there are no pauses in the conversation she finally gives up and is silent for the rest of the consultation, as is the patient.We explored how clinicians communicate with diabetic patients in interpreter-mediated consultations. We found that the essential elements of both patient-centered communication and provider/interpreter collaboration were often lacking. CommuniOur study was small and exploratory, involving only 8 clinicians and 2 interpreters. Had we broadened our sample to include other clinicians and clinical contexts, we might have identified additional practices. We were also unable to explore how individual clinicians’ communication styles vary according to the presence/absence and type of interpreter . For example, we don’t know whether clinicians in our study use more patient-centered communication techniques with their German-speaking patients. A Dutch study found, for example, that doctors were more verbally dominant with immigrant patients and showed more empathy and involvement with Dutch patients.Despite the limited scope of our study, our findings resonate with findings elsewhere. For example, Seale and colleagues found thEffective communication is the key to patient-centered care. A lack The authors declare that they have no competing interests.All authors were involved in defining the research question and developing an initial analysis plan. PH analyzed and coded the transcripts, with feedback from NJP, MDD and AB. PH drafted the manuscript. All authors critically reviewed the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2296/14/163/prepub


While textual analysis of the journal literature is a burgeoning field, there is still a profound lack of user-friendly software for accomplishing this task. RLetters is a free, open-source web application which provides researchers with an environment in which they can select sets of journal articles and analyze them with cutting-edge textual analysis tools. RLetters allows users without prior expertise in textual analysis to analyze word frequency, collocations, cooccurrences, term networks, and more. It is implemented in Ruby and scripts are provided to automate deployment. The journal literature is massive, and grows at an astounding rate. One estimate, for example, puts the size of the Google Scholar index at around 160 million documents . If the With the digitization of the journal literature, however, a new way of answering such questions is beginning to emerge. A substantial fraction of the journal literature has now been digitized, numbering in the hundreds of millions of pages. This opens up opportunities to use automated tools to examine at a broad scale how research happens. Unfortunately, however, there is a lack of tools for studying this corpus of texts in a rigorous yet user-friendly way.In order to address the lack of tools for automated analysis of the journal literature, we have created RLetters, a general-purpose, web-based tool optimized for the analysis of journal articles in plain text. RLetters may be deployed by any user desiring to host their own searchable and analyzable archive of journal articles, and requires only a web server running Ruby on Rails and an Apache Solr server, each of which is relatively simple to deploy. RLetters comes with scripts which can automate the process of deployment to a new server or virtual machine. A JSON-based API for search is already available, and further interoperability is planned for future versions.When compared to extant tools for textual analysis, we believe that RLetters offers advantages over most of the solutions now available. Several, including TAPoR Tools  and MONKA wide variety of analysis methods are implemented in RLetters. The more common analyses are described quickly, and two of RLetters’s more powerful algorithms are discussed in more detail.It is advised, as with all digital humanities tools, that users interested in working with these analysis methods for publishable work not treat RLetters as a black box. Each of the analysis methods available has its limitations and its advantages, and some varieties of data for which it is suitable and some for which it is not. Users should locate papers or books describing each method (some of which are provided as citations in the following) and investigate these to determine whether or not their analyses provide the sort of insights they require.Users can compute term frequency tables for a given dataset, for either single words or multiple-word phrases (n-grams). These are the most common inputs for other kinds of textual analysis algorithms, meaning that users can easily extract term frequencies and use them to run their own analyses locally if desired. The options and features in the word frequency generator are modeled after those found in KWIC Concordance , modifieUsers can visualize the network of words occurring in the immediate vicinity of a given focal word of interest, an analysis useful for determining which words often “travel together” in the literature .All proper names  found in journal articles can be extracted. This analysis can be useful to detect locations of field research, organizational networks, etc. This analysis uses the Stanford Natural Language Processing toolkit .Users can graph the publication dates of a dataset, which is particularly useful if the dataset contains only those articles which match a complex search.Lastly, a dataset can be exported in a variety of citation formats to a user’s citation manager, including EndNote and BibTeX.difference. Consider some corpus, divided into two groups, A and B. The Zeta algorithm tells us which words within A mark a text out as (probably) belonging to A rather than B (and vice versa). Further, the Zeta algorithm has the advantage of providing us with words that are far less likely to appear overall, as opposed to words singled out by traditional T-tests. For example, while a T-test might pick out the more frequent use of a common word like ‘upon’ as a marker of membership in one group rather than another, the Zeta algorithm is more likely to give us much rarer, and hence more meaningful words.Users can request an analysis of words which are likely to mark out an article’s belonging to one dataset as opposed to another. The algorithm implemented here is the Zeta algorithm, as described originally by Burrows  and extew in the corpus, we then simply add the fraction of A chunks in which w appears and the fraction of B chunks in which w does not appear. The maximal Zeta score for a word is thus 2—for words that appear in every chunk of A and in no chunk of B. The minimal score would be 0—for words that appear in no chunk of A and in every chunk of B. Clearly, high-scoring words are a very good indicator of a text’s belonging to the A group, and low-scoring words are a very good indicator of membership in the B group.The Zeta algorithm is relatively simple to describe. We take our two groups of texts (A and B) and divide them into chunks of 500 words. For each word The output of the algorithm, therefore, is two collections of “marker words”—words that, if found in a given random sample of text, mark that text out as, respectively, much more likely to be a member of dataset A or a member of dataset B. For an example of how this algorithm can be used in practice, see below.Users can use RLetters to locate both statistically significant immediate pairs of words (known as collocations), or to detect significant correlations between words at the sentence, paragraph, or article level (known as cooccurrences) .Collocation analysis is commonly used to track technical terms or immediate patterns of word usage. To refer to a common example from linguistics, collocation analysis can detect that “strong tea” is a common locution in English, and that “powerful computers” is as well, but that both “powerful tea” and “strong computers” would be highly unusual, as these two pairs are very rarely found in a standard English corpus. Collocation analysis can also detect technical term usage, such as the strong association of word pairs like “genetic drift” or “statistical mechanics.”Cooccurrence analysis extends collocation analysis to look for significant correlations within sections of a document of a given size.  The significance of cooccurrences can be measured using a variety of traditional statistical measures, including mutual information, T-tests, or log-likelihood. Cooccurrences provide a different sort of information about texts than collocations. Sentence- and paragraph-level cooccurrence provides interesting information about patterns of speech—for instance, that researchers working on human decision-making very often speak of “recognition” and “inference” in the same sentence, but only very rarely connect “recognition” and “aversion” (drawn from an unpublished study in progress).The backend of RLetters consists of an Apache Solr server , used boThe frontend is implemented as a web application in Ruby on Rails. The web application first proceeds by allowing the user to select a research question in which he or she is interested. The next step is to provide data for the analysis—a set of articles of interest, saved as a permanent object called a ‘dataset’. Datasets are constructed by performing complicated searches using the search interface, which allows users to search on a variety of different metadata fields  and filter the results by author, journal, and publication date. Once the desired set of articles has been located, it is named and saved for future use in analyses. See The dataset is then analyzed using the algorithm appropriate to answering the intended question. Data analyses in RLetters are not interactive, as some are quite computationally expensive. Analysis is thus executed in the background and, upon completion, users are e-mailed and return to the site to retrieve their results. While it is difficult to provide accurate timing for how long a given job will take, users are shown a list of estimated completion times for datasets of various sizes, and can use these as a rough idea of how long their analysis might take to complete. All results produced in RLetters may be viewed online as well as exported, both in open formats (such as CSV spreadsheets) and, in many cases, as visualizations (such as PDF files).http://www.rletters.net, or at its GitHub page, http://github.com/rletters/rletters. It is released as open-source software under the MIT License, and is under active development. Further, it comes with a set of scripts which automate the deployment of an RLetters instance to any RHEL 7 or CentOS 7 server.The source code of RLetters can be freely downloaded from its website, https://demo.rletters.net, containing a variety of full-text articles from various PLoS journals. The demonstration database contains 13,555 articles and the full suite of RLetters analysis tools.A demonstration instance of RLetters may be found at PLoS journals or those available as part of the PubMed Central Open Access Subset [http://github.com/cpence/evotext).As with most textual analysis endeavors, the hardest problem with performing large-scale analysis of the journal literature is obtaining rights to the full text of journal articles. RLetters takes as its input a set of XML files containing the full text of articles as well as metadata about them, including authors, title, journal, DOI, and licensing information. With Open Access articles, such as those published in the s Subset , simple s Subset  allow foFor closed access content, RLetters has the ability to store only the metadata for an article and a link to its full text as stored on an external server. When an analysis of a closed-access article is requested that requires the full plain text of an article, it is fetched, analyzed, and destroyed when the analysis completes. Future versions of RLetters will include support for interfacing with the text-mining APIs of journal publishers, such as that provided by Elsevier .https://demo.rletters.net. As mentioned above, this installation contains some thirteen thousand articles from PLoS journals, taken from their freely available NLM XML-format full text. These data are available under the CC-BY license. The server was run using the latest version of RLetters (v2.0.0).To demonstrate the sort of analysis that RLetters can perform, an example analysis was run using the RLetters Demo, available publicly at PLoS Biology or PLoS Computational Biology. The publication guidelines for PLoS Computational Biology state that it seeks manuscripts which “further our understanding of living systems at all scales—from molecules and cells, to patient populations and ecosystems –through the application of computational methods.” But how might a researcher be more certain that his or her article is “computational enough” to qualify? Here, the Zeta algorithm can help. Applying Zeta to the corpora of PLoS Computational Biology and PLoS Biology can give us lists of marker words—and if a sufficient number of the Computational Biology marker words appear in our researcher’s paper, he or she can make a much more educated guess about the appropriate home for the manuscript in question.Our example considers the following question. Imagine a researcher with a moderately-computational article, attempting to decide whether to submit his or her article to PLoS Biology and one containing all articles from PLoS Computational Biology. The marker lists were generated, and RLetters also created word clouds for each set of marker words, included as PLoS Computational Biology, while if it contains words in the left-hand cloud, it is likely to belong better at PLoS Biology.To get these sets of marker words, two datasets were constructed—one containing all articles from Computational Biology papers are more likely to discuss “models,” “simulations,” “parameters,” “value(s),” “networks,” and “dynamics.” Biology papers, on the other hand, are more likely to discuss “animals,” “mice,” “genes,” and the details of experimental protocol, such as “staining,” “antibodies,” “PCR,” “GFP,” and tissue sections measured in “μm.”The marker words show a few expected trends, and a few surprises. On the unsurprising side, Biology articles, for example, “experiments” are discussed, while in Computational Biology articles, “experimental” is the common usage. A follow-up collocation analysis indicates that some of the most frequent pairs including “experimental” are “experimental data,” “results,” “observations,” “evidence,” and “studies.” Further, Biology articles are more tentative about their results—the words “suggesting,” “indicated,” and “whether” are all markers for PLoS Biology.More interestingly, however, we see changing patterns of usage in the way that experiments themselves and their results are discussed. In PLoS Biology and PLoS Computational Biology. The very language used to discuss the experimental data that these articles invoke is profoundly different. Consulting these lists of marker words should, in fact, make it very clear which disciplinary idiom a given article uses.This example, therefore, points to more than a simple difference in focus between There is a demonstrated need for usable applications in text analysis of the journal literature, and RLetters helps to fill this need. We provide here a full-featured web application that can be deployed by anyone wishing to analyze a corpus of journal articles. Our example demonstrates that even in relatively straightforward applications, this level of textual analysis can offer interesting and useful insights into the journal literature that provide tangible benefits to researchers.


While numerous studies highlight the relevance of socio-cultural factors influencing incidence and prevalence of obesity, only a few address how obese people perceive causes and prevention of or intervention for obesity. This study contributes to a more thorough understanding of subjective aetiologies and framing themes for a mainly understudied but promising field. Thus it may serve for the development of effective public health strategies to combat obesity.Autobiographically based in-depth interviews were conducted with 20 patients (adolescents and young adults) institutionalised in the obesity rehabilitation centre INSULA in Bischofswiesen (Germany). The data were analysed with Atlas.ti with regard to two main perspectives: (1) How the interviewees perceive ‘their’ obesity from a subjective point of view and (2) which conclusions they draw from their own ‘story’ concerning prevention/intervention strategies.The interviewees did not indicate a clear starting point for their overweight. Nevertheless, certain life-events (e.g. divorce or illness of parents) were identified as catalysing weight gain. As a consequence of coping with distress, body weight rises rapidly and not continuously. Obesity was generally framed as a problem primarily located within the family and not in the wider environment. Corresponding to this, the family was identified as the main and most important addressee of preventive measures. The interviewees highlighted the importance of personal responsibility as a prerequisite for self-determined action against obesity, but denied any link between responsibility and guilt.This study contributes substantially to a broader perspective on the prevention of obesity. First, more attention has to be paid to the interactions of medical aspects and the social dimension of obesity. Second, prevention efforts should be more aware of the relevance of subjective aetiology when it comes to the definition of reasonable and effective governance strategies in tackling obesity. Third, current assumptions concerning the importance of personal responsibility for obesity prevention might underestimate the relevance of self-determined action of the obese. Obesity remains a substantial health problem. For one thing this is shown by the current data of prevalence, for example, in Germany , Sweden The second desideratum, which is closely linked to the first, affects the use of methods. If the aspect of subjective perceptions is taken seriously, it will have immediate consequences for the further use of methods: A systematic integration of the perspectives of the affected is only partly possible if the sole focus lies on a quantitative-empirical research perspective. Thus qualitative-empirical methods should be chosen more often as they already have been in various medical-scientific contexts. In the field of clinical or psychiatric care, for example, this approach has been used for some years now. The instruments of qualitative research aim especially at capturing a broad range of subjective attitudes or perceptions in different environmental contexts. This is how they open up an in-depth dimension that can hardly be depicted by the sole use of quantitative methods . TherefoHealth-related research in general and obesity research in particular are increasingly using qualitative methods. Examples include the development or refinement of quantitative instruments , 14 as wAgainst this background, the present study starts with a threefold hypothesis: First, the subjective reconstruction of the development of the individual obesity aetiology is understood as an essential factor leading towards a more detailed understanding of different obesity formation pathways. Although it is not assumed that a more detailed understanding of the subjective aetiology does directly lead to an increasing amount of effective and efficient preventive strategies, it would certainly ease this very process. Second, possible explanations for the ineffectiveness of prevention strategies that have been developed so far have to be worked out. In this context, particular importance has to be paid to the alleged difference between professionally diagnosed aetiologies and the subjective aetiologies. Thirdly, this study assumes that a detailed comprehension of differences between subjective and professionally diagnosed aetiologies can be gained by means of qualitative-empirical methods.For the present study autobiographically based interviews –25 were 2 (range: 30.0-97.2 kg/m2). All participants could be classified as extreme obese patients (as they were above 35.0 kg/m2 at least at some point in their life). All of them have experienced the ineffectiveness of different prevention approaches and therapeutic regimes. They invested considerable efforts in decreasing weight and thus offered a broad amount of experiences and knowledge in the field of self-perception of incidence as well as the prevalence of their obesity. The participants’ level of education was also surveyed and segmented according to ISCED (see Table The average age of the participants was 18.8 years (range: 16–25 years), the participants were patients in the clinic for an average of 99 days (range: 1–360 days) at the time of the interviews and their average BMI was 42.33 kg/mThe interviews were autobiographic-narrative and problem-centred oriented, and they were conducted according to a standardised framing. With regard to the concepts of ‘grounded theory’, this framing wasn’t used to set a fixed agenda of questions but rather as a rough topic structure in order to warrant the comparability within the study. Therefore the interviews were divided into three parts: The first and at the same time most extensive part of the interviews served as the reconstruction of the environmental experiences of the participants with their usually extreme form of obesity. Special attention was paid to the participants’ subjective linking between certain life-events or past experiences with phases of considerable increase in weight. Similarly, their experiences in fields of life as family, school, work place and health care system in relation to their obesity were considered.In the subsequent part of the interview, individual aspects of the first section were taken up more thoroughly and possible areas in which stigmatisation could have been perceived were sampled. Stigma and discrimination toward obese persons are surmised to pose numerous consequences for their psychological and physical health and thus seem to interfere with effective obesity intervention efforts , 27. In All interviews were digitally recorded. For analysing purposes, the data were at first made anonymous and afterwards transcribed. For reasons of comprehensibility the original transcripts will be presented prior to their English translation in the following part. The evaluation of the interviews was conducted detached from the interviewers in several independent steps. In order to extrapolate the different elements of the subjective obesity aetiology in the imaginations and narrations of the participants, two steps were undertaken. First, the data were theoretically coded , 30 and The analysis of the data leads to three essential results regarding the first focus of evaluation: The evaluation shows that the participants (1) could not give a genealogical starting point for their obesity, (2) they each identified different life events  as catal“Pummelig war ich eigentlich schon mein Leben lang. Das (2) begann schon bei der Geburt, wo ich .. über 5000 Gramm war” .“I’ve always been chubby, actually my whole life. That (2) began when I was born when I .. had over 5,000 grams”First, neither of the participants could clearly identify a genealogical starting point for their weight gain. Obesity was rather experienced as something that has always been present:“Also, .. ich war mit drei schon übergewichtig, also irgendwie immer” “Well, .. I was already overweight at three, actually I have somehow always been”In some cases participants were able to provide more precise periods of time in which they gained weight. However this did not change their assessment that overweight could not be attributed to an initial life event:“Also, ich war schon immer dick, also auch als Kind, als Fünf-, Sechsjähriger hat das angefangen laut meinen Eltern” “Well, I have always been big, even as a child, as a five-, six-year-old it started according to my parents”Even if certain temporal markers were added, most of the time this had no real implication. They were just part of the subjective story line but were not understood as a genuine part as such:This result can be found throughout all samples and was independent of age, gender or level of education.Though no initial meaning was attributed to the life events for the genesis of obesity, they seem to function as catalysts for the further increase of weight in a significant way. These life events were perceived as fateful on the one hand, but were at the same time determined as possible chances of intervention. At this point, it is crucial to make clear that the participants did not primarily understand such means of intervention as interventions concerning their weight. Instead they understood their eating and mobility behaviour as reactions and strategies of coping with the problem seen as primarily responsible. By the participants, interventions were only considered as having a chance to succeed if they primarily focus on the priority impairments and thus only indirectly address disposing with the eating and mobility disorder.“… Erwartungen, die ich halt so .. an ’n Vater gestellt hab, also von – Vater hatte – (2) kam nie rüber – also Desinteresse v o n Vater, Missachtung von der Mutter, .. zum Teil auch häusliche Gewalt von der Mutter. ] und  and  und  and ”The analysis shows the following relationships between the different life events and the weight increase: First, the individual life events may accumulate and cannot always be clearly separated from one another. Second, many participants considered excessive eating as an act of defiance towards the family and simultaneously as a very important factor in the respective story lines. Various possible events, such as experiencing domestic violence, the separation of the parents or the death of a family member were considered as leading to these acts of defiance:“Ähm und (2) dann, äh, is mein .. Vater auf Kur gegangen, .. im selben Jahr und is dann, äh, nach der Kur, .. ähm – .. hat uns dann verlassen, also er hat sich von meiner Mutter getrennt und .. is weggezogen und, .. ähm, ja dann .. war sehr viel Trauer in der Familie und, äh, .. ich, ja, ich konnte (?den dann) nich so ganz bewältigen zu dem Zeitpunkt und hab mich dann sehr zurückgezogen, .. hab dann auch angefangen, exzessiv am Computer zu spielen, und, .. ähm, zu dem Zeitpunkt hatt ich au’ nicht mehr sehr viel soziale Kontakte wegen .. Vorfällen davor, .. wo sich mein Freundeskreis, äh, sehr ausgedünnt hat.] und  and [Hm, .. well, I believe, if (2) – if my father had, uh, decided differently then, um, .. about leaving us, .. I think I would have been on a good way, .. hm, not to gain that much, because I – I was then, let’s say, relatively lean .. bym-, uh, by my standards and, .. um, I had been out of cure for half a year, it went – it went all relatively well and, .. um, .. well, but I did fall, as I said, into a very deep hole when he was gone here, and, uh, (2) I think if that didn’t happen, then I would, uh, not be here now, then I would probably have an apprenticeship now and .. would probably live on my own.”Excessive eating was often a means for compensation for these life events which were perceived as severe and threatening. While this behaviour was sometimes understood as open protest, for example to call for attention to the particular problem, it served at the same time as an internal strategy of dealing with the problem. Such a separation, however, proves to be rather artificial concerning the progress of the whole storyline. In fact, there are often transitions in the temporal perception of the respective modes of behaviour:In the preceding quote the participant’s explanations patterns can definitely be understood as protest or a strategy of coping with the described life event. Depending on this differentiation of protest or coping strategy, distinct types of intervention were considered adequate. Besides the act of defiance towards their families, another explanatory model for the excessive consumption of food was to regard it as a reaction to changes in the respective stage of life. Changes of the familiar surroundings due to moving or school transition as well as the start of puberty were mentioned most frequently. Whereas the excessive consumption of food was often associated with particular life events, the lack of activity was not. Instead the latter was attributed to continua of experience. Thus, especially the persistent stigmatising experiences – and thus the co-occurrence of labelling, stereotyping, separation, status loss, and discrimination  – withinTaken as a whole, it can be stated that different life events were on the one hand identified as starting points for enormous increase in weight. On the other hand, attempts to either stop further weight gain or starting weight loss were only considered to be reasonable and expedient if the obesity was directly linked to the previously described life events. This aspect was also confirmed by the fact that the participation in different medical programmes for intervention at the very time of these critical life events did not achieve any or just a negligible short-term effect: obviously, they did not address the actual problem nor did they identify it.“Äh, schon, .. also, hm, .. meine Mutter ist übergewichtig, meine Schwester auch .. und mein Bruder auch, aber die beiden haben das jetz auch hingekriegt mit Abnehmen .. u n d mein Vater, der is eigentlich auch ’n bisschen moppelig.” “Uh, even, .. well, hm, .. my mother is overweight, my sister too .. and my brother too, but both of them have by now managed to lose weight .. a n d my father, he’s actually also slightly pudgy.”Closely connected to this second point, there is a third aspect, namely the participants’ view of obesity being mainly a family issue. However, such a localisation is also ambivalent. First and corresponding to numerous existing studies on the connection to maternal and paternal weight , 37 and “das Gewicht und auch das Essverhalten war eigentlich dann wirklich das einzige regelmäßige Thema, über das man so gesprochen hat.” “the weight and also the eating behavior was actually really the only regular topic about which you talked.”Second, the view of obesity being a family issue is supported by the fact that all participants pointed out that, from their perspective, the family was the only reasonable setting where a strategy of prevention has to begin. Medical interventions as well as behavioural-preventive measures at kindergarten or at school were less appropriate according to the subjective perspective of those affected. Although they were regarded as important and expedient as flanking measures, they would not address the actual challenge. However, even if intervention within the realms of the family was existent, by focusing (too) strongly on the respective intervention a certain factor of resignation became apparent with the participants:Third, this resignation also had its effect on the evaluation of suggestions for interventions outside of the family. For example, by launching a school intervention concerning the consumption of high-calorie drinks, the subject matter would have been omnipresent not only at the participants’ homes but in their every-day environment which thus constantly pointed at their “problem”.The focus on the family as the primary setting of intervention, however, didn’t reveal anything about the affective or emotional proximity of the participants towards their families. It can rather be regarded as some relatively pragmatic information for the localisation of the source of obesity: Obesity as a domestic outgrowth. This means that the essential starting point for intervention has to be set within the family.“es auch so ein bisschen, äh, das gehört auch zu mir, dass ich dick bin, also, ich in– identifizier mich wirklich damit, ähm, ich kann mir das jetz nich vorstellen, .. eben weil’s auch noch nie war, dünn zu sein, und ich mag es auch nich, meine Knochen zu spür’n und, ähm, .. genau deswegen würd ich eigentlich doch schon eher dazu tendieren, nich unter 90 zu kommen.” “it’s also a bit like, uh, it’s part of me that I’m big, well, I in- identify myself with that, um, I can’t imagine, .. precisely because it’s never been like that, like being thin, and I also don’t like it to feel my bones and, um, .. that’s exactly why I’d actually rather tend to not come below 90.”Concerning the second evaluation focus, i.e. in how far the participants regarded their own story as changeable and shapeable, there are two substantial results. Firstly, overweight was understood as an essential marker of identity which they, if possible, didn’t want to lose completely.Despite of the existing awareness of their obesity, their own weight is understood as something that is part of their own identity. It presents a positive as well as a negative distinction from the physical as well as aesthetical norm which is characterised as the societal ideal. The participants – especially in the self-reflective parts of the inquiry – questioned vehemently which instance is actually authorised to determine what is to be regarded as still normal and what as already anomalous. Dealing with such social norms and images took up an essential part when forming their own identity. By negating the social weight norm, the affected marked a distinction that has been shown to be a constitutive element of the participants’ own social localisation.“Ja, ich hab mein Gewichtsproblem schon selbst verursacht, weil ich halt schon viel gegessen hab. (2) Ich fühl mich aber nich schuldig, .. weil .. das schadet ja eigentlich nur mir .. und .. ja, .. es is halt mein Problem.” “Yes, I’ve caused my weight problem myself because I’ve eaten quite a lot. (2) But I don’t feel guilty .. because .. that only Johanna Jäckl 22. September 2014 12:48: harms me.. and .. well, .. it’s just my problem.”“Alle anderen hat’s eigentlich nich zu interessieren, weil das nich ihr Körper is, und mir selber – .. nein ).” “It’s none of anyone else’s business because it isn’t their body, and for myself Johanna Jäckl 22. September 2014 12:49: – ..no ).”Simultaneously, all participants insisted on their responsibility for their own health. Personal responsibility was viewed as an essential requirement for being able to intervene at all. The research furthermore showed the striking fact that according to the participants’ perspective the acceptance of responsibility for their own health is not connoted with the assumption of guilt.“.. das seh ich definitiv so, also, .. wer war’s denn sonst, ) also ich mein, .. hat mich ja niemand zum Essen gezwungen. ((stöhnt leicht auf))” “.. I definitely see it like that, well, .. who else was it, ) well, I mean .. no one forced me to eat. ((moans quietly))”As clearly as the participants objected a socially ascribed guilt, they vehemently held onto their own responsibility for their overweight. Linking this aspect to the results above seems to put out an ambivalent and perhaps contradictory result. On the one hand, the participants viewed the genesis of their obesity as intrinsic to them as well as to extrinsic factors as different life events. At a first glance, it seems to fit in with such an interpretation that the role of the “scapegoat” is transferred to life events described above. However, this does not entail that the origin of the participants’ overweight fully falls outside their own area of responsibility.Undoubtedly there are supposed intrinsic or extrinsic factors which are partly responsible for the current obese situation of the participants. However, the participants insisted that the only way to deal with these “factors” was to refigure the modes in which they regard and handle them.An additional factor with regard to self-perceived responsibility is that of the overall assumption that the overweight will not remain a life-long problem: rather it is seen a challenge which can be dealt with and for which the participants will assume responsibility.The following results have to be pointed out as especially significant: Firstly, according to the perspective of those affected, overweight is regarded as something that has always been present and which has no clearly definable starting point. Secondly, different life events can however be understood as catalysts for the enormous gain of weight. Therefore it seems not to be appropriate to assume that there is a rectilinearly continuum from normal weight to extreme obesity. Rather the different life events seem to function as initiations for periods of accelerated weight gain. Thirdly, the participants consider obesity to be a domestic issue, both concerning the incidence and the possibilities of intervention. Fourthly, the results of the study show that the challenge in dealing with the own obesity can neither solely be solved by medical nor by social parameters, but is always entailed with the question about the participants’ self-conception and the norms they accept as valid. The fifth essential point regards the relationship of personal responsibility and guilt. In the context of this inquiry, no connection between taking up personal responsibility and assigning guilt emerged. On the contrary, the participants understood personal responsibility as an essential room for possibilities of the self-determined shaping of their own way of life. The results of the inquiry suggest the assumption that the participants consider themselves responsible for the increase of their weight without associating an accusation of guilt with it.Even though the setting of the study was in so far special as all participants were already at a point of institutionalised intervention when the inquiry was conducted, the results of this study can provide important additions and adjustments to the previous strategies in the field of obesity prevention.The previous approaches of obesity prevention cannot be accused of not having recognised the importance of obesity as a domestic phenomenon, but most intervention studies, with their limited effectiveness, chose their starting point majorly in the obesogenic environment, and not in the families themselves. Of course, there are a few studies within the field of family prevention strategies  struggliFloodlighting the previous aspect, the results draw attention to the fact that obesity itself is not the actual issue but rather particular life events. Problems concerning the development of the body weight happen to appear as accompanying and consecutive phenomena of life issues. If this observation holds true, this will have enormous consequences for the further research in the field of obesity prevention: the effectiveness of the preventive measures, for example, seems to be – largely – dependent on how far the respective recipients of the prevention see themselves as recipients of these interventions.These considerations are closely related to the question about the objective of obesity prevention. If the first results of this study can be confirmed, the question concerning the norms governing the interventions will have to be asked all over again. Not only conceptual questions regarding the respective understanding of disease and health will have to be brought into focus , but alsThroughout the research literature a connection between the reference to individual responsibility and a simultaneous attribution of guilt is pointed out consistently. However, this assumption can no longer be sustained in the context of this study’s results. One of the ambivalently discussed concepts in the current debate is the expression of personal responsibility since it is connected to the fear of an illegitimate attribution of guilt  concerniFor further adjusting current as well as future prevention strategies, it would be worthwhile to widen the scope of research by including the perspective of those affected. Special attention should be paid to systematic consequences for obesity research. Nevertheless, these results also stress the requirement of an initial debate on both, the understanding as well as the scope of family prevention.Generally, the necessity for developing a systematic approach including both medical and social parameters for obesity prevention can be supported against the background of these results , 41. Thi