Alcohol control has emerged as an important global health challenge due to the expanding influence of alcohol companies and limited control measures imposed by governments. In the Peruvian Andean highland, the ritual function of collective drinking is reported to have been weakened in response to the increased availability of alcohol and the experience of political violence. This study seeks to merge the broader political economy with local experience and culture to provide a deeper understanding of the dynamic between global processes and local realities.n = 28) and focus group discussions (n = 19) with community participants, teachers, health workers, alcohol vendors and police officers. Thematic analysis identified patterns of individual and collective meaning situated in relation to social, political and economic factors.We used purposive sampling to recruit participants. We conducted in-depth interviews (Local perspectives and behaviour regarding loss of control over alcohol are shaped through the complex patterns of power and meaning exerted and experienced by different actors. Participants’ emphasis on parents’ lack of control over alcohol use by “abandoned” children reflects the structural vulnerability of some Andean families struggling with economic hardships. Participants also emphasized how alcohol consumption was tied to forms of control exerted by men in households. Participants expressed that some men demonstrated their masculine identity and symbolic power as the breadwinner through spending on alcohol. The third emphasis was tied to the market economy. Participants expressed that the expansion of the alcohol market and perceived absence of government control coupled with macroeconomic conditions, like poverty, shaped patterns of alcohol consumption.Our findings illustrate how problem drinking is shaped not simply by an individual drinker’s lack of self-control but also by a regulatory environment that enables the unrestrained marketing of alcohol products and the creation of a culture of consumption. Harmful consumption is mediated by the reshaping of the Andean cultural practice of collective drinking. Attending to local perspectives is essential for policies and interventions that connect structural dynamics with the cultural and experiential aspects of alcohol consumption. The 2018 Global Status Report on Alcohol and Health indicates that alcohol use results in approximately 3 million deaths per year and numerous other social problems , 5. The Amplifying the risk of alcohol company influence is the fact that over half of the governments in the world do not have one health protective policy in place to control the alcohol market . Weak orWhile the emphasis on universal harms, industry practices, and best practices for alcohol control is critically important to alcohol control, there is also a need to understand how these universals intersect with local understandings and practices. This understanding can lead to a more sensitive and responsive approach to alcohol control that respects the unique ways in which global processes influence cultures of consumption, and how these cultures insulate from or respond to global processes.We know that the problem of harmful alcohol use has been conceptualized using different points of emphasis and epistemic frameworks specific to the time and culture, pointing to the need for a localized understanding of global processes , 12. ForNeoliberal rationality is a mode of governing that aspires to produce self-regulating citizens . This mochicha (fermented corn beer) has been traditionally consumed at a ritualistic part of community fiestas since the pre-Spanish conquest period, beverages with high alcohol concentration such as aguardiente de caña (sugarcane spirit) became available with the introduction of distillation in the sixteenth century, followed by commercialization of beer in the nineteenth century , unpublished). Ethnographic studies in Andean highlands have documented collective intoxication as a cultural phenomenon that is associated with Quechua identity, Andean history and socio-cultural context  to ask help,” or “not [having] any trustful friend” .Another pattern of problem drinking is using alcohol to cope with daily struggles such as family problems and financial problems, and emotional suffering from relationship problems, which may lead to a bad habit (“No hay control” (There is no control), which was used to represent the multiple ways in which the reported shifts in patterns and motivations for problem drinking were attributed to various forms of control or absence of control, including control of parents over their children, men’s control over the household and self-control by drinkers, the absence of control by the government over the growing local alcohol market.A dominant theme identified through our analysis was captured by the recurrent trope When asked about the general alcohol use in the community, most participants raised concerns over adolescent alcohol use. Participants repeatedly stated that “children are abandoned,” attributing underage drinking to a lack of parental control and supervision. Others said that children drink with friends to create a substitute family situation to counteract feelings of loneliness and absence of parental emotional support.selva (the Amazonian jungle) or to other cities to earn money to meet household economic needs. The children then live with relatives such as cousins and grandparents. During fieldwork in 2016, a 15-year-old girl died after being sexually and physically assaulted by several intoxicated adolescents at a party in a neighbouring district. The assault occurred in a house with no adult supervision or presence. This incident was often mentioned as an example of how children are placed in insecure situations without parental care, supervision, or control. Young community participants, health workers, and police officers in Carmen Alto often referred to fiesta semaforo as a facet of contemporary youth culture. Specifically, male and female adolescents invite each other to underground parties involving excessive drinking of cheap liquor mixed with water or soda  and sexual activity using secret codes transmitted by cellphone and Facebook to avoid the attention of parents and authorities. During one focus group in Carmen Alto, participants described this context:chacra (field). Who is going to control this kid?P6: It has been an invasion [of land], parents have come [as] they wanted to occupy a plot of land, and they have brought their children. They brought their kids here so that the kids can study. And then parents are in P7: No one.P5: When a friend comes, and then they go to drink.P4: They go to fiesta, and then they drink.P5: Disco.P6: This largely happens in this community.Many participants from Carmen Alto explained that this precarious family environment involved children relocating to urban areas for the purpose of education while their parents remain in rural areas. Relocation of children for education in Socos is not as common as in Carmen Alto. In Socos, parents often embark on short-term travel to the chacra (plot of land). They are gone at 4 o’clock in the morning because of the lack of an economy”.Persistent economic hardship forces parents to work long hours, which results in separating parents from children and/or limiting their time together. One 48-year-old female focus group participant from Carmen Alto stated: “I have seen mother and father are dedicated to chicote (whip) to inculcate obedience and respect, and this was considered useful to “give good orientation” . Participants reported that children were today becoming “rebellious and dominate their parents”  by referring to human rights and knowledge of institutional protection. It was noted that this situation contributed to youth alcohol consumption. “Parents were previously stricter and never let children go out in the night” . Most participants still largely considered the chicote as an effective and acceptable disciplinary tool. In this context, “DEMUNA” and “law” were frequently cited as barriers for parents to control their children’s alcohol use. DEMUNA  was established in 1993 to promote and protect the rights of children and adolescents. It has the responsibility to intervene any time the human rights of children and adolescents are violated. In December 2015, Peru also adopted a law prohibiting the use of physical and other humiliating punishment with children and adolescents . The law, social services, and intervention by DEMUNA to protect women and children from violence were largely appreciated. A 60-year-old female focus group participant in Socos stated: “Now the law prevents men from hitting women”. At the same time, others see some parents having difficulty controlling their children’s misbehavior because the parents fear that their children will report them to DEMUNA, claiming that their parents’ discipline is an abuse of children’s rights.Participants further stated that, compared with their own upbringing, parents are having a hard time controlling their children. Participants noted that in the past parents and elders used “I think now we cannot pressure children. They drink and say ‘[If] you say something, then I am going to report you [to DEMUNA]’ and mother has this fear of being accused.”recreos.Lack of control was also mentioned to describe the way adult male drinkers, who were initially happily drinking and dancing, start to express their problems, cry, or become aggressive, sometimes to the point of violence, and end up falling asleep on the street until the next morning. It was not uncommon to see security guards or other community members intervening when male intoxicated drinkers started to argue and fight during the community fiestas and machismo to explain this “little control with respect to male drinkers” . Machismo was generally cited to describe gender inequality in current everyday life. In reference to drinking specifically, community participants, police officers, schoolteachers, and health professionals noted that machismo was related to how men justify their drinking practices, spending ‘hard-earned money’ on drinking as an entitlement from being a ‘breadwinner’. The common answer to the question, “Who drinks more? Women or men?” was “The one who has more money; men.” . The Andean way of sharing drinks is entangled with the practice of machismo. During a bout of drinking, men show not only physical toughness by the amount of consumption but also by their ability to purchase drinks for others.Many participants referred to the cultural concept of arrependimiento, pesares) and guilt (culpa) the following day when they remember what they did and how much they spent on alcohol the previous night.When competitiveness accelerates drinking, controlling drinking and spending becomes challenging. A young male focus group participant in Socos stated: “Before you become drunk, you think. When you drink, the alcohol [level] goes up, and you start losing control of yourself. You practically forget everything for the moment.... Now the experience is that while you are drunk, you could be what you wish to be without control....”. Many male community participants stated that they often feel regret A common practice among Andean individuals engaged in labor-intensive agricultural work is to regularly drink a “minimal proportion” of alcohol to “feel motivated to continue working”. In contrast, drinking a “maximum proportion [of alcohol] can result in economic loss” . One 48-year-old male focus group participant in Carmen Alto stated: “If you do not control alcohol, alcohol controls you. For this reason, it is necessary to know up to what point you can drink. There are others who do not have this kind of control.” On one hand, the duration of a bout of drinking and the total number of drinks consumed “depends on the money”  and “If you have money, you can [continue drinking] till dawn or continue” . At the same time, men try to exhibit control over the household economy and their health by “calculat [ing] the quantity of beer” they pour into the glass, as they know that it is their turn to buy another round of drinks if they empty the bottle . They know “who buys and who does not buy”, while being seen as a free rider  has a risk of “not being invited for the next time” .borracho (intoxicated) but seeing some women borracha is bad.” With this cultural norm, a 60-year-old female focus group participant in Socos mentioned, “some couples drink together and the wife needs to control herself”.The gendered division of labor in the family seemed to excuse men’s lack of control over their alcohol consumption. Young male focus group participants from Carmen Alto considered that married women with children drink less than single women because the former are responsible for taking care of children. During the fieldwork, the first author frequently witnessed women drinking with men during community fiestas and family gatherings. Most women consumed only a small amount of alcohol and often left earlier than men, suggesting that their alcohol use, while frequent, is distinct from that of the men. Female intoxication is largely frowned upon, as a nurse in Socos stated: “We see men being chicha (fermented corn beer), commercial beer, caña and trago  are commonly consumed. Chicha is largely consumed as a ritualistic part of community fiestas, while drinkers of cheap caña and trago are commonly perceived as those with limited economic resources, who are often campesinos . In addition, some men are reported to spend a disproportionate amount of money on alcohol, often to the point of spending all received wages during a weekend or life savings at a fiesta patronal, even though both they and their spouses work to cover household expenses. While participants often joked that “people work to drink” in Ayacucho , spending earnings on alcohol rather than on household expenses as a demonstration of manliness was questioned and considered a lack of responsibility. Particularly evangelists, health professionals, and high school teachers characterized men’s spending on alcohol consumption to be reckless extravagance in contradiction with the economic situation of Ayacucho where some “children are still without bread” .The apparent lack of control in men’s drinking reflects not only excessive alcohol use but also men’s identity-making and power representation in public and domestic spaces. In public spaces, the type of alcohol drinks can mark the socio-economic status. In both districts, In the domestic space, men’s spending money on alcohol was criticized for the negative impact it had on the household economy, potentially leading to conflict between spouses. Some female participants showed their frustration with their husbands’ spending on alcohol by describing that “It is worse when a drunken husband responds, ‘I do not drink with your money’” .cultura etílica”, which expresses an individual’s responsible drinking and self-control. A psychologist explained that cultura etílica is “control, [with awareness that] I am drunk and I can cause some problem because I know how I am,” unlike “others [who] have many responsibilities the next day and know how they are but they do not control” . Among community participants, it is also commonly understood that people “should drink rationally  only up to the point [they] can afford” .Health workers and high school teachers often cited the concept of “P5: Instead of spending money on alcohol, it is better to eat.P4: It is better to eat no matter how little.P6: You should fill yourself up with 100 Soles, not with beer.P4: Sometimes we spend in vain.Julián: Spending in veinP3: When we are drinking with friends, we challenge ourselves. And then we use our money and nothing remains for our wife.costumbre , which was attributed to the lack of control over the expanding alcohol market. One young male focus group participant in Socos described this expansion by stating: “If you leave [home], you see people drinking on the street, [and] at the corner. There is no respect … At one corner, you see one fiesta, and at another corner, you see another.” The easy availability of alcohol has also shaped drinking practices in the community. While the traditional community fiestas still play a role in strengthening social relations through the practice of Andean reciprocal support, ayni, many participants no longer attributed to fiestas the values and meanings that they once held. For instance, a schoolteacher in Carmen Alto stated:Participants also noted the normalization of drinking described as fiesta patronal … Yes, it used to be something cultural, but in the past few years, it is not any longer. The economic aspect is added. Profit.[Traditional] fiesta is commercial. Now it is already a commercial activity because now everything is about selling. For example, I see people want to make money, profit in the mayordomo ,” who “takes the responsibility [of hosting the fiesta] with money with caprice [not with faith]” .Many community participants shared this sentiment. One elderly male participant in Socos described the organizing of traditional fiestas of Catholic Saints as being costlier as it becomes “more modern”, stating that nowadays, “Only the one who has money can be techada de casa (house building), we help each other and drink and dance, this is how we build casa (house). In techada de casa, we become close to each other, drink, if we do not do it, there is nothing.”On one hand, in resource-scarce rural settings in the Andean highlands like Socos, community fiestas with collective drinking are still considered to be a practical mechanism to sustain subsistence living by strengthening and maintaining the bond of relatedness among family and community members. One 50-year-old female focus group participant in Socos stated: “In recreo and events such as festivals and music concerts, the improved road conditions and accessibility of transportation between Ayacucho and Socos, and the availability of low-cost alcoholic beverages mixed often with soda drinks.Participants in both districts often compared the availability of alcohol to staple food. As one stated: “Bread can run out, but beer is always [available] at each store, it is ever-present” . In addition, participants in both districts noted the increase in drinking venues such as cantina (bar) all over the world” . Despite the poor economic conditions, alcohol is affordable and accessible. This includes caña  and trago , which are thought to make people drunk rapidly and be harmful to health. One nurse in Socos stated: “caña damages our brain more and [it is better] to choose beer.” These types of alcohol can be easily found at local vendors who also sell alcohol on credit to regular customers, facilitating access even to those who have limited resources. The diversification of alcoholic beverages was also noticeable; as one 43-year-old female focus group participant from Carmen Alto stated: “Now those businesses are innovating that theme of beer. Now there is beer made of quinua (quinoa) and trigo (grain)”. Also, when the first author returned to Ayacucho in March 2019, she saw Budweiser, which had become available in the Peruvian market in 2017  is another frequently cited example. Participants were conscious that this was a marketing strategy to add an occasion to drink during the week, as drinking on the weekend with colleagues, friends, and family members is already an established practice.An advertisement for Pilsen beer that proclaims “Thursday is a day of buddies”  to avoid [unofficial] factories of those alcohol. We need to cut these alcoholic beverages. Up to now they do advertisement for P7: Fathers’ day, Friends’ day, everything [about drinking is] everywhere in the city.Jueves patita ha ha ha …P6: From the same manufacturer. P5: Because everything about this is to motivate drinking.With the felt impact on alcohol availability, the alcohol industry is blamed for creating alcohol-related problems in the community while making profits off of consumption. Participants repeatedly mentioned Peru’s largest brewery, Backus, as making huge profits: “[Alcohol] business is making millionaires, Backus is a millionaire” .alcoholismo . Some participants suggested that the alcohol companies take advantage of this vulnerability to pursue profits. Community participants framed problem drinking as the result of market forces that push the rural poor unable to find a solution to their problems to consume alcohol.Parallel to excessive alcohol use at community fiestas and weekend social gatherings, participants expressed that alcohol use can be a means of coping with psychological distress for “some [who] do not know how to manage problem and seek alcohol” and “think that they can solve problems while being drunk” . They described solitary drinkers—those who drink as a means of coping with hardships such as family conflict, financial concern, and breakup who gradually develop costumbres . Day by day, they do not organize fiestas with this purpose. We do fiestas with the purpose of getting people to consume alcohol, and this is the purpose of business. Those who benefit are only big business. How much revenue do we generate for Backus? Whatever quantity, people like, people like to organize fiestas, every weekend, fiesta in Arenales, [fiesta] in San Luis, now for the Day of All Saints. We have a number of fiestas. Then, those businesses benefit, and we do harm to ourselves, people in the rural area. People who are not prepared. People who cannot solve their problems dedicate themselves to alcohol. “I drink to take refuge in alcohol” [they say].” Previously, possibly in the 80s and 70s, here in our community, people used to celebrate, organize activities with the purpose of reevaluating our The active promotion of alcohol for economic gain was contrasted with the economic hardships and precarity of those who were consuming alcohol. This sentiment was summarized by one participant, who stated: “Some people who have economic problems take refuge in alcohol even though they do not have [money] to buy other types of things” .alcohólicos, those who use alcohol as a means of coping with suffering, some community participants continue to blame the government. A female focus group participant in Carmen Alto stated:Alcohol sales have been increasing in Peru, exemplified by a 24.6% increase in Backus’s sales of beer from 2012 (S./3160.2 mil) to 2017 (S./3939.0 mil) , 46. Comalcohólico doesn’t seem to become alcoholic because he wanted to, but there are reasons. They can be infidelity, others can be a factor related to work, lack of economic resources, and if he has a family, the more he drinks, the more fights [due to] the consumption of alcohol … Yes, the authorities are to be blamed for allowing stores to sell alcohol … there is ethyl alcohol which they sell, mixed with water, and that is what causes them to become ill, and that really gives me pena (sadness), when I see an alcohólico …An Participants associated this lack of government control with the benefits they received from an expanding alcohol market.With this drinking including [drinking by] minors, when people drink, there is more revenue for the government because of more consumption. Although people say there would be pills, medication [for addiction], the government will not approve it because there is more revenue for the government wherever there is a factory for alcohol, or even coca. For this reason, drinking will not disappear.recreo to sell food to hungry drinkers, while paying the municipality some monthly fee to use the street for their business.The local government collects tax from flourishing business activities in the entertainment zone of Carmen Alto. One Saturday night in Carmen Alto, I saw many women opening street stalls in front of bars and The local perspectives described above highlight the complex patterns of power and meaning exerted and experienced by different actors at different levels, which shape behaviour and local understanding regarding loss of control over alcohol. Many of these sites of control, which have been maintained by static power hierarchies at family and community levels, have shifted dramatically with the globalization of markets and cultures, and the influence of transnational alcohol companies. One high school teacher in Socos described a growing consumer culture and circulation of ideas and images linked to transnational markets in students’ clothes and music , 48. WheIn this context, some health professionals stressed the lack of self-control as a driving factor of current alcohol use in Ayacucho. This aligns with a common perspective that attributes excessive alcohol use to a failure in self-management. However, there is also evidence that this perspective risks subjecting the drinker to stigma and social marginalization , 19. Impcampesinos (peasants) as a means of coping with frustration and disillusionment due to limited economic opportunities  [is difficult] because this is very much a theme of culture or socio-cultural. It is ingrained … To say people ‘Do not do’ is like [saying] ‘Stop being Peruvian. Be Chilean.’” This relationship between culture, identity and the political and economic conditions is an important aspect of intervention. This analysis has illustrated that the conditions of consumption intersect at different levels to condition environments of consumption, while the moralistic narrative of responsible drinking and control can distract from the social, economic, and policy conditions that lead to consumption [While the market, social, and governance forces can contribute to alcohol-related illnesses that also stigmatize and isolate drinkers, the notion that “sumption , 81. Peosumption , 50. Easalcoholismo [The political economy approach adopted in the study unpacked complex macro-micro interactions and power dynamics that constantly shape the meaning and practice of alcohol use in the south-central Andean highlands of Peru. A major limitation of the current study is one of scope, namely the limited exploration of the role of religion in the popular perspective on control. In the Andean highlands, evangelical churches associate alcohol use with backwardness, laziness, and lack of self-control, while playing a role of healing site of a range of illnesses including oholismo , 82. In oholismo . In focuFurthermore, female participants might have had difficulty sharing their perspectives on and experiences of alcohol use with other participants and/or research team members. While male and female participants were separated during focus group discussion, the existing cultural norm that female alcohol use outside of community fiestas and family gatherings is not widely acceptable, particularly in Socos, may have constrained the access to the full range of female participants’ accounts. The cultural significance of female alcohol use and its impact on power relations and family dynamics in the present research setting and other LMICs could be deepened in future studies.In this paper, participants’ perspectives illustrate how problem drinking is shaped not simply by an individual drinker’s lack of self-control but also shaped by an environment that enables the unrestrained marketing of alcohol products and the creation of a culture of consumption. Harmful consumption is mediated by the reshaping of the Andean cultural practice of collective drinking. Attending to local perspectives is essential for policies and interventions that connect structural dynamics with the cultural and experiential aspects of alcohol consumption.


This manuscript explores the relationship between positive psychology and political philosophy, revealing an inter-disciplinary approach that speaks to the concerns of the common good. Since positive psychology has been expanding its reach into social and political spheres, its relationship to philosophical arguments has been worthy of exploration. Positive psychology is associated with utilitarianism, and aspects of hedonic psychology. However, an alternative concept of eudaimonic well-being has enabled this psychology to have links to other political philosophies. Therefore, this manuscript provides an overview of contemporary political philosophies: first, it discusses the debate between liberalism and communitarianism, and secondly, it summarizes the subsequent developments of liberal perfectionism, capability approach, and deliberative democracy. Then, the configuration of these political philosophies is indicated by the figure of two axes of “individual/collective” and “ethical/non-ethical.” The following section compiles the inter-relationships between the conceptions of citizenship, justice, and well-being, regarding the main political philosophies: egoism, utilitarianism, libertarianism, liberalism, communitarianism, and conservatism. Utilitarianism is associated with happiness, while liberalism and libertarianism rely on the concept of rights, which is almost equal to the idea of justice. Accordingly, utilitarianism is a philosophy of well-being, while liberalism and libertarianism are philosophies of justice. However, there is little connection between well-being and justice in these philosophies because the two kinds of philosophies are incompatible. The latter kind criticizes the former because the maximization of happiness can infringe on people’s rights. Moreover, these philosophies do not particularly value citizenship. In contrast, communitarianism is intrinsically the political philosophy of citizenship most attuned to increasing well-being, and it can connect an idea of justice with well-being. The final part offers a framework to develop an inter-disciplinary collaboration. Positive psychology can provide the empirical basis of the two axes above concerning political philosophies. On the other hand, the correspondence makes the character of political philosophies clearer. While libertarianism and liberalism correspond to psychology as usual, utilitarianism and communitarianism correspond to positive psychology, and the latter can be regarded as positive political philosophies. This recognition leads to the interdisciplinary framework, enabling multi-disciplinary collaboration, including work with the social sciences, which could benefit the common good. This manuscript will explore “Psychology for the Common Good” by examining the association between psychology and philosophy, more concretely, positive psychology in the context of political philosophies. Positive psychology investigates the good life scientifically. On the other hand, philosophy examines ideal ways of living and suggests ways to improve our society. Combining philosophical inquiries with contemporary science can assist us in exploring new ideas and practices related to personal and public well-being. This article seeks to accomplish this task by extending the recent developments of positive psychology.1Let us begin by reviewing the basics. There are several major contemporary political philosophies: utilitarianism, libertarianism, liberalism, communitarianism, or republicanism. Although there are various sub-types, intermediaries, and combinations, this manuscript first focuses on these major representative philosophies for making the relationships between political philosophies and psychology clear.Positive psychology has been frequently associated with utilitarianism within these political philosophies . The reaHowever, there has emerged a considerable amount of criticism against this ascription. Some scholars have argued against using pleasure as a measurement of well-being, and they have objected to such ideas as Hedonia, putting forth instead a new concept and measurement based on the word “Eudaimonia,” which originated in ancient Greece. They pushed forward the idea of “eudaimonic well-being,” suggesting that conceptions such as growth, self-realization, engagement, and meaning constitute eudaimonic well-being.This was followed by a heated debate between those arguing for subjective well-being e.g.,  and thosTherefore, it follows from this debate that the philosophical underpinnings of positive psychology should not be confined to classical utilitarianism. While the classical utilitarianism of Bentham is viewed as hedonic and quantitative, J. S. Mill later proposed qualitative utilitarianism. Moreover, there have appeared various variations of consequentialism or welfarism from this tradition in contemporary philosophy. Consequentialism signifies that specific normative properties depend on consequences, which are calculated by the sum of pleasure in classical utilitarianism but are inferred by more sophisticated ways in non-utilitarian consequentialism today.Welfarism in economics is a kind of consequentialism, which regards the impact on welfare as morally significant. This economic idea depends on the conception of utility, and it assumes that social welfare can be conceived as an aggregation of individual utilities. As utility means the degree of pleasure or satisfaction an individual receives from economic activity, it is more or less a hedonic conception. In contrast, welfarism in a broad sense, signifies “nothing but welfare matters, basically or ultimately, for ethics” , p.184, As qualitative utilitarianism recognizes the difference in the quality of pleasure, it is closer to communitarianism discussed below than original utilitarianism. In contrast, non-utilitarian consequentialism is frequently unrelated to a specific human description. Accordingly, there is little relationship between these currents originating from utilitarianism and psychology. In addition, while economic welfarism is basically hedonic and preserves the utilitarian element, welfarism in general is compatible not only with utilitarianism but also with the other political philosophies discussed below , p. 186.It would then be necessary to examine the relationship between the other political philosophies and positive psychology.Apart from this debate, positive psychology has been criticized on various points since its birth . For exaThe second point is closely related to the subjects of political philosophy. One of the most scathing criticisms against positive psychology is that it is permeated with a Western-centered or American-inspired brand of individualism. As a result, it does not sufficiently deal with a societal, cultural, and political force .In reality, the manifest of positive psychology enumerated its three pillars as “subjective emotion, individual traits, and institution”. AccordiNonetheless, it cannot be denied that its focuses have been on the former two, namely, the investigations of personal well-being and character strengths. As a result, early hopes for exploring new fields like positive anthropology and positive social sciences have gone “unfulfilled” , p. 108.Accordingly, as a response to this criticism, there have been some noteworthy attempts at deploying positive psychology for the development in social or political spheres  or the aMoreover, the first point has relevance also in the collective spheres. Unfortunately, the world remains full of negative political and social phenomena such as misery, poverty, conflicts, war, corruption, dictatorship, and pandemic like COVID-19. Thus, there are many issues of “political philosophy  as usual”. In contrast, positive ideas, including justice, fairness, and the common good, are included within central political philosophy conceptions. Accordingly, it is necessary to deal with both dark and bright sides in social or political spheres.Fortunately, there have appeared new waves of positive psychology for amending the two weaknesses. Second wave positive psychology aims to integrate the positive and negative sides dialectically, exploring the complex relationships between both sides . Then, t2 similar to “positive social psychology”  on the reasoning of the priority of the right over the good in opposition to virtue theories and consequentialism.“The priority of justice over the good” in these thoughts was challenged by Michael From the outside perspective, the difference originates from their views on the good associated with various worldviews. It is difficult to decide what justice is regarding the environment, security, bioethics, and welfare, without mentioning values. Consequently, it is necessary to conduct public discussions on these issues concerning the good life and determine what is just through public deliberation. That is to say, justice is related to the conception of the good life. In other words, the right is concerned with the good. This idea is the core of the communitarian concept of justice. Therefore, it is important to dare discuss these public issues referring to the good life to revitalize democratic politics.A Theory of Justice includes the view of self  orientation: it attaches importance to various collaborative activities and communities, as well as to the good life sustained by morality and virtue, not only in private lives but also in public lives. As this debate presents one of the essential issues in contemporary political philosophy, the two ethical and communal (or public) axes found in this debate will be helpful to overview the other recent developments in the next section.Partly due to the impact of the communitarian charge, some new approaches from within liberal currents are somehow opposed to typical deontological rights-based liberalism, and they have led to the “troubled dominance of the liberal paradigm” , p. 5.First, concerning the ethical dimension, the neutrality thesis was amended even within liberal theorists. Some admitted that any liberal belief of state neutrality could not be consistently justified: some ethical goals and ideals may be supported by the state because many virtues or conceptions of the good such as love and friendship are entirely uncontroversial. In sum, the thesis is an illusory myth  consequentialism after his criticism of welfarism , p.39.The Theory of Moral Sentiments (1759) and the Wealth of Nations (1776), corresponding to moral philosophy and economics. Thus, Sen tries to recover the bridge between the ethical and engineering approaches in economics, each of which existed in the origin of modern economics  instead of utilitarian welfarism and defined the concept of capability as an “alternative combination of functioning the person can achieve, and from which he or she can choose one collection” , p. 9.On the other hand, he valued the concepts of rights for their essential role in overcoming the shortcoming of welfarism. Accordingly, he tried to integrate consequentialism and deontology by proposing the concepts of a “coherent goal-rights system,” emphasizing the necessity of freedom . Thus, hIn addition, philosopher Martha Nussbaum collaborated with Sen in the quality of life project at the World Development Bank because Sen invited her to cooperate. This project influenced the idea of human development embodied in the Human Development Index of the United Nations Development Program.At the time, Nussbaum proposed a kind of Aristotelian philosophy . Although Sen does not support constructing a universal and comprehensive list of capabilities , NussbauHowever, in 1998, Nussbaum surprisingly radically shifted her approach to replace the conception of human capabilities from the Aristotelian framework into Rawlsian political liberalism . ConsequThirdly, theories of deliberative democracy have surged since 1990’ with regard to the communal or public dimension. Before then, the predominant theories of liberal democracy theories do not value civic participation and discussion, for example, in the elitist theory of democracy (J. Schumpeter) and political theories grounding on the assumption of self-interests . Instead, deliberative democracy has focused on citizens’ democratic reflection and debate and regards deliberation as central to decision-making , p. ix fThe deliberative process can change people’s preferences before decision-making. This transformative nature of deliberation is different from bargaining and aggregation of preferences. Therefore, in contrast to aggregative democracy, deliberative democracy requires citizens to transcend their private self-interests predominant in the market and search for public interests. For this purpose, public forums for deliberation and reason are evaluated and proposed, exemplified by empirical research and proposals such as deliberative polls and deliberative day .As the similarity to republicanism is evident, republicanism can be a type of deliberative democracy cf. . Some trHowever, representative theorists tend to differentiate their ideas from current republicanism  because This ideal procedure seems to be inspired by Jürgen Habermas’ idea of ideal speech situation . InspireThe most salient difference between republican and liberal or discursive deliberative democracy is that while the former indispensable element is civic virtue, the latter does not necessarily refer to such a substantial ethical conception. Accordingly, while the former embraces the aim of “a comprehensive or thick common good,” the latter holds that of a “non-comprehensive or thin conception of the common good”  and the communal orientation. Within its cardinal concept of the common good, “common” signifies communal orientation, and “good” indicates the virtuous.In contrast, egoism, libertarianism, and liberalism in the third quadrant are neither communal nor virtuous. These are individualistic. At the same time, egoism and utilitarianism are hedonic; libertarianism and liberalism are non-ethical because they do not assume any particular view of persons.While utilitarianism or utilitarian consequentialism in the fourth quadrant somehow holds the collective elements in summing the happiness of all people, it lacks the virtuous moment.Secondly, liberal perfectionism in the section “Liberal Perfectionism” is situated in the second quadrant because this is both individualistic and ethical (virtuous).Thirdly, the other recent developments in the section “Beyond Deontological Rights-Based Liberalism” can be mapped at intermediate places between plural quadrants. For example, Sen’s capability approach started from utilitarian consequentialism and integrated liberal ideas of rights with consequentialism. It attempts to bridge the consequential fourth quadrant and the liberal third quadrant. Moreover, he introduced some ethical elements such as sympathy, and his approach is related to the second quadrant to some degree. On the other hand, while early Nussbaum’s Aristotelian capability approach is interpreted in the second quadrant as liberal perfectionism, the present approach is mapped in the third quadrant because of its Rawlsian liberal framework.The deliberative democracy is opposed to aggregative democracy, which is grounded on self-interests, associated with a version of egoism. Accordingly, it holds the collective or the public orientation in the right-hand spheres. Thus, while the republican deliberative democracy is mainly situated in the first quadrant, the liberal version bridges liberalism in the third quadrant with the collective or public domain somewhere between the first and the fourth quadrant.Thus, it is possible to map these political philosophies in this diagram, indicating the recent noteworthy attempts in relation to the main political philosophies and liberal perfectionism. The most recent developments can be seen as the intermediary or combination of some main typical political philosophies. Moreover, although mainstreams of both the capability approach and deliberative democracy are liberal political philosophies, they embrace another remarkable version tangent to liberal perfectionism or communitarianism: Former Nussbaum’s Aristotelian capability approach is close to the former, and republican deliberative democracy adjoins the latter. This tangency proves that the four quadrants are adequate for mapping these theories.Accordingly, it would be sufficient for this paper to summarize the essential characteristics of main political philosophies from the epistemological or methodological point of view, especially regarding “citizenship, justice, and well-being.”The New Golden Rule  viewpoint “Individualism (Atomism)/ Collectivism (Holism).” Psychological and ethical egoism is strongly individualistic and hardly communal, and their self-views are “egoist” or “selfish” because they suppose that people act in self-interest or for hedonic pleasure; they are epistemologically based on the atomistic world-views. Since Epicurus in ancient Greek, various theories have more or less associated some forms of egoism: for example, psychoanalysis and behaviorism in psychology, neo-classical economics, and rational-choice theory in political science.In contrast, utilitarianism is based on the sum of the happiness of individuals, and therefore mildly individualistic and substantially collectivistic (holistic): its self-view is “selfish” in valuing self-interests or pleasure. Its collective aspect is criticized by libertarianism and liberalism. Their self-views are “separable” entities, and the liberal self-view is also “abstract” because, for example, Rawls’ theory assumes the hypothetical situation under the veil of ignorance.The individualistic and collective orientations of libertarianism and liberalism are respectively “strong” and “weak”. The individualism of libertarianism is more potent than that of liberalism: the collectivism of the former is weaker than the latter because liberalism results in some concern for the welfare of the poor, in contrast to libertarianism. Social conservatism is on the opposite side of liberalism and libertarianism, and the individualistic and collectivistic orientation is respectively “weak” and “strong”. Liberal communitarianism is in the middle ground between liberalism and conservatism. Accordingly, its individualism and collectivism are respectively “mild” and “substantial (considerable)”: its collective orientation signifies the “communal” element as can be seen in various communities, and its self-view is “relational” or “encumbered”. The individualistic and collectivistic orientations of social conservatives are respectively weaker and more potent than those of communitarianism. Its self-view is “order-oriented,” that is, “obedient” to authority, and its solid collective orientation is “traditional” or “conventional”.The ethical features of these political philosophies are closely related to the Hedonia/Eudaimonia mentioned above. The well-being of egoism is “hedonic” as well as that of utilitarianism, while that of communitarianism is “eudaimonic.” Both libertarianism and liberalism have no particular conception of well-being, but they regard the pursuit of happiness as “private” matters, which should have no relation with public decisions. The conception of well-being held by conservatism is culturally “traditional” or “conventional.” Accordingly, there is almost no ethics or morality in egoism, and they are weak or feeble in utilitarianism because utilitarian morality relies on hedonic pleasure. They are also non in libertarianism and liberalism because they have “no” connection with particular morality, or they are “weak” or “thin” because the conception of rights is sometimes considered thin ethics . In cont3 This manuscript focuses on the former two, called “legal citizenship” and “political citizenship” hereafter.The concept of citizenship is “composed of the three main elements or dimensions”: (1) legal citizenship of rights status classically formulated by T. H. The concept of justice also includes these meanings: legal justice, political and economic justice, and ethical justice. Legal justice is closely associated with the concept of rights for some liberty. Political and economic justice has had a connection with distributive justice since the time of Aristotle, and the central theme of justice in politics is still distributive justice in contemporary political philosophy. Ethical or moral justice signifies the quality of being morally fair and right from some ethical or transcendent point of view. So then, these three aspects will be called “liberal justice,” “distributive justice,” and “ethical justice”.Psychological or ethical egoism has little concern for these because activities related to citizenship or justice require time and energy, which are not part of their interests: egoists usually have no concern with these, and they use legal rights as they need them for themselves. So then, there is typically “no” relationship between citizenship/justice and well-being, or if there is one, it is “weak”.Utilitarianism does not necessarily emphasize citizenship but sometimes recognizes its value  because its preservation can contribute to people’s general happiness. Accordingly, their commitment to citizenship is “weak” or “mild,” and its relationship to citizenship and well-being is “mild” in the contribution of citizenship to general well-being.Utilitarianism judges justice by the utilitarian principle, and its relationship between good and justice (the right) exists because the maximization of “hedonic” happiness (the good) is justice. As the good of the people concerned signifies hedonic well-being, its relationship between justice and well-being is also “firm” and “direct”. However, as its commitment to citizenship is “mild”, its relationship between citizenship and justice is also “mild” because citizenship is deemed to contribute to the maximization of happiness only to some degree.Both libertarianism and liberalism depend on the concept of rights, and they regard legal citizenship and liberal justice as necessary. Nevertheless, libertarianism mainly values economic, legal rights such as property rights, while liberalism also values welfare rights as distributive justice. Accordingly, their commitments to  citizenship are “firm” in private spheres, but that of libertarianism and liberalism are, respectively “weak” and “substantial” in public or social spheres.Their relationship between citizenship and well-being lies in their “enabling possibility” rather than the existence or the degree such as weak/strong. The reason is that legal citizenship enables citizens to pursue happiness by using their legal rights, but that its existence does not necessarily guarantee the realization of well-being.Their concepts of justice are almost equivalent to legal rights, and they are not related to the good, and there is no relationship between good and justice, as explained in the section “The Debate Between Liberalism and Communitarianism: Justice and the Good Life”.From their perspective, citizenship mainly signifies the legal aspect, namely, rights, and justice is largely equal to “legal rights”. Therefore, concerning their relationships between citizenship and justice, former conceptions are identical to the latter. Accordingly, their relationships between justice and well-being are equal to those between citizenship and well-being, namely “enabling possibility”. However, these are “indirect” relationships because rights as justice do not necessarily lead to well-being but only prepare the conditions for an individual’s well-being.Nevertheless, while libertarianism and some version of liberalism tend to disregard political citizenship, liberal republicanism respects it as the execution of legal and political rights. Accordingly, there can be a mild relationship between justice and citizenship in liberal republicanism, in contrast to libertarianism and non-republican liberalism.Furthermore, communitarianism evaluates highly political citizenship, accompanied by civic virtues/activities, as well as legal rights. Therefore, its commitment to citizenship is most “substantial”. Moreover, as civic activities are thought to promote people’s well-being, the relationship between citizenship and well-being is also “substantial”.The conception of justice in communitarianism is “ethical” as well as legal and distributive, and its relationship between good and justice exists (“yes”). The good is based on the philosophical concept and “eudaimonic,” as was explained before. Its relationship to citizenship and justice is different from that found in the relationship in libertarianism and liberalism. Communitarian justice is both legal and ethical, and its citizenship includes not only legal citizenship but also political citizenship. Political active citizenship tends to contribute to realizing justice; the relationship between the two is “substantial”.Moreover, its relationships between justice and well-being are also “substantial” because its ethical justice contributes to realizing the common good, almost equal to public well-being. Thus, the relationship is “direct” in that justice directly leads to well-being compared to the indirect mode of the two rights-based theories.The commitment of conservatism to citizenship is “mild” because they tend to disregard fundamental human rights and active citizenship. They instead value duties and the concept of nationality. Accordingly, its relationship between citizenship and well-being is “weak” or “mild” because of its disrespect of citizens’ rights. Its justice depends on the “traditional norms” and national “security/interests”. Accordingly, its relationship between the good and justice “exists (yes)” on the condition that the good is the “traditional and national” in contrast to the communitarian “eudaimonic” conception.Its relationship between citizenship and justice is “weak” or “mild” because simple nationality is not necessarily related to substantial justice. Its relationship between justice and well-being is “mild” because its justice of traditional norms and national security/interests are respectively associated with its well-being of traditional order and national interests, but only to some extent. The reason is that the national kind of well-being sometimes corresponds to the public well-being of citizens but that the former can contradict the latter in some cases, for example, in which states begin unnecessary wars for the interests of the military-industrial complex in the name of protecting their national interests.In summary, the relationships between citizenship/justice and well-being in each of the political philosophies are “non or weak (egoism)”, “mild or firm (utilitarianism)”, “enabling possibility ,” “substantial (communitarianism),” and “weak or mild (conservatism)”. Consequently, the interdependence among citizenship/justice and well-being is the most substantial in communitarianism and the second strongest in utilitarianism. On the other hand, the interdependence in libertarianism and liberalism remains a possibility; conservatism is the second weakest; egoism is the weakest.Moreover, the relationship between citizenship and justice is mild in utilitarianism and substantial in communitarianism. Therefore, interdependence among citizenship, justice, and well-being is the most substantial in communitarianism.The reason for the difference related to interdependence can be summarized as follows. Utilitarianism has been historically associated with happiness, while liberalism and libertarianism rely on the concept of rights, which is almost equal to the concept of justice in these philosophies. Accordingly, utilitarianism is a philosophy of well-being, while liberalism and libertarianism are philosophies of justice.Accordingly, there is little connection between well-being and justice in these philosophies because these are incompatible. Libertarianism and liberalism criticize utilitarianism because the maximization of happiness or utility can infringe on fundamental human rights. On the contrary, the latter criticizes the former because the two deontological philosophies neglect consequential well-being.In addition, utilitarianism emphasizes (hedonic) well-being but does not emphasize citizenship, while libertarianism and liberalism evaluate legal citizenship but do not take well-being into account. As a result, one is contradictory to the other: the connection between citizenship/justice and well-being is not strong between citizenship and well-being (utilitarianism) or between justice and well-being .In contrast, communitarianism is intrinsically the political philosophy of citizenship most attuned to increasing well-being, and it can connect an idea of justice with well-being. It respects fundamental human rights in its liberal wing and well-being in its communal wing. Therefore, citizenship and justice are not only compatible with consequential well-being but also essential for the latter because they enable the realization of public well-being, namely, the common good. Therefore, citizenship and justice are significant ingredients of civic life and politics. It follows from these arguments that the interdependence among citizenship, justice, and well-being is the most substantial in communitarianism.It will be helpful to offer an inter-disciplinary framework depicting the correspondence between political philosophy and positive psychology to develop the collaboration between the two for pursuing the issues such as citizenship, justice, and well-being. Positive psychology can offer empirical evidence or evidence-based theories corresponding to the two axes of contemporary political philosophies.First, regarding the first ethical axis, in addition to the eudaimonic well-being mentioned above, Martin Seligman and Christopher Peterson proposed the classification of virtues or character strengths in the name of Value in Action Inventory (VIA). They classified character strengths under six virtues: wisdom and knowledge, courage, love and humanity, justice, temperance, and transcendence . These aFlourish  and engagement (E). In addition, his close collaborator, a philosopher J. O. Pawelski pushes forward the idea of “eudaimonic turn” in humanities such as literary studies (Seligman’s theory of well-being (PERMA model) in Flourish  is multi studies . Moreove studies .The eudaimonic turn in positive psychology is in tune with communitarianism and liberal perfectionism , political philosophy can be regarded as a relational public philosophy. Correspondingly, in psychological research, “relational welfare” has already been explored regarding the co-creation of health and well-being for all .Concerning the relational aspect of society, as was touched on cursorily in the section “Criticism Against Positive Psychology and Its Two Frontiers”, an eminent social psychologist Corey Keyes pushed forward a social model of well-being by proposing the measure of “social well-being.” This scale measures the collective orientation for the community, society, and the world , 2005.While much community psychology intervention such as prevention is still “individualistic or micro-centere micro-centered” , p. 11. In addition, there was also the concept of the common good in the values of organizational well-being and community well-being . AccordiFurthermore, the idea of positive critical psychology recently emerged. Its handbook  containsIn addition, the pioneering work by Jonathan These empirical psychological studies can increase or decrease the relative reliability of specific political philosophy in This recognition of the association between positive psychology and political philosophies makes the theoretical character of political philosophies clearer from the perspective of the former. The tenet of positive psychology is that it studies the positive side of human mental conditions. In contrast, “psychology as usual” has focused on the negative side of mental disease for its remedy. This characterization is helpful for grasping the opposition between the two rights-based deontological political philosophies  and communitarianism.Similarly, libertarianism and liberalism are non-ethical and mapped in the lower half, as indicated in This element corresponds to “negative liberty” , which iIn contrast, communitarianism is both virtuous and positive and mapped in the first quadrant. The aim of the common good is positive: it indicates various desirable things, such as a suitable environment, peace, and welfare, for people in the community. This element is equal to “positive liberty” (I. Berlin), which is expressed by “freedom to.”Accordingly, utilitarianism and communitarianism are positive political philosophies. These are teleological because their purposes were maximization of happiness (utilitarianism) or the common good (communitarianism). While the former depends on the hedonic conception of happiness, the latter requires people’s virtues, including civic virtue. Accordingly, these are, respectively mapped in the fourth and the first quadrant: the attention to human nature corresponds to its psychological counterpart, namely, positive psychology.Positive psychology sometimes encounters criticisms because it neglects the importance of curing mental illness’s negative phenomenon. Likewise, liberalists and libertarians attack utilitarianism and communitarianism as follows: Their pursuit of positive ideals may lead to negative politics such as repression, dictatorship, and violation of human rights.Positive psychologists reply to the reproach that they do not deny the importance of psychology as usual, and they are only adding a new field of inquiry to it. Seligman and others suggested the goal of “a balanced psychology” as “an integrated, balanced field” . SimilarOn the other hand, such a philosophical typology can inspire psychology. First of all, “psychology as usual” . Therefore, it is sufficient to focus on major political philosophies to investigate the relationship between citizenship, justice, and well-being. Then, thirdly, Fourthly, this framework can also illuminate political philosophies from the perspective of psychology. This clarification and classification of political philosophies can inspire positive psychology or psychology for the common good. For example, empirical research on the relationship between citizenship, justice, and well-being will be possible, bearing the classificatory framework in mind. This kind of empirical research will benefit remarkably political philosophy and, furthermore, social sciences in general.Psychopathology and Politics . It would be natural to conceive the following correspondence between an individual and a collective factor: biological gene and culture, circumstance and society, and voluntary control and politics (or policy). Then, the collective well-being may be expressed by a formula: CoW(level of collective well-being) = CuW + SoW + PoW. While cultural well-being is associated with a cultural set range, social well-being depends on social circumstances, and political well-being can change by voluntary collective control of policies.Accordingly, the introduction of the idea of political well-being may be effective just as community well-being or social well-being. First, citizenship and justice can affect the level of political and social well-being, then collective well-being, and finally, overall well-being. The increase of collective well-being empirically indicates the level of realizing the common good.Theory of Justice .The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Prior to the 2019 novel coronavirus (COVID-19) outbreak, the South African healthcare system was already under severe strain due to amongst others, a lack of human resources, poor governance and management, and an unequal distribution of resources among provinces and between the public and private healthcare sectors. At the center of these challenges are nurses, the backbone of the healthcare system, and the first point of call for most patients in the country. This research investigated post-traumatic stress and coping strategies of nurses during the second wave of COVID-19 in the country. A structured self-administered questionnaire captured the biographic characteristics, perceived risk factors for COVID-19, and views on infection control of 286 nurses Data were subjected to descriptive and binomial logistic regression analyses. More than four in every 10 nurses screened positive for higher levels of post-traumatic disorder (PTSD). Self-reported risk for contracting COVID-19 mainly centered on being a health worker and patients’ non-adherence to infection prevention guidelines. Unpreparedness to manage COVID-19 patients, poorer health, and avoidant coping were associated with PTSD. Nurses voiced a need for emotional support and empathy from managers. Emotional, psychological, and debriefing intervention sessions that focus on positive coping strategies to actively address stress are recommended. Pandemics are a unique form of disaster, resulting in adverse psychological symptoms and behavioral reactions . HealthcPrior to the 2019 novel coronavirus SARS-CoV2 (COVID-19) outbreak, the South African healthcare system was already under severe strain due to amongst others multiple disease burdens, a lack of human resources for health, poor governance and management, and an unequal distribution of resources among provinces and between the public and private healthcare sectors ,7,8. At While there are international studies, largely emanating from China, reporting on the psychological impact of COVID-19 on HCWs, there is limited research in this field in Africa. Studies in Wuhan, China found that frontline HCWs are at increased risk for mental health disturbances such as anxiety, depression and distress ,15,16,17a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, or rape or who have been threatened with death, sexual violence or serious injury”  just because I’m a student it does not mean that I won’t get it or I don’t have a family to go home to or I’m not scared of the virus. We all are […] it’s affecting all of us and we should all be working together to fight against it. It shouldn’t only be the nurses’ responsibility alone. It’s a pandemic which affects all of us and has the same effects on all of us regardless of age or appearance. Managers should please allow all of us nurses to nurse COVID patients. We all took an oath.”There were also requests for managers . It was suggested that “All PPE should be procured from province, institutions SCM [supply chain management] because they are not nurses, don’t do their work and at the end we work without proper PPE e.g., plastic aprons, they are now telling us that there is no money.”Nurses also indicated that they should be provided with sufficient and good quality PPE . Nurses who tested positive for COVID-19 needed assistance with medical care: “Give us the medication course we don’t have money to buy medication […] medical aid didn’t pay for it” and emotional support: “Ensuring that they receive counseling not only when they are sick, but throughout this period, it should be done routinely and free.” Concerns were also raised about sick leave when testing positive for COVID-19: “Special leave is to be granted if you tested positive. Currently they deduct it from your sick leave.”There were also requests for more training and up-to-date information on COVID-19  indicated that the provincial health department should provide financial support in the form of danger pay or COVID-19 bonuses: “[…] incentives, due salary increase plus 5% for nurses as nurses were at the physical forefront for this pandemic for even longer periods than even other [HCWs] […] I am not discrediting others’ roles”; and “Also give us Risk Allowance as we didn’t expect this monster and we risked our lives to take care of patients in this difficult times.”Finally, almost a quarter of the nurses  likely also relate to the state of the healthcare system in the country. For example, South Africa has 1.3 nurses/midwives per 1000 population compared to 3.8 globally . Accordicedures” . Unfortuy serve” . Univariy serve” ,56.Self-reported risk for contracting COVID-19 mainly centered on being an HCW and patients and the public not adhering to COVID-19 infection prevention and control guidelines. Lai et al.  also repWhile the unpreparedness to care for COVID-19 patients was associated with PTSD, this did not appear to relate to training per se: firstly, a high percentage of nurses reported receiving COVID-19 related training. Secondly, there were not many requests for training on COVID-19. However, there were numerous requests for emotional and psychological support for nurses both from immediate managers and the provincial health department. A systematic review of post-traumatic stress symptoms in HCWs during COVID-19 highlighted a lack of social support as a predictor of post-traumatic stress . SimilarWe found an association between nurses who viewed their current health as being worse since COVID-19 and PTSD. This is supported by other research which reported that underlying illnesses are a risk factor for poor psychological health during COVID-19 . DescripFinally, the research found an association between avoidant coping styles and PTSD. Avoidant coping styles include self-distraction, denial, venting, substance use, behavioral disengagement, and self-blame. According to the literature, individuals opt for dysfunctional coping strategies when faced with an uncontrollable event . When this occurs, the focus is on coping with the problem and not on dealing with emotions , and is Based on the findings of this study, the following areas require attention to address increased levels of post-traumatic stress amongst all categories of nurses working both in the public and private healthcare sectors in South Africa: emotional support from managers; psychological interventions and debriefing sessions that focus on positive coping strategies to actively address stressful events; and the provision of sufficient and appropriate PPE. Nurses who are emotionally and physically equipped to manage COVID-19 at work, at home and in the broader community, will have a better chance at dealing with stressful events. These are not new recommendations, but have already been made in relation to coping with other pandemics, for example the 2014 Ebola outbreak in West Africa , the 200As with all research, our study has limitations. Firstly, we used an online survey to collect data, which could have been accessed by anyone who had seen the advertisement for the study. We attempted to mitigate against this by commencing with a filter question, where only respondents who indicated that they were a nurse, could continue with the survey. In addition, while the study was advertised on social media, our main recruitment drive was to work through public and private healthcare managers to advertise the study. Secondly, the sample size was small, and a larger sample is required to verify the results. Thirdly, the cross-sectional nature of the study does not allow interpretation for causality and due to changes in post-traumatic stress, dynamic observation would add value to such research. Fourthly, as this was a self-administered online questionnaire, we were cognizant of the length of the questionnaire and the time it would take to complete. As such, we were limited in the number of questions that we could ask and potentially excluded issues that could also have contributed to increased levels of PTSD, for example education level, salary level and shift working status.This research among public and private sector nurses in the Free State found that more than four in every 10 nurses screened positive for PTSD. Self-reported risk for contracting COVID-19 mainly centered on being an HCW and other persons’ non-adherence to COVID-19 infection prevention guidelines. Unpreparedness to manage COVID-19 patients, poorer health, and avoidant coping were associated with PTSD. Nurses voiced a need for emotional support and empathy from their managers. Emotional, psychological, and debriefing intervention sessions that focus on positive coping strategies to actively address stress; positive and open communication between managers and their subordinates; psychological support through the Employee Assistance Programme and occupational health units; referral for more intensive psychotherapy where necessary; regular debriefing sessions where nurses can share their experiences; positive messaging from the provincial and national health departments; and an uninterrupted supply of quality PPE are recommended.


In 2025, Japan’s baby boomers will cross the threshold of 75 years of age; a phenomenon that has been referred to as “the 2025 crisis”, resulting in a significant burden on the healthcare system. To address this issue, the Japanese government is establishing the Integrated Community Care System, to provide comprehensive medical and long-term care services in each community. In cooperation with government and affiliated organizations, the Japan Geriatrics Society (JGS) has been working to develop the Integrated Community Care System. As a result of this effort, geriatric medicine is being integrated into the health care system through incentives for practitioners. For instance, medical facilities can be reimbursed if they perform comprehensive geriatric assessments (CGA) and CGA-based management/care. Additionally, home care medicine and polypharmacy are emerging issues of interest to the government. In this symposium, I will discuss how JGS has been trying to achieve “Aging in Place” in Japan.


Diagnostic testing using PCR is a fundamental component of COVID-19 pandemic control. Criteria for determining who should be tested by PCR vary between countries, and ultimately depend on resource constraints and public health objectives. Decisions are often based on sets of symptoms in individuals presenting to health services, as well as demographic variables, such as age, and travel history. The objective of this study was to determine the sensitivity and specificity of sets of symptoms used for triaging individuals for confirmatory testing, with the aim of optimising public health decision making under different scenarios.Data from the first wave of COVID-19 in New Zealand were analysed; comprising 1153 PCR-confirmed and 4750 symptomatic PCR negative individuals. Data were analysed using Multiple Correspondence Analysis (MCA), automated search algorithms, Bayesian Latent Class Analysis, Decision Tree Analysis and Random Forest (RF) machine learning.Clinical criteria used to guide who should be tested by PCR were based on a set of mostly respiratory symptoms: a new or worsening cough, sore throat, shortness of breath, coryza, anosmia, with or without fever. This set has relatively high sensitivity (> 90%) but low specificity (< 10%), using PCR as a quasi-gold standard. In contrast, a group of mostly non-respiratory symptoms, including weakness, muscle pain, joint pain, headache, anosmia and ageusia, explained more variance in the MCA and were associated with higher specificity, at the cost of reduced sensitivity. Using RF models, the incorporation of 15 common symptoms, age, sex and prioritised ethnicity provided algorithms that were both sensitive and specific (> 85% for both) for predicting PCR outcomes. If predominantly respiratory symptoms are used for test-triaging,  a large proportion of the individuals being tested may not have COVID-19. This could overwhelm testing capacity and hinder attempts to trace and eliminate infection. Specificity can be increased using alternative rules based on sets of symptoms informed by multivariate analysis and automated search algorithms, albeit at the cost of sensitivity. Both sensitivity and specificity can be improved through machine learning algorithms, incorporating symptom and demographic data, and hence may provide an alternative approach to test-triaging that can be optimised according to prevailing conditions.The online version contains supplementary material available at 10.1186/s12879-021-06810-4. PCR testing to identify SARS-CoV-2 cases is a fundamental pillar of pandemic control. The decision on which set of symptoms to use for determining who should be tested by PCR will ultimately depend on resource constraints and public health and disease control objectives in the country and, where possible, aim to minimise test error rates. Therefore, the criteria for PCR test eligibility has varied by time and between countries. For example, at the time of writing, for a person in the community not being investigated as a contact of a known case, in the UK it is necessary to have a fever, a new, continuous cough and loss of sense of taste or smell to be eligible for a government-funded PCR test , in AustThe choice of symptoms that are required to meet the clinical criteria will directly affect the number of individuals put forward for PCR testing and the ability to detect cases in the community. If the chosen combination of symptoms lacks sensitivity, many true cases are likely to be missed, in addition to asymptomatically infected individuals not being captured through screening or contact tracing. If the combination of symptoms lacks specificity, then a large number of individuals will be tested unnecessarily. This has implications for preventing community transmission (lack of sensitivity) and for resourcing (lack of specificity). Therefore, any clinical criteria defined for testing based on symptoms need to balance the need to detect disease to prevent transmission, against the risk of overwhelming the testing and public health services with individuals that are not COVID-19 cases.To date in New Zealand, an ‘elimination strategy’  has beinOther studies have described the use of self-reported symptoms to develop and train models that can identify infection, with the aim of identifying cases early in the course of infection, enabling prompt self-isolation and testing –6. TheseThe aim of this study was to provide a quantitative approach to creating symptom-based criteria for testing using data collected at the time of presentation to health services. We use detailed data collected on New Zealanders tested in the community during the ‘first wave’ of COVID-19  to descrth February 2020 to the 9th June 2020, during which time New Zealand recorded 1153 confirmed and 350 probable cases of COVID-19 [E and N genes [The study period is from the 26COVID-19 . Diagnos N genes . During All suspect cases of COVID-19 who presented to health services during the study period and were notified to Public Health officials via EpiSurv, the national notifiable disease database, were considered in this analysis (N = 7549). Of these individuals, 7036 were tested by PCR and reported as either positive or negative for SARS-CoV-2. Those with a confirmatory PCR test were classified as confirmed cases. Probable cases were close contacts of confirmed cases with compatible clinical illness where PCR testing results were negative or inconclusive. This analysis includes only the 6224 cases who were classified as symptomatic, and of these 1125 were classified as ‘confirmed’ cases, 349 were classified as ‘probable’ cases and 4750 were classified as ‘not a case’. Patient symptom data were collected at notification along with diagnostic, demographic, outcome and risk factor details using a standardised case report form on EpiSurv,Variables included the presence or absence of symptoms and epidemiological variables, including age, sex and prioritised ethnicity. Age and sex were determined from the standardised case report form, and prioritised ethnicity was self-determined and obtained by linkage to the national patient demographics dataset  and grouped in order of prioritization to Māori, Pacific, Asian then European and Other .G), Anosmia (loss of sense of smell) (A), Coryza (runny nose) (Z), Cough (C), Diarrhoea (D), Fever (F), Headache (H), Nausea/Vomiting (V), Pain:Abdomen (P), Pain:Chest (S), Pain:Joint (J), Pain:Muscle (M), Shortness of Breath (B), Sore Throat (T), General Weakness (W). All symptoms were specific fields in the standard case report form (https://surv.esr.cri.nz/episurv/CaseReportForms/Coronavirus_Sep2020.pdf) with the exception of ageusia which was noted in the free text ‘other symptom’ field.Symptom variables considered in this analysis (and their symbols) are those that occurred in at least 100 individuals: Ageusia (loss or reduction of sense of taste) .The frequencies of different symptoms and symptom combinations for those classified as ‘Not a case’, ‘Confirmed case’ and ‘Probable case’ were displayed as ‘UpSet’ plots using the R package ComplexHeatmap  using the R packages FactoMineR and factoextra . MCA is Supplementary variables are not used to calculate the pairwise distances between individuals in the MCA but their coordinates are predicted and plotted on the MCA plot.The supplementary variables were considered as follows:Status: “Not a case”, “Confirmed case” and “Probable case”Prioritised Ethnicity: “Māori”, “Pacific Peoples”, “Asian”, “Middle Eastern/Latin American/African”, “European or Other”, “Unknown”.Age Group: “ < 1”, “1–4”, “5–9”, “10–14”, “15–19”, “20–29”, “30–39”, “40–49”, “50–59”, “60–69”, “70 + ”.Sex: “Male”, “Female”, “Unknown”Month of year: “2”, “3”, “4”, “5” and “6”Informed by the MCA, groups of variables linked by Boolean ‘AND” and ‘OR’ statements were assessed against ‘status’ as a quasi-gold standard, after omitting probable cases, to determine the sensitivity and specificity of each set of symptoms. This was augmented by the application of an automated search algorithm  partitions a dataset recursively using binary splits based on the predictor variables, at each stage seeking to maximize the ‘purity’ of the components of the partition in terms of the target variable . Here thOne of the limitations of simple decision tree analysis is that, unless the dataset is very large, the tree topology can vary markedly, depending on the random selection of the training and test subsets of the full data. An extension of this method is the machine learning method using ‘Random Forests’. This method generates a large number of decision trees, each constructed using a different subset of the full dataset for training. The subsets are selected by sampling at random and with replacement from the full data set. These multiple decision trees (i.e. a forest of trees) are used to determine a classification consensus. One of the outputs of random forests includes a determination of the importance of each variable in terms of its impact on accuracy and ‘impurity’ (using the GINI index). The mean decrease in accuracy for a given variable is an estimate of the loss of prediction performance if that variable is removed from the training dataset. Random forest analysis was performed using the R packages ‘randomForest’ and ‘caret’ , 18. ForBoth the decision tree analysis and the random forest analysis randomly selected 60% of the 4750 symptomatic ‘not cases’ and 1125 ‘cases’ for training, and 40% for testing. Given the ‘unbalanced’ nature of the dataset a number of approaches were used to optimise the performance of the models in terms of their ability to predict confirmed cases (i.e. sensitivity) and individuals that were not a case (i.e. specificity). These included sampling from the two groups, for example up-sampling the minority class “Confirmed case”, or down-sampling of the majority class “Not a case”, and the use of other similar methods such as the ‘rose’ and ‘smote’ algorithms  and varyMethods and results of other analyses are included in the Additional file Further details of the implementation of the statistical methods, including code, are available from the authors on request.Frequencies of symptoms for ‘Confirmed’ N = 1125) and ‘Not a case’ (N = 4750) individuals are shown in Fig. 125 and ‘Figure Figure Figure Further, symptoms (present or absent) which occur more frequently within the same individual tend to group together on the plot, whereas symptoms that are on opposite sides of the plot origin (i.e. opposed quadrants) tended not to occur in the same individual. For example, diarrhoea, chest pain, muscle pain and general weakness tended to occur together, whereas fever and anosmia were less likely to occur together. Categories that are most discriminatory (i.e. explain relatively more of the variation in the data) tend to be furthest away from the origin (i.e. further from where the two dimensions intersect). Anosmia, ageusia and joint pain are good examples of symptoms that were very discriminatory, and that often occurred in the same individual.The MCA analysis, in particular the position of the symptoms per se and their location relative to the ‘Status’ variables, was used to propose and compare combinations of symptoms in terms of their ability to predict confirmed cases and individuals that were not cases. This is analogous to determining the sensitivity and specificity of clinical signs using the ‘status’ variable (‘confirmed cases’ or ‘not a case’) as a quasi-gold standard. Note, in this analysis we just consider individuals presenting with clinical symptoms . Table Table During high incidence scenarios, where health services are overwhelmed, there may be an urgent need to reduce the burden on testing stations by optimising screening using clinical symptoms. This could be achieved by choosing a set of non-respiratory symptoms to triage individuals with enough respiratory symptoms to consider themselves possibly having COVID-19, and hence presenting to health services for possible testing. This would result in many fewer individuals being put forward for testing, with a relatively modest reduction in sensitivity. The first non-respiratory set (A|D|H|M|W) would have resulted in ~ 3,000 fewer PCR tests . The effect of varying the cut-off value and the inclusion of additional covariate is illustrated in Fig. The inclusion of more predictor variables improves the performance of the model, as determined by the area under the curve (AUC) moving from Fig. The symptom analyses presented here were performed on observational data routinely collected from patients presenting with acute respiratory infections during the first wave of COVID-19 in New Zealand. Similar analyses using machine learning algorithms for test prioritisation based on symptoms have been conducted using data from other countries including Israel and Brazil –24. GiveClinical criteria used to guide who should be tested by PCR based on one or more of a set of mostly respiratory symptoms  has high sensitivity (> 90%) but very low specificity (< 10%). Use of the respiratory symptom criteria alone will therefore result in a large proportion of individuals being tested that do not have COVID-19. Depending on outbreak size, this could overwhelm community testing capacity at sampling/testing stations and laboratories and negatively affect the country’s ability to successfully trace and eliminate.Alternative ‘intuitive’ rules combining symptoms with AND/OR statements can increase specificity, but this is inevitably at the cost of sensitivity, with the inherent risk of missing true cases. It is noted that infected individuals without symptoms would be missed completely if triaging were exclusively based on clinical signs , and somMarked improvements in both the sensitivity and specificity of rules based on machine learning algorithms can be achieved using decision tree and random forest methods that include both symptoms and epidemiological/demographic variables, such as age and sex. Predictions based on these algorithms can achieve sensitivities and specificities that are both greater than 80% and could be incorporated into easy to access decision support tools , such asAlthough a variety of approaches have been used in this analysis of the dataset of individuals reporting COVID-19 symptoms in New Zealand, the inferences are broadly consistent. The data support the following conclusions:A study analysing the epidemiology of COVID-19 in the United Kingdom used information from approximately one million individuals with a valid swab test, of which only 11.1% recorded symptoms. Seven symptoms were reliably associated with a PCR positive swab: anosmia, ageusia, fever, new persistent cough, chills, appetite loss and muscle aches , 5. ManyThe symptoms anosmia and ageusia, although relatively rare, were shown to be highly discriminatory and specific in this study, and this is consistent with other reports , 7, 31. There are likely to be major biases in reporting of symptoms. Many individuals were involved in the recording of symptom data and there are likely to be differences in the way questions were asked and interpreted. Recall bias is likely to be important, and the ability to determine certain symptoms in very young children, such as anosmia and ageusia. Similarly, the ‘worried well’ and raised media awareness may have contributed to over-reporting of symptoms in individuals keen to be tested for COVID-19, whereas the lack of inclusion of symptoms such as ageusia in the standard report form (it was only noted under ‘other symptoms’), may have resulted in them being underreported.Reporting bias is likely to vary over time. For example, ageusia, anosmia and coryza were not included in the set of standard symptoms in New Zealand until March/April, although they were recorded in free-text fields. We partially addressed this by including ‘calendar month’ as a categorical variable in multivariate analyses; despite the temporal variation in reporting of symptoms, this variable did not emerge as an important predictor in any of the analyses.Symptoms at the time of presentation/testing may not be representative of the symptoms an infected or non-infected individual experienced over the time of their infection. For example, some symptoms such as body aches or anosmia may have developed later in the time course of infection. Other similar studies have considered symptoms recorded over multiple time points , but theIn the multivariate analyses all individuals were analysed together regardless of whether they presented as ‘sought healthcare’, ‘contact’, ‘point of entry’ ‘repatriation’, ‘unknown’ or ‘blank’ . Inclusion of this as a variable in the multivariate analysis was not informative, and subset analyses  did not reveal any major differences in the conclusions.a-priori sampling design had been intended, there was no clear definition of the target population at the time. As the first wave evolved in New Zealand, selection criteria for most individuals triaged for testing was based on symptoms, and the choice of symptoms then changed over time. Thus, some degree of sampling bias could not be ruled out. To mitigate sampling issues, we used different subgroups in the LCA analysis. The general consistency of the results and conclusions from these different subgroups, while not emphatic, provides useful evidence in support of the choice of symptoms developed in the paper. It suggests that results are robust enough to apply to different populations including other countries and jurisdictions.The data available for analysis are a by-product of the monitoring and control measures put in place for COVID-19 in New Zealand. The data are observational and have not been collected via a probability-based sampling scheme. Ideally, data would have been collected for the specific purpose of estimating sensitivities and specificities and would have involved random sampling of the target population and the collection of data on other potential confounding variables. However, even if an The specificity of algorithms based on symptoms will vary according to the prevalence of other diseases in the population. For example, during periods when respiratory allergies are more common, the specificity of symptoms associated with coryza will reduce, whereas when other viral infections such as influenza or rhinovirus infection are more prevalent symptoms such as fever, headache, joint pain and muscle pain may have lower specificity. Border closures and lockdown occurred in March in New Zealand, ahead of the Southern Hemisphere influenza season, meaning these data were collected during a period of low prevalence of common seasonal respiratory viruses. The effect of varying prevalence of COVID-19-associated symptoms in the populations attributable to other conditions will be considered in a follow-on analysis of symptoms recorded during periods in which other respiratory infections are more prevalent.The random forest model performed well at predicting test data from training data, particularly when more demographic variables were included. However, the model with more variables predicts outcomes for much larger arrays of covariate patterns and is less intuitive. For example, a rule to test an individual may indicate different outcomes according to ethnicity, when all other variables, such as symptoms, age and sex, are the same. The age, sex, and ethnicity of cases in NZ were determined by the features of the first wave of the pandemic in New Zealand, associated with large linked clusters of cases and a strong impact of travel-associated cases, and this will affect the generalisability of the models and predictions.The addition of prioritised ethnicity to the random forest machine learning algorithm resulted in a marginal improvement in the sensitivity and specificity. However, extreme care would need to be taken when considering the addition of ethnicity as a variable, particularly given the well-described inequalities in health outcomes associated with Māori and Pacific populations in New Zealand –35 and tWhile the application of ‘intuitive’ and more advanced model-based approaches can appear to perform well for predicting COVID-19 status in the symptom dataset provided for this study, it is important to consider other limitations of this approach. These include, but are not limited to, the following:After elimination of the first wave of COVID-19 in New Zealand, the country experienced a series of smaller outbreaks of community transmission, which were eliminated by the application of public health measures, including national and regional lockdowns . In AuguUsing data from the first wave of the COVID-19 pandemic in New Zealand this paper describes how symptom-based criteria for diagnostic testing can be systematically derived, updated and applied to support control of COVID-19. A specific application of this approach could be the development of a tool, based on a machine learning algorithm informed by surveillance data, that guides policy for testing and aids public health decision making for the prevention and control of COVID-19 in the event of sustained community transmission. Updating models as new data become available is likely to improve their performance as a tool for selecting individuals for testing under different scenarios; including a change in the prevalence of other respiratory diseases, the introduction of alternative diagnostic assays, or a change in the priorities of a control programme. This is practically relevant for COVID-19, given the large number of symptoms and symptom combinations associated with the disease. Depending on the pandemic control phase, algorithms using clinical criteria to guide testing might be focussed on avoiding unnecessary testing to protect resources or driven by the need to detect as many cases as possible. The ability to define symptom-based criteria derived from country specific data provides an opportunity for countries to fine tune and adapt their testing strategies to balance the need to detect disease to prevent transmission, against the risk of overwhelming the testing and public health services with individuals that are not COVID-19 cases. Applying such an approach, using a combination of multivariate methods and machine learning, may allow countries to develop and continually update models, using evidence from ongoing surveillance, to support decision making tailored to specific phases of a disease control programme.Additional file 1. Additional material. Figure S1. Distribution of the combination of 15 symptoms reported by confirmed, probable and ‘not a case’ individuals. Only symptoms reported in >100 people and combinations that occurred in 5 or more individuals are included. Figure S2. Multiple correspondence analysis plots showing the location of each individual in the first two dimensions, coloured by their PCR status (plot A), and symptoms (plots B-L) and 90% prediction ellipses . Plots B and C are symptoms strongly correlated with the second dimension and determine the 3 distinct groups. The upper group are individuals with ageusia and anosmia , the middle group are more likely to be those with anosmia but no ageusia, and the lower group are those without ageusia or anosmia. Plots D-L are symptoms more strongly correlated with the first dimension . Plots K and L are examples of two respiratory symptoms that are not correlated with either dimension. Figure S3. Scatterplot of sensitivity and 1-specificity for combinations of symptom variables using ‘status’ as a gold standard. A A rule based on combinations of at least one of 5 symptoms. The red dot in the left plot identifies the current case definition based on respiratory symptoms (A|Z|C|B|T). The green and blue dots are sets of largely non-respiratory symptoms used for comparison. B A rule based on one or more of respiratory symptoms  AND one or more of 5 non-respiratory symptoms. The table shows the estimated values for the example sets highlighted in the figure. Figure S4. Posterior distributions of the sensitivity (upper row) and specificity (lower row) of both the symptoms  and the PCR assay, estimated using Bayesian Latent Class Analysis, based on three chains of 20,000 iterations after a burn-in of 5,000. Figure S5. Scatterplot of sensitivity and 1-specificity for combinations of symptom variables estimated using Bayesian Latent Class Analysis. A A rule based on combinations of at least one of 5 symptoms. The red dot in the left plot identifies the current case definition based on respiratory symptoms (A|Z|C|S|B). The green and blue dots are sets of largely non-respiratory symptoms used for comparison. B A rule based on one or more of respiratory symptoms  AND one or more of 5 non-respiratory symptoms. Figure S6. Decision tree built using a machine learning algorithm that minimises the misclassification of cases and non-cases. The thickness of the lines denotes the proportion of the population heading down each branch. Darker shading indicates greater node purity.