This short article discusses how different fantasy narratives have come togetherduring the Covid-19 crisis in various far-right movements, parties and audiencesacross the world and how much of these fantasies rely on racialised and genderednotions of a fantastical world-order in which particular forms of emotionalgovernance provide a relief and sense of security to certain societal groups.This involves a close engagement with crisis and crisis narratives in relationto ontological insecurity and anxiety; how such crisis narratives havematerialised in fantasies related to borders and corona nationalism, and theemotional governance of these particular fantasies in the hands of populistleaders and their increasingly receptive audiences. However, behind these immediate effectsof the pandemic experience lie less visible crisis scenarios narrated to the publicas past and future happenings. Crisis narratives rely on imaginations, predictionsand visions concerning what that future may look like, how particular pasts are tobe blamed or glorified, and the specific actors responsible for the crisis. Thesefantasy narratives tend to converge in much far-right populist conceptions in whichspecific emotions become tied to fantastical visions of the past, present andfuture, involving everything from fabricated lies to myths and re-imagined memoriesof a past moral order. In this short paper, I discuss how such fantasy narrativeshave come together during the Covid-19 crisis in various far-right movements,parties and audiences across the world. The extent to which such fantasies rely onracialised and gendered notions of a fantastical world-order is here important forunderstanding how emotional governance can provide a relief and sense of securityfor certain societal groups. Hence, I discuss what we mean with crisis and crisisnarratives in relation to ontological insecurity and anxiety; how such crisisnarratives have materialised in fantasies related to borders and corona nationalism,and the emotional governance of these particular fantasies in the hands of populistleaders and their increasingly receptive audiences.As some countries are slowly adapting to what looks to be a post-pandemic experience,a number of questions arise in terms of what this experience will entail for thefuture. How has the widely dispersed state of uncertainty changed underlyingperceptions of self and others; what will a ‘new normality’ look like in the face ofcomplex borders, anti-vaxx movements, and an increase in anti-liberal tendencies? Towhat extent has populist and authoritarian movements capitalised on the pandemiccrisis narratives and what, if any, creative possibilities have this experiencegiven rise to? These are some of the questions addressed in this short paper, whichis focused on understanding the linkage between crisis, fantasy narratives andemotional governance with a particular emphasis on far-right populist movements andpolitical leaders. That the pandemic has created a widely dispersed state ofuncertainty is hard to refute. Coping with sickness and deaths, with quarantine,daily restrictions, face masks, border closure and distant emotional relations havechallenged the everyday routines of individual citizens and have, for many, createda deep sense of insecurity; of not knowing what tomorrow holds – what Giddens A crisis, in this sense, is both a concept and an event and has profounduncertainty as its underlying dimension. Global crisis narratives thus span acrosslocal, national and global contexts and can be of a more perceptible, such as wars,conflict, migration, the environment, a pandemic or of a more abstract kind, forexample, economic recession, failing democracies, permanent poverty. As Chernobrov has argued, uncertainty itself can produce a crisis in the ontologicalnarrative or it can be imagined in ways that reaffirm the crisis narrative. Feelinguncertain, at loss, or experiencing one’s existence as a void is likely to generateanxiety and frustration, an ontological insecurity focused on relief and redemptionin order to escape falling into the ‘abyss’. However, such emotions do not occur in a vacuum. In relation to populistdiscourse, we can, with Moffitt, see ‘crisis as a phenomenon that is mediated and performed, and experiencedculturally and socially’. This, what Moffitt calls the ‘spectacularization of failure’, entails for populist leaders andmovements a separation of ‘“the people” from those who are responsible for thecrisis’ and thus ‘legitimate their own strong leadership as a way to stave off orbring about an end to the crisis’. Crisis is thus not to be viewed as an exogenousevent, an ‘outside shock’, which actors react to but as an endogenous construction‘where ontological questions about the relationship between agent and structure areintegrated and thus problematized’. As Resende argues in relation to the pandemic, this ‘spectacularization of failure’ hasbeen actively created by populist forces in their ‘questioning of science,institutions and experts in relation to the virus’.The absence of political visions and the presence of unclear futures provide afoundation for crisis narratives to emerge and take hold. Crisis narratives can beboth backward- and forward-looking. The forward-looking dimension often involves avision of a forthcoming dystopia or catastrophe, but can also enable action andproductive power, while the backward-looking dimension tends to envisage someelements of going back to an imagined uninterrupted past or at least to a previouslydefined present in terms of an imaginary status quo – a ‘foregoing normal’. However,a crisis can also produce a sentiment of existing in a void – being stuck in the‘fixity’ of a calamity – a state that is often exacerbated by society’s initialemotional outburst in relation to a crisis, followed by a demand to return to normality. description of how psychic defense mechanisms work in order to handle anxietyat the societal level through a process of unconscious social collusion andbargaining, where eventually a legitimate social defense mechanism is produced. Notonly does such culturally mandated defense mechanisms become integral aspects ofinstitutions, including the state, but they also work as an important way in whichto control anxiety. They become, in other words, an aspect of intersubjectivereality that exercises power over subjectivity. These defense mechanisms ‘kick in’ in response to an ontological insecurityset on constructing a secure image of what tomorrow holds, and can make masses andelites that may otherwise have little in common unite around an ideology thatrelieves them from the void by providing an apocalyptic and redemptive narrativevision of possible solutions to the crisis. Understanding such unconscious defense mechanisms requires an understandingof ontological security as a ‘security of becoming’ rather than a ‘security ofbeing’ as originally understood by Giddens, in which the ontological insecurities people experience at times of crisiscompel a ‘leap in faith’ in terms of an imagined secure past and future that can relieve theindividual from their present predicament.This is akin to John Cash’s covering eight European countries affected by the pandemic. Here the authorsargue that in comparison to other crises, the pandemic did not lend itself to thetraditional appeal to ‘the people’ as a basis for support. Instead, far-rightpopulist leaders found themselves identifying new lines of conflict built onnationalism, and ‘neo-natalism’ with an emphasis on ‘we, the national people’against both the EU and other member states. However, rather than confronting thepandemic per se, the far-right populist focus has often been on keeping the crisisnarrative going in a continuous process of ‘naming, blaming, and claiming ofsystemic contradictions’ in a quest for crisis ownership. Owning the crisis thus requires a constant shift in terms of imaginedsolutions to the pandemic, in which fantasised objects of blame are to cover up forthe inability to handle the insecurities at heart of the crisis.Constructing such a ‘leap in faith’ has been evident in the crisis narratives of thepopulist right as detailed in a recent book by Bobba and Hubé This means that fantasy is more than an escape from reality; rather it is ‘aconstant and unavoidable component of real experiences’. The Covid-crisis is indeed a very real experience with more than 660 millionbeing infected to date and more than 6.7 million deaths, and signifies a number of sub-structural crises, such as the lack ofequipment and hospitals, lack of affordable health care and insurance, andexacerbated conditions of precarity for the most vulnerable worldwide. However, this‘realness’ does not make it separable from fantasies about the crisis. Rathercrises, like traumas, require significant psychological excertion for subjects tointegrate traumatic events into an accessible interpretative framework and is oftena step towards closure – a closing off of potential ambiguities and complexities ofthe social world. This is where fantasies come in as necessary but always imagined responses toa crisis narrative in order to bring uniformity and significance to our existence. As Allen has argued, such essential fantasies can be more or less certain about theclosures they provide as well as about the ‘realness’ of the reality they bring intobeing. As fantasies they are tied to the institutionalisation of shared collectiveidentities, or master signifiers, and stimulate members to experience sharedemotions and united understandings of a situation or event. The ways in which particular fantasies come to dominate is thus related totheir emotional and structural history. In this sense anxiety can be ‘healed’, and asense of ontological security restored, through fantasies of closure that string anemotional and structural chord with their subjects. Nations and national bordersconstitute particular powerful fantasies in their attempts to objectify the state,and state borders, by imagining it as a person or a group writ large.The term ‘fantasy’ can be understood in psychoanalytical terms as ‘a deep template inthe unconscious mind of the individual which predisposes that person to experiencepeople, events and situations in a particular way’. – often in relation to ascribed national fantasies. Such border anxieties areclearly visible in terms of how contagious diseases have been ‘othered’: the Spanishflu, the Ebola as ‘African’, the coronavirus as ‘Chinese’. In terms of the Covid-19pandemic, those on the other side of the border (any border) have been perceived asa threat, as carriers of Covid-19, while the border itself is presented as aprotective tool – an anxiety-reducing mechanism. However, the spread of the virushas also affected internal othering, as witnessed in the blaming of Muslimminorities in India – defined as ‘super-carriers’– after the Muslim religiousorganisation, the Tabligh-et-Jamaat, had its main gathering in March 2020. This canbe compared to other election meetings and religious gatherings in India, especiallythe 2021 Kumbh Mela, supported by the current far right Hindu nationalist governmentin which the majority is perceived as innocent, or at least neutral, in the nationalcrisis narrative. Similarly, in the US under Trump, Latinos were characterised asthe vectors of the disease at the same time as more than 1700 anti-Asian hateincidents were reported, while in Europe the Roma, but also migrants more generally,were blamed for spreading the virus.The pandemic has thus been yet another instance in which fantasies of secure borders– borders as being ink on the map, rather than lines in the sand – become imaginaryanxiety-reducing responses. This ‘corona-nationalism’ has been geared towards thoseperceived to be outside of these borders, so called ‘fantasmatical’ others In addition to a process of ‘naming’ abject others, this has also involved apersistent ‘shifting of blame’ and a continuous promise to ‘victim-perpetrator reversal’. In terms of the pandemic, it has exposed dehumanising fantasies about ‘dirty’immigrants carrying diseases, while the rapid spread of the virus among local inhabitants often hasremained unproblematised.Noticeable during the Covid-19 pandemic is how fantasies of external others spreadthrough the circulation of memes and social media commentary, scapegoating entirepopulations as being responsible for the virus and its spread. In more specificterms, and related to far-right populism, is how fantasies of clear objects wereimagined as being either reclaimable or restorable in order to establish a cohesivesense of identity and community. These fantasies ranged from Covid-19 being a ‘Chinese bioweapon’; a weapon‘planned by the Bill and Melinda Foundation’; a ‘vaccine experiment’; a‘media-constructed virus’, to evangelical claims that ‘only those not chosen by Godwould be affected by the disease’. Underlying such claims and uniting the protesters worldwide, seemed to be acirculation of collective experiences of anger and resentment. Experiences directednot just at the establishment but also at particular others, such as immigrants,Muslims, Latinos, Chinese. This suggests that ‘emotions are not simply “within” or“without” but that they create the very effect of the surfaces or boundaries ofbodies and worlds’. Fantasies thus supply a particular form of emotional governance in thefar-right populist narrative by delineating ‘the bodies of individual subjects andthe body of the nation’ This, what Richards refers to as an ‘emotional public sphere’, specifies the detailed emotionsinvolved in these delineations, such as ‘fear, hatred, and contempt towards outsiders’.In protests around the world against anti-lockdown measures, we have seen howanti-vax, conspiracy theories and QAnon have merged together in a number of fantasynarratives and how these have gained followers across contexts. QAnon, together withother apocalyptic conspiracy movements, rely on the crowdsourcing of crisisnarratives. This is what led the World Health Organisation to describe the shiftfrom a pandemic to an ‘infodemic’ – the spreading of false information, orfantasies, about Covid-19. Another significant dimension of emotional governance and far-right populistdiscourse during the pandemic has been connected to the fantasies involved innon-mainstream information. In country after country, we have witnessed howpresentations of different versions of scientific expertise were deployed andcommunicated in response to the crisis. Accusing establishments of ‘fake news’deployed to manipulate the electorate or as governmental conspiracies to keepcitizens unaware of ‘real’ treatments to avoid catching Covid-19, has meantportraying them as being behind the misery. Continuing with the Italian example, theleader of the Lega, Matteo Salvini, thus ‘repeatedly shared alleged success storiesand updates on the plasma treatment for Covid-19’, ‘opposing the “arrogance” and“inadequacy” of “intellectuals” and “schoolmarms” in the government’. Both features contributed to the projection and dissemination of an‘impending doom’ that if crossed over ‘cannot be reversed’. This is what make far-right portrayals of political community as ultimatelygrounded in national belonging unique and an ultimate ‘fantasmatical’ resource ofontological security.In terms of far-right, and in most cases anti-elite populist discourses, emotionalgovernance takes a number of forms. One is the organisation of unease, fear andresentment, which under the pandemic has come to include areas related to health andsocial protection. In the case of Italy for instance, the far-right party, the Lega,changed the fantasies of the unknown, different and foreign in the public sentimentsto fathom a domestic fear – the fear of the virus and by extension the fear of everyperson. The message conveyed of the Lega was ‘that any recovery from the economicdistress caused by the pandemic needs to go through more security, more discipline,“more unkindness”, “zero tolerance” for criminals, and particularly for foreignersand threats to national borders’. asserts in her description of affective economies, ‘emotions dothings, and they align individuals with communities—or bodily spacewith social space—through the very intensity of their attachments’. Attaching a signto a body, by constituting it as an object of fear, is part of a racialised andgendered fantasy of ‘the ordinary’  as being under threat. In the far-right populist fantasy, it is such ordinarypersons that constitute ‘the real victims’. ‘The white subjects claim the place ofhosts (“our shores”) at the same time as they claim the position of the victim, asthe ones who are damaged by an “unmerciful government”’. This is a process in which ideological and cultural fantasies areinternalised and increasingly normalised. However, this does not automatically implythat far-right populist forces have been ultimately successful in taking ownershipof the pandemic crisis. As Bobba and Hubé’s eight country study of populism and Covid-19 reveals, the pandemic crisis hasalso provided space for forms of political collaboration or ‘non-hostile’ tacitagreements in the name of national and international solidarity. While this mayprovide some temporary comfort, it does not fundamentally challenge an increasinglynormalised political reality of closure, unity and homogeneity as the ultimatenarrative resort to exclusionary politics.As Sara Ahmed


Background: Rural populations experience poorer access to the necessary health services for chronic health conditions. Although studies of rural healthcare access continue to expand, most are based on quantitative data, yet normative views and lived experiences of rural adults might offer a better understanding of healthcare access and their specific unmet needs. This qualitative study sought the views of both rural-centric older people and healthcare professionals to understand health needs, barriers, and enablers of accessing health services, with a focus on chronic health condition(s). Methods: Between April and July 2022, separate in-depth interviews were conducted with 20 older people (≥60 years) in a rural South Australian community. Additionally, focus group interviews were conducted with 15 healthcare professionals involved in providing health services to older adults. Transcripts were coded using the NVivo software and data were thematically analysed. Results: Participants described a range of unmet care needs including chronic disease management, specialist care, psychological distress, and the need for formal care services. Four barriers to meeting care needs were identified: Workforce shortages, a lack of continuity of care, self-transportation, and long waiting times for appointments. Self-efficacy, social support, and positive provider attitudes emerged as crucial enabling factors of service use among rural ageing populations. Discussion: Older adults confront four broad ranges of unmet needs: Chronic disease management care, specialist care, psychological care, and formal care. There are potential facilitators, such as self-efficacy, provider positive attitudes, and social support, that could be leveraged to improve healthcare services access for older adults. The global population is increasingly ageing at an unprecedented rate ,2. OlderRurally living older people are considered vulnerable for several reasons. Rural communities have limited access to medical specialist services. Depending on the size of the community, there may be limited health infrastructure, limiting acute and chronic medical care for the diagnosis and management of complex diseases . Rural oSurprisingly, few research projects have investigated the healthcare needs and service provision challenges of rural older people in Australia ,9,11. FoIt is not clearly understood how rural older adults perceive their access to healthcare, particularly during the period of COVID, and how this has affected barriers to needed services, their coping strategies, and their preferred policy directions to meeting their health needs. To comprehensively understand the perceptions of needs and barriers to care services, normative views from the consumer and supply sides would provide valuable insight. Such information may help in the cross-validation of common concerns or themes and offer an opportunity to identify any discrepancies in perceptions about care delivery. Moreover, the views of health service providers are crucial because the quality of services ultimately depends on them . Therefo(a)What are the perceived unmet healthcare needs of community-dwelling older adults in rural South Australia?(b)What are the challenges to care access and facilitators of health-service utilization among rural older adults?To determine this, the following specific questions served as a guide to the study:This study is guided by Andersen’s model of health services utilisation. This behavioural model of health service use was originally proposed in 1968 but has undergone stages of revisions ,15. The Employing Andersen’s model, Wandera and Kwagala  demonstrBased on our research questions, we assume in this current study that need factors (complex chronic conditions) and the enabling/barriers  would shape health services uptake by rural older adults living with chronicity(s).Qualitative studies can capture comprehensive information about beliefs, perceptions, and the lived experiences of a population of interest . These qIn-depth interviews were conducted with older people, and three focus group discussions were organised with health service providers in rural communities. The decision to conduct individual interviews with older adults rather than a group setting was based on the ethical consideration of safeguarding participants’ health information (privacy issues). Since this study gathered information on chronic health conditions, it was not ethically approved for the disclosure of private health information to anyone except to only the research team members.Interviews were conducted by the lead author (D.A.) who is a doctoral student, and the group discussions were moderated by the last author (V.I.), the project supervisor. Co-authors (C.S.M.) and (D.P.) provided critical clinical support during data analysis and interpretation. It is important to note that none of the study participants had prior relationships with the researchers.We used a purposive sampling strategy to gather a range of opinions that were then used to recruit participants to determine differences and similarities in experiences, perceptions, and beliefs ,27. The A range of professionals was invited to participate in the study. The sample included generalists, nurses, mental health professionals, and social workers. We reached out to candidates via email with information sheets. Moreover, the first author (DA) visited hospitals and medical centres and distributed flyers and information sheets in care facilities. Two general medical practitioners, two mental health nurses, four general nurses, and seven social workers agreed to participate.Older adults were interviewed by D.A. and V.I. in English between April and July 2022. Demographic data including age, health status, driving status (able to drive a car or not), and living arrangement  were taken. Subsequently, a semi-structured interview guide was followed with a series of open-ended questions about health needs, experiences and perceptions of health services access, challenges, facilitators including factors shaping their help-seeking and care, and opinions on how their care can be improved. Typically, the interviews lasted between 30 and 45 in the participants’ agreed-upon convenient environment.Three focus group interviews were conducted with health professionals at different time periods. Two of the group discussions were conducted virtually via Teams software (Version 1.6.00.1381) with V.I. as the moderator. The third and final team discussion was moderated by D.A., and this was conducted face-to-face with two GPs in a medical centre. All focus discussions began with open-ended questions about participants’ work roles and responsibilities, professional backgrounds, and working experiences with providing care to older adults. Their views on the health needs of their older clients and access issues were sought. The group interviews lasted between 45 and 60 min. Of note, all interviews and/or discussions were digitally recorded and professionally transcribed for analysis.Two research team members (D.A and V.I) analysed the transcripts through a thematic framework ,29,30,31During the familiarization stage, D.A and V.I reviewed the transcripts to grasp the content of the data. Using Andersen’s model of health services utilization as our theoretical framework, codes were developed through both deductive and inductive processes . PredeteIn the indexing phase, a line-by-line examination of the data to match the codes was conducted by the researchers. Memos were used to annotate coders’ decisions and questions about the content of the transcripts and reflections on the analysis. Regular discussions were held on the annotations for the consistency of coding. The charting and mapping process involved organizing similar codes into themes and comparing emerging themes between older adults and health professionals. At this stage, we matched health professionals’ codes with identified themes from older adults’ transcripts when appropriate. Patterns and themes from both data sources  were compared for discrepancies and/or validation.In the interpretation stage, major themes and typical quotes were identified to summarize the findings. We shared the results with participants for confirmation, and no disagreement emerged on the findings. NVivo (version less or 2020 edition) software was used to aid in the qualitative analysis.Ethics approval: Ethics approval was granted by the Flinders University Human Research Ethics Committee (Project No: 4647). A written participant consent form assuring the anonymity of volunteers’ identites was signed by all participants. Participants were offered a shopping voucher valued at AUD$ 20 for their involvement in the study.n = 7), mental health nurses (n = 2), general nurses (n = 4), and general medical practitioners (n = 2)  and 15 healthcare professionals. Among the older adults, the mean age was 63.65 (range 60–87) years, 11 were women, 5 could not drive, and only 3 were living alone. Most of the healthcare personnel in this study were social care workers ( (n = 2) .Based on the primary objective of this study, the findings from our data have been categorized into three prominent themes, namely, unmet health needs, access to healthcare services, and facilitators/enablers of health services utilization. Unmet health needs comprised chronic disease management, specialist care services, psychological distress, and formal caregiving. Access challenges included workforce shortage, continuity of care, transportation, and waiting time for an appointment. Facilitators involved health self-efficacy, social support, and positive attitude of service providers. Older adults’ self-reported (chronic) health condition(s) including heart diseases, cancer, diabetes, sleep apnoea, asthma, glaucoma, depression, bipolar, arthritis, and osteoporosis. Chronic health conditions require a structured and well-coordinated management plan to prevent health decline and the onset of new conditions. Interestingly, our data highlighted many interrelated factors showing an association between reduced chronic disease management and a decline in physical activity and an increase in common mental health disorders. Both older people and health professionals placed an emphasis on the need for care.Often, almost everyone’s got a shopping list of six to eight things for 15 min, which means two minutes a problem with a quick hello as well. So, you’ve got less than two minutes a problem” . Older adults were more concerned about the handling of their health data records. They raised issues with the norm of carrying their health records around any time they visited new practitioners or facilities. One older patient in his 70s noted:Participants described factors including the lack of interprofessional coordination, unstructured chronic disease management plan, data transfer/sharing, and limited consulting time. Both patients and providers mentioned that the typical period of consulting that ranges from 15 mins to 20 mins is not enough for dealing with multimorbid conditions and screening for any new onset health condition or worsening of pre-existing conditions. A general medical practitioner indicated that … “I do think record keeping on my health could be better. My personal record is up here, but it should be instantly available to all doctors anywhere……it simpler for a doctor to hone in on exactly what he’s trying to see based on what he’s thinking might be the problem with this patient.”“Interprofessional coordination and a structured chronic disease management plan were primarily discussed by health professionals as the only effective and efficient way of managing chronic conditions of older people. There was a perception that a lack of coordination and a structured management plan affects the provision of needed services to a wider coverage of older adults. A senior generalist practitioner had this to share:Everyone’s doing something different, no one’s working together with a clear plan of how the system or service is supposed to be working….. even just in between doctors, doctors will want to do their own sort of thing. The only way we can make it work and make it work really well is to make sure we’re super organised.”“Most of the older people reported that accessing specialty care meant waiting for specialists to come from urban Adelaide or making a trip to tertiary care centres located in Adelaide. Older people expressed being concerned about the long trips for some specialist care. Those unable to drive long distances rely on relatives to access specialty services. Specialist appointments were considered very difficult to secure by the study participants. Except for life-threatening emergencies, patients wait several weeks for appointments, a situation that health professionals feared could lead to the deterioration of chronic conditions, the onset of new conditions, and rapid functional decline due to delayed treatment. One participant stated:Then in terms of visiting specialists, there’s often long waits to get into them for these more complicated conditions, if the specialist even comes up to the area as well and being three hours away from Adelaide, often people don’t want to travel, or they can’t afford to travel or they’re too sick to travel. If they can’t get into the specialist, we end up doing the care which is quite complex and complicated.”“My heart condition has required operations and stents and all sorts of things which—that’s a specialist care field and you’ve got to go to Adelaide to access that. If I go to make an appointment, they say, oh well, it’s six weeks. In six weeks, the problem’s either a lot worse or it’s gone away.”“to see a specialist, like I see an eye specialist and it’s pretty hard. I book three or four months in advance for an annual appointment.” . The waiting time varied for different services  and communities. One woman said, “I think it’s disgraceful. I don’t know what the answer is but if you need to see a doctor, you should not have to wait four to six weeks to see the doctor of your choice necessarily I don’t think.” .Older people expressed dissatisfaction with waiting too long to have access to physicians. One woman said, “Even on the day of the appointment, patients are sometimes made to wait several hours before they are able to see a doctor, a situation that is, according to them, very stressful to bear given their health conditions and age. Healthcare providers agreed that obtaining access to doctors, particularly specialists, is sometimes difficult.… Interestingly, I think there was a depression associated with that that wasn’t treated at the time. Now, I’ve got ongoing management…” . GPs described their awareness of patient distresses normally coexisting with multimorbid physical health conditions … “We see a lot more chronic depression and anxiety around poor health conditions.” . However, the time limitation does not allow for screening and treatment unless there is a manifestation of severe symptoms:More than half of the older adults reported two or more health conditions, and most of these people discussed psychological distress associated with their physical condition. There is a perception among older people that psychological distress and other distress that might be coexisting with their chronic conditions do not capture the attention of doctors as much as their physical conditions. A 75-year-old cancer patient shared her experience of untreated depressive symptoms that coexisted with her physical condition “Yeah, we just don’t have the time to do a DASS-21 or a DASS-42 or something like that…. But for a standard GP consult in 15 min, there’s normally so many medical conditions, acute and chronic. Even if it’s just a chronic disease consultation, that person always brings in some acute problems as well.”“(GP1)it’s not just the access, but it’s that ongoing navigation of our health system. you’ve got most—a lot of people have more than one chronic illness. They’ll have two or three. They’ll have a combo of things that trying to get all those specialists or people working and the client doesn’t know where they’re at with all their medications and things like that” Healthcare providers also discussed the complexities in the health system as a source of mental stress to older adults. As a mental health nurse put it: “Some older adults did not consider symptoms of depression and emotional distress as medical conditions requiring formal assistance but rather as normal symptoms of ageing.Older adults discussed the need for support in carrying out activities of daily living. For instance, participants frequently mentioned needing domestic assistance . They also described the need for help to do grocery shopping and access certain public places. Older adults indicated a preference for receiving help from formal support networks or organizations. Health professionals, particularly social workers and nurses, added personal care , transport, and assistance with medication. As one social worker put it:We need to put in personal care, because when we—people need to shower, they need to look after their skin integrity. Older people become incontinent; how do we manage that? So somewhere in there, I’d like to see personal care and transport put in.”“From our discussions with the participants, four categories of barriers to health services access emerged: Workforce shortages, continuity of care, transportation, and difficulty scheduling appointments/long waiting times. Of note, patients described their challenges accessing health services and difficulties they believed their peers also faced.they are obviously overworked and tired. Not enough of them, too many of us. Too many patients, not enough doctors”.Participants were focused on the limited number of healthcare practitioners in their localities and linked this phenomenon to unbearable workload (on providers) and limited consulting time and/or limited healthcare supply. Discussion about the inadequate number of health professionals included difficulty attracting GPs, specialists, nurses, and other care providers to rural communities. One man in his 80s said, “Once they do their thing up here, next minute, they’re gone. But then I suppose, too, a lot of them, their—once their children get to a certain age, the better schools are down that way, where the kids [that] go to uni, so they tend to move.” (Participant 12). In discussing staff shortages, a social worker had this to say, “I think it comes down a lot to, once again, there’s a staff shortage. We don’t have enough support workers. There are very few allied health disciplines within Port Pirie.” (Participant 27).Many older adults find the high healthcare professional turnover rate in their communities very problematic. However, they believed limited opportunities in rural locales are to blame for the situation, as one woman indicated, “What I want is I want one doctor—just one—who doesn’t have to be the world’s best doctor, but I want them to know about me. I don’t want every time I go to the doctor to have to explain this and this and this and they get on the computer and they—oh yes, I see.” . In the words of a 70-year-old woman, not being able to see her regular doctor has resulted in a medical error that she must live with. An excerpt from her account is as follows:The lack of continuity of care emerged as one of the critical barriers to required healthcare. Two main issues arose, namely, irregular or unstructured appointments and a lack of regular doctors or widespread provider turnover. Older people wanted to see a particular doctor for a longer period to build trust and for the doctor to know them and their conditions well. This, they believed, will ensure the continuity of patient care, minimise medical errors, and promote the efficient use of limited consulting time. One man shared his frustration, “Very hard to see the GP that you want to see. I had to see a registrar when my voice went strange, and he told me it was laryngitis, and it was lung cancer. So, I was a bit annoyed, but we all make mistakes, don’t we?……but it’s nice to see your own doctor who knows you. Because he knows me, he would have known that I’d lost a bit of weight and he knew as soon as he saw me in the supermarket that something was wrong. So, if I’d seen him, maybe things would have been a bit different, but who knows?”“(Participant 9)Yeah, like the man with my voice. Maybe if he’d read a bit more of my history, maybe he would have been a little bit more thorough.There was a perception among older adults that new providers normally do not have enough time to abreast themselves of the conditions of patients … … if you’ve got good continuity of care, you can normally pick up when someone’s mental health has dropped off. Even if we see them four times a year, it’s enough. (GP1).On the part of health professionals, continuity of care promotes physical and mental wellbeing outcomes. As a generalist put it My heart condition has required operations and stents and all sorts of things which—that’s a specialist care field and you’ve got to go to Adelaide to access that.”(participant 5). One woman indicated that without assistance from friends and relatives to drive her, she may not be able to attend her appointments as she did not feel confident to drive, especially after medication … I possibly could but I probably don’t feel confident to drive after I’ve had the injection in the eye.” . Similar sentiments were shared by the health professionals. They described transportation as one of the frequent reasons older people cited for missed appointments.Issues of transportation were featured significantly in the interviews. Primarily, transportation barriers included limited public buses, traveling out of town for specialty appointments, the inability to drive longer distances, parking problems in the city, and limited medical transportation programs. Many older adults reported they travel long distances to urban areas for health services that went unmet in their communities, particularly for specialists’ consultations. One man commented, “Despite the challenges of accessing health services, most older adults we interviewed described three broad factors including self-efficacy, social support, and positive attitudes toward health services providers that help them to navigate the healthcare system to access their healthcare needs.Older adults who described themselves as more assertive, hopeful, and aware of the benefits of healthy behaviours and asked questions about their conditions and treatment options reported that they always feel encouraged to seek help whenever needed. As a 72-year-old man said when asked to share factors that facilitate access to needed services:I’ve been involved in a number of health programs, reaching out for the community. Stress management, stop smoking programs. One time, weight loss and because of my awareness of—it’s the importance of maintaining good health, I think that’s sort of helpful in my situation. It keeps me focused that if there’s something that I feel is not right, I like to get it checked out.”“(Participant 12)I’ve never been frightened to actually ask something or get them to explain something if there’s—yep.” .Another woman shared, “ The people who are proactive often get a better outcome because they’re prepared to take responsibility for their own needs, and they’re prepared to ask for help. Their prepared to find out what needs to be done.” (Participant 27).Healthcare providers reported that older people who are more proactive and confident in asking questions tended to make regular appointments and follow-ups to improve their conditions. As a nurse discussed, “ I haven’t got a car, so they’re [her children] driving around everywhere. I just tell them straight out, I say you drive. So that’s it, they take me there.” (Participant 13). On the other hand, older people with an inadequate social support network sometimes delayed their treatment or lost out on their medications. A 65-year-old woman commented, “sometimes if you go down to Adelaide and you need to stay there, those are just extra costs and that - and then also getting medication is an extra cost. Sometimes, I don’t even get my medication because I can’t afford it.” When asked whether she could receive support from friends and relatives, she responded, “No, because they’re in the same boat.” (Participant 4).Getting help from friends and relatives to attend out-of-town appointments including specialty care appointments in Adelaide, encouragement, and financial support from relatives, according to older adults, were very crucial in meeting their healthcare needs. As exemplified in the words of a woman in her 70s, “they’re accommodating”, “they’re respectful”, “they’re polite”, “they’re quite good”, they’re doing their best”, and “quite pleased”. The professional conduct and positive behavioural disposition of care providers, according to some older people, encourage them to use the needed services. In response to the question “what is your experience with the healthcare system and providers?” one man submitted:Even though older people discussed various struggles in accessing healthcare services, most spoke highly of their healthcare providers. Their primary concern had to do with the lack of a long-term, trustworthy relationship due to the regular change in doctors. However, older adults generally reported satisfaction with their providers. In discussing their experiences with health services providers, older people frequently used phrases such as “I think they’re doing a—I value the doctors who own the practice, I value their experience. If I can, I’ll see them.”“sometimes, we—depending on risk, we might need to transport [patients] ourselves …. Again, not really our business, but we can’t sort of ignore that so we then reopen another referral and help them navigate that whole process” .Healthcare providers sometimes went beyond their responsibilities to help older patients to prevent conditions from worsening. They noted that such decisions were normally made based on risk assessment and in strict consideration of professional ethics. A social worker described a typical case: “In our interviews with the participants, we sought their opinions on interventions or programs they believed can help reduce the barriers to health services delivery and access. Although both healthcare providers and older people proffered solutions that targeted workforce shortages more broadly including recruiting and training more locals, attracting professionals from abroad, and instituting incentive packages for rural practice, healthcare providers further suggested the need for structural changes in the healthcare system. Further discussions on the suggested interventions are being developed as part of the broader project objectives into a manuscript. However, below are excerpts of the suggestions made by the participants:We’ve got to attract them to the country, and we’ve got to retain them in the country…If you’re a doctor in the country, you’ve got an additional cost associated with educating your kids, if you want them to be privately educated, and accessing additional training is all much more difficult if you’re a doctor in the country. So, I think the answer is to recruit more doctors to the country”“(Participant 13)We’ve got to consider other options……why can’t we attract doctors from abroad? we’ve had different—doctors from different countries in our local town and we’ve found them to be just as good as the Australian doctors”“(Participant 7)I think yeah for a medical clinic or any medical service to be successful in providing good chronic disease care, both physical and mental health issues, the whole clinic or the whole service needs to be working together and on the same page. There’s no point… We’ve seen it. There’s no point where the doctors will be doing one thing, the receptionist will be doing another thing, and the nurses will be doing one thing. Everyone’s doing something different, no one’s working together with a clear plan of how the system or service is supposed to be working. So, certainly we inherited a very broken system”“(GP 2)We conducted a qualitative study with older adults with chronic health conditions and healthcare providers in rural areas to understand their perceptions of needs. The data highlighted four interrelated unmet care needs: (a) Chronic disease management, (b) specialist care, (c) psychological distress, and (d) formal caregiving. Participants discussed four major barriers to health services including workforce shortages, the continuity of care, transportation, and waiting times for appointments. These challenges are partly mitigated through health-related self-efficacy, social support, and the provider’s positive attitudes. Andersen’s health services utilization framework  providesBoth respondent groups discussed suggestions believed to improve health services delivery and access for older adults. Overall, the findings highlight the critical gaps and opportunities for a geriatric care model for rural older adults with chronic health conditions.This work builds on prior literature on older people’s experiences with rural healthcare systems in accessing health services. As reported in earlier studies ,26,34,35The unmet care needs of rurally living older adults have been a longstanding public health concern in many parts of the globe, and this phenomenon is attributed to exacerbating barriers to healthcare services in rural locales ,38,39,40An important care need identified by participants that has not been previously discussed in the population studied was formal care. Participants reported that chronic health and formal care needs were addressed as separate issues for older adults, with a limited understanding of how these are interrelated. Available studies on the unmet care needs of rural older adults have reported mental health services ,34, chroTransportation was also identified as a critical barrier to accessing the healthcare needs of rural older adults with chronicity. Accessing care that is not available in local communities, especially specialty care, normally required long-distance travel to urban areas. Some older adults discussed their inability to cope with long-distance driving and, hence, made them dependent on relatives to access such services when there is no public transport. A similar Australian study  and anotFor older people to access the required health services in a timely manner, self-efficacy, social support, and positive attitudes of healthcare staff are crucial. Self-efficacy has been shown in the general population to be associated with positive health behaviours ,46. The Our participants shared their opinions on how the perceived barriers to healthcare could be addressed. Both older adults and care providers concurred with the need to address the inadequate workforce to reduce the workload of current practitioners and improve waiting time for appointments. Suggested strategies, however, differed slightly between providers and older adults. While providers were in favour of structural adjustments to attract more providers and ensure efficient use of care resources, patients tied workforce shortages to limited economic gains and suggested financial incentive packages to attract more providers to rural areas.As explained earlier, Andersen’s behavioural model of healthcare services use is a widely applied framework to analyse health-seeking behaviours. The framework assumes that health service use is a function of three constructs, namely, predisposing characteristics , need variables , and enabling factors  ,15. Our The findings of this study should be interpreted considering the following potential limitations. First, the study sample of older adults were from rural SA. As such, the generalisation of this study’s results to different states would need further replication studies, such as, in different Australian regional areas. Second, the views shared by participants, especially healthcare workers, may be influenced by patient privacy issues and social desirability bias. Again, we did not stratify the views of healthcare professionals in the focus group interview. It is plausible that if we probed participants separately, differences in perceptions or contradictions may occur. However, the aim of the study was to explore unmet healthcare needs, barriers, and enablers in accessing health services from the perspectives of demand and supply sides in a composite manner. In this regard, the study has contributed to knowledge in several ways. Theoretically, the study shows the applicability of Andersen’s model in qualitatively investigating the lived experiences of rural older adults in accessing healthcare. Through this, how various factors interact to shape health-seeking behaviour among older people in rural environments is demonstrated. The results also augment the literature on older adults with complex healthcare needs in rural environments. Again, this study is among the first to sample the voices of rural older adults and their healthcare providers in evaluating needs, barriers, and enablers of health services use. Hence, more qualitative studies will be necessary to explore this and other relevant details to contribute information and potentially shape policy by providing a forum in which older people and rural health practitioners can voice unique issues related to the rural healthcare system.We explored the perspectives of older adults and healthcare professionals on health needs, barriers, and enablers of accessing health services among rural older adults with a chronic health condition(s). Older adults confront four broad unmet needs: Chronic disease management care, specialist care, psychological care, and formal care. Many access barriers have contributed to the unmet care needs; however, there are potential facilitators that could be leveraged to improve healthcare services access for older adults. The findings reinforce the need for governments and other stakeholders to act effectively to think of ways to improve care services in rural areas. Particularly, the existing system of formal care services provided in areas of personal hygiene, daily activities, and engagement in community and social activities that may be strengthened. Importantly, the provision of geriatric care services in rural settings needs to be reassessed and efforts should be made to train more professionals through scholarships and other appropriate incentive packages to work in rural care facilities. The study also provides new insight into the care needs and facilitators of services use. Particularly the impact of health self-efficacy on health services use in late life and formal care needs, which has not been previously reported. The awareness of self-efficacy levels of older patients may assist providers in identifying those in need of enhanced self-management support. Overall, the findings of this study provide valuable data on perceived unmet healthcare needs and barriers to and facilitators of health services use (answering the research questions posed) and highlight the need for comprehensive stakeholder engagements, particularly older adults, in an effort to address their care needs in rural environments.


The aim of this work is to uncover the preferences and perspectives of college educators as they interpret medical documentation outlining medically requested return-to-learn (RTL) instructions. Participants were recruited from five colleges across campus at a large Midwest public university. They each engaged in a private, one-on-one, audio-recorded interview. All recordings were transcribed and inductively analyzed using a grounded theory approach and two-coder system. All codes and themes were finalized once agreement was reached by both coders. Resultant themes from axial coding had to represent the voices of at least 80% of participants. Three characteristics emerged as being desired by college educators: brevity, clarity, and direction. Educators also expressed considerably less utility with medical documentation designed for pediatric students with concussion. College educators desire medical notes that are brief, clear, and provide straightforward direction, in addition to documentation that is tailored for the college setting. These divergent characteristics prompted this group to investigate the utility of medical notes used to support students as they RTL. Thus, the primary aim of this investigation was to uncover educator preferences as they evaluate the usefulness of medical notes containing RTL instructions.Still in its beginnings, the delivery of academic support within the college setting is concurrently being explored. Recent grounded theory data indicate that awarding academic accommodations in the college environment largely hinges upon the presence of a medical note.Twenty-three college educators from a large public institution were recruited from five schools across campus . All participants were current faculty with teaching responsibilities and a previous history of instructing students with concussion. Permission to interview participants was given by the Indiana University Institutional Review Board and received exempt status.Semistructured, private, audio-recorded, one-on-one interviews were utilized. Interviews were recorded by voice recorder in a closed-door location of the participant's choosing. All interviews were conducted by a single researcher and were an average of 62 min in length.1 whereas During the interview, participants were asked to review two sample medical notes . SupplemAfter giving their opinions, participants were then given the college note to repeat the process. Paper versions of these notes were used, allowing participants to physically annotate as they reviewed.® , which included an iterative process of grouping segments of text that embodied a similar meaning. From this, desirable medical note characteristics were identified. In order for a characteristic to be desirable and representative of the sample, it had to include matching codes from at least 80% of the sample. This cut-off value was chosen because it signifies robust homogeneity among educators, while not excluding characteristics that did not reach unanimous representation.Transcripts were independently open- and axially coded by two researchers. Coding was completed using Microsoft Word9Credibility methods  and confirmability methods  were incorporated to maintain methodological rigor and mitigate researcher bias.Twenty-three faculty volunteered to participate in the investigation. Data analysis revealed three themes that characterized a useful note; 1) brevity, 2) clarity, and 3) direction. Here we will provide participant responses that delineate the source of these characteristics.The cohort habitually commented on the length and density of information within the K-12 note : “It's t“On the surface, the difference between these two notes may be a collegiate level for Appendix B, and high school or middle school for Appendix A. I almost think that the different level of the student would tailor into how these notes are received. Cause again, for college students, the instructor is only going to see them a couple times a week, so it's (the note) only pertaining to their individual class. So I think that a collegiate instructor just needs to know that this (concussion) is a condition, this is why you cannot come to class, do your assignments, take your exams, this is when you can, and this is what to expect from me. Where I think, the high school or middle school teacher who technically will be in proximity to a student throughout the day may need to be more in tune with the signs and symptoms, how students are feeling, how they may react, what they can and cannot do throughout the day, and what things may help and hinder them. So I think the symptoms checklist and the personal narrative of Appendix A would be more beneficial for younger students and teachers that have proximity with them all day, where the official letter type of format of Appendix B would be better for a collegiate instructor to legitimize the short period of time they have them throughout the week.”Some content even appeared nonessential, as summarized here:Contrastingly, two participants with a background in K-12 pedagogy found value in the list of accommodations outlined in the K-12 note: “I like understanding that there is a range of symptoms. I like that it breaks it down and it's informative, rather than just saying, ‘don't do this, don't do that,’ and these are some of the symptoms.”; and “We're going to get folks who won't read this. But, for those who actually read it, I think this is amazing.”Because participants were given paper copies of both notes, we were able to identify words and phrases that were routinely marked as elucidating or helpful. According to the K-12 note: “many students will benefit from some accommodations”; and “Recovery typically takes between several days to several weeks.” According to the college note: “mild traumatic brain injury”; “students who appear healthy may actually be ill”; “the student is responsible for following up with you”; “no class attendance, homework, exams or screen time for 6 days”; and “the student will be returning to the Health Center on xx/xx/xx.”Participants identified the goal of a medical note to be an “action item,” requesting the educator to perform a duty or provide support for the student. Therefore, the following responses iterate the ease-of-use in finding the action item(s) within a note.“The format of Appendix B is useful for doing what I want to do… So when I got the email (note), I remembered scanning it for whoever has a concussion. Okay, she has a concussion. And then I went like this, what do I have to do? What do I have to do? Which is this bottom part (of Appendix B).”“Okay, I like this one (Appendix B). I like it a lot better. I mean it says they're going back to the health center. It says no class attendance, homework exams or screen time for six days, then to attend class, to return to completing homework assignments, which I would accommodate … it also indicates they're going to go in for a recheck, so then it's not up to me to evaluate their current situation.”Although informational, educators found the K-12 note to be non-specific and left many unsure as to what was being requested.“It said the student can return to school when they can concentrate on schoolwork for 30 minutes before symptoms worsened significantly. Okay, so let's say they return to school, but they're in my lecture hall and in 15 minutes they can't tolerate it, and they leave the classroom. Does that mean I have to pull them out as an instructor? Do they go back to the physician? What does that mean for me?”“There's no to-do here. It says, here's the symptom, here's the effect on school learning, here's an accommodation that I assume is helpful, and I could link it back to the current symptoms, but what do I do with this information is the question I have. I understand the symptom. I understand the effect on learning. I understand what accommodation is helpful. Is the goal my understanding, or am I supposed to do something about it?”The presented data introduce the preferences of college educators as they examine medical notes containing RTL instructions. Brevity, clarity, and direction emerged as sought-after characteristics. The data also highlight specific phrases that offered clarity and straightforward guidance. Overall, the current findings lead us to hypothesize that college educators seek medical documentation with the capacity to quickly answer the following questions: 1) “Who is involved ?”; 2) “What is the illness/injury?”; and 3) “What must I do as an instructor, and for how long?”.6 Additional investigations corroborate the importance of providing educational materials for K-12 teachers.10–12 These data, however, contrast the sentiments shared by our cohort, who stressed the importance of clear direction from medical documentation versus the freedom of using their understanding of concussion to subjectively assess and implement academic adjustments. Other qualitative research echoes this, identifying how middle and high school teachers “expressed the need for specific guidance on how to support their students with concussion.”13 Further, providing instructional programs for educators with the intent to equip them in the future departs from the role that educators have assumed within the RTL team. College educators have identified their role as “peripheral and responsive,” with K-12 educators portraying their duty as “reactive, not preventive, when it comes to concussion.”13 Taken together, these data propose that K-12 and college educators seek a level guidance that is contrary to what is presumed in the literature.One participant detailed at length how they would receive the given medical notes, placing a specific emphasis on why the accommodations table in 14 Further, giving teachers the autonomy to implement classroom supports for a student with concussion is conceivably negligent, given that this effectively gives educators the authority to dictate how a temporary neurological disability is academically treated—a duty for qualified medical personnel.Desiring objective direction from qualified medical personnel is logical, especially given that previous work has shown that completion of a concussion education course by educators inadequately translates to classroom application 6 months later.In keeping with the characteristics elected by our sample, this group proposes that the following note  be used The current study is not without limitations. First, our cohort was asked to analyze a sample medical note that was currently in use at the studied university. Additionally, inclusion criteria dictated that all participants have previously instructed a student recovering from concussion. Therefore, study participants may have already been familiar with The sampled cohort of college educators identified three preferential characteristics to include in RTL notes: 1) brevity, 2) clarity, and 3) direction. Educators also expressed a preference toward the content and length of the sample college note, indicating that documentation for RTL should be tailored to the level of academia in which it will be implemented. As efforts continue to mold RTL into a robust prong of post-concussion management, identifying setting-specific distinctions becomes prudent. Future investigations should use these findings to determine the utility of other notes in circulation, in addition to our proposed note for higher education. Widespread perceptions of this novel document may also act as a proxy for the accuracy of our identified themes. Finally, follow-up studies must include educators with no RTL experience, to address whether familiarity dictates a person's RTL viewpoint.


Personal wellbeing (PW) including quality of life and work life is a very complex concept that influences health professionals’ commitment and productivity. Improving PW may result in positive outcomes and good quality of care. Therefore, this study aimed to assess the pattern and perception of wellbeing, quality of work life (QoWL) and quality of care (QoC) of health professionals (HPs) in southwest Nigeria. The study was a convergent parallel mixed method design comprising a cross-sectional survey (1580 conveniently selected participants) and a focus group interview (40 purposively selected participants). Participants’ PW, quality of life (QoL), QoWL, and QoC were assessed using the PW Index Scale, 5-item World Health Organization Well-Being Index, QoWL questionnaire, and Clinician QoC scale, respectively. The pattern of wellbeing, QoWL and quality of care of HPs were evaluated using t-test and ANOVA tests. Binary regression analysis was used to assess factors that could classify participants as having good or poor wellbeing, QoWL, and quality of care of HPs. The qualitative findings were thematically analyzed following two independent transcriptions. An inductive approach to naming themes was used. Codes were assigned to the data and common codes were grouped into categories, leading to themes and subthemes.Of 1600 administered questionnaires, 1580 were returned, giving a 98.75% response rate. Only 45.3%, 43.9%, 39.8% and 38.4% of HP reported good PW, QoL, QoC and QoWL, respectively; while 54.7%, 56.1%, 60.2% and 61.6% were poor. There were significant gender differences in PW and QoC in favor of females. With an increase in age and years of practice, there was a significant increase in PW, QoWL and QoC. As the work volume increased, there was significant decrease in QoWL. Participants with master's or Ph.D. degrees reported improved QoWL while those with diploma reported better QoC. PWI and QoC were significantly different along the type of appointment, with those who held part-time appointments having the least values. The regression models showed that participant’s characteristics such as age, gender, designation, and work volume significantly classified health professionals who had good or poor QoC, QoWL, PW and QoL. The focus group interview revealed four themes and 16 sub-themes. The four themes were the definitions of QoC, QoWL, and PW, and dimensions of QoC.More than half of health professionals reported poor quality of work life, quality of life and personal wellbeing which were influenced by personal and work-related factors. All these may have influenced the poor quality of care reported, despite the finding of a good knowledge of what quality of care entails. Health professionals (HPs) are a heterogeneous mix of health care service providers who work towards caring for patients as the most important goal, by applying the available best evidence domiciled within the respective professional contexts , 2. AccoDue to the occupational demands, health professionals are a high-risk group when it comes to stress, burnout, and lower levels of wellbeing, even during non-pandemic times . HoweverHealth professionals provide services differently because of the professional ‘heterogeneity’ of the group , as well as the diversity of patients’ needs . Also, vHealth professionals work within healthcare organisation contexts and systems that are largely, a reflection of the quality of work life (QoWL) . QoWL deThe cross-sectional study utilized a convergent parallel design of both qualitative and quantitative data collection . Our study was grounded on the concept of complementarity in mixed methods approach . We chosThe participants for the study were health professionals from selected hospitals in southwest Nigeria. The designated health professionals were medical practitioners, nurses, pharmacists, physiotherapists, occupational therapists, medical laboratory scientists, radiographers, and others . In Nigeria’s context, medical practitioners refer to the heterogeneous group from the various specialties of medicine, as well as dentists. The rest of the health professionals are referred to as allied healthcare workers. The hospitals involved in this study were teaching/tertiary hospitals. To be included in the study, a hospital must (i) be a tertiary hospital , (ii) be public-funded, (iii) have at least 300-bed capacity, (iv) and at least 500 employees. Four of the tertiary hospitals that met the inclusion criteria were selected. The hospitals are the Federal Medical Centre (FMC), Abeokuta and Olabisi Onabanjo University Teaching Hospital (OOUTH), Sagamu, both in Ogun State; Obafemi Awolowo University Teaching Hospital Complex (OAUTHC), Ile-Ife, Osun State; and the University College Hospital (UCH), Ibadan, Oyo State. UCH, OAUTHC, FMC and OOUTH have bed capacities of 850, 842, 400, and 354 with workforce of 3000, 1490, 2000, and 566 health professionals, respectively.p) = 0.5, error margin = 0.05, Z-score = 1.96 and population size for selected hospitals = 7056. The minimum sample size to power the study is 1200. The calculated minimum sample size was 1200; however, in anticipation of incomplete surveys and attrition, we distributed 1600 surveys of which only 1580 surveys were returned completed. Quantitative and qualitative data were collected between May and November 2021.A convenience sampling technique was used to recruit the designated health professionals for the quantitative survey. Participants were included in the quantitative study if they were (i) health care workers in any of the four selected hospitals, (ii) fluent in the English language, able and willing to complete the questionnaire, and (iii) granted informed consent. Prior to the study, sample size was determined using a standard formula , the calTo explore peculiar experiences concerning perceptions of quality of care received at the public-funded hospitals selected in this study, a qualitative focus group interview of health professionals was carried out. A purposive sample of 8 to 12 designated health professionals were recruited from each of the selected hospitals. The participants were individuals at the middle or senior professional cadres, with a minimum of five years of working experience, who were considered to provide the best information on the concepts of discussion. A sample size of 30 is adjudged large enough for a qualitative study to allow the unfolding of a ‘new and richly textured understanding’ of the phenomenon under study . In sum,The researchers were a multidisciplinary team of scholars with expertise in both quantitative and qualitative methodology. The moderator for the focus group interview was a female physiotherapist in academics who holds a Ph.D. degree with over 15 years of experience in qualitative methodology. The interviewer used her knowledge of hospital settings in Nigeria to probe the respondents further.For the quantitative cross-sectional aspect of the study, standard tools were used to assess the construct of interest. The questionnaires that were used in the study were self-administered and were distributed through hand delivery.The 5-item World Health Organization Wellbeing Index (WHO-5)  and PersThe 5-item World Health Organization Wellbeing Index (WHO-5) is a brief and generic global rating scale measuring subjective wellbeing. The WHO-5 which was derived from the WHO-10 [e WHO-10  tool, hae WHO-10  and has e WHO-10 –34. The Personal Wellbeing Index Scale (PWI) was used to measure Quality of life. The scale consists of 8 items. Each item corresponds to a quality of life domain of standard of living, health, achievement in life, relationships, safety, community-connectedness, future security and spirituality. The first seven domains are the core domains while the spirituality domain is optional. It is measured on an 11-point Likert scale ranging from zero to ten . Higher scores reflect a higher level of satisfaction with each domain. The PWI was found a valid and reliable measure of life satisfaction for use in various populations with Cronbach’s alpha ranges from 0.88 to 0.92 [ to 0.92 , 35, 36.The quality of work life questionnaire by Van Laar et al.  was utilThe assessment of quality of care was from health professional's perspective. Thus, the Clinician Quality of Care scale was employed . It is aFour face-to-face focus group interviews were conducted in private, well ventilated, noiseless rooms without distraction. There was one focus group interview in each of the selected hospitals. Each interview consisted of a moderator, a note taker, and selected health professionals. An interview guide was utilized with questions, prompts, and guides provided by the moderator. The semi-structured interview questions were open-ended to ensure that participants expressed their views and shared their experiences about how quality of care was hindered by their wellbeing and quality of work life in their respective work settings. The interview was audio recorded and field notes were also taken during the interview. Each of the focus group interviews lasted for 90 min.The quantitative data analyses were completed using descriptive and inferential statistics. Descriptive statistics – frequency (percentage) and mean ± standard deviation were used to summarize the sociodemographic characteristics of the participants. For inferential statistics, the data was diagnosed and fixed for missing variables, and univariate and multivariate outliers; all data were normally distributed. Therefore, an independent samples t-test  and one-way analysis of variance  were used to determine the mean differences in participants’ pattern of wellbeing, QoWL and quality of care across the sociodemographic characteristics. Binary logistic regression  was used to determine the set of factors that best-classified participants into good or poor wellbeing, QoWL and quality of care. In a situation like our study, where multiple predictors were simultaneously tested, the Forward Wald (stepwise) approach was used to limit the final model to statistically significant predictors. The alpha value was set at 0.05. Statistical analyses were carried out using SPSS 27.0 version software .The qualitative findings were thematically analyzed by two independent transcriptionists (who transcribed the recording) and also used field notes. Codes were assigned to the data and common themes were described based on frequencies. The themes were derived from the data. An inductive approach to naming codes and themes were used. A Computer assisted qualitative data analysis software known as ATLAS.TI (version 9) software was used for the analysis. One thousand five hundred and eighty 1580) health professionals participated in the quantitative aspect of the study out of 1600 that were invited, giving a response rate of 98.75%. Most participants were females  who had bachelor’s degree  with full-time employment . The 40 focus group participants were gender-matched and most (87.5%) had ≥ 11 years of practice. More information on the participants’ characteristics is presented in Table 580 healtTable p < 0.001) and twice  the likelihood of reporting good QoL, respectively. Only nursing and medical practitioner designation significantly predicted good QoL. Medical practitioners were 0.466 less likely to report good QoL compared with nurses. The health professionals with ≥ 11 years of practice were 0.525 less likely to report good QoL compared with ≤ 2 years of practice. Those in age ranges 40–49 and 50–59 years were 1.961 and 2.403 more likely to report good QoL, respectively compared to age ranges 20–29 years.Only 693 (43.9%) health professionals reported good QoL while 887 (56.1%) were poor. Poor and good PWI, QoWL, QoC were reported by 864(54.7%) and 716(45.3%); 973(61.6%) and 607(38.4%); 95160.2%) and 629(39.8%) health professionals, respectively. Table % and 629P < 0.001). Those in age ranges 50–59 years were 1.54 more likely to report good wellbeing compared to age ranges 20–29 years. With a unit increase in QoWL, QoC and QoL, there is 3.0, 1.5 and 3.4 more likelihood to report good personal wellbeing, respectively , 52%  and 65%  less likely to report good QoWL, respectively compared to < 20 h. Health professionals with master or Ph.D. degrees were twice likely to report good QoWL compared with diploma holders . Those in age ranges 50–59 years were twice likely to report good QoWL compared to age ranges 20–29 years .Table P = 0.018). Those in part time appointment were 37% less likely to offer quality of care compared to full time . Those with work volume > 60 h were 1.891 more likely to offer good quality of care compared to < 20 h. With a unit increase in personal wellbeing and QoWL, there is 1.43 and 2.07 more likelihood to offer good quality of life “Quality of care could be optimal care or standard care offered to client.” Three discussants from OAUTHC described quality of care to be the standard care that is given to a patient.“In my own opinion, I can describe quality of care to mean a kind of care I give such that I as a physiotherapist is satisfied, and my client also feels I have done the best I can in my capacity. So, the quality of care is perhaps related to both the caregiver as well as the person being care for. So, in my opinion, it stems from both ends, but as it relates to me as a health care provider, I can also say that quality of care could mean my own competence to be able to do what I’m supposed to do in that particular situation - how quality and how qualitative it is and how good it is – and also the satisfaction of the client.” “Well, for quality of care as we have said, there is a standard, there’s a minimum requirement that should be given to patients. So what comes to our mind is, has it been achieved? Has the environment and the equipment, and the personnel, are we equipped to offer that quality of care. And is everything actually okay with the caregiver, to provide that quality of care? To me that is very important.” Two discussants from FMC described quality of care to be a kind of care focused on satisfaction of both the patient and the healthcare provider. Two discussants from OAUTHC group agreed but argued that quality of care cannot be standard except the patient is satisfied with care received and the healthcare giver is also satisfied with giving care. Both parties must have satisfaction.“I'd like to add that it also has to do with efficiency, making sure that the quality of life of individuals improved because that is what quality care is. The goal is to improve their quality of life.” Two discussants from FMC stated that quality of care has to be timely, efficient, excellent, and equitable.“When you are talking about quality of care, I want to say care that is quality, valuable, worth the price, the care that is safe, that is timely, that you give at appropriate time.” Other discussants from OAUTHC and OOUTH agreed with them.“When you are talking about quality, like in my own perspective, like we do in nursing practice, we want to talk about the patient-centered care. A care that the patient would appreciate.” “What I understand about quality of care is a care that is safe so that the patient would have the best and the whole community; a holistic thing for a universal health coverage.” The remaining participants from UCH and OOUTH defined quality of care as overall working conditions of the healthcare system centered on the patient.Different aspects that contribute to the wellbeing of the patient and the caregiver were visited by the discussants as important to quality care.“Talking about quality of care, we are health professionals, and we want to give adequate necessary care, a holistic care to our clients in all the departments in the teaching hospital.…….. the facility should be well equipped to be able to produce this care to pass it across to every client seeking help in this hospital. We are talking about manpower, we are talking about funding, we are talking about the orderliness of the environment; all the spheres. There should be adequacy in the provision made available to be able to care for all our patients.” Speaker 7 from OOUTH emphasized adequacy as something very important and a dimension to quality of care.“It covers different level of operations. That’s what dimension is, because it entails what is obtainable at the primary center is different from what is obtainable at the tertiary sectors. Although there is quality of care that is acceptable in the primary care but what is more important is that excellent care given by the caregiver consistently within the available resources.” A Speaker from OAUTHC shared similar thoughts, however, he emphasized more on consistency in giving of care within the available resources.“Let me first start with the fact that to get quality of care by any patient, the patient actually will need a conducive environment to ensure that the quality is given. It is not only for the patient but for the caregiver. So, in one way or the other when the infrastructure is deficient both the caregiver and the patient suffers. The patient in the sense that they may not be able to get the best.” Other discussants agreed that one of the dimensions to quality care is a conducive environment that is safe and offer holistic, timely and efficient care. A speaker from FMC pointed out the vitality of having conducive environment for both patient and the health caregiver.“Like participant 2 rightly said I think the safety, being time bound, being efficient about it, having a good environment to work and also available facilities.” Two other participants from the same group echoed similar view:“Well, as much as I agree with everybody, I believe the quality of care should also be related to the acceptable standard, not just for your own environment, except you have a standard by which you can rate the service you are giving, you may assess yourself to have done well and even the care – the person you have cared for could have assessed you to have done well. So, that is to say that there must be a standard to which you are relating whatever you are doing to; and the standard must be in terms of qualitative and quantitative measures. And that thing must be measurable and it must be reproducible –……reproduce what you have done and in terms of you being able to standardize it so that it gets to anyone in the world. The same thing that I’ve done for this person is what will be done not based on the locality that you find yourself or that particular period that you are carrying out the service to the individual.” However, a speaker from FMC opined that whether that patient is rich or poor, young or old, politician or not, that person should be able to access the same type of care everywhere globally.“I think it should also be equitable, there should be equality that’s what I want to add.” Another discussant from OOUTH group added similar point:“When we talk about the quality of care, …. combination of factors that makes the patient to have high level of satisfaction. Number one, early diagnosis to be able to make your diagnosis, prompt treatment. That is one, then short interval that is short waiting time, then respectful interaction. Treat them with dignity and honour and then empathy, sympathy with minimal morbidity, with minimal complications so those are the ones that can easily be” Another discussant from OAUTH mentioned different dimensions to quality care. He emphasized the importance of early diagnosis and prompt treatment of patient in respectful manner.“I will just give a scenario. A situation whereby the equipment is there, you have everything. But simple pregnancy test reagent is not available in the hospital. Pregnancy test, may be 10 naira or 20naira strip but the hospital is expected to provide it. you know that the frustration is both on the patient and even the health caregiver and you will be saying that simple thing like PT strip this hospital cannot provide so I believe that in terms of the working environment, it plays a major part.” Some discussants from all the groups expressed the importance of having needed hospital equipment in providing quality care. Lack of these useful materials can incapacitate care for the patient. A speaker from FMC buttressed this point with a scenario:“Just like when we try to refer to the World Health Organization's definition of health, personal wellbeing is beyond the physical health or physical well-being. There are other dimensions to it, even psychologically, emotionally and when we are now talking about, personal wellbeing in relation to what we are discussing, even the ergonomic implication of your workplace, your workstation, and how it eventually impacts on your physical well-being.” A participant from UCH divided wellbeing into psychological and emotional dimensions. This participant made mention of ergonomics at workplace and its effect on physical wellbeing.“And even if the environment is also not conducive ….you talk about ergonomics, sitting arrangement, back pain for the academics and things like that, this affects it too, the workspace will affect our physical health.” “…..even the ergonomic implication of your workplace, your workstation, and how it eventually impacts on your physical well-being. For example, you have come to work, you have by virtue of the relationship of your workstation to your own characteristics, they are incompatible. And then you end up having challenges even within your body physically, in terms of pain, in terms of whatever. So, eventually, even this impact on the physical well-being a good number of times, you end up with certain symptoms that you have to manage.” Most participants described their physical wellbeing in terms of physical comfort in their working environment.“Then talking about psychologically, you leave home, I'm going to work, I have this target, I want to do this today, I want to do that today. Sometimes, the most annoying part, maybe as you're coming in along the corridor, you see the light, and as you're just entering the door of your office like this, the light goes off that means certain plans are already distracted, you can't do what you have planned. And already psychologically, it depresses you, even emotionally, you get frustrated and things. So all these have impacted on me in the past.” A participant discussed the issue of unstable power supply which reduces zeal and passion to work.“At times the health care workers start contributing to be able to save life, this is very common in my unit. We need to save lives we need to provide for them. Like today now we've been contributing. It’s psychological torture for the care worker, you know what to do? You want to render the service but you are incapacitated.” Another discussant shared how bearing the financial burden of the patients could lead to psychological torture for the caregiver.So coming to work every day before I leave home, I'll just say my wife pray for me so that I will come back home completely. I work in the accident and emergency, to be sincere that’s very fatal”. Another discussant shared how he was assaulted by a patient’s relatives.“……..Because financially the patient is handicapped and the patient needs help from the system. ……it is for me to use personal money to do many things. ……we need to start contributing to be able to save life I've given a patient 40 Pampers, when she finished using this, she's asking me another one that ‘Madam, my pampers has finished’..” Another participant talked about financial constraints of patients as she had bought pampers/diapers for a patient before.The participants from all centers discussed extensively on their quality of work life.“Like everybody have said, we are all in the same boat, as an assistant director in the laboratory, I do not have any office too. So aside from offices, like my colleagues said, basically, you come to work, there are things expected of you, we want to attend to our patients.” “And of course, we are also human beings. For example, you have your office, like I speak to you now. I don't have a very furnished office in this hospital. So I have to stay on campus, find my way down here, sitting inside my car and all that.” The participants were able to identify physical structures and environments within hospitals as the key dimension of quality of work life. Quite a number of the healthcare practitioners discussed about lack of offices and office furniture. Some said they had to be sleeping in their cars, walk around or stay at main university campus.“Apart from that, mosquitoes are always coming in because it's close to the gutter, so mosquitoes we just come and your legs would bite you, you know you're treating patient, you're always beating your legs, so I was always having malaria maybe every month or every 2 months. The people who do night too, we have to sleep to put whatever maybe mat or whatever and sleep.” Another participant from FMC made mention of always treating malaria because of mosquito bites from hospital environments and surroundings.₦5000 was ridiculous.“So, and then to me as a person, that I'm able to feel fulfilled, happy and then have financial reward for my activities that the financial reward is commensurate to my input.” “Okay, let's look at inadequate salary. Salary. So, if you have you have to get this or say most of these things are not even provided in the hospitals like my nurse talked about you want to get anti-malaria, you have to come get it on your own, and the money is not just there. It's not enough, you can imagine ₦5000 for hazard allowance in hospital sector with.” Participants here expressed their dissatisfaction at inadequate salary structure in healthcare system generally. A participant even said collecting hazard allowance of “I want to talk about my own personal experience now, my last promotion was in 2012. This is 2021. So like they expect that if you are the SON type you should go to the university which I have done, my BSc, my master's everything you just keep reading and they're keeping the certificate for you, nothing is being done. Like the salary I was earning in 2012. That's what I'm still earning and we are expected to give quality care, well I don't know how I'm going to do that. Because I'm not happy. No promotion, nothing.” Participants weren’t happy with delayed promotions in their workplace. A participant reported being on the post of Assistant director for over nine years. Another participant who has also spent nine years on a post said all the management could do was to read and keep the certificates for them.“And also about the postgraduate training, for example, I will not want to cite personal instances. But why I personally was embarking on a Ph. D program, we have to be called to the management level. And we had to be given a threat to either stop the program or we lose our job. And because I was just at that time bringing up a young family, I had to stop the program, the Ph. D program, to actually stay on the job. But that does not actually discourage me, I had to raise a lot of funds in foreign currency to pursue the PhD outside the country.” Participants were of the opinion that the world is evolving and there is a need to go for trainings and continuing professional development. A participants made a point of being turned back anytime the chance for professional development comes up. Another participant said he was at one point threatened to lose his job if he continued his PhD program.This study described pattern and perception of wellbeing, quality of work life and quality of care offered by health professionals in southwest Nigeria. More than half of the participants reported poor personal wellbeing, quality of work life and quality of care offered to patients. This proportion is substantial as the wellbeing of health professionals is crucial for the provision of quality health care. Health professionals in Nigeria, like many African countries, reported poor personal wellbeing, work life quality and care compared with international health professionals , 40–43. ₦5000 ($12) was ridiculous. Participants were disappointed with delayed promotions in their workplace. A participant reported being on the post of Assistant Director for over nine years. Another participant who has also spent nine years on a post said all the management could do was to read and keep the certificates for them. A participant made a point of being turned back anytime the chance for professional development came up. Another participant said he was at one point threatened to lose his job if he continued his PhD program.Adverse psychosocial work condition has been shown to results in poor quality of life among health care workers with imbalanced effort-reward i.e. high effort/low reward . The resDemanding and high strained work environment was also suggested to contribute to poor wellbeing of health workers . NigeriaOur data demonstrate unique patterns of personal wellbeing. It is noteworthy the gender difference in personal wellbeing of health professionals in this study in favor of females. This was corroborated by the results of logistic regression. Males were much less likely to report good personal wellbeing compared to females. Previous studies have documented females having better wellbeing/quality of life than males , 44. GenMany health professionals  in this study reported poor quality of work life. This was in accordance with previous studies who reported poor or dissatisfied quality of work life among health professionals , 43, 46.The sociodemographic patterns of quality of work life are similar with previous study . Health Despite adequate knowledge of what quality of care entails exhibited by the participants, only few health professionals in this study reported providing quality care to the patients. It seems they have good sense of what good quality of care means as the focus group participants listed standard care; satisfaction of patient and healthcare provider; timely, efficient, excellent and equitable treatment; and holistic patient-centered care in their definition of quality care . Our datThis study has some policy implications. Addressing wellbeing of health professionals is critical and important for quality health care provision. Health organizations should direct effort at lowering job stress (which impact wellbeing) to reduce discordant care and strive to increase job resources to promote person-centered care. Focus oThis study has some strengths and limitation. The major strength is the mixed methods design employed in the present study making it unique. The large number of included participants from different health disciplines added to the strength. However, the samples are from southwest Nigeria and not nationally representative. Thus, the results cannot be overgeneralized to all health workers in Nigeria. However, the sociodemographic characteristics of our study participants are very similar to previous studies of Nigerian health care workers at national and regional levels. The health care workforce in Nigeria is dominated by women who are mostly nurses and physicians , physiotMore than half of health professionals reported poor quality of work life, quality of life and personal wellbeing which is influenced by personal and work-related factors. All these may have influenced poor quality of care reported despite exhibition of good knowledge on what quality of care entails. Effort directed towards improving personal wellbeing and quality of work life of health professionals may result in good health care delivery and quality outcomes.


Thank you for the opportunity to respond to comments gracefully raised by van der Pluijm et al.  and refeFirst, as a potential limitation to our study, van der Pluijm et al. correctly state that the nominator of this equation is “polluted” by publications that randomly happen to mention the drug of interest and the word “resistance”. To offset this “pollution”, we included only drugs with more than 20 yearly citations. Assuming random noise, we ignored any drug with signal-to-noise ratios below 4.67 (S = 20, N = Second, as a potential limitation to our study, van der Pluijm et al. correctly state that both known and unknown factors contribute to the rise and fall of normalized citations. For example, Halofantrine was first marketed in 1984, and not surprisingly, its citations only begin in that year. Notably, the citations decline after 1995, following concerns over halofantrine cardiotoxicity. We agree that resistance dissipates with infrequent use and adheres to Darwin’s principle of natural selection. Thus, given the right conditions, resistance can fall after linear rises. For example, we hypothesize that artemisinin resistance can decrease following a period of discontinued use. We do not know if rising artemisinin resistance evolved in ancient China or whether it predates modern medicine. Our data suggest that artemisinin resistance was registered before 2008–2009 and evolved gradually. We know that, given natural selection, ancient genes gradually evolve new functions, such as drug resistance, and that new functions gradually degenerate without natural selection. This is clearly illustrated in the example brought forward by van der Pluijm et al. in Sub-Saharan Africa, where chloroquine resistance has declined after a period of infrequent use. We believe that antimalarial resistance is governed mostly by its use, very much like antibiotic drug resistance . We agreFinally, as a potential limitation to our study, van der Pluijm et al. correctly state that normalized citations cannot accurately predict future trends. However, given enough data, we believe that resistance trends may be approximately projected.