Extensive social psychological research emphasises the importance of groups in shaping individuals’ thoughts and actions. Within the child sexual abuse (CSA) literature criminal organisation has been largely overlooked, with some key exceptions. This research was a novel collaboration between academia and the UK's Child Exploitation and Online Protection Centre (CEOP). Starting from the premise that the group is, in itself, a form of social situation affecting abuse, it offers the first systematic situational analysis of CSA groups. In-depth behavioural data from a small sample of convicted CSA group-offenders (n = 3) were analysed qualitatively to identify factors and processes underpinning CSA groups’ activities and associations: group formation, evolution, identity and resources. The results emphasise CSA groups’ variability, fluidity and dynamism. The foundations of a general framework are proposed for researching and assessing CSA groups and designing effective interventions. It is hoped that this work will stimulate discussion and development in this long-neglected area of CSA, helping to build a coherent knowledge-base. Humans’ thoughts, beliefs and actions are influenced heavily by “the power of the social situation” , p. 15. In the 1970s, In general, however, criminology has neglected groups, focusing primarily on individual disposition or, in the case of situational theories, individual decision-making . Althougmodi operandi , the majority of work has sought to identify traits distinguishing offenders from the wider population and to inform, thereby, effective treatment . Far lesn = 16) had been knowingly involved with other CSA offenders pre-arrest and only 4% (n = 7) had co-offended (n = 213) had one of the lowest co-offending rates at only 4.7%. Given the enduring taboos against sexual offences, in particular against children, such results are not entirely surprising.Until recently, those exceptional studies that measured group involvement in CSA found low levels. What is thought to be the largest such study to date found that of the 182 convicted CSA offenders questioned, only 9%  was subject to in-depth analysis to test the utility of this approach in improving understanding of CSA groups. The results are by no means conclusive, but rather represent the first steps towards constructing a framework against which these and other situational dimensions to CSA groups could be assessed in a systematic and replicable manner. Such a framework could facilitate cross-study comparisons and the development of a coherent literature around this neglected aspect to CSA. From a practical perspective, this could guide resource allocation and inform counterstrategies that could inhibit the formation of groups and disrupt their activities.Starting from the premise that group involvement is an integral part of the crime environment , in thisIn the absence of a consensual definition of groups, let alone crime groups, a working definition of a CSA group was required. Contrary to popular stereotypes of stable, fixed and hierarchical criminal groups, most co-offending groups are more like loose federations  that mayThe research data were provided by the Child Exploitation and Online Protection Centre (CEOP), part of the UK's Serious Organised Crime Agency (SOCA). As part of their ongoing research and training programme, CEOP's Behavioural Analysis Unit conducts interviews with diverse convicted CSA offenders: to date, 24 such individuals have been interviewed over the past decade. While the interview script did not feature group-specific questions, subjects had the opportunity to discuss their group involvement when answering questions about offending behaviour. To filter the archives inclusion criteria were developed, as shown in The majority of the 24 potential subjects were solo offenders only, and as such not suitable for this study; a few others were excluded due to age, gender or a non-UK conviction. Only three subjects met all 10 criteria, and together their offending histories span six decades, from the 1950s to the 2000s. While all three subjects were involved in CSA groups, each also had a history of solo offending, as is common for co-offenders in general . SometimAll interviews were conducted by the third author (Joe Sullivan) in full compliance with CEOP's ethical review process and with prison access granted by the National Offender Management System. Subjects gave informed consent to participation, audiovisual recording, archival of these records and their use in future (non-specified) research in the interests of harm reduction. CEOP's research panel approved the use of these secondary data in this particular study prior to its commencement. All names and possible identifiers have been changed in order to protect subjects’ anonymity. The interviews were reviewed and transcribed in a secure office on CEOP's premises, where they are stored in accordance with the Data Protection Act 1998. All authors were security cleared to a high level.n = 3) was that it allowed detailed analysis of a problem that had not been addressed previously in this manner. A qualitative approach was preferred due to the extensive behavioural data required in order to deconstruct this complex phenomenon. The method of choice was thematic analysis, a flexible, adaptive method with a preference for small sample sizes. The analysis followed This study's aim was to identify immediate situational processes and factors shaping the associations and activities of CSA groups. Sampling difficulties are relatively common when dealing with hard-to-reach populations such as CSA offenders and, although it would have been preferable to include more subjects, the benefit of the small sample (The first and second authors (Ella Cockbain and Helen Brayley) transcribed the interviews in full, entered the verbatim transcripts into the NVivo software package and analysed them using the six-stage model set out above. While coding, they strove to balance the need for focus and clarity with that of avoiding imposing assumptions and preconceptions onto the data. New nodes were created as required and material coded to an expanding set of nodes. Intercoder reliability was measured for one interview using Cohen's kappa : at 0.83Each subject was involved in multiple groups, often at the same time, which varied greatly in their duration—from a matter of minutes to many weeks, months or even years. This underlines the multiplicity, fluidity and dynamism of group affiliations in CSA, something common to research into other forms of criminal collaboration . The subEach theme applied to all three subjects: indeed, it is suggested that most, if not all, CSA groups could be assessed along these themes. Within each, however, the subthemes relate to specific manifestations of the themes; for example, four different pathways to recruitment were identified. In some cases, subthemes are mutually exclusive alternatives (e.g. for group identity), whereas in others they may be complements (e.g. for group resources). No claim is made to have compiled the definitive, comprehensive framework for assessing CSA groups: neither the themes nor their subthemes are exhaustive. These are simply the first pieces, as it were, in a much bigger jigsaw puzzle that comprises group involvement in CSA.There was evidence of four distinct ways in which individuals became involved in CSA groups, each either taken actively or observed and discussed by these subjects.Through introduction. A group can form, or expand, when offenders are introduced to one another by mutual contacts in their wider networks of association. Simon became involved with another travelling CSA offender in this way: the pair was then introduced, via a further contact, to a professional photographer who doubled as a producer of indecent images and procurer of children for contact abuse.We had an introduction [letter] to someone he knew who was a photographer. [Simon]Introductions were equally important online. Les, for example, was reluctant to engage when approached by a stranger, only reconsidering after a mutual acquaintance intervened.I didn't know this guy from Adam and it wasn't until I went back online at a later date that someone that I did know said to me … he's alright, I know him. [Les]Introductions may be a popular route into CSA groups due to the association with increased safety: mutual contacts acting as vouchsafes reduce the risks of inappropriately “outing” oneself as sexually interested in children and of law enforcement infiltration.Through recruitment. Pre-existing groups or interested individuals may recruit others actively, providing a ready route into group involvement. Recruitment can be targeted or more general: Les, for example, was singled out as a producer of indecent images and asked to join a secretive but prolific online group, one of the most notorious to date:All of a sudden I'm very popular and everyone's mad keen to say hello. [Les][T]hat was the only reason that they invited me to join the group. Otherwise, because I was so green … I would never have stood a chance. [Les]Meanwhile, Simon was recruited by members of a CSA group that also advocated on behalf of those with a sexual interest in children who attended his trial, which had generated considerable publicity as one of the first prosecutions under new child pornography legislation.There were two fellows turned up to my trial who I knew nothing about at the time … and over the following years we became very good friends. [Simon]Through opportunity creation. Offenders may seek out one another actively, either by speculatively visiting places with reputations for sexual deviance or targeting specific locations, on- or offline, using privileged knowledge gained through their network of contacts. These approaches amount to the deliberate creation of opportunities for CSA group involvement, as opposed to merely capitalising on opportunities that present themselves. Clive highlighted several places where interested offenders could find like-minded individuals:You can be in a toilet … hear them outside, you go into cafés you hear it, you go into pubs you hear it. I can name you … one, two, three, four, five, six, seven areas of Leeds. [Clive]There is an online parallel to this: Les met his future group-mates by trawling indecent image sites:I met SugarLove through this sort of bulletin board and we became quite friendly, chatting and talking. [Les]Initially an observer, he gradually engaged with others in a more active manner:I was what you call a lurker for long time, just sort of sat watching things … until I plucked up the courage to post myself. [Les]Through chance meetings and pre-existing social networks. Groups can form through chance meetings in apparently random locations or arise within pre-existing social networks. Simon, for example, witnessed a CSA group form in this way, although he did not join in himself, when his colleagues became involved in sexually abusing children at work. From this data set, it remained unclear how offenders establish their shared sexual interest safely and reliably in such environments without obvious cues: perhaps subtle probes are used to test the water, rather than declaring interest or intent openly. This could mitigate the risks of negative responses, such as stigmatisation, attack or disclosure to police. Indeed, Les realised the danger of not concealing his sexual preferences after lending a colleague his “barely legal” magazine in which the centrefold featured readers’ photos of minors:I once had a comment off a mate about the contents of the centre pages. After that I removed all the centre pages from those magazines so nobody got to see them. [Les]modi operandi.These particular offenders formed no CSA groups, defined as involving co-offending, through prison, although Clive in particular referred to extensive networking on sex offender wings, sharing information about victims and inside a group, through members’ shared codes and values, for example. The latter is projected upon a group through the way outsiders react or refer to a set of individuals. The two can diverge greatly in the level of cohesion and identity they involve, as demonstrated by Clive's irritation that the group with whom he was tried was portrayed in the media as a clear-cut, regular circle of n offenders. This was at variance, he claimed, with its true identity. Similarly, Les objected to how his case was covered in the media as involving Group X, when in fact members of an entirely different group had been arrested:Group identity can be an internal or an external construct. The former arises from … the police didn't arrest hardly anyone out of that group, it was the other one. [Les]The subthemes below are based on examples of internally constructed identity, evident in the subjects’ interviews, although the distinction may be equally applicable to externally constructed identity. They represent two ends of what the authors posit is a spectrum running from casual, ill-defined, loose linkages to clear-cut groups with strong markers of membership.Weakly-defined groups. Here, members do not see themselves as a group in any formal sense. Such groups may be more likely to form opportunistically: individual offenders converge temporarily in pursuit of a shared goal, such as image-transfer, and separate on completion of the task. Such short-term collectivities are unlikely to share a name, codes or lasting goals. It was difficult to identify cases of the absence of an identity in the transcripts, especially as subjects were not questioned directly about their groups. Simon, however, downplayed ties to one group by describing members as “acquaintances…rather than friends”.In theory, CSA offenders as a whole could be viewed as a group, although not under the definition used here with its co-offending requirement. The notion that all CSA offenders are somehow alike was rejected by the subjects, all of whom, instead, emphasised the distinction between “good” and “bad” CSA offenders:Certain people said, ‘They're the same bloody mob as you'. And I said, ‘No they ain't'. I said, ‘I don't have to go behind a fucking vicar's cloth. [Clive]They hear the word ‘paedophile’ and think, ‘This is a chap who's going to be raping my three-year old daughter … there's just no way I'd have the slightest inclination. [Simon]Clearly-defined groups. Here, groups share a name, fixed membership, terminology or other markers of a common identity. Simon was involved in a clearly identified group of so-called “intellectual paedophiles”, who engaged in advocacy as well as abuse. Meanwhile, Les was involved with several clearly identified groups online:[We were] known as SKIF … like the initial of each of our nicknames. [Les]Motivations to form or join groups can differ greatly from the actual benefits of group involvement: while the data gave little insight as to the former, the subjects revealed much about the latter. A major advantage of group involvement seems to be access to resources, of which five categories were identified here, including those critical to the crime-commission process. Depending on the individual offender, group involvement may be a prerequisite for accessing such resources, or a way to accrue them more quickly, with less risk or in greater quantities.Access to children. Group involvement can give subjects access to more children, including those to whom they are less attached and from whom there is less risk of disclosure, thus enabling abuse to escalate. Before joining a group of seasoned offenders Simon's CSA was limited to photographing, and occasionally groping, boys he met opportunistically. Once in the group, however, he had ready access to his co-offenders’ so-called “ménage” of longstanding victims:He wasn't only photographing him, he was screwing him fairly regularly and most of the other boys as well: so the boys were very experienced … they were perfectly happy. [Simon]Like Les, Clive already abused his own stepchildren by himself, but through his groups he gained access to a wide range of other children, abducted or coerced into exploitation by various members. The CSA in which they engaged was largely non-commercial, although there were clear instances of payments to a third-party facilitator and/or to the victim:That person who supplies the good is paid for supplying the goods … and then that young person has to be paid …in four hours she's been abused by about 10 or 12 people. She only gets one payment, she doesn't get payment for him, him, him, him. [Clive]In CSA with a commercial element such as this, group involvement enables offenders to pool their funds: what might be too low a “fee” from one offender alone may become acceptable if matched by others:You'll put so much in the pot for that young person who's got to give you entertainment for the night. [Clive]Well, one's that way, one's having that way, one's down that way. He gets it three ways … and they may only pay about ten quid and they've got him all night. [Clive]Access to abuse locations. These subjects described diverse types of abuse location, varying in their comfort, convenience and security. Often, group involvement gave offenders knowledge of and access to desirable locations. Simon, for example, was taken to isolated rural spots of which he, as a foreigner and outsider, would never have been aware:We would go off each day in the minibus to some convenient place. It might be a nice sort of secluded castle, it might be a wood. [Simon]In cases such as this, access to abuse locations went hand-in-hand with access to children, who were procured by a group member for the others. Clive described invitation-only parties hosted by a group member in his own home:Eight or nine adults come to his flat … and he'd go, ‘Come in the bedroom'. And he's got the children there starkers. [Clive]He also mentioned so-called “syndicates”: highly organised enterprises offering members an “all-inclusive” type deal:You go down, you pay your club membership and you go in there and everything's laid out on a silver platter for you. [Clive]Access to indecent images of children. Group involvement has clear benefits where the distribution of indecent images is concerned, enabling offenders to amass a large and varied collection:I was amazed at the amount of images he had … Twenty thousand plus. [Les]This is particularly true with advancements in technology that enable the rapid sharing of files and their easy, convenient, discrete electronic storage. In an account that recalls the frenzied buzz of a bank's trading floor, Les described his shock at the scale and speed at which material was shared in online trading rooms:I couldn't believe it the very first time I went on to it. It moved so fast, there were so many people in there, so many people talking at once and advertising and trading. [Les]According to Les, online CSA groups involved in image-exchange particularly value two types of offenders—first, those collectors with extensive, well-labelled collections including rare series, rather than messy and ubiquitous material:You can tell if someone's got real crap: they've got images like 1, 2, 3, 4, x, y, z. Instead of series names like Angela 1–10. [Les]Secondly, producers are valued, as their involvement in a group guarantees brand-new and exclusive content. The first time Les posted his own images online it was to one co-offender alone, who promised to circulate them no further. Trust can be a fragile commodity, however, and this contact leaked the images to his other groups:I'd actually given some to him on the condition that he never spread them and [it] was my naivety to say, ‘These don't go anywhere, there are personal they never get traded. [Les]While increased access to indecent images is a desirable commodity, it carries heightened risk. Simon was jailed after his “treasure-trove” of indecent material was discovered by the police. This “Aladdin's Cave”, as he called it, of hard-copy images was an amalgam of his own collection and that of his co-offender: the latter clearly benefited from his group involvement because he could leave his precious collection for safeguarding while out of the country. Both Les and Simon emphasised the risk in disposing of hard-copy CSA material in particular:I'd always meant and wanted to try to sort it out but what do you do with the damn stuff? You can't go and take it down to the tip. [Simon]I didn't want to just throw it in the bin for someone to find it. I didn't want to just go and burn it in case someone saw what I was doing. [Les]Access to specialist skills. Joining a group can give offenders access to others with specialist skills useful in enabling offending and evading detection. Such skills may be put to the group's services or taught actively to members: the latter is more dangerous than the former, as it protects against a single point of vulnerability and increases capability and resilience. When Simon started taking indecent photographs of children, amateurs could typically only develop their creations in black and white. One of his groups included a professional photographer, whose ability to develop in colour made him valuable to the group. From a skill perspective, however, group involvement carried most obvious benefits to Les when he became involved in online CSA. He selected a username to emphasise his “newbie” status and elicit sympathy and guidance. This worked, and Les quickly became involved in a tightly knit group of four, including one offender with considerable technological abilities: he taught the other three techniques to share material rapidly and effectively and protect themselves against detection. Consequently, Les became technologically literate very quickly, at a time when few people were:I've just learned by other people telling me what to do. Yes, I'm an intelligent bloke, I learn quickly, but I'm not a master computer engineer. [Les]Access to psychological rewards. Alongside the practical, tangible benefits detailed above, group involvement can bring considerable psychological gains. Awareness of others’ offending helped neutralise Simon's own qualms, spurring him on to experiment with intrusive forms of abuse against “well-worn”, and therefore in his eyes legitimate, victims. Moreover, group involvement offered some clear relief after years of concealing their highly taboo sexual interests. Simon compared his groups to Alcoholics Anonymous, offering:Mutual society, help and comfort … in prosperity and adversity. [Simon]For Les, the expressive function of his online groups soon overtook even the instrumental one of collecting images:Towards the end my preoccupation was community-based, rather than sexually based. I dropped everything for the fact I was in an online community of people I could talk to, that understood me, that I could talk openly and honestly to. [Les]He would leave work mid-shift to go home and go online and eventually began to socialise with his online group contacts offline as well. His descriptions of their meetings recall a small-scale sex offender convention, whereby alongside discussing shared deviant interests in his home they went drinking in the pub, a form of more conventional male bonding. Although emphatic that his stepchildren were off limits, the meetings enabled him to show off his victims:For them, from what I understand, it was like meeting a star, if you like. Somebody that they'd seen doing things with me and to actually see in real life. [Les]There was evidence in these data of four ways in which groups evolved, varying in speed and deliberateness, and a fifth is also posited.Expansion. A group can expand organically or through the purposeful introduction or recruitment of new members, for which the processes involved have already been discussed. According to Clive, “everything works in a circle, it all starts with one man in the middle”. As expansion can be risky, groups may implement protective mechanisms, some of which were described by Les in relation to online CSA:He wouldn't tell me the name or any of the details, just the fact that this secret channel existed … That's when I went into the vetting procedure. [Les]First of all you'd trade with them … on the understanding that law enforcement couldn't trade … and once you've traded with them successfully and without any hassle … you'd pull them into a personal chat and say, ‘Would you like to join an exclusive channel?’ [Les]Depletion. Groups may deplete for numerous reasons, including arrests, members’ relocations or deteriorating group dynamics arising, for example, through breach of trust or internal rivalry. Despite stereotypes of a cohesive CSA group in which shared sexual deviance outweighs all differences, from these data it was clear that members may have little in common. There was extensive evidence of tensions and disputes, as well as gradual drifting apart:[I] cut myself off from the people in that association now because I reckon most are a little bit too dodgy. [Simon]He tried to pick up a [colleague's] son one day. What does that make me look like? A bloody idiot. [Clive]That was the first inkling … [that] absolutely everything had to be done his way. [Simon]Schism. Schisms occur when a group fragments into two or more groups. Les described a dramatic schism creating two rival groups from a notorious online collective:They'd split … they had an argument over security … and there were personality problems and they got upset with each other. [Les]Cessation. A group may simply cease to exist, temporarily or permanently, for example if an entire group is arrested or simply as the natural conclusion of a gradual depletion:We fell out completely. [Simon]I stayed offline after Kidster was arrested, because I'd been trading with him the night before his arrest and I panicked. [Les]It can be difficult to establish if a group has ceased to function, relocated or simply paused its activities temporarily. Moreover, as offenders may be involved in multiple groups, a group's cessation need not signal the end of its members’ activities.Merger. Although there was no evidence of this process in this data set, the reverse counterpart to a schism could be a merger: the unification of two or more groups into a single group. Indeed, police evidence suggested that the two groups formed by the schism described above subsequently reformed in this manner.The powerful influence of groups on their members’ thoughts and actions has been well documented, although much situational research has overlooked the immediate social drivers of crime in favour of physical drivers . The preWhat differentiates this study from previous investigations of CSA groups, and indeed of other crime groups, is its attempt to establish a preliminary framework for assessing such groups. An encouraging indication of the framework's broad applicability is how it aligns with findings from earlier studies that described particular characteristics of specific CSA groups. For example, psychological rewards derived from involvement in CSA forums have been an important theme in research into online CSA . MeanwhiCommonalities was also identified with crime research more broadly. The range of tangible and intangible commodities provided by group involvement, for example, recalls While comparative analysis of subjects’ solo and co-offending was beyond the remit of this preliminary study, it should be noted that all three subjects, chosen for their group involvement, also committed solo offences. Moreover, they were all involved in multiple, often concurrent groups, whose duration, stability and other characteristics varied greatly. Such variation challenged the notion of CSA groups as self-explanatory units, in which shared deviance trumps or obscures any distinctions between members. Together, the results underline the complex, heterogeneous and dynamic nature of CSA groups, which corresponds with findings from the co-offending and organised crime literatures . This isThe results of this small-scale, exploratory investigation need to be corroborated and further developed through both qualitative and quantitative studies. Qualitative analysis of a much larger sample, for example, could test the applicability of this framework's existing components and identify missing themes and subthemes. Quantitative analysis, meanwhile, could test for the effects of variables such as CSA subtype, members’ gender or group size on the type of subtheme manifested.Traditional responses based on lone offenders may be insufficient and ill-guided when dealing with groups . Effecti


One morning in 1630, fourteen-year-old Richard Wilmore from Stratford vomited ‘black Worms, about an inch and a half long, with six feet, and little red heads’. After vomiting, he ‘was almost dead, but a little time after he revived’. The next day, the boy's father went to see a doctor called John Hall, ‘earnestly desiring’ his advice. He brought with him some of the worms ‘wrapped in Paper’, which, upon examination, ‘crept like Earwigs, and were very like, save in colour’. Richard was so ‘cruelly afflicted’ that ‘he was ready to tear himself in pieces’. Dr Hall administered a medicine which made the boy vomit seven times, and bring up ‘six Worms’, the like of which the doctor had ‘never beheld or read of’ before. Dr Hall noted with satisfaction that this treatment ‘delivered’ Richard from his infestation, so that when ‘I met him two years later’, he ‘gave me thanks… [and] told me he had never been troubled with it since’.1The Sick Child in Early Modern England.I encountered this bizarre case in the published medical notebook of the eminent Stratford physician John Hall, who happens also to have been Shakespeare's son-in-law. It sparks a host of questions about childhood illness in early modern England. Were children's medicines the same as those of adults? What role did parents play in the care of ill offspring? How did young people like Richard respond emotionally to illness and suffering? These are some of the questions addressed in my book, Centuries of Childhood (1962), argues that the concept of childhood did not exist in pre-modern societies, as evidenced by the tendency of artists to depict children in adult dress.5The first myth, is that for much of the early modern period, children were regarded as miniature adults. This idea is most famously associated with the French scholar, Philippe Ariès, whose book A foray into the medical sources of early modern England shows that this was not the case: children's bodies, diseases, and treatments, were distinguished fundamentally from those of adults. The physiological uniqueness of children resided in their ‘humours’. Rooted in Hippocratic and Galenic medical traditions, it was believed that all living creatures were made up of four fluids called humours – blood, choler, melancholy, and phlegm.According to this theory, children were more warm and moist than other ages, abounding in the humour blood. This great humidity made their bodies weaker and softer than those of adults. The royal physician Walter Harris wrote in his 1693 medical text, ‘children's’ [flesh], bones and cartilages, are like soft Wax, curdled or gathered butter… or sammed cheese’, whereas in old men, they are ‘dry and wither’d’.9Children also differed from adults in their disease vulnerability. Early modern paediatric treatises usually list between thirty and forty-five diseases, which include conditions as diverse as ‘nightmares’, ‘pissing the bed’, and ‘breeding of teeth’ (teething). An analysis of domestic recipe books – collections of manuscript medical recipes for use in the home – indicate that laypeople also recognised children's susceptibility to a particular range of diseases. The most commonly cited diseases in these recipe collections are listed in were distinct to children. The most important, was the child's humidity. As explained by J.S., ‘every Age hath a peculiar temper, and so a similtude with some Diseases’.What were the causes of these diseases, and were they specific to children? The overarching cause of illness was sin: God sent disease as a punishment for human transgressions. God's method for bringing disease into fruition was the imbalance or corruption of the bodily humours, a theory of causation which was the same for all ages. However, crucially, many of the factors that precipitated the humoral imbalance Turning from disease to treatment, children's medicines differed from those of adults. ‘A special regard’, declared the English physician John Pechey (c. 1655–1716), ‘is to be had to the Methods and Medicines, for Children by reason of the weakness of their bodies, cannot undergo severe methods or strong Medicines’.As well as giving children different treatments, it was considered necessary to adapt the medicines in various ways. Doses were lessened for children, and the more powerful ingredients were often omitted. The Brumwich family recipe book, dated 1625, stated that ‘a man’ must ‘Take 11 drops’ of the ‘spirit of Vitterell’, while ‘a child of 10 years old not above 6 or 7 drops’, ‘a child of 5 years old not above 4 drops’, and finally ‘a child of 3 years old not above 2 drops’.In short, rather than regarding children as miniature adults, doctors and laypeople depicted this age-group as medically distinct. The term I have coined to refer explicitly to this notion, is ‘children's physic’. Through this research, I hope to highlight the importance of age more generally in early modern times: historians have tended to favour gender over age as a category of analysis, and therefore my book seeks to raise the profile of this other, crucial variable.19We now reach the second myth: that high rates of death in the early modern period discouraged parents from investing too much affection in their children.22and fathers tended their children with devoted care, bestowing earnest prayers, and nursing their offspring day and night. In 1679, the East Anglian clergyman Isaac Archer recorded that he ‘sate by’ his six-year-old daughter Frances all night, and ‘wrestled with God with much earnestnes for the child's life, so as I never was in such anguish before’.25Contemporary sources throw doubt on these assumptions. During illness, mothers Take Egremony Rue Wormwood, sollendin, Angelica Sage, Tormentil…Scabius, Baume, Mugwort, Pimpernell, Spermint, Scordium or Scordus, Cardus, Dragons, Fetherfew, Galiga, Rosasolis, Lilly of the vally, Marygold flowers, Barage flowers, Cowslip flowers, Pancy flowers, of each of these a quarter of a pound. Fenell seeds, Coriander seeds and Anniseeds, Cardimum seeds of each an ounce, half a pound of Rosmary Ledoary or Zedaree halfe an ounce Scorzonera a handfull, shred the herbs small… putt them into an earthen pott well glazed, then put into the pott 3 gallons of Sack & then cover it & past it up very close let it stand 8 or 9 dayes, then put it into the still & add to it 2 ounces of fine Methridate 3 ounces of Venice Treacle, of Cinnamon, Cloves & Nutmegs of each halfe an ounce & still it gently.26Parents also spent much time preparing and administering medicines. To give one example, the Trumbell family's recipe for ‘plague water’ required parents to,The processes involved in concocting medicines could be physically arduous, as well as tedious, to carry out.29a violent passion of the Soule, entertained by some sensible discontent… a torment of the mind’.The most poignant evidence of parental affection is their expression of grief. Grief was defined as ‘Witnessing the actual moment of death caused unspeakable distress. After several months of illness in 1665, twelve-year-old Caleb Vernon from London finally announced, ‘Now I think I shall die’. Seeing his father ‘gush out into tears’, Caleb cried ‘Father do not weep, but pray for me[:] I long to be with God’. He began to grow breathless, ‘as if choaked with plegm’, and his, who was ‘in great care for him’, father ran downstairs to fetch some medicines ‘for his relief’. Returning quickly, he saw his son ‘thrusting, first, his finger, and then his whole hand in to his mouth’ to clear his throat. Hearing his father coming, Caleb gasped, ‘O Father, what shall I do?’, and then ‘immediately lay back’, uttered ‘God, God’, and died.The next stage of grief occurred in the minutes, hours, and days after the child's death, and was labelled ‘distraction’ by contemporaries. In the same week that Ralph Verney's daughter Pegg died, her baby brother Ralph also passed away. Their mother, Mary, was in the middle of writing a letter to her husband when she found out about their deaths. The surviving letter, 35[W]ee finde many times in our bitterest griefes, that teares diminish our paine, and mollifie our miseries… when wee powre forth teares, we cast out that which afflicts us, & emptying the humor which oppresseth us, and smothers us within, by this meanes we free our selves from a heavy burthen which lay upon our hearts.38‘Distraction’ referred to a grief that verged on madness: it was characterised by periods of delirium and weeping.Tears were thus associated both with the humours and with the passions, providing a link between the spheres of body and mind.39In the years that followed a child's death, parental sorrow often persisted, though it may have lost some of its sharpness. Certain situations could rekindle the painful remembrances. The Verney parents were asked if they could look after a friend's little girl one day: Mary replied, ‘Since itt has pleased god to take away.. my deare gerle’ Pegg, ‘I cannot have patience to lett any Bodies elces [daughter] dwell with me for the sight of them in my owne howse would butt make my wound dayly bleed afresh’.The third myth is that it is impossible to investigate the experience of childhood in the early modern period because children rarely left written records.43But, there is one context in which children's voices can be heard: illness. Acutely aware of the likelihood of death, parents and relatives recorded the thoughts, words, and actions of their offspring in detail, conscious that these might soon be cherished as last memories. The resulting evidence provides rare and intimate insights into the lives, illnesses, and deaths of early modern children. At bedtime in 1625, three-year-old Elizabeth Wallington from London, ‘then being merry’, said to her father, ‘Father I goe abroode tomorrow and bye you a plomee pie’. The reason this everyday sentence was recorded by Elizabeth's father was that, ‘These were the last words that I did heere my sweete child speeke’, for a few hours later, ‘the very panges of death seassed upon her… [which] were very grievous unto us the beholders’, and she died at four o’clock in the morning.Children's emotional responses to pain were sometimes recorded in parents’ diaries. In 1650, the Essex puritan clergyman Ralph Josselin lamented that his eight-year-old daughter Mary, who was dying from worms, was ‘heavy, and joylesse’, pointing to her tummy, and crying out, ‘poore I, poore I’.Young people's attitudes to medical treatments frequently emerge in the sources. Following several months of wearing a brace to correct his crooked back in the 1650s, fifteen-year-old Edmund Verney told his father, ‘I may truly say the cure is almost perfected’; he added with glee, ‘I am almost as tall, if not taller than my cousin Spenser’. This cure came at a price, however – in a previous letter, Edmund had complained that, ‘[A]fter first wearing the brace I found that I was in great pain… when all nine screws are in place [it causes] the continual heat of my body [which] is trapped in me always’.Children's responses to other aspects of their care can sometimes be glimpsed. In 1661, the father of thirteen-year-old James Barrow from London ‘set apart’ three entire days for the seeking of ‘the Lord in behalf of my Child’.Oh! my dear Father, thou hast been very tender and carefull over me, and hast taken great pains with me in my Sickness’.While sickness was undoubtedly distressing in many ways, the picture is not entirely bleak. Often, children seem to have derived comfort from the tender care they were shown by their families. The Yorkshire Quaker Thomas Camm described how his eight-year-old daughter Sarah lay in his arms during her illness in 1682, and told him, ‘What did children think about death? It is often assumed that such questions are beyond the scope of historical enquiry, due to scant evidence.Some children worried about the practical problems of death and salvation. Six-year-old Joseph Scholding from Suffolk, ‘one Morning as he lay in his Bed very ill’, said to his mother, ‘Mother… I am thinking how my Soul shall get to Heaven when I die; my Legs cannot carry it, [because] the Worms shall eat them.’A voice from heaven, [to] the youth of Great Britain, published in 1690. The author warned, ‘Consider that you may perish as young as you are; there are small Chips, as well as great Logs in the Fire of Hell… The Child that will tell a Lye, must one Day roar in Hell, for a Drop of Water to cool his Tongue!’Infinitely more terrifying than these concerns, however, was the prospect of hell. When fifteen-year-old Joseph Taylor read ‘a little Book’, which gave ‘a Pathetical Description of Hell’, he was ‘put into sore Amazement and very great Terrour’. He sat ‘groaning in the dark’, crying ‘O!… How shall I bear the tormenting Flames of Hell for ever and ever!’And Jesus called a little child unto him, and set him in the midst of them, and said, Verily I say unto you, Except you be converted, and become as little children, you shall not enter into the kingdom of heaven. Whosever therefore shall humble himself as this little child, the same is greatest in the kingdom of heaven. And whoso shall receive one such little child in my name receiveth me.59Despite the widespread awareness of hell, it seems that on the whole, children were convinced that their destiny was heaven. This prospect helped mitigate children's anxieties, enabling them to respond to death with a degree of positive resignation, and sometimes, occasionally joy. In 1644, eight-year-old Tabitha Alder from Kent had ‘a longing to be with’ God, declaring ‘in a kind of extasie of joy’, ‘[I] shall be with Jesus… and I shall live with him for ever!’Given this cultural backdrop, and the intense religious conditioning of children from an early age, it is quite conceivable that some children would have been able to attain a sophisticated knowledge of Christian doctrines, which may then have shaped their emotional responses to death.It is better for me now to dye than to live’.63There were a number of powerful reasons why the prospect of death may have been welcomed by children. Firstly, children seem to have had especially vivid imaginations of heaven. When ten-year-old Christian Karr was seriously ill in 1702, she told her family, ‘O I think I see Heaven, I think I see Heaven, That is a glorious sight… the Walls and the streets of that City are like burning Gold. And I think I see all the Saints, arrayed in Whyte there’.In short, illness provides a unique opportunity to glimpse the feelings of early modern children. I have argued that their experiences of sickness were profoundly ambivalent: illness was often painful, frightening, and a source of spiritual anxiety. But on the other hand, it could be a time of love, attention, and power, and occasionally spiritual joy. This mix of positive and negative experiences stemmed from the religious doctrines of salvation and providence, together with the more practical and social consequences of patienthood. The idea that illness could in some ways be experienced positively acts as an antidote to the common historiographical assumption that sickness was a purely miserable experience, owing to the backwardness of early modern medicine.65is possible to capture the experiences of the young, even though the evidence is often indirect. By investigating the subject of children's illness, the wider aim of my research is to draw together the histories of medicine, family, religion, and emotion, fields which have rarely enjoyed much interaction.Childhood in the early modern period has often been depicted as a miserable experience, characterised by disease, physical hardship, and aloof parenting. My research on children's sickness adds to the growing view amongst historians that society at this time was rather more humane than we might think. Children were not regarded as miniature adults: they were distinguished fundamentally from other ages in their physiology and medical treatment. Abounding in moist and warm humours, they were vulnerable to a different set of diseases, and in need of medicines of a gentler nature. Parents loved their children with the same intensity that we would expect today. The sheer effort, time, and emotion devoted to sick and dying children testifies the extraordinary affection of both fathers and mothers, for their offspring. I’ve sought to show that it To end on a cheerful note, children did not always die: almost two thirds of children lived beyond the age of fifteen.


Use of over-the-counter analgesics among adolescents has increased markedly. High consumption of over-the-counter analgesics among adolescents is associated with frequent pain, lower self-esteem, reduced sleep, lower educational ambition, binge drinking, higher caffeine consumption, and part-time employment. Knowledge about life experiences of adolescents who frequently use over-the-counter analgesics may be useful to prevent health problems. The purpose of the study was to increase knowledge about adolescents who suffer from frequent pain and have a high consumption of over-the-counter analgesics.A qualitative study, employing one-on-one, in-depth interviews using a thematic interview guide. Data were collected in Norway in 2013–2014. Three boys and sixteen girls; aged 14–16 years, who continuously consumed over-the-counter analgesics were recruited from ten high schools in urban and suburban districts. Candidate participants were excluded if they were medically diagnosed with an acute or chronic illness, requiring extended use of over-the-counter analgesics within the last year. The interviews were taped, transcribed and analysed as text according to Kvale’s three contexts of interpretation: self-understanding, common sense and theory.All participants disclosed unresolved physical and psychosocial distress characterized as pain. Frequent pain from various body parts made everyday life challenging. Methods of pain self-appraisal and over-the-counter analgesics use often mimicked maternal patterns. Participants reported being raised under unpredictable circumstances that contributed to long lasting family conflicts and peer-group problems. Participants wanted to feel appreciated and to be socially and academically successful. However, pain reduced their ability to manage everyday life, hampered experienced possibilities for success, and made social settings difficult.Childhood experiences influence how adolescents experience pain and use over-the-counter analgesics. Coping with difficult situations or attempting to mask symptoms with over-the-counter analgesics can perpetuate and amplify underlying problems. High consumption of over-the-counter analgesics and frequent pain may be warning signs of adolescents with possible health threatening conditions and reduced quality of life. These adolescent might be in need of support from school nurses and General Practitioners. This study identifies new perspectives that may lead to novel approaches to identify, guide, and support adolescents with frequent pain and high consumption of over-the-counter analgesics. Adolescents, aged 12–17, frequently use over-the-counter analgesics (OTCAs) to alleviate common ailments and Norwegian studies shows that during the last two decades, this use has increased markedly . The mosthe individual’s perception of his or her position in life, within the cultural context and value system he or she lives in, and in relation to his or her goals, expectations, parameters and social relations. It is a broad ranging concept affected in a complex way by the person’s physical health, psychological state, level of independence, social relationships and their relationship to salient features of their environment . I’m mostly between a 5 and a 6, so I’m not happy’. (P.18)Throughout the interviews, it became clear that the adolescents pressured themselves intensely to perform well, especially on visible tasks. This sentiment was clear in this girls’ statement:‘It was mostly that I didn’t like who I was, so I tried to improve my confidence by dieting… that was when I started using painkillers’. (P.6)Most of the adolescents were preoccupied with attaining and maintaining a good appearance, such as expressing polite behaviour, having fit bodies, and dressing properly. Several, like this girl, expressed dissatisfaction with themselves and said they often tried to change their appearance through intensive dieting and exercise:‘Now I’m focusing on doing well in school as well as trying to remember everything I need to do at home. I still want to be with friends, though. I’m trying, but it’s hard living up to everyone’s expectations’. (P.4)The adolescents said they strived for acceptance, and they tried to comply with others’ expectations, like this girl:‘I’m not one who gives up easily. I don’t give up, and I’m really sort of stressed … I feel I always need to have control’. (P.10)The adolescents needed to maintain control, which was experienced as stressful, as expressed by one girl:‘You never know what the other girls are saying behind your back, so you go around thinking about it’. (P.13)Many of our adolescents were extremely attentive to signals indicating social conflict within their peer group. To avoid conflicts some, like this girl, lay awake at night thinking about what to say and how to behave.‘I’ve had conflicts with one of the girls, and it’s like social suicide if you become her enemy’. (P.11)Almost every adolescent in this study mentioned a fear of getting involved in social conflicts, both at home and at school. Tremendous energy was expended trying to avoid these difficulties. Several, like the girl quoted below, had been bullied and learned to avoid conflicts:‘I don’t really like conflicts, so I often say what other people want to hear. I hate it when I feel like people don’t like me’. (P.18)Declining to take part in conflicts, even when a friend is bullied, was experienced as being cowardly. Yet, this might be necessary. Some expressed an inner feeling of guilt and a pressure to speak up. At the same time, they didn’t want to attract attention. A girl explained how she suppressed her feelings:‘I have many friends here as well as many from all over Norway, because I’ve moved around so much’. (P.15)In several of the adolescents’ stories, their feelings of loneliness and their desire to put on a successful facade eventually emerged. In the beginning of the interviews, the adolescents mostly related their ‘success’ stories. This included telling the interviewer about their many friends, as revealed by this girl:‘I don’t feel like I have a good friend, someone that I can tell everything to … I have a good feeling that I will find this friend in high school’. (P.3)Later on in the interviews, many participants expressed a longing for a close friend, one they could trust, be open with, and reveal their real feelings to without putting on a facade of a ‘successful’ appearance. Mostly, the adolescents kept hoping that they would find a good friend, like this girl:Some of the adolescents had thought about taking their own lives; a few engaged in self-harm such as cutting themselves. Many said that they had been rejected by parents and/or friends, and this left them in a very fragile state, as shown in the following excerpt from one of the girls’ interview:‘I thought nobody liked me, and there was no reason to live, because I was going to die someday anyway. I did not want anyone to help me. I felt afraid and ashamed. I did not dare tell my parents. I had no need to tell anyone’. (P.11)‘I have always felt quite different really… never felt that I’ve fitted right in. In lots of situations I’ve felt I must adapt myself properly… and it’s like the worst feeling in the world to me. Now I’m really just trying to be myself, and it works much better. It is so difficult to adapt to everything. You get really tired of it and very stressed. It’s so tiring beyond the teens. I think there are lots of people who feel that way, girls at least. So I do not think it was a coincidence that just I went on painkillers. Yeah, it sounds like I’m talking about drugs here, but somehow painkillers is something you feel is well known, and they’re available without prescription, so they’re so easy to get and a very easy solution at things’ (P.12).The findings presented illustrate how the need to feel appreciated and appear successful cause stresses that affect the use of OTCAs, as this girl expresses:In this and other instances, the availability and perceived safety profile of OTCAs reinforced ongoing analgesic usage. The lack of definitive medical solutions or alternative interventions for ongoing pain, unpredictable family circumstances, and social stressors motivated adolescents to take OTCAs both preemptively and during pain precipitating events.The adolescents in the present study experienced complex intersecting problems including moderate-to-severe pain, fatigue, sleeping problems, lack of concentration, feelings of loneliness, stress, worry, sadness, and anxiety. They struggled hard for success in various areas and had high expectations for their achievements. Most reported serious family problems throughout their childhood. As an illustration of the load of psychosocial problems described, many also talked about serious eating problems, more than half had been bullied and almost one third had required support from the Child Protective Services. The adolescents described continuous feelings of not being good enough. In addition, they missed having a close friend. The adolescents used OTCAs to deal with the various problems, even though the problems often were outside the known medical indications for OTCAs. Most participants had tentative or incomplete medical insights into their pain leading to uncertainty and rationalization regarding their need for OTCAs. According to the adolescents, mothers were the prime care givers throughout their childhood and the mothers engaged naturally in caregiving to alleviate pain and improve their child’s health. Several had transitioned from mother-assisted OTCA use to become more autonomous.The adolescents stated that they suffered from severe pain and that understanding the source of their pain was difficult. Some were unsure whether their ‘pain’ was really pain. Some linked pain to stress. Others described how they may have manipulated themselves by focusing exhaustively on bodily sensations, thus giving themselves a reason to use OTCAs. In our analysis, the word ‘pain’ seemed to be a proxy for adolescents to describe their feelings when these became troublesome, regardless of the source. In the biomedical literature, pain is defined as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage . Pain caThe current study shows how participants’ individual needs for establishing predictability, stability, attention, and continuity were not properly met , 39. ChiThe adolescents described experiencing relationship problems with parents and friends. Almost all struggled intensely to fit in, and several were bullied. Unsatisfactory social relations are associated with feelings of loneliness , 53. At Most of the adolescents expressed dissatisfaction with themselves, their appearance, and their achievements. They seemed to have learned to conceal their inner feelings in order to be accepted and included both in the family and among peers. According to adolescents in another Norwegian study, specifically feeling good, being satisfied with oneself, having an overall positive attitude, and a positive self-image were important for having a good QOL . AdolescThe main author, who conducted the interviews, has specialized in psychiatric nursing. During the interviews, she may have used psychiatric interview techniques which revealed more in-depth information, in comparison to other interview approaches. Also, the fact that the interviewer was female may have made the girls, who made up the majority of the interviewees, feel more comfortable and willing to disclose information than the boys. A potential limitation of the present study is that, of the 19 participants, only 3 were boys. Perhaps additional, different viewpoints would have been revealed if more boys had been included in our sample. Another limitation was the ethical requirement to inform parents of the study. This may have excluded students who did not want to fully disclose their OTCA use to their parents. Further, we did not recruit adolescents from all ten schools and there may be other adolescents with special experiences to which we did not have access. We do not believe our results are geographically biased. A previous study failed to find a difference in the consumption of OTCAs among adolescents living in urban regions compared to those in rural regions of Norway . We wereChildhood experiences affect adolescents’ pain experience and OTCA use. Appraisal of pain and use of OTCAs may be learned. Expressing pain may also provide a way for adolescents to receive support from caregivers. Furthermore, expressing pain can serve as a proxy and an ‘acceptable’ way of revealing unpleasant thoughts and feelings. Indeed, experiences early in life might influence the regulation of stress systems in ways that shape one’s future responses with regard to pain expression. Coping with stress by avoiding it or hiding its symptoms can perpetuate or even amplify underlying problems. These complex mechanisms may reduce adolescents QOL and must be considered in order to identify, map and support adolescents with severe pain and a high consumption of OTCAs.Our findings apply to the practice of both school nurses and general practitioners supporting adolescents. Health professionals should be aware that frequent pain and high use of OTCAs may be caused by complex and serious conditions that the adolescents may attempt to conceal. Social support is found to increase optimism and improve health in early adolescence and this may be a target for an intervention . The ado


Modern healthcare is characterized by high complexity due to the proliferation of specialties, professional roles, and priorities within organizations. To perform clinical interventions, knowledge distributed across units, directorates and individuals needs to be integrated. Formal and/or informal mechanisms may be used to coordinate knowledge and tasks within organizations. Although the literature has recently considered the role of physicians’ professional networks in the diffusion of knowledge, several concerns remain about the mechanisms through which these networks emerge within healthcare organizations. The aim of the present paper is to explore the impact of institutional and professional homophilies on the formation of interphysician professional networks.We collected data on a community of around 300 physicians working at a local health authority within the Italian National Health Service. We employed multiple regression quadratic assignment procedures to explore the extent to which institutional and professional homophilies influence the formation of interphysician networks.We found that both institutional and professional homophilies matter in explaining interphysician networks. Physicians who had similar fields of interest or belonged to the same organizational structure were more likely to establish professional relationships. In addition, professional homophily was more relevant than institutional affiliation in explaining collaborative ties.Our findings have organizational implications and provide useful information for managers who are responsible for undertaking organizational restructuring. Healthcare executives and administrators may want to consider the structure of advice networks while adopting new organizational structures. Coordination and work in healthcare increasingly occur through informal networks of relationships rather than through channels that are tightly prescribed by formal reporting structures or detailed work processes . PhysiciThe propensity to create professional relationships is strongly driven by homophily that is, the preference of individuals to choose others who are similar to themselves as partners . IncreasThe principle that “similarity breeds connection”  simplifiIn the healthcare sector, professional categories delineate the boundaries of the social space in which collective norms, rules and behaviors are generated and adopted by individuals . For exaMany Western healthcare systems  have implemented healthcare reforms aimed at the adoption of new organizational models that focus on fostering patient-centered care and a team-based approach in the development of clinical activities ,32. ThesThe understanding of homophilous relationships is particularly interesting in the healthcare setting, where the final aim is the integration and standardization of healthcare processes. Indeed, the organizational models created to achieve these goals are considered ineffective if they do not encourage interactions among professionals. It is crucial to investigate the determinants of these interactions and to provide the management with an informative basis for evaluating the quality of organizational action. Organizational and social proximity, defined as the closeness among individuals within a certain context or network, make physicians more likely to link closely. Given this proximity, linked physicians become progressively similar because of the induced homophily guiding their choices . For exaGiven this theoretical background, in this paper we assume that the social environment in which physicians interact is a relevant factor affecting homophilous ties. More formally, the aim of the present paper is to explore the impact of institutional and professional homophilies on the formation of interphysician professional networks. According to previous literature, people who share similar interests are more likely to form relationships -38. MoreOn the other side, an individual’s professional background could influence interconnections among individuals. In particular, similar perspective and social capital could act as predictors of networks. In this study, we define “professional homophily” as the likelihood that individuals will establish relationships with others who are similar in terms of their field of specialization. We assume that people who generally share a similar background are more likely to create ties.A cross-sectional SNA study was conducted on a community of physicians affiliated with six hospital sites in Bologna’s local health authority (LHA), one of the largest healthcare organizations in the I-NHS. In Italy, LHAs aim to promote and protect the health of all resident citizens in a specific jurisdiction. Currently, there are 145 LHAs representing the basic elements of the I-NHS. Based on the criteria of efficiency and cost-effectiveness, LHAs provide care directly through their own facilities or indirectly by purchasing services from accredited providers, such as independent public and private structures.The LHA of Bologna serves approximately 800,000 individuals residing in 50 municipalities in the province of Bologna, with more than 80,000 hospitalizations per year. In Bologna’s LHA, hospital activities are carried out according to a matrix organizational model. Six hospital facilities perform hospital activities, which are provided by three clinical directorates. In this LHA, moderately heterogeneous clinical wards and medical specialties are merged into clinical directorates. Moreover, the time elapsed since the new model was formally adopted is satisfactory to ascertain whether behavioral changes, such as new patterns of collaboration between clinicians, are at play.a. The main purpose of the first section was to collect attributional data on clinicians, including their age, gender, hospital tenure, prior experience in the I-NHS, specialization, and managerial role. The second section was designed to collect data on the information exchange network relationships between clinicians. Consistent with Burt [Data used in this paper refer to a previously published observational study ,29,40, with Burt , we usedith Burt , in ordeQuestionnaires were submitted online from February to November 2007 to all 329 physicians affiliated with the six hospitals of the LHA. Physicians completed questionnaires during breaks at work or while at home. Participation was voluntary, and respondents were assured that their responses would be confidential and used for research purposes only. According to Italian law, ethics approval was not necessary because no information concerning patients was collected and no experimental research was performed. However, all physicians provided written informed consent for their participation in the study.To achieve the aim of the present study, we used a dyadic approach and assumed the dyad  as unit of analysis. We used one-mode squared matrices to appraise the relationships among actors in the networks, as well as the differences and similarities among each pair (dyad) of actors .Our dependent variable was relational in nature because it captured interpersonal collaborative relationships between the sampled physicians. Unfortunately, ordinary regression techniques are not suitable to regress the formation of social networks on several independent variables . We transformed all covariates representing individual attributes into dyadic explanatory variables. This transformation allowed us to translate attributional data into “relational” data. Specifically, continuous covariates  were entered into the statistical model as absolute differences between “sender” and “receiver” physician values. Smaller differences indicated greater similarity between physicians, and values of “0” indicated that the physicians were identical with respect to a given attribute. In other words, we assumed that differences in continuous attributes measured the degree of homophily among dyad members, and that positive (negative) signs for continuous variables indicated larger  differences. Thus, the heterophily (homophily) of physicians positively (negatively) predicted the propensity of physicians to establish collaborative ties with colleagues. In contrast, individual attributes represented by categorical covariates  or binary covariates  were transformed and entered into the model as binary variables, which took the value “1” if both members of the dyad belonged to the same category, and “0” otherwise.The interpersonal collaborative network was included in our model by considering a measure of relational “strength” describing the frequency of collaboration among physicians. This dependent variable, named “Professional Network”, was obtained and used to build an adjacency matrix describing the strength of the interconnections among professionals within each dyad with the UCINET 6 software package .Similarity in age occurred when the difference in age between associates was within a range of ±4 years, in accordance with Feld . Age, asSimilarity in gender, as a categorical attribute, was reported as a value of “1” when a pair of actors had the same gender, and a value of “0” otherwise.To ascertain whether similarity in seniority was a predictor of professional interconnections, we considered different variables in the model. First, we measured the number of years since graduation, calculating the absolute difference (in years) for each dyad. Second, we measured the tenure within the I-NHS, expressed by the length of service of respondents. Temporal measures were continuous attributes; therefore, we evaluated the absolute difference (in years) for each dyad. Third, we considered the tenure within the LHA that each professional belonged to, measuring the absolute difference (in years) for the dyad. Fourth, we considered whether each professional covered a managerial position (director) or not in his/her organization. Because this attribute was categorical, we assumed the value of “1” when there was similarity in the managerial role in the dyad, and the value of “0” otherwise.“Professional homophily” refers to the likelihood that a professional will establish relationships with others who are similar in terms of professional interest or who belong to the same field of specialization. Because this attribute was categorical, we reported a value of “1” when similarity in the field of specialization occurred in the dyad, and a value of “0” otherwise.“Institutional homophily” refers to the likelihood that a professional will establish relationships with others in the same clinical directorate. This attribute was reported with a value of “1” when both physicians in the dyad were affiliated with the same clinical directorate, and a value of “0” otherwise.Physical distance can impact the creation of professional networks and can explain network characteristics . We consSNA was performed to analyze the collected relational data. SNA is a method of collecting and analyzing data from multiple actors (or nodes) interacting through ties (or edges) with one another . In our We performed a multiple regression-quadratic assignment procedure (MR-QAP) to identify predictors of interphysician collaborative ties. MR-QAP is a combinatorial data-analysis procedure adopted routinely in social-network research ,29,46. Tb Table The sample consisted of 297 physicians (response rate was 90%). All data needed for the analyses were available for the entire sample. Given the relational analytical framework adopted in this paper, the analysis was conducted on 87,912 dyads.The network variable was slightly correlated with “Gender (same category)” , whereas it was positively correlated with “Professional Homophily (same category)”  and “Institutional Homophily (same category)” . Thus, having the same specialization or belonging to the same clinical directorate increased the likelihood that a link would be observed between two physicians. The network variable was negatively and significantly associated with “Managerial Role (same category)”  and “Geographical Distance” . Thus, physicians who were located further from each other or who had similar roles in their respective organizations were less likely to create collaborative links. A strong positive correlation was found between the variables “Age (difference in)”, “Years since Graduation (difference in),” “Tenure I-NHS (difference in)”, and “Tenure LHA (difference in)”. Therefore, the difference in age between physicians reflected differences in terms of seniority academically, within the I-NHS, and within the currently affiliated organization.Interestingly, we observed a positive and significant correlation between the two variables capturing the different types of homophily, namely “Professional Homophily (same category)” and “Institutional Homophily (same category)” . Although the level of correlation was moderate, this finding suggest that a certain degree of homogeneity encompassed the criteria for merging clinical wards and hospital specialties into clinical directorates .Table “Years since Graduation (difference in)” and “Managerial Role (same category)” were significantly associated with the dependent variable of the network. The variable “Years since Graduation (difference in)” was negatively associated with the professional network . Thus, collaborative ties were less likely to be observed between physicians that exhibited larger differences in the time elapsed since graduation. This finding may indicate that attending university during the same time-span can influence the similarity of physicians’ mental models, blueprints, and schemata, which can later affect partner selection within hospital organizations. We believe that this is an important finding deserving further analysis. The negative parameter for “Managerial Role”  indicated that collaborative ties were less likely to be observed between physicians who had the same role in an organization. Clinicians may be requested to integrate and combine different types of knowledge, competences, and responsibilities when establishing collaborative linkages with colleagues. Collaborations between individuals holding different managerial roles may enhance the achievement of a satisfactory level of complementarity in daily hospital activities.Finally, the coefficient of determination in the model was moderate in degree. This finding clearly indicated that other factors not included in the present study can also explain interphysician collaborative network ties. Prior relationships, friendship ties, and the joint involvement of clinicians in ad hoc organizational task forces or teams are relevant examples of other predictors that future studies should explore.The flow of clinical knowledge and integration across professional and organizational boundaries is a major challenge for healthcare administrators in many countries. Throughout the world, numerous organizational and technological innovations have progressively dictated hospital restructuring, with the aim of guaranteeing multidisciplinary service provision. New models and practices have been implemented to boost coordination and integration. Notwithstanding their adoption, these interventions risk remaining largely ineffective if they do not impact on how physicians communicate and interact . This stWe tested how institutional homophily  and professional homophily  affect the propensity of physicians to establish a connection. As documented, homophily can arise from the social context (“induced homophily”) or from individual preference (“choice homophily”) . In our Our first result is that homophily matters in the formation of connections within healthcare organizations. This finding is consistent with numerous studies in other settings, which have found that homophily strongly affects connections. People expect, a priori, that self-similar colleagues are more likely to accept them, be trustworthy, and hold similar beliefs, thereby mitigating the potential conflicts, misunderstandings, and monitoring costs that come with making connections ,36.Our second result is that the homophily effect related to specialty  is stronger than the effect related to organizational structure . This finding is new and may be explained by the theoretical arguments of professionalism in healthcare. The culture, beliefs, wisdom, and cognitive mental models of physicians are formed well before they enter healthcare organizations . As docuThe current study has some limitations. First, network data were collected and analyzed at one point in time. As observed, network configurations may be influenced by previous patterns of relationships. Thus, future longitudinal studies are needed to extend the validity of our results. Second, we demonstrated that people are more likely to create social ties with self-similar others; however, no research has investigated whether, over time, people are more likely to maintain homophilous or heterophilous relationships. Third, random sampling was not used. However, because of the large organizational context of the study, the characteristics of the investigated organization, and the quality of the collected data in terms of compliance, we believe that our results might be extended to analogous organizations within the I-NHS. Yet, the generalizability of this piece of evidence to other healthcare contexts remains limited.Fourth, institutional homophily is likely influenced by the timing of adoption of new arrangements and models. Professionals are uncertain about the costs and benefits of a new model at the time of its adoption. As time elapses, clinicians will be more likely to acknowledge and understand organizational innovations. Moreover, the process of identifying physicians as relevant partners may change over time. Homophily is highly dynamic, subject to change, and influenced by exogenous forces that affect the processes of individuals’ social identification . The adoThis study proposes and applies homophily theory as a way to capture the formation of professional and institutional networks among physicians. SNA revealed the interpersonal communication structure, which could not be visualized by conventional surveys.Our findings have several implications for hospital executives. Managing intraorganizational networks involves two opposite management tasks. Managerial interventions are required because organizations primarily use these networks to integrate dispersed knowledge. On the other hand, the networks are strongly self-organizing and emergent in nature, independent from (or even negatively influenced by) interventions by management . To be ea The questionnaire is available from the authors upon request.bRelational data are generically represented by squared “n × n” sociomatrices, where “n” is the number of actors. Our 297 sampled clinicians eventually generated a sample of 87,912 dyads, which equals “297 × 297” .


Domestic violence (DV) is reported by 40% of married women in India and associated with substantial morbidity. An operational research definition is therefore needed to enhance understanding of DV epidemiology in India and inform DV interventions and measures. To arrive at a culturally-tailored definition, we aimed to better understand how definitions provided by the World Health Organization and the 2005 India Protection of Women from Domestic Violence Act match the perceptions of behaviors constituting DV among the Indian community. Between September 2012 and January 2013, 16 key informant interviews with experts in DV and family counseling and 2 gender-concordant focus groups of lay community members were conducted in Pune, India to understand community perceptions of the definition of DV, perpetrators of DV, and examples of DV encountered by married women in Pune, India. Several key themes emerged regarding behaviors and acts constituting DV including 1) the exertion of control over a woman’s reproductive decision-making, mobility, socializing with family and friends, finances, and access to food and nutrition, 2) the widespread acceptance of sexual abuse and the influences of affluence on sexual DV manifestations, 3) the shaping of physical abuse experiences by readily-available tools and the presence of witnesses, 4) psychological abuse for infertility, dowry, and girl-children, and 5) the perpetration of DV by the husband and other members of his family. Findings support the need for a culturally-tailored operational definition that expands on the WHO surveillance definition to inform the development of more effective DV intervention strategies and measures. Approximately 40% of Indian women report lifetime physical, sexual, or psychological domestic violence according to recent national estimates . Such acIn recent years, recognition of the high prevalence of DV and the associated morbidity and mortality has fueled community and government momentum in India to develop enhanced strategies to curb its occurrence and increase support for women experiencing DV. In 2005 the Government of India passed the 2005 Protection of Women from Domestic Violence Act (PWDVA). The PWDstridhan ), broadens the definition to abuse perpetrated by any member of a shared household against the woman, and defines violence in terms of the physical, mental, psychological, or economic harm resulting to the woman or her natal family , that ‘he won’t let me use my mobile.’ This is ‘violence’ too nowadays. Or ‘he reads my SMS [text message], doesn’t give me space, this is violence against me.’ So as the state is changing, the definition changes as well.”Family court counselor speaking on the changing definition of DV to encompass stalking and control of new-age communication strategies: stridhan.Several key informants also reported their clients experiencing financial control. This included having power over the woman’s earnings, restricting her access to family income, and her access to “Whatever he [the husband of a social worker] earns temporarily, temporary worker, or whatever he, periodically, sporadically, whatever he earns, he has full right over that income. That doesn’t form a part of the family income. He has…he does what he likes with that. Whereas, whatever the woman earns becomes the family income, including his own needs to drink, to booze…so she supports that.”A women’s NGO leader speaks of the personal experiences of the social workers within her organization: “If we look into the financial type [of domestic violence], then even if the wife works [outside the home], all of her salary goes to the husband. And therefore, she has no economic independence. If sometimes she feels like giving some money to her maher [her own parents], [like] if her mother is sick, father is sick, then how can [she] spend her own money? She cannot spend her money on her own, so due to that, financial harassment occurs. And if she is not earning, then she won’t have any money at all. That becomes a form of financial harassment.”Family court counselor: “Many a times, there is stridhan [the gold or silver ornaments that are given by the girl’s parents at the time of wedding], stridhan that she brings, many ornaments at the time of wedding, but all those are taken away and kept in the cupboard. When the mother-in-law says, only that day those should be worn. So that all falls under ‘economical violence.’ Or they dispose of her wealth and her salary on their own….”DV lawyer: Some participants discussed that marital family members also exerted power over a woman’s dietary preferences or her access to fresh food and that these behaviors constituted DV.“Like if at her parents’ [home] they do not eat non-veg [meat] at all, and if she has to make it after she goes to her husband’s place. And if she is forced to eat it, although she still doesn’t want to, then that too is emotional harassment. She has to do it against her will. She has to do it against her beliefs. That is what we call ‘violence,’—that which is happening against her will.”Family court counselor: “[The husband would tell the wife],‘see my father, etcetera, will eat good food but you have to eat this stale food. My mother, my father, my brothers and sisters will not eat the stale food, you have to eat it.’”An Islamic Mufti spoke of a case where the husband prioritized his own family’s access to food over his wife’s: Case reports of sexual abuse were reported by several key informants, many of whom discussed the widespread acceptance of sexual DV.“[If] the woman doesn’t want to have sex, and she is forced into it by the husband, it is domestic violence. But unfortunately, in India, women do not look at it like this. This is violation of their rights to be assertive about sex, they don’t even look at it like violation. You talk to ten women and nine will say that that is his right to have sex, to demand sex, and when he wants, whether the woman wants it or not, is his right.”Women’s NGO leader: “She’s living in her mother’s house. Her brother is married. His children, her two children, and her husband—everyone lives in that house. She says that in the evening, whenever he wants, he just takes me, drags me, takes me inside [the] room and closes the door. In front of everyone, sister, I feel like I’m dying. Dying at 5 o’clock, 6 o’clock, 7 o’clock, 5:30…whenever he wants it. He just closes the door from the inside. He makes me feel like I’ve died and died.”Women’s NGO leader: “…so she always used to say that he would not even leave me during the four days of my period. Regularly, every day he wants sex. So I was trying to make him [the husband] understand during counseling…So, in that, he said to me that a ‘wife is just like toplayatli bhakar [bread in a basket].’ Whenever he wants, he can just break it and eat it. Whenever I want my wife, I should be able to have her—and that’s the meaning of a marriage.”Similarly, a family court counselor explained her interaction with an abusive couple she counseled through her work: “Then sometimes in such relationships we have seen that the father-in-law eye his daughter-in-law [with sexual intentions] and he wants to have illicit relations with his own daughter-in-law. People are like that too. Then everyone together they hit her. And whether educated or non-educated, it is happening in all sectors.”Human rights lawyer: Some participants discussed how sexual abuse was particularly common among couples employed in the information technology sector, one of the largest industries in Pune. They attributed this to a large disposable income allowing for the purchase of pornography (or blue films).“But in information technology, computer sector, I think it is my personal opinion, that they are earning out of proportion and because of that what happens is they do not have money as an issue or problem. So as money is not an issue they keep on experimenting things. I mean, there is a relationship with it, experimentation and money. So then they watch different blue films [pornography], different sex videos, sex films, and then they expect their wives to perform like that…there was a man, he made his own rule in the house. Only two of them used to stay there. He made the rule that all the windows should be closed and she should do everything in a naked situation. Everything. She should not wear clothes. And if she would wear clothes, then he would hit her, that ‘did you ask me? Why did you wear clothes?’ and whenever he felt like doing sex, he can do anywhere. So sometimes in the kitchen, the other time somewhere else, anywhere.”Human rights lawyer: “Then in many cases, blue films [pornographic films] are shown, and [the women] are asked to replicate that. And in some high-profile [settings] group sex—they are forced to perform this. And there are some cases that have come to us where the husband takes [his wife] and asks her to have sex with another person in front of him. Even if that woman does not want that, she is forced to do it. In some cases, I have come across such examples in which the husband had a fantasy to video shoot the actual act during sexual intercourse, and he used to video shoot it in the mobile [cell phone], in the mobile [camera] he used to shoot it.”Family court counselor: Physical abuse was also reported, although none of the participants shared stories of abuse in which guns or knives were used as weapons of abuse. Rather, severe forms of abuse included burning and use of more readily available tools such as sticks.“They are arm-twisted because of dowry. For example, if they have received less dowry, then they torture her to get more money. She is ill-treated, beaten, or even in Maharashtra, many cases have occurred when she was burnt alive or poisoned, and her parents aren’t even made aware. Then they inform them that your daughter has suddenly died. If they get the money, then there won’t be any problems, but they would ask for money again.”A 63-year-old, married, female focus group participant: “The woman was bedridden because of the burn injuries. She was attempted to be murdered by burning her. And see the whole disfigured body that her skin had stuck to even the hand, even her hand was unable to be taken out, it was stuck to the body as all her skin had melted…She took her thumb impression on the authority letter [since] she was not in a position to sign. Her thumb was burnt. It was taken like that, all blood and ink together. I mean, even judge asked us that, ‘how did you take like this red-colored thumb impression, isn’t that lady educated?’”Human rights lawyer: “‘He slapped me, he hit me in the head, in front of 4 people he used abusive language,’—he pulled her sari in the bazaar and yelled at her. This is all abuse—isn’t it?”The perceived severity of abuse experienced seemed to be influenced by whether others were present to witness the event. For example, a women’s NGO leader gave particular importance to a woman being slapped by her husband when others were there to observe them: Physical eviction of a woman from her own marital home was also noted by several participants.“Even such cases are there where they were beaten up, kicked or beaten with the sticks, or slapped in the face, or thrown out of the house at odd hours—even such cases are there.”An HIV counselor described: “they are thrown out of the house. For any damn reason, you get out, you didn’t bring this, that due to such reason they throw her out of house, or if her behavior is not liked or if she doesn’t know how to cook, there was more salt in the food, due to many such reasons the women are thrown out of the house.”Family court lawyer: Many also discussed how women commonly experience psychological abuse or are shunned by their marital families, whether for lack of provision of sufficient dowry or wedding-related gifts, infertility, or delivery of a girl-child.“There are many arguments over the give and take [dowry]. Now we are heading towards 21stcentury, but still in many cases we are seeing…like dowry and all doesn’t exist, but still, your parents did not give this in the marriage’ [or] ‘the wedding should have been done like this’ [or] ‘they did not do our maan-paan [/providing the groom’s family members special respect and gifts during the wedding/].”Family court counselor: “She thinks, ‘if I open my mouth then these people [her in-laws] would torture me more.’ So she keeps quiet and goes to her parents and tries to get the money. If she doesn’t get the money, then she would be tortured more, even beaten.”A 69-year-old, married, male focus group participant further elaborated: “There was one such case that had come to me in which the woman could not have a child. They had tried a lot, but they could not conceive a child. And the mother-in-law used to blame her for everything. There was a vine in their garden, and that vine never produced flowers, so she was always used to say, ‘throw away that infertile vine. It should not be kept in our garden. Throw away that infertile vine…’ Now that is a kind of indirect emotional harassment. And she came to realize that ‘this is being said to me.’ That ‘throw her out of the house, throw her out of the house,’ this is what her mother-in-law wanted to tell her son, but each time she would give the example of the vine. And because this [taunting] became more frequent, she too began feeling that ‘we are not able to bear a child, so it’s my fault. Mother-in-law is also harassing us.’ …When the sister-in-law delivered a baby and she went to the naming ceremony, she was not allowed to touch the baby because she [was] infertile.”The family court counselor explained a case she encountered of a woman being verbally tormented by her mother-in-law for being infertile: “There are some who torture their wives because she has only daughters. They never consider that even they [the husbands] are equally responsible. My own sister’s example, still as in, even after her daughters are educated, they are now engineers, and they are married to good husbands—still my sister is berated.”67-year-old, married, female focus group participant: “I have seen a woman delivering a girl-children and the husband, the in-laws, never visiting them. If they visit, they are too harsh on the mother, they criticize her, they make her repent, make her cry, make her feel that she has done a big crime.”Obstetrician/gynecologist: This qualitative study provides a detailed, comprehensive understanding of community perceptions regarding the definition of DV in the Indian context. The key informant interviews explored expert knowledge and beliefs regarding behaviors that constitute DV and allowed for in-depth exploration of individual case stories. The key informants, shaped by the diversity of cases they encounter through their varied professions, shed light on different legal, religious, cultural, psychosocial, and medical aspects of the definition. In contrast, the focus groups offered insight into broader, lay community views through provoking discussions regarding behaviors constituting DV and explanations of conflicting perspectives. A comprehensive, culturally-tailored definition of DV emerged that encompassed forms of physical, sexual, and psychological abuse as well as control. Exertion of control over a woman’s reproductive rights, financial expenditure, her socialization with friends and family, and access to food and nutrition were raised by many participants as being dimensions of the Indian definition of DV.While many central elements of DV are universal, our study findings suggest that certain manifestations of abusive behavior in India differ because of its culture, evolution of technology, and material availability . For exastridhan, property, and the couple’s earnings) and psychological abuse over dowry or maanpaan , 2) “new-age” social control, stalking, or psychological abuse via text messages and social media, 3) control over reproductive and contraceptive rights and psychological abuse for infertility or delivering a girl-child, 4) confinement to, or alternatively, eviction from the marital home, and 5) nutritional deprivation or control (i.e. through enforcing fasts and forcing dietary change away from vegetarianism against religious beliefs). The WHO definitions are comprehensive in regard to physical and sexual DV; however, specific mention of the commonly-used tools to inflict physical abuse (that women may not perceive as weapons) may improve the sensitivity of the physical DV definition. Similarly, surveying forced sex during times perceived as sexually-humiliating like menses in addition to surveying humiliating sexual acts may enhance sensitivity of the sexual DV definition. We thus propose to expand the Indian operational definition of DV to include physical, sexual, and psychological abuse, stalking, and economic and other forms of control perpetrated against a married woman by her spouse or other members of the family in which she marries. Surveys that stem from this definition should consider inclusion of the various aforementioned forms of DV (summarized in Thus, while the WHO definition serves as an essential starting point to develop an operational DV definition for India, our results stress the need for it to be culturally-adapted. For example, although the WHO acknowledges DV can be perpetrated by any member of the household, current WHO studies limit the definition to abuse perpetrated by intimate partners—not other marital family members. While the purpose of doing so is likely to make meaningful cross-country comparisons, it runs the risk of dangerously underestimating DV experienced by women in India. Second, although not explored in our study, the 2013 WHO systematic review definition surveys abuse occurring after age 15, but may fall short in capturing early experiences of DV for the 27% of Indian women who are married before then . Next, iOur findings also have several implications for DV prevention interventions and policy development in India. First, prevention strategies should incorporate increasing awareness of the many forms of abuse that constitute DV beyond physical abuse alone and emphasize that the PWDVA offers protection against many of these. Second, they should consider incorporating content that heightens knowledge that infertility and fetal sex determination is a biologically-driven phenomenon out of the woman’s control. Third, they should teach couples the difference between sexual intercourse and marital rape, and engage them to discuss means of ensuring that sexual intercourse is enjoyable for both. Additionally, perpetrator intervention programs should consider engaging not only husbands but other members of in the in-law family.Our study possesses some limitations. First, we limited our participant pool to Pune, an urban, well-developed metropolis, in the western state of Maharashtra. In doing so, we may have not captured the DV experiences of those in rural and tribal communities, or other regions of India where DV may manifest differently. SimilarIn conclusion, our study emphasizes the need to broaden the surveillance definition of DV in India to truly capture the abuse and control experienced by women at the hands of their marital family. The findings not only add to the literature informing the development of future culturally-tailored DV interventions, but also call for an India-specific measure to better quantify DV and evaluate the efficacy of such interventions.